Out-of-pocket payments for health care in Romania undermine progress towards universal health coverage

Romania has a high incidence of catastrophic health spending compared to other European Union (EU) countries, a new report by WHO/Europe finds. In 2015, 1 in 8 households incurred out-of-pocket payments that exceeded 40% of their capacity to pay for health care, the report reveals. Catastrophic health spending means a household can no longer afford to meet other basic needs, such as food, housing and electricity.

The report produced by the WHO Barcelona Office for Health Systems Financing is the first comprehensive analysis of financial protection – otherwise known as affordable access to health care – in Romania. The analysis shows that catastrophic health spending is heavily concentrated among the poorest 40% of households and older people. It is mainly driven by out-of-pocket payments for outpatient medicines, followed by dental care and outpatient care. 

Between 2010 and 2015, the incidence of catastrophic health spending grew, particularly among poorer households. Although access to health care improved during this period, the rates of unmet needs for health care and dental care in Romania continue to be well above the EU average.

Gaps in coverage

Reforms introduced in the last few years have expanded the range of health benefits provided by Romania’s National Health Insurance House (NHIH), and levels of public spending on health have increased.

Despite these positive developments, the report also draws attention to persistent gaps in health coverage. 

  • 12% of the population is uninsured and can only access a few publicly-financed health services. People need to pay health insurance contributions to access NHIH benefits, which some people with low incomes cannot afford.
  • Exemptions from user charges (co-payments) for prescribed medicines do not target people with low incomes, and there is no overall cap on co-payments. Balance billing and extra billing by health care providers is also problematic and undermines transparency.
  • Access to dental care is limited due to budget constraints.

Other factors that contribute to financial hardship and unmet needs include:

  • informal payments to health workers and for medicines and supplies, particularly in inpatient care;
  • issues with service quality and ageing infrastructure in public hospitals; and
  • a shortage of health facilities and professionals in rural areas.

Making access to health care affordable for everyone

The new report sets out a series of policy recommendations to improve access and financial protection in Romania. These include the need to:

  • ensure the whole population is covered by the NHIH and has access to the same set of benefits;
  • extend exemptions from co-payments to low-income households and introduce an income-based cap on all co-payments;
  • limit the ability of health care providers to charge people additional user charges through balance billing and extra billing;
  • continue to improve the way in which the NHIH purchases medicines, including over-the-counter medicines;
  • strengthen the coverage and purchasing of dental care to address high levels of unmet needs in the poorest households; 
  • address informal payments, starting with better monitoring; and 
  • support these changes with increased public investment in the health system; public spending on health is still low in Romania compared to most EU countries, at 4.6% of GDP in 2019 compared to an EU average of 6%.

WHO supports countries in moving towards universal health coverage

Financial protection is central to universal health coverage, which is at the heart of the European Programme of Work, WHO/Europe’s strategic framework. Through the WHO Barcelona Office for Health Systems Financing, WHO/Europe monitors financial protection in over 40 countries. 

Financial protection is an indicator of the Sustainable Development Goals and part of the European Pillar of Social Rights. The WHO Barcelona Office provides tailored technical assistance to countries to reduce unmet need and financial hardship by identifying and addressing gaps in coverage.


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