Assessment of Public Hospital Governance in Romania: Lessons From 10 Case Studies

Document Type : Original Article


1 ALLDMHEALTH, Seville, Spain

2 Oxford Policy Management, Oxford, UK


The Government of Romania commissioned international technical assistance to help unpacking the causes of arrears in selected public hospitals. Emphases were placed on the governance-related determinants of the hospital performance in the context of the Romanian health system.
The assessment was structured around a public hospital governance framework examining 4 dimensions: institutional arrangements, financing arrangements, accountability arrangements and correspondence between responsibility and decision-making capacity. The framework was operationalized using a 2-pronged approach: (i) a policy review of broader health system governance arrangements influencing hospital performance; and (ii) a series of 10 case-studies of public hospitals experiencing financial hardship. Data were collected during 2016-2017 through key informant interviews with central authorities and hospital management teams, exhaustive semi-structured questionnaires filled in by hospitals, as well as the review of documentary sources where feasible.
Overall, the governance landscape of Romanian public hospitals includes a large number of seemingly modern legislative provisions and management instruments. Over the past 30 years substantial efforts have been made to put in place standardised hospital classification, hospital governance structures, management and service purchasing contracts with key performance indicators, modern reimbursement mechanisms based on diagnosis-related groups (DRGs), and regulatory requirements for accountability, including internal and external audit. Nevertheless, their application appears to have been challenging for a range of reasons, pointing to the misalignment between the responsibility and decision-making capacity given to hospitals in a questionably conducive context. Incoherent policy design, outdated and often disjointed regulatory frameworks, and cumbersome administrative procedures limit managerial autonomy and obstruct efficiency gains. In a context of chronic insufficient funding, misaligned incentives, and overly rigid service procurement processes, hospitals seem to struggle to adjust service baskets to the population’s health needs or to overcoming financial hardship. External challenges, combined with the limited strategic, operational, and financial management capacity within hospitals, make it difficult to exhibit good financial and general performance.
Existing governance arrangements for Romanian public hospitals appear conducive to poor financial performance. The suggested framework for hospital governance assessment has proved a powerful tool for identifying system and hospital-specific challenges contributing to sub-optimal hospital performance.


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Main Subjects

  1. OECD. Health at a Glance 2017: OECD Indicators. Paris: OECD; 2017. doi:10.1787/health_glance-2017-en
  2. OECD.Stat. Health expenditure and financing.  Published 2017.
  3. Ministry of Health (MoH). Kenya National Health Accounts 2012/13. Nairobi: MoH; 2015.
  4. Ministry of Health and Social Welfare. Tanzania National Health Accounts Year 2010 with Sub-Accounts for HIV and AIDS, Malaria, Reproductive, and Child Health. Dar es Salaam; 2012.
  5. Racelis R, Dy-Liacco F, David L, Nievera L. Health Accounts Estimates of the Philippines for CY 2012 Based on the 2011 System of Health Accounts. Philipp J Dev. 2016;41-42(1-2):188-210.
  6. National Health Systems Resource Centre. National Health Accounts Estimates for India (2013-14). New Delhi; 2016.
  7. James C, Berchet C, Muir T. Addressing operational waste by better targeting the use of hospital care. In: Tackling Wasteful Spending on Health. Paris: OECD Publishing; 2017:193-225. doi:10.1787/9789264266414-en
  8. Tracking Universal Health Coverage: 2017 Global Monitoring Report (Joint WHO/World Bank Group report).  WHO website.  Published December 2017.
  9. National Institute of Statistics. Health Sector Activity Statistics 2017. Bucharest; 2018.
  10. National Health Insurance House. Annual Evolution of the National Health Insurance Fund 1999-2018. Bucharest; 2018.
  11. Vladescu C, Scintee S, Olsavsky V, Hernandez-Quevedo C, Sagan A. Romania Health System Review. Health Syst Transit. 2016;18(4):1-170.
  12. Presidential Commission for the analysis and elaboration of public health policies in Romania. A Health System Centered on Citizens’ Needs. Published 2008.
  13. European Commission. Country Report Romania 2015 Including an In-Depth Review on the Prevention and Correction of Macroeconomic Imbalance. European Commission; 2015.
  14. European Commission. Balance of Payments Assistance Programme, Romania 2013-2015. Luxembourg; 2015.
  15. Duran A. A framework for assessing hospital governance. In: Saltman R, Duran A, Dubois HFW, eds. Governing Public Hospitals. Reform Strategies and the Movement towards Institutional Autonomy. Who; 2011.
  16. Arah OA, Westert GP, Hurst J, Klazinga NS. A conceptual framework for the OECD Health Care Quality Indicators Project. Int J Qual Heal Care. 2006;18(suppl_1):5-13. doi:10.1093/intqhc/mzl024
  17. Groene O, Botje D, Suñol R, Lopez MA, Wagner C. A systematic review of instruments that assess the implementation of hospital quality management systems. Int J Qual Health Care. 2013;25(5):525-541. doi:10.1093/intqhc/mzt058
  18. Veillard J, Champagne F, Klazinga N, Kazandjian V, Arah OA, Guisset A-L. A performance assessment framework for hospitals: the WHO regional office for Europe PATH project. Int J Qual Heal Care. 2005;17(6):487-496. doi:10.1093/intqhc/mzi072.
  19. The International Federation of Accountants (IFAC). International Standard on Assurance Engagements (ISAE) 3000 “Assurance Audits Engagements Other Than Audits or Reviews of Historical Financial Information.” IFAC; 2013.
  20. Ruiz F, Lopert R, Chalkidou K. Technical Assistance in Reviewing the Content and Listing Processes for the Romanian Basic Package of Health Services and Technologies: Final Report. NICE International; 2012.
  21. Chiriac N, Musat S, Shah J, Vladescu C. Romania – experience and new steps in the context of the international patient classification system. BMC Health Serv Res. 2011;11(Suppl 1):A12. doi:10.1186/1472-6963-11-S1-A12
  22. WHO Europe. Evaluation of Structure and Provision of Primary Care in Romania - a Survey-Based Project. Who; 2012.
  23. Radu C-P, Pana BC, Furtunescu FL. Drug Policy in Romania. Value Heal Reg Issues. 2018;16:28-32. doi:10.1016/j.vhri.2017.11.003
  24. Barasa EW, Molyneux S, English M, Cleary S. Hospitals as complex adaptive systems: A case study of factors influencing priority setting practices at the hospital level in Kenya. Soc Sci Med. 2017;174:104-112. doi:10.1016/j.socscimed.2016.12.026
  25. De Geyndt W. Does autonomy for public hospitals in developing countries increase performance? Evidence-based case studies. Soc Sci Med. 2017;179:74-80. doi:10.1016/j.socscimed.2017.02.038
Volume 8, Issue 4
April 2019
Pages 199-210
  • Receive Date: 28 February 2018
  • Revise Date: 29 November 2018
  • Accept Date: 01 December 2018
  • First Publish Date: 01 April 2019