Contrasting Clustering in Health Care Provision in Romania: Spatial and Aspatial Limitations

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Procedia Environmental Sciences 32 ( 2016 ) 290 – 299

Peer-review under responsibility of the organizing committee of ECOSMART 2015 doi: 10.1016/j.proenv.2016.03.034

ScienceDirect

International Conference

–

Environment at a Crossroads: SMART approaches for a sustainable

future

Contrasting Clustering in Health Care Provision in Romania: Spatial

and Aspatial Limitations

Liliana Dumitrache*

, Mariana Nae, Daniela Dumbr

ă

veanu

, Gabriel Simion, Bogdan

Suditu

University of Bucharest, Faculty of Geography, 1 Nicolae Balcescu Avenue, Bucharest, 010041, Romania.

Abstract

Despite its over 26 years of continuous efforts to reform the health care system, Romania is facing serious problems in meeting population health care needs, mainly due to chronic underfunding of public health care units, shortage of medical personnel, lack of GP in rural areas. The economic crisis has deepened these problems, making the access to health care more difficult for disadvantaged or vulnerable groups of population. Poor health status of the population, the demographic aging, the large share of socio-economic dependent population and the high level of chronic diseases incidence all lead to increased health care need therefore healthcare costs. Health care activity is mostly based on the public sector and is financed from public funds; alth ough private health services have had an extraordinary development recently, they are restrictive for the most of the population due to high costs and geographic location. Geographical distribution of medical personnel reveals major disparities among regions and in particular between urban and rural areas: less than 20% of the physicians (5,592 from 52,541 in 2012) are practicing in rural areas, 66% of the medical personnel being concentrated in six large cities while 5% of the rural communities have no doctor. Over 15,000 health professionals (30% of total) have left Romania since 2007 and about 40% of the medical graduates (2,500) are emigrating every year. By using quantitative and GIS techniques, this study is aiming to examine the spatial distribution of healthcare resources in order to point out the large rural-urban divide in health care provision and to highlight the deep territorial discrepancies related to supply of health services and potential population needs.

Peer-review under responsibility of the organizing committee of ECOSMART 2015.

Keywords: health care resources; health care potential needs; vulnerable groups; spatial and aspatial limitations; health policies; Romania.

* Corresponding author. Tel.: +4-021-315-3074; fax: +4-021-315-3074.

E-mail address: [email protected].

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1. Introduction

Health and Health care system are important issues for all, either political or social actors interacting in a social arena and reflect a particular context and a certain social reality. Usually, the social reality depends on the political system and on the way society organizes itself. The health care system is a key factor for public health which theoretically should meet the needs of the population. Better health outcomes depend on effective interventions

delivered by better health systems1. Uneven distribution of health care resources, the social inequalities may affect

the access of particular groups of population to health care services, generating inequities and inequalities in medical services utilization. In order to reduce such inequalities, particular importance must be paid by stakeholders and political actors to the role they are playing in organizing the health system and planning health care resources or implementing health policies. Even if recently, global and regional research of health care services has focused on access inequalities to health care, in Romania, this issue is still far for being comprehensively analysed, since the spatial dimension has received little attention and has been largely ignored. At a global scale, several studies have addressed a variety of subjects related to health or health care services, among which health care system difficulties

in the recent context of political and economic changes, otherwise topics listed by the main agendas of many

international organizations [1, 2, 3]. The final resolution of the United Nations Conference “The Future We Want”, also highlighted the importance of health universal coverage "we recognize the importance of universal health coverage to enhancing health, social cohesion and sustainable human and economic development” [3]. Other studies have demonstrated the effectiveness of health policies [4], the raising geographical inequalities [5, 6], aspects of inclusion and exclusion [7], equitable allocation of resources [8], the effect of health care systems reform in the

context of economic crisis[9, 10, 11, 12]. Multidimensional research has prevailed at regional scale (taking as sole

reference the Central Eastern European countries - the CEECs), most studies being related to post-socialist or post transitional changes of health system [13, 14, 15], health care crisis and informal payments [16, 17, 18], access to the health services [19, 20] and the reform of hospitals [21].

Issues of health care including changes in the Romanian health system have been tangentially and limitedly explored by various reports of different international and national bodies or NGOs's [22, 23, 24, 25, 26]. Transformations of the Romanian health system have obviously been analysed by researchers from various perspectives, studies being generally oriented towards the nature, the intensity and on their effects on different domains of life quality or on the population health status. Similar patterns of socio-political reality of CEECs, that have experienced a particular type of post-socialist transformations (decentralization of the economy, slow privatization, the challenges of the new political regime, demographic decline and labour force migration), have stimulated, at least in Romania, comparative studies on healthcare reform, population health outcomes, health care provision or distribution of health resources.

Most studies outcomes have revealed, particularly the tribulations of health reform, the health system failures [27, 28] (in)effectiveness of health policies, and various aspects of healthcare services supply [29]. However, from the perspective of Geography of Health, at least concerning Romanian case, there are no studies to emphasize the importance of space in managing health resources or of the ways in which geographical space is (re) structuring particular socio-economic characteristics and migration. Geographers emphasize, the importance of space in distributing health care resources from a ‘container space’ perspective, drawing the attention to the particular characteristics of the Romanian healthcare system.Through this preliminary study, authors intend to point out at the importance of space as well as at the inequalities occurring inside distribution of health resources, starting with the valences of socio-geographic reality. These inequalities in the distribution of health resources may be considered, at local or regional level, as generators of inequities, in terms of access to medical services, significantly affecting vulnerable populations [30]. The causal relationships between space and its demographics or socio-economic component (assuming that elderly population as well as economically vulnerable people may raise the pressure on the health care system), constitutes additional research subjects. Vulnerable populations are social groups who

experience limited resources and consequent high relative risk for morbidity and premature mortality [31].

The objective of this study is to examine the territorial discordances between the spatial distribution of health care resources and the population potential need for care; study looks and outlines certain particularities of health resources distribution in Romania, displaying a landscape of care, divided between east and west as well as between urban and rural areas, which responds with difficulty to the real or potential population needs. There is an applied

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dimension attached to the study which may be of use to the health authorities, policy makers and to planners, as the availability of medical personnel and health care facilities in the immediate geographic proximity is a precondition for access and addressability to medical care. This is not necessarily correlated with a higher level of delivery and it does not guarantee the quality of health services, but it is a prerequisite [30].

2. Methodology and data

Since there are no studies in Romania, nor to evaluate the necessary health workforce, neither to assess the real population needs, this study begins from the premise that an efficient health system should respond effectively to the demands of the population; health care activity is sustained through health resources (medical personnel and medical units) and their spatial distribution should be in accordance with the potential needs of the population. In this respect, earlier studies have shown that the more vulnerable population has become, the higher the healthcare needs are [32]. Also, recent studies have highlighted the disparities in access of vulnerable populations to health care or contributed to their critical approach [33, 34, 35]. Access to a variety of data and advanced GIS techniques enable the researchers to more accurately determine the size of the vulnerable population also providing clearer identification of health care underserved areas. To be able to highlight the uneven territorial distribution of health care resources, there have been taken into account, the number of doctors (GP or specialists, practicing in public and private sector, except stomatologists) and the number of hospitals by categories. To see the spatial distribution of population groups potentially vulnerable, which would exert significant pressures on the health care system and raising health care

costs, two large groups have been considered: the aged population over 65 years and the share of the population

over 75 years of the total elderly population (starting from the premise that many of them need permanent

assistance) but also economically dependent population, with limited financial resources that do not contribute to the

health insurance system or are uninsured.

Complex phenomena such as health, poverty, distribution of resources, and quality of life can be measured into their multidimensionality, requiring a combination of methodologies, by using composite indicators [36, 37]. A composite indicator is formed when individual indicators are compiled into a single index on the basis of an underlying model [38]. Even if there have been suggested several types of social and economic vulnerabilities in order to asses its different forms only few have been tailored to the elderly population by being considered key variables in health policies. Principally based on deductive approaches, the vulnerability indices normally use several sets of variables and are usually related to the natural risk factors [39, 40, 41]. It is well known the fact that the availability and comparability of health data represents a methodological drawback for composite indices, thus subject to change and adaptable to the local context. This index has been designed starting with the known indices from within the literature related to general vulnerability. Social Vulnerability and Environmental Index (SeVi) covers several fields: education, employment, social assistance and the presence of the elderly [42, 43].

Therefore, depending on the availability of data and their established correlations, in this case, the economic vulnerability was outlined on the basis of a composite index (Economic Vulnerability Index) as result of standardization and aggregation of variables such as: the share of unemployed in the total active population, the proportion of housewives, the percentage of disabled people with a variety of disability degree, the percentage of people receiving social assistance, the proportion of any others dependents, the share of pensioners of the total population. At the end of normalization and standardization processes (by calculating Z - scores), the composite index was calculated by simple additive techniques, resulting values, ranging between 0 and 1, higher values indicating a higher degree of economic vulnerability.

All data variables in this analysis were initially assigned to a commune (territorial administrative unit), the smallest administrative unit in Romania. The source for health care and socio-demographic data is the National Institute of Statistics [44, 45] and Ministry of Health (2011, 2012, 2013 or 2014 data files). Geographic information systems were used to map and highlight underserved or high vulnerable areas. One serious limit encountered was the restricted access the statistical data on health and health care at micro-territorial level, the scarcity and the weak reliability of the existing statistical information, which reduces the possibilities to construct a complex index or correlate health indicators with other social economic indicators.

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3. Results and discussions

3.1.Romanian Health Care system and its perpetual reform

Romanian health care system has experienced several more or less successful targeted reforms, to commence with its decentralization in 1990, to continue with the gradual privatization, after 2000, which has entailed major

structural and institutional changes and cleavages. The inherent problems of a ‘two tiers system’ have become

recurrent over two decades of democracy: chronic underfunding, informal payments, legislative inconsistency discrepancies between the public and private sectors, and the inability of the health authorities to regulate and coordinate the subordinate institutions. According to the Presidential Commission Report (2008), the essential problems of the Romanian health system, come from its reduced financing, mainly caused by low contributors- beneficiaries’ ratio to the health services and by the non-transparent allocation of health funds [46].

During the last years of the health reform, the “medical power soft” resulted in two opposite and contradictory discourses: on one hand the political actors and media, struggling to implement the reform measures, and on the other, the health professional actors (i.e. the medical staff), criticizing the inherent difficulties of the reform and the fiscal pressures. Health system decentralization has been a significant starting challenge in making the system itself to function, by bringing in and imposing new established institutions, leading to excessive bureaucracy and poor coordination among all [47]. Decentralization has also led to the multiplication of financial flows while the responsibility to cover investments remained unclear, completely disregarding the territory. After 26 years into the reform, the Romanian health system is not amongst the best performing in Europe, as reflected by both, the negative trend of health indicators and the reduced percentage of GDP allocated to healthcare. The total budget allocated to health has remained on average at about 4% of GDP per year (3.9% in 2013) compared to 8% in the EU, meaning 370-450 USD / inhabitant, the lowest within Europe, insufficient to cover population needs and health investments. Health care activity is mostly based on the public sector and is financed from public funds (80%), while private funds are holding a low share compared to other EU countries; although the private sector has experienced an extraordinary development, mostly after 2000, while about 80% of doctors and auxiliary medical personnel (except stomatologists and pharmacists) are still practicing in the public sector, including a majority of hospitals relying on public funding (364 from 473 in 2012) as well as a large part of GP offices.).

3.2.‘Space matters’ and the distribution of health care resources

Geographical space and location matter in the distribution and configuration of health resources, hence resulting the availability and accessibility for the population, but these largely depend on the health policies and on the capacity of the state to allocate sufficient resources. “Health care utilization and health care need are not, however, identical. Supply of service is a prerequisite for accessibility. Availability in this most general of interpretations depends largely upon the state of medical technology and the allocation of resources to health care” [48]. Health resources distribution depends on space and time and can be interpreted from a relational perspective.

The configuration of geographical space determines specific patterns in the distribution of resources and of the activities, hence the importance of emphasizing their complementarity. From this point of view, humanist geographers have been concerned with the explanations of spatial processes and phenomena from the relational perspective (relational approach), human activities being interconnected with the space in the “constellation of human practices” [49]. Thus, attention was paid to the context and factors and the role they play, into the geographical space and place, into capacity of explaining differences and variations of healthcare dimensions; spaces and places are better visualized as nodes and networks, being dynamic and fluid, not autonomous or separate [50, 51, 52, 53].

Health and healthcare systems are dynamic; hence geographers are interested in their changes over time and space. All these changes have been highlighted by various conceptual models (including the relational approach mentioned above), which outlined the complexity of the theory in geomedical research, and, despite modern methods and techniques do not fully explain the peculiarities of a health system as “some social theory lacks a strong enough interpretation of dynamic, emergent processes to help us understand complex systems” [54]. The nature of the interactions between the actors of the health system in the geographic space is important. From

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geographical point of view, the nature of interactions is influenced both by the produced social space and by the institutionalized decision-making processes (laws, rules, reform institutions).

It is common knowledge that the social space is a construct but the way in which it gets produced is important in analysing the concentration of health resources. Accessibility, infrastructure, transport networks are essential factors in the attractiveness of potential health resources, or, in our case, could represent significant spatial limitations.

Identifying the limitations of accessibility to health care services allows planners to understand the eơects of

opening, closing, relocating health care facilities or modifying the services provided by existing facilities [55].

Uneven distribution of health professionals and health care units

In Romania after 1990, the number of doctors varies but overall, it has increased from 41,813 in 1990 to 53,681 physicians in 2012 (according to NIS). However, the value of doctors per inhabitant ratio is below the European average, with only 2.5 physicians/1000 inhabitants compared to 3.4 /1000 inhabitants, the EU average (2012), Romania being confronted with a shortage of medical personnel. Compared to the communist period, even if, admission into the medical faculties has become less difficult leading to an increased number of students and specialization opportunities, the insertion of medical graduates on the labour market in Romania is rather low. According to Romanian College of Physicians, approx. 2500 graduates/year (40% of total medical graduates) are leaving the country since 2011.

Shortage of medical personnel is often presented as a consequence of emigration. Emigration of health professionals is indeed an alarming phenomenon that has grown particularly after 2007 following Romania's EU

accession. Although it is difficult to estimate the volume or the intensity of the migration flows in terms effective

migration, due to scarce official data records (the available official data is rather keeping records of the potential migration or otherwise called intention to migrate, since it relies on the number of requests for certificates of study recognition), one can say that Romania is a sender country, with main destinations being France, the UK, and Germany [56]. Accordingly, since 2007, more than 15,000 health professionals (30% of the total) have left Romania, public expenditures on their education exceeding 80 million euro (Romanian College of Physicians, press statement). Emigration of health professionals follows the territorial pattern, where the major urban centres are the

highest emigrants’ providers, due to the large number of doctors and existence of medical faculties [57]. There is

also, the aspect of medical elite’ migration related to the economic development which involves complex processes further on translated into political and institutional changes, socio-demographic evolutions, territorial recomposition [58]. Although the average number of doctors is lower compared to many EU countries, studies assessing the necessary of doctors have not been done. However, even if it is not clear how many doctors are needed, their uneven geographical distribution is generating much more serious issues than the number.

Geographical distribution of medical personnel reveals major disparities among regions and in particular between urban and rural areas, to the disadvantage of the latter, thus limiting people's access to healthcare (Fig. 1). Therefore, less than 20% of the physicians (5,592 from 52,541 in 2012) are practicing in rural areas although about 50% of the Romanian population is living in these areas. In fact, 66% of the medical personnel is concentrated in six large cities (Bucharest, Iasi, Timisoara, Cluj-Napoca, Craiova, Galati) which polarize the largest number of doctors from both, public and private sector, as opposed to towns (small urban centres) or rural settlements (5% rural communities in Romania have no doctor while in 400 localities, representing approximately 13% of total number of communes, the number of patients / physician exceeds 3,000). The territorial distribution of physicians shows evident inequalities between the north, northwest and southeast regions of the country and the other regions, the lack of doctors in poorer regions, in small cities or remote rural areas has become a common phenomenon, with little immediate solutions.

Organizational malfunctions and weak delivery of primary health care services lead to an increased rate of utilization of hospital services, where population access hospitals for simple investigations, thus raising the overall health costs. The financial difficulties faced by the country determined health authorities to take measures to increase the efficiency of the health system as: reducing the number of hospital beds, hospital classification by quality, merging several hospitals and even hospital closure (69 hospitals in 2011) in order to reduce health expenditures (Fig. 2).

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Fig. 1. Concentration of medical personnel (doctors)

Fig. 2. Distribution of hospitals (public and private), by cathegories (2011

Decisions such as closing TB and chronic diseases hospitals, in remote former mining areas were justified while

closing several municipal hospitals from mountainous areas, for example, wasn’t at all the same case, since they

were providing care for extended population who could not then benefit from medical assistance due to: long distances (sometimes over 60 km), lack of transportation means and extra costs involved. Hence, 26 hospitals have currently been reopened. Although apparently the distribution of physicians and medical units at national level would be consistent with that of large cities, the health care network is not adapted to cope with the challenges currently induced by the demographic aging or by raising rural population’s vulnerability.

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Vulnerable groups and potential needs for healthcare

There are obvious geographic disparities concerning the availability of health services which are generated by both types of factors: spatial (distribution in space), and aspatial (deficient configuration of transport infrastructure, the travel cost, lack of financial resources, preference for certain doctors and hospitals). Thus, the spatial dimension of accessibility and availability of health services should be considered in territorial planning activities. From geographical perspective, it is necessary to know how these resources are distributed, which are the underserved areas, in order to develop a more efficient planning health workforce as well as health care facilities, therefore the healthcare system could respond efficiently to the population needs. In Romania, there are so far neither studies, to have had assessed population’s health care needs, nor any health resource planning strategy has been developed to take into account the territorial reality. It is common knowledge the fact that elderly population everywhere, not only in Romania, is the main consumer of health services, since there are certain chronic diseases associated with aging. Taking into account the challenges of demographic aging, a process quasi generalized in Romania, health resources and services will continue to experience significant pressure, since the elderly population shows an ascendant trend; demographic aging affects mostly, rural areas from the east, southeast and south part of the country. Furthermore, a significant proportion in this age group is over 75 years old, and in some administrative units, the percentage of those over 75 years exceeds 50% of the entire elderly population (Fig. 3). This means additional challenges for the social and health services, where many people of this age require permanent assistance. In addition, a continuously increasing vulnerability of the population, caused by economic factors, could lead to future additional health costs. These economic vulnerable groups of population are often uninsured, have limited financial resources and cannot afford to pay for medical services. The absence of doctors or medical facilities in proximity, the high costs associated to the access of medical services in major cities, determines the decreased addressability to medical services while the rate of substitution is high (self-medication, pharmacists, traditional healers). The ‘Inverse care low’ shows that generally, where the population is disadvantaged, the health care needs are higher but

health services supply is lower [32]. An illustrative index, used by this analysis is the economic vulnerability index.

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Fig. 4. Economic vulnerability of the population

The most common values ranging from 0.300 to 0.500 are concentrated in the eastern, south-eastern and western part of the country, overlapping areas underserved by medical personnel. The more these high values are prevalent and are dispensed in many ATU's, the more significant pressure they put on health resources and on the capacity of the health system to cope with double challenges: increasing elderly population, on the one hand, and growth of economically vulnerable population, especially in rural areas, on the other hand (Fig. 4).

The lack of reliable information on the population needs or demands in terms of health and health care, contributes to widening inequalities in access to medical services, where the elderly, as well as the economic dependent groups of populations are being the most disadvantaged. In these circumstances, the role of stakeholders in planning health resources and also in formulating and implementing health policies, under perpetual context of reforming the Romanian health system is crucial. The legitimacy of these actors, either political, professional or media, extends logically with the development of scientific knowledge, based on the historical background and the influence of health actors (physicians, pharmacists, environmental health staff).The political actors are those who exercise a political power, invested through a political mandate (parliament, government, local authorities) while media actors [59] have a double role: directly, through the scientific and professional press and indirectly (certain groups to raise awareness for a particular cause). This means that there is need to clearly identify health policy makers and mechanisms through which decisions are taken and how public money is spent. Often, the most difficult are to precisely identify the main actors. Normally, actors collaborate but in practice, they have separate missions and tasks (professional and administrative) without establishing bridges between them [60].

4. Conclusions

Spatial distribution of health care resources and unequal population access to them, particularly the vulnerable groups, are the key elements in shaping the particularities of a divided landscape of care in Romania. Hence, this study attempted to reveal from a relational perspective of contrasting clustering of health care provision considering on the one hand the territorial distribution of health care resources and on the other the vulnerable population spread. By taking into account the limited financial resources available to some population segments, there have been outlined the important spatial variations of the economic vulnerability index in the context of demographic ageing. This also relates to the starting premise that the distribution of the high values of the index, together with the highest

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share of the oldest old population implies economic and social effects and a general raise of health costs. The economic dimension of health resources needs to be paid more attention as well as to the costs involved by treating the illnesses but also to the access of vulnerable people to health services. A person may ignore an illness or not seek care when ill due to lack of economic access [61]. Obviously, to better underline these contrasting clustering, it is necessary to accurately assess the limits of population accessibility to health services; this research project, based on GIS techniques is currently in progress. Identifying spatial or aspatial limitations of accessibility to the health services allows planners to understand the effects of health care facilities location. Beyond the fact that health on its whole can be considered a tool for territorial development at least for Romania, the relationship health – territory has not yet been taken into account by the medium and long term health policies. Thus the territorial component becomes an ‘invisible’ and ‘intangible’ one.

The lack of planning in human resource for health has led to shortage of medical personnel in Romania as well as to denting inequalities in the territorial distribution of health personnel and geographic disparities in healthcare provision, where the most disadvantaged are clearly the rural areas. Beyond the numerous dimensions of health, the relationship between health and territory remain very actual and legitimate [60]. Unfortunately, in Romania, the territorial aspect was often ignored. The spatial dimension of health and health care, the layout of geographical space and its demographic and socio-economic characteristics have never been considered in the process of health care policies elaboration or health resources planning. Given the context of health services liberalization, hospital reform, weak financing of the system and raising health professional migration, numerous areas remain underserved by health services and with unmet population needs. Hence the role of the actors form inside the system is either overestimated or minimalized.

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