Resurse şi costuri în sistemul de îngrijire a sănătăţii mintale

Introduction

Financial management in mental healthcare is an essential component for ensuring an efficient and sustainable health system. Efficiency and cost-effectiveness as well as the allocation of resources in mental healthcare services are important aspects in the development of psychiatric reform plans and programs⁽¹⁾.

Healthcare spending constitutes strategic investments made by public authorities and private entities, with the objective of ensuring the population’s access to essential services and resources for the protection of physical and mental health. These expenditures are distributed across numerous sectors, including medical services, remuneration of medical personnel, and the development and maintenance of the infrastructure necessary for the performance of medical activities^(1,2).

In order to carry out a rigorous and comparable assessment of health spending, it is essential to use the methodological framework provided by the System of Health Accounts (SHA). SHA is a statistical system through which financial flows related to the consumption of health goods and services are described and which was developed based on the European methodology and the joint recommendations of the Organization for Economic Co-operation and Development (OECD), Eurostat and World Health Organization^(3,4). This system allows the classification, quantification and analysis of financial flows related to health services, facilitating a detailed understanding of the sources of financing, types of expenditures, and their beneficiaries^(5,6).

The greatest consumption of healthcare services is carried out directly by individuals, and it is intended to meet the individual needs of the population. Within the International Classification of Health Accounts, individual healthcare services are grouped into generic categories, such as: curative care (HC.1), rehabilitation (HC.2) and long-term care (HC.3), preventive services such as immunization (HC.6.2) or screening (HC.6.3), as well as the provision of medicines and medical goods (HC.5). A key element in the development of public policies in the field of healthcare must be the analysis of the relationship between the distribution of individual health services to the population and the resources involved in their provision⁽⁷⁾.

Financing mechanisms of the Romanian healthcare system

Financing of current expenses for services, goods and other activities within the national health system is carried out:

• at the level of local public authorities, from the state budget or from own revenues, through the Ministry of Health or through the budgets of other ministries and institutions with their own health network;
• at the level of local public authorities, from local budgets, through county, municipal, city or communal councils; from the own revenues of hospitals subordinated to local administrations;
• from the own funds of non-profit institutions serving households (non-profit organizations);
• from non-reimbursable external funds;
• from direct payments by households or legal entities that purchase medical goods and healthcare services;
• from funds allocated by employers for medical services provided to their own employees in occupational medicine offices or in the form of services contracted within medical subscriptions^(8,9).

According to SHA, in 2022, the national healthcare system, as a whole, recorded current expenditures of 80,563.5 million RON. In terms of financing sources, of the total current healthcare expenditures, 77.8% were made from public funds (through the financing schemes of the central and local public administration, from the National Single Health Insurance Fund and from the State Social Insurance Budget), only 0.8% with private sector funds (private health insurance), and 21.4% direct payments by households (final consumer)⁽¹⁰⁾.

From the perspective of medical services provided to the population, of the total current health expenditures recorded in 2022, the largest share was spent on curative services – 54.3% (43,758.4 million RON). Of these, 33,913 million RON were allocated to curative services provided to hospitalized patients, 9722 million RON represented the expenses for curative services provided on an outpatient basis, and 123.3 million RON were allocated to curative home care services. 20,598.4 million RON were spent on prescribed or nonprescribed medical goods, representing 25.6% of total current expenditures. Medical recovery services represented 1.7% (1 396.9 million RON) of current expenditures, long-term care services represented 5.7% (4 612.9 million RON) of current expenditures. In total current expenditures for long-term care services, the largest share was spent on services provided in a continuous hospitalization regime – 66% (3 044.4 million RON)⁽⁷⁾.

Healthcare spending in Romania is among the lowest in the EU both per capita – 1 663 euro in Romania versus 4029 euro in EU, and as a percentage of GDP – 6.5% in Romania versus 11% in EU.

Over 50% of total healthcare spending in Romania was spent on inpatient care, ranking it among the EU countries with the highest percentage, after Greece and France^(5,9).

Another major category of spending is on medical products, especially pharmaceuticals, with Romania ranking fifth in terms of percentage of healthcare spending on medicines (26%) out of 23 EU member states. However, pharmaceutical spending per capita in Romania is low compared to the EU average⁽⁵⁾.

Infrastructure of the psychiatric medical system in Romania versus EU

In Romania, there are 115 psychiatric units:

• five maximum security hospitals – 1927 beds
• 32 single-specialty psychiatric hospitals – 9920 beds
• 91 psychiatric departments within general hospitals – 5427 beds.

There is a total of 17,274 psychiatric beds, representing 12.63% of the total number of hospital beds (136,682).

Also, there are 79 Mental Health Centers^(11,12).

By the specialty for which hospital beds were allocated in 2024, out of the total number of 136,682 beds for continuous hospitalization, most hospital beds were registered for internal specialties (19.17% – 26,205 beds), surgery (17.57% – 24,022 beds) and psychiatry (12.63% – 17,274 beds)⁽⁷⁾.

Regarding the distribution of psychiatric beds at the level of socioeconomic macroregions (MR) and geographical areas in Romania, reported to Eurostat, MR 4 – Banat and Oltenia has the highest number of beds per 100,000 inhabitants (105.96), followed by MR 1 – Transylvania (103.27), MR 2 – Moldova and Dobrogea (74.19), and MR 3 – Muntenia which has the lowest number of psychiatric beds (68.18 beds/100,000 inhabitants).

• MR1 – North-West and Centre (Transylvania).
• MR2 – North-East and South-East (Moldova and Dobrogea).
• MR3 – South-Muntenia and Bucharest-Ilfov.
• MR4 – South-West and West (Banat and Oltenia).

On average, there are 87.9 psychiatric beds/100,000 inhabitants in Romania.

Following a European-wide comparative analysis on the distribution of psychiatric beds in EU hospitals, according to Eurostat, in 2022 there were 321,500 beds, representing 14% of total hospital beds. Belgium has the highest ratio, at 140.7 beds/100,000 inhabitants, followed by Germany, with 131.3 beds/100,000 inhabitants. At the opposite end, Cyprus, with 18.6 beds/100,000 inhabitants, and Italy, with 8.1 beds/100,000 inhabitants, are the only EU member states that reported less than 20 psychiatric beds/100,000 inhabitants⁽⁵⁾. Italy’s position with the lowest number of psychiatric beds in the EU is explained by the fact that the deinstitutionalization reform in Italy entailed the closure of the last single-specialty psychiatric hospital in 2015, and in 2017 the last penitentiary hospital was also closed, making Italy the only country in the world to extend the deinstitutionalization reform to penitentiary hospitals⁽¹³⁾.

Human resources in psychiatry in Romania versus EU

In terms of medical and health personnel, in 2024 there were working 2717 psychiatrists – 3.65% of all doctors in Romania. Of these, 1903 worked in a form of public ownership, 919 in a form of private ownership, and 679 were resident doctors. There is a significant imbalance in the distribution of psychiatrists between the counties and regions of the country, with a significant concentration in large university cities and a chronic deficit in other regions⁽⁷⁾.

Regarding the distribution of psychiatrists, in Romania we have an average of 11 psychiatrists/100,000 inhabitants, well below the EU average of 17 psychiatrists/100,000 inhabitants. According to data published by Eurostat, there are approximately 90,000 psychiatrists at the EU level. The highest number of psychiatrists per capita is in Finland, Sweden, The Netherlands and France. Eight EU countries have registered over 200 psychiatrists/million inhabitants. At the opposite pole, nine member countries have less than 150 psychiatrists/million inhabitants, the lowest level being recorded in Bulgaria, Poland, Malta, Romania (106 psychiatrists/million inhabitants) and Spain^(5,6).

Costs of mental healthcare services

The economic costs of mental healthcare are substantial, with direct and indirect costs estimated at 2.1% of GDP in Romania, meaning 3.4 million euro⁽⁷⁾.

As in other areas of healthcare, the costs of mental health services are highest for inpatients. Large institutions absorb most of the available funding, leading to underfunding of community-based services⁽¹⁴⁾.

Although policies aimed at reorienting towards the community and integrating the provision of mental health services within primary care have been implemented since the 2000s, the number of beds has increased and the mental health workforce has remained small⁽¹⁵⁾.

Eighteen years ago, when Romania, under EU pressure, made its first plan for reforming mental healthcare services, called the “Action Plan for the Implementation of the Strategy in the Field of Mental Health” and which was published in the Official Gazette of Romania on 29 May 2006, the authors of this plan estimated that 150 community mental health centers were needed, with an estimated annual cost of 48.3 million euros for the operation of the community psychiatry network (322,000 euros annually per center). This meant that the operation of community centers would have required an investment of 0.03% of Romania’s GDP in 2006⁽¹⁶⁾.

If we look strictly at GDP percentages, today we lose 70 times more as a country by not having a functional community psychiatry infrastructure than the operation of these structures would cost us.

Conclusions

In order to optimize mental healthcare services, a reassessment of resource allocation and budgeting is needed. By addressing regional inequalities and aligning financial resources with service requirements, the efficiency and effectiveness of mental healthcare services can be significantly improved.

The evaluation of the costs and budgetary implications of the individualized service plan is necessary evidence to inform and convince policymakers, and can serve as an aid in the political debates regarding the reform of the Romanian healthcare system.