This chapter examines the key characteristics of Romania’s health system and the policies supporting its sustainability and resilience. The first section focusses on system financing and financial sustainability, outlining challenges and recent efforts to enhance sustainability. The second section assesses the health workforce, addressing shortages and uneven distribution while outlining recent reforms aimed at improving retention. The third section reviews recent developments to address communicable diseases, tackle antimicrobial resistance, and enhance the system’s preparedness for effective crisis response.
OECD Reviews of Health Systems: Romania 2025
Abstract
4.1.1. Spending on health is relatively low, but with high out-of-pocket payments
Health expenditure in Romania increased over the past decade, but remains within the lowest spending compared to OECD countries and neighbouring EU5 countries. Health expenditure has been increasing steadily in the period 2012-2022, which supported the objectives of the national health strategy, including the workforce retention, national health programmes, and better access to medicines, as well as the response to the COVID‑19 pandemic. There was a notable slowdown in health spending growth in 2022, as the country exited the acute phase of the pandemic. The latest data available show that Romania spent 5.8% of GDP on health, on par with Luxembourg and Mexico, but lower than the neighbouring EU5 average (8.3%) and the OECD average (9.3%) (Figure 4.1, panel A). In per capita terms, Romania’s health spending is close to that of Hungary, but represents less than half the average per capita across OECD countries. In 2024 (or the latest year available), Romania spent USD 2 311 per capita on health, compared to the neighbouring EU5 average of USD 4 430 and the OECD average of USD 5 967, adjusted for differences in purchasing power (Figure 4.1, panel B).
Note: For Panel A: 1. OECD estimate for 2024. 2. 2022-2023 data. For Panel B: 1. OECD estimates.
Source: OECD (2025[1]), Health at a Glance 2025: OECD Indicators, https://doi.org/10.1787/8f9e3f98-en, based on OECD Health Statistics and WHO Global Health Expenditure Database.
The public share of health spending in Romania (76%) is in line with the average in OECD countries (75%). NHIF finances most of healthcare (62% of health spending) while the state budget, through the MoH, finances capital investments (e.g. material and infrastructure), national health programmes, and contributions to NHIF for vulnerable groups such as unemployed and retired people, and people on social benefits (14%) (Figure 4.2). Private financing is made primarily from household’s out-of-pocket (OOP) payments. OOP spending is mainly driven by pharmaceutical expenditure and represents 23% of health spending, higher compared to the OECD and EU5 averages. OOP payments usually include both payments made on a fully discretionary basis and those as part of some co-payment arrangements. High OOP creates financial barrier to access to healthcare and puts less affluent families at risk of financial hardship and catastrophic expenditures.1 In addition, informal payments are reported to be higher in Romania than in other EU countries (see Section 2.2 in Chapter 2).
Note: Data refer to 2023 or nearest year, Category “Other” refers to financing by NGOs, employers, non-resident schemes and unknown schemes. 1. All spending by private health insurance companies reported under compulsory health insurance. 2. Latest available data from 2022.
Source: OECD (2025[1]), Health at a Glance 2025: OECD Indicators, https://doi.org/10.1787/8f9e3f98-en.
4.1.2. Inpatient and outpatient medical care are largely publicly financed, while dental care is virtually fully privately financed
Romania had a higher public share of spending of inpatient services compared to OECD averages, while dental care is nearly fully financed privately. Public financing covered 99% of inpatient care expenditure in Romania in 2023, compared to 89% on average in OECD countries. The share of public expenditure on outpatient medical care in Romania was close to the OECD average. For dental care, pharmaceuticals and therapeutic appliances, the share of public financing was much lower than the OECD averages. Only half of pharmaceutical spending is from public sources, lower than both OECD and EU5 averages. Dental care is nearly fully privately financed, with only 7% covered by public financing – almost five times lower than the OECD average (Figure 4.3).
Note: Data refer to 2023 or nearest year. Outpatient medical services mainly refer to services provided by generalists and specialists in the outpatient sector. Pharmaceuticals include prescribed and over-the‑counter medicines as well as medical non-durables.
Source: OECD Health Statistics 2025.
4.1.3. The private health insurance market is small, but there is interest in expanding it
The contribution of voluntary health insurance (VHI) as a share of total health spending is marginal: Romania’s VHI represents 1% of total health expenditure versus 5% in OECD countries in 2023. However, the interest for private health insurance has been recently growing. The share of VHI increased by 60% total health spending over the past decade. Today, private health insurance covers 700 000 people through company insurance plan, equivalent to 3.6% of the population. VHI in Romania has a supplementary role (i.e. offering quicker access to healthcare services that are already covered publicly, such as outpatient services and dental care, with greater choice of healthcare providers or enhanced amenities).
Private health insurance companies have established contractual agreements with private clinics, through which they have negotiated pricing and agreed upon key performance indicators (KPIs), including quality indicators. They provide coverage for outpatient services and dental care, while coverage for emergency care and outpatient prescriptions are excluded. VHI is seen as a way to get faster access to services and greater choice of healthcare providers or enhanced amenities (e.g. superior accommodation, meals). However, there are challenges associated with VHI. VHI may raise concerns about inequities in access to healthcare services based on insurance status and create incentives for providers practising in both the public and the private sector to prioritise care for privately insured patients. In particular, private health insurance is associated with the risk of creating a two‑tier system. Higher-income people who can afford VHI may have faster and greater access to higher quality services, leaving those with lower income facing access problems, potentially exacerbating social and regional inequalities in health. To address these challenges, it is essential to set a regulatory framework for VHI, define equal quality standards across both the public and the private sectors and define the standards for practice for providers that practice both in the public and private sectors. Learning from the experience of other countries with important VHI markets, such as Australia, Ireland and Israel, would also be helpful.
4.1.4. Hospital services account for nearly half of the expenditure, while primary care accounts for just under one tenth
Hospital spending remains high in Romania. Compared with OECD countries, the country has a relatively high level of hospital-related expenditure, on par with Czechia and Poland, and below countries such as Türkiye and Costa Rica. In 2023, hospital activities received 44% of the health financing in Romania, substantially exceeding the OECD and neighbouring EU5 averages (39% and 41%) (Figure 4.4). The proportion spent on hospital services has increased over the last decade by about 5 percentage points (p.p.) in Romania, while it remained mostly unchanged for the OECD and neighbouring EU5 averages. In contrast, the shares of the expenditure attributed to ambulatory care and LTC providers (respectively, 17% and 1%) are considerably lower compared to the OECD and neighbouring EU5 averages.
Note: Data refer to 2023 or nearest year. “Other” includes ancillary service providers (e.g. patient transport and laboratories); health system administration, public health and prevention agencies; households in cases where they provide paid long-term care (LTC); and atypical providers, where healthcare is a secondary economic activity. 1. 2022 data.
Source: OECD (2025[1]), Health at a Glance 2025: OECD Indicators, https://doi.org/10.1787/8f9e3f98-en.
Most of the health spending is dedicated to inpatient care services (42%), while outpatient care and LTC represent about one‑quarter of health expenditure in Romania (Figure 4.5). The share of inpatient care spending is the second highest when compared with OECD countries. Looking at hospital expenditure, Romania has one of the highest proportions of spending on day care with 21% of total hospital expenditure. This is almost four times higher than the OECD average, but the data must be taken with caution as they might not be comparable across countries due to methodological deviation.
Note: Data refer to 2023 or nearest year. Countries are ranked by curative‑rehabilitative care as a share of current expenditure on health. 1. Refers to curative‑rehabilitative care in inpatient and day care settings. 2. Includes home care and ancillary services. 3. Medical goods financed by government and compulsory schemes are included either under inpatient our outpatient care. 4. Latest available data from 2022.
Source: OECD (2025[1]), Health at a Glance 2025: OECD Indicators, https://doi.org/10.1787/8f9e3f98-en.
Strengthening primary care is essential to improve care co‑ordination and health outcomes, while also reducing the number of unnecessary hospitalisations and the costs associated with them. Romania’s spending on primary care and prevention is relatively low, suggesting limited financial resources to strengthen primary care. Spending on primary healthcare services represented 9% of current health expenditure in 2023, lower compared to OECD and EU5 averages (Figure 4.6), and spending on prevention was only 1% (versus 3% in the OECD average).
Note: Data refer to 2023 or nearest year. 1. Spending on general outpatient care can include pharmaceuticals. 2. Latest available data from 2022.
Source: OECD (2025[1]), Health at a Glance 2025: OECD Indicators, https://doi.org/10.1787/8f9e3f98-en.
4.1.5. More efforts are needed to reduce the pressure on the healthcare system
Romania’s health system requires a continued transformation towards primary healthcare and community settings in order to respond to the rapidly shifting health needs towards chronic conditions due to an ageing population. This would not only better reflect the needs of the populations, but also help reduce pressure on spending by helping patients being treated in less resource‑intense and more adequate care settings. The National Health Strategy 2023-2030 and the Operational Health Programme 2021-2027 set clear objectives to operationalise this transformation, while NRRP allocates funds for the modernisation of the primary healthcare facilities (EUR 250 million are allocated for renovating and equipping family physician’s practices and outpatient care units, representing one fifth of the budget allocated to hospital’s modernisation). In addition, it is essential to reduce unnecessary hospitalisations and associated costs, by giving greater responsibilities to health professionals in primary care regarding early detection, screening and management of NCDs, improving care co‑ordination for the management of NCDs, and improving the flows of health information across the care pathway.
4.1.6. While Romania has recently carried out a health sector spending review to inform budget decisions, further actions are required to increase efficiency and cut wasteful spending
Romania, like many OECD countries, is facing a dual challenge of health spending pressure and resource constraint. Healthcare demand is likely to increase with rising income and ageing population, while new technologies will drive up expenditure. Romania has a high public deficit, and its health spending represented 11% of the public spending in 2023 (versus 15% in OECD), suggesting the country has limited fiscal capacity to spend a greater share of national budgets on health. Romania has taken important steps towards good budgeting practices in order to increase the efficiency of health spending. To streamline public spending on healthcare, Romania’s Ministry of Finance, in collaboration with the MoH and CNAS, have newly carried out a health spending review in 2023, that served to draft the 2024 budget proposal. The review defined five medium and long-term efficiency measures, including (1) increasing the number of preventive consultations, (2) optimising the monitoring of patients with chronic diseases, (3) rationalising expenses associated with sick leaves, (4) abolishing SHI contribution exemptions for some worker categories, and (5) optimising medicines prescribing and spending (e.g. prioritizing the prescribing and issuing of biosimilar and generic medicines). In 2023, Romania has also implemented a new framework contract for healthcare services contracted between CNAS/DHIH and providers. This new framework contract aims to incorporate standards for performance as part of budgeting process, making CNAS/DHIH more active purchasers of healthcare services. Recent initiatives include a reconfiguration of provider remuneration and a P4P scheme to incentivise GP’s preventive activities (see Section 2.2 in Chapter 2), although this could be extended to a broader set of providers and activities. In addition, Romania has taken a series of measures in 2023 to increase budget revenues (adopted by Law no. 296/2023). These include measures related to the health sector, such as increasing excise values for tobacco and alcoholic products, and introducing an excise on non-alcoholic beverages containing added sugar for which the total sugar level is higher than 5 g per 100 ml (Fiscal Council of Romania, 2024[2]).
Conducting and using a health spending review marks an important step. It is vital to pursue the objectives set in the spending review, with clear and regular monitoring of progress both in terms of rising revenues and in terms of efficiency improvements. Efforts to further reduce corruption in public procurement (see Section 2.2 in Chapter 2) will also contribute to tackling inefficiencies and wasteful spending. Romania should consider further options that will increase efficiency and ensure the fiscal sustainability of the health system. These options include cutting ineffective and wasteful spending (e.g. pharmaceuticals), shifting services from hospitals to new settings for the delivery of primary healthcare to rationalise hospital spending and improve care continuity, relying on new provider payment schemes to incentivise care quality and continuity, and expanding the use of health technology assessment (HTA) to define and update the benefit basket provided by SHI. These options are further described thereafter.
Continue efforts to improve value for money in medicine prescribing and utilisation
Romania has taken significant measures to address ineffective pharmaceutical spending, such as increasing biosimilars prescribing and limiting the use of antibiotics. The country has notably increased the share of biosimilars prescribing, especially for erythropoietins and tumour necrosis factor inhibitors, resulting in a reduction in list prices for the total market of these medicines. To achieve this goal, the country took a series of measures such as improving guidance for doctors, monitoring prescriptions every six months, and reaching out to doctors with non-compliant prescribing behaviours. Stepping up efforts by extending the measures to further biosimilars and generics is required to achieve higher gains. Increasing patient and doctor awareness and education to combat misperceptions about the lack of safety of generics and biosimilars is also a key lever for the update of generics and biosimilars. Regarding antibiotics which are dispensed only with a doctor’s prescription except for emergency cases, Romania passed a law to enable monitoring of antibiotic dispensing in emergency situations –- through the collection of patient and pharmacy data, aiming to limit misuse and prevent repeated unregulated dispensing. This measure is expected to reduce the very high volumes of antibiotics prescribing (about 50% higher than the OECD average, see Section 4.3), and ultimately reduce wasteful spending and limit the progress of antimicrobial resistance.
Consider new ways to rationalise hospital spending and improve care continuity
Romania aims to shift the care paradigm towards primary care, but spending on hospital services remains significantly higher than in most OECD countries. The country should consider ways to rationalise hospital spending by improving efficiency, thus creating more fiscal capacity to allocate budget for primary care. For instance, low rates of bed occupancy in some hospitals identified by RHSMs indicate that hospital beds could be transferred to day care and LTC beds or reduced. This would ultimately address the inefficient use of acute care beds. Early discharge home‑based programmes reduce length of hospital stays, lower the risk of readmission, and show good clinical outcomes (OECD, 2020[3]). Romania should thus consider further developing community care facilities and home‑based programmes that are effective to improve care continuity and reduce the use of resource‑intensive hospital beds. For instance, Canada and the United Kingdom have introduced virtual wards to provide short-term transitional care at home for high-risk patients with complex needs recently discharged from hospitals (OECD, 2020[3]). In a step forward to facilitate the provision of home‑based care, Romania has recently revised regulations and tariffs.
Consider further provider payment schemes based on performance
While Romania is newly introducing P4P remuneration scheme to incentivise family physicians to provide prevention services, further payment modalities also exist to increase efficiency gains. Romania can envisage new provider payment schemes that reward performance, improve care quality and continuation and reduce costs, such as add-on payments and bundled payments. About half of OECD countries have introduced add-on payments that remunerate specific activities, such as early discharge from hospital and care co‑ordination (OECD, 2020[3]). These can help improve care processes and co‑ordination, and cost-efficiency efforts, but their impact on health outcomes is limited. Bundled payments, used for instance in Australia and Belgium, -consisting of one payment per patient, per chronic illness, covering the cost of all healthcare services provided by different providers during a specific defined time period- show some promising results in containing cost and improving patient outcomes and satisfaction (OECD, 2020[3]). These payment models are however difficult to implement and require advanced information systems to monitor and follow-up process and outcome indicators.
Develop Health Technology Assessment to define and update the goods and services included in the publicly defined benefits package
HTA in Romania is used to define medicines that are included in the reimbursement list. The HTA process, led by NAMMD since 2014, involves a scoring system that relies largely on HTA reports and decision making from other selected jurisdictions, including France, Germany and the United Kingdom. Romania’s HTA system faces many challenges, including a short institutional history, a lack of comprehensive evaluation capacity, inconsistencies due to siloed operations with no formal links to national health programmes or clinical guidelines, limited collaboration, a fragmented data system and insufficient capacity building (Lopert, Ruth; Ruiz, Francis; Gheorghe, Adrian; Chanturidze, Tata, 2017[4]). However, Romania is willing to learn from other countries and participate in joint international work, such as the European Network for Health Technology Assessment (EUnetHTA).
To leverage the potential of HTA in Romania, it is important to improve methodological and human capacity, upgrade the information system, and develop collaborations. Expanding the use of HTA and integrating economic evaluation into routine HTA practices could help further inform reimbursement decision and better define and update the goods and services included in the publicly defined benefits package, thereby improving efficiency of public spending and improving care quality. HTA could be extended to high-cost medical technologies, diagnostics, and surgical procedures. For instance, in France, the Haute autorité de santé uses HTA to evaluate medical devices or medical interventions (in addition to drugs and vaccines). It also makes recommendations on reimbursement levels and evaluates the actual benefit and the improvement in actual benefit which are essential for price negotiations and the formulation of clinical guidelines.
4.2.1. Workforce capacity has remarkably improved to levels comparable to OECD countries, but emigration to other EU countries remains significant
Romania’s workforce capacity has seen a remarkable increase, with physician numbers increasing by 40% over the past decade and reaching the OECD average (3.7 versus 3.9 practising physicians per 1 000 population) and close to the average of the neighbouring EU5 countries (3.8) (Figure 4.7). On the other hand, despite a steady increase of 41% over the same period, practising nursing capacity in the Romanian health system is still below the OECD average (9.2), with 8.2 nurses per 1 000 inhabitants in 2023 (Figure 4.7). This was nevertheless above the EU5 average of 7.3.
Note: Data refer to 2023 or nearest year. The OECD average is unweighted. For physicians: 1. The data include physicians-in-training (interns and residents) in most countries (including for countries such as France and Italy which were not including them previously). 1. In Chile, Greece and Portugal, data refer to all doctors licensed to practice, resulting in a large over-estimation of the number of practising doctors. 2. In Colombia, the Slovak Republic and Türkiye, data include not only doctors providing direct care to patients but also those working in the health sector as managers, educators, researchers, etc. (adding another 5‑10% of doctors). 3. In Sweden and the United States, latest data from 2021-2022. 4. In Luxembourg, latest physician data from 2017. For nurses: 1. Associate professional nurses with a lower level of qualifications make up more than 50% of nurses in Slovenia and Romania; between 33% and 50% in Greece, Iceland, Korea, Mexico and Switzerland; and between 15% and 30% in Australia, Canada, Hungary, Japan, the United Kingdom and the United States. 2. In Colombia, Portugal, the Slovak Republic, Türkiye and the United States, nurse data include nurses working in the health sector as managers, educators, researchers and similar. 3. In Chile, nurse data include all nurses licensed to practise. 4. In Greece, data only refer to nurses employed in hospitals. 5. In Belgium, France, Japan and Sweden latest data from 2021-2022. 6. in Luxembourg, latest data from 2017.
Source: OECD Health Statistics 2025.
Medical training capacity has increased by about 80% in the last decade, boosting medical graduate numbers to 28 graduates per 100 000 population in 2023 (Figure 4.8). The significant increase in the number of medical graduates is also the result of the internationalisation of medical education, which Romania has undertaken following its accession to the EU in order to attract foreign students. In the 2018/19 academic year, almost all medical schools offered education in English and/or French, in addition to the Romanian programme. The latest data available show that the capacity in foreign language medical programmes increased by 75% between 2011/12 and 2018/19, while there was almost no growth in the programmes provided in the Romanian language (OECD, 2019[5]). However, as is the case for domestic medical graduates, the health system remains unattractive for international students to stay in the country after graduation, despite some recent effort to improve remuneration.
Note: A large number of medical graduates are international students in some countries (e.g. Romania, Latvia, Ireland, the Slovak Republic, Hungary and Czechia). 1. Data excludes international students, resulting in an under-estimation. 2. Latest data from 2022.
Source: OECD (2025[1]), Health at a Glance 2025: OECD Indicators, https://doi.org/10.1787/8f9e3f98-en.
Romania also produces a high number of nursing graduates, with 100 per 100 000 population in 2023 – more than double the OECD average of 43. However, much of the current nursing workforce still consists of professionals with legacy diplomas that do not meet EU standards for automatic recognition (82%). In 2024, a targeted amendment (Directive (EU) 2024/505) brought Romania’s 2014 “special revalorisation” programme into EU legislation (OECD/European Observatory on Health Systems and Policies, 2025[6]), which should reduce the share of non-compliant nurses over time, though skill gaps may persist. At the same time, nursing is becoming less attractive to young people: only 1.4% of 15‑year‑olds expressed an interest in pursuing the profession in 2022 according to the OECD PISA survey – a 20% decline since 2018 and below the OECD average of 2.1%, threatening the future supply of nursing students (OECD, 2025[7]).
4.2.2. Intention to emigrate among doctors remains high, posing a challenge for meeting rising demand for healthcare
Emigration of health workers remains an impediment to overcome. Both nurses and doctors tend to move to other European countries, particularly to Germany, Italy and France, a trend that has accelerated with Romania’s accession to the EU in 2007. Dissatisfactions with working conditions, including outdated health infrastructure and equipment, bureaucracy and inefficient management, explain the high level of outmigration. As in other OECD countries, Romanian doctors struggle with high workloads and unsatisfactory working conditions particularly exacerbated after the COVID‑19 crisis, such as high numbers of night shifts, paper-based documentation and outdated equipment. The outflow of health workers seems to have stabilised in the recent years, thanks to the significant increase in health professionals’ salaries (detailed below). However, according to a survey of the Romanian College of Physicians, almost two‑third of doctors under age 35 still intended to leave the country in 2023 following the pandemic (Romanian College of Physicians, 2023[8]). Although intention to leave does not necessarily reflect actual migration numbers, the high proportion of doctors intending to leave poses a future risk for meeting rising demand for healthcare and calls for further measure to address both push and pull factors in the country. A health professionals register is currently under progress, which will provide more understanding about the migration trends of health workers.
4.2.3. An ageing doctor workforce and decreasing attractiveness of family medicine are likely to put primary care under dual pressure in the coming years
General practitioners (GPs), which mainly correspond to family physicians in Romania, represent 18% of the Romanian doctors, a proportion lower than the OECD average (21%), but still higher than the neighbouring EU4 average of 14% (Figure 4.9). The numbers of GPs had generally shown a downward trend until 2019 and then remained mostly stable. However, this still represents a 9% decline between 2010 and 2023. The decline was also reflected in national sources, as the number of primary care practices contracted with CNAS fell from 10 157 in 2018 to 9 125 in 2024 (CNAS, 2025[9]). This is potentially due to reduced interest in family medicine and emigration among young physicians, signalling the need for tailored interventions to encourage physicians to choose family medicine as a career.
Note: Data refer to 2023 or nearest year. EU4 refers to Czechia, Hungary, Poland and Slovenia. 1. Includes non-specialist doctors working in hospitals and recent medical graduates who have not yet started postgraduate specialty training. 2. In Portugal, only about 30% of doctors employed by the public sector work as GPs in primary care – the other 70% work in hospitals. 3. Latest data from 2022.
Source: OECD (2025[1]), Health at a Glance 2025: OECD Indicators, https://doi.org/10.1787/8f9e3f98-en.
An important outflow factor affecting the future labour market is the age distribution of the current workforce. Romania has a considerably lower share of older medical workforce compared to OECD countries, with only one in five doctors aged 55 years and older in 2023 (OECD average: 32%). However, looking at primary care providers, GPs under the age of 35 account for 15% of the total number of GPs, while those aged 61 and over comprise 41% (National Institute of Statistics, 2025[10]). This indicates that Romania’s primary healthcare is likely to face a dual pressure of an ageing workforce and decreasing attractiveness among young physicians over the coming years.
4.2.4. An overwhelming majority of health professionals are located in urban settings, leaving rural areas underserved
In Romania, hospitals and other healthcare facilities in urban areas are overstaffed, while rural areas struggle to fill posts. In 2024, more than 90% doctors were employed in urban settings, reflecting the striking uneven distribution of physicians (National Institute of Statistics, 2025[10]). Similar disparities exist among GPs: in 2023, the Vest region had the highest GP density at 4.7 per 10 000 population, while Nord-Est and Sud-Est lagged significantly behind at just 2.2 (OECD/European Observatory on Health Systems and Policies, 2025[6]). This is partly because most young graduates choose to stay in urban areas upon their graduation due to better career prospects and working and living conditions. Likewise, the number of community nurses is low, representing less than 1% the country’s nursing capacity.
4.2.5. Romania has significantly increased doctors’ salaries to retain them, but retention also requires measures going beyond salary improvements
The main lever to mitigate the emigration of the health workforce and improve the shortage in rural areas has been the increase in remuneration in recent years. In 2018, the government introduced impressive salary increases for doctors working in public hospitals, with 130% increase for senior doctors and 160% for junior doctors (European Observatory on Health Systems and Policies, 2018[11]), which helped to improve retention (OECD/European Observatory on Health Systems and Policies, 2019[12]). Regarding private practices, the capitation payment (which is capped at 2 200 patients per doctor under the current system) was relaxed for family physicians working in rural areas by allowing them to register more than 2 200 patients. In 2019, the government revised the regulations, in order to permit family physicians to open two practices in different locations or even in the same location if they are in specified rural areas (European Observatory on Health Systems and Policies, 2022[13]). To further incentivise family physicians to practice in rural areas, the 2023 new framework contract reduced the minimum registration requirement (from 1 000 to 800 patients) (European Observatory on Health Systems and Policies, 2022[13]), and provided financial incentives. Further, since 2023, new family physicians working in rural settings benefit from a 50% increase in payment for six months compared to their urban counterparts. This increase can be up to 100% if they choose to work in an area where there are no family medicine physicians. These issues and approach are not unique to Romania, and evidence suggest that those incentives are helpful but not sufficient to entirely address the challenge (WHO, 2020[14]).
The most often cited reasons for intention to leave among doctors are the limited health infrastructure and working conditions (Romanian College of Physicians, 2023[8]), signalling the need to go beyond salary improvements and take actions on working conditions and other underlying factors. As in other OECD countries, Romanian doctors struggle with high workloads and unsatisfactory working conditions, which were exacerbated after the COVID‑19 crisis, such as a high number of night shifts, paper-based documentation, and outdated equipment. Fragmented care delivery and the lack of an adequate HIS, which currently relies on paper documentation, result in unnecessary doctor visits, administrative burdens, and extra workload. The MoH has recently taken steps to reduce paper documentation to alleviate the administrative burden on doctors, but these strategies have not yet resulted in a significant improvement. Some regions are taking independent actions to improve working conditions: an exemplary initiative is from the Prahova region which has managed to attract physicians only by digitalising administrative process and offering accounting assistance for opening practices. Such efforts should be extended at the national level to avoid the competition between regions to attract doctors, which would only deepen regional disparities. The authorities should 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. Further, encouraging students from rural backgrounds to pursue careers in healthcare and promoting rural clinical placements in primary care settings for medical students could also improve rural workforce recruitment and retention (Russell et al., 2021[15]).
A greater capacity of community nurses would be vital for the implementation of preventive programmes in underserved areas struggling with doctor shortages. Romania plans to train 2 000 additional community nurses using European funds to bolster primary care, especially in rural areas. To further address workforce gaps, the country could introduce advanced practice nursing roles, enabling nurses to take on expanded responsibilities through task sharing – a strategy that could alleviate pressure on doctors and improve service delivery. Strengthening pay and working conditions, particularly for community nurses, will be key to retaining this essential workforce, as post-training retention is currently low, with many nurses leaving after just one or two years due to inadequate remuneration.
4.2.6. Romania’s Multi-Annual Health Workforce Development Strategy is an important step towards better workforce planning and retention
To address the lack of a strategic plan for workforce planning and retention, Romania took an exemplary step by announcing the Multi-Annual Health Workforce Development Strategy for 2022-2030. The plan was developed in collaboration with WHO following the National Health Strategy 2030 and NRRP, and identified five strategic areas to work on: building workforce capacity, leadership and governance, identifying and responding to issues related to working conditions, and improving retention. The plan seeks to identify successful initiatives to attract and retain doctors in underserved areas, such as different payment models, improve medical education and training programmes, particularly through the use of digital tools, and revise medical practice regulations to meet European standards. The programme also aims to improve the collection and analysis of health workforce data to forecast current and future needs, monitor health workforce, and manage and govern it with a more tailored approach. However, the government has not yet set a dedicated budget for the actions needed to implement these strategies.
4.3.1. While hepatitis B and C and tuberculosis remain significant concerns, Romania is implementing programmes to prevent and control the spread of diseases
Romania had one of the highest prevalence rates of hepatitis B and C in the EU (ECDC, 2022[16]) and across OECD countries in 2022 (Figure 4.10). A series of screening pilot programmes implemented during 2021-2023, led to improvements in disease diagnosis, and partly explained the higher prevalence. To control the spread of the diseases, the country has set up a National Framework Plan for the control of viral hepatitis 2019-2030. Co‑ordinated by MoH, this plan aims to strengthen the surveillance system, reinforce primary prevention, and extend access to treatment to all. As a step forward to the pilot projects, hepatitis B and C testing has been made available to the uninsured population as of July 2024, as newly regulated in the framework contract. Furthermore, Romania successfully increased the vaccination coverage for hepatitis B (reaching 94% of the new-borns in 2024) (WHO, 2025[17]). However, in order to control the prevalence rates of viral hepatitis, further long-term actions are required to curb the figures.
Note: Data refer to 2022. Countries are ranked by rising prevalence rate of hepatitis B.
Source: WHO, 2022. Hepatitis - prevalence of chronic hepatitis among the general population, https://www.who.int/data/gho/data/indicators/indicator-details/GHO/hepatitis---prevalence-of-chronic-hepatitis-among-the-general-population.
Tuberculosis (TB) is another cause for concern in the country. In 2022, TB caused 3.6 deaths per 100 000 population in Romania, a number that exceeded all OECD countries and four times higher than the OECD average (0.8 deaths). Until 2017, the mortality rate had been falling steadily as a result of community public health programmes and an established network of TB treatment and surveillance services, but it stabilised in the following years. More worryingly, TB incidence, which had been declining before the pandemic, increased by 22% between 2020 and 2022, almost reaching pre‑pandemic levels (ECDC, 2022[18]). As a response to the increasing incidence and the unfavourable trend in mortality, the government approved the National Strategy for Tuberculosis Control for 2022-2030 and launched its implementation. The plan aims to eradicate TB by 2035 and sets out objectives to achieve TB eradication such as shifting care delivery from hospital to ambulatory care, adapting the financial model to encourage prevention and early detection, increasing the use of innovative diagnostic tests and vaccines, and improving access to treatments (Ministry of Health, 2022[19]). While TB screening programmes for Ukrainian refugees and rural population have been rolled out in 2021 and 2023, the country also plans to reinstate a TB screening programme for vulnerable populations.
Romania is committed to prevent and control infectious diseases. The National Health Strategy 2023-2030 plans to reduce the burden associated with priority communicable disease, such as TB, viral hepatitis, and HIV/AIDS, by improving prevention, increasing the capacity for diagnosis and for rapid and adequate treatment, as well as monitoring of patients, mainly in ambulatory, and favouring their social reinsertion. The country has national action plans against TB, HIV/AIDS and others sexually transmitted diseases underway.
4.3.2. Declining childhood vaccination coverage and the increasing measles cases call for new strategies to improve the vaccination coverage
In 2024, only 68% of children in Romania are estimated to be immunised against measles, which is one of the lowest rates after Poland and Estonia, and below the OECD average (89%) (Figure 4.11). For diphtheria, tetanus and pertussis (DTP), vaccination coverage among children aged one year old was only 66% in 2024, below the OECD average (93%) (Figure 4.11). Like half OECD countries, Romania falls short of the WHO-recommended minimum immunisation level for measles (95%) and DTP (90%). The country has experienced a decline in children’s vaccination coverage (especially for measles) over the past decade, a trend observed in OECD countries, especially during the COVID‑19 pandemic. As a consequence, measles cases surged, and the country has declared a national measles epidemic in December 2023. In 2024, 30 692 measles cases were reported in Romania, representing 87% of all cases in EU/EEA countries (ECDC, 2025[20]).
Note: Data refer to 2024. 1. Latest data from 2023. 2. Data refer to estimates. Lines indicate WHO minimum targets of 95% for measles and 90% for DTP.
Source: OECD (2025[1]), Health at a Glance 2025: OECD Indicators, https://doi.org/10.1787/8f9e3f98-en.
About 23% of those aged 65 and over were immunised against influenza in Romania in 2023, below the OECD average (51%) but higher than the average of the neighbouring EU5 countries (17%) (Figure 4.12). Influenza vaccination uptake has increased by 12% since the pandemic.
Vaccinations are advised but not mandatory, and vaccines included in the national immunisation programme are free‑of-charge for children and at-risk population. For children, the national vaccination schedule covers hepatitis B, tuberculosis, diphtheria, pertussis, tetanus, poliomyelitis, streptococcus pneumoniae, haemophilus influenzae B, measles, mumps and rubella. In 2017, a proposed vaccination law aimed to mandate children’s vaccinations by reviewing children’s vaccination records at school entry, but the proposal was vetoed by the parliament. All vaccines included in the national immunisation programme are available for free at delivery point, funded by the state budget. In order to facilitate greater access to vaccination, the MoH issued since 2023 a legislative framework that enables the provision of additional vaccines (e.g. human papillomavirus (HPV) and pneumococcal) at no cost or with partial reimbursement to at-risk populations. Specifically, HPV vaccine is provided free of charge to all girls and boys aged 11‑26 (OECD/European Observatory on Health Systems and Policies, 2025[6]). These vaccines are funded from the health insurance fund.
Note: Belgium’s data excludes people in nursing homes. Iceland’s data covers people aged 60+. and the Slovak Republic’s data covers people aged 59+. 1. Latest data from 2022.
Source: OECD (2025[1]), Health at a Glance 2025: OECD Indicators, https://doi.org/10.1787/8f9e3f98-en.
Low vaccination coverage and the downward trend must be explained by factors other than cost, given that children vaccinations and the influenza vaccine for at-risk populations are available for free at delivery point under the national immunisation programme. Potential reasons include low level of health literacy, family doctors’ concerns about administering vaccines, delays in vaccine procurement, and an increase in cross-border migrants (Rechel, Richardson and McKee, 2018[21]). For instance, following the 2016 measles outbreak in Romania, although 92% of the population was aware of the measles outbreak, only 43% identified the lack of vaccination as the main cause (Rechel, Richardson and McKee, 2018[21]). This suggests there is room for enhancing health literacy and assisting people in making informed decisions regarding vaccination and public health.
Another challenge to address is vaccine hesitancy among some medical practitioners, while others require guidance on how to persuade patients to get vaccinated. In response, in 2024, Romania developed a specialised curriculum for physicians dedicated to vaccination, to enhance their competencies. Vaccination in pharmacies was also introduced as a new initiative with pharmacists trained for influenza vaccination. However, further action is needed to achieve greater coverage in children’s vaccination and reduce infant mortality. It is crucial to introduce effective national communication campaigns through traditional and social media to address misinformation, thereby improving health literacy to overcome vaccine hesitancy. Outreach vaccination programmes are also required to reach those living in rural areas and uninsured populations. These strategies must be implemented at national, regional and local levels to address public health concerns and vaccine hesitancy effectively.
4.3.3. Romania is actively tackling the rise in antimicrobial resistance
Antimicrobial resistance (AMR) is of serious concern. Romania recorded the highest AMR composite index in the EU, with nearly 70% of bacterial isolates resistant to key antibiotics in 2022-23 (ECDC, 2024[22]). Without further policy actions, AMR is expected to further grow in the coming years. A significant driver of AMR is the overuse and misuse of antibiotics. The volume of antibiotic consumption in Romania is very high, well above the OECD average in 2023 (26 defined daily doses (DDDs) per 1 000 inhabitants compared to 16 DDDs in OECD), which has not changed over the last decade (Figure 4.13). Regarding the safe use of antibiotics, Romania falls short of the WHO target for the use of Access-group antibiotics – which are first and second-line pharmacotherapies with lower potential for AMR. With just above 50% in 2023, Romania remained below the WHO minimum target of 65% (OECD/European Observatory on Health Systems and Policies, 2025[6]).
Note: 1. Latest data from 2019. 2. Latest data from 2021. Data refer to antibiotics prescribed in community setting only.
Source: OECD (2025[1]), Health at a Glance 2025: OECD Indicators, https://doi.org/10.1787/8f9e3f98-en., based on ECDC (for EU countries and United Kingdom); OECD Health Statistics.
Romania has been actively taking actions aligned with the National Health Strategy preventing HAI and combating AMR 2023-2030. To effectively reduce antibiotic consumption, the country passed a law to enable monitoring of antibiotic dispensing in emergency situations – through the collection of patient and pharmacy data, aiming to limit misuse and prevent repeated unregulated dispensing. Other concrete measures recently implemented include providing training and education to healthcare staff on AMR and supporting awareness campaigns at local and/or sub-national level about risks of AMR and actions to address it. To strengthen its actions against AMR, Romania should consider incorporating the financial provisions for the implementation of the AMR action plan into the national action plans and budgets. To optimise antimicrobial use in human health, it is essential to ensure that national guidelines are implemented and that data on antimicrobial use is systematically fed back to prescribers. To improve infection prevention and control, it is recommended that good practices are systematically implemented at national and health facility levels, compliance and effectiveness are assessed, and that guidance is regularly updated. The OECD estimates that investing just USD 1 per person annually in policies that respect the One Health2 approach would result in saving in healthcare costs of USD 8 million for the Romanian economy (OECD, 2023[23]).
4.3.4. The COVID‑19 crisis highlighted important shortcomings in Romania’s preparedness and response to health outbreaks and other emergencies
In response to the COVID‑19 pandemic, the Romanian Government enacted a series of measures in alignment with the WHO recommendations and the International Health Regulations. Despite these measures, the rates of testing and vaccination remained low, resulting in a mortality rate from COVID‑19 that was about 12% higher than the EU average. Specifically, Romania recorded approximately 1 790 deaths per million population due to COVID‑19, compared with an EU average of about 1 590 between 2020 and 2021 (OECD/European Observatory on Health Systems and Policies, 2021[24]). This suboptimal response underscores the need to reinforce crisis preparedness and response, including in updating preparedness plans, better intersectoral preparation, more effective communication, and improved co‑ordination at the national and sub-national levels.
Beyond pandemics, Romania is exposed to several potential public health risks including natural and climate‑related disasters. Romania’s earthquake risk is among the highest in the EU. In each of the last five centuries, the country has on average experienced two earthquakes of magnitude 7 or above (World Bank, 2019[25]). And, three in four inhabitants lives in areas that are susceptible to earthquakes (World Bank/Romanian Government, 2023[26]). Climate change is expected to lead to more frequent and persistent heat waves and more severe droughts. Romania is particularly exposed to hot weather, increasing people’s health problems and mortality risk. For instance, nearly half (48%) of the Romanian population is exposed to hot summer days (days where the temperature exceeds 35°C), compared to 29% on average in OECD countries (OECD, 2023[27]). In addition, following the Russia’s war of aggression against Ukraine, the inflow of people arriving from Ukraine are also placing considerable strain on the health system. Since the war began, over 3 million refugees have crossed into Romania, with around 77 000 Ukrainians residing in the country as of March 2024 (WHO, 2024[28]). The Romanian healthcare system has responded to the refugee’s health needs, by granting free of charge medical care to displaced people arriving from Ukraine.
Romania’s self-assessed capacity for public health emergencies, as measured by the WHO e‑SPAR tool, was 62% in 2024, well below the EU average of 75% (OECD/European Observatory on Health Systems and Policies, 2025[6]), particularly reflecting gaps in infection prevention and control, human resources, risk communication, and health services provision (WHO, 2024[28]). The authorities recognise the importance of strengthening their capacity for preparedness and responses to health crisis. Concrete measures include upgrading the laboratory infrastructure and establishing a national reference laboratory to enhance testing and surveillance capabilities during health emergencies. Together with WHO, the country has initiated a project dealing specifically with strengthening emergency co‑ordinating structures at national and county level and with developing standard operating procedures for the co‑ordination of joint operations for emergency response (WHO, 2024[28]). To improve resilience to various types of disasters, Romania has adopted the National Strategy for Disaster Risk Reduction 2023-2035. This strategy aims to improve preparedness and responses for a range of potential hazards, such as forest fires, earthquakes and epidemics, through a multi-sectoral and comprehensive approach that engage all relevant stakeholders. Strategy implementation efforts are co‑ordinated by the Ministry of Internal Affairs, through the General Inspectorate for Emergency Situations and the Department of Emergency situations. To effectively address future health challenges, it is important to strengthen efforts and speed up the implementation of measures to prepare for and respond to any future crises.
References
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← 1. Catastrophic expenditure is defined as household OOP spending exceeding 40% of total household spending net of subsistence needs (i.e. food, housing and utilities).
← 2. One Health is an integrated strategic approach aiming to establish multisectoral collaboration between public health, veterinary, and environmental actors to address cross-cutting health challenges such as antimicrobial resistance or food safety (World Health Organization).