New Public Management in Health System in Romania
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Transcript of New Public Management in Health System in Romania
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
Part made by Corina Taban
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
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
(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
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..
Conceptions on New Public Management
Ferlie et al., 1996 Borins, 1994;
move to board
of directors mode
split between strategic core and large
shift to greater
relationship in the
provider roles to
the public sector
be performed by
the public sector
as opposed to the
with a variety
stress on private
sector styles of
public and private
on output controls
stress on quality,
and measures of
rewarded on the
stress on greater
budgets to be
managers need to
market-oriented government: leveraging change through the
deregulation of the labour market anticipatory government: prevention rather than cure
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
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
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.
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
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
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
7. Enterprising government: earning rather than spending;
8. Anticipatory government: prevention rather than cure;
9. Decentralized government: from hierarchy to participation and teamwork.
Part made by Madalina Gogu
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
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.
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
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
contributions only from insured persons paying the whole contribution (such as the self-
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.
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
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.
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.
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
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
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
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
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.
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
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
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
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
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
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
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
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
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
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
None of the GPs who participated in the survey for Romania reported using ePrescribing.26
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)
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
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
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
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
and the eHealth strategy. Also NCOEHIS could ensure the connection with the EU eHealth
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.
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
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
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.
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