This section presents the three indicators of institutional resilience and assesses their status during the COVID-19 crisis in Romania. Table 1 includes these indicators and the subsections below explain the scores we provide for each of them.
There are many signs that the health care system in Romania was not prepared for the pandemic. We provide a score of 2 for three reasons. First, Romania has the lowest public expenditure on health care in the EU, way below the average. In terms of percentage of the GDP, Romania allocates 5% to health compared to 9.8% the EU average. In terms of per capita expenditure, Romania has 1029 € compared to 2884 € as the EU average (Eurostat 2020). This low health care expenditure is reflected in a lack of appropriate medical infrastructure and medical supplies. For example, hospitals had a low testing capacity and insufficient beds for intensive care units. In general, there was limited medical equipment for the pandemic. Based on the European Centre for Disease Prevention and Control data, the testing capacity in Romania was lower than half the EU average, with only 1090 weekly tests per 100,000 persons during the peak month of November 2020. This was the lowest testing capacity level in the EU—alongside Bulgaria—while the positivity levels in the country in the same interval were double that of the EU average levels (ECDC Website 2021). At the national level, only a little over 1000 intensive care units (ICU) with ventilators existed in Romania at the beginning of the pandemic, despite having over 500 hospital beds per 100,000 persons compared to the EU average of approximately 300. Throughout the peak of the pandemic in 2020, ICU capacity was full, with many new admissions unable to receive specialised care.
Second, most health facilities in Romania were outdated, built during the communist period, with non-systematic facility improvement over the past decades, and heavily skewed towards some regional poles. The territorial network of medical facilities was not equipped to manage appropriately specialised treatment such as intensive care. Even early diagnostic and at-home care was problematic in many of the poorer counties in Romania, where the number of general practitioners has decreased significantly over the previous decade (Social Monitor 2021). The hospital units did not meet the safety and hygienic-sanitary norms, determining increased risk of infections and a high degree of unsatisfied medical needs. Several fire incidents with multiple casualties in public hospitals during the first year of the pandemic occurred because of poor safety measures and implementation of technical standards.
Service delivery is also affected by the poor medical infrastructure in Romania. Roughly 11% of the population remains uninsured and has access only to a restricted package of services. There is a decreasing trend in the coverage of health care insurance in Romania, with a significant gap between urban and rural areas. The level of unmet medical needs is about 28% higher in rural areas than in the whole country (Ministry of Investments and European Projects 2021). This is reflected in the poor accessibility to specialised care for less developed regions and rural areas. Almost 20% of health care expenses are out-of-pocket in Romania, which rises to almost 50% for chronic disease, such as cancer, where patients travel sometimes up to 12 h to reach a specialised treatment centre or wait for up to 6 months for a diagnosis (Volintiru et al. 2021).
Third, the Romanian health care system is plagued by a massive exodus of medical staff, especially in key specialisations for pandemics such as nurses or intensive-care personnel (Interview Vlad Mixich 2021). Until recently, the public sector salaries in Romania were very low compared to private sector employment. The austerity measures in 2009 meant a further 25% decrease in health care salaries that led to outward migration of medical personnel (Interview with Raed Arafat 2021). Although in the recent years, there is a significant rise in the wages of medical personnel, there is a time lag in retaining future generations of medical professionals. In 2017, Romania had 2.9 doctors and 6.7 nurses per 1000 inhabitants compared to the EU average of 3.6 doctors and 8.5 nurses (Eurostat 2020). Drawing back medical personnel is much harder to achieve. Romania’s public health care system has a deficit of almost 40,000 health care workers today, equivalent to 17.46 percent of staffing needs at public hospitals (Gillet 2020).
The assessment of agility for the Romanian health care system is done relative to the swiftness of reaction and to the type of decision-making process. We provide a score of 3 for two main reasons. First, there was a centralised decision-making system characterised by speed and coordination (Interview with Raed Arafat 2021). At central level, there was a prompt reaction about the threat of the pandemic. A state of emergency was declared in March 2020, allowing for an increased effectiveness of governmental measures especially in imposing and enforcing restrictions. Government measures aimed at diminishing the spread of COVID-19 before vaccination involved travel restrictions, curfew, and quarantine. These measures had a direct negative impact on the economic activity in a country with a GDP linked greatly to consumption. Consequently, gradual relaxation ensued and the initial advantage from the agile reaction in the beginning of the pandemic in terms of controlling the spread of the disease was lost by the fall of 2020 when the number of cases rose significantly.
Second, the capacity of the health care system components such as hospitals or local directions from public health officials in charge of the epidemiological management varied greatly, and so did the agility of their reactions. Better organized institutions had a more agile reaction in adopting national regulations and developing their own internal procedures. However, in Romania, hospital management is usually filled by medical professionals. Due to either the heavy work burden of medical care or to poor managerial specialization, the hospital administrative procedures often lagged behind. Overall, hospitals had a slow reaction both in terms of internal organization (e.g. access circuits in hospitals) and of logistics and acquisitions (e.g. public procurement for ventilators or personal protection equipment). For example, most of the first line medical personnel lacked personal protective equipment for several months after the beginning of the pandemic. Time-consuming public procurement procedures at hospital level made the system highly ineffective in ensuring necessary supplies. Due to this low agility of public institutions regarding the public procurement, much of the medical staff became sick and there was high incidence of COVID-19 infections during hospitalisation.
Two dimensions of the Romanian health system contribute to a score of 3 for the robustness of the health care system: the specialised infectious disease hospitals and the emergency services. First, the Romanian health care system managed to turn one of its liabilities into a key capability during the pandemic. Romania has a relatively high number of stand-alone dedicated facilities because of a high incidence of infectious disease. Furthermore, being old buildings from the in-between the war period, many Romanian hospitals still have a pavilion-based architecture that facilitated the safety circuits for the care of COVID-19 patients (Interview with Medical Professional 2021).
The second element of robustness in the Romanian health care system is the emergency service. The system has a complementary Department for Emergency Situations within the Ministry of Internal Affairs that coordinates all emergency services including fire and rescue, civil protection, prehospital medical emergency response, air rescue and emergency departments. The Department coordinates the Mobile Emergency Service for Resuscitation and Extrication in collaboration with county, regional and local public authorities. This structure integrates the reanimation teams specialized in providing emergency medical and technical assistance, as well as teams with paramedical personnel, specialized in granting qualified first aid. This integrated emergency system compensated to a large extent for many of the institutional weaknesses of hospitals related to their quick reaction. It offered standardized procedures and action plans, coordinated hospital needs and resources, and addressed to the best of its ability the many disparities of capacity across Romanian medical facilities.
Stocks of key medical equipment such as ventilators and personal protection equipment became a norm of preparedness for health care systems around the globe (Ranney et al 2020). As hospital management procedures were moving decisively towards efficiency and diminishing costs (Eurofound 2017), the general assumption was that it was not worth having large stocks of such products. Hospital managers in Romania struggled with a trade-off between efficiency and the resilience of their institution in the face of a medical crisis like COVID-19 (Interview with Hospital Manager 2021). While the national authorities recognize the resilience requirement of stocks to achieve the robustness of the health care system, national auditing institutions have changed their legal position thus creating the potential for future blockages (Interview with Raed Arafat 2021).
Finally, the health care system in Romania is plagued by corruption that affects both the immediate and long-term resilience of the health care system. As medical professionals in Romania were scrambling to get personal protection equipment on their own, the national procurement agency was still engaging in kick-back negotiations with overpriced suppliers (Gascón Barberá 2020).