Overview of the main incremental health care reforms introduced between 2014 and 2020 in Romania

Aim : On 2014 the Government of Romania has committed to improving health and health system through the implementation of the 2014–2020 National Health Strategy: Health for Prosperity. An official evaluation of the strategy implementation is not publicly available yet. This paper aims to provide an overview of the main incremental reforms taken during this period in Romania and to analyse the results from the perspective of the main Strategy goals. Methods : Information was collected from legislative documents, statistical and scientific publications. The main implemented or initiated incremental reforms, during the assessed period, were assigned to five main clusters: ”governance”, “resources for health”, “coverage and access”, “organization of health care”, “quality of care” and were analysed in accordance with the aim, the type, the implementation stage and the corresponding objectives of the Strategy. Results : The 2014–2020 National Health Strategy has definitely not reached all its objectives, but one sign of prosperity, is that based on 2019 per capita income (of $12,630) World Bank classified Romania, for the first time, as a high-income country. The health status of the population has increased in many aspects, yet Romanians’ health has still remained among the poorest in the European Union (EU). Conclusion : Incremental reforms might be successful, but the small steps should be taken in a holistic approach, and should be tailored to specific needs. Previous strengthening health systems resilience and plans for overcoming possible risks and obstacles might ensure successful implementation. Assessments of the reforms might draw lessons that help policymakers in shaping further health policies and designing of next strategies.


Introduction
Under the perspective of signing the 2014-2020 Partnership Agreement with the European Commission on funding through the European Structural and Investment Funds, the Government of Romania approved the 2014-2020 National Health Strategy "Health for Prosperity", as one of the ex-ante conditionalities to ensure the effective and efficient use of these funds.The Strategy development was based on the European Commission's country-specific recommendations for the health sector and a functional review of the Romanian health sector performed by the World Bank (WB).Besides following the aims of the European Commission growth strategy "Europe 2020", the document is aligned with the WHO health policy framework for the European region "Health 2020" (1).As well, even if not mentioned in the Strategy substantiation note, it fits the main principle of the South Eastern European 2020 strategy that integrates health as part of the broader economic growth strategy (2), pursuing the achieving of a healthy and productive nation through improving equity in health; strengthening human resources for health; and improving intersectoral cooperation and governance.The National Health Strategy 2014-2020 provide a framework for improving the health of the population in Romania, ensuring equitable access to quality and cost-effective health services, and also highlights cross-cutting measures for ensuring health system sustainability and predictability (3).Each of the three main areas of intervention has general and specific objectives with subsequent strategic measures.The measures concerning improvements in population health are targeted to the main public health concerns in Romania: health and nutrition of mother and child, communicable diseases (including tuberculosis, HIV/AIDS, hepatitis B and C) and non-communicable diseases (including cardiovascular diseases, cancer, diabetes, mental health, rare diseases).The scope of the envisaged measures is wide, ranging from prevention and control to disease registries, treatment and rehabilitation.The measures in the area of health services are directed mainly towards shifting the balance of health care services from inpatient to ambulatory and community care, increasing access to quality health care and tailoring services to the needs.The cross-cutting measures include: strengthening planning capacity at all levels (national, regional, local), ensuring sustainability by mobilizing sufficient resources, increasing efficiency in the health system through e-health and reducing inequities in access by developing the health care infrastructure.national and local levels" run over 2019-2022 (5).The current paper is not an evaluation of the implementation of the National Health Strategy 2014 -2020, but it aims to provide an overview of the main incremental reforms implemented over the same period, framing each of them within the objectives of the National Health Strategy and its expected results.

Methods
The methodology was inspired by the one used by the European Observatory on Health Systems and Policies in a study comparing the 2018-2019 reforms in 31 high-income countries, but much simplified, given that it concerns only one country (6).The implemented or initiated incremental reforms, during 2014 -2020, were listed, then assigned to five main clusters: "governance", "resources for health", "coverage and access", "organization of health care", "quality of care".
-"Governance" refers to the changes at the decision making level, either concerning governing bodies or the governance process in healthcare.-"Resources for health" category includes reforms that attempt to increase the general level of financial, physical and human resources for health, but also to ensure better allocation and efficient spending.-"Coverage and access" category refers to the reforms aiming to increase the number of people covered with services, or to the increase of the types or number of services provided.This category includes also coverage and access of people to the public health services (health promotion, disease prevention and other interventions aiming at improving health and prolonging life).
-"Organization of health care" category refers to changes in the model of service delivery including the interface between outpatient/inpatient care, primary/specialized care, rehabilitation/palliative care, continuity of care and any other dimensions of health care provision.
-"Quality of care" includes all the changes introduced with the aim of providing more effective, peoplecentred, timely, equitable, integrated, efficient and safer health services.For each cluster were chosen five reforms (see Table 1).Each reform was described as content, aim, type (e.g.legislation, plan, implemented project) and implementation status and it was matched to one of the objectives under the three main strategic directions of the National Health Strategy 2014-2020, respectively: improving the health of the population, ensuring equitable access to quality and cost-effective health services, and ensuring health system sustainability and predictability (see Box 1).The reforms were then analysed in terms of common characteristics regarding the aim, the type and the implementation stage, the extent to which they replied to the objectives of the National Health Strategy 2014-2020 and, were data available, the possible impact on the expected results of the Strategy.Information on the incremental reforms during the assessed period was collected from the legislative documents published in the Official Gazette, documents on planned changes and funded programmes and projects from the official websites of the Ministry of Health (www.ms.ro),National Health Insurance House (www.casan.ro),and the National Institute of Public Health (www.insp.ro).Information on current population health status and health services were collected from the World Bank and Eurostat databases, as well as from other reports and publications listed in References.The limitation of the study is given by the data collection based on publicly available data only, not taking any deeper investigation on the way the reforms were put on the policy agenda, the implementation process and resources, the major obstacles or the impact evaluation.

BOX 1 THE NATIONAL HEALTH STRATEGY 2014 -2020 GENERAL OBJECTIVES. PRIORITY STRATEGIC AREAS
INTERVENTION STRATEGIC AREA 1: "PUBLIC HEALTH" GO 1. Improving the health and nutrition of mother and child GO 2. Decreasing morbidity and mortality due to communicable diseases, and their impact at individual and social level GO 3. Reducing the rate of increase in morbidity and mortality from non-communicable diseases and reducing their burden on the population through national, regional and local preventive health programs INTERVENTION STRATEGIC AREA 2: "HEALTH SERVICES" GO 4. Ensuring equitable access to all citizens, especially to vulnerable groups, to quality, cost-effective health services

INTERVENTION STRATEGIC AREA 3: "CROSS-CUTTING MEASURES FOR A SUSTAINABLE AND PREDICTABLE HEALTH SYSTEM"
GO 5.An inclusive, sustainable and predictable health system through the implementation of priority cross-cutting policies and programs GO 6. Increasing efficiency of the health system through e-health solutions

Results
The incremental reforms were considered for this study, as there was no major change to existing institutions, organizational structures and management systems that define structural reforms over the assessed period (7).The predominant type of reform was a legislative change (88%), while 22% of reforms were initiated through WB or European Union (EU) structural funds financed projects.Some 32% of reforms were mixing legislation with project implementation.Most of the reforms (60%) responded to the third strategic direction of the National Health Strategy 2014-2020, which includes measures aiming at ensuring health system sustainability and predictability.Fewer reforms were oriented towards the other two directions of the strategy: ensuring equitable access to health services (24%) and improving the health of the population (16%).The reforms contributing to the third strategic direction were concentrated  Considering that the main vision of the Strategy is to shift the balance of health care services from inpatient to ambulatory and community care, from the services utilization perspective there were some achievements: the hospital discharges per 1000 population decreased slightly from 213 in 2014 to 211 in 2018, but the number of outpatient consultations also decreased from 5.3 to 5.2 (12,13).The self-reported unmet medical care needs also decreased from 9.4% in 2014 to 4.9% in 2018 (12,13).The share of hospital expenditure has increased from 39% to 46% of total health expenditure, but the increase might have been due to the increase of day-care provision (12,13).As well, an important and costly measure aiming to alleviate the shortage of human resources was the threefold increase in health personnel salaries.This could be also related to the increase in the availability of both doctors and nurses per 1000 population, from 2.7 to 3.1, respectively from 6.2 to 7.2 over 2014-2018 (12,13).

Discussion
Reforming the health system in Romania has started in the early 1990s once with the general social and political restructuring after the fall of communism.The main structural reforms consisted of the introduction of the social health insurance system and the purchaser-provider split (14).Their implementation was a lengthy (1994)(1995)(1996)(1997)(1998)(1999) and difficult process and they were followed by many incremental reforms.There were also reform initiatives that were abandoned.Comparing the implementation of the reforms in different periods in Romania, a first observation is that the EU support, which for the assessed period represented the programming and accession of 2014-2020 Structural Investments Funds, was an important driver for change.Besides the commitments represented by the signature on the programming documents, adequate financial resources were available.Some reforms were favoured by EU legislation that applies to all member states.One example is the implementation of HTA that after several unsuccessful attempts was introduced into Romanian law following the European Union Directive 2011/24/ on the application of patients' rights in cross-border health care (15).Other reforms were initiated by the EU policy agenda, such as the use of digital technologies and online services (16).Increasing efficiency of the health system through e-health solutions was included as the general objective of the Strategy, but until 2020 there have been only several isolated projects on telemedicine covering emergency services in remote areas and on the further development of electronic solutions such as Electronic Health Records (17).Real big steps in the implementation of e-health were taken when this turned into a "must" by the COVID-19 pandemics.It is difficult to say if the Strategy objectives have all been reached since they are not accompanied by measurable targets and performance monitoring (18).The health status of the population has been improved in many aspects, including the self-reported unmet medical care needs, yet Romanians' health has remained among the poorest in the EU.
The strategy is accompanied by an Action Plan which focuses on results and includes the estimated budget, financing sources, responsibilities and monitoring indicators (4).Reporting was due annually for the most of indicators, though the only publicly available implementation report is the one for 2015, which is too early to draw any conclusion on the Strategy results.The analysis of the strategy implementation could support the shaping of further health policies and the design of the next strategies.The evaluation of the National Health Strategy 2014-2020 and the development of the National Health Strategy 2021-2027 are planned within a larger Structural Funds financed project on "Developing the strategic and operational framework for planning and reorganization of health services at Scintee SG and Vladescu C. Overview of the main incremental health care reforms introduced between 2014 and 2020 in Romania.(Original research).SEEJPH 2022, posted: 21 May 2022.DOI: 10.11576/seejph-5477 P a g e 4 | 13 Scintee SG and Vladescu C. Overview of the main incremental health care reforms introduced between 2014 and 2020 in Romania.(Original research).SEEJPH 2022, posted: 21 May 2022.DOI: 10.11576/seejph-5477 P a g e 5 | 13 Scintee SG and Vladescu C. Overview of the main incremental health care reforms introduced between 2014 and 2020 in Romania.(Original research).SEEJPH 2022, posted: 21 May 2022.DOI: 10.11576/seejph-5477 P a g e 6 | 13 mainly on improving the quality of health services, strengthening planning capacity, ensuring sufficient financial and human resources for health and developing the infrastructure of the hospital and ambulatory care.Reforms oriented towards improving the quality of health services, consisted either of measures stated by the Strategy, as implementing Health Technology Assessment (HTA) and fighting nosocomial infections, or measures not specified by the Strategy, but leading to the specific objective of assurance and monitoring of health services quality.Strengthening planning capacity consisted mainly in training and learning by doing through technical assistance within EU structural funds financed projects.The development of health care infrastructure has also been beneficiating by these funds.Mobilization of resources was done through specific legislation that mainly increased the budget for health, including the threefold increase of health personnel salaries.The reforms corresponding to the health services development strategic direction, consisted in measures over the governance of some sectors of care (palliative and home care), organizational measures in other sectors (primary health care, community care) and measures to increase the coverage and access to health services.The reforms in this category listed under the governance and organization of healthcare clusters can be found as specific measures in the Plan of action for the implementation of the 2014-2020 National Health Strategy, while the measures for better coverage and improved access to health services are not specified in the Strategy, but contribute to the achievement of the general objective of this strategic directionensuring equitable access to quality, cost-effective health services to all citizens.The reforms related to the improvements in population health strategic direction included also governance measures through addressing the incomplete legislation to ensure better intersectoral collaboration for controlling environment-related risk factors and better transplant services and measures to increase coverage and access such as improving screening and treatment for cancer and ensuring access to the innovative treatment of Chronic Hepatitis C. Most of the reforms (64%) are still ongoing.They consist of projects still under implementation or main legislation that need subsequent implementation norms development.Several legislative measures have been already implemented: increase of health financing and health personnel salaries, the establishment of new institutions or organizational structures (the National Authority for Quality Management in Health Care, the National Centre for Human Resources) or provisions related to coverage and access.In what concern the changes in the state of health, the 2014 data were compared to 2019.The period 2020-2021 was not eligible for comparison due to COVID-19 pandemics that influenced the trend of most indicators.Scintee SG and Vladescu C. Overview of the main incremental health care reforms introduced between 2014 and 2020 in Romania.(Original research).SEEJPH 2022, posted: 21 May 2022.DOI: 10.11576/seejph-5477 P a g e 7 | 13

Table 1 . Incremental reform clusters, 2014-2020 Starting Year Reform content Aim of the reform Type of reform
(12)11)lthy life years at birth increased from 59.0 in 2014 to 60.2 in 2019(9).Infant mortality had a spectacular decrease over 2014-2019, from 8.2 to 5.8 deaths per 1000 live births(9).The preventable mortality decreased from 310 to 306 deaths per 100,000 population over the 2016-2018 period, while treatable mortality increased from 208 to 210 deaths per 100,000 population over the same period(10,11).Despite the highest annual average growth rate in per capita health spending in the EU, 7.8 over the 2013-2019 period, Romania still had the lowest health expenditure per capita, of 1,292 EUR PPP, almost half of the EU average of 2,572 EUR(12).