ΠΑΝΕΠΙΣΤΗΜΙΟ ΑΙΓΑΙΟΥ

Content

1. Introduction. Overview and aims 4

2. New Public Management 5

3. New public management in health care 14

3.1. General problems with new public management 14

3.2. Physicians professions 14

4. New Public Management in Health system in Romania 15

4. 1 Health and statistics 15

4.2. Institutions 17

4.2.1. Ministry of Public Health 17

4.2.2. National Health Insurance Fund 18

4.2.3. Professional associations and trade unions 18

4.2.4. Federative Chamber of Physicians 19

4.2.5. The Romanian Medical Association and the Society of General Practitioners 19

4.2.6. The College of Pharmacists 20

4.2.7. The Order of Nurses and Midwives 20

4.2.8. Association of Nurses 20

4.2.9. Sanitas 20

4.2.10. Health care providers 20

5. Information and communication technology as a part of New Public Management in

the Health system in Romania 21

5.1. Information for patients 21

5.2. Information systems 21

6. eHealth strategies 23

6.1. Motivation of the eHealth Strategies study 23

6.2. Survey methodology 25

6.3. ICT use of general practitioners 26

6.4. Current strategy 27

6.5. eHealth strategy 28

6.6. Administrative and organisational structure 29

6.7. ePrescription 31

Bibliography 33

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Part made by Corina Taban

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1. Introduction. Overview and aims

As noted, the 1980s witnessed a renewal of interest in public sector ethics issues and

problems. This decade also witnessed the steady blurring of private/public sector lines,

unending bashing of bureaucrats and bureaucracy by the media and American republican

presidents (remember it was Ronald Reagan who quipped, “Washington is not the solution to

our problems; it is the problem”), and a steadily growing belief in the application of private

sector management tools to public sector management problems (quality circles, total quality

management, team building, etc.).

Thus, when the former city manager Ted Gaebler and the management consultant David

Osborne published Reinventing Government in 1992, the stage was set for even more

dramatic change in our thinking about administration and management. The “reinvention”

movement, as it is often called, was galvanized when the Clinton administration assumed

office. In October 1992, the administration released the National Performance Review, a

document that embodied the spirit and soul of reinventing government per Osborne and

Gaebler, by promising to turn the federal government into a government that “works better

and costs less.”

The “new public management” would require men and women who steer organizations—not

row them; empower citizens and coach workers through teamwork and participation; thrive

on and promote competition; reject rule-driven organizations in favor of mission-driven

organizations; seek results, not outcomes; put customers first; foster enterprising and market-

oriented government; and embrace community-owned government. New public managers

(NPMs) are also likely to find the privatization of public goods and services an attractive

alternative and adopt new management tools such as benchmarking, strategic planning,

reengineering, and total quality management as the situation warrants. This new way of

thinking about management casts public managers into the forefront of getting the job done

for Americans in an economical and cost-effective fashion. The era of the administrator who

responds to citizen requests and demands rather than meeting the customer’s needs, fixes

problems when they arise rather than preventing them before they become uncomfortable, and

promotes the public interest per the new public administration or some other value set is over.

The aim of this paper is to describe and clarify the phenomenon of New Public Management

by exploring views of specialists and principles and ideas of the current. Also, one of the main

focuses of this essay is to determin the impact of New Public Management on the Romania

Public Administration.

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2. New Public Management

Management and managerialism have stimulated intense argument and large literatures in

economics, industrial relations, organization and management studies as well as sociology and

political science. It is difficult and dangerous to generalize from such diverse fields, but it is

essential to focus on some defined features of managerialism as a set of beliefs and practices,

and on management as a distinctive social group.

Management as a separate function within the work process emerged with the development of

mass production in industrial capitalism (Clegg and Dunkerley 1980). It is inextricably

connected with the development of bureaucracy and indeed derives its importance from the

need for strategic planning, coordination and control of large and complex decision making

processes (Dandeker, 1990). In modern capitalist enterprises, maximizing profits (or output or

productivity) for owners and shareholders necessitated an exploitative division of labour in

which subordinate workers were expected to comply with subordinates’ demands and

instructions. It also led to the belief that industrial and other work organizations could be

more efficient if responsibility for policy and planning and overall control was separated from

implementation, routine operations and production tasks. Cadres of specialist managers and

systems of surveillance and control were thus established to monitor work flow and quality,

and to discipline the workforce, while other functions were also created (finance, marketing,

corporate management) to plan investment and to assist companies with strategic intelligence

about their products, costumers and competitors. It is this cluster of activities and occupations

that are now labeled “management”.

Reed (1989) has noted that management has been situated as a system of authority, as a set of

skills, and as a social class of selectional interest group. He suggested a generic and

apparently natural working definition in which management is a set of activities and

mechanisms for assembling and regulating productive activity (Reed 1989:ix). But like Clegg

and Dunkerley, he also reminds that management and managers assert the right to determine

resource allocation, to resolve conflict within an organization and to impose ultimate

authority by virtue of heir role and delegated mandate from owners/shareholders.

New Public Management defines a set of broadly similar administrative doctrines which

dominated the public administration reform agenda of most OECD countries from the late

1970s (Hood, 1991; Pollitt, 1993; Ridley, 1996). It captures most of the structural,

organizational and managerial changes taking place in the public services of these countries.

According to Pollitt, New Public Management has variously been defined as a vision, an

ideology or (more prosaically) a bundle of particular management approaches and techniques 5

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(many of them borrowed from the private for-profit sector). New Public Management is thus

seen as a body of managerial thought (Ferlie et al., 1996) or as an ideological thought system

based on ideas generated in the private sector and imported into the public sector (Hood,

1991, 1995). New Public Management shifts the emphasis from traditional public

administration to public management (Lane, 1994). As the title of Clarke and Newman’s

(1997) book, The Managerial State, reflects, New Public Management is pushing the state

toward managerialism. The traditional model of organization and delivery of public services,

based on the principles of bureaucratic hierarchy, planning, centralization, direct control and

self-sufficiency, is apparently being replaced by a market-based public service management

(Stewart and Walsh, 1992; Walsh, 1995; Flynn, 1993), or enterprise culture (Mascarenhas,

1993). A review of the literature suggests that New Public Management is not a homogenous

whole but rather has several, sometimes overlapping, elements representing trends in public

management reforms in OECD countries. Its components and features have been identified by

a number of writers, including Hood (1991, 1995), Dunleavy and Hood (1994), Flynn (1993),

Pollitt (1993;1994) and Summa (1997) and Borins (1994). A clear view about the conceptions

of New Public Management held by some key writers on this subject is presented in the table

below. It is apparent that there are several parallels and overlaps, but also important

differences in the way New Public Management is perceived. It is worth noting, for example,

that Hood’s original conception of New Public Management did not explicitly feature the

issue of consumers’ rights. Another idea is the issue of consumers to prominence and has

since become a key feature of most New Public Management discussions. Osborne and

Gaebler’s approach also contains some important differences in emphasis from the general

New Public Management approach, and especially from the more ideological politics

associated with it. Unlike the ideologically driven New Public Management underpinned by

the public bad, private good, ethos in the United Kingdom (Talbot, 1994), Osborne and

Gaebler assert their belief in government. They also assert that privatization is not the only, or

often the most appropriate, solution and that in some cases, bureaucracies work better (e.g., in

social security). Beyond these differences, there is much in common with the different views

on New Public Management. Following the authors view, we can identify what may be

regarded as the key components of New Public Management. A look at the components

suggests that the ideas and themes may be put in two broad strands. On the one hand there are

ideas and themes that emphasize managerial improvement and organizational restructuring,

i.e., managerialism in the public sector. These clusters of ideas tend to emphasize

management devolution or decentralization within public services. On the other hand are

ideas and themes that emphasize markets and competition. It should be pointed out, however, 6

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that these categories overlap in practice. They should therefore be seen as a continuum

ranging from more managerialism at one end (e.g., decentralization and hands-on professional

management) to more marketization and competition at the other (e.g., contracting out). As

Hood (1991) has noted, the two broad orientations of New Public Management are explained

by the marriage of two different streams of ideas (see also Mellon, 1993). The first stresses

business-type managerialism in the public sector and freedom to manage, and comes from the

tradition of the scientific management movement (Hood, 1991:6-7; Ferlie et al., 1996).

This neo-Taylorist movement (Pollitt, 1993) was driven by the search for efficiency and,

according to Hood: “... generated a set of administrative doctrines based on the ideas of

professional management expertise as portable, paramount over technical expertise, requiring

high discretionary power to achieve results ... and central and indispensable to better

organizational performance, through the development of appropriate cultures ... and the active

measurement and adjustment of organizational outputs” . The proponents of New Public

Management see the Weberian bureaucratic model as rigid, rule-bound, with slow moving

bureaucracies that are costly, inefficient and unresponsive to their users.

In short, New Public Management advocates argue that the dividing line between public and

private sectors will diminish or be blurred and the same good management practices will be

found in both sectors. As Turner and Hulme (1997) have pointed out, the proponents of the

New Public Management paradigm have been successful in marketing its key features

and .persuading potential costumers of its benefits, sometimes backing up their claims with

empirical evidence of substantial savings in public expenditure and improved services. For

adjusting and crisis states the New Public Management prescriptions have tended to be

applied through powerful international donor agencies and the World Bank..

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Conceptions on New Public Management

Hood, 1991;

Dunleavy and

Hood, 1994

Pollitt, 1993

and 1994

Ferlie et al., 1996 Borins, 1994;

Commonwealth,

1996

Osborne and

Gaebler, 1992

hands-on

professional

management

decentralizing

management

authority within

public services

decentralization;

organizational

unbundling; new

forms of

corporate

governance;

move to board

of directors mode

increased

autonomy,

particularly from

central agency

controls

− decentralized

government:

promoting

more flexible,

less

layered forms

of organization

shift to

desegregation of

units into

quasicontractual

or quasi-market

forms

breaking up

traditional

monolithic

bureaucracies

into

separate agencies

split between strategic core and large

operational periphery

catalytic

government:

steering

not rowing

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shift to greater

competition and

mixed provision,

contracting

relationship in the

public sector;

opening up

provider roles to

competition

introducing

market and

quasimarket

type

mechanisms to

foster

competition

elaborate and

develop

quasimarkets

as

mechanisms for

allocating

resources within

the public sector

receptiveness to

competition and

an open-minded

attitude about

which public

activities should

be performed by

the public sector

as opposed to the

private sector

competition

within public

services: may

be intra-public

or

with a variety

of alternative

providers

stress on private

sector styles of

management

practice

clearer separation

between

purchaser

and provider

function

split between

public funding

and independent

service provision

creating synergy

between the

public and private

sectors

driven by

mission not

rules

greater emphasis

on output controls

stress on quality,

responsiveness to

customers

stress on

provider

responsiveness to

consumers;

major concern

with service

quality

providing

highquality

services

that citizens

value; service

users as

customers

customer-

driven

explicit standards

and measures of

performance

performance

targets for

managers

more transparent

methods to

review

performance

organizations and

individuals

measured and

rewarded on the

performance

targets met

result-oriented

government:

funding outputs

not inputs

stress on greater

discipline and

parsimony in

resource use;

reworking

budgets to be

transparent in

accounting terms

capping/fixed

budgets

strong concern

with value-

formoney

and

efficiency gains

provision of

human and

technological

resources that

managers need to

meet their

performance

targets

enterprising

government:

earning

not spending

changing

employment

relations

downsizing

market-oriented government: leveraging change through the

market

deregulation of the labour market anticipatory government: prevention rather than cure

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Characteristics of New Public Management:

Gaebler and Osborne have listed ten features of New Public Management: 

1. Catalytic Role of Government. The government should perform a catalytic role or a

steering mechanism for various service providers, such as public sector, private sector

and various non-governmental organizations.

2. Empowerment of Citizens. The government should promote and facilitate

empowerment of citizens and communities so that they can solve their own problems.

3. Efficiency and Economy in performance. The performance of public sector agencies

should be cost effective. Thus agencies should concentrate on their outcomes.

4. Emphasis on goals rather than Rules. The new public management perspective pleads

for a goal-oriented administration. The approach of the administration should not be

towards over-emphasis on rules and regulations.

5. Customer-oriented government. The New Public Management perspective defines

clients as customers and pleads for offering those choices, making services convenient

and seeking their suggestions for the improvement of services.

6. Competitive Government. The government should promote competitive environment

among different service providers both public and private which could bring about

efficiency and economy.

7. Anticipatory Approach. It signifies that the government should anticipate the problems

beforehand and prevent them rather than devising cures after the problem have

complicated.

8. Enterprising Government. The New Public Management perspective suggests that

government should focus on earning and saving money rather than on spending. The

monetary resources can be mobilized through saving, user charges, enterprise funds

etc.

9. Decentralization of Authority. The authoritative structures of the government should

be decentralized in order to get rid of negative consequences of hierarchy. The

decentralized authority should promote participatory management and team work.

10. Emphasis on Market Mechanism-Influenced by neo-liberal Philosophy and public

choice approach, the New Public Management perspective pleads for the adoption of

Market Mechanism rather than bureaucratic Mechanism.

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The above ten features of the New Public Management perspective find place in the Al Gore

Report of the National performance Review 1993 in the U.S.

Summarized, the core characteristics of the New Public Management perspective include

emphasis on productivity and cost-effectiveness in public services, adoption of market

strategies by public sector, customer-orientation, decentralization of authoritative structures,

and making a distinction between a policy and its execution. 

The practical implications of these principles are: emphasis on managerial skills in policy

making, adoption of suitable management practices, autonomy and decentralization of public

sector, setting standards for measurement of performance, preference for private ownership

deregulation and promoting competition, contracting out appropriate government services,

responsive and effective public service delivery etc

Christopher Hood (1991) provided in his article, A Public Management for All Seasons, a list

of the main doctrines of the New Public Management:

1. Hands-on professional management of public organizations, i.e., managers are provided

extreme autonomy to manage their organizations. This is expected to contribute to sufficient

accountable administration.

2. Explicit standards and measures of performance, i.e., goals are well defined and

performance targets set (later defined as performance indicators). This is also expected to

enhance efficiency and ensure accountability.

3. Greater emphasis on output controls, i.e., resources are directed to areas according to

measured performance, because of the need to stress results rather than procedures.

4. Shift to desegregation of units in public sector, i.e., breaking up large corporative units

around products, funded separately and dealing with one another on an arms length basis.

5. Shift to a greater competition in public sector, i.e., move to term contracts and public

tendering procedures, as rivalry is always the key to lower costs and better standards.

6. Stress on private-sector styles on management practice, i.e., military style bureaucracy is

discarded. There should be more flexibility in hiring and rewards.

7. Stress on greater discipline and parsimony in public sector resource use, which means

cutting direct costs, raising labour discipline, resisting union demands and limiting

compliance costs to business.

Osborne and Gaebler (1992), in their book Reinventing Government: How the

Entrepreneurial Spirit is Transforming the Public Sector, have also described the main 11

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principles behind the New Public Management theory. They had put forward the following

principles for reinventing the government:

1. Catalytic government: steering rather than rowing;

2. Community-owned government: empowering rather than serving;

3. Competitive government: injecting competition in service delivery

4. Mission-driven government: transforming rule-driven organizations;

5. Results-oriented government: funding outcomes, not inputs;

6. Customer-driven government: meeting the needs of the customer, not the

bureaucracy;

7. Enterprising government: earning rather than spending;

8. Anticipatory government: prevention rather than cure;

9. Decentralized government: from hierarchy to participation and teamwork.

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Part made by Madalina Gogu

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3. New public management in health care

3.1. General problems with new public management

There exists massive critical studies and literature on new public management. Especially, the

aspect of implementing performance measures, which is criticised for ignoring social relations

and not understanding social behaviours resulting in lack of motivation among employees.

The reason is that public management as an integrated management tool is static and uniform

and thereby lacks to differentiate between people but rather categorise them in an

inappropriate manner. Moreover, it ignores the fact that public employees are not trained in

the economic discursive way of thinking, which several aspects of new public management

assumes. One particular outcome of this decoupling is that they generate lists of strategies and

goals as if they are independent of each other and they have a tendency of selecting measures

before they decide how to use them. Moreover, the implementation of new public

management in health institutions has given a large increase in administrative work and is a

massive obstacle for the employees. Frequently, performance measurements are assumed to

measure predictable links, causes However, human beings can act powerfully and

unintentionally. This is one reason why economic development and outcome of planned

social interventions can end up being powerful compositions of control, which may never

have been intended. The conclusion is that financial and non-financial measures ignore

organizational behaviour theories, which creates different conflicts when implementing new

public management. One of the larger conflicts is that of the profession.

3.2. Physicians professions

Adding to the lack of understanding employee relations is the fact that within health care there

are strong professions such as physicians. This strong profession tend to resist changes when

being challenged. In restructuring health sectors in several European countries physicians are

being highly challenged since there has been a power switch away from physicians to

administration. The physicians professions and basic assumptions about their purpose are

being highly opposed by this restructuring, since within public management their basic

purpose of functioning as physician is ignored. Physicians basic assumptions of their

professions are qualitative results rather than quantitative results. Moving the focus from

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quality to financial performance the basic philosophy and purpose of physicians are

challenged greatly, since quantitative measures are not the physician’s basic objective.

Moreover, collective rewards, within a health care sector, contribute far more to the learning

organisation than financial rewards. This is because people working with social outcomes

have complete different basic assumptions than the usual private sector, which focuses largely

on competition, changing environments and financial outcomes. This is not the case in health

institutions. Several studies have shown that physicians would like and need more stability,

less administration and close contacts to patient and colleagues which are in conflict with

implementing new models and specifically performance measurements and earned autonomy.

Therefore to be able to still fulfill their core duties and basic professional assumptions,

physicians tend to only adopt public management because of obligation and legitimatization.

In other words, to keep the pressure at a distance, so they can focus on their prime duties. One

of the major consequences of this is manipulation of numbers.

Overall, the literature show large conflicting issues around new public management and the

profession. However issues around other stakeholders such as the administration and patients

seem to be lacking. This suggests an increasing need to understand the complex setting and

the effects of new public management tools within these particular stakeholders, both

profession, administration and patients, in health care.

4. New Public Management in Health system in Romania

4.1. Health and statistics

Romania has gone through a period of rapid and major change in every sector since the

revolution of 1989.

Demographic trends since 1989 show continual population decline: the population declined

by 5% between 1992 and 2006, from 22.81 million inhabitants to 21.58 million. The

reduction was caused by emigration, a fall in the birth rate and a rise in mortality. Health

status in Romania is poor compared with the other European countries. The average life

expectancy in Romania was 72.7 years in 2006 (69.2 years for men and 76.2 years for

women), six years shorter than the European Union (EU) average (78.5 years in 2005) and

seven years shorter than the average for the EU Member States prior to May 2004 (79.7 years

in 2005). Infant and maternal mortalities are among the highest in the European Region

despite a large decline in maternal mortality since 1990.

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In 2006, there were 13.91 infant deaths per 100 000 live births, and 15.49 maternal deaths per

100 000 live births. Overall, in Romania, the most important causes of death are

cardiovascular diseases (62.1% of all deaths in 2006), cancer (17.6%), digestive diseases

(5.5%), accidents, injuries and poisoning (4.9%) and respiratory diseases (4.9%). Romania

has one of the highest levels of cardiovascular disease in the European Region.

For four decades, from 1949 to 1989, Romania had a Semashko health system. Major reforms

began in 1989 and by 1998 the centralized, tax-based system had been transformed into a

decentralized and pluralistic social health insurance system with contractual relationships

between purchasers, the health insurance funds and health care providers. The Health

Insurance Law issued in 1997 has already been modified several times, being continuously

adapted to the changing political, social and economic context. The current reforms are

focused mainly on the continuation of the decentralization process, the focus on prevention

and primary health care, the enhancement of the provision of a minimum package of services

through more effective emergency services, the development of the private sector and the

establishment of clear relations between the systems of health and social care. These

directions of reform have been facilitated by the introduction of the Health Reform Law in

May 2006.

Following the implementation of mandatory social health insurance in 1998, the roles of the

main actors in the health system have changed. The Ministry of Public Health no longer has

direct control over the financing of a large part of the network of providers. Its main

responsibilities consist of developing national health policy, regulating the health sector,

setting organizational and functional standards, and improving public health. The

representative bodies of the Ministry of Public Health at the district level are the 42 district

public health authorities (DPHAs). The health insurance system is administrated and

regulated by the National Health Insurance Fund (NHIF), a central quasi- autonomous body.

At district level there are 42 District Health Insurance Funds (DHIFs) responsible for

contracting services from public and private providers. There are also two countrywide

insurance funds established in 2002, one belonging to the Ministry of Transport and the other

to the Ministries of Defence, Justice and Interior and the agencies related to national security.

Between 1999 and 2002, the DHIFs were responsible for raising social health insurance

contributions locally from employers and employees working in the respective district. They

retained and used 75% of collected funds, 25% being sent to the NHIF for redistribution.

Since 2002, the contributions have been collected at the national level by a special body under

the Ministry of Finance (the Fiscal Administration National Agency), and DHIFs have raised

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contributions only from insured persons paying the whole contribution (such as the self-

employed).

4.2. Institutions

4.2.1. Ministry of Public Health

The Ministry of Public Health is the state’s institution responsible for ensuring the health of

the nation. It does so through the definition of policies and strategies, and planning,

coordinating and evaluating outcomes. Since 1 January 1999, the Ministry of Public Health

ceased to have direct control over the financing of a large part of its network of service

providers. Responsibilities consist of:

• Stewardship role in engaging main stakeholders in different types and different stages of

health policies and strategies formulation, implementation and evaluation;

• Defining and improving the legal environment in the context of wide public circulation that

includes views of stakeholders and of patients;

• Ensuring increased transparency in managing the state’s budgetary allocation for health. The

Ministry of Public Health retains responsibility for financing and managing the national

public health programs, selected specialty services and investments in buildings and high-

technology medical equipment.

• Regulating both the public and the private health sectors, and their interface.

• Ensuring leadership in conducting research and developing policy and planning in relation

to developing reform policies and monitoring their impact; monitoring the impact of financing

reforms; monitoring the need to upgrade buildings, major repairs and high-technology

medical equipment; and monitoring the emergence of the private health sector;

• Defining and improving the legal and regulatory framework for the health care system. This

includes regulation of the pharmaceutical sector as well as public health policies and services,

the sanitary inspection and the framework contract.

• Developing a coherent human resources policy and for building capacity for policy analysis

and management of the health care system.

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4.2.2. National Health Insurance Fund

The NHIF is an autonomous public institution that administrates and regulates the social

health insurance system. Between 2002 and 2005, the NHIF was under the coordination of the

Ministry of Public Health. In 2005, the NHIF regained its independent status and is currently

mainly responsible for:

• developing the strategy of the social health insurance system;

• coordinating and supervising the activity of the DHIFs;

• elaborating the framework contract, which together with the accompanying norms sets up

the benefit package to which the insured are entitled, and the provider payment mechanisms;

• deciding on the resource allocation to the DHIFs;

• deciding on the resources allotted between types of care.

The NHIF has the authority to issue implementing regulations mandatory to all DHIFs in

order to insure coherence of the health insurance system.

According to the initial Health Insurance Law, the leadership of the NHIF was meant to be

established through national election. However, a 2002 government ordinance decided that

the Council of Administration of the NHIF should be appointed differently. At present,

according to the Health Reform Law (95/2006), the Council of Administration consists of 17

members with the following composition:

• five representatives of the government: one each appointed by the Minister of Public Health,

the Minister of Labour, Social Solidarity and Family, the Minister of Public Finances, the

Minister of Justice and the Romanian President;

• five representatives of trade unions;

• five representatives of employers’ associations;

• two members appointed by the prime minister upon consultation with the National Council

of the Elderly.

The president of the NHIF is appointed by the prime minister. The Council of Administration

has two vice-presidents, elected by Council members.

4.2.3. Professional associations and trade unions

The College of Physicians. The CoPh is responsible for regulating the medical profession. It

has a national structure – the Romanian College of Physicians – and local, independent

organizations at district level. Membership is mandatory for all Romanian physicians. The

boards, both at national and district level, are elected every four years. The CoPh has 18

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important and extended responsibilities in all areas of concern for physicians, including

training and accreditation. In order to have the right to practise, all physicians should be

registered with the district CoPh and pay a membership fee. Newly established medical

practices should also be approved at the district level of the CoPh, in accordance with a set of

criteria issued by the national level of CoPh. Legislation was passed in 1995 to establish the

CoPh. Elections were held for this body but were confirmed by the government only after the

1996 election. The CoPh started to function in 1997. The CoPh is the organization where

doctors must compulsorily register, as provided by the 1995 law. The CoPh originally had

important and extended responsibilities in all areas of concern for physicians. This involved

most fields of the health care sector, including the health insurance system, where the CoPh

was involved in negotiating the framework contract that forms the basis for all individual

contracts between DHIFs and providers. By virtue of this, the CoPh had an influence on the

contents of the benefits package for the insured population, the type of reimbursement

mechanisms in place for health service providers, and what drugs are compensated and in

what proportion. After the change of government following the 2000 elections, new

legislation initiated by the Ministry of Public Health considerably reduced the powers of the

CoPh in areas related to health policy; consequently, the CoPh currently has only a

consultative role in the majority of the health policy decisions in which it was previously

involved. (Section 7.3 has more information on the role of the CoPh in recent reforms.)

4.2.4. Federative Chamber of Physicians

The trade union of doctors is the Federative Chamber of Physicians. It is struggling to keep its

traditional trade union role in face of the trade union role assumed by the CoPh.

4.2.5. The Romanian Medical Association and the Society of General Practitioners

The Romanian Medical Association is the successor of the single professional association that

existed before 1989 during the communist regime. Today, the association has limited its

activities to scientific concerns, professional issues being dealt by the CoPh. The Society of

General Practitioners (GPs) was established initially as a purely scientific society. However,

gradually it has started to be involved also in matters of the profession, since GPs felt that the

CoPh does not deal properly enough with their profession, the management being dominated

by specialist physicians coming mainly from hospitals.

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4.2.6. The College of Pharmacists

This is the national association with which all pharmacists should register as provided by

specific legislation; its influence has decreased in the last two years as the government

enacted legislation that diminished its powers. However, they remain in a strong position in

influencing the number of pharmacies as they issue the legal agreement for each new

pharmacy. As with the CoPh, the organizational settings apply to the profession at national as

well as district levels.

4.2.7. The Order of Nurses and Midwives

This is the most recent established professional association based on Law 307/2004 and is the

professional organization where nurses and midwifes have to register prior to getting

permission to practise their profession. Like the other professional associations, it is organized

at district and national level. Its main role is to control and monitor the way in which nursing

and midwifery is practised in Romania and to influence and contribute to the policies

regarding these two professions. To date, its influence has been limited to the harmonization

with EU requirements of professional training in both professions.

4.2.8. Association of Nurses

There is also an Association of Nurses, a professional association that is promoting a change

of culture in the profession, developing training programmes and projects for change, but this

organization has little influence on the broader decision-making process.

4.2.9. Sanitas

The trade union for nurses is Sanitas. It plays the traditional role of a trade union and is more

influential in promoting nurses’ interests as part of a strong national trade union, whose leader

is currently a former Romanian President.

4.2.10. Health care providers

The majority of health care providers are no longer public servants and state employed; rather

they are paid through different contractual arrangements by the DHIFs. Primary care 20

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physicians are known as “family doctors”, having been assigned the new role of private

practitioner. They are paid by a mix of capitation and fee for service. For specialist care from

ambulatory facilities, the former polyclinics have been turned into independent medical

facilities. Specialists working in ambulatory care are paid by fee for service. Hospitals receive

prospective payments consisting of a mix of payment methods. Payment for medical

personnel working in hospitals is still based on salary, but the hospital boards can fix salaries

according to individual competency and workload (within some limits set by financial

regulation).

Most hospitals are (still) under public ownership, with very few initiatives of private practice.

The Romanian Hospital Association is the association of hospital managers.

It has grown in the last few years, mainly owing to the financial pressures on hospitals and the

consequent need of managers to interact, but it has little influence in the decision-making

process. However, hospital directors as individuals have played an important role in

influencing the health policy process, managing to preserve the hospital system almost

unchanged since 1989.

5. Information and communication technology as a part of New Public Management in the

Health system in Romania

5.1. Information for patients

Within a 2002 project financed by PHARE, the NHIF together with the Ministry of Public

Health, the national CoPh and the Centre for Health Policies and Services (Centrul pentru

Politici si Servicii de Sanatate) issued The insured chart (Centre for Health Policies and

Services, 2002). This contains basic information about social health insurance system

organization and functioning, health service providers, the terms under which the insured can

benefit from health services, a list of services that are not covered by social health insurance

and contact details of each DHIF where patients can address further questions and complaints.

The Law on Health Reform issued in 2006 introduced a contractual relationship between the

insured and the health insurance fund, outlining the rights and obligations of both parts.

5.2. Information systems

Since the profound political changes of the 1990s, the health care system and the health

insurance system have moved through a series of successive reforms. The Government of 21

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Romania Ordinance 53/2000 on obligatory disease reporting and vaccination stipulates that

physicians, both public and private, are obligated to report all communicable and some

noncommunicable diseases in conformity with the methodological norms of the Ministry of

Public Health.

While physicians in the public sector comply with this reporting system, private physicians do

not. The data flows from the private sector are not yet clearly defined.

The principles stipulated in health information legislation can be summarized as follows: state

institutions are responsible for the collection, storage and analysis of data on health

determinants with the objective of creating a national database; they define and ensure the

information flow and guarantee and protect the fundamental rights of individuals and the

security of data; they make existent data and information accessible to decision-makers.

Progress towards these objectives is currently underway.

Various changes are still ongoing, which deeply influence the structure and functioning of the

health information system. At present the system is struggling to keep up with decreasing

staff and increasing requests for data and information.

Information systems are not coordinated across hospitals, and patient medical records do not

follow the patients.

Access to information held by the National Centre for Health Statistics is regulated by an

Order of the Minister of Public Health from 2002 “on pricing the services for a fee charged by

the National Centre for Health Statistics upon request from both individual and juridical

bodies”. This order contains the list and prices of all services that can be delivered. The order

does not specify whether the fees apply to all requesters from within and outside the health

system, or whether they apply to all types of statistical information or only to the data that

imply more sophisticated statistical processing.

At all levels, the Romanian health information system suffers from a shortage of qualified

professionals. Recruiting and retaining skilled specialists is difficult because of the

unattractive remuneration and the overburdening of professionals with repetitive tasks. This

results in a loss of motivation and interest in the work. The lack of purpose for data collection,

in conjunction with the lack of feedback, leads to poor data quality. The health information

system relies heavily on data provided by primary care providers, who are especially at risk of

losing interest: the large share of their time dedicated to filling forms distracts them from their

main responsibility of patient care.

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6. eHealth strategies

In Romania the Health Reform Law 95/2006 established the re-organisation of healthcare.

The law requires the Ministry of Health to create an integrated information system for public

health management. Requirements are expressed for information on communicable diseases,

emergency care, community assistance, hospital information, health insurance cards etc. In its

Strategic Plan for 2008-2010, the Ministry of Health (MoH) implements these requirements.

Several “eHealth strategies” have been proposed by MoH workgroups or independent experts,

all of which took into account the main provisions of the EU eHealth Action Plan (2004),

none of these have yet been officially adopted.

In order to consider Romania’s position regarding eHealth interoperability objectives the

following eHealth applications have been examined: patient summaries and electronic health

records, ePrescription and telemedicine. In overview Romania’s situation is as follows:

An EHR project was launched in 2009 by the MoH, in the frame of an ICT Policy Support

Program, but the realisation of the project was suspended due to overrun deadlines and issues

with solving technical demands. In 2010 the National Health Insurance House (NHIH)

announced the intention to realise, by the end of 2011, a national EHR project, in connection

with its Unique Integrated Information System (SIUI) system. The Health Reform Law

foresees that the National Health Insurance Card will be used to access electronic health

records and will contain a kind of patient summary.

Until now, ePrescription services in Romanian have been concentrated on computerised

procedures for prescriptions (e.g. transmission of prescriptions) which have been used mainly

in hospitals, between physicians and internal pharmacies. In 2010 NHIH announced the

intention to realise by the end of 2011 a national ePrescription project, in connection with its

SIUI system. NHIH has the support of the Ministry of Communications and Information

Society for this project.

6.1. Motivation of the eHealth Strategies study

The 2004 eHealth1 Action Plan required the Commission to regularly monitor the state of the

art in deployment of eHealth, the progress made in agreeing on and updating national eHealth

Roadmaps, and to facilitate the exchange of good practices. Furthermore, in December 2006

1 European Commission 2004

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the EU Competitiveness Council agreed to launch the Lead Market Initiative 2 as a new policy

approach aiming at the creation of markets with high economic and social value, in which

European companies could develop a globally leading role.

Following this impetus, the Roadmap for implementation of the “eHealth Task Force Lead

Market Initiative” also identified better coordination and exchange of good practices in

eHealth as a way to reduce market fragmentation and lack of interoperability.

On the more specific aspects of electronic health record (EHR) systems, the recent EC

Recommendation on cross-border interoperability of electronic health record systems 3 notes

under “Monitoring and Evaluation”, that “in order to ensure monitoring and evaluation of

cross-border interoperability of electronic health record systems, Member States should:

consider the possibilities for setting up a monitoring observatory for interoperability of

electronic health record systems in the Community to monitor, benchmark and assess

progress on technical and semantic interoperability for successful implementation of

electronic health record systems.” The present study certainly is a contribution to monitoring

the progress made in establishing national/regional HER systems in Member States. It also

provides analytical information and support to current efforts by the European Large Scale

Pilot (LSP) on cross-border Patient Summary and ePrescription services, the epSOS -

European patients Smart Open Services - project.4

With the involvement of almost all Member States, its goal is to define and implement a

European wide standard for such applications at the interface between national health

systems.

Earlier, in line with the requirement to “regularly monitor the state of the art in deployment

of eHealth”, the EC already funded a first project to map national eHealth strategies – the

eHealth ERA "Towards the establishment of a European eHealth Research Area" (FP6

Coordination Action)5 - and a project on "Good eHealth: Study on the exchange of good

practices in eHealth"6 mapping good practices in Europe - both of which provided valuable

input to the present eHealth Strategies work and its reports. Member States’ representatives

and eHealth stakeholders, e.g. in the context of the i2010 Subgroup on eHealth and the annual

European High Level eHealth Conferences have underlined the importance of this work and

the need to maintain it updated to continue to benefit from it.

2 European Commission 20073 European Commission 20084 European Patients Smart and Open Services (epSOS)5 eHealth Priorities and Strategies in European Countries 20076 European Commission; Information Society and Media Directorate-General 2009

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This country report on Romania summarises main findings and an assessment of progress

made towards realising key objectives of the eHealth Action Plan. It presents lessons learned

from the national eHealth program, planning and implementation efforts and provides an

outlook on future developments.

6.2. Survey methodology

After developing an overall conceptual approach and establishing a comprehensive analytical

framework, national level information was collected through a long-standing Europe-wide

network of national correspondents commanding an impressive experience in such work. In

addition, a handbook containing definitions of key concepts was distributed among the

correspondents to guarantee a certain consistency in reporting.

The key tool to collect this information from the correspondents was an online survey

template containing six main sections:

A. National eHealth Strategy

B. eHealth Implementations

C. Legal and Regulatory Facilitators

D. Administrative and Process Support

E. Financing and Reimbursement Issues

F. Evaluation

Under each section, specific questions were formulated and combined with free text fields

and drop-down menus. The drop-down menus were designed to capture dates and stages of

development (planning/implementation/routine operation). In addition, dropdown menus were

designed to limit the number of possible answering options, for example with regard to

specific telemedicine services or issues included in a strategy document. The overall purpose

was to assure as much consistency as reasonably possible when comparing developments in

different countries, in spite of the well-know disparity of European national and regional

health system structures and services.

Under Section B on eHealth implementation, questions regarding the following applications

were formulated: existence and deployment of patient and healthcare provider identifiers,

eCards, patient summary, ePrescription, standards as well as telemonitoring and telecare.

The data and information gathering followed a multi-stage approach. In order to create a

baseline for the progress assessment, the empirica team filled in those parts of the respective

questions dealing with the state of affairs about 3 to 4 years ago, thereby drawing on data

from earlier eHealth ERA reports, case studies, etc. to the extent meaningfully possible. In the 25

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next step, national correspondents respectively partners from the study team filled in the

template on recent developments in the healthcare sector of the corresponding country. These

results were checked, further improved and validated by independent experts whenever

possible.

Progress of eHealth in Romania is described in chapter 3 of this report in the respective

thematic subsections. The graphical illustrations presented there deliberately focus on key

items on the progress timeline and cannot reflect all activities undertaken.

This report was subjected to both an internal and an external quality review process.

Nevertheless, the document may not fully reflect the real situation and the analysis may not be

exhaustive due to focusing on European policy priorities as well as due to limited study

resources, and the consequent need for preferentially describing certain activities over others.

Also, the views of those who helped to collect, interpret and validate contents may have had

an impact.

6.3. ICT use of general practitioners

In terms of infrastructure, 66% of the Romanian GP practices use a computer. However, only

about half of those practices with a computer are connected to the Internet as well.

In Romania, broadband connections have not yet arrived; they are used in only 5% of GP

practices.

Romania displays its best eHealth performance in the area of patient data storage and the use

of a computer for consultation purposes. Half of Romanian practices register administrative

patient data and about one-third of GP practices store at least one type of medical electronic

patient data.

In Romania, computers are used in consultation with the patients by 22% of GP practices. The

use of Decision Support Systems (DSS) is also rather the exception than the rule. They are

used for diagnosis or prescribing purposes in only 11% of Romanian GP practices.

The electronic transfer of individual patient data has not yet arrived on the agenda of

Romanian GPs. Only 6% of Romanian GP practices exchange medical data with other carers

and only around 2% of the practices transfer administrative patient data to reimbursers via

networked connections. The exchange of medical data via networked connections is equally

little established: only 2% of the GP practices participating in the survey reported having

exchanged medical data with other care providers while 4% received results from laboratories

this way.

None of the GPs who participated in the survey for Romania reported using ePrescribing.26

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The rather low level of eHealth use in Romania can be attributed to the fact that this policy

field is relatively new in Romania. A first and very basic eHealth strategy was only drafted as

late as 2005.

In addition to the study results, and before entering into the core of the survey, the following

eHealth projects should be mentioned to illustrate the overall situation in Romania:

In the 70s and 80s of last century, hundreds of IT applications were realised in Romanian

healthcare. With few exceptions, they were isolated, local achievements, mainly for research

purposes. Starting in the late eighties several, mainly administrative, hospital information

systems were implemented. In the 90s, a boom of PC oriented commercial eHealth

applications occurred, developed mainly by local private companies.

As of 2010 all public hospitals (427) and all family doctors (over 11500) have a minimal IT

endowment. A survey conducted in 20087 showed that 411 public hospitals subordinated to

the Ministry of Health had an average of around 8 hospital beds per computer, half of them

used in clinical and pre-clinical fields. Also, the reporting of all hospitals, medical offices, and

pharmacies to the National Health Insurance House (NHIH)8, for reimbursement of services

and products, is completely computerised. Not all reporting is done through the network, CDs

and memory sticks are being used too.

The most important eHealth project in Romania in recent years, started in 2003 and still in

progress, is the Unique Integrated Information System (SIUI) of Social Health 17 The notion

of „compound indicator“ designates an indicator build from a set of other indicators/survey

questions regarding the same topic. The compound indicator reflects an average calculated

from different values. (see Annex) The final results of the study on eHealth Indicators is

available at www.ehealth-indicators.eu.

6.4. Current strategy

In Romania the Health Reform Law 95/200624 establishes the organisation of healthcare,

institutions, financing, organisation of health insurance, personnel (doctors, dentists,

pharmacists etc.), their responsibilities and official organisations etc. The law thus continues

the transformation of the Romanian from a state financed model to an insurance based

healthcare system as started by the Health Insurance Law in 1997. The law requires the

Ministry of Health to establish an integrated information system for public health

7 Dr. mat. Dan D. Farcaş and Progr. Eugenia Crăciunescu 20098 in Romanian: Casa Nationala de Asigurari e Sanatate (CNAS)

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management. Requirements are expressed for information on communicable diseases,

emergency care, community assistance, hospital information, health insurance cards etc.

In its Strategic Plan for 2008-20109, the Ministry of Health (MoH)10 implements these

requirements underlining in particular the necessity of a new integrated health services

information system, including patient monitoring and registries for non-communicable

diseases. However, this was not followed by an official eHealth strategy or formal eHealth

national roadmap. There is also no legislative act to enforce an eHealth strategy and no

organisation to monitor compliance with such a strategy.

Several eHealth strategies were proposed in the last 20 years by MoH workgroups or

independent experts11. After 2000 they were made in cooperation with the Ministry of

Communications and Information Society12 (MCIS, responsible for a greater eGovernment

project named eRomania13.

6.5. eHealth strategy

Even though this strategy was used in some projects, it was not endorsed by the Ministry of

Health as an official document (in December 2008 the Minister of Health and his top staff

were replaced due to the change in Government after elections). In 2009 another National

eHealth Strategy for Romania was worked out by a private company, as a result of a project

funded in the framework of the European program “Phare” at the Ministry of Health. This

strategy has also not been endorsed.

But in May 2010 the MoH took the initiative to organise a new working group to realise a

national information strategy for the healthcare system. This group has not met to date.

As the country still has a tightly centralised government system, no regional eHealth

strategies were considered in Romania.

A “Feasibility study for the implementation of an Integrated Health Information System”, was

realised for MoH, in 2009, by a local company through a dedicated project14. They worked in

close consultation with the main Romanian eHealth stakeholders, but the study has remained

until now only a paper. The main objective of the new information system proposed ought to

be: the integration of the main Romanian health information systems, the inclusion of the

9 Ministerului Sanatatii [Ministry of Health]10 Ministerul Sanatatii [Ministry of Health] 201011 Phare Project: RO 97/12/L002: Reform of Health Sector Financing in Romania – Information Strategy Framework – 200212 Ministerul Comunicaţiilor şi Societăţii Informaţionale [Ministry of Communications and Information Society] 200913 2Ministerul Comunicaţiilor şi Societăţii Informaţionale[Ministry of Communications and Information Society] 200914 Media Net Design- ClubAfaceri 2006

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existing solutions, a citizen focused approach towards public health and a patient-focused

approach for curative medicine. European interoperability was considered also important.

Besides the MoH, strategic eHealth documents were initiated by some other national

institutions too, such as: The National Health Insuring House (NHIH)15, and College of

Physicians16. But these organisations do not have all encompassing competence regarding

Romanian healthcare issues and the solutions proposed were not endorsed by the MoH.

All eHealth strategies proposed took into account the main provisions of the EU eHealth

Action Plan (2004)17. They emphasised the necessity of a single computerised information

system, organised around a cluster of national databases (population, healthcare units,

healthcare professionals, drugs, coding, standards etc.). This central cluster would be used by

the information systems of MoH, healthcare units, health insurance, professional

organisations etc., avoiding double data gathering, and facilitating interoperability with other

information systems, as well as diversity of technical solutions.

In the absence of agreed strategies for Romania, the issues which should have been included

had an erratic trend. Several endowments of IT equipment (hospitals, family doctors) were

made by individual projects, without a strategic vision, without evaluating the real needs and

without taking into account other projects in progress. Publicly funded projects for specific

applications (hospital management, health records, ePrescription etc.) have been launched,

sometimes in parallel by different public bodies, without taking into account any existing

applications and disregarding each other. Only essential coding (e.g. ICD-10 or the ID code

for the population) was commonly used as standards. An attempt of several companies to use

HL7 for data exchange arrived only at the level of a private initiative in progress.

Although there were proposals, no initiative was taken in this direction.

6.6. Administrative and organisational structure

Currently Romania has not a clearly appointed authority to coordinate the national eHealth

policy and to be a technical partner of the European Commission for common targets, as, for

example, eHealth interoperability.

The Ministry of Health is the only institution connecting together all health related activities

of the country. But MoH had in the recent years a limited and more administrative interest in

eHealth, following some IT projects. The driving force behind the implementation of eHealth

15 National Health Insurance House (NHIH) – Casa Nationala de Asigurari e Sanatate (CNAS) 201016 Colegiul Medicilor din Romania [College of Physicians in Romania] 200817 Commission of the European Communities 2004

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applications and concepts has really been the IT community rather than MoH. Of the four

ministers in the last three years, none have had any discussion with IT professionals

subordinated to MoH about issues of eHealth, even less about eHealth strategy. For some

periods of time, one of the advisers of the minister was in charge of the IT projects in

progress. In response to requests to attend eHealth initiatives issued by European Authorities,

the MoH used to send randomly selected persons, who were unable to ensure continuity of

commitments. For example, in August 2007 the Minister of Health signed, on behalf of

Romania, the “Letter of Intent” for the participation in the eHealth Initiative for initiating the

preparation of a successful proposal for a Large Scale Pilot on interoperability, without being

followed by deeds. The frequent changes of MoH officials are a partial explanation for the

situation.

The Ministry of Health, during the last 20 years, had an office including IT (with 1-3 IT

professionals). It is now the “Service for patrimony and informatics”18 but it’s IT activities

used to be oriented mainly toward servicing internal IT issues of the MoH. Lately this office

has taken some initiatives towards national eHealth (organising some representative eHealth

committees) but this activity is still inconclusive.

The main eHealth competence centre in Romania was, between 1970 and 2006, the Centrul de

Calcul si Statistica Sanitara (Centre for Health Computing and Statistics – CHCS),

subordinated to the MoH. It had the great advantage of being a stable structure of IT

professionals, not influenced by government changes. CHCS was also responsible for the

health coding and health statistics for Romania. Starting in 1972 CHCS realised national

electronic databases (healthcare organisations, healthcare professionals, endowment, registers

of chronically ill persons etc.) and coordinated Romanian healthcare IT policy. After 1995,

with the reform and decentralisation of the Romanian health system, the IT function

diminished and the number of (underpaid) IT employees was gradually reduced.

In 2006 CHCS was restructured as the “National Centre for Organizing and Ensuring the

Health Information System”19(NCOEHIS - “Centrul Naţional pentru Organizarea şi

Asigurarea Sistemului Informaţional şi Informatic în Domeniul Sănătăţii”) with the same

attributes. In NCOEHIS there are several IT departments, including a small Office for eHealth

Strategies and Projects, involved in all strategies exposed above, and another small office for

eHealth research and standardisation. Therefore NCOEHIS could be a permanent focal point

to gather stakeholders to develop a strategy agreed by all and to ensure the technical body to

evaluate and approve the correspondence of the publicly funded eHealth projects proposed

18 Ministerul Sănătăţii [Ministry of Health] 201019 National Centre for Organizing and Ensuring the Health Information System 2009

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and the eHealth strategy. Also NCOEHIS could ensure the connection with the EU eHealth

technical bodies.

Due to budgetary restrictions on July 1st, 2010, the NCOEHIS was abolished as an

organisation with legal personality. The activity of the NCOEHIS was acquired by absorption,

by the National Institute of Public Health20. Also MoH is expected to ask that the little

existing staff of NCOEHIS be further reduced. This is in spite of the need for a central body

to support the development of eHealth strategies, and to certify the spending of public money

only for projects coherent with this strategy, and although NCOEHIS was the only IT unit

subordinated to the MoH and with national vocation.

Due to lack of authority within eHealth strategies and projects for public funding described

above, in the last decade in Romania different actors launched their own health information

systems, creating “parallel” coding, data gathering, circuits and files leading to waste of the

scarce resources, inconsistencies and interoperability problems. These actors also organised

their own, small eHealth competence centers. One example is the National Health Insurance

House (NHIH)21. In Romania there are several health insurance companies both in the public

(Army, Justice, Railways etc.) and private sector, but because NHIH covers the majority of

the population it now claims the right to control IT projects (EHR, ePrescription, health cards)

for the entire population of the country.

Another small but active competence centre belongs to the College of Physicians22.

6.7. ePrescription

In the framework of this study and following work in epSOS23, ePrescription is understood

as the process of the electronic transfer of a prescription by a healthcare provider to a

pharmacy for retrieval of the drug by the patient. In this strict sense, only few European

countries can claim to have implemented a fully operational ePrescription service.

In Romania, the competent authorities in the field of medical products for human use are the

Ministry of Health and the National Medicines Agency (NMA)24. The Health Reform Law

95/200625 establishes how the prescriptions are made. The Social Health Insurance Houses

20 MINISTERUL SĂNĂTĂŢII [Health Ministry] 201021 National Health Insurance House (NHIH) – Casa Nationala de Asigurari e Sanatate (CNAS) 201022 Colegiul Medicilor din Romania [College of Physicians in Romania] 200823 European Patients Smart Open Services24 National Medicines Agency 201025 PARLAMENTUL ROMÂNIEI [Romanian Parliament] 2006

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reimburse, in part or entirely, the pharmacies the cost of drugs prescribed by physicians, as it

is established in the framework contract or in subsequent government ordinances.

ePrescription is seen as a set of at least three types of application, namely: electronic

medication records, decision support systems, electronic transmission of prescriptions.

Till now, computerised procedures for prescriptions (e.g. transmission of prescriptions) have

been used mainly in hospitals, between physicians and internal pharmacies, but mainly for

administrative purposes (e.g. consumption, stock management) and not, let us say, for

recording medication to control incompatibilities (however it is possible to have some such

local IT applications, but they were not rolled out).

The IT applications for pharmacies outside hospitals are made by private companies and used

mainly for the stock management or for reimbursements from Health Insurance.

In the frame of ICT Policy Support Programme, and funded by the European structural funds,

an ePrescription project was launched in 2009 by MoH26. The project was intended in its first

phase to control the drug flow. Due to organisational flaws and legislation infringement

issues, the realisation of the project was shut down.

In 2010 the National Health Insurance House (HNIH) announced the intention to realise by

the end of 2011 a national ePrescription project, in connection with its SIUI system.

NHIH has the support of the Ministry of Communications and Information Society for this

project.

Legally no specific provisions on ePrescription are foreseen in Romanian Law. Order no.

832/302/2008 does specify the model of the medical prescriptions, but this mainly entails that

prescriptions need to be signed, dated and stamped with the physicians’ code.

Bibliography

26 DgMarket-Auctions Worldwide 2009

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1. Contribution to the New Public Health Development in the South Eastern Europe, 2000-

2010, Prof. Doncho M. Donev, MD, PhD, Adriana Galan, IT Specialist, Silvia Gabriela

Scintee, MD, Management in health, XIV/3/2010

2. Country Brief: Romania, Authors D. Farcas, J. Artmann, J. Heywood and Jos Dumortier,

October 2010, European Commission, DG Information Society and Media, ICT for Health

Unit

3. Country Public Management Profile: Romania, Dr. Calin Hintea, Public Administration

Department, Babes Bolyai University, Romania, NISPAcee 14th Annual Conference

11-13 May 2006, Ljubljana, Slovenia, Working Group on Public Sector Quality

4. Health Systems in Transition, Written by Cristian Vlădescu, Victor Babes University of

Medicine and Pharmacy, Timisoara, Gabriela Scîntee, Centre for Health Policies and

Services, Bucharest, Victor Olsavszky, WHO Country Office in Romania, World Health

Organization 2008, on behalf of the European Observatory on Health Systems and Policies

5. New Public Management in Health Care - its effects and implications, Thesis Proposal

By Margit Malmmose Peyton, September 1st, 2009, Aarhus School of Business Aarhus

University

6. Strengths and Weaknesses of the New Public Management (NPM)- Cross-Sectional and

Longitudinal Analysis - Part I of a wider analysis of the NPM -, Dr. Iulia Monica Oehler-

ŞincaiI, Researcher, Romanian Academy Institute of World Economy, Romania, Paper for the

Conference organized by the SOG and the QoG Institute, University of Gothenburg – New

Public Management and the Quality of Government, November 13-15, 2008

7. New Public Management and Substantive Democracy, Richard C. Box, Gary S. Marshall,

B.J. Reed, Christine M. Reed, University of Nebraska at Omaha, Public Administration

Review, September/October 2001

8. Management Theory, Dr. Stephen W. Hartman, New York Institute of Technology

9. New principles of management in modern organizations, Søren Voxted, University of

Southern Denmark, Jens Lind, Aalborg University, Denmark

10. Major Trends for an Effective Public Management in the Romanian Administration,

Armenia Androniceanu, Faculty of Management and Public administration, Bucharest,

Romania

11. New Trends in Public Sector Management in Health, Applications in Developed and

Developing Countries, R. Paul Shaw, World Bank Institute, April 1999

12. In search for an optimal level of decentralization in Romania, Cătălin Dumitrică, PhD(c)

Teaching assistant, National School of Political Studies and Public Administration Faculty of

Public Administration, EGPA Conference 2010, Toulouse, France, 8-10 September, 201033

ΠΑΝΕΠΙΣΤΗΜΙΟ ΑΙΓΑΙΟΥ

13. Estimation of Romanian Hospitals Efficiency in Relation to Hospital Market Competition,

Simona VASILACHE, Mihaela Cornelia PREJMEREAN, Academy of Economic Studies,

Bucharest, Management & Marketing (2008) Vol. 3, No. 3

14. Romanian Public Management Reform, Theoretical and Empirical Studies, Lucica

MATEI, Collection of Socio-economics, English Series

15. Profilul managerial al institutiilor publice din Romania, Deaconescu Veronica,

Universitatea Babes-Bolyai , Cluj-Napoca, Masteratul de Politici de Sanatate si Management

Sanitar

16. Planification des soins: approches en matière de politiques et de planification des

ressources

humaines de la santé, par Pat Armstrong, Ph.D., Université York et Hugh Armstrong, Ph.D.

Université Carleton, octobre 2002, É T U D E N o 2 8

17. Tactical Management: Adapt, Adopt, Improve, By Richard A. Reda and Jean B.

Lenderking, managing the skies • november/december 2004, www.faama.org

18. Theories of Governance and New Public Management: Links to Understanding Welfare

Policy Implementation, Jo Ann G. Ewalt, Department of Government, Eastern Kentucky

University, Prepared for presentation at the Annual conference of the American Society for

Public Administration, Newark, NJ, March 12, 2001

19. Health management information systems, Eldis Health Key Issues, DFID Health Resource

Centre

20. Social Marketing and Public Health, Lessons from the Field, A Guide to Social

Marketing, from the Social Marketing, National Excellence Collaborative, May 2003

21. Key Concepts in Medical Sociology, Jonathan Gabe, Mike Bury and Mary Ann Elston,

Sage Publications, London • Thousand Oaks • New Delhi

22. HR and New Approaches to Public Secyor Management: Improving HRM Capacity, Dr

Stephen Bach, World Health Organization, Department of Organization of Health Services

Delivery, Geneva, Switzerland, 2001

23. Healthcare Project Management in the New Economy, Schlichter and Thomas Healthcare

Project Management in the New Economy

24. New Public Management, a Key Paradigm for Reforming Public Management in

Romanian Administration, Armenia ANDRONICEANU, Academy of Economic Studies

Bucharest, ADMINISTRATIE SI MANAGEMENT PUBLIC, 8/2007

25. Strategic Management of Clinical Services, Alexander S. Preker, Martin McKee, Andrew

Mitchell and Suwit Wilbulpolprasert

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ΠΑΝΕΠΙΣΤΗΜΙΟ ΑΙΓΑΙΟΥ

26. “New Public Management” Impact on Romanian Public Administration, Androniceanu,

Armenia, Publisher: Academy of Economic Studies Bucharest, Bucharest, 2006.

27. New Public Management, a Key Paradigm

for Reforming Public Management in Romanian Administration, Androniceanu, Armenia,

Publisher: Academy of Economic Studies Bucharest, Bucharest, 2007.

28. Strategic changes in public management at the local level

of the Romanian Public Administration, Androniceanu, Armenia, Publisher: Academy of

Economic Studies Bucharest, Bucharest, 2007.

29. Professionals and the New Managerialism in the Public Sector, Exworthy, Mark,

Publisher: Open University Press, 1998.

30. Country Public Management Profile: Romania, Hintea,Calin, Public Administration

Department, Babes Bolyai University, Cluj-Napoca, Romania

31. Handbook of Public Management, Liou, Kuotsai Tom, Publisher: Public Administration

and Public Policy, New York, 2001.

32. Noul management public - o privire de ansamblu asupra pozitiei sale actuale, Pollitt,

Christopher, Publisher : Public Management Institute, Katholieke Universiteit Leuven, 2007.

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