Normalizing Bribes as a Solution to Romania’s Deteriorating Health System

Abstract

There is an old Romanian folk tale about a young boy and a magical ox named Tellerchen.  The boy, abandoned by his cruel stepmother, is starving when he is found by a kind, rich man.  The young boy works on the man’s farm for seven years, and when he is finally old enough to leave, the rich man gifts the boy with Tellerchen, the magical ox, as a thank you for the years of hard work.  Tellerchen has the ability to produce just enough bread and wine from his horns to feed the boy.  The boy returns home, hoping to regain the favor of his stepmother, but she is jealous of the boy’s good fortune and demands that the boy slaughter the ox.  The boy is distraught, and that night, tries to set Tellerchen free.  However, Tellerchen tells the boy to trust that it is okay have him slaughtered.  The ox tells him to save only his horn after he is killed and to open the horn once he is far away.  The boy reluctantly slaughters Tellerchen the next day, saving only the horn before his stepmother banishes him from his home.  The boy is starving without Tellerchen and desperately wishes that he had not slaughtered his magical ox.  However, the boy remembers to open Tellerchen’s horn, and a herd of magical oxen appears, with powers even greater than Tellerchen’s.  The boy is saved from starvation, and he lives the rest of his days wealthy and prosperous.  The moral of the story?  A seemingly unthinkable action, which may appear to lead to negative consequences, can, with trust and faith, instead favor those brave enough to take the leap. And in no time and place is this more applicable than in Romania’s current healthcare situation.

Romania’s health system is currently perched on a dangerous precipice- it faces a major dual dilemma of a “brain drain” of Romanian physicians to other European countries, as well as negative health outcomes from the widespread practice of bribery in physicians and other healthcare practitioners.  Compared to their western counterparts, Romanian physicians lack prestige, power, and profits, a dangerous lack of incentives for an already weak health system.

Romania’s current healthcare problems has roots in the mid-20th century, during which both the west and the east experienced their own revolutions.  In the west, a scientific revolution.  In the east, especially across eastern Europe, a communist one.  Though Romania was only officially within communism’s chokehold for about forty years, the bruises from this indelible part of Romania’s history are apparent even now, almost thirty years later.  While mid-twentieth century physicians in western Europe and the United States were blessed with a golden age, in which medicine was glamorized in popular media and shined with “miracle” breakthroughs, Romanian physicians were suppressed under a communist rule that favored the common farmer and factory worker over the intellectual.  And now, that historic disregard for physicians has translated into a weak foundation for healthcare in Romania.  As a result, its healthcare remains severely underfunded, and physicians are emigrating in search of better status and higher wages.

Romanian-born and educated doctors are fleeing the nation as if escaping from a plague, and the impact of such is nearly as deadly.  In 2011, there were 21,400 doctors in Romania.  As of November of 2013, there were 14,400.[1]  Romania has lost nearly a third of its skilled physicians to the UK and other countries in the European Union, and the number of Romanian doctors emigrating to work abroad has rocketed since.  This mass exodus of thousands of highly-skilled physicians is taking its toll on the country, in almost ridiculous statistics.  For a population of 19 million, Romania has only 48 radiotherapy physicians, despite high rates of cancer across the country, and only 54 geriatric physicians, despite the ageing population.[2]  In comparison to its central and eastern European peers, in Bulgaria, Hungary, and the Czech Republic, Romania has the lowest life expectancy at birth, the highest infant mortality rate, and the highest incidence rates of AIDS, tuberculosis, and syphilis.[3]

The root of the problem is that Romanian doctors are not being paid enough.  Romanian doctors earn a measly 400 euros a month,[4] which is hardly enough to support themselves, let alone a family.  Wages are an alarming eight to ten times higher abroad than in Romania.[5]  Thus, it is no surprise that Romanian physicians are emigrating for better working conditions and higher financial benefits. 

However, an even more significant implication of Romania’s inability to provide sufficient physician wages is the toxic bribery culture that has erupted within its health system.  In 2014, Romania was found to be the second most corrupt country in the European Union, and within the health field, some physicians refuse to even treat patients without a bribe.[6]  Sadly, stories of impoverished Romanians ignored in hospitals because they lack the money for a bribe, or a woman in labor being coerced into a bribe to just have her child birthed are common anecdotal woes.  Here as well, Romania’s communist history has played a role in normalizing bribes.  During the communist regime, it was common practice to use bribes to acquire scarce products, and as healthcare is now also becoming a scarce product, with the lack of doctors, so must bribery seem socially acceptable.

With a measly 3.6% of Romanian GDP allocated to healthcare, compared to 11% in both Germany and France,[7] the nation spends the least on healthcare compared to any other country in the European Union.[8]  However, with the current state of the economy, it does not seem feasible for the government to subsidize physician wages.  On the other hand, instead of seeking to extinguish bribes, Romania should legalize bribes and build these “informal payments” into healthcare costs.  It is time for Romania to modify its socialized medical insurance by introducing a copayment system that will place some responsibility for payment on its citizens in a legitimatized fashion.  Romania’s current mandatory health insurance system has been chronically underfunded, and complete government support for all healthcare is unsustainable.  Many Romanians are already paying for these higher healthcare costs through bribes, with about 25% of Romanians reporting that a doctor or nurse had pressured them into paying a bribe for medical service.[9]  Legalizing these informal payments will give the Romanian government the authority to standardize prices across hospitals and physicians, as well as more closely monitor payment practices to ensure equity amongst all patients.

This proposal may seem like a radical step.  However, a similar plan was enacted in 1997 in Cambodia, a country that, like Romania, has also had a communist past and a crippling bribery issue.  A formal fee schedule was introduced, with the informal payments built into the cost of healthcare.[10]  And for critics wary of increasing the financial burden on patients, after just one year of reform, patients were actually paying less than they had paid before the reforms.  In short, these informal payments were replaced by formal payments, and this change did not add much additional financial burden to Cambodian patients because the government was able to standardize prices of these supplementary payments.  When a similar program was introduced in Albania in the early 2000s, some physicians even saw their incomes quadruple.[11]  Not only will this plan provide better equity of care to all citizens, but physicians will also receive higher wages and will hopefully retain Romanian physicians.  In an effort to promote health equity, government funds can be used to give cash vouchers to the poorest in the nation so that they can afford these copayments.  This will allow a better, more efficient use of government funds than the current health insurance system allows.

Romania needs a bold step like this to halt the deterioration of its health system.  Action is needed now to stop the bleeding out of physicians from Romania before the country becomes too weakened.  With over 19 million lives on the line, maybe it’s time for this small eastern European nation to take back control over its current trajectory and to remedy the consequences of its past.  I’m sure that Tellerchen would agree.

References

[1] Gillet, Kit, and Matthew Taylor. "Romanian health service in crisis as doctors leave for UK and other states." The Guardian, February 2, 2014.

[2] Ibid.

[3] World Health Organization. "Highlights on health in Romania." (1999).

[4] Lungescu, Oana. "Romanian healthcare on verge of collapse." BBC News Europe, August 12, 2010.

[5] Toma, Diana. "Romania’s health service on brink of collapse." World Socialist Web Site. Last modified June 18, 2010. Accessed June 29, 2016. https://www.wsws.org/en/articles/2010/06/roma-j18.html. 

[6] Transparency International. Corruption Perceptions Index 2014: Results. Corruption Perceptions Index. N.p.: n.p., 2014.

[7] "Health Expenditure, Total (% of GDP)." In The World Bank. 2015. Last modified 2015. Accessed June 29, 2016. http://data.worldbank.org/indicator/SH.XPD.TOTL.ZS.

[8] Lungescu, Oana. "Romanian healthcare on verge of collapse." BBC News Europe, August 12, 2010.

[9] European Commission. Corruption. Special Eurobarometer 397. N.p.: n.p., 2014.

[10] Vian, Taryn. "Corruption in the Health Sector: Informal Payments." Lecture, Boston University School of Public Health, Boston, MA. 

[11] Vian, Taryn. "Corruption in the Health Sector: Informal Payments." Lecture, Boston University School of Public Health, Boston, MA.