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.”
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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. |
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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'
incomes.
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.”
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