This document provides an introduction and background to a study comparing the healthcare systems of Romania and Poland. It begins by discussing the motivation for the study from a documentary about healthcare issues facing Roma women in Romania. It then provides context about the countries' transition from communist rule and healthcare models. The author hypothesizes that Romania's healthcare system is less effective than Poland's due to inability to transition to a market economy and more corrupt institutions. The methodology will use a most-similar systems design to compare variables like GDP spent on healthcare and institutional effectiveness between the two countries.

1. Matthews 1
INTL 4510: Comparative Analysis of
Healthcare Systems — Romania & Poland
-Kierrah Matthews
Introduction
The motivation behind this study
came from a film I saw a couple of years
ago, called Angela. It is a documentary that
follows the life of a 17 year-old Roma girl
who is about to give birth to a set of twins.
Going beyond her daily routines, the film
inadvertently addresses several key issues
that are detrimental to the health of the
Roma people, particularly young women in
rural communities. This film made me
question what the current healthcare system
was doing to protect these women who
become pregnant, some of whom are
kidnapped, forced to marry, and unable to
feasibly access and/or afford medical
services.
During the same time, I was enrolled in a
comparative politics course and did a five-
minute presentation comparing the
healthcare systems of Poland and Romania.
Unsatisfied with the research that went into
that project, I decided to further my research
in hopes of addressing my previous research
question, which is “despite the many
commonalities between Poland and
Romania, why is the general health of the
Romanian people significantly worse off
than Poland?”
Both countries claim to have universal
healthcare coverage (UHC), yet Romania’s
government is constantly warding off
protesters, the people are partaking in
medical tourism, and doctors are fleeing the
country at an obscene rate because the state
is unable to pay for their wages. For the
purposes of this study, I will be using the
World Health Organization’s definition of
UHC, which ensures “that all people have
access to needed promotive, preventive,
curative and rehabilitative health services, of
sufficient quality to be effective, while also
ensuring that people do not suffer financial
hardship when paying for these services.”
(World Health Organization website).
After the collapse of the Soviet Union
(USSR), the countries located within central
and eastern Europe (CEE) went through a
quick and severe transition period that made
significant changes to how their institutions
operated, including the healthcare sector,
which was previously under the Semashko
model (WHO “Rocky Road”). The
Semashko model was named after the
USSR’s first Minister of Health, Nikolai
Semashko, and it was a completely
centralized, state-controlled system that
provided CEE countries the opportunity to
receive basic medical services (WHO
“Rocky Road”). Professor Igor Sheiman of
the National Research University in
Moscow believed that this model was one of
the first, and closest to achieving universal
health coverage, stating that it “made it
possible to integrate the activities of other
medical services and was very efficient in
the economic sense: low cost, health-care
coverage could be universal and was rolled
out to everyone free of charge,” (WHO
“Rocky Road”).
“The severe economic downturn in the
1990s, coupled in many countries with
rising unemployment, inflation, low salaries,
tax evasion and a large informal sector, led
to specific challenges, such as substantial
deficits in the public financing of health
systems. Countries struggled to retain the

2. Matthews 2
coverage levels of the communist
period.”(Tambor et al.)
Now, patients seeking medical attention will
either participate in cost-sharing payment
plans, rather than receiving service free of
charge as it is stated in the constitutions of
multiple CEE countries, or find health
providers in the private sector, or the main
response has been informal payments under-
the-table to ensure that they receive quality
service (Tambor et al.). To put it in
perspective, out-of-pocket (OOP)
expenditure as a percentage of private
expenditure on health in 2014 for Romania
was 96.3% versus 80.85% in Poland (World
Bank Data). It has become normal for these
payments to be the primary source of
healthcare financing. Considering the GDP
per capita for each country is relatively low
as compared to the rest of the European
Union, a lot of the population has a difficult
decision to make when it comes to going
without food to afford a lifesaving surgery,
even if that includes bribery, or avoid the
surgery in its entirety.
“The current economic crisis has already
led to an increase in the level of
unemployment throughout the CEE region
and in some countries, deepened poverty
and social inequality, while high public
budget deficits led some governments to
increase their reliance on private sources of
health care financing.” (Tambor et al.)
Theory/Background
For the past 27 years, Poland has strived to
become a steady democracy with a strong
centralized health system. The success
behind their health care system resides
within the hands of the National Health
Fund (NFZ) and the Ministry of Health,
which are platforms created to oversee
financing and contacts with public and
nonpublic health care providers and an
essential policy-creators and regulators in
the health system, respectively (Panteli 13-
15). Due to OOP creating a high private
expenditure rate, predominantly resulting
from assisted and informal payments,
mandatory health insurance covers nearly
98% of Poland's population (Panteli xxiii).
Poland's health care system has improved
the health population of its citizens
immensely, increasing the life expectancy of
its men and women. Despite its success,
Poland's health system does leave room for
improvement. Nevertheless, measures have
been taken in recent years to enhance
payment mechanisms, quality control, and to
improve wide-spread public coverage and
shortages in the workforce (Panteli xxiv-
xxviii).
Similar to Poland, Romania has been trying
to expand their healthcare system since the
dismantlement of the Soviet Union, but at a
much slower rate with little success. Health
in Romania leaves much to be desired with
its continual decrease in population,
resulting from “emigration, declined birth
rate, and rise in mortality” (Vlădescu xiii).
During the transition period, Romania made
major health reforms which transformed
their pervious “centralized, tax-based
system” to more of a multi-tiered,
decentralized “social health insurance”
program headed by the National Health
Insurance Fund (CNAS) (Vlădescu 23).
Hypothesis
After reviewing the histories of the two
countries, I hypothesize that Romania’s
healthcare system is significantly less
effective than that of Poland’s due to their
inability to effectively move towards a
market economy, but mainly because of
their corrupt institutions. To determine if my
hypothesis is correct, I will conduct and
examine a series of qualitative analyses
including, but not limited to, the overall
effectiveness of health institutions,

3. Matthews 3
corruption index levels, wages of medical
staff, and informal payments.
Methodology
In order to determine the underlying
causal factor(s) as to why these two
countries experienced different outcomes
regarding healthcare, I will take a
comparative research approach by using the
most-similar systems design method. In
theory, the states will share many
similarities, which should assumingly lead
to similar political outcomes (class notes).
Because this is not the case between Poland
and Romania, I will be looking for
variations between the data to effectively
analyze the dissonance in outcomes (the
state of the healthcare system). Below I have
created a table from the information
displayed on the World Health
Organization’s website; it depicts the
different variables I will be studying:
Most-Similar Systems Design
The main discrepancies I found were the
significant differences between the
proportions of gross domestic product
(GDP) that is dedicated to healthcare
funding, as well as the effectiveness of their
institutions. There is not much variation in
the percentage of GDP that is spent on
health between the countries, but just
looking at the dollar amounts it is
substantial. Why is that? Well, a possible
reason to Poland’s ability to be able to spend
this much in the healthcare sector could be
due to the fact that it transitioned smoothly
into a democracy and market economy.
Between the years of 1995 and 2009, there
was a “five-fold increase in healthcare
expenditure” ($4.42 billion to $23.65
billion) (Panteli xxiii). As impressive as this
looks, the growth of GDP at this time was
increasing as well, so the percentage
devoted to health expenditure only increased
by 1.9% (5.5% to 7.4%) (Panteli xxiii). One
can also assume that because of this easy
democratization, the state was able to
establish stable political institutions to allow
GDP to grow, which allowed for this
increase in healthcare financing.
Unfortunately the same cannot be said for
Romania, and because of this, ineffective
institutions have formed and allowed
corruption and slow privatization to
infiltrate the system and have damaging
effects.
Strong as the Institution
What constitutes an effective institution?
Well, I expect good governance to include
all, but not limited to, the following
definitions, which are taken from the Good
Governance Guide. These factors are what I
will be looking for in each institution:
 “Accountability: report, explain, and
be answerable for the consequences
of decisions it has made on behalf of
the community it represents
Poland Romania
Geographical
Location
Yes Yes
Post-
Communist
Yes Yes
Semi-
Presidential
Yes Yes
Similar Land
Mass
Yes Yes
Life Expectancy 76.80 years 74.56 years
GDP per Capita $12,495 $8,973
Health as % of
GDP (2014)
6.3%
($34.34 billion)
5.6%
($11.14 billion)
Effective
Political
Institutions
Yes No
Healthcare
System
Good Poor

4. Matthews 4
 Transparency: clearly see how and
why a decision was made – what
information, advice and consultation
council considered, and which
legislative requirements (when
relevant) council followed.
 Responsiveness: serve the needs of
the entire community while
balancing competing interests in a
timely, appropriate and
responsive manner.
 Rule of law: decisions are consistent
with relevant legislation or common
law and are within the powers of
council.”
(www.goodgovernance.rg.au)
As previously mentioned, many CEE
countries have stated in their constitutions
that healthcare will be provided for its
population, regardless of economic status. In
Poland, Article 68 of the 1997 Constitution
reads (“Poland’s Constitution” 14):
 “Everyone shall have the right to
have his health protected.
 Equal access to health care services,
financed from public funds, shall be
ensured by public authorities to
citizens, irrespective of their
material situation. The conditions
for, and scope of, the provision of
services shall be established by
statute.
 Public authorities shall ensure
special health care to children,
pregnant women, handicapped
people and persons of advanced
age.
 Public authorities shall combat
epidemic illnesses and prevent the
negative health consequences of
degradation of the environment
 Public authorities shall support the
development of physical culture,
particularly amongst children and
young persons.”
There are two main actors in Poland’s
healthcare system: the Ministry of Health
(MoH) and the National Health Fund (NFZ).
There is a clear separation between the two,
the MoH is superior to NFZ, mostly
involved in “national health policy, major
capital investments and for medical research
and education,” while the NFZ is in charge
of insurance schemes (Panteli 19). The NFZ
uses health insurance premiums from the
Social Insurance Institution and Agricultural
Social Insurance Fund to contract services
with health providers. To ensure that power
is balanced amongst the different
institutions, there is a check and balances
system in place, where the MoH oversees
the finances in the NFZ and then those
finances are “entrusted with the Ministry of
Finance” (Panteli 13-14).
Interestingly enough, Article 34 of
Romania’s 1991 (with amendments)
constitution is nowhere as detailed and
thorough as Poland’s. They are very broad
concepts that are somewhat ambiguous and
have different interpretations (“Romania’s
Constitution” 14):
 “The right to the protection of health
is guaranteed.
 The State shall be bound to take
measures to ensure public hygiene
and health.
 The organization of the medical care
and social security system in case of
sickness, accidents, maternity and
recovery, the control over the
exercise of medical professions and
paramedical activities, as well as
other measures to protect physical
and mental health of a person shall
be established according to the law.”
The main financial institution in Romania is
known as the National Health Insurance
Fund (NHIF). Until 2005, the NHIF was
supervised by the Ministry of Public Health

5. Matthews 5
until it gained autonomy and is now
responsible (Vlădescu 26):
 “developing the strategy of the social
health insurance system;
 coordinating and supervising the
activity of the district health
insurance funds (DHIF);
 elaborating the framework contract,
which together with the
accompanying norms sets up the
benefit package to which the insured
are entitled, and the provider
payment mechanisms
 deciding on the resource allocation
to the DHIFs
 deciding on the resources allotted
between types of
 The NHIF has the authority to issue
implementing regulations mandatory
to all DHIFs in order to insure
coherence of the health insurance
system.”
Two out of the six responsibilities outlined
in the NHIF’s charter explains that they
must make decisions involving resource
allocation, they have failed. Due to the fact
that their healthcare thrives off of OOP,
resources are consolidated and unfair. When
it comes to the needs of the community, they
have not been responsive. There is not the
same level of access and care of health
provision administered to different
demographics, or even geographical region.
There is hardly any oversight, any
accountability, any real funding, and frankly
that is why they are still in this mess. The
problem is not there are a lot of levels to
their current system (i.e. NHIF, DHIF,
MoH, district councils, hospital, medical
staff, Romanian College of Physicians, etc.),
rather a lot of levels trying to work together,
but doing it ineffectively.
Corruption Kills
*At a protest in Bucharest, these women wear
surgical masks that read ‘Corruption Kills’*
(McGrath)
Despite its improvement within the
health care system, Poland still struggled to
attack the ever present problem of
corruption. Ranking 67 in Transparency
International's 2004 Corruption Perception
Index--among 145 countries reviewed--
Poland suffered from under-the-table
payments, wrongful distribution of medical
equipment, pharmaceuticals, and drugs, and
malpractice physicians (Panteli 158).
Nonetheless, in hopes to improve the
corruption within the field of health, the
Ministry of the Interior created an
Anticorruption Strategy to right the wrongs
of unethical health care participants, in 2005
(Panteli 158). To elevate the war on health
care fraud and corruption, the Ministry of
Health created the Committee for the
Elimination of Fraud and Corruption in
Health Care, which resulted in high
measures of health system reform. The
Committee created several benefits within
the dishonest system, such as reducing the
fearful amount of informal payments. The
only disparaging results of the reform
resided within the relationship
between patient and doctor.
Regardless of its flaws, Poland's health care
corruption did not compare to the issue
arising in Romania. In 2004, Transparency

6. Matthews 6
International Corruption Index ranked
Romania 20 places higher than Poland in
corruption, at number 87 (Vlădescu 7).
Many health care investors, particularly the
FDI, neglected to invest in Romania's health
care system due to its slower evolution of
privatization process, poor quality
information, little to no progress in
introducing and implementing standards and
institutions of western Europe countries, and
the vast and magnitude of obstacles
investors underwent in starting an
establishment. As a result of these
problematic occurrences, the reoccurrence
of micro-corruption was hard for investors
and the public to overlook (Vlădescu 7). To
dissuade the increase of corruption, health
care reforms were implemented to obtain
major objectives: aimed to promote
universal and fair access to rational
packaging of health services, control of the
cost of health services, and create effective
distribution and allocation of health
resources. As of this day, the objectives
have not been accomplished. Despite the
government proclaiming its staunchness to
fight corruption, the real test of
implementation still awaits.
Money, Money, Money
*Above photo depicts young doctors taking to the
streets of Warsaw to protest low wages
($809/month)* (“Women and Young Doctors”)
*Above photo shows a person protesting the low
wages of doctors; the photo includes a refrigerator
full of food and the other empty reading “8 years of
school versus 8 years of general medicine”* (Moisil)
A current discussion in my policitics
of population and migration course
surrounds medical tourism. Medical tourism
can be defined as persons leaving their
origin country to receive medical services in
another country because it is either
available, cheaper, legal, etc. In my opinion,
even though this is a form of economic
migration, the willingness of the doctors
themselves to leave their origin country to
gain work somewhere else should be
considered medical tourism.
As of right now, both Poland and Romania
are experiencing a serious brain drain,
meaning many of their high skilled health
professionals are fleeing to neighboring
countries in hopes of a more prosperous
future. Healthcare in Romania is generally
underfunded, so patients are often faced
with providing the very basics of medical
equipment (i.e. needles) and supplies (i.e.
cotton swabs) for their treatment. In an
effort to improve the healthcare system,
including decreasing corruption, Prime
Minister Victor Ponta proposed the
legalization of bribery, he is also facing
charges of bribery (Odobescu). He believes
that if doctors accept “gifts” from their
patients, then they just need to claim that on
their taxes. Problem solved? As of now it is

7. Matthews 7
unclear if this proposal will even go through,
but the fact that 28% of Romanians claim to
have given bribes to their physicians in
comparison to 5% in “27 other EU
countries,” it seems that the problem should
be more focused on improving medicine
rather than reforming black market financial
negotiations (Odobescu).
In Poland, it is somewhat of a different
circumstance. Although the salaries of
doctors are relatively low compared to the
rest of the EU, most are fleeing to fill
positions in other parts of the EU due to
demand for their skill and specialization. It
has become more of an opportunity for
young professionals to create new career
opportunities, improve their standard of
living, and also get paid for what they are
worth.
The table above illustrates the minimum and
maximum wages per month of medical
personnel across European Union countries.
Romania: min $376/max$847
Poland: min $809/max $1740 (Medlines).
Conclusion
After my research, I do believe my
hypothesis is correct. During the period of
transition, there was no clear designation of
authority, coordination, or plan as to how
the state of Romania would move forward
after gaining independence. Some issues I
encountered was trying to find reliable and
substantial research regarding the
institutions themselves. It seemed as though
the different scientific journals I read
recognized that Romania’s healthcare
system was inadequate and unacceptable,
but did not really offer solutions as to how
the problem could be addressed, or fully
understand why. This topic is really
fascinating because in my opinion, health
legislation is not talked about much,
compared to environmental issues, or
national security concerns, but healthcare
should be a national security concern, it is
an environmental issue. I also
underestimated just how complex the entire
system is, also how time consuming it was
to make sense of it all. There are hundreds
of public institutions that are involved
without clear designation of authority. If
Romania can somehow implement a plan
similar to Poland in that their Ministry of
Public Health regains power to strengthen
policy, then maybe there would be an
establishment of clear roles, and leadership,
hopefully proving to be beneficial. As time
goes on, it seems that both countries are
recognizing healthcare as a serious issue
judging by the increase in spending,
however, accessibility still needs
improvement.
Finally, the main issue that separated the
two countries was level of corruption.
Anticorruption strategies have been
proposed in both states, and thanks to the
media, citizens are finally making their
government knowledgeable of their
dissatisfaction and holding them

8. Matthews 8
accountable, which is allowing for greater
transparency, responsiveness, and attention
to community needs. Limited financing
proves to be a hurdle in trying to attain
“good quality of health care services and in
improving patient satisfaction with the
system,” but as long as these governments
can explicitly assert that they are committed
improve legislation, especially by increasing
their administrative and institutional
capacity, then development is possible
(Panteli xxviii).
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