Overview

Romania is located between Central and South-Eastern Europe, bordering Ukraine (North), Moldova, Ukraine, the Black Sea (East), Bulgaria (South) and Hungary and Serbia (West). It is a member of the European Union since 2007, the ninth largest country by area and seventh largest population of the EU - 21.5 million people. The capital and largest city is Bucharest, which is also the sixth largest city in the EU with 2 million inhabitants. The language spoken is Romanian, a language of Latin origin, similar to French, Italian and Spanish.  Local currency is Romanian Leu (plural Lei, abbrev RON). 1 Euro = 4.2 Lei. Almost half of the country is covered with natural and semi-natural ecosystems - it has one of the largest areas of undisturbed forest in Europe and the largest and least damaged wetland complex in Europe (Danube Delta).
 

Health care

Health care in Romania is organized in two different systems.

- The public system which is financed mainly through social health insurance contributions which are mandatory, with some exemptions for children, students, the unemployed and low income persons. Employees contribute 5.5% of their monthly wage and employers add an extra 5.2% for each employee. The National Health Insurance House (CNAS) administers all the funding and is responsible for planning and purchasing , through its county branches, health services from both public and private hospitals, laboratories, pharmacies, ambulatory care specialists, GPs etc.

- A smaller private system where patients have to pay out of their own pocket for each health service they request. There are no private insurance funds, only small private schemes, mainly connected to life insurance agencies or private health clinics. Private health services are used only by a small percentage of the population, as most use the public system services, which are free of charge at the point of delivery.

General practice in Romania was recognized as a clinical specialty in 1991, with a 3 year vocational training postgraduate program. In 1999, general practice became known as family medicine, thus marking the primary health care reform in Romania - GPs/family doctors became independent professionals, self-employed and were no longer Government employees. Since 1999, GPs work under contract with the county branches of the National Health Insurance House (CNAS), receiving payment for the health services they provide to all those insured under the social health insurance scheme.

 
Romanian GPs have a gatekeeper role for the public system (CNAS), but not for the private system. This means that those benefiting from free services can't access any other service unless they are seen first by their GP. Patients who choose the private system don't need to see a GP first, as they can access any service through direct payment. Government subsidized prescriptions are available only in the public system and there is a co-pay of 10-50%.

Most patients in Romania are registered with a GP of their choice, without limitations regarding the area in which they live. Most choose a GP close to home and don't change the GP for many years. However, patients can change GPs after a 6 month minimum period.

There are 11400 GPs in Romania, the average list of registered patients is 1600, with some practices caring for just 1000 patients (minimum accepted limit for a contract with the CNAS) while about 20% of practices look after over 2200 patients. GPs are a third of the total number of doctors in Romania. Most GPs work in single-handed practices, especially in rural areas. In urban areas there usually are larger primary care clinics, but GPs still work in solo practices, with at least one nurse for each GP (a requirement of the contract with the CNAS). Apart from GPs who own their own practice, there are also salaried GPs who work for GPs with solo practices but with more than 2200 registered patients or for large private clinics. Romanian GPs can also work in Emergency Departments or on ambulances, after a 6-month training in Emergency Medicine.
 

The number of GP consultations per year is approx. 50 million and an added 2.5 million home visits.  Same day consultations are usually available and patients can make appointments. The referral rate to secondary and tertiary care is approx. 15%. About half of GPs use computers in their daily activity for record keeping and reports to the CNAS. By 2012 the CNAS stated that a national e-prescription system, the electronic health card and EHR will be in use.

Regarding payment, since 2010 a change in the per capita / pay-per-service system was made, and GPs now receive 50% of the income from pay-for-service and 50%  for the patients registered with their practice. Income is low, as is the budget of the entire health care system in Romania (only 3.6% of the GDP in 2011). Pay-for-service is limited by the government imposed 15' consultation time, meaning a GP working for 5 hours doing office consultations and 2 hours doing home visits can only receive pay under the contract with the CNAS for a maximum of 20 consultations/day and 1 home visit/day. GPs who care for more than 2200 patients are allowed to work an extra office hour. Most GP practices aren't open during weekends or after normal working hours. Out-of-hours care is assigned to dedicated centers with GPs, usually in rural areas. Some rural areas aren’t covered by GPs, due to lack of involvement of the local authorities. An important percentage of practices, especially in rural areas, don’t have ECGs, ultrasound or basic lab tests equipment.

Romanian GPs are organized since 1991 in a professional association called the National Society of Family Medicine (SNMF), WONCA member since 1994.  Membership is not mandatory, but each year more GPs join the Society. SNMF organizes 2 National and 8 Regional Conferences each year, over 30 workshops, course, symposia, publishes a newspaper and a handbook each year distributed for free to all GPs, developed an eLearning platform for GPs and a strong communication network: e-mail, telephone, SMS, newsletter, website, online message board (3300 members, 3000 messages/month). Romania is also represented in all WONCA networks - EURACT, EGPRN, EQuIP, EURIPA and VdGM. Society website is www.snmf.eu.
 

Medical education

Romania has 12 medical universities, each with its own Family Medicine Department and postgraduate 3-year GP training program. Medical school duration is 6 years and graduates must pass a national MCQ exam to gain access to any specialty training program. Specialties can be chosen according to the results from the MCQ exam. Full licence to practice is gained only after finishing the training program and passing the specialty exam. Each year approx. 4500 students graduate and there are about 2500 specialty training posts available, out of which one third are in Family Medicine (GP).

The GP specialty training program has a duration of 3 years and consists of training in the GP office in the first 6 months and last 9 months of training. This can only be done in urban GP practices, in the same city with the medical university responsible for training. Clinical training in hospital posts is divided into rotations in internal medicine (4 months), peadiatrics (4 1/2 months), surgery, ob-gyn, oncology (2 months each), dermatology, psychiatry, neurology, diabetes, infectious diseases, epidemiology & management (1 month each), bioethics (2 weeks).

In order to become a GP specialist and gain a full license to practice, trainees must pass a written exam and a clinical skills exam (assessment of a real life patient - one adult and one child) in a hospital setting.