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February - 2005

Feature - Looking for a cure

A deal for life

Chronic under-funding and a black market in bribes for every service, from doctor's appointments to serious operations, are undermining Romanians' trust in the medical profession and threatening the health of the country

“Doctors do not realise how terrorised the population is,” says Patrick Colquhoun, director of Medical Support in Romania, a British-based charity that promotes high standards in medical care in central and eastern Europe.
He argues that corruption in healthcare is the biggest problem the country faces, as it undermines the professionalism of doctors and nurses and fails to bring the country into line with European values in medical care. “This is one of the headaches of the Ministry of Health, every decision maker and policymaker,” adds Victor Olsavski, liaison officer for the World Health Organisation in Romania. “It is difficult to remedy, but not impossible.” The problem is most serious within hospitals, where a system of negotiating prices in an illegal market begins once a patient finds a bed. “Starting with the orderly and finishing up with the doctors, a patient has to pay a bribe,” says a 29-year old nurse in a public hospital in Bucharest. “If you don't pay the orderly, she will not change your bedclothes and will not help you if you need her. It is worst for the old because they do not have enough money for the hospital fees. It is hell for them.
The cost is around 100,000 lei (2.5 Euro) to each nurse and orderly per day. For the attention of doctors, we're speaking about millions of lei. If you do not pay, you do not count.” Prices for operations, basic services and even tests are either negotiated beforehand, in many cases with the nurses acting as brokers for the doctors, or they are expected afterwards, in the form of tips for an operation that can start at around a third of a citizen's average monthly salary.
A 30 year old mother found that the medical profession in Romania has a subtle method of extracting cash for its supposed free-at-the-point-of-access service.
"When I was giving birth to my son, I wanted to have my own personal doctor who treated me during the pregnancy, so I could only go into labour when I knew she was on her shift,” she says. “After she had delivered the baby, she came up close to the hospital bed with the nurse, orderly and midwife and said: 'You know these are the people who all participated in the birth of your son'. This was obviously a way of manipulating me to pay them all.
Every moment when the nurses gave me some assistance in the morning and evening I had to pay them 50,000 lei (1.2 Euro) each time. In total, the birth of my son costmeabout 100 Euro.” A month later when her son was sick with stomach pains, her family doctor sent her back to the hospital. “Once there I stayed in the waiting room and asked for help, but no doctor or nurse would assist me - until I showed them some money,” she said. “Then they put me in a private room where they let me stay with my boy, I was visited nonstop by the doctors. But I had to pay them well, in coffee and also in cigarettes.
"Costs charged for services vary from doctor to doctor and hospital to hospital. If a patient has a broken leg, we have been quoted that this can cost as high as 300 Euro to mend, plus another 50 Euro for the anesthetist. This is almost triple the average monthly salary for Romanians. Appendicitis? That could be 125 Euro for an operation. In Emergency departments, some patients are not even noticed until they hand over brown envelopes.
But the situation is worse for those without the medical insurance - a system of paying for medical care through salaries.
“If you do not have insurance, the amount you must pay for a night in the hospital is almost the same as a bed in a three star hotel,” says a 28 year-old
hospital nurse. “This is about one million lei (24 Euro). It must be terrible for a young person who is working without a contract. God forbid if they have a problem and cannot afford to be hospitalized!”
There are not many options for the non-insured. “Someone who is sneezing, will just have to keep sneezing,” says Olsavski. “But if he has been in an accident, the Emergency department will receive him, care for him and then bill him.”
But there does exist a system for taking care of socially marginalised people. The unemployed can go to a town hall and ask for a certificate, which means they can subscribe to a family doctor.
The situation is most tragic for the old who cannot afford to pay costs on a minimum pension of around 25 Euro per month.A30-year old nurse working in an old people's shelter says that when a resident becomes sick, the treatment is out of their hands. “Once he is there and the doctors find out that he is from the shelter and has no family, no one cares about him,” she says. “They know no one will come to pay them, so after a week the hospital calls us back at the shelter and asks us to take him home, mentioning that he doesn't need surgery - even if this is not the case. They let him die! We are doing everything that we can to save them, but if they need surgery at the hospital, they are as good as dead.”
Colquoun says that bribery is all pervasive both in terms of medical as well geographical areas. “There is no area where bribery will not cause damage,” he adds. “In anesthetics, patients can feel totally vulnerable, and therefore particularly susceptible to the pressure to give the accepted level of bribes.”
The population is terrified not to pay, especially when they are looking for care for the old, chronically sick or children - the weakest members of society. “So the more vulnerable are the people involved,” says Colquhoun, “the greater the terror.”
In Romania there are two types of doctors: general practitioners (GPs) or family doctors, who, since 1999, have been able to manage their own business with funding from the Government based on how many patients they treat. Then there are specialists, such as surgeons, who are employed by hospitals.
“We have noticed that the percentage of illegal payments for GPs dropped as soon as they became entrepreneurs,” says Olsavski. “Because a GP has a salary based on payments per patient it is in the interests of the doctor to look after the patient.”
But among the hospital staff and specialists, this figure has not seen a reduction. According to a study from the Centre of Health Policy, the majority of doctors claim they do not take under the table payments and the percentage of doctors who ask for them is very small. In ambulatory care, with CT scans, lab analysis, ante-lab analysis, all this is paid for by the insurance system, so there should, in theory, be no need for bribery.
But Olsavski does concede that the problem is worse than other central European countries, such as Poland, Hungary and the Czech Republic. “My fear is a lack of a quality surveillance system,” says Olsavski, “those who do or do not take under-thetable payments are excluded from a quality control.”
The black market creates an atmosphere of mistrust as doctors compete for cash from the patients and illegal income becomes a more serious motivation for work than maintaining general health.
“Collaboration between doctors is less, as sharing the credit means sharing the bribe,” says Colquhoun. Instead a black market in referral processes emerges. "The family doctors are the worst,” says one 60 year old woman pensioner. “I asked my doctor for a prescription note to take some tests in the hospital and she told me to go to the
doctor's own private clinic and pay the radiographer 500,000 lei (12.5 Euro).
They also send you for tests to friends or colleagues of themselves where you have to pay. This health care system, through the referral process, is working very well in Romania. They switch patients between one another, so all of them can make a profit."
The initial motivation for bribery is an ailment many public workers in excommunist states suffer - bad wages. "The salaries in the health care system are very low and maybe that's why we accept and some of us ask for bribery,” says a 29 year-old nurse, who earns around 3,775,000 lei per month (100 Euro). “This is possibly an excuse for bribery, but it is one thing if a patient gives you a bunch of flowers or a pack of coffee and another to demand a payment.”
Extra money for nurses can come from working longer hours and weekends. The Government has also promised to give nurses food tickets worth around 33 Euro per month. “But we haven't received anything so far,” said one Bucharestbased nurse last December, “and I don't believe we will ever receive them.” It is hard for a nurse to survive on four million lei per month, a senior nurse on 5.3 million lei per month (130 Euro) and a doctor on six and a half million (160 Euro). A junior doctor's salary in Romania is around 95 Euro per month, compared to 300 Euro in Poland and around 2,500 Euro in the UK. “Here the state should make a difference,” said one nurse.
Low income, together with an atmosphere of bribery, could provoke honest doctors to leave the country as soon as possible, especially when the European Union accession comes to fruition in 2007, and opportunities to work abroad, in understaffed hospitals in theUKand Germany, emerge.
"I have been tempted to leave the country for some years,” said one Bucharest-based nurse. “I could work as a nurse in another place where I would be paid the wage I deserve. In Romania I earn about 80 Euro per month, but in Europe I could earn 2,000 Euro per month. If you know a foreign language and you have luck you can work abroad.
Everyone, even doctors, wants to leave Romania and the only reason is the money." Although the wages are dire, the bad management of funds and an overcentralised system has led to a crisis in how health funds are allocated.
“As far as healthcare issues are concerned, Romania's problems are major,” says President of the Doctors' College of Romania [and newly appointed Minister of Health] Mircea Cinteza. “First, we have the worst general health among the candidate countries to the EU. Second, we award the smallest amounts of budget money to the health sector and third, we manage those little amounts of money badly.”
The current percentage of GDP on healthcare is just above four per cent. Although this is less than the percentage in the late nineties, in real terms, the WHO says the funds have doubled since 2000. “But Romania could do better with the available resources,” says Olsavski.
Cinteza adds that Romania compares poorly among its candidate neighbours, with Bulgaria awarding six per cent of its GDP to healthcare, Hungary seven per cent and other EU countries eight per cent.
In cash terms, he says this works out as 80-100 Euro per year awarded by the Romanian state to each citizen, almost half of Bulgaria's 160 Euro per year, the Czech Republic's 700 Euro per year and, in other EU countries, 1,200 Euro per year.
“There are only four million tax payers and such a poor country cannot insure proper health services out of such a limited source of finance,” he adds. Hospitals are under-resourced, but it is not unfamiliar to come across a large and expensive piece of equipment where the walls are leaking and there are not enough beds.
Colquhoun adds: “Proper resourcing is needed, but not the extravagant throwing around of inappropriately expensive medical equipment, the running costs of which cannot be afforded. And this is done, when, for instance, even basic items of Infection Control are not funded, such as towels to dry hands with in the wards.”
Practitioners may also not know how to understand results properly from over sophisticated equipment. “A frequently misused item of equipment is ultrasound. Pretty pictures can be produced, but that does not mean the doctor knows how to interpret them,” says Colquhoun. “In district hospitals, without clinical meetings between clinicians, radiologists and pathologists, the growth of knowledge is unduly stunted.”
Many hospitals have brand new machinery, but there is no consistency among hospitals or departments. Olsavski says that Bucharest, for example, may have the highest number of CT scans taking place in the central European area. “There is a lack of planning or misplanning and no clear system of allocating funds,” he says. “It is the loudest voices among the hospital directors who receive money for their equipment.”
The Ministry of Health will soon start implementing a strategy using the 'Diagnostic Related Group' (DRG) system to correlate financial management with the quality of the medical service according to elements such as the difficulty of the patient's case, the number of solved cases and the length of hospitalization.
For a year tertiary Fundeni Hospital, Colentina, has adopted the DRG system. Director of Fundeni Clinical Institute Dan Tulbure, says: “The major impediment in properly applying the DRG system in Romania, is, though, the fact that the actual cost of a specific medical service has not been calculated by an independent, authorised body.”
Also the National Institute for Examination and Development for Health (INCDS), under the supervision of the Ministry of Health, is researching the costs of appendix surgery and cardiac by-pass because, at present, there is no clear evaluation of these costs.
In an interview with The Diplomat last November, Traian Basescu said that in the first year of Government he would increase the health budget by one per cent of GDP and, in the second year, by two per cent, which would bring it into line with Bulgaria. “But the health system does not have a difficult problem from a financial point of view,” said Basescu, “it is very badly managed.”
Until 2001, the budget was handled by the House of Health Insurance (Casa Asigurarilor de Sanatate CAS), which collects the health insurance funds and then the Ministry of Health itself took charge.
“When this moved, the disaster started,” said Basescu, “with bad administration of financial resources.” He told us he would allow the National House of Health to handle resources. “When we are convinced they are well managed, we will see if they need additional resources.”
But an overhaul of the institutionalized corruption is the largest necessity. “The doctors and others who give treatment only on the receipt of bribes have already lost their professionalism,” says Colquhoun. “But it is also an insult to suggest that a doctor can only be honest if his or her salary is increased, especially as there are many honourable exceptions who do not take bribes.”
Experts argue that nursing needs to be given a better status, so that workers feel they are part of a proper profession, distinct from acting as assistants to the doctors, and that directors of hospitals also need better management training. Colquhoun adds: “A determined effort could result in Romania becoming the first former communist country to stop this brand of medical terrorism.”


Right to choose:
the new policy
The ambitions of the incoming Government and the new minister of health, Mircea Cinteza are to destroy inequality in the healthcare system, while encouraging a private healthcare that will ultimately benefit the rich.
Does this sound paradoxical?
You decide… as we summarise the Coalition's new strategy:
- To give its citizens the right to choose its healthcare, free of state restrictions. This means encouraging the development of a private system of health insurance.
- To support the privatization of the infrastructure of medical units, except facilities where costs are high and cannot be supported by private operators and those of strategic importance to public health.
- To encourage the competition between healthcare and insurance providers.
- To ensure the health sector is given a decent budget, which aims to be six per cent of theGDP by 2008.
- To decrease the level of inequality in the system and ensure the dignity of the medical profession, which includes strong measures to diminish corruption in the medical system.
- To introduce a state-financed national emergency insurance system to provide all regions with paramedics. To allow family doctors to provide healthcare for non-life threatening emergencies.
- To give family doctors a proper health counselling role, which will be backed up by better pay for the medical services the
family doctors can provide,
giving a supplementary income for emergency consultations and overtime.

Power without responsibility

Patients need to know their rights, as prosecutions against underperforming medical staff are very few

A lack of a coherent law on medical malpractice, only a dozen medical practice licenses revoked in six years and a lack of patient representation has led many to ask: If something goes wrong in the process of a medical operation, who is held responsible?
“The healthcare system is not accountable,” says Victor Olsavski, liaison officer at the WHO. “The system is set up to promote collective, not individual accountability.” This means that any responsibility for a botched operation or a massive bribe is hard to pin on one person.
“So to whom can you complain?” he adds. “The manager or the doctor of a hospital? About whom? His close friend and colleague?”
Ideally, wronged patients can either sue doctors for malpractice in the courts or make a complaint to the Romanian Medical College - a process that is a difficult task for any one citizen to undertake.
In the last six years, the college has received around 3,500 complaints. “Out of this figure far less than a half have been solved in the favour of the complainant and 12 medical practice licenses have been revoked,” says Mircea Cinteza, former President of the Romanian medical college. “As far as I know, there isn't a malpractice law in Romania.”
It is difficult to punish a doctor in Romania. One analyst adds that there is a different mentality in southern and northern Europe, with Romania stolidly following the former. In northern Europe, if doctors make a mistake there is a professional body that investigates the problem and if found guilty the doctor will be punished, isolated or struck off by the profession because the bad doctor brings down the quality of the whole profession, argues the analyst, adding that in Southern Europe if doctors make a mistake, there is an investigation, but the doctors get together to try to help him escape in all the ways that are possible.
"There is no neutral system, particularly in Romania, to judge cases,” says Olsavski. It is also a hard task for patients to judge the quality of their care, as standards are elusive. “The only things the patient can judge in the hospital is the quality of the food,” says Olsavski, “Is the room clean or isn't it? Are there bugs or aren't there bugs?”
Olsavski says that this should change as patients and doctors become more aware of contracts that exist between the two, and patients become more informed about their rights. To aid accountability, each hospital needs an independent "patient representative", suggests Director of Medical Support in Romania Patrick Colquhoun. “This office could help stop the culture of under-the-table bribes,” he adds. “Patient representatives in hospitals would help give the doctors and the hospitals improved reputations, which are currently low.”


Paying over the counter

Private healthcare is developing at a gradual pace in Romania compared to most eastern European nations, but keen investors are already taking advantage of customers' preferences to make legal payments for services

Private healthcare is developing at the same rate in Romania as the middle classes - slowly. A few entrepreneurs and foreign firms are grasping the nettle of an industry which will, in the future, attract a large customer base. However now there is a confused legal status regarding the terms of what private medical insurance will mean. Also the firms entering the Romanian market are only licensed to undertake specific services and must outsource many of their activities to the state.
This means private companies are maintaining a presence and proceeding cautiously into the Romanian market. “In Budapest we experienced a much faster growth in the private system both in clinics and private hospitals,” says private healthcare firm Medi Help General Manager Cristina Andrei. Although in principle private healthcare may ask citizens to pay for a service which should be their right to access for free, in practise these firms are making payments to doctors legitimate and at some rates, it is estimated, that are cheaper than a package of bribes for an
operation in a state facility.
“What do we have that the public system does not? Trustworthiness, first of all,” says Medicover Business Development Manager Dr Marina Otelea. “If we promise something, we will do it. The patients are paying for the services they receive and make no further payments.”
Andrei adds: “There is no need for extra payments or small gifts which often makes it uncomfortable to go to the doctor. You think: is it enough or not? When and how should I pass the doctor my envelope? In private clinics, you look at the price list and it's up to you how much you want to pay, if you can afford it or not.”
At Medicover patients either pay for each individual service or through a subscription, similar to an insurance scheme, of ten to 120 Euro per month. This includes access to a call centre where doctors answer and offer advice, ambulances, home visits and general medical research and tests, depending on the rate of subscription. “We also offer hospitalisation in public hospitals,” says Otelea, “but in private side-rooms; there we deal with everything we pay for the cleaning costs and for the costs of the bribery of the nurses.”
In some cases paying for healthcare out-sources the need to make direct bribes, which does, at the very least, offer some comfort to already sick and nervous patient and his or her concerned family.
Of the private options, Biomedica's office manager Flori Dinu, says "prices are not very expensive" which include ambulatory and hospital services and cosmetic surgery, “but they seem huge because the buyer power is lower. However the cost against the efficiency is equitable.”
Diagnostic and Treatment Center Victor Babes's PR manager Anca Cernea adds: “In the private system the costs are apparently high, but that is actually the real cost of a responsible medical act made with professionalism and dignity...
But this burden could be easier if there was a reorganization of the insurance law, fiscal code and the development of economy and competition. While the public medical services are apparently free, they have a doubtable quality.”
But anesthesia and surgery can still only occur in a hospital within the state system. Dealing with traumatology and intensive therapy and chronic diseases such as TB and neurophysiological diseases are also currently out of the private jurisdiction.
This month Centrul Medical Unirea (Unirea Medical Center), which operates a dispensary, is opening a small hospital equipped with ten beds, a one day surgery with laparoscopy, in-vitro fertilization and specializations in gynaecology, but is still cooperating with local hospitals for maternity services.
Supported by a two million Euro investment, general manager Wargha Enayati does not believe there are too many firms fighting for the middle class dollar. “I am not afraid of the actual competition, but who knows what tomorrow will bring?” he says.
Enayati says his practice's services will be seven times more costly than the health insurance. “The prices will probably be the most expensive in Bucharest.” Meanwhile MediHelp is making its business by offering ex-pats healthcare in Romania such as air evacuation, health insurance and local medical assistance.
“At the moment, private clinics don't offer emergency rooms and there is very little development in the possibility of offering minor surgery procedures,” adds Cristina Andrei.
“For us as a private clinic, the patient comes first,” says Otelea. “The absence of communication in the public health care system is a big problem.We have to fight to change our colleagues in the public system and also to change the opinion that we're God and the patients only mortal and so this way we will build a partnership over a long period of time.”
Otelea says wages in the private system are double those of the state system and can increase. “In the public system the black market salary system contributes to a lack of team spirit,” she adds. “For the nurses the salary is at least double that of the public system.”
But, in regard to the whole new industry, Dinu disagrees. “There is no a difference in payments between these two systems,” she says. “Both are badly paid in proportion with the socioeconomic activity that we undertake.” Enayati says he will be attracting the best in medical staff, helped by the fact that the salaries in his private system are three times general those of the public sector.
“When we choose our doctors we make a detailed selection and choose only one from 50,” he says. The private system is gaining pace. A new private hospital on Calea Floreasca is under construction, between the existing emergency hospital and the Dynamo football stadium. Bucharest's Fundeni Hospital, a tertiary institution which has services in liver and kidney transplant, is in the process of entering into a private-partnership scheme where a private firm runs part of the hospital, but remains a client of the state.
“I support the idea of privatising not only clinics, but also hospitals,” says Dan Tulbure, Director of Fundeni Clinical Institute. Fundeni has for two years been a part of an IFC [International Finance Corporation] project to, at first, implement private management. Lately, the idea of “a concessionary” has been put forward in the last few months. Tulbure says an international tender will soon take place and the winner will then receive the Fundeni Hospital for a limited number of years.
However the incoming Minister of Health Mircea Cinteza, in his previous capacity of the head of college of doctors, told The Diplomat he believes privatization of hospitals should be done “at a slower pace”.
Accession to the EU is likely to bring increased incomes and stimulate the development of private health care system and also boost incomes . An increased buying power can start competition between the state and the private health care system,” says Dinu. Cernea believes this should also being a real need to reform the medical insurance law.
“For two years we have spoken about the new norms regarding the insurance law, but it still hasn't been improved,” adds Enayati. The new Government has lately only issued a statement claiming that those wishing to take out private medical insurance will also have to pay the state contributions. Because of its cheap and skilled medical workforce, Romania sees a massive increase in the amount of medical tourism from the USA and Germany for cosmetic and dental surgery, and this also seems to translate into essential healthcare provision.
Andrei says costs for tests such as ultrasounds, mammography and X-rays are approximately 30 to 40 per cent higher in Hungary than in Romania and a consultation to a specialist can be up to twice as expensive.
Maybe before long it will no longer will it be a frightening prospect to get sick in Romania, but the cheapest option on the global market.


The private life of Romania
There are two systems of “paidfor” healthcare in Romania: one autonomous from Government, the other purely independent.
In the primary sector, family
doctors tend to bind together with four or five colleagues to form small polyclinics and the cost for each service is paid through health insurance from the Government, collected from the patients'
There are also a growing number of completely private operations, separate from the Government, such as Medicover, Victor Babes and Unirea, which can offer
ambulatory and home visits, as well as liaising with the state hospitals, in costs paid for by a fee per service or through monthly
subscription fees.
By 1999 public funds were open to the private sector in the primary healthcare field. Family doctors have a contract with the Health Insurance House and payment is based on the number of patients the doctors have. So the incentive for doctors is to care for more people.
Health insurance is paid for by 14 per cent tax on gross salary (as we went to press , the new Government had yet to change this). This burden is shared between the employers and employees. This is a high cost to employers, argue some private firms.
Mircea Cinteza, president of the College of Medicine, Romania [and now Minister of Health] told The Diplomat : “Most of the polyclinics are not privatized, but the tendency to make the leap to a private system is increasing.”