Evaluation of structurE and provision of primary carE in Primary care in the WHO European Region summary Although the strengthening of primary care services is a priority of health refor
The theoretical framework of the PCET and PCQMT
Although the strengthening of primary care services is a priority of health reforms in many countries, the background and motivation of reforms vary from region to region
In western Europe, emphasis on primary care is expected to address rising costs and changing demand resulting from demographic and epidemiological trends, whereas in central and eastern Europe—and in countries formerly part of the Union of Soviet Socialist Republics—the goal is to strengthen primary care, expand access, and reform financing to manage limited resources and shifting disease burdens.
Efforts in the Soviet Socialist Republics are aimed at boosting overall health system performance and cost-effectiveness, with primary care being developed from a previously underdeveloped or non-existent state into a central, accessible part of the system This development intends to provide adequate, responsive health services closer to the population, and these health care reforms are part of broader, profound changes in essential societal functions and values.
Evaluations and performance measurements increasingly play a role in health care reforms
Stakeholders need reliable evidence to guide decisions and steer the health system toward better outcomes In the past, reforms were not always based on evidence; progress often reflected political arguments or the interests of specific professional groups rather than the results of rigorous evaluations This pattern is changing, as increasingly evidence-informed assessments influence policy choices and drive more effective health-system reforms.
Stakeholders in health care, governments not the least, are increasingly held accountable for their activities and this requires evidence, for instance on the progress of reforms.
Demographic and epidemiological changes require health system adaptation, including evaluating the responsiveness of health services from the patients’ perspective These evaluations generate information about access and convenience of services, how patients are treated by health staff, how patients perceive information and communications that can impact their behaviour and well-being, and how their care is managed at the primary care level or beyond.
Further, evaluations and performance assessments should be explained within the respective (country) context Only then can performance information serve as a direct input into policy making and regulation However, the role of governments goes beyond the direct use of information The stewardship role also implies that a necessary flow of information is generated and made available to other stakeholders in the health care system, and that the necessary analytical capacity is available (3)
A final major requirement of evaluations and performance assessments is to start from a proper developmental framework to ensure the relevance of the (proxy) indicators and the good coverage of identified areas The following sections describe the framework used to develop the PCET.
1 1 2 Primary care evaluation and the health systems framework
A health system is a structured network of resources, actors, and institutions involved in financing, regulating, and delivering health actions that provide health care to a defined population Health actions are any activities whose primary aim is to improve or maintain health The overarching objective of a health system is to optimize the health status of the entire population throughout the life cycle, taking into account premature mortality and disability.
Health systems aim to achieve three fundamental objectives:
• improved health (e.g., better health status and reduced health inequalities);
• enhanced responsiveness to the expectations of the population, encompassing re- spect for the individual and client orientation; and
• guaranteed financial fairness on both sides with protection from financial risks result- ing from health care) (1,4).
Health system performance is ultimately reflected by the level of attainment of these goals Because health conditions and health systems vary by country, it is essential to account for the country context when comparing performance across systems Consequently, performance measurement should cover not only goal attainment but also the resources available and the processes that deliver care.
According to the WHO health system performance framework (see Fig 1), performance is determined by how the four key functions—stewardship, resource generation, financing, and service provision—are organized While international literature offers other performance measurement approaches, they share similar insights or related concepts These four functions can be applied to the health system of a country as a whole, with sub-characteristics for primary care, or to primary care alone.
Fig 1 WHO health system functions and objectives
Stewardship is an overarching function in health systems, broader than regulation, that oversees all basic health system functions and directly or indirectly influences health outcomes It encompasses defining the vision and strategic direction, setting policies and governance standards, ensuring accountability, coordinating stakeholders, and aligning resources to improve performance and health results.
Functions the health care system performs Objectives of the health care system
Financing direction of health policy shapes reform through regulation, advocacy, and the collection and use of information It covers three core aspects: setting, implementing, and monitoring the rules for the health system; ensuring a level playing field for purchasers, providers, and patients; and defining the strategic directions for the health system as a whole Stewardship is a key component of financing direction and comprises six subfunctions: overall system design, performance assessment, priority setting, regulation, intersectoral advocacy, and consumer protection In short, stewardship encompasses governance, information dissemination, coordination, and the regulation of the health system at multiple levels.
Every level of a health system relies on a balanced mix of resources—physical assets (equipment and facilities), consumables, human resources, and knowledge—to function effectively, and these resources must be continually developed and expanded to sustain health services across time, levels, and geographic areas The quantity and quality of health workers must align with service demand and be distributed equitably nationwide, with up-to-date skills and knowledge that keep pace with technological advances and evidence-based medicine Policy development for human and physical resource planning, along with a robust regulatory framework for quality assurance and consumer protection, falls under stewardship, while measuring workforce size, distribution, and ongoing professional development typically occurs within the resource generation function.
In general, financing deals with the mobilization, accumulation and allocation of funds to cover the health needs of the people, individually and collectively, in the health system
Health financing, as defined by Murray and Frenk, is the process of collecting revenues from primary sources (households and firms) and secondary sources (governments and donor agencies), pooling these funds in fund pools, and allocating resources to provider activities This financing function comprises three sub-functions: revenue collection, fund pooling, and purchasing Revenue collection mobilizes funds through mechanisms such as out-of-pocket payments, voluntary insurance based on income or on risk, compulsory insurance, general taxes, earmarked taxes, donations from non-governmental organizations, and transfers from donor agencies To share and reduce health risks, funds can be pooled through various forms of health insurance Purchasing allocates pooled funds to cover the costs (staff, durables and running costs) of specific health service interventions by providers, whether institutional or individual The way these sub-functions are organized and executed influences access to health services.
Health service provision is the mix of inputs required for producing health interventions within a specific organizational setting, leading to the delivery of health services It encompasses preventive, curative and rehabilitative care for individual patients as well as population‑level activities such as health education and promotion, delivered through public and private institutions Providing services is the core function of the health system, and while there are four key characteristics that define “good provision” (see below), the focus is on what the health system does, not on what it is.
The Primary Care Evaluation Framework
Definitions of primary care differ across countries, and its defining characteristics vary by context (see Annex 2) Nevertheless, a comprehensive or well-developed primary care system typically exhibits a set of core features that distinguish it from fragmented or limited care arrangements.
Primary care serves as the entry point to the health system, welcoming individuals with new health concerns and guiding them through initial assessment and ongoing management It is patient-centered and longitudinal, prioritizing the person over the disease and providing comprehensive care for most conditions while referring only the rare or unusual cases to specialists It also coordinates and integrates care across different providers and settings, ensuring a seamless, continuous care experience.
Figure 2 illustrates the Primary Care Evaluation Framework (PCET), which integrates the four functions of a health care system with the four key characteristics of primary care services that underpin service delivery, as derived from the above definition.
Fig 2 The Primary Care Evaluation Framework
Access to health services can be defined as the ease with which health care is obtained, or more specifically as the patients’ ability to receive care where and when it is needed Barriers to access may be physical, psychological, sociocultural, or financial, restricting patients’ ability to obtain care In the PCET scheme, access is shaped by geographical access (distance to and distribution of general practices), organizational access (office opening hours, distant consultations, and timeliness), and financial access (costs incurred by patients via cost-sharing and copayments).
Primary care interventions should be tailored to patients' health care needs over the long term and across successive episodes of care Continuity of care is essentially the ongoing follow-up from one visit to the next, ensuring sustained management The World Health Organization broadens this concept by recognizing the possible involvement of multiple health care providers and settings, with an emphasis on coordinated, patient-centered care across the care continuum.
Delivery of primary care services Creating resources
Access to services Continuity of care
Relevant services must be able to deliver interventions that remain coherent in the short term, ensuring cross-team and intra-team coordination (cross-sectional continuity) They should also provide an uninterrupted sequence of contacts over the long term (longitudinal continuity) to maintain a seamless continuum of care.
Continuity of care encompasses several levels: informational continuity—the organized and accessible medical and social history of each patient available to any health care professional treating them; longitudinal continuity—the ongoing care at a familiar site where a patient routinely receives services from a coordinated team; and interpersonal continuity—the sustained, trust-based relationship between patient and provider Additionally, Reid et al identify a fourth dimension, management continuity, which involves delivering timely, complementary services within a shared management plan.
The PCET scheme includes informational, longitudinal and interpersonal continuity of care.
Primary care serves as the entry point to health care and often performs gatekeeping, making the coordination of services at the primary level a key determinant of how responsive health services are and how well the health system functions Coordination challenges are most evident at the primary–secondary care interface and at the boundary between curative care and public health services, including health promotion Coordination can be defined as a technique of social interaction in which multiple processes are considered together and their development is arranged to maximize benefit for the whole system More specifically, it is a service characteristic that yields coherent treatment plans for individual patients.
An effective care plan should set clear goals and include only necessary and effective interventions—neither too much nor too little Cross-sectional coordination involves aligning information and services within a single episode of care to ensure coordinated delivery Longitudinal coordination, on the other hand, describes the ongoing linkage among clinicians, staff, and partner agencies across a longer course of treatment to maintain continuity of care (11)
In the PCET scheme, the various dimensions of coordination encompass collaboration within the same primary care practice, within the same level among providers (e.g FDs/
GPs, community nurses, physiotherapists, etc.) and between primary care and other levels concerning consultation and referral systems.
Comprehensiveness in primary care is the degree to which a full spectrum of services is provided, whether directly by a primary care physician or other providers, or coordinated through external arrangements In the primary care setting, it covers curative, rehabilitative, and supportive care as well as health promotion and disease prevention The scope of comprehensiveness is demonstrated not only by the range of services offered but also by the quality of practice conditions, facilities, and equipment, and by the professional skills of the primary health care providers.
In addition, the community orientation of primary care workers plays a role All these dimensions have been taken into consideration for the PCET scheme.
The Primary Care Evaluation Scheme
Based on the Primary Care Evaluation Framework, the Primary Care Evaluation Scheme concentrates on country-specific issues, policies and health care priorities relevant to each nation It comprises measurable topics and items tied to essential features and national priorities for change in primary care, alongside the facilitating conditions that enable such reform The Primary Care Evaluation Scheme, which in turn forms the basis of the PCET, is structured as follows.
• delivery of primary care, subdivided into: ằ accessibility ằ continuity ằ coordination ằ comprehensiveness of services.
Table 2 reveals that for every primary care system function, a number of key dimensions have been identified, and each dimension, in turn, has been translated into one or more information items or proxy indicators representing that dimension.
Table 2 Overview of selected functions, dimensions and information items
Function Subfunction Dimension Selected Items/Proxies
Stewardship Policy development Policy priorities
Professional development (Re) accreditation system
Conditions for the care process Laws and regulations
Conditions for responsive- ness Involvement of professionals and patients in policy process Patient rights; complaint procedures
Resource generation Workforce volume Numbers and density
Professional development Role and organization of professionals
Function Subfunction Dimension Selected Items/Proxies
Scientific development and quality of care
Professional morale Job satisfaction Facilities and equipment Medical equipment
Financing and incentives Health care/Primary care financing Funding
Health care expenditures Expenditures Incentives for professionals Entrepreneurship
Financial access for patients Cost sharing/co-payment
Delivery of care Access to services Geographical access Distance to practice
Distribution of physicians Organizational access List size
Provider workload Care outside office hours Home visits
Electronic access Planning of non-acute consultations Responsiveness Timeliness of care
Service aspects Clinics for specific patient groups
Delivery of care Continuity Informational continuity Computerization of the practice
Medical records Longitudinal continuity Patient lists
Patient habits with first contact visits/ referrals
Endurance of patient-provider relation- ship
Interpersonal continuity Patient-provider relationship
Coordination Cohesion within primary care Practice management
Collaboration among general practi- tioners/family doctors
Collaboration of physicians with other workers
Coordination with other care levels Referral system/gatekeeping
Function Subfunction Dimension Selected Items/Proxies
Comprehen- siveness Practice conditions Premises, equipment
Disease management Community orientation Practice policy
Monitoring and evaluation Community links Professional skills Technical skills
To assess the complexity of any primary care system, information is gathered at different administrative levels and from both the supply and demand sides (health providers and patients) The Primary Care Evaluation Tool (PCET) uses three separate questionnaires: one for experts addressing national policies and structures, one for primary care physicians, and one for patients Together these instruments cover all identified primary care functions, their dimensions, and the information items defined by the framework The physician and patient questionnaires are pre-structured with predefined answer choices, while the national-level questionnaire includes both structured items and open-ended questions and requests a list of statistical data to be provided.
PCET development and pilot testing
Parallel development of the PCET and PCQMT began in February 2007 and was completed in May 2008, making both instruments available to WHO for health system support activities with Member States The project advanced from desk research and topic discussion to pilot implementations and an international meeting to share experiences and results, with further development details described in sources 18, 19, 25, and 26.
As an initial step, NIVEL researchers conducted a targeted literature study based on the WHO performance framework to identify ways to operationalize the key functions of primary care, with particular attention paid to relevant indicators and existing performance measurement tools and questionnaires, which culminated in a preliminary listing of dimensions and items for the tool.
1 4 2 First exchange with experts of the WHO European Region
In March 2007, an international expert meeting reviewed the literature study findings with the aim of building consensus on key concepts and definitions, validating the provisional set of dimensions, proxy indicators, and information items, and refining the first version of the scheme (see Table 2) to facilitate questionnaire development, while also initiating the initial pilot implementation of the provisional tools.
1 4 3 Drafting, validating and translating questionnaires
Draft versions of the three questionnaires were developed from the information and feedback gathered at the expert meeting Incorporating expert comments, new versions of all three questionnaires were created These revised questionnaires were subsequently tailored to fit the specific contexts of the countries where the tools would be piloted.
Turkey and the Russian Federation for the PCET and Uzbekistan and Slovenia for the
PCQMT terms were adapted to national contexts, and at the request of health authorities in the four Member States, additional questions addressing national primary care priorities were included The translations were first prepared in the local language with input from a primary care expert and subsequently back-translated and compared with the original version to ensure accuracy and consistency.
The provisional PCET was pilot-tested in two provinces in Turkey and two districts in the Moscow region of the Russian Federation, while the provisional PCQMT was piloted in three regions in Uzbekistan and two regions in Slovenia Under the supervision of the WHO Regional Office for Europe and the respective ministries of health, local partners with the NIVEL technical lead organized the details of the fieldwork, including sampling procedures, training of fieldworkers, and the logistics of data collection and data entry In all countries, expert meetings were held to discuss and validate the answers on the national-level questionnaires All data were analyzed, conclusions and policy recommendations formulated, and a draft report produced, including a section on lessons learned in the pilot implementation (18, 19, 25, 26).
Draft reports were discussed during a two-day review meeting with international experts at the WHO Regional Office for Europe in Copenhagen on 14–15 April 2008 This meeting led to revisions of the questionnaires, as follows.
• Questions were made more factual; avoiding forsaking for opinions.
• The sequence of topics and questions was reordered.
The national level questionnaires were transformed into a standardized template to produce a more comprehensive background document, which would be prepared by a small team of local experts and subsequently discussed and validated in a focus group meeting led by the World Health Organization (WHO) and NIVEL.
• The PCET questionnaires for patients and physicians were shortened.
• The terminology and wording throughout the questionnaires were made more con- sistent.
In addition to survey results, the team will rely on complementary information sources, including available literature, relevant articles, interviews with healthcare workers and experts, and the researchers’ own observations gathered during site visits.
• Countries were allowed to add questions related to specific national priority areas
• Final reports would contain a set of proxy indicators.
After revision the Tools were available to be used in the countries An implementation scheme was produced for the information of Member State counterparts, describing subsequent steps for implementation.
Implementation of the combined tools
Between 2010 and 2011, Romania and the WHO Regional Office for Europe implemented the combined PCET and PCQMT as part of a bilateral cooperation agreement (BCA) Preparations began with a June 2009 visit by WHO Europe representatives to Romania, during which the tools were introduced and a national working group was formed to guide the project and comment on the draft report To emphasize primary care quality, the PCET was supplemented with questions from the PCQMT The official project partners were NIVEL (as a WHO collaborating centre) and CHPS Technical preparations for implementation effectively started in January 2010.
1 5 2 Country visits for information and planning
A team of experts from the WHO Regional Office and NIVEL conducted three visits to the country at different stages of implementation The first visit, held from 23–25 June 2009, included a preparatory mission designed to set forth the objectives of the engagement.
• to conduct site visits to assess the relevance and feasibility of the application in Romania;
• to introduce the tools to the Ministry of Health;
• to inform stakeholders and building commitment; and
• to identify candidates from local research institutions to carry out the fieldwork.
A second visit took place on 22–24 February 2010, and included:
During the study, we conducted visits to the National Society of Family Medicine (SNMF) and its Bucharest branch, the NHIH, CHPS, and a range of family doctor (FD/GP) practices, including a rural FD/GP Permanence that provides out-of-hours services These visits illuminate how urban and rural family medicine clinics operate, highlight the roles of SNMF in professional development, and underscore the importance of accessible after-hours care for patients in diverse communities.
• discussions of the project strategy, including target population and selection of re- gions and mode of sampling;
• introduction and discussion of the questionnaires; taking suggestions for changes;
• discussion of primary care issues and validation of the answers on the national level questionnaires; and
• coordination of activities with the WHO Country Office, Romania.
A third visit was made on 10–13 May 2010, dealing with:
• practice visits in Brasov and environs and to Monastirea in the Danube Valley;
• training of eight fieldworker coordinators, each to coordinate about 15 fieldworkers;
• discussion of the results of a pre-testing of questionnaires and finalization;
• further preparations for the fieldwork;
• preparations for data entry (including software adapted to the latest versions of the questionnaires);
• explanation of requirements for the fieldwork reports to NIVEL;
• discussions of CME, incentives and new developments; and
• detailing and planning of coming activities.
Information received and observations made at meetings and practice visits have been used as background for the current report
1 5 3 Adaptation and extension of the PCET/PCQMT
Collaborating with the national working group, the questionnaires were adapted for use in the Romanian context In addition to these adaptations, questions from the PCQMT were inserted into both the national level questionnaire and the questionnaire for FDs/GPs The FD questionnaire includes items on guideline availability, updating, and instructions, as well as who should decide on CME courses The national level questionnaire was expanded with additional items to capture broader information.
• responsibilities for quality assurance management
• mechanisms and indicators for service quality monitoring
• (re)certification procedures and requirements for FDs/GPs
• interprofessional collaboration in CME courses
• continuing education for health managers
• evaluation of guideline use and CME courses and programmes
• regular assessment of professional competence of FDs/GPs and nurses.
Translated versions of the preliminary adapted questionnaires for FDs/GPs and patients were pre-tested on a limited scale, as a basis for the final versions and subsequent translations
1 5 4 Target populations and survey approach
The physician survey targeted NHIH-contracted family doctors and general practitioners, while the patient survey focused on visitors to FD/GP practices aged 14 and above and the accompanying adults for younger visitors The study was designed to achieve nationwide coverage To ensure adequate regional representation and balanced sampling, we drew stratified random samples from the FD/GP population, with strata defined by nine cultural regions and five urbanization levels.
In Bucharest, subsamples proportional to the population size of each of the six districts were drawn to ensure district-level representation The sampling frame consisted of an official list of NHIH-contracted family doctors (FDs) and general practitioners (GPs), from which the subsamples were selected.
A sample of 405 FDs/GPs was drawn, representing 3.6% of Romania’s total population of 11,348 FDs/GPs To realize this sample, 1,000 FDs/GPs were randomly contacted until the required number was reached The FDs/GPs survey used self-administered questionnaires distributed either by mail or personally handed over by fieldworkers when the practice was also selected for the patient survey For the patient survey, 120 FDs/GPs from the total responding FDs/GPs were randomly selected These practices were visited by trained fieldworkers who asked the patients at the practice on that day to fill in a questionnaire, with the fieldworker’s task completed after 15 patients had filled in the questionnaire Patient questionnaires could be self-administered, or fieldworkers could provide support if necessary.
Following telephone follow-up, the net response rate among FDs/GPs was 405 (40.5%) A target of 15 patients in each of 120 FD/GP practices was achieved, yielding 1,800 completed patient questionnaires Tables 3 and 4 show the distribution of realized responses among FDs/GPs by urbanization categories and regions, compared with the actual FD/GP population distribution, with only small deviations These results indicate that, despite considerable non-response, the response coverage across areas of differing urbanization and across regions was satisfactory.
Table 3 Comparison of the study response among FDs/GPs with the real FD/GP distribution in the five urbanization categories
Table 4 Comparison of the study response among FDs/GPs with the real FD/GP distribution in the regions *
* Two regions with few FDs/GPs have been added to the adjacent region.
Note: The following districts belong to the identified regions:
A1 Bac u, Neam , Suceava, Vrancea, Boto ani, Vaslui, Gala i, Ia i
A2+5 Arge , Dâmbovi a, Prahova, Buz u, Br ila, Giurgiu, Teleorman, Ialomi a, C l ra i, Tulcea, Constan a
A3 Dolj, Mehedin i, Olt, Gorj, Vâlcea
A6+9 Alba, Hunedoara, Bra ov, Sibiu, Cluj, Mures, Bistri a-N s ud, S laj, Covasna, Harghita
A7 Maramure , Satu Mare, Arad, Bihor,
Fieldworkers were essential to data collection from patients, recruiting and informing patients, and distributing and collecting questionnaires among patients and the physicians at the practices they visited; they and their regional coordinators were recruited and trained by CHPS, with training addressing relevant topics to equip them for field activities.
• the context and objectives of the survey
• the basic principles and structure of the tool and the type of questions used
• the specific topics of the questionnaires
• approaching and assisting respondents and establishing a good rapport
• creating a suitable environment for patients to fill in the questionnaire
• checking readability and completeness of answers
• logistics, such as allocation to the locations, planning and transport.
1 5 8 Information gathering at the national level
A team of six experts contributed to answering the national questionnaire, from the
National Institute of Public Health, NHIH, Romanian College of Physicians (2), National
School of Public Health and CHPS The answers and statistical data were forwarded to
NIVEL for analysis, and served as the basis for the description of the national primary care situation in Chapter 3 of this report.
1 5 9 Data processing, analysis and reporting
Data entry was conducted under the auspices of CHPS in Bucharest, with NIVEL designing a dedicated data-entry programme using a SPSS Data Entry Station Raw data files were subsequently sent to the NIVEL research team for processing and analysis A draft report presenting results and preliminary recommendations was discussed with Romanian and WHO experts in Bucharest on 19 October 2010 Following suggestions for changes and requests for additional information from that meeting, along with peer-review comments, the draft report was revised Details on the application of the PCET in Romania are summarized in Table 5.
Table 5 Key data on the application of the PCET in Romania
Elements of the implementation Explanation
Target groups • FDs/GPs with NHIH contract
• Patients (visiting FD/GP practices)
• Health care experts (national) Locations • All regions and districts of Romania
• FDs/GPs: survey using pre-structured questionnaires (disseminated by field workers and by mail; follow up by telephone)
• Patients: survey using pre-structured questionnaires (personally handed over by trained fieldworkers)
• Health care experts: mixed approach; questionnaire and meeting for validation and feedback
• Practice visits and interviews with FDs/GPs
• FDs/GPs: stratified random samples in all regions
• Patients: the first 15 patients attending the practice of 120 randomly selected FDs/GPs among respondents
• Health care experts: identified and recruited by local partner
Planned sample sizes • FDs/GPs: 1000
• Patients 1 800 (in 120 FD/GP practices; each 15 patients)
• Local coordinator: methodology of sampling and recruitment; identifica- tion of study populations; lists of FDs/GPs; logistics of surveys
• Field work coordinators: explanation of questions; how to approach and assist respondents; quality aspects
• Respondents: introduction to the questionnaires; introduction/support to patients by fieldworkers
• Fieldworkers: information of respondents; correct administration of data collection in their facilities
• NIVEL: general supervision during and after field visit Data entry Organized by CHPS under auspices of NIVEL
Analysis & draft reporting NIVEL (Utrecht, Netherlands)Validation and final report NIVEL, with WHO Regional Office and Ministry of Health
The country
Romania covers about 237,500 square kilometers and is home to roughly 21.5 million people, making it one of the European Union’s largest countries by area and population As Fig 3 shows, Romania sits at the crossroads of central and eastern Europe It borders Ukraine and the Republic of Moldova to the northeast and has a southeastern coastline along the Black Sea To the west lie Hungary and Serbia.
Bulgaria lies to the south of Romania, and Figure 4 illustrates the historical and administrative divisions Romania is divided into 41 counties, which are grouped into nine regions, also known as economic development regions.
An historical division of the country distinguishes three parts: the east (with Moldova as the centre), the west (Transylvania and adjacent regions) and the south (with
Muntenia at the centre) Where this report presents results by region, this historical division is used
From an economic standpoint, Romania remains in transition from communism toward a market economy, with EU accession representing a pivotal milestone in this process The accession is widely supported by the population, reflecting strong optimism about its benefits In 2004, 70% of Romanians viewed EU accession as a good thing, while only 3% considered it a bad thing.
Union Member States after May 2004 (EU-25) of those days, 47% were positive and 17% negative (32) Most Romanians trusted the EU, and continue to trust the EU as Table
3 Sources: Vl descu et al (27); The world factbook (28); B dulescu (29)
Table 6 Public trust in EU bodies in 2004 and 2009
EU membership has acted as a powerful catalyst for Romania, attracting foreign investment and unlocking EU funds, while rising domestic consumption supported solid GDP growth of 6% in 2007 and 7.1% in 2008, making Romania’s late-2008 performance among the strongest in Europe Yet the global financial crisis reversed momentum, with GDP contracting by nearly 7% in 2009 Although a slow recovery was anticipated for 2010, the economy remained at risk due to a persistent negative foreign trade balance, high external debt, and sizable budget deficits Despite consistent growth since 2004, Romania’s GDP remains relatively low within the EU, and today nearly a quarter of the population lives below the poverty line, one of the highest shares in the European region.
Fig 4 GDP per capita in 2009 in US dollars
Romania's population stood at 21.4 million in 2010, and as shown in Figure 5, the population has gradually declined over the last decade, a trend also seen in neighboring countries The decline is primarily driven by a low fertility rate and substantial emigration to more affluent EU member states.
5 Sources: Vl descu (27); The world factbook (28); Arghisan (35); Falzon (36); Hamers (37); Saltman (38)
Republic Moldova Ukraine Serbia Romania Bulgaria Hungary EU 0
Fig 5 Population of Romania 1998–2010 (in millions)
More than half the Romanian population (54%) lives in urbanized areas The capital
Bucharest is Romania’s largest city, with a population of over 2.3 million Romanians account for about 90% of the country’s population, while among ethnic minorities, Hungarians make up the largest group at roughly 6.6% Estimates of the Roma population vary from 550,000 to more than 2 million, with many Roma living under deprived conditions.
As shown in Fig 6, Romanian men have a life expectancy of 69.2 years and Romanian women 77.5 years, values that are comparable to those of men and women in Hungary, Serbia, and Bulgaria, and higher than those in Moldova and Ukraine In a broader context, these figures are contrasted with EU-15 countries (those that were European Union Member States before May 2004) to illustrate Romania's relative position in life expectancy.
Romanian men and women have a considerably shorter life expectancy (minus 8.1 years and 6 years, respectively).
Fig 6 Male and female life expectancy at birth, 2009 (in years)
Source: European health for all database (34).
Romania Republic of the Moldova
Ukraine Hungary Serbia Bulgaria* EU-15 40
In 2009, Moldova was the only country in Table 7 where the share of people aged 0–14 (15.1%) exceeded the share aged 65+ (14.9%) In all other neighboring countries and EU-15 states, the elderly outnumber the young Nevertheless, Romania remains part of the general European population aging trend, a pattern linked to a low total fertility rate.
The maternal death rate in Romania has positively developed, but it can be further reduced Since the 1990s it declined sharply as a result of the liberalization of abortions and the introduction of a National Mother and Child Health Programme and a sharp reduction of unsafe and unskilled abortions However, the maternal death rate still is the second highest among the countries listed in Table 7, after the Republic of Moldova, as is the case with infant mortality.
The death rate in Romania is comparable to that of the Republic of Moldova, whereas Ukraine, Hungary, Serbia and Bulgaria have higher death rates and EU-15 countries have a lower mean death rate Death from circulatory system diseases accounts for almost half of all deaths in Romania Romania’s eastern neighbours Ukraine and Republic of Moldova, as well as Bulgaria, have higher death rates due to these diseases The dif- ferences in mortality due to malignant neoplasm are less pronounced among Romania, its eastern neighbours and EU-15 countries and are lower in Romania than in Hungary and Serbia The mortality rates from external injury and poisoning has been declining sharply in the last 15 years, below that of the Republic of Moldova, Ukraine and Hungary but higher than that of Bulgaria, Serbia and EU-15 countries
Although TB incidence has been declining in recent years, Romania’s estimated TB burden remains more than ten times the EU-15 average and higher than in most neighboring countries, with Moldova as the notable exception In the late 1980s and 1990s, Romania experienced a major HIV epidemic in which thousands of institutionalized children were infected through unsafe blood transfusions and repeated injections with inadequately sterilized equipment By contrast, today’s HIV situation in Romania is relatively low and stable, with incidence below the EU-15 average and prevalence still lower than in Moldova and Ukraine, where HIV remains epidemic.
The abortion rate is, despite the introduction of the National Mother and Child Health Programme in the 1990s, still high and exceeds all neighbouring countries and EU-15 countries.
Romania shows relatively modest smoking levels on the international stage, with women smoking at notably lower rates than many peers About one-third of Romanian men smoke, a rate comparable to men in Hungary, Italy, the Netherlands, Serbia and Spain Female smoking in Romania is similar to that in Moldova and Ukraine, but substantially lower than in Hungary, Serbia, and most Western European countries.
Table 7 Selected demographic, health and lifestyle indicators (2009)
Republic of Moldova Ukraine Hungary Serbia Bulgaria EU-15
Death from diseases of circulatory system
Death from malig- nant neoplasms (per
Death from external cause injury & poi- soning (per 100 000 pop SDR)
The health care system
During the Ceausescu era, Romania operated a Semashko-style health care system that was highly centralized, standardized, and geographically organized Persistent underfunding and inefficiency prevented the system from meeting even basic health needs, contributing to a decline in population health This deterioration was reflected in a falling life expectancy from 1975 into the early 1990s Following the 1989 revolution, the new government pursued health care reform to reshape the sector, emphasizing decentralization and efficiency incentives to improve structure, governance, and service delivery.
Romania has historically allocated a smaller share of its GDP to health than other EU countries, with 2008 figures showing around 5.5% of GDP spent on health (4.5% public and 1% private), the lowest level among EU members whose 2008 average was about 9.2% A major turning point in the reform process was the 1998 Law on Social Health Insurance, which established compulsory health insurance linked to employment Contributions are income-based and are paid in equal shares by the insured and the employer People without an income—such as children and young people, the disabled, war veterans with no income, and dependants of insured individuals—receive free access to health insurance, while for special groups like conscripts and prisoners, insurance contributions are funded through the budgets of different ministries.
As shown in Table 8, Romania spends relatively little on health care services, with only 5.5% of GDP allocated to health, far below the levels of neighboring countries and the EU-15 In EU-15 countries, weighted health expenditures per capita are about five times higher than in Romania Romania also records the lowest numbers of physicians, nurses, dentists, and pharmacists per 100,000 people among neighboring countries and EU-15 members Hospital bed capacity in Romania is intermediate but notably higher than in the EU-15, with only Hungary and Ukraine having more hospital beds per 100,000 people Despite this, the length of hospital stay in Romania is relatively short, and the number of outpatient contacts per person is relatively low.
During the communist period in Romania, the healthcare system was state-provided and hospital-centered, with primary care delivered through a nationwide network of dispensaries The concept of family medicine did not exist, and members of the same family—children and adults—were treated by different doctors, with no option to choose their own physician Each dispensary housed a general practitioner for adults and another for children, supported by several nurses (some specialized in pediatrics), a midwife, and administrative staff.
After the 1989 changes, the primary care system gradually shifted toward a model increasingly based on family medicine This transition changed the working conditions for family doctors and general practitioners In 1994, health reforms assigned FDs/GPs a gatekeeping role and introduced a new contracting scheme that combined capitation and fee-for-service payments, including incentives.
Efforts to increase access in underserved areas and improve 24-hour availability have led to a model where family doctors (FDs) and general practitioners (GPs) become independent, though contracted, and run their medical practices as private entrepreneurial ventures, expanding the reach of care while preserving clinical autonomy.
Following these reforms, family doctors and general practitioners boosted their output by increasing consultations and home visits, enrolling more patients, and expanding emergency care coverage These positive results occurred even as actual primary-care spending consistently lagged behind planned budgets, while hospital expenditures exceeded their planned allocations.
In recent years the expenditures on primary care are decreasing In 2010 these expen- ditures were 27% lower than in 2008 (See Table 9).
Table 9 Primary health care financing 2008–2010
% of total health insurance expenditure 8.8 7.2 6.1
Table 8 Selected indicators of health care resources and utilization (2009)
Indicator Romania Moldova Ukraine Hungary Serbia Bulgaria EU-15
Total health expen- ditures as % of GDP
Total health expendi- tures per capita
Outpatient contacts per person (per year) 4.7 6.3 10.7 12.0 8.5 n.a 7.8**
Source: European Union for all database.
3 primary carE in romania: thE national contExt
This chapter provides an overview of Romania's primary care priorities, regulatory framework, and organizational structures, detailing national policy and legislation, financial arrangements, the workforce and education of providers, and quality assurance with a focus on patient involvement Based on responses from national experts to the national-level questionnaire, the findings are presented according to the health system functions and dimensions defined in the Primary Care Evaluation Scheme (see Table 2) It also sets the context for the results from surveys of family doctors (FDs) and general practitioners (GPs) and their patients, which are described in Chapters 4 and 5.
Stewardship / governance
Constitutionally, Parliament holds a central position in the health policy process due to its approval power, but the government can initiate certain health measures without direct Parliament interference through emergency ordinances, such as Ordinance No 150/2002 that amended the Health Insurance Act of 1997, alongside numerous ordinances that have amended the Health Care Reform Act of 2006.
The President’s proactive approach helps fast-track health topics onto the political agenda, signaling a decisive commitment to health reform He has appointed a special commission to analyze and draft a strategy for developing the national health system, with a strong emphasis on primary care principles This plan aligns with the 2008 report “A health system focused on citizen’s needs.”
The Ministry of Health is responsible for ensuring appropriate health care services throughout the country In the absence of a dedicated primary care department, its Directorate for Medical Care and Public Health Policies assumes that responsibility There is a Committee on Family Medicine, but it has yet to be convened The Ministry’s responsibilities include overseeing medical care delivery and shaping public health policies to support nationwide health outcomes.
• engaging main stakeholders in health policy and the formulation, implementation and strategy evaluation;
• carrying out broad public consultation, including the views of main stakeholders and the patients;
• ensuring transparency in the state’s budgetary allocation for health; 7
• regulating the public and private sectors and their interface;
The Ministry of Health no longer directly controls the financing of most health care since 1999, but it remains responsible for funding and managing national public health programmes, selected specialty services, and investments in health infrastructure and equipment.
• conducting research, policy, planning and monitoring of reform, financing, the private sector and infrastructure and equipment;
Efforts are directed at developing a comprehensive legal and regulatory framework for the health care system that encompasses the pharmaceutical sector, public health policies and services, and sanitary inspection, while also establishing a framework contract for all health care providers in collaboration with the NHIH This overarching framework aims to strengthen governance, ensure compliance, improve service delivery, and promote consistent standards across the health sector.
• developing human resource policy and capacity building for policy analysis and management.
The Ministry of Finance is central to health-sector decision-making, because any policy document involving public expenditure requires the approval of the Minister of Finance Consequently, budgets for the NHIH and the Ministry of Health’s programmes must be approved by the Ministry of Finance before implementation.
Furthermore, the Ministry of Labour and Social Protection, the Ministry of
Transport, the Ministry of Defence and National Security, the Ministry of the
In Romania, the Interior Ministry, the Ministry of Justice, and the Romanian Intelligence Agency maintain parallel health care systems, each operating its own hospitals, polyclinics, and dispensaries Two national health insurance funds exclusively cover workers employed by the Ministry of Transport, the Ministry of Defence, and National Security These funds are regulated in the same way as the DHIHs, but their premiums are sourced from different target populations.
Since 2002, local governments own nearly all public health care facilities, positioning them to shape health services in their areas However, limited financial and human resources greatly constrain their influence In practice, the role of lower-level government has remained very limited.
In 2010, the Ministry of Health and the government relaunched health reform by delegating the management of lower-level public hospitals—360 out of 432—to local authorities However, the decentralization process requires stronger regulation to ensure integrated health services that align with population and community needs Looking forward, local governments are expected to assume increasing responsibility for the delivery of health care services.
The NHIH sets the rules for the social health insurance system and co-ordinates the 42
DHIHs It can redistribute funds among districts and has the right to impose regulations on them with the aim of maintaining the coherence of the health insurance system
Every year, the NHIH together with Ministry of Health initiates the framework contract
(approved by a governmental decision) that specifies the insurance benefit package and regulates care provision Providers, including FDs/GPs, have very limited input in negotiating the framework contract.
Initial decentralization and shifting towards a social health insurance based system started with the Public Administration Act of 1991, which created 42 District Health
Directorates, under the authority of an appointed political leader, are responsible for funding and managing health services, including dispensaries, and they sign agreements with FDs/GPs specifying standards and services The Social Health Insurance Act of 1997 aimed to create a decentralized and pluralistic health insurance system in which citizens contributed based on their income to purchase services from providers, including the newly independent FDs/GPs At the district level, the health management function and the funding function were separated, with District Health Directorates split into District Public Health Directorates (DPAHs) and DHIHs DPAHs, as Ministry of Health entities, became responsible for developing public health programmes, evaluating health care provision and health care providers DHIHs became responsible for premium collection (until 2002, when this was taken over by the Ministry of Finance) and reimbursement of providers, under NHIH supervision The NHIH may also redistribute up to 25% of premiums to underfinanced districts.
From 1995 to 2000, a series of health-care laws reshaped the sector by establishing a formal regulatory framework: the 1996 Act on the Practice of the Medical Profession, the Establishment, Organization and Functioning of the College of Physicians, the 1997 Social Health Insurance Act, the 1998 Public Health Act, and the 1999 Act on the Organization, Functioning and Financing of Hospitals These measures laid the groundwork for a more decentralized health care system, with clearly defined roles and responsibilities for all stakeholders that are codified in regulations and regulatory guidelines.
3.1.2.2 Developments from 2000–2011 Major topics addressed since the year 2000 are the further recognition of family Medi- cine and improving the health system’s coherence by integration in primary care and substitution
The Social Health Insurance Act of 1997 marked a major milestone in family medicine by turning general practitioners into independent providers who contract directly with District Health Insurance Houses (DHIHs) The Act established a framework contract that defines the entitlements of the insured and the conditions under which all providers, including family doctors (FDs) and general practitioners (GPs), deliver medical care within the social health insurance system, as well as the payment and incentive structures that support service delivery.
The Health Reform Act of 2006 marked a pivotal milestone in the professionalization of family medicine and primary care, signaling a modernization of frontline healthcare delivery It targeted family medicine, covered nearly all fields within the health care sector, and integrated previous legislation into the Acquis Communautaire framework The drafting of the law involved consultations with NGOs and the College of Physicians to ensure broad stakeholder input and legitimacy.
That year, Romania’s Presidential Commission for Public Health Policy Analysis and Development published "A Health System Focused on Citizens’ Needs," outlining a vision of horizontal integration among health care providers with primary care as the key element The report is viewed as an important blueprint for advancing primary care reform, though its recommendations have yet to be implemented It identifies several subjects to be addressed in reform efforts.
Prioritizing the development of multidisciplinary primary care teams, authorities should promote associations of two or more family doctors and the formation of broader primary care teams that include nurses, midwives, social and community workers, physiotherapists, and administrative personnel, serving 3,000–7,000 people depending on regional demographics This scaling up aims to better prepare primary care for community-based services such as health promotion, prevention, and rehabilitation, which have a significant impact on quality and effectiveness.
• Efficiency and diversification of services