Assuring the health of the general public is a major objective of each country’s public health system. To insure this goal the public health system needs to offer good quality and prompt services according to the population’s needs The paper presents the main results of a two step sampling procedure applied within the medical institutions from Bucharest in July 2007. Using a representative sample of 407 persons the paper presents the main descriptive statistics calculated on the most important variables that were taken into account in order to quantify the impact of the reform measures applied in the public health care system on the quality of the medical services provided to the general public.Statistical sampling, Descriptive Statistics, Public Health Care System, Reform

Andrei Tudorel

Calin Catalina

Stancu Stelian

Tusa Erika

English

Research Papers in Economics

810 
 CARACTERIZING THE PUBLIC HEALTH SYSTEM REFORM 
USING THE STATISTICAL SURVEY APPROACH
 287 
Andrei Tudorel  
Academia de Studii Economice, Bucure￿ti, andreitudorel@yahoo.com 
C￿lin C￿t￿lina Liliana 
Universitatea de Medicin￿ ￿i Farmacie “Carol Davila”, Bucure￿ti, ccatalina97@yahoo.com 
Tusa Erika
 
Academia de Studii Economice, Bucure￿ti, erika_tusa@yahoo.com 
Stancu Stelian
 
Academia de Studii Economice, Bucure￿ti, stelian_stancu@yahoo.com 
 
Abstract 
Assuring the health of the general public is a major objective of each country’s public health system. To 
insure this goal the public health system needs to offer good quality and prompt services according to the 
population’s needs. 
The  paper  presents  the  main  results  of  a  two  step  sampling  procedure  applied  within  the  medical 
institutions from Bucharest in July 2007.  
Using a representative sample of 407 persons the paper presents the main descriptive statistics calculated 
on the most important variables that were taken into account in order to quantify the impact of the reform 
measures applied in the public health care system on the quality of the medical services provided to the 
general public. 
Key words: Statistical sampling, Descriptive Statistics, Public Health Care System, Reform  
1. Introduction 
Assuring the health of the general public is a major objective of each country’s public health system. To 
insure this goal the public health system needs to offer good quality and prompt services according to the 
population’s needs. The latest economic evolutions in Romania have are determining a new approach of 
the  medical  care  and  are  closely  related  to  the  following  factors:  financial  constraints,  the  need  of 
reforming the health care system and the integration of Romania in the European Union’s structures. 
In order to achieve a clear image of the reform process in the health care system, this paper presents a 
research based on a statistical survey of the public health system in Romania. The paper presents the 
characteristics of the sample, its structure and the main results of the analysis. 
2. The characteristics of the sample 
The sampling procedure was established based on the literature related to the main world tendencies of the 
public health system as well the reform strategy developed for Romania by the Ministry of Public Health. 
The main stakeholders considered in the implementation of the reform process in the health system were 
taken into account: 
−  Family doctors 
−  Medical personnel from hospitals and clinics 
−  Personalities from the medical world 
The research is based on a statistical sampling procedure developed based on a questionnaire that considers 
three aspects related to the reform process in the public health system: 
−  the reform measures undertaken by the Ministry of Public Health,  
−  the models applied in the European Union for analyzing the performance of the public health 
system and 811 
−  the preliminary discussions with specialists from institutions with interests in this field. 
The questionnaire has a set of questions addressing issues related to the quality of the reform process in the 
public health system, the policy of the MPH, the medical education of the population, the analysis of the 
improper behavior of some of the personnel from the public health institutions, the research capacity and 
the current activities characteristics of the public health institutions.  The number of questions defined for 
each area of research is presented in the following table: 
 
Table 1. The structure of the questionnaire, by area of research 
Nr. 
Crt. 
Area of research  Number of closed 
questions 
Number of variables 
1.  General aspects of the public health system reform 
process 
5  41 
2.  The public policy framework defined by the MPH  5  18 
3.  The  general  public’s  education  related  to  health 
aspects 
7  18 
4.  The analysis of the improper behavior of some of the 
personnel from the public health institutions 
7  24 
5.  The research capacity of the public health system  6  23 
6.  Current activities’ characteristics of the public health 
institutions 
2  6 
7.  Personal identification data  12  32 
8.  General data  8  11 
The sample  was constructed using a two steps survey. The first step included the  medical units from 
Bucharest (hospitals, clinics, health centers). The second step was represented by the selection of medical 
doctors for each primary sampling unit. For Bucharest municipality the statistically representative sample 
size was established at 407 persons and it was chosen a 95% confidence in the result and a representativity 
error of ±5%.  
The data was stored and tabulated using the SPSS program. 
3. Significant results of the analysis 
The main results of the descriptive statistics analysis at the sample level are presented below for the most 
relevant variables that are characterizing the reform process in the public health care system in Romania.  
The first question tries to assess the perception of the medical personnel referring to the reform in the 
public health system.  
The results presented as percentages from the total number of responses corresponding to each of the 5 
qualitative measures are presented in the following table: 
A. How do you appreciate the following aspects of the public health system reform?  
 
Very 
weak  Weak  Satisfac
tory  Good  Very 
good 
1. Financing of health system  38,12   46,78   13,12   1,73   0,25  
2. reform measures in your institution  19,10   42,96   26,88   9,55   1,51  
3. Medicines acquisition system  23,75   38,50   26,75   10,25   0,75  
4. decentralization system   22,40   44,27   24,74   8,33   0,26  812 
5. Hiring and promotion of medical doctors  29,57   35,59   24,81   9,27   0,75  
6. Hiring and promotion of nurses  21,16   35,52   32,24   9,57   1,51  
The major problem identified by most of the respondents is related to the financing of the public health 
system. More than 85% of the specialists from the medical field consider as negative or extremely negative 
this aspect directly related to the proper functioning of the system. Only an insignificant percent of around 
2 perceives the financing of the health system good or excellent.  
Another aspect that has a negative impact on the efficiency of this public service regards the hiring and 
motivation of the medical staff – both doctors and nurses. This might justify the fact that in the last years 
an  important  number  of  doctors  and  nurses  left  Romania  and  wet  to  practice  medicine  in  different 
developed countries. According to an estimation of the Ministry of Public Health, the medical system lost 
around 5% of its staff that left Romania for better paid jobs. This trend might continue unless some rapid 
measures will be taken in order to stimulate the medical personnel. 
The medical personnel have rather a negative view on the evolution of the public health sector in the near 
future.  The  respondents  were  asked  about  the  improvement  of  the  quality  of  medical  services,  their 
accessibility, financing, salaries and equipments.      
The answers were given on a scale from 1 (extremely unfavorable evolution) to 5 (very positive evolution). 
The answers for hospitals, clinics and medical labs are presented in the following tables:  
A. Hospitals   
  1  2  3  4  5 
Improvement of the quality of medical services  5,15  13,40  36,86  41,49  3,09 
Improvement  of  the  public’s  accessibility  of  the 
medical services  3,60  17,48  36,76  37,79  4,37 
Improvement of the financing of the public health 
system   10,73  23,82  39,53  24,35  1,57 
Salary raise   9,21  15,26  44,74  27,89  2,89 
Improvement of medical equipments  6,61  12,17  33,07  44,71  3,44 
B. Clinics 
  1  2  3  4  5 
Improvement of the quality of medical services  3,18   11,56   43,93   37,86   3,47  
Improvement  of  the  public’s  accessibility  of  the 
medical services  1,98   13,03   42,21   35,98   6,80  
Improvement of the financing of the public health 
system   5,19   22,48   47,55   21,90   2,88  
Salary raise   5,51   13,33   51,01   26,67   3,48  
Improvement of medical equipments  6,41   16,62   42,27   30,61   4,08  
C. Medical labs 
  1  2  3  4  5 
Improvement of the quality of medical services  2,6   6,5   22,3   57,8   10,9  
Improvement  of  the  public’s  accessibility  of  the 
medical services  0,9   10,2   24,4   53,2   11,3  813 
Improvement of the financing of the public health 
system   5,2   12,5   39,1   35,4   7,8  
Salary raise   4,4   11,8   40,5   37,9   5,3  
Improvement of medical equipments  3,9   10,4   23,8   50,0   11,9  
The  reform  process  requires  insuring  the  medical  institutions  with  all  the  needed  resources  (medical 
endowment, qualified staff, medicines, and management), an efficient organization system and coherent 
policy measures. The most important results related to these issues are summarized in the following table:  
 C. How do you appreciate the following aspects in your medical institution?  
  Very weak  Weak  Satisfactor
y  Good  Very 
good 
1. Medical endowment  13,65   34,49   31,51   16,38   3,97  
2. Assuring the required stock of medicines  13,53   37,09   28,82   17,54   3,01  
3. Internal organization of the institution  9,55   21,36   41,46   19,35   8,29  
4.  Assuring  highly  qualified  medical  staff 
(with university degree)   3,99   18,45   28,68   35,16   13,72  
5. Assuring medical staff  (nurses)  9,50   29,25   26,50   29,75   5,00  
Almost half of the specialists consider as the most important problems the poor condition of the medical 
endowment and the medicines in hospitals and clinics. The general opinion is favorable with respect to the 
quality of medical staff, both medical doctors and nurses. 
D.    How  do  you  appreciate  the  evaluation  system  of  the  quality  of  the  medical 
services in your institutions?  
  Unsatisfactory  Satisfactory  Good  Very good 
1.  Performance  indicators  system  in 
evaluating the institution’s performance  25,75   51,00   21,75   1,50  
2.  Annual  evaluations  of  the  employees 
performance   24,50   44,00   25,00   6,50  
3. Permanent feedback from the patients 
on the quality of medical services   38,13   36,11   21,97   3,79  
 
The results from the table above show the following aspects: a poor performance evaluation system in the 
medical care institutions and a lack of feedback from the patients regarding the quality of the medical 
services. These deficiencies could be corrected on a relatively short period of time if the management of 
change in the medical sector would be tackled in two distinct phases: the political pre-decision followed by 
a managerial (post)decision   814 
E.  How  do  you  appreciate  the  transparency  of  the  Ministry  of  Public  Health 
regarding  the  measures  taken  during  the  reform  process  in  the  public  health 
system? 
  Unsatisfactory  Satisfactory  Good  Very good 
1. Consulting  the  professional 
associations  when  passing 
legislation related to the reform in 
health system  
60,65   23,31   13,78   2,26  
2. Informing the mass media about 
them  47,25   30,25   18,75   3,75  
 
The transparency as well good communication from the decision makers to all the stakeholders represents a 
condition of success in a reform process. Unfortunately, the results in the sample show major deficiencies 
in the communication between the Ministry and the stakeholders. More than 83% of the medical doctors 
have a negative opinion regarding the consultation of the professional associations when passing legal acts.  
F. How do you appreciate the following aspects related to the policy measures in the 
public health system? 
 
Unsatisfact
ory  Satisfactory  Good  Very 
good 
1. The public expenses on health (as % in GDP)  76,50  19,00  4,5  0,00 
2. The national policy measures developed by MPH   49,11  39,75  10,4  0,76 
3.  The  transparency  in  using  the  public  funds  when 
acquiring compensated or free medicines    64,65  26,52  8,1  0,76 
The formulation and implementation of the policy measures in the public health as well as the level of 
public funds spent on medical care is view as unsatisfactory by most of the respondents.  
G. Appreciate the level of public’s accessibility of the medical services  
  Very small  Small  Medium  Large  Very large 
1. primary  6,72   14,18   44,03   28,86   6,22  
2. secondary  6,31   21,46   51,01   19,19   2,02  
3. tertiary  9,87   29,87   44,30   13,16   2,78  
 
By contrary, the level of public’s accessibility of medical care services if viewed as a good one by most of 
the medical doctors. 
When asked about the influence of the new legislation on the hospitalization of a patient, the opinions 
varied among the medical doctors. Some of them perceive that the new legislation will increase the hospital 
costs or the expenses on compensated medicines, other the opposite.  815 
H.  How  do  you  think  the  new  legislation  will  impact  on  when  hospitalizing  a 
patient?  
  Negative 
Moderately 
negative 
No 
influence 
Moderately 
positive 
Positive 
1. Hospital costs  7,03  25,00  31,77  35,68  0,52 
2.  Expenses  on  compensated 
medication   8,09  21,67  43,86  25,85  0,52 
3. Public health  10,70  15,67  43,34  28,72  1,57 
4.  Administrative  activity  in  the 
hospital  21,41  27,68  31,85  16,45  2,61 
An  agreement  of  the  medical  doctors  is  achieved  regarding  the  impact  of  new  legislation  on  the 
administrative activity in the hospital – more than 80% of them expecting a negative impact or no influence 
regarding this aspect.  
4. Conclusions 
Several reform measures in the public health sector were backed up with some programs that received 
external  financing  (such  as  the  PAL  program  of  the  World  Bank  or  the  Post  Accession  Structural 
Adjustment Program). 
The reform process in the public health system will be a long time one and will involve not only the 
Ministry of Public Health but the medical institutions and staff as well. 
This paper showed the opinion of the medical doctors selected in a representative sample from Bucharest 
regarding the impact of the reform measures applied in the public health care system on the quality of the 
medical services provided to the general public. 
It becomes clear the need of improving the financing of the public health care system as well as the 
improvement of the staff motivation and evaluation process. 
In order to evaluate the quality of the medical services it is recommended to construct a frame model for 
this system that will allow the analysis of the dependency between the results of the public health care 
system and the market policies and the management process  
References 
1.  A.  Jevcak,  Healthcare  reform  –  unpopular  even  in  Slovakia,  Economic  Analysis  from  the 
European Commission’s Directorate-General for Economic and Financial Affairs, Ecfin Country 
Focus, Volume 3, Issue 2, 2006; 
2.  C. AbouZhar, T. Boerma, Health information systems : the foundations of public health, Bulletin 
of the World Health Organization, August 2005, 83(8), pg. 578-583, 2005; 
3.  C. Jagger, B. Cox, S. Le Roy et al., Health Expectancy Calculation by the Sullivan Method: A 
Practical Guide, EHEMU Technical Report 2006_3, June 2007; 
4.  T. Andrei, Statistic￿ ￿i Econometrie, Editura Economic￿, Bucuresti, 2003 
 
 
 
 

CARACTERIZING THE PUBLIC HEALTH SYSTEM REFORM USING THE STATISTICAL SURVEY APPROACH

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CARACTERIZING THE PUBLIC HEALTH SYSTEM REFORM USING THE STATISTICAL SURVEY APPROACH

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