The complexity of the problem the national health care program confronts with and which must be solved through the measures of the respective reform lead to a SWOT analysis, particularly for this reform. The strong points consists of the voting And coming into force of the Law concerning the health care reform, the large number of services suppliers, for every type of medical assistance, the existence of medical excellence centres leading to an afflux of patients, regardless of the area where they live. The implementation of the hospital financing system - DRG – financing based on solved case – represented a process approved through a MH project that has benefited from the financial support of the European Union, through PHARE 2003 program. The Romanian health care system consists of the following weak points: - The necessity to increase the financing level of the Romanian health care system; - The lack of a unique integrated information system; - The lack of real self-sufficiency; - The high rate of infectious and chronic diseases; - The rate of problems related to the lack of knowledge of related servicesindicators system, SWOT analysis, strong points, weak points, financing health care, health care expenditure.

Claudiu CICEA

Cristian BUSU

English

Research Papers in Economics

         Special Number 1/2011                         Review of International Comparative Management  188 
 
THE SWOT ANALYSIS  
OF THE ROMANIAN HEALTH CARE SYSTEM 
 
 
Claudiu CICEA 
Cristian BUSU 
The Bucharest Academy of Economic Studies, Romania 
 
 
 
  KEYWORDS:  indicators  system,  SWOT  analysis,  strong  points,  weak  points, 
financing health care, health care expenditure 
 
 
Introduction 
 
One  of  the  objectives  of  sustainable  social  development  could  be  the 
increase of healthcare services financing and a more effective management of the 
existing  resources,  taking  into  account  that  social  development  is  directly 
influenced  by  the  investment  in  human  capital.  The  problem  consists  of  the 
efficiency  of  the  resource  collection  and  management  system  and  of  the 
acknowledgement of public healthcare field as a sector requiring investments, for a 
long-term sustainable development.  
 
ABSTRACT 
The complexity of the problem the national health care program confronts 
with and which must be solved through the measures of the respective reform lead to a 
SWOT analysis, particularly for this reform.  
The strong points consists of the voting and coming into force of the Law 
concerning the health care reform, the large number of services suppliers, for every 
type of medical assistance, the existence of medical excellence centres leading to an 
afflux of patients, regardless of the area where they live. The implementation of the 
hospital financing system - DRG – financing based on solved case – represented a 
process approved through a MH project that has benefited from the financial support 
of the European Union, through PHARE 2003 program. 
The Romanian health care system consists of the following weak points: 
  The necessity to increase the financing level of the Romanian health care system; 
  The lack of a unique integrated information system; 
  The lack of real self-sufficiency; 
  The high rate of infectious and chronic diseases 
  The rate of problems related to the lack of knowledge of related services  
 Review of International Comparative Management                              Special Number 1/2011  189 
1. Strengths of the romanian healthcare system  
 
We can consider strengths the voting and proceeding to bring into effect 
the Law on healthcare reform
1, the relatively high number of service suppliers by 
each type of medical care, the existence of medical centres of excellence which 
leads to an inflow of patients, regardless of the area they live in.  
 
Implementation of hospital financing system – DRG – case-based financing  
The DRG system has been successfully applied in Romania since 1999, by 
means of several projects run by MS (Ministry of Health), CNAS (National Health 
Insurance Funds), CMR (Medical Board), INCDS (National Institute for Health 
Research  and  Development)  and  the  Centre  for  Health  Statistics  and  Medical 
Documentation  (CSSDM)  with  the  financial  support  of  USAID  Romania.  The 
system was officially initiated in 2002, as a financing mechanism for 23 hospitals. 
Based  on  local  experience  and  on  experience  of  other  health  care  systems,  the 
decision was made to introduce gradually this system, through a series of stages to 
be  completed  within  the  next  three-five  years.  To  support  this  process,  a  MS 
project  was  approved  and  has  received  the  financial  support  of  the  European 
Union, through PHARE 2003 program. 
Diagnosis-related  groups  were  developed  in  the  USA,  at  the  Yale 
University,  by  a  group  of  doctors,  economists,  statisticians  that  were  trying  to 
imagine  a  system  for  assessing  hospital  results  (the„70s).  The  Health  Care 
Financing Administration in USA (HCFA) has adopted the system, has generalized 
it and decided to use it for hospital financing starting with 1983 (the financing 
currently exists based on the model). Other countries also use this system, either 
for assessing hospitals activity, or for their financing: Belgium – hospital activity 
assessment,  Italy  –  private  hospital  financing,  France,  Ireland,  Austria,  Spain, 
Hungary,  Germany,  Singapore,  Norway,  Finland,  Sweden,  Denmark  –  public 
hospital financing and regional settlements, Portugal, Australia – public and private 
hospital financing and regional settlements. 
Classification of a discharged patient in a diagnosis-related group  
First stage: Obtaining clinical data regarding discharged patients – there 
are seven mandatory data categories for each patient: age, gender, hospitalization 
duration, main and secondary diagnoses, surgeries or other therapeutic procedures 
or  diagnosis  performed:  condition  at  discharge;  weight  at  birth  (for  newborns 
only); data are collected from the general clinical record of the patient. 
Second  stage:  Encoding  diagnoses  and  procedures  in  view  of  report 
standardization; the encoding is performed based on the international classification 
diseases ICD 10, developed by OMS. 
Third stage: Electronic collection of data required for classification within 
DRG  in  a  database  comprising  all  discharged  patients  and  their  clinical  data. 
Hospitals reports discharged cases to INCDS according to the order of the Minister 
                                                        
1 Nicolăescu Eugen, Reforma sistemului sanitar – scenariul Nicolăescu. Medica – Revista Colegiului 
Medicilor din Romania, Anul 1, Nr. 2, 2009, pp.4-5          Special Number 1/2011                         Review of International Comparative Management  190 
of  Health  no.  29/2003.  To  ensure  data  confidentiality,  all  files  are  sent  in  an 
encrypted form. 
Fourth stage: Grouping of every patient in a diagnosis group, based on an 
algorithm. This automatic process uses software that is also knows as a grouper.  
 
2. Weaknesses of the Romanian health care system 
 
• The necessity of increasing the financing level of the Romanian health 
care system 
What has taken place in Romania after the introduction of health insurance 
system in 1997 was in fact (in contradiction to the ruled objectives at the initiation 
of the reform) the existence of a hybrid system between the financial control of the 
Health  Insurance  Funds  and,  at  the  same  time,  of  the  Ministry  of  Financing, 
resulting in many distortions in resources allocation and, first of all, a conversion 
of a part of these out of the medical system. Analyzing the operation of this hybrid 
system, some specialists in the field consider that there was no need for Romania to 
switch to the health care insurance system.  
But people dissatisfactions and expectations where diffuse after 1990 and 
they were not related to a certain means of functioning, but to the obviously poor 
quality  of  medical  services  and  doctors  discontent  related  to  low  wages  and 
difficult  work  conditions,  under  the  conditions  of  lack  of  sanitary  materials, 
facilities and utilities. In my opinion, the transition to the new financial pattern has 
created a new administrative mammoth, an annual consumer of important financial 
resources, I am talking about the National Health Care Insurance Funds (including 
also the county branches), whose administrative efficiency in relation to the costs is 
controversial. 
Why was the insurance-based system chosen? This is one of the questions.  
Analyzing the European models
1, the two options for a change would have 
been: the actual Bismark model, currently used in Germany, Austria, France, based 
on insurance and the Beveridge model in Great Britain, Italy and Sweden, based on 
general tax revenues.  
One of the specialists‟ explanations
2, is that the chosen model was more 
convenient to the Romanian inter-war reality and that is was a middle way between 
two  options  supported  by  two  sides:  the  supporters  of  the  free  market  for  the 
functioning of the health care system and the supporters of government planning.  
According  to  some  interviews  taken  to  policymakers  in  the  healthcare 
field, the transition to the new system was performed without a very clear analysis 
of the implications of various European models in the Romanian context and it has 
rather consisted of preferences of clerks and officials within that government for 
the German health care insurance model. In fact, during the period following the 
                                                        
1 Doboş Cristina, “Serviciile publice de sănătate şi dezvoltarea socială”. CALITATEA VIEŢII, XVI, 
nr. 3–4, 2009, pp. 1-13, http://www.iccv.ro/romana/revista/rcalvit/pdf/ cv2009.3-4.a11.pdf. 
2 C. Vlădescu (coord.), Sănătate publică şi management sanitar. Sisteme de sănătate,  2004 Review of International Comparative Management                              Special Number 1/2011  191 
‟89 moment, in Romania there were not many trained specialists in the health care 
management or health care policies field.  
The  question is  whether initial  expectations of people and professionals 
within the system were met. These expectations included: the increase of services 
quality  and  the  increase  of  medical  personnel  wages,  through  the  financial 
independence  of  the  system,  the  increase  of  its  financial  resources  and  the 
transparency of resource allocation. 
The  current  problems  within  the  system  are  related  to  the  fact  that  the 
current functioning and legislation have deviated from the initial objectives and 
philosophy  of  the  Health  Insurance  Law,  as  the  analyses  performed  by  the 
indicated author have shown a significant difference between the alleged policy 
and  the  implemented  reality  in  almost  all  listed  sections:  decentralisation,  new 
mechanisms for resource allocation, institutional autonomy
1.  
Health Insurance Law was came fully into effect only in  1999. It was 
subject  to  a  series  of  consecutive  amendments  during  the  years  after  the 
implementation (one of the Romanian post -revolutionary traditions, as this has 
happened  to  multiple  laws),  so  that  the  initial  philosophy  of  the  law  was 
significantly changed. According to several studies, even from the beginning, the 
new law has only introduced partial changes by means of its regulations. 
The precarious condition of financial resources allocate to the health care 
system during 1990–2009  has  continued  the  trend  of  scarce  investment  in  the 
health care system  over the past decades  in Romania. This has led to the poor 
endowment of public health care units with modern medical equipment and high-
tech utilities and to low wages for the personnel within the system as compared to 
their  self-perceived  status.  The  result  has  reflected  directly  on  the  quality  of 
medical services people benefitted from. The way the medical personnel perceive 
the work conditions provided by the system and their social status, along with the 
dissatisfaction towards low remuneration enables them to request extra-payments 
for the medical services. This restricts the access of poor people to medical services 
as they also consider that additional payment is a necessary/established practice.  
Public  health  expenses amounted to  only 2.8% of GDP in 1997 and to 
3.8% in 2009. Thus, the overall health care expenses as a GDP percent and as net 
income  ranks  Romania  at  the  end,  between  Central-European  countries  and 
between countries with similar GDP/per capita. Public health care expenses are less 
than half, as compared to many European countries. Hence, by introducing social 
insurances, the resources have only increased with 1% of GDP.   
Currently,  financing  sources  for  public  health  care  expenses  are:  health 
care insurance  funds, the state budget,  local budgets, own  income and  external 
resources. 
The  budget  of  the  Ministry  of  Health  and  the  budget  of  the  National 
Unique  Social  Insurance  Fund  manage  about  95-96%  of  the  total  health  care 
expenses and the rest is managed by other ministries with own health care network. 
                                                        
1 Doboş Cristina, “Serviciile publice de sănătate şi dezvoltarea socială”. CALITATEA VIEŢII,  XVI, 
nr. 3–4, 2009, pp. 1 – 13           Special Number 1/2011                         Review of International Comparative Management  192 
The  lack  of  an  unique  built-in  information  system  interconnecting  all 
medical services suppliers as well as the institutions with responsibilities in health 
insurance, allowing a better management of available funds and, at the same time, 
providing  an  "intelligent"  method  to  store  data  that  would  lead  to  a  database 
allowing long term synchronic and diachronic analyses and forecasts that would 
increase system adaptability to the real needs of people. 
• Lack of real financial and  managerial autonomy,  impairing all  major 
aspects of the activities of qualified institutions within health care system, from 
functional  organization,  to  collection,  financing,  contracting,  settlement, 
information etc.  
•  High  incidence  of  contagious  and  chronic  diseases.  The  low  living 
standard and the lack of information are some of the reasons why statistics rank us 
among  the  “foremost”  as  regards  severe  contagious  diseases  such  as  AIDS, 
syphilis, TB, Hepatitis C or chronic diseases such as diabetes – the treatment of 
which amounts in certain cases to 6 – 7 thousand RON/month for an insurant. This 
also leads to an increase of pressure over the system, i.e. the continuous increase of 
medical services demand following the constant deterioration of population health 
condition.  
• The incidence of problems related to the ignorance of services related to 
family planning, a problem with multiple consequences, from the large number of 
abortions due to the lack of information, thus problems that are not only related to 
health but also to demographic aspects, to STDs. 
 
3. Threats – Opportunities 
 
THREATS – OPPORTUNITIES 
1.Major determinants of health condition  
1. Recoil  
of social-
economical 
determinants  
a) Although Romania amounts about 6% of the total EU inhabitants 
(15), only produces 1.5% of GDP (PPS) of UE. 
b)  The  analysis  of  the  human  development  index  (HDI)  in 
Romania, during 1990-2009, reveals important differences, not 
only against the countries within EU (15), but as well against the 
last 10 countries that have accessed (0.778 in 2009 at Romania 
level, as compared to index between 0.936 and 0.946 in EU-15 
and  between  0.895  and  0.850  in  countries  such  as  Slovenia, 
Cyprus, Malta, Poland). 
c)  As  compared  to  the  EU  average  (15),  Romania  distinguishes 
itself by a high share of people aged between 25-64 and with 
an average education level: 60.9% against 43% (UE average-
15); but in Romania, the segment of population aged between  
25-64, with a higher education level, only amounts to 9.6%, 
as compared to the same share on the EU assembly -15 of 21%. 
d)  Employment  indicators  in  Romania  highlight  the  existing 
difference against those registered by EU-15. 
 Review of International Comparative Management                              Special Number 1/2011  193 
THREATS – OPPORTUNITIES 
2. Unreasonable 
health care 
behaviour 
related to 
health risk 
factors  
a) Tobaccoism incidence has mainly increase on male segment, as 
Romania distinguishes by a cigarette consumption (62% of the 
adult  population  in  2009),  highly  exceeding  the  EU  countries 
average  (where  the  range  of  this  share  varies  between  19%  - 
Sweden and 47% - Greece). 
b)  The  average  yearly  consumption  of  certain  foods  that  can 
impair health show for Romania an alarming deterioration of 
people  nutrition,  having  effects  over  the  health  condition, 
mainly  for  deprived  segments  of  population;  it  is  noticed  the 
tendency  to  increase  consumption  per  inhabitant  during 
2000-2007, of all foods (not including sugar) considered risk 
factors that can harm health: calories from 2953 (year 2000) to 
3233  (year  2007),  alcohol  from  8.9  l  to  9.6  l,  vegetable  and 
animal fats from 14.3 kg to 17.2 kg. 
3. Poor 
environmental 
conditions  
a)  The  huge  difference  Romania  registers  as  compared  to  EU 
countries related to the environmental conditions is emphasized 
by the very low share of population having access to a quality 
water  source  (58%  in  2000)  and  quality  sanitary  installations 
(53% in 2000). 
b) Possible morbidity shocks, under the conditions of the powerful 
damage  to  the  environment  (acts  of  God)  and  of  the  urban 
decline (the absence of investments in utilities), marginalisation 
of the dropped behind areas 
4. Health 
promotion 
As opposed to  UE, where a series of effective measures were 
taken,  with  visible  results  and  retrieved  as  synergetic  effect  in 
reducing  the  morbidity  and  mortality  degree  of  population,  in 
Romania  is  it  possible  to  assess  that  a  conjugated  action  is 
required of all involved factors in ensuring the performance of 
the national health system, so much the more as morbidity rates 
have  increased  for  the  main  contagious  diseases  (tuberculosis, 
syphilis, viral hepatitis...) 
 
Conclusion 
 
At the level of all European health systems, there are discussions about the 
profitable,  effective  development  direction  of  health  care  services  in  view  of  a 
sustainable social development. Fiscal pressures also cause developed countries to 
pose questions regarding new financial sources, a new management as effective as 
possible of these or alternate ways to organize services.  
We can say that, at European level, health is considered a social right all 
citizens must have access to, as opposed to USA, for example, where health is an 
individual good for which people must pay high costs.
1. 
 
                                                        
1 Vlădescu Cristian (coord.), Sănătate publică şi management sanitar. Sisteme de sănătate, Bucureşti 
(Centrul pentru politici şi servicii de sănătate), Editura CPSS, 2004          Special Number 1/2011                         Review of International Comparative Management  194 
The paper represents partial results of the scientific research entitled “Social and 
economic efficiency in the public health system in Romania, the fundamental vector 
of the sustainable growth and increased wealth”, within the postdoctoral school 
“The  Economy  of  the  Knowledge  Transfer  in  Sustainable  Development  and 
Environment Protection” (POSDRU / 89 / 1.5 / S / 56287 project). 
 
 
  References 
 
1.  Doboş  Cristina,  “Serviciile  publice  de  sănătate  şi  dezvoltarea  socială”. 
CALITATEA  VIEŢII,  XVI,  nr.  3–4,  2009,  pp.  1-13,  http://www.iccv.ro/ 
romana/revista/rcalvit/pdf/cv2009.3-4.a11.pdf 
2.  Doboş  Cristina,  “Serviciile  publice  de  sănătate  şi  dezvoltarea  socială”. 
CALITATEA VIEŢII, XVI, nr. 3–4, 2009, pp. 1 – 13 
3.  Nicolăescu  Eugen,  “Reforma  sistemului  sanitary”  –  scenariul  Nicolăescu. 
Medica – Revista Colegiului Medicilor din Romania, Anul 1, Nr. 2, 2009, 
pp.4-5 
4.  Vlădescu Cristian (coord.), Sănătate publică şi management sanitar. Sisteme 
de sănătate,  2004 
5.  Vlădescu Cristian (coord.), Sănătate publică şi management sanitar. Sisteme 
de sănătate, Bucureşti (Centrul pentru politici şi servicii de sănătate), Editura 
CPSS, 2004 
 

Reforma sistemului sanitary” – scenariul Nicolăescu.

Sănătate publică şi management sanitar. Sisteme de sănătate,

Sănătate publică şi management sanitar. Sisteme de sănătate, Bucureşti (Centrul pentru politici şi servicii de sănătate), Editura CPSS,

Serviciile publice de sănătate şi dezvoltarea socială”.

The SWOT Analysis of the Romanian Health Care System

http://rmci.ase.ro/no12vol1s/Vol-12_No-1S_Article-30.pdf

The SWOT Analysis of the Romanian Health Care System

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