The State Law on Health Organization passed in 1949 initiated a gradual transition from the pre-war Bismarck system into a Semashko health care system⁸³. This system was based on the principles of universal coverage and free access at the point of delivery. The main features of the Romanian health care system during this time were: government financing, central planning, rigid management and a state monopoly over health services. Also notable were the absence of a private sector (as the private system was abolished) and the fact that all professionals in the health system had the status of salaried civil servants. Central to this system was the state providing services to all members of society, leaving little or no choice to the user but seeking to achieve a high level of equity. In sum, a highly regulated, standardized and centralized system was operated through the Ministry of Health.⁸⁴

There was a long period of underfunding of the health care system in Romania during the Ceausescu regime. After 40 years of central control and nationalized economy, with rather poor health status of the population, the Romanian health care system was in crisis. After the breakdown of the communist regime in Romania in 1989, the reforms of the health care system began. The Ministry of Health initiated a new health policy, which included universal accessibility to health care, solidarity in funding health services, and incentives for effectiveness, efficiency, and adequacy of health care delivery to health care needs. In addition, autonomy of health professionals and cooperation between health care and other services that influence health (such as education and social services) were promoted⁸⁵. Between 1990 and 1995, the government and the Ministry of Health issued a series of decrees and orders which over time have led to many changes. Starting in 1995, important laws concerning the structure and organization of the Romanian health care system were passed. The new regulations practically changed the entire structure of the health care system and established the legal framework for the shift from an integrated, centralized, state owned and controlled tax-based system to a more decentralized and pluralistic social health insurance system, with contractual relationships between health insurance funds as purchasers and health care providers.⁸⁶

The Romanian health care system is thus in a transition phase from a situation in which it was almost entirely state-owned and coordinated by the Ministry of Health, towards a situation in which the relationships are more complex and the number of actors involved is bigger. Yet although a series of reforms are being implemented, the problems of the pre-1989 health care system remain evident. Melina Dumitrescu, founder member and administrator of Hospice Casa Sperantei, identifies some of the structural challenges:

‘…unfortunately key people in the Ministry have changed so fast and only since I've been employed by the hospice since '96, there were seven or eight Ministers of Health changed… I think I find it very hard to, the very sudden and unexpected changes in the structure of the authority that I have to deal with, and whenever you get a good response and people begin to understand…what we're doing, then suddenly you see the door is closed and the next time you go there's someone else and you have to start from scratch again… And they're always different persons and it always takes time to build up a new relation and then you find…people leave their jobs or resign or are changed without passing on any information, and all the little steps that you agreed to are forgotten or are not handed over to anybody. So then you have to start again.’⁸⁷

These difficulties are underlined by commentary from the European Observatory on Health Care Systems:

‘The main obstacles faced in the implementation of reforms were – and are – due to problems related to both political and managerial issues. Between June 1996 and June 1998, there were 6 different Ministers of Health and 8 different Secretaries of State; between January and August 1999, there were 3 different Presidents of the National Health Insurance Fund. At the district level, this situation of constant change was even more pronounced …’⁸⁸

In 2003, the total per capita expenditure on health care⁸⁹ was Intl $540 (6.1% of GDP)⁹⁰. Among the countries of Central and Eastern Europe, this figure falls within a spending range of Intl $ 327 in Bosnia-Herzegovina (9.5 % of GDP) and Intl $1,669 in Slovenia (8.8% of GDP). At 5.3% the smallest spending as a percentage of GDP is in Estonia (Tables 5 and 6).

The WHO overall health system performance score places Romania 99/191 countries. This composite measure of overall health system attainment⁹¹ is based on a country’s goals relating to health, responsiveness, and fairness in financing. The measure varies widely across countries and is highly correlated with general levels of human development as captured in the human development index.