Prevention is better than cure, say Romanian doctors
An epidemic of noncommunicable diseases is sweeping Romania. An underfunded health-care system focused on treatment rather than prevention is struggling to meet the challenge. Viviana Balanescu reports.
Bulletin of the World Health Organization 2011;89:248–249. doi:10.2471/BLT.11.030411
The problems started with a missed diagnosis. Ioana Gheorghe (not her real name), 75, who lives in the western city of Timisoara went to her general practitioner twice complaining she felt poorly. “The GP told me there was nothing wrong. In his opinion, my condition was perfectly fine for my age.” She had her first stroke shortly thereafter, and then a second following a period of hospitalization.
Gheorghe is one of a growing number of Romanians struggling with the debilitating effects of cardiovascular disease – especially heart disease and stroke – which now accounts for an estimated 60% of all deaths in the country, making it far and away the leading cause of death in this nation of 21 million in south eastern Europe. This represents one of the highest levels of cardiovascular disease in the 53-country European Region of the World Health Organization (WHO).
For Dr Irinel Popescu, head of the Surgery and Liver Transplantation Centre at Fundeni Hospital, Bucharest, the epidemic of cardiovascular disease is to a large extent driven by lack of awareness among Romanians regarding the importance of diet, exercise and giving up smoking. This he blames on the lack of national cardiovascular disease prevention efforts, which, he says, have been limited to a few media campaigns.
“There was a national initiative that started with a pilot programme in the Prahova County focused on the prevention of cardiovascular diseases,” he says, but it did not progress much beyond good intentions “due to a combination of cost and a not very positive evaluation of the pilot.”
Professor Dan Gaita, president of the Romanian Heart Foundation, echoes Popescu’s view, noting that poor people are particularly affected. “Poor people have limited access to information and, consequently, have a low level of awareness,” he says. “Fruit and vegetables cost more than fat. Poor people also smoke more and suffer more from stress which significantly influences the major cardiovascular disease risk factors.”
For Gaita the lack of prevention campaigns is only one part of the problem. He gives equal weight to a health-care tradition that puts too much emphasis on treatment. “As doctors, we were taught to treat a disease, not to prevent it,” he says, adding: “That’s what we learned at school and for 20 years that is what we have been doing!” The problem with this approach is that it misses important opportunities for risk reduction.
There is a clear need for prevention of a disease developing in the first place and, once it has developed, early diagnosis and treatment. “Earlier diagnoses have the potential to produce better treatment outcomes, especially with regard to cardiovascular diseases and some cancers,” says Dr Andreas Ullrich, cancer expert at WHO. Gaita says: “Now it’s time to focus on prevention.”
Romania has a national cancer programme, but here, too, the vital prevention components are still missing. “All in all, we have stayed at the level of cancer prevention via mass media campaigns and periodical check-ups of women for the early detection of cervical pre-cancer lesions,” says Popescu. Romania has the highest mortality rate for cervical cancer in the WHO European Region, despite the fact that the deaths from cervical cancer can be substantially reduced by screening programmes with referral for treatment services. Vaccination against the human papilloma virus (HPV), the main cause of cervical cancer, is an option to further reduce incidence. However, currently due to the inefficiency of the screening programme “detection of cervical cancer is delayed and cervical cancer is diagnosed in advanced stages,” Popescu says. “An HPV vaccination programme was abandoned after a controversy over possible side-effects in girls who took the vaccine,” he adds.
From 1949 to 1989, Romania had a centralized state-run health system. But after the fall of Communism in 1989, major health system reforms began and by 1998 a decentralized social health insurance system had been established. Health reforms in the 2000s aim to shift the focus to prevention, but this is still a work in progress.
The focus on treatment, especially tertiary (hospital) care, rather than prevention and early detection at the primary health care level is reflected in the government’s health expenditure too, which focuses narrowly on hospitals at the expense of primary health care. For Dr Liviu Stafie, at the Regional Health Insurance House (Casa Judeteană Iasi de Asigurări de Sănătate or CNAS) in the city of Iasi, this focus on hospitals is one of the biggest problems Romanian health care faces. “Half of the resources provided by CNAS is consumed by hospitals, which treat only 10% of the total population,” he says.
The underfunding of health care is another issue Stafie worries about. Total health expenditure is difficult to measure because the records of private expenditure are incomplete, notably with regard to fees charged by private providers and informal or ‘under-the-table’ payments made in the public sector, but according to the available data, from 2000 to 2005 total health expenditure as a percentage of GDP increased from 4.1% to 4.4%, considerably lower than in most European Union countries. Mandatory health insurance was introduced in 1998, and became the main financing mechanism for health (the rest is made up from general tax revenue) but for Stafie social health contributions are too low and too many people are exempt from these contributions for it to be effective.
Popescu, a former president of CNAS, shares Stafie’s despair over funding, noting that only a small portion of the population pay these contributions. “The rest of the population does not contribute because of various exemptions. The contribution rate is approximately 5.2% (of income) for an employee, 5.7% for an employer and less than 11% for those who have their own business,” Popescu says. “If we want to follow the European level of expenditure on health, other mechanisms must be found to assure the budget of the CNAS is sufficient.” Popescu notes that there has been talk of introducing co-payments as a way of making up the shortfall in funds, but believes that this will have limited impact.
So what needs to change? Popescu says that one suggestion to close underperforming units could assure additional resources for the performing hospitals and for general practitioners who struggle on shoestring budgets. Dr Maria Suciu, a general practitioner based in the western city of Arad, says: “The amount of money we receive from the National Health Insurance House is very small and we cannot equip our office.” Suciu says that she is unable to carry out even basic diagnostic procedures such as measuring blood sugar and cholesterol levels. She estimates that it would cost €30 000 to equip her office for such tasks with a minilab, and with that equipment 40% of the noncommunicable diseases she sees could be managed much better over the next 10 years.
Broader collaboration can make a difference, according to Dr Kwok-Cho Tang, a health promotion expert at WHO. “To sustain positive behavioural change, media campaigns alone, more often than not, will not work. There must also be interventions for policy and environmental changes.” He adds: “To effectively address noncommunicable diseases, collaboration is required within and beyond the government sectors.”
Suciu does her best to alert patients to the dangers of sedentary lifestyles, smoking, and eating foods that are high in salt, sugar and fat content, but such warnings have their limitations: “Most of my patients do not follow my advice regarding prevention,” she says. That’s why she also wants a strong primary health care system in Romanian, so that more can be done to prevent noncommunicable diseases because at present, “primary health care is the Cinderella (poor relative) of the (health) system.”