This chapter summarises the in-depth assessment conducted as part of Romania’s accession review and presents key recommendations to enhance the performance of the health system across critical dimensions, including sustainability, efficiency, quality, access, and resilience. Romania’s health system has made notable progress, but health status and performance remain low relative to OECD countries. To be adequately prepared to meet the 21st century health challenges, Romania would need to sustain its efforts and accelerate the transition towards a more sustainable and resilient health system, specifically by reducing inefficiencies, cutting wasteful spending, strengthening primary care and prevention, and improving access to care.
OECD Reviews of Health Systems: Romania 2025
Abstract
Romania’s population has been ageing and declining – especially after its accession to the European Union (EU) in 2007, which facilitated emigration, including among health professionals. Although the pace of decline has recently slowed, demographic trends continue to place significant pressure on the health system. As many OECD countries, Romania needs to adapt the health system to the needs of its ageing population – including the burden of chronic diseases and long-term care needs, while ensuring fiscal sustainability.
Population decline also poses risks to the financial stability of the social health insurance system by reducing the contributor base. Romania’s social health insurance system is financed through mandatory social insurance contributions from working residents, making it sensitive to workforce emigration. Founded on the principle of solidarity, the system provides a comprehensive basic benefits package to 89% of the population as well as a minimum package to uninsured individuals.
At the same time, the Romanian Government faces a high fiscal deficit and has limited capacity to increase the public budget of the health sector, while relying on significant EU fundings to restore and modernise its health infrastructure and digital environment. The Romania’s health system has also faced additional pressure from the inflow of over 3 million refugees crossing the country since Russia’s war of aggression against Ukraine began, requiring addressing their health and humanitarian needs.
Conscious of these challenges, Romania has initiated a series of measures to enhance the fiscal sustainability of the health system. The country has demonstrated a clear commitment to shifting towards primary care and community services, as outlined in the National Health Strategy 2023-2030 and the Operational Health Programme 2021-2027. In addition, efforts are made to strengthen prevention and screening within primary care settings, supported by investments of the National Recovery and Resilience Plan (NRRP). This transition aims to build a more resilient and efficient and sustainable health system capable of meeting the 21st century health challenges.
Romania became an OECD accession candidate in 2022. As part of the accession process, the OECD conducted a review of the Romania’s health system, policies and practices. This chapter summarises the in-depth assessment and formulates recommendations to enhance the performance of the health system across critical dimensions, including sustainability, efficiency, resilience, quality and access. It focusses on three priority areas: increasing efficiency in the health system, strengthening primary care and prevention and leveraging health data use to enhance resilience, and improving access to healthcare.
Life expectancy in Romania has increased by more than 5 years over the last two decades, reaching 76.4 years in 2023. Infant mortality was reduced by 68%, and maternal mortality by about 40% over the last two decades. Despite this progress, health outcomes and performance remain relatively low compared to OECD countries and five European OECD countries with comparable income level in the same region (Czechia, Hungary, Poland, the Slovak Republic and Slovenia, “EU5” here after), as reflected in OECD indicators on health status, risk factors for health, access, quality of care, and healthcare capacity and resources (Figure 1.1).
Avoidable mortality in Romania is one of the highest compared to OECD countries, signalling persistent challenges in public health policies and in the healthcare system. Almost a third of all mortality in Romania was attributable to behavioural risk factors which are preventable. Smoking, drinking, obesity and overweight rates are well above the OECD averages and the EU5 averages – except for the smoking rate which is close to the average of neighbouring EU5 countries (Figure 1.1). To address key behavioural risk factors for health, Romania has implemented some good practices but broader and more robust reforms in public health and disease prevention are still required.
Note: A green dot stands for the best performing OECD country, whereas a red dot stands for the least performing OECD country. The exception of the colour-coded groups is for health resources, where indicators cannot be classified as showing better or worse performance. For this reason, lighter and darker shades of blue signal whether a country has less or more resources than the OECD average. The EU5 average is calculated across five EU neighbouring countries (Czechia, Hungary, Poland, the Slovak Republic, and Slovenia).
Source: OECD Health Statistics 2025, Eurostat (2025[1]), Self-reported unmet needs for medical examination due to financial reasons, long waiting list or distance by sex, age and risk of poverty threshold - % of the persons having the same needs, https://doi.org/10.2908/HLTH_SILC_08B.
Romania has improved budgeting practices in the health sector with the aim of increasing the efficiency of health spending. In 2023, Romania’s Ministry of Finance collaborated with the Ministry of Health and the National Health Insurance House (CNAS) to carry out a health spending review, to inform the 2024 budget proposal and streamline public healthcare expenditure. In addition, in 2023, Romania has introduced a new framework contract for healthcare services payment models between CNAS, district health insurance houses (DHIH) and health providers. This new framework contract aims to incorporate performance standards into the budgeting process, making CNAS and DHIH more active purchasers of healthcare services.
Despite these efforts, Romania needs to step up its actions to ensure financial sustainability to meet the growing demand of healthcare of an ageing population. Romania would need to prioritise spending in areas where improvements in health outcomes can be expected to be the highest. Key priority areas include, for example, reducing avoidable hospital admission, decreasing reliance on hospital care, addressing corruption and bribery, as further detailed below.
OECD indicators suggest persistent inefficiencies in the Romanian health system. For instance, Romania has a high rate of hospital admission for diabetes (228 per 100 000 population versus 111 in the OECD average), which is avoidable with effective prevention and treatment in primary care. The volume of prescribed antibiotics in Romania is very high, above the OECD average (26 versus 16 defined daily doses per 1 000 inhabitants) and the EU5 average (16 defined daily doses) (Figure 1.1).
Romania is making effort to increase efficiency. For example, masterplans have been developed – with support of Europeans funds – to assess regional healthcare needs and provider capacity, enabling a more rational allocation of resources. Measures to strengthen primary and community care include the establishment of integrated community centres across the territory. A recent noteworthy reform introduces the monitoring of antibiotic dispensing in emergency situations through the collection of patient and pharmacy data, aiming to limit misuse and prevent repeated unregulated dispensing. But further efforts are needed to cut wasteful spending and make further efficiency gains. This entails strategies such as increasing value for money in medicine prescribing, better targeting the use of resource‑intensive hospital care by improving care co‑ordination and shifting chronic disease management (e.g. diabetes) to lower levels of care, thereby reducing reliance on hospital services. Others can also include strengthening and expanding care quality measurement and policies, and making greater use of health technology assessment to more clearly define the goods and services covered by the public benefits package.
Corruption and bribery have been a long-standing issue in the Romanian health system. Romania has taken recent measures to address these issues, including increasing doctors’ salaries to reduce incentives for informal payments, raising awareness among medical staff and patients, implementing a patient feedback system in public hospitals, and providing integrity-related training, with the support of NRRP. The country would need to further strengthen the transparency and integrity management in the health sector. In particular, the lack of co‑ordination, low institutional capacity and political engagement has hindered the adoption and implementation of the National Anti-Corruption Strategy measures in the health sector, underscoring the need for further action.
To strengthen the fiscal sustainability of the health system, Romania is raising the National Health Insurance Fund revenues by increasing the number of people paying contributions through payroll taxes. Only one‑third of insured individuals paid wage‑based contributions in 2023, as many groups – including children, older adults, people with disabilities, certain patient groups, and workers in specific sectors – were exempt from them. Since 2023, Romania has begun phasing out some of these exemptions, starting with workers in agriculture, construction, and the food industry. Additional reforms introduced in 2025 further reduced exemptions for other groups, a move expected to broaden the contributor base in the coming years.
Romania is also envisaging leveraging the potential of private voluntary health insurance (VHI). Today, the contribution of VHI as a share of total health spending is marginal, yet about 700 000 inhabitants (3.6% of the population) are covered through company health insurance plan. While VHI creates opportunities for increasing patient choice and stimulating service capacity, it can also create inequities in access to healthcare based on insurance status and incentives for providers practising in both the public and the private sector to prioritise care for privately insured patients. It is thus essential to define a regulatory framework for the expansion of VHI to minimise the risks and maximise the benefits.
Romania has initiated the development of a strategic vision for a more efficient, people‑centred and resilient health system, particularly with the adoption of the National Health Strategy 2023-2030. Continued efforts would need to focus on enhancing quality of services, strengthening primary care, improving prevention of non-communicable chronic diseases (NCDs), pandemic preparedness and response, building an integrated mental health system, and modernising the health information system – as further detailed below.
Romania is actively developing a strong culture of care quality and patient safety, with an initial focus on hospitals. The National Authority for Quality Management in Healthcare (ANMCS) was created in 2015, and patient engagement was increased, for instance through patients’ participation in ethics committees in each hospital and in the National Patient Safety Council. While most effort has focussed on hospital’s accreditation and the setting of hospital standards, further actions are needed to establish a system fostering continuous quality improvement and performance assessment that focusses on sectors outside the hospital.
Strengthening primary care is essential to build a more resilient health system and respond to epidemiological shifts that are occurring due to ageing population and the increased prevalence of diseases. Romania has taken some initiatives to boost primary and community care settings, but its healthcare system still heavily relies on hospital services. The hospital bed rate is above the OECD average (7.3 versus 4.2 hospital beds per 1 000 inhabitants in 2023) (Figure 1.1). Patients tend to directly go to hospitals bypassing lower levels of care, while up to 72% of emergency department visits could be managed within primary care settings according to researchers (Lăcătuș et al., 2024[2]). Hospital services account for 44% of the expenditure (vs. 39% in the OECD average, in 2023), while primary care accounts for just 9% (vs. 14% in the OECD average). Romania needs to reinforce its efforts to shift the system toward primary care and community settings, for instance by transforming acute hospital beds into day care and long-term care in regions identified in the Regional Health Services Masterplans, strengthening the gatekeeping system, and reinforcing incentives for health professionals and patients for appropriate use of hospital services.
Despite efforts made to improve infection prevention and control, public health policy targeting NCDs and associated risk factors is insufficient. Preventable mortality rate is above the OECD average (251 vs. 145 deaths per 100 000 population), which is also reflected in high levels of behavioural risk factors such as tobacco and alcohol consumption (Figure 1.1). The leading cause of death in Romania is cardiovascular diseases, followed by cancers. Romania has established a “riskogramme” screening questionnaire and other preventive activities in primary care settings, incentivised through performance‑based payments. But more efforts are needed to implement a more comprehensive prevention strategy addressing the social determinants of health, including policy initiatives beyond the health sector, such as education, regulation and fiscal measures.
Secondary prevention also needs to be strengthened. Screening rates for cervical, breast and colorectal cancers are significantly lower than the OECD averages (Figure 1.1), mainly due to the lack of effective population-based programmes. Romania is actively participating in EU-funded pilot projects to develop population-based screening and is working on a national cancer registry (OECD, 2023[3]). To reach out to the disadvantaged populations in underserved areas, the country has also acquired ten mobile caravans through the NRRP funding to deliver cervical and breast cancer screenings. Further, it has initiated the use of health mediators to bridge communication between the health system and the Roma population, although this initiative has yet to be expanded. However, additional funding is necessary to procure more diagnostic and treatment equipment and to train staff for diagnosis.
Romania’s capacity for crisis preparedness and response was highly challenged during the COVID‑19 pandemic. Mortality rate from COVID‑19 was about 12% higher than the EU average (OECD/European Observatory on Health Systems and Policies, 2021[4]). The response to the COVID‑19 crisis was suboptimal, underscoring the necessity to better prepare for future public health emergencies. Romania has also recently experienced a measles epidemic, exacerbated by declining childhood vaccination coverage. In addition to health outbreaks, the country is exposed to several potential public health risks. Natural and climate‑related disasters pose a considerable threat, with three in four inhabitants residing in areas vulnerable to earthquakes and nearly half exposed to heat waves. Russia’s war of aggression against Ukraine and the inflow of people arriving from Ukraine are also placing considerable strain on the health system. Romania is enhancing its crisis preparedness and response capacities, focussing on strengthening emergency co‑ordination and upgrading laboratory infrastructure. Romania has also adopted a multi-sectoral and comprehensive National Strategy for Disaster Risk Reduction 2023-2035 to improve the resilience to various disasters such as earthquakes, forest fires, and epidemics.
Mental health disorders are the second leading cause of years lived with disability in Romania, but the prevalence of mental health disorders was substantially lower than in OECD countries in 2021 due to stigma and limited access to diagnosis. Unmet needs for mental healthcare in Romania are higher than in European OECD countries, and suicide rates rose in adolescents and in the older population. The mental health system relies heavily on institutional care and pharmacotherapy, with allegations of ill-treatment in three psychiatric hospitals and a call for urgent actions made from the Council of Europe (Council of Europe, 2023[5]). In response, Romania set up an inter-institutional working group in 2023 and developed a 2024-2029 action plan to improve psychiatric hospital conditions and ensure that patients are treated with dignity. But beyond this action plan, a broader national mental health strategy, supported by adequate resources and strong political commitment, is essential to address mental health through a whole‑of-society approach.
Strengthening health data system and governance is vital for a more efficient, people‑centred and resilient health system. Romania’s capacity to share internationally comparable data on health is of a high standard, also compared to OECD countries. However, despite the routine collection of health data, the national health information system remains highly fragmented, with significant duplication in data collection that undermines overall data quality. Romania has legally introduced electronic health records, but their usage is currently limited to administrative and accounting purposes, and not for supporting clinical optimisation and research. Different IT systems operate in several institutions, and the absence of an anonymised unique patient identifier limits data linkage and system interoperability. While Romania has established legislation and policies for health data governance, in practice, personal health data are not yet effectively accessible and used for research and public interest purposes. In addition, staff training on privacy protection and digital security responsibilities is lacking. Romania is currently working on a National Digital Health Strategy to improve the potential for health data use. This strategy will aim to establish the National Agency for Digital Health, which will oversee data pooling, analysis and dissemination, the setting of data standards and development of a telemedicine system, among others.
Romania is facing significant challenges in meeting the medical needs of its population. Unmet needs for medical care in Romania are high compared to OECD and EU5 countries (Figure 1.1), mainly due to low population coverage and high cost-sharing for certain services. Specifically, 11% of the population is uninsured (compared to an OECD average of 2%), and the share of out-of-pocket payments is high and above the OECD average (23% vs. 19% of health expenditure), resulting in financial barriers to access to healthcare and putting less affluent families at risk of financial hardship (OECD/European Observatory on Health Systems and Policies, 2025[6]).
Shortages in health professionals and uneven distribution on the territory also hinder access to healthcare services. Many nurses and doctors have migrated to other European countries, a trend that has accelerated with Romania’s accession to the EU in 2007. In response, Romania has introduced impressive salary increases which have reportedly curbed the emigration to some extent. The salaries of doctors and nurses working in public hospitals have increased by up to 160% in 2018 (European Observatory on Health Systems and Policies, 2018[7]). This was complemented by the increase and reconfiguration of remuneration in ambulatory care. Over the last decade, Romania’s workforce capacity has also remarkably grown thanks to increased training capacity, with the physician number reaching the OECD average but the nursing capacity still below the OECD average in 2023 (Figure 1.1). Nevertheless, almost 60% of doctors under age 35 still had an intention to leave the country in 2023, posing a major challenge in meeting the growing healthcare demand. The most often cited reasons for emigration are poor working conditions, including inadequate health infrastructure, signalling the need to go beyond salary improvements and focus efforts on improving working conditions and other underlying factors.
Romania also faces important geographical imbalances in healthcare provision. In 2023, more than half of the Romanian population were living in rural areas, where access to healthcare and basic needs is reportedly more limited than in urban areas. Healthcare resources remain heavily concentrated in cities: more than 90% of the total number of hospitals and independent specialist clinics, and 60% of independent general practice offices were located in urban areas in 2024 (National Institute of Statistics, 2024[8]). This urban-rural divide is further compounded by the country’s large size and the presence of remote, hard-to-reach regions – especially in the Carpathian Mountains and during winter snowfalls. The underserved population includes the Roma communities who represent about 9% of the total population and are primarily located in rural and underserved regions (OECD, 2022[9]).
To close the gap in rural territories, Romania aims to expand community nursing capacity by training 2 000 additional community nurses to work in community health centres. Considering new roles – or expanding existing roles – of health professionals, including nurses, to share some of the tasks would help addressing limited supply of doctors in these regions. Authorities could also develop collaborations with local governments to improve both working and living conditions, such as offering support for housing or education in return for public service. Telemedicine is another lever to improve access to care in underserved areas, which Romania has legislated and started to use during the pandemic, but a dedicated secure telemedicine platform has yet to be established. Digitalisation can additionally attract physicians to work in underserved areas by improving working conditions. For instance, the Prahova region has provided digitalised administrative processes and accounting assistance for opening practices, an exemplary initiative to improve doctors’ working conditions. As a significant step forward in the development of a strategic vision for workforce planning and retention, the government launched the Multi-Annual Health Workforce Development Strategy 2022-2030.
Box 1.1 highlights policy areas where Romania could target its policy efforts to improve the health system performance, strengthen resilience, and bring it closer to OECD standards and best practices.
Romania can consider the following recommendations as part of its strategy to improve the Romanian health system performance and strengthen its sustainability and resilience, to be further aligned with OECD standards and best practices.
Improve access and quality
Work towards achieving effective universal health coverage, by extending coverage to uninsured groups such as people without identity documents or not registered in the social security system, informal and self-employed workers. Reassess cost-sharing mechanisms to improve access to care and reduce unmet needs for medical care.
Improve access to care in rural and underserved areas, by increasing the provision and use of community centres and out-of-hours healthcare services. Scale up the development of “integrated community centres” backed up with sufficient laboratory and equipment capacity. Continue promoting teleconsultation and mobile health services to better reach remote populations.
Attract health professionals to work in rural and underserved regions by developing collaborations with local authorities to improve both working and living conditions, such as offering support for housing or education, and/or offering digitalised administrative and accounting assistance for new opening practices. Consider advanced roles for community nurses, such as through task sharing, to alleviate rural doctor shortages. Retain community nurses by improving their pay and working conditions.
Invest in and operationalise a national workforce planning based on population needs and on regional distribution of healthcare workers, as outlined in the Multi-Annual Health Workforce Development Strategy for 2022-2030.
Foster continuous quality improvement at the system level. Consider quality management beyond the accreditation of hospital facilities by strengthening post-accreditation monitoring mechanisms and incorporating continuous quality assessment, while extending these efforts to ambulatory care. Consider introducing payment systems that reward care quality in both hospital and primary care, such as add-on payments and bundled payments to encourage care co‑ordination and effective and efficient management of chronic diseases.
Develop population-based screening programmes for cervical, breast and colorectal cancers. Train specialised staff for diagnosis and procure more diagnostic and treatment equipment for cancer care.
Strengthening efficiency, fiscal sustainability and transparency
Strengthen the role of CNAS as an active purchaser of care, by introducing standards for performance as part of budgeting process. This will result in greater consideration to the creation of incentives for performance in healthcare provision, with the introduction of further performance‑based payment schemes for providers.
Strengthen primary healthcare, by improving the gatekeeping system and collaborating with health professionals and patients to ensure an appropriate use of services. Provide a greater role for family physicians in early detection, screening and management of NCDs. Encourage the development of home‑based programmes and other delivery arrangements to reduce unnecessary hospitalisations. Strengthen patient pathways and co‑ordination across different care levels by harnessing multidisciplinary teams or nurse co‑ordinators for NCD management and improving the flows of health information across the care pathway.
Operationalise measures to implement the Regional Health Services Masterplans, such as transferring hospital beds to day care and long-term care -or reducing them- in the regions identified with low bed occupancy.
Utilise health technology assessment (HTA) to better identify benefits to be covered. Expand the use of HTA to high-cost medical technologies, diagnostics, and surgical procedures.
Increase value for money in medicine prescribing and use. Increase biosimilars and generics prescribing by applying a series of measures, such as patient and doctor awareness and education, guidance to doctors, monitoring prescriptions, and reaching out doctors with non-compliant prescribing behaviours, that have shown to be successful.
Improving integrity in the health system by expanding the scope of the national anti-corruption strategy based on an analysis of risks in the health sector. Such an analysis could support further reforms, such as developing a comprehensive anti-corruption policy for the health sector, incorporating integrity as a component of institutional performance, and implementing monitoring mechanisms for key processes such as allocation funds, appointments and medical input procurement.
Improving resilience and preparedness
Increase children’s vaccination coverage. Address vaccine hesitancy by boosting health literacy. Address misinformation by introducing effective national communication campaigns through traditional and social media. Roll out vaccination programmes to reach those living in rural areas and the uninsured populations. These strategies must be implemented at national, regional and local levels to address public health concerns and vaccine hesitancy effectively.
Strengthen actions against antimicrobial resistance (AMR) by incorporating the financial provisions for the implementation of the AMR action plan into the national action plans and budgets. Ensure that national guidelines are implemented and that data on antimicrobial use is systematically fed back to prescribers.
Reinforce primary prevention of NCDs by addressing behavioural risk factors for health, such as smoking and harmful alcohol use. Implementing policy measures beyond the health sector, such as education, regulation and fiscal measures. Consider raising tax share of tobacco products to reach the WHO recommended level, implementing tobacco plain packaging, introducing alcohol minimum unit pricing, limiting alcohol availability, and strengthening marketing to children.
Speed up the implementation of measures to better prepare for and respond to future public health emergencies, by upgrading laboratory and testing infrastructures, and strengthening emergency co‑ordinating structures at national and county levels.
Improving mental health and integrated policies
Develop a national roadmap for mental health by engaging in with patient organisations and non-governmental organisations with a particular focus on stigma, protection of vulnerable groups including the Roma population, mental health literacy, suicide in young and older age populations, and hospital conditions.
Expand the provision of mental health services at primary care level, particularly for early detection and intervention of mild- to moderate‑ mental health conditions.
Improve the capacity to implement education and employment policies to achieve a whole‑of-society approach for a better integration of people with mental health conditions without discrimination.
Strengthening health data infrastructure and governance
Adopt and implement the national digital health strategy to encourage the availability and use of personal health data for public interest purposes. Accelerate the creation of the National Agency for Digital Health.
Accelerate the functioning of disease registry datasets at the national level (e.g. cancer and diabetes) to improve care quality and benchmark performance against national guidelines. Establish standardised data collection mechanisms on formal long-term care and patient experiences.
Introduce data de‑identification policies with an agreed unique patient identifier nationwide, to facilitate secondary data usage. Build capacity and training for healthcare workers, policymakers and the public in using personal health data.
Develop an integrated secure digital health and telemedicine platform.
Encourage the effective use of electronic health records and telemedicine. This is important to improve care co‑ordination and quality.
References
[5] Council of Europe (2023), Report to the Romanian Government on the visit to Romania carried out by the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (CPT), https://rm.coe.int/1680acbdde.
[7] European Observatory on Health Systems and Policies (2018), Measures to alleviate the shortage of human resources in the Romanian health system, https://eurohealthobservatory.who.int/monitors/health-systems-monitor/updates/hspm/romania-2016/measures-to-alleviate-the-shortage-of-human-resources-in-the-romanian-health-system.
[1] Eurostat (2025), Self-reported unmet needs for medical examination due to financial reasons, long waiting list or distance by sex, age and risk of poverty threshold - % of the persons having the same needs, https://doi.org/10.2908/HLTH_SILC_08B.
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