This chapter provides an overview of access to and quality of care in Romania’s health system, assessing its performance, recent policy reforms and opportunities aimed at improving equity, efficiency and resilience. The first section analyses unmet healthcare needs and services utilisation, highlighting the suboptimal use of primary healthcare and persistent geographical disparities in access. The second section explores the quality of care, outlining key challenges and policy initiatives to reduce avoidable hospitalisation and improve cancer care. The third section focusses on mental health needs and service provision, identifying gaps and policy efforts to strengthen community-based care. The last section examines long-term and palliative care, underscoring limited resources and capacity constraints.
OECD Reviews of Health Systems: Romania 2025
Abstract
3.1.1. Unmet needs for medical care are high, especially among people at risk of poverty and those living in rural areas
In 2023, 6% of Romanians with medical care needs reported that their needs were unmet due to costs, geographical distance or waiting times, a figure higher than the OECD average (5%) (Figure 3.1). Socio-economic disparities are marked: people at risk of poverty reported three times higher unmet needs than the total population, a gap considerably wider compared to the OECD average. Similarly, people living in rural areas reported almost 1.5 times higher unmet needs compared to those located in cities (Eurostat, 2025[1]). In 2024, 6% of adults also reported unmet needs specifically for primary care – twice the EU average – highlighting significant access challenges in this foundational layer of the health system (Eurofound, 2025[2]).
Note: The EU average is weighted. Data refer only to individuals who reported having medical care needs. People at risk of poverty are defined as those with an equivalised disposable income below 60% of the national median disposable income.
Source: Eurostat Database 2025, based on EU-SILC data.
3.1.2. Routine care remains costly due to low population coverage and high cost-sharing
In Romania, financial costs are the main reason people forgo necessary healthcare – in contrast to most OECD countries, where waiting times are more commonly cited. In 2023, over half of those reporting unmet needs said they did not seek care because it was too expensive (Eurostat, 2024[3]). This is closely linked to the relatively low insurance coverage in the population (see Section 2.2 in Chapter 2) and the significant cost-sharing requirements for services such as outpatient-prescribed medicines and rehabilitation. While the Social Health Insurance (SHI) scheme offers a comprehensive benefits package for insured individuals, uninsured people have access only to a limited set of services, leading many to resort to emergency care to avoid high upfront costs. Even among the insured, high out-of-pocket payments – especially for outpatient medicines – expose households to financial hardship and deepen existing health and socio-economic inequalities (OECD/European Observatory on Health Systems and Policies, 2025[4]).
High healthcare costs can put people at risk of financial hardship, particularly those who are the most vulnerable, potentially exacerbating health and socio-economic inequalities. To mitigate these barriers and improve equitable access to care, Romania should prioritise expanding the depth and breadth of coverage and clarifying the scope of the benefits package, particularly for vulnerable groups. Clearer benefits and lower cost-sharing would help reduce financial burden, unnecessary emergency care use, and unmet health needs.
3.1.3. The primary care system is weak, leading to over-use of specialist and emergency care services
Family physicians who work mainly in independent practices are the first point of contact for patients in Romania, and they act as gatekeepers by providing referrals to specialist consultation as needed. However, in practice, they are often used to obtain referral for higher levels of care rather than providing direct care. This stems from two key issues: the limited scope of practice for family physicians and the absence of co-payments to discourage unnecessary specialist visits. Additionally, broad exemption rules allow certain groups – including people with mental health conditions or those enrolled in national curative programmes – to bypass the referral system altogether, even for conditions that could be managed effectively at the primary care level.
Consequently, this leads to inefficient use of primary care resources for chronic condition management, long waiting times for certain specialties (particularly in rural areas), and encourage patients to use emergency departments as a shortcut to access specialist care. The problem is compounded by chronically low investment: in 2023, only 9% of total health spending went to primary care – the lowest share in the OECD – resulting in insufficient capacity and weakened ability to serve as a true first point of contact.
3.1.4. Emergency care is overburdened and becomes inaccessible during winter in some rural areas
Emergency care is primarily available at regional emergency hospitals, which are equipped with specialised emergency units and are managed by regional authorities. These hospitals serve for their designated regions with each county having one regional emergency hospital (except Bucharest having several). The distribution of emergency services remains uneven between rural and urban areas, with ambulance services facing challenges particularly during adverse weather conditions in winters (AHEAD, 2022[5]). To modernise its emergency care infrastructure, Romania purchased IT and medical equipment to connect 131 emergency units to the regional telemedicine emergency centres, which would in turn facilitate immediate transfer and ensure timely care for patients (European Observatory on Health Systems and Policies, 2024[6]).
Emergency care in Romania is often overburdened due to bottlenecks in primary and specialist care. Many patients with non-emergency complaints visit emergency care services for faster access to care: in 2018, less than 18% of patients visiting emergency rooms had urgent conditions, according to a national report (Department for Emergency Situations Romania, 2018[7]). A more recent analysis also showed that around 80% of patients in emergency care services were assigned green codes, signifying non-immediate conditions, while 72% of the total cases had diagnoses that could have been managed at the primary care level (Lăcătuș et al., 2024[8]).
As an alternative to emergency care services, out-of-hours primary care centres offer basic emergency and primary care services regardless of a patient’s insurance status. These centres are staffed by family physicians who provide 24/7 on-call service but remain limited in number and distribution. In an effort to expand these services, the government increased tariff rates for providers in 2018, but this has not fully addressed the capacity and availability issues related to family physicians (European Observatory on Health Systems and Policies, 2018[9]). Out-of-hours centres have the potential to reduce the burden on emergency care, and Romania should consider enhancing the workforce and logistic capacity of these services. Intensifying efforts to increase their public awareness is also crucial to maximise their use for non-urgent conditions, as only about 5% of emergency care patients reported being aware of these centres (Lăcătuș et al., 2024[8]).
3.1.5. Rural areas have limited access to healthcare facilities, but community health centres and mobile medicine can improve access
More than half of the Romanian population (54%) was living in rural areas in 2023, where significant challenges in access to healthcare persist. There is a concerning disparity in allocated resources between urban and rural places, with urban areas holding more than 90% of the total number of hospitals and independent specialist clinics, and 60% of independent family physician offices in 2024 (National Institute of Statistics, 2024[10]) (Figure 3.2). The distribution of health workers also shows a similar pattern, with workers overwhelmingly concentrated in urban areas (see Section 4.2 in Chapter 4).
Note: Data refer to 2024.
Source: National Institute of Statistics (2024[10]), Activitatea retelei sanitare 2024, https://insse.ro/cms/sites/default/files/field/publicatii/activitatea_retelei_sanitare_in_anul_2024_0.pdf.
Community health centres bring additional capacity to care for vulnerable populations living in underserved areas, including the Roma communities. These centres focus on preventive care and basic health needs. Managed by local authorities, they operate through collaborative efforts among general practitioners, social services, and other health professionals, including community nurses and health mediators. While community nurses play a central role in these centres, their numbers remain insufficient to expand these services throughout the country, and their training often relies on international funding (see Section 4.2 in Chapter 4). Health mediators, introduced in 2002, also play a key role in improving healthcare access for the Roma population. They mainly take role in facilitating communication between patients and the healthcare system, with an aim to ensure care delivery without discrimination.
The NRRP aims to expand the role and coverage of community health centres in Romania. Funding is allocated to upgrade these facilities into “integrated community centres” by enhancing their logistical and equipment capacity. This includes establishing laboratories for basic diagnostic tests, creating dental offices, and acquiring medical equipment for certain specialties. These centres will therefore be able to employ family physicians, specialists and dentists to work in a collaborative manner. Further, collaboration with the Ministry of Labour will also allow these centres to have better access to social services when needed. The initial plan is to establish 200 integrated community centres, either renovated or newly built, with half of them located in marginalised areas. However, the full functioning of these services hinges on overcoming crucial challenges, particularly in training and attracting community nurses and doctors to work in these centres.
Mobile services are also a means to deal with accessibility issues in rural areas, particularly for disadvantaged populations. For the past decade, several non-governmental organisations (NGOs) have voluntarily provided free medical care through medical caravans and units. The government has recently passed a legislation to establish and co‑ordinate these services based on the needs identified in the rural communities (Mobile Healthcare Act). This legislation allows doctors and other health workers to treat patients in mobile medical units, even if employed elsewhere. Services will include, but not limited to, medical check-ups, preventive screenings, and medical treatments covered by the national health programmes. In addition to doctors, nurses or other health professionals such as therapists, health mediators, social workers or paramedics can also work in these medical units. As a first step towards improving access in rural areas, the country has purchased ten mobile caravans to perform cervical and breast cancer screening in underserved areas (see Section 3.2 in Chapter 3).
3.1.6. Financial incentives and telemedicine have partially addressed the critical health workforce shortages in rural areas, but efforts need to continue
Healthcare workforce shortages in rural areas remain one of the most critical challenges to equitable access in Romania, as 90% of physicians and nurses are located in urban healthcare settings. Although doctors are permitted to open a practice anywhere as long as they meet minimum patient registration requirements, many choose to work in more developed areas with better professional and personal prospects. This results in stark regional disparities, with some rural hospitals unable to recruit essential specialists such as cardiologists or paediatricians, while urban areas remain saturated with medical professionals. To address these imbalances, Romania has primarily relied on financial incentives and relaxed regulations to encourage doctors to establish practices in underserved areas. However, these measures alone have proven insufficient. A more comprehensive strategy – including supportive infrastructure, professional development opportunities, and stronger integration of rural healthcare into broader workforce planning – is needed to ensure equitable distribution of health professionals across the country (see Section 4.2 in Chapter 4).
The increased availability of teleconsultations during the pandemic helped improving access to care to some extent. The share of the population who had received a remote medical consultation increased from 22% to 30% between June/July 2020 and February/March 2021 thanks to the legislation enabling the widespread use of telemedicine (OECD/European Observatory on Health Systems and Policies, 2023[11]). In 2020, the government promulgated an emergency ordinance to boost the use of telemedicine, which subsequently helped to offset access problems in rural areas in particular. The ordinance simplified the administrative procedure for video consultations and GP prescriptions for patients with chronic conditions (OECD/European Observatory on Health Systems and Policies, 2023[11]). Following the regulation, the healthcare act was modified in 2022 to enable telemedicine further by setting the legal framework, which subsequently led to the identification and adoption of medical services and requirements for telemedicine (European Observatory on Health Systems and Policies, 2022[12]). However, teleconsultation uptake has been hindered by misaligned financial incentives. Under the previous payment system, remote consultations were covered under capitation, whereas in-person consultations generated fee‑for-service payments – discouraging doctors from offering remote care. To address this, the new contractual framework now specifies teleconsultation services, with dedicated reimbursement rates to make them financially attractive for providers. Once the associated authorisation requirements are finalised, these services will be formally included in the CNAS service package, paving the way for broader telehealth expansion.
Digital engagement in health remains low in Romania compared to OECD countries, reflecting broader challenges in telemedicine implementation and system digitalisation. In 2024, only about 30% of Romanians used the internet to search for health information – roughly half the OECD average of 60%. Even fewer (around 10%) booked medical appointments online or accessed their health records, despite modest gains since 2018. The gap with OECD countries has widened most notably in these transactional services, underscoring the slow uptake of digital tools in routine care (Figure 3.3) (Section 2.3 in Chapter 2). As a next step to translate legislative action to tangible improvement, Romania would greatly benefit from an integrated telemedicine platform that would allow doctors to remotely consult with patients and access their data at the same time. During the pandemic, doctors mainly provided teleconsultations through communication apps, which posed significant risks to data privacy and security. Establishing such platform will be the first and most important step in ensuring secure digital access to care and facilitating information sharing and exchange between providers.
Source: Eurostat (2025[13]), Individuals - internet activities, https://doi.org/10.2908/ISOC_CI_AC_I. Adapted from OECD/European Observatory on Health Systems and Policies (2025[4]), Country Health Profile 2025: Romania.
3.2.1. Avoidable admissions are high for diabetes, asthma and COPD, but remain low for congestive heart failure
Diabetes mellitus is one of the NCDs with increasing prevalence in Romania, and avoidable hospital admission rates due to diabetes are among the highest compared to OECD countries. In 2023, there were 228 admissions per 100 000 population after the pandemic-induced decline in visits to hospitals (Figure 3.4). This is mainly due to weak NCD management at primary care level, as well as late diagnosis and intervention of diabetes: 70% of diabetes cases are diagnosed at an advanced stage, when complications are already present and require more intensive interventions (The Romanian Diabetes Forum, 2022[14]).
Note: Data refer to 2023 or nearest year available. 1. Latest data from 2021-2022.
Source: OECD (2025[15]), Health at a Glance 2025: OECD Indicators, https://doi.org/10.1787/8f9e3f98-en.
In 2020, Romania adopted its first National Diabetes Prevention Programme, financed by the Ministry of Health, to strengthen early detection and prevention: this enabled family physicians to screen high-risk individuals and run health education initiatives. However, they still play a limited role in ongoing diabetes management, as specialist care remains the dominant treatment pathway. This contributes to delays in intervention due to long waiting times at secondary care level – a growing challenge, given that the national curative health programme for diabetes served 1.3 million patients in 2024 (CNAS, 2025[16]). In an effort to relieve pressure on specialists, the government has recently allowed family physicians to prescribe certain antidiabetic medications for non-complex cases, signalling an important but modest shift toward primary care‑based management.
To meaningfully improve chronic disease outcomes and reduce avoidable hospital admissions, Romania needs clearer action to strengthen care co‑ordination and leverage the full potential of primary care. While the National Health Strategy 2023‑2030 outlines goals such as multidisciplinary team-based care and nurse‑led co‑ordination, no concrete steps have yet been taken to operationalise these efforts. A crucial missing component is a national diabetes registry: the current National Diabetes Programme collects only basic statistics on service use and patient numbers, without tracking clinical outcomes or adherence to treatment guidelines. With NRRP support, Romania plans to establish such a registry, which would play a vital role in benchmarking care quality, tracking patient outcomes, and ensuring guideline‑based diabetes management nationwide.
Avoidable hospital admissions for congestive heart failure, asthma and chronic obstructive pulmonary disease (COPD) have declined between 2019 and 2021 in Romania, as in many OECD countries. The steep reductions in hospital admissions for these chronic conditions were largely due to disruptions in hospital services and hesitancy among patients to seek hospital care during the COVID‑19 pandemic. The most recent data show that avoidable admissions for asthma and COPD remain very high compared to OECD and EU5 averages, but admissions for congestive heart failure is in the lower range (Figure 3.5).
Note: For Panel A: 1. Latest data from 2021-2022. For Panel B: 1. Latest data from 2021-2022.
Source: OECD (2025[15]), Health at a Glance 2025: OECD Indicators, https://doi.org/10.1787/8f9e3f98-en.
3.2.2. 30‑day mortality rate for acute myocardial infarction is high
In Romania, 30‑day mortality rate for acute myocardial infarction (AMI) was 13.1 deaths per 100 patients aged 45 and over in 2023 (linked data), much higher than the EU5 average of 9.9 deaths and the OECD average of 8.6 deaths (Figure 3.6 Panel A). While Romania has an established acute intervention programme for AMI in emergency hospitals, there is considerable room for improvement for acute intervention of AMI: in 2023, 24‑hour mortality rate for AMI was 4 per 100 patients aged 45 and over, almost double the OECD average (Figure 3.6 Panel B). This suggests that bottlenecks in early diagnosis and rapid treatment initiation continue to undermine the effectiveness of acute cardiac care.
Note: For Panel A: 1. Latest data from 2020-2022. 2. Data do not include deaths outside acute care hospitals. For Panel B: 1. Latest data from 2020-2021.
Source: OECD (2025[15]), Health at a Glance 2025: OECD Indicators, https://doi.org/10.1787/8f9e3f98-en.
3.2.3. Cancer mortality is high, suggesting room for improvement in early detection and treatment
Cancer mortality is among the highest, but major prevention gains are possible through addressing behavioural risk factors
Cancer mortality rate was among the highest compared to OECD countries (211 compared to 191 deaths per 100 000 population in 2022) but remained below the neighbouring EU5 average (239) (Figure 3.7). The gap between men and women is wide: 294 deaths per 100 000 population from cancer in men, compared to 154 deaths for women. This is mainly due to large differences in risk factors between men and women, as excessive alcohol consumption and smoking are mainly problems among men (OECD/European Observatory on Health Systems and Policies, 2023[11]).
Reducing behavioural risk factors would have significant health benefits. According to OECD Strategic Public Health Planning (SPHeP) modelling, meeting tobacco reduction targets alone could prevent more than 65 000 cancer cases in Romania between 2023 and 2050. In addition, achieving national goals on alcohol consumption and obesity could avert a further about 25 000 cancer cases respectively over the same period (OECD, 2024[17]).
Note: Data refer to 2023 or nearest year. 1. 2021-2022 data.
Source: OECD (2025[15]), Health at a Glance 2025: OECD Indicators, https://doi.org/10.1787/8f9e3f98-en.
Cancer care is free of charge through the national curative health programme in Romania, both for insured and uninsured people. However, this has not led to better cancer outcomes yet. Cancer mortality has decreased only modestly between over the past decade and remained the second leading cause of mortality in Romania in 2022, partly reflecting slow progress made in the quality and performance of cancer care.
While lung, colorectal, and prostate cancers were the most common causes of cancer deaths in men in 2021; breast, colorectal, and lung cancers were the top causes in women (OECD/European Commission, 2025[18]). With more than 100 000 estimated new cancer cases in 2022, overall cancer incidence rate in Romania was lower than the EU average – partly due to underdiagnosis (OECD/European Observatory on Health Systems and Policies, 2025[4]).
Population-based cancer screening is not effectively in place for common cancers, but the country is making progress
Poor cancer outcomes in Romania are closely linked to the absence of effective, population-based screening programmes that enable early detection. According to programme data, only 6% of Romanian women aged between 20 and 69 years had a cervical screening in 2023, a figure well below the OECD average (59%) and neighbouring EU5 average (52%) (Figure 3.8). The programme data are not available for other common cancers such as colorectal and breast cancer. However, survey data showed that about 3% of Romanians aged between 50 and 74 years reported having had colorectal cancer screening in 2019, around 15 times lower than the OECD average of 45%. Around one in ten women aged between 50 and 69 years had reportedly mammography for breast cancer screening, almost seven times lower than the OECD average. As in many OECD countries, there is a clear socio-economic disparity in the uptake of screening. This is primarily due to the absence of population-based programmes: reliance on opportunistic screening has entrenched stark socio-economic inequalities, with wealthier individuals significantly more likely to be screened than those on lower incomes (OECD, 2023[19]).
Note: Data refer to 2023 or nearest year. Programme data unless otherwise stated. 1. Survey data. 2. Latest data from 2020-2022.
Source: OECD (2025[15]), Health at a Glance 2025: OECD Indicators, https://doi.org/10.1787/8f9e3f98-en.
Romania launched a cervical cancer screening programme in 2012 for women aged 25 to 64 years, regardless of insurance status. As of now, it is the only active nationwide screening initiative, but its effectiveness has been hampered by several deficiencies. In the first five years, only 12% of eligible women received programmatic smear tests, while up to 30% underwent opportunistic testing (OECD, 2023[19]). The programme fell short of its goals due to the absence of a clearly defined pathway for managing positive results, causing confusion, particularly among uninsured individuals. A shortage of skilled personnel to interpret diagnostic materials further impeded its success. In response, Romania developed new methodology and guidelines for cervical cancer screening in 2019, and family physicians took on new responsibilities to facilitate test material collection in cervical screening in 2024. Quality and safety indicators for cervical cancer screening were also adopted in 2024 (OECD/European Commission, 2025[18]). As a next step, the country aims to establish a national screening registry to ensure proper follow-up for women with positive smear tests.
The country has also intensified its efforts to improve population-based screening programmes for breast and colorectal cancers by carrying out EU-funded pilot projects. In 2022, the country announced the National Cancer Plan 2022-2027 that dedicates approximately EUR 400 million to cancer prevention, early detection and screening, diagnostics and treatment, research infrastructure, professional training, and the development of standards and practice protocols (OECD, 2023[19]). In 2024, national plans were put in place to scale up pilot screening projects to fully fledged population-based programmes. These plans include new training programmes for primary healthcare physicians and other health workers, increased involvement of community nurses and health mediators, and specific provisions to use national and structural funds for testing, diagnostics, and treatment of precancerous lesions among vulnerable population groups (OECD/European Commission, 2025[18]). Supported by the EU funds, and the country has recently acquired ten mobile caravans to deliver cervical and breast cancer screenings in underserved areas. While these initiatives are a step in the right direction, it is clear that more robust action is needed to enhance the efficacy of screening. To expand these initiatives beyond the regional level, additional funding is also necessary to procure more diagnostic and treatment equipment and to train specialised staff.
Cancer care is hampered by inadequate medical equipment and a lack of national registries
Medical equipment capacity in the country is insufficient to meet demand in cancer care. Positron emission tomography scanner numbers were markedly lower than both the OECD and neighbouring EU5 averages in 2023 (Figure 3.9, Panel A). Similarly, Romania had around 5 radiation therapy units per 1 000 000 inhabitants in 2023, a figure significantly lower than the EU4 average and the OECD average (Figure 3.9, Panel B). The shortage in equipment, combined with inadequate human resources and insufficient investment in technology, leads to territorial disparities in cancer care.
Note: Data refer to 2023 or nearest year.
Source: OECD Health Statistics 2025.
The suboptimal functioning of national cancer registries poses a challenge for cancer care management and quality. Data fragmentation and a lack of systematic collection makes it difficult to monitor patient progress, follow-up, and outcomes after positive cancer screenings. Following the announcement of the National Cancer Plan 2022-2027, the MoH has begun designing a national cancer registry to consolidate data on cancer cases and treatment from eight regional centres. Funded by NRRP, the digitalisation of this registry will enable better evaluation of cancer care quality and effectiveness, ultimately improving cancer surveillance.
Effective implementation of the National Cancer Plan 2022-2027 and more funding will be key to progress
Romania has a National Cancer Plan 2022-2027 and benefits from the Europe’s Beating Cancer plan addressing cancer control. Approximately EUR 400 million from the National Health Insurance Fund has been allocated for its implementation, covering prevention, early detection and screening, diagnostics, treatment, research infrastructure, professional training, and the development of clinical standards and practice protocols. Additional investment from the European Regional Development Fund under the Operational Health Programme 2021‑2027 is helping to modernise oncology wards and institutes, including upgrades to radiotherapy and chemotherapy units. Romania is also preparing to open its first proton therapy centre, funded through the Health Operational Programme, marking a significant step forward in advanced cancer treatment capacity.
3.2.4. Despite feeling supported, patients with chronic conditions in Romania report poor health outcomes and experience major gaps in digital and co‑ordinated care
People with chronic conditions in Romania reported notably poorer health outcomes and experiences compared to the average of countries participating in the OECD Patient-Reported Indicator Survey (PaRIS). In 2024, only 43% of patients rated their general or physical health as good (OECD PaRIS average: 66%), and just two in five felt confident managing their own health (OECD PaRIS average: 59%) (OECD, 2025[20]). Although a majority reported receiving adequate support to self-manage (70%), primary care capacity remains limited in key areas (Figure 3.10). About one in five patients consulted a practice that was well-prepared to co‑ordinate care, and only 5% were seen in practices capable of EHR exchange – a stark contrast to the OECD average. Patients with multiple chronic conditions were also less likely to receive sufficiently long consultations or regular follow-up, highlighting broader system-level capacity constraints in managing complex care needs.
Percentage of people with chronic conditions
Note: Results for people with one or more chronic conditions who are registered with a practice. Co-production: Patient receiving enough support and feeling confident in using health information from the internet (eHEALS), as reported by patients. Co‑ordination: Patients managed in practices that are well prepared to co‑ordinate care and that can exchange medical records electronically, as reported by patients and participating primary care practices. OECD PaRIS average does not include the United States for practice‑level indicators.
Source: Does Healthcare Deliver? Results From the Patient-Reported Indicator Surveys: Romania (2025).
3.2.5. Romania needs to take concrete action to improve care continuity and co‑ordination for patients with complex needs
Patients often face a lack of co‑ordination among different care providers in Romania, leading to fragmented care and patient pathways, particularly for patients with complex needs. Oncology patients need services that extend beyond cancer treatment, such as palliative care, pain management or psychosocial support. Meeting patients’ needs in a seamless manner is an objective pursued by the National Cancer Plan, but actions so far have been limited. The recent changes in the framework contract aims expand access to cancer care and psycho‑oncology services, but palliative care services remain suboptimal (OECD/European Commission, 2025[18]).
To improve care quality for patients with chronic conditions, Romania’s RSHMs sets out plans for better care co‑ordination and continuity. This entails defining referral systems across care levels, establishing patient pathways for key patient groups, and developing metrics to evaluate hospital activity and referral mechanisms. These plans have been recently released but putting them into practice will first and foremost require stewardship, commitment, and collaboration across authorities.
3.2.6. Romania is committed to address nosocomial infections and should continue efforts to improve reporting
Healthcare associated infection (HAI), also known as nosocomial infections, are infections acquired while receiving healthcare that were absent upon admission. HAIs are often caused by antibiotic-resistant bacteria (see Section 4.3 in Chapter 4). According to the European Centre for Disease Prevention and Control (ECDC), the average prevalence of HAI was 6.8% in EU countries in 2022, while the prevalence was 3.1% in Romania, one of the lowest in the EU (ECDC, 2024[21]). In contrast, the country shows unfavourable levels of infection, prevention and control (IPC) capacity (e.g. IPC nurses, beds with alcohol based handrub dispenser) compared to EU countries, suggesting that the low HAI prevalence could be related to under-reporting of cases rather than better performance (Iancu et al., 2023[22]) (Table 3.1). Despite significant improvements in HAI reporting in Romania, with reported incidence nearly tripling in the last decade, HAIs still appear to be underreported (European Observatory on Health Systems and Policies, 2023[23]). The country requires hospitals to report nosocomial infection rates to inform the surveillance system for communicable diseases and to report to the ECDC. However, evidence show data on nosocomial infections are not systematically collected and reported, calling for further improvement. Gaps in HAI reporting were identified in an activity report from 2019 underlining that 25% of the clinics analysed did not comply with the annual nosocomial infection surveillance and control plan, 8% did not have a register, and 8% did not collect data on the incidence and prevalence of HAI (Szabó et al., 2022[24]).
Note: Data refer to 2022. Refers to EU and European Economic Area (EEA) countries. Green colour indicates better performance than EU/EEA mean/median, and orange colour indicates worse performance than EU/EEA mean/median.
Source: Adapted from the country factsheet of Romania published with the Point Prevalence Survey of Healthcare‑Associated Infection and Antimicrobial Use In Acute Care Hospitals 2022-2023 report (ECDC, 2024), https://www.ecdc.europa.eu/en/publications-data/country-factsheet-romania.
In 2023, the government adopted the National Strategy for Preventing and Limiting Healthcare‑Associated Infections and Combatting Antimicrobial Resistance (2023-2030) to improve patient safety and quality of care in hospital settings. The strategy’s objectives include (1) improving awareness and understanding of antimicrobial resistance (AMR) through communication, education and training, (2) improving surveillance and research on resistant bacteria, (3) implementing infection prevention and control measures, and (4) optimising the use of antibiotics. The plan is being translated into action following its introduction, especially with the establishment of a special training for HAI dedicated to nurses. Further, NRRP also invests in equipping at least 25 public hospitals with HAI prevention and control equipment and tools. Romania should strengthen efforts to operationalise measures set out in the strategy and continue to improve reporting and monitoring of HAIs.
3.2.7. The commendable progress made in care quality management in hospitals should now extend to measuring and assuring quality outside hospital settings
Romania is committed to fostering a robust culture of care quality and patient safety, a goal underscored by the establishment of ANMCS in 2015. ANMCS plays a key role in the development of quality management and the accreditation of healthcare providers through an objective, systematic process. It assesses quality standards and grants hospital accreditation based on indicators such as sentinel events, 30‑day readmission rates, and the number of recorded patient complaints. Currently, clinical (technical) audits and performance indicators are not included in the accreditation process. Additionally, the reporting of nosocomial infections is not required in the accreditation process. This is to prevent hospitals from perceiving it as a potential form of penalisation for high infection rates, which may ultimately result in under-reporting of such cases.
Hospitals must obtain accreditation and establish quality management units to secure contracts with CNAS. The responsibility for monitoring the quality of care in contracted hospitals lies with CNAS and DHIHs. Due to a shortage of specialised staff, these bodies primarily focus on performance indicators rather than a comprehensive assessment of care quality. In response, ANMCS is currently in collaboration with INMSS to train “quality experts” to evaluate quality standards in hospitals and engage in international projects to learn from other countries’ training and evaluation systems.
While most effort has traditionally focussed on hospital’s accreditation and setting standards, quality measurement and monitoring in ambulatory services outside the hospital sector lags behind. However, ensuring continuous quality improvement and enhance quality infrastructure requires going beyond hospital settings and strengthening post-accreditation monitoring mechanisms. ANMCS has recently published the specific quality management standards for ambulatory settings, but the quality assessment process is on a voluntary basis in these settings.
Romania faces several obstacles to effectively implementing healthcare quality standards and measurement systems. A key issue is the absence of a structured, system-wide framework for quality monitoring, compounded by fragmented and poorly digitalised health information systems (see Section 2.3 in Chapter 2). Currently, the CNAS and ANMCS collect data independently for separate purposes – resource allocation and hospital accreditation – with little integration or standardisation. In primary care, the continued reliance on paper-based documentation further hinders reliable assessment of care quality and safety. These structural shortcomings are exacerbated by limited financial resources and low awareness among medical staff regarding quality and patient safety practices. To drive improvement, Romania needs to establish a cohesive system for measuring, reporting, and analysing healthcare quality and safety metrics, underpinned by accelerated digitalisation. Better use of EHRs and telemedicine could enhance communication across care settings, reduce medical errors, and strengthen co‑ordination – all essential for embedding a culture of quality and safety in healthcare delivery.
Although progress has been made in defining care quality standards, Romania still lacks a mature system for measuring performance and incentivising high-quality care. A promising development is a pilot programme funded through the NRRP and co-developed by the Ministry of Health, CNAS, and ANMCS. The initiative aims to introduce quality metrics tied to performance‑based payments through the new Health Service Quality Fund. The first phase focussed on developing and testing quality indicators in hospitals, with plans to expand the programme to ambulatory care providers by the end of its implementation period.
Romania has consistently engaged in the OECD PaRIS project and the work of the OECD Working Party on Healthcare Quality and Outcome to improve quality and safety of healthcare with the involvement of ANMCS. To further improve care quality measurement and performance assessment, the country could also consider developing a health system performance assessment (HSPA) framework drawing from international best practices. Developing such framework would ultimately benefit from the digitalisation of the health system which allows systematic data collection for performance assessment and reduces reliance on paper-based reporting. A key initiative in this effort is the establishment of the National Observatory for Health Data through the Operational Health Programme. The Observatory could facilitate real-time data collection and analysis, which would contribute to build a robust and dynamic HSPA. By leveraging digital technologies, Romania can create a data-driven healthcare system that continuously improves based on timely and accurate performance metrics.
3.3.1. Mental health disorders have substantial costs to the health and other sectors, despite the relatively low prevalence of mental health disorders
Mental health disorders costed almost EUR 3.5 billion to Romania in 2018, equivalent to 2.1% of gross domestic product (GDP). While direct costs on the health system and social benefits accounted for 1.4% of GDP, indirect costs on the labour market were equal to 0.7% (OECD/European Union, 2018[25]). A more recent analysis revealed that the total cost estimation increased to around EUR 10 billion in 2022, representing 3.8% of GDP (Economic and Social Council of Romania, 2023[26]). Mental health disorders are the second leading cause of years lived with disability in Romania, with mental health problems accounting for 12% of total unmet needs in the population (see Section 2.1 in Chapter 2).
3.3.2. The mental health system remains hospital-centric
Romania has markedly higher number of psychiatric beds, with 0.9 beds per 1 000 population in 2023 and exceeded the large majority of OECD countries (Figure 3.11). Bed capacity increased by 4% compared to a decade ago, despite the initiatives to reorganise the system towards community-based care. Mental health disorders were one of the most common hospital diagnoses and accounted for 6.2% of hospital admissions in 2020 even during the pandemic, reflecting the persistent reliance on institutional care (National Institute of Public Health, 2020[27]).
Note: Data refer to 2023 or nearest year.
Source: OECD Health Statistics 2025.
The mental health system remains hospital-centric with high reliance on institutional care and pharmacotherapy in Romania. Stigma, coupled with shortages of physical and human resources, hinders patient re-integration and limits access to psychosocial support. As a result, many individuals with long-term mental health needs experience a “revolving door” pattern of repeated hospitalisation due to the lack of adequate follow-up care at the primary level. Post-discharge support, including for patients who have attempted suicide, is often fragmented and insufficiently focussed on rehabilitation and social reintegration. Staff shortages also contribute to concerning conditions in some psychiatric facilities, including hygiene and sanitation issues. While many hospitalised patients report good interactions with healthcare staff, there have been documented allegations of ill-treatment in certain mental health hospitals (Economic and Social Council of Romania, 2023[26]; Euractiv, 2023[28]).
3.3.3. Mental health services are available at both public and private settings
Mental healthcare is free of charge for insured people, and most people often visit psychiatrists for their needs. Specialist care is accessible at both public and private settings through mental health centres, mental health hospitals, general hospitals, private clinics or individual practices. People with chronic mental health conditions are also entitled to medication for free, if prescribed in line with the treatment guidelines by a CNAS-contracted psychiatrist.
There are 52 community mental health centres and 34 mental health hospitals, located mainly in urban and densely populated areas. Community mental health centres provide care for people with mental health conditions including early detection, psychosocial rehabilitation, consultation and treatment. The services are managed by multidisciplinary teams consisting of psychiatrists, nurses, other mental health professionals. The availability of these services, particularly in rural areas, is reportedly hampered by lack of specialised mental health professionals. Community assistance programmes and health mediators also take part in outreach activities and the management of mental healthcare provision for vulnerable groups, such as the Roma population or those living in rural areas. However, there is a lack of integration between community mental health services and other sectors. For instance, community centres do not offer social care, counselling for education or employment, or crisis management for individuals at risk of suicidal or homicidal activities.
Psychotherapy and counselling are available in both public and private settings for the insured population. However, the availability of psychotherapy and counselling in public services is nearly absent due to the lack of staff, leading to people seeking care in private settings with high out-of-pocket payments.
3.3.4. INSP and NGOs take role in prevention and promotion activities, but a standalone national mental health strategy plan is missing
Romania does not have a standalone national strategy plan for mental health, but relevant actions and strategies are defined and set under the National Mental Health Programme and the National Health Strategy 2023-2030. The National Mental Health Programme is one of the national curative health programmes run by CNAS and consists of three distinct subprograms targeting substance misuse, autism spectrum disorders, and major depressive disorder. The National Health Strategy 2023-2030 defines goals for the promotion, prevention, and intervention of mental health disorders. The objectives include identifying relevant mental health actors in society, improving community-based services through multidisciplinary teams, developing preventive mental health interventions, and monitoring epidemiological trends. However, the implementation of these strategies suffers from lack of funding and poor digitalisation in the health system.
Romania’s efforts to prevent mental ill-health have mainly focussed on raising awareness through national campaigns. INSP carries out national campaigns periodically to raise awareness among citizens and to promote early detection of mental health disorders. In 2024, the national “Don’t let depression control your life!” campaign targeted youth mental health, while the previous ones focussed on mental health issues among elderly and maternal mental health (National Institute of Public Health, 2023[29]; National Institute of Public Health, 2024[30]). On a smaller scale, INSP also runs campaigns to raise awareness among health staff and education professionals and to combat stigma.
Romania lacks dedicated strategies or plans targeting key mental health issues such as stigma, dementia, child mental health, suicide or alcohol use. The National Health Strategy 2023-2030 has one objective addressing the monitoring of alcohol consumption to devise evidence‑based interventions but does not mention stigma and suicide. Despite the worrying trend in suicide rates among adolescents, the National Strategy for Child and Adolescent Mental Health 2016-2020 only addresses suicide prevention once, without specifying the actions to be taken. To enhance the effectiveness of suicide prevention, a multifaceted programme could be implemented. For instance, the programme Suicide Prevention in Austria incorporates several components such as providing support to individuals at risk, restricting access to means of suicide, and safe‑guarding of hotspots for suicide attempts (OECD, 2025[31]).
NGOs and civil society also play a role in promotion, prevention and intervention. Mainly funded by the European Union, the Estuar Foundation has been involved in a variety of activities such as establishing psychosocial support programmes for Ukrainian immigrants, introducing first call centre for the Romanian health workers during the pandemic, providing housing and shelter for those in need, and offering counselling and psychiatric consultations for people with mental health conditions. Similarly, another non-profit organisation set up the only hotline in Romania for people with suicidal thoughts with the aim of providing emergency counselling in crisis situations (Civic Labs, 2023[32]). However, as of now, there are no mental health-related patient organisations to further support these activities and promote patient rights.
3.3.5. The National Health Strategy 2023-2030 sets out the objectives to strengthen community-based care
Shifting the care paradigm from institutional care to community-based care is a slow but ongoing process in Romania. The very first efforts started around in the early 2000s, yet the country still hasn’t made substantial progress except for the establishment of community mental health centres. More recently, the National Health Strategy Plan 2023-2030 sets out the objectives to strengthen community-based services and increase the capacity to respond to the mental health needs of Romanians. The Plan places particular emphasis on the integration of mental health interventions at community level to improve the re-integration of patients into society. To achieve this, the Plan foresees an increase in the workforce and logistical capacity of community-based outpatient mental health services to establish multidisciplinary teams with a focus on prevention and early intervention. To ensure the accessibility for disadvantaged communities, community health nurses and health mediators will play a pivotal role in these multidisciplinary teams to facilitate the communication between patients and care providers. Additionally, family physicians are expected to play a greater role in the identification and timely management of mental health conditions through the introduction of appropriate diagnostic and referral tools. Overall, the plan aims to reduce the number of hospital admissions due to mental health conditions by enhancing community-based care, thereby alleviating the burden on hospitals (Ministry of Health, 2022[33]).
3.3.6. Mental health is touched upon in education and employment policies, but more effort is needed for the full implementation of strategies
The protection of mental well-being at workplace is ensured by legislations in Romania. According to the law, the employers are obliged to periodically assess and take action against the risks of occupational injury and diseases, including psychosocial risks. Post-traumatic stress syndrome is recognised as an occupational disease, and burnout syndrome have also been recently recognised under the scope of moral harassment at workplace. In 2022, a new legislation mandated a better protection of employees against discrimination and unfavourable treatment, particularly by prohibiting firing of employees who filed a complaint due to violation of their legal rights or discrimination. However, half of the workers in Romania reported being exposed to risk factors that can adversely affect their mental well-being in 2020 (Eurostat, 2023[34]) (Figure 3.12). Further, according to the European Survey of Enterprises on New and Emerging Risks 2019 survey, over two‑third of people (64%) working in the establishments with 20 employees or more reported that their workplace did not have a procedure in place to address bullying or harassment in their workplace, compared to the EU average of 54% (European Agency for Safety and Health at Work, 2022[35]). There is a need for better co‑ordination and inspection mechanisms to ensure the full implementation of these legislations, particularly in co‑operation with health and social care services.
Note: Data refer to 2020.
Source: Eurostat (2024).
The re-integration of people with mental health conditions into the labour market is addressed to some extent, mainly through legislation. Employers receive subsidies for hiring people who have graduated from special education schools or who come from marginalised groups. People with disabilities additionally benefit from vocational training courses and job counselling both before and during employment. Return-to-work plans are available to facilitate the transition to full-time employment after long sick leave. However, they are reportedly not feasible in all sectors, as some employers are reluctant to accept these plans due to financial and logistical constraints. If possible, some employers offer other options such as flexible working hours, job reassignment or partial teleworking (Civic Labs, 2023[32]). Employees with psychiatric diagnoses reportedly stay in the system for short-term after a long sick leave, usually followed by an exit from the labour market due to disability.
Persons with chronic mental health conditions are eligible to get a disability degree that allows them to receive a monthly allowance and social assistance. In 2023, more than half (52%) of people with disability followed in social assistance institutions1 had a psychiatric diagnosis in Romania (National Institute of Statistics, 2025[36]). Social services are provided by counties, in a co‑ordinated manner with the health authorities.
In the education sector, Romania provides free medical, psychological and speech therapy assistance in schools or in medical centres, primarily to meet the needs of children with special needs. A legislation is available to tackle psychological violence and bullying in the pre‑university education system, and psychopedagogical services can be accessed through dedicated school offices and county centres. School counsellors are available in schools, but there are reportedly insufficient number of counsellors to cope with the high number of students (Civic Labs, 2023[32]). County centres also organise a range of other services for both students and schools, such as speech therapy, professional guidance or advice on inclusive education in schools. Students in higher education can also seek psychological support and therapy in university psychosocial units. However, it is not clear how many of these services are accessible in school settings given that the country struggles with insufficient number of mental health professionals.
3.3.7. Increasing resources and introducing a national mental health strategy will be key to achieve a whole‑of-society approach to mental health
National plans and policies set the ambitious goals for improving mental health in Romania, but not enough action has been taken yet. The country does not have a separate budget for the mental health system to improve community-based care and the conditions in mental health hospitals. Following the Council of Europe’s report on ill-treatment and poor living conditions in Romanian mental health hospitals (Council of Europe, 2023[37]), an interinstitutional working group was established in 2023. The group announced a 2024-2029 action plan to improve human rights in hospitals and to ensure patients to be treated with dignity.
Poor multisectoral collaboration, and insufficient financial and human resources undermine the implementation of actions set out in policies and plans. The absence of a national strategic plan for mental health further obstructs the way to achieve a whole‑of-society approach. Romania would benefit from adopting a comprehensive policy package, backed by a national mental health strategy across all relevant sectors, to strengthen mental health support. This approach should be developed with the involvement of patient associations and NGOs and be backed by adequate resources for its implementation.
3.4.1. Long-term care in Romania is underdeveloped with limited resources and capacity
Long-term care (LTC) organisation is currently dispersed across various systems, including health, social assistance (for frail elderly people), social protection (for disabled people and children), and pension (for those benefiting from disability pension). The Ministry of Labour organises care for elderly people, while the National Authority for Disabled People, subordinated to the Ministry of Labour, is responsible for people with disabilities.
LTC can be provided at home, in residential or day care centres or by personal workers, although the vast majority of LTC is provided at home. Romania reported to the OECD that about 400 000 people receiving at-home services in 2023, and about 36 900 people received LTC in institutions in 2022. Out of the 400 000 LTC at-home recipients, nearly half (about 192 000 recipients) were aged 65 and over.
Romania’s LTC system is under-funded, and most LTC expenditure is spent on hospital-based services. The tight budget allocated to LTC spending in Romania reflects the limited volume in LTC. The latest available data shows that the country spent 0.3% of its GDP on LTC in 2023, a remarkably low share compared to the OECD average of 1.7% and the neighbouring EU5 average of 1.0. Contrary to most OECD countries, hospital-based LTC accounted for nearly half of total LTC spending in Romania, substantially higher than in OECD countries (43% in Romania compared to the OECD average of 9% and a neighbouring EU5 average of 10%). Conversely, expenditure on nursing homes in Romania was significantly lower than in OECD countries (30% compared to the OECD average of 52% and a neighbouring EU5 average of 46%) in 2023.
Romania has a relatively low residential LTC capacity and relies more on hospital beds than on institutional beds. The country has a relatively low rate of LTC beds in both institutions and hospitals, with 17 LTC beds per 1000 population aged 65 and over, more than twice lower than the OECD average (41 beds per 1000 population) and the neighbouring EU5 average (38) (Figure 3.13). Rural areas are particularly affected by the insufficient capacity of LTC beds and suffer from geographical constraints in accessing LTC (WHO Regional Office for Europe, 2020[38]). Hospital beds represent 31% of residential LTC beds in Romania, compared to 8% in the OECD average and 12% in the neighbouring EU5 countries, suggesting scope for improving LTC provision and reducing intensive hospital resources.
Note: Data refer to 2023 or nearest year. 1. Latest data from 2021-2022. 2. Data only includes beds in institutions.
Source: OECD Health Statistics 2025.
The demand for LTC in Romania, as in many OECD countries, is likely to raise as the population ages, calling for improvements in LTC provision and capacity. The share of people aged 65 and over was equal to 20% in 2023, and this is projected to increase further to 31% by 2050 (Eurostat, 2023[39]). Almost one‑quarter of people aged 65 and over reported having severe or some limitations in daily activity in 2021‑2022, compared to an average of 22% in OECD countries and the neighbouring EU5 countries (Figure 3.14).
Note: Data refer to 2021‑2022 (or nearest year). 1. 2017-2019 data.
Source: OECD Health at a Glance 2025, based on SHARE wave 9 (2021 22); ELSA, wave 9 (2019), for the UK; HRS (2018) for the United States; KLoSA (2018) for Korea; SSJDA (2017) for Japan, TILDA wave 5 (2018) for Ireland.
The costs of LTC in Romania are often unaffordable for many people aged 65 and over, putting them at a high risk of poverty. Public social protection mainly supports people with severe needs, while those with low and moderate needs receive little or no assistance. As a result, out-of-pocket expenses for care are substantial. Consequently, poverty risks linked to home care remain well above the EU average across all levels of need, even after receiving public social protection (OECD, forthcoming[40]).
3.4.2. While the formal care capacity is limited, informal carers and family members are the backbone of long-term care
The capacity of formal LTC workers is insufficient to meet the demand for formal care for older people in Romania. Romania has a very low number of formal LTC workers, with one LTC worker per 100 older persons in 2021‑2022, lower than the OECD average of 5 LTC workers and the EU5 average of 2 (OECD, 2025[15]). Difficulties to recruit LTC workers include low salaries and working conditions. The shortage of LTC staff has negative impacts on the quality of both care and life of beneficiaries, including situations of violence and abuse (World Bank, 2023[41]), which ultimately results in high reliance and burden on informal care workers.
Family members are the main carers of dependent older people, although this tends to be more common in rural areas. In Romania, around 6% of people aged 50 and over reported they provided informal care on a daily or weekly basis, compared to 13% in OECD countries in 2021‑2022 (OECD, 2025[15]). Most family caregivers are women, usually wives or daughters. In Romania, 60% of informal daily carers were women in 2021‑2022, on par with the OECD average of 61. Further, only 10% of informal daily carers in Romania reported they worked in addition to caring, which contributes to increase the burden of informal care (OECD, 2025[15]). Yet, the country has no policy in place seeking to address and support informal carers.
3.4.3. Palliative care is insufficient to meet the needs, calling for increased capacity
Palliative care in Romania remains insufficient to meet the growing needs of the population. An estimated 170 000 people need palliative care each year (Ministry of Health, 2017[42]). Yet only around 5% of palliative care needs are met. Most patients – nearly 30 000 out of 33 000 patients requiring palliative care – were hospitalised because inpatient services are largely the only available option. Home‑based palliative care, which would offer more accessible and patient-centred support, covered just 5% of patients, and is predominantly offered by private providers (OECD/European Commission, 2025[18]). While developments in medical and nursing education and training have helped to improve the provision of palliative care, the shortage of specialist palliative care services and staff continues to limit the reach and effectiveness of palliative care.
Recent initiatives have begun to expand palliative care capacity, though gaps remain. Funding through the European Regional Development Fund of Health Programme 2021-2027 aims to enhance the infrastructure of palliative care, particularly in regions with significant shortages (OECD, 2023[19]). Legislative measures introduced in 2024 have led to a significant increase in the number of beds contracted with health insurance houses. However, there is still a lack of providers offering such services in specialised outpatient clinics and for home‑based palliative care.
3.4.4. The National Strategy on long-term care guides Romania on transition from institutional care to community-based care
Romania has introduced a strategy on Long-Term Care and Active Ageing for the period 2023-2030, which aligns with NRRP. The strategy’s objectives include strengthening LTC service management for the elderly, ensuring a continuum of services, securing sustainable financing, and improving service quality. Additionally, it aims to improve the workforce dedicated to elderly care and promote active social participation among older individuals.
The strategy emphasises the need for moving away from institutional care to community-based services, which would ultimately yield more efficient social assistance spending over time and a positive impact on the quality of care for the elderly. NRRP earmarks an investment of EUR 87 million to create a network of day care centres for assistance and recovery of elderly people. As for residential care centres, the government is in the process of closing large institutions and transferring beneficiaries to local centres to ensure better LTC care delivery. Further, a legislative reform has been introduced in 2024 to regulate the minimum package of social assistance and the financing of social assistance funds to beneficiaries, as well as giving more responsibility to local and regional authorities for the provision of LTC services.
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← 1. Social assistance institutions include care and assistance centres, occupational therapy and integration centres, recovery and rehabilitation centres.