Emerging technologies, demographic shifts, and economic shocks are reshaping labour market priorities, requiring proactive strategies to maintain Romania’s long-term competitiveness. Digitalisation, automation, artificial intelligence (AI), and environmental concerns represent key opportunities for modernisation, highlighting the need for sustained investments in education and infrastructure.
Amid macroeconomic trends, lower external demand and inflation, Romania's real Gross Domestic Product (GDP) growth fell from 4.1% in 2022 to 2.1% in 2023, with 2024 projections below 2%, according to INS data. Inflation dropped to 10.4% in 2023, down from 13.8% in 2022. However, the National Bank of Romania (NBR) estimates inflation could still reach 5% in 2024, driven by adverse food sector developments and rising labour costs, with a particular impact on service prices.
In 2023, the unemployment rate, as per the methodology of the International Labour Organization (ILO), remained at 5.6%, with higher rates among men (5.9%) compared to women (5.1%) and a notable rural-urban gap (8.8% vs. 3.0%). Youth unemployment (for those aged 15-24) was the highest at 21.8%. By education level, those with higher education had the lowest unemployment rate (1.6%), while individuals with medium and low education faced rates of 4.9% and 14.6%, respectively.
In the first half of 2024, unemployment showed a slight decline, reaching 5.3% in Q1 and dropping by 0.3 percentage points in Q2. Despite this, Romania continues to record the highest share of young people not in employment, education, or training (NEETs aged 15-29) in the European Union (EU) at 19.3%, down from 19.8% in 2022, yet still well above the EU average of 11.2%.
Romania faces pressing demographic challenges, including population decline and accelerated aging. Between 2011 and 2021, the country lost over 1.1 million inhabitants, with projections indicating a loss of 3 million by 2050 and 6 million by 2100. Despite recent population increases of 9.1 thousand in 2023 and 9.9 thousand in 2024, this growth stems from migration, while the birth rate continues to decline. The last positive natural increase was in 1991, and in 2023, the negative balance reached -89 thousand. The number of newborns fell to 156 thousand in 2023, a 27% drop over the past decade.
At European level, population growth is also driven by migration, as deaths (4.84 million) exceeded births (3.67 million) in 2023. Romania maintains a positive migration balance, with more immigrants than emigrants, though it registered about 50.000 permanent emigrants in 2022. The International Organization for Migration reports that 4 million Romanians live abroad, with estimates from the Ministry of Foreign Affairs suggesting up to 5.7 million.
Romania’s aging population is evident, with those aged 65+ increasing from 19.7% in 2023 to 20% in 2024, while the share of children aged 0-14 remains at 16.2%. The pension replacement rate in Romania is 0.52, below the EU average of 0.58, contributing to a high risk of poverty and social exclusion—32% of the population, compared to the EU average of 21.4%.
Despite scoring 7.7 in life satisfaction, Romania ranks 44th globally for quality of life according to the Social Progress Index, behind countries like Argentina and Bulgaria.
Encouraging and running professional retraining programmes dedicated to those over 50 years old is essential to capitalise on the experience gained, giving them the opportunity to expand their activity in current sectors. These programmes can include specialised training in IT, digital marketing, social entrepreneurship, and other high-demand areas in the market, making the transition easier and providing new career opportunities and financial stability.
The working life of seniors should be encouraged through lifelong learning programmes, flexible work policies (such as teleworking and part-time working), and mentoring schemes, which build on the experience gained and a coherent policy of social integration and talent attraction should be developed, supporting the adaptation of both immigrants and returnees and facilitating the effective use of their skills in the new labour market context.
The integration of Romanians in the diaspora should be supported by the offering of personalised advice on finding a job, administrative support, and access to social and educational services, as well as the development of mentoring networks through which local professionals can provide expertise to returnees to ensure harmonious professional and social integration. Moreover, dedicated programmes can be developed for the whole family, from educational access for children to cultural and social activities, which could strengthen the connection with the community to which they choose to return.
Support should be given to entrepreneurial initiatives of Romanians in the diaspora who return home to capitalise on the skills and expertise they have acquired, including start-up grants, business incubators, and networking events.
Access to affordable, high-quality daycare services should be enhanced, enabling working parents to return to work earlier while fostering a supportive environment to encourage families to have more children.
LABOUR SUPPLY
Human resources are the strategic pillar of economic growth for each country. For Romania, the decrease in the active population and demographic aging represent significant challenges to the prospects for long-term prosperity. Moreover, the departure of workers over the years, especially young people and specialists, has reduced the country's active base.
In 2023, Romania's total active population was 8152.1 thousand, of which 94.4% were employed and 5.6% unemployed, with an employment rate of 63% (15 – 64 years old), down from 2022 by 0.1 percentage points and the third lowest employment rate in the European Union (EU average: 70,4%). There are differences between women and men (71.7% for men, 54.3% for women), between urban (68.6%) and rural (57.1%), and between those with high and low levels of qualifications: higher education graduates have the highest employment rate (89.9%), followed by people with a medium level of education (65.6%), in contrast to those with a low level of education, with an occupancy rate of 36.9%.
Of the total employed population, the largest share is represented by employees (85.7%), although the proportion has decreased compared to the previous year, followed by self-employed workers and unpaid family workers. The manufacturing industry, trade, and construction comprise the largest share of the employed population.
Issues such as accelerated urbanisation and regional disparities significantly influence workforce distribution. The most important economic hubs, such as Bucharest, Cluj-Napoca, Iasi, Timisoara, Brasov, Constanta, and Craiova, are attractive for skilled workers; moreover, according to data from the NBR, the seven most critical economic poles contribute more than 50% of the country's GDP. As these cities and regions of the country become stronger and stronger centres of economic growth, regional disparities increase, and rural areas and small towns face reduced economic opportunities and, thus, a decreasing labour supply.
LABOUR DEMAND
Labour demand is a key macroeconomic indicator reflecting market activity and employer confidence. In early 2024, according to NBR data, labour market tension decreased compared to the previous year, signalling slower labour demand amid economic changes. The Directorate-General for Economic and Financial Affairs (DG EFCIN) surveys also indicate that businesses expect short-term labour demand moderation. National Institute of Statistics in Romania (INS) data shows a reduction in annual job vacancies by 5,200 and a 0.12 percentage point drop in the vacancy rate in 2023. This downward trend continued into 2024, with the second quarter showing 34.5 thousand job vacancies—4.9 thousand fewer than in 2023. Romania’s vacancy rate, at 0.7%, is the lowest in the EU, where the average is 2.6%.
In Q2 2024, the highest job vacancy rates were recorded in electricity and heat production (1.54%), entertainment (1.41%), and financial services (1.24%), while the lowest were in mining (0.17%) and education (0.23%). Most vacancies were in manufacturing (24%) and the public sector (21%). Increases in vacancies were noted in construction, healthcare, and entertainment.
NBR data on wages shows that the average gross salary’s annual growth rate reached 16.7% in Q1 2024, up by 0.3 percentage points from Q4 2023. Growth moderated to 16.1% in Q2. Public sector wages rose by 19.6% in Q1 and 20.3% by May, up from 16.4% in Q4 2023. Private sector wage growth slowed from 16.4% in Q4 2023 to 15% by May, reflecting lower inflation expectations and reduced labour productivity.
To meet the demand for labour and attract the inactive population, Romania should make labour legislation more flexible, adopting new forms of employment adapted to modern economic realities. By the introduction of flexible contracts, such as on-demand, zero-hours contracts and teleworking, encouragement of the gig economy, as well as facilitation of part-time and fixed-term work, the labour market would become more inclusive and adaptable. These measures would boost the employment of parents, students, the elderly, and others who need more autonomy, thus helping to reduce labour shortages and increase economic competitiveness.
Special programmes should be developed dedicated to supporting the integration into the labour market of people able to work from families benefiting from social assistance, including professional training and personalised support services, to increase their chances of employment and facilitate the achievement of a guaranteed minimum income.
SHORTAGE OF SKILLED LABOUR
Demographic shifts, the transition to a green and digital economy, and changes in economic dynamics heighten the need for specific skills to sustain growth. Across Europe, labour shortages threaten competitiveness. In response, the EU declared 2023 the European Year of Skills and hosted the Val Duchesse summit in January 2024, emphasising better recognition of qualifications and easier integration of non-EU workers. The Val Duchesse Declaration highlights commitments to attract workers, improve conditions, and enhance the labour market.
The Joint Employment Report, adopted in March 2024, identified labour shortages as a major economic barrier, with a 2.7% job vacancy rate in mid-2023, notably higher than the 2013-2019 average of 1.7%. Acute shortages are evident in healthcare, Health Information and Communication Technologies (ICT), construction, and services. The European Centre for the Development of Vocational Training (Cedefop) reports that 80% of EU employers struggle to find suitably skilled workers, with 25% hiring underqualified employees due to limited options. Additionally, 1 in 3 EU employees is either overqualified or underqualified for their job.
Romania faces similar issues. Cedefop’s 2023 forecast predicts worsening shortages up to 2035, exacerbated by a 24% decline in the labour force by 2050 due to low participation, emigration, and demographic decline. Although Romania's job vacancy rate is below the EU average, skill mismatches persist, with only 17.9% of the population having completed tertiary education in 2023, compared to 33.7% in the EU as a whole. Projections suggest job polarisation, with 70% of future opportunities requiring mid-level skills. At the same time, demand for high-skills will remain below the EU average, while demand for low-skills is expected to remain negligible.
MANAGING THE SHORTAGE BY IMPORTING LABOUR
For many organisations in Romania, importing labour has become an increasingly popular solution to counteract the effects of labour shortages. According to data from the IGI, in the first 9 months of 2024, 77,426 employment permits were issued nationwide for foreign workers, of which most were granted for permanent workers, totaling 76,713 permits. 310 permits were granted for highly qualified workers, 214 permits were granted for seasonal workers, 151 notices were granted for posted workers, 37 notices for ICT workers (intra-company transferees), and one notice was granted for cross-border workers.
An Economedia analysis showed that, at the end of 2023, over 75,000 foreign citizens were working in Romania, most from Nepal and Sri Lanka. Most had settled in Bucharest (over 15,000 people), Ilfov (over 7,800 people), Constanta (over 6,100 people), Timiș (over 4,200 people), Brașov (over 2,600 people), Cluj (over 3,300 people), and Sibiu (over 2,600 people).
The attractiveness of the Romanian labour market for non-EU workers should be increased by simplification of recruitment and integration procedures, including removing specific legislative barriers and simplifying procedures for obtaining work visas and other relevant documents.
The integration of foreign workers should be supported through the development of support and adaptation programmes to facilitate their transition into Romania's social and professional environment (access to Romanian language courses, information about their rights and obligations, and support in accessing essential resources: housing, medical services, and education for children).
STAFF TRAINING
Romania’s ability to harness talent and train its workforce is crucial for economic growth and global competitiveness. However, a significant skills gap challenges its development, as education and vocational training lag market demands. Over the past seven years, Romania’s ranking in the European Skills Index has dropped from 26th to 28th, despite a score increase from 28.2 to 32.8. It ranks last in skills activation, second-to-last in skills development, but 5th in skills adaptation. Lifelong learning is vital to sustain workforce competitiveness, yet adult participation in continuing education remains at 6.7%, below the EU average of 12.8%.
Romania’s National Strategy on Adult Training aims to raise this rate to 12% by 2027, supported by EU funds and new legislation. Initiatives include vocational counseling, lifelong learning accounts, and a Second Chance Program for school leavers. Despite these efforts, coherent implementation and inter-institutional coordination are needed to ensure success. Meanwhile, participation in early education has dropped to 74.8%, while school dropout rates increased to 16.6%, with rural areas most affected. Without addressing these issues comprehensively, Romania risks falling further behind in adapting to future economic demands.
DEVELOPING THE SKILLS OF THE FUTURE
Adopting lifelong learning, reskilling, and upskilling is essential for workers to stay relevant, and organisations must invest in employee development and inclusive work environments, boosting digital skills, according to the World Economic Forum. Key training priorities include analytical and creative thinking, AI and big data proficiency, leadership, and adaptability. By 2027, 6 in 10 workers will need training, yet only half currently have access to it.
In Romania, a 2023 KPMG-Casa Paleologu study highlights the growing importance of emotional intelligence, adaptability, and continuous development for leaders in an increasingly digitalised environment. Technology can revolutionise all sectors, requiring adequate employee training and support to manage digital transitions effectively. However, a World Bank report warns that technological advances, while boosting productivity, have widened income inequality, benefiting university-educated workers more than less-educated ones. This highlights the critical role of vocational education and lifelong learning.
Romania has prioritised digital transformation, allocating €5.8 billion from its National Recovery and Resilience Plan and €3 billion from cohesion funds. Despite some progress, only 28% of its population has basic digital skills, the lowest in the EU, according to the Digital Economy and Society Index.
Strategic partnerships should be encouraged between the public sector, private organisations, and universities to develop training and internship programmes appropriate to market requirements, including internship and mandatory internship programmes in key areas.
Vocational training programmes should be aligned with current and future labour market needs, including by the integration of relevant digital skills into the school and university curriculum.
To improve digital skills nationwide, investments should be made in digital infrastructure and free courses should be provided in underserved regions. Partnerships with local government and NGOs could establish community training centres. Additionally, companies should be eligible for subsidies to deliver in-house training programmes covering both basic and advanced courses.
Romania is the eighth largest country in the European Union (EU), situated in the south-eastern part of central Europe. Its population is also among the largest in the EU (seventh largest). Still, it has decreased since the 1990s due to declining fertility and birth rates, relatively high death rates, and outward migration. Here we review recent developments in the Romanian health system in terms of organisation and governance, health financing, health care provision, health reforms, and health system performance.
SIGNIFICANT DEVELOPMENTS IN THE HEALTHCARE SECTOR
Healthcare Funding: The Romanian government has increased its healthcare budget to address long-standing issues such as staff shortages and outdated medical equipment. This funding aims to improve the overall quality of healthcare services and reduce local imbalances in healthcare provision.
Digital Health Initiatives: Romania is investing in digital health technologies to enhance healthcare delivery. This includes the introduction of electronic health records (EHRs) and telemedicine services, which have become more prominent since the COVID-19 pandemic.
Focus on Mental Health: There is a growing emphasis on mental health services, with new programmes aimed at increasing access to mental health care and reducing the stigma associated with mental health issues. This includes the expansion of community-based mental health services and training for healthcare professionals.
Public Health Campaigns: The government has launched several public health campaigns to address significant health risk factors such as smoking, obesity, and alcohol consumption.
Healthcare Infrastructure Improvements: Significant investments are being made to modernise hospitals and healthcare facilities across the country. This includes the construction of new hospitals and the renovation of existing ones to meet European standards.
EU-Funded Projects: Romania benefits from various EU-funded projects to improve healthcare services and infrastructure. These projects focus on enhancing the resilience and accessibility of the healthcare system.
These developments are part of Romania's broader efforts to improve health outcomes and align its healthcare system with EU standards.
ROMANIAN MINISTRY OF HEALTH
The Romanian Ministry of Health has launched several key health strategies to improve the healthcare system. Here are some of the most important:
National Health Strategy 2023-2030: This comprehensive strategy focuses on improving access to healthcare, reducing mortality rates from communicable and non-communicable diseases, and increasing the efficiency of healthcare delivery. It aims to address health disparities and ensure equitable healthcare services across the country.
Digital Health Initiatives: In collaboration with the World Health Organization Regional Office for Europe (WHO/Europe) , Romania has embarked on a multiyear partnership to enhance digital health services. This includes introducing electronic health records (EHRs) and telemedicine, with the aim of improving the health information system and increasing the quality and availability of data.
Mental Health Programmes: There is a growing emphasis on mental health, with new programmes designed to increase access to mental health care and reduce stigma. These initiatives include expanding community-based mental health services and providing training for healthcare professionals.
Public Health Campaigns: The Ministry of Health has launched various public health campaigns targeting major health risk factors such as smoking, obesity, and alcohol consumption. These campaigns aim to promote healthier lifestyles and prevent chronic diseases.
EU-Funded Projects: Romania benefits from several EU-funded projects aimed at improving healthcare services and infrastructure. These projects focus on enhancing the resilience and accessibility of the healthcare system.
REFORMS
Reform in the Romanian health system has been both constant and yet frequently ineffective, due in part to the high degree of political instability. Recent reforms have focused mainly on introducing cost-saving measures, for example, by attempting to shift some of the healthcare costs to drug manufacturers (by means of the clawback tax) and to the population (through co-payments) and on improving the monitoring of healthcare expenditure.
Romania’s healthcare system could greatly benefit from prioritising prevention and health promotion to reduce the burden of disease. Empowering individuals through education and preventative care can build a healthier society. Despite the crucial role of prevention, Romania continues to experience high mortality from preventable causes due to decades of underfunding and poor access to preventative services. Systemic challenges include financial barriers, insufficient infrastructure, staff shortages, and inadequate public health policies.
In 2023, Romania ranked first in the EU for deaths caused by preventable factors. Key drivers include limited access to preventative healthcare, high smoking and alcohol consumption rates, and socioeconomic disparities. While resources are primarily allocated to curative services, a balanced approach between treatment and prevention is essential for long-term health improvements. Current preventative efforts mainly focus on vaccination, but initiatives promoting healthy behaviours and improving public health literacy remain underfunded.
Low health literacy, regardless of socioeconomic status, hampers the adoption of healthy lifestyles and access to healthcare.
According to the WHO, health literacy goes beyond reading medical pamphlets; it involves equipping people with knowledge and confidence to take charge of their health. The WHO urges governments to enhance public access to health information, enabling citizens to actively engage in their well-being. Unfortunately, Romanian patients remain among the least informed in Europe. A 2023 European Health Literacy Survey revealed that individuals with poor health often exhibit the lowest levels of health literacy, further exacerbating healthcare inequalities.
Romania’s National Plan for Prevention and Health (NPPH) targets improvements in key areas: preventative healthcare, health education, equal access to services, public health campaigns, and collaboration with healthcare providers. By strengthening these areas, Romania can reduce preventable mortality and foster a healthier, more informed population.
The National Public Health Strategy 2022-2030 aims to decrease the mortality rates from preventable and treatable causes while promoting health literacy and vaccination using evidence-based, cost-effective interventions. The FIC’s main recommendation is the implementation of a concrete plan to achieve the strategic directions developed in the National Public Health Strategy 2022 – 2030.
Regular screenings and vaccinations programmes should be implemented nationwide for regular health screenings and vaccinations to detect and prevent diseases early.
A healthy lifestyle should be promoted by encouragement of physical activity, balanced diets, and giving up smoking through public health campaigns and community programmes.
Access to preventative services should be supported by ensuring that they are accessible to all, especially in underserved and rural areas.
Sustainable development of the prevention and health literacy-orientated pillar of the health sector should start with institutional and professional capacity building, especially of the Public Health Network, the Education Network, and local public authorities, as well as collaboration with the Ministry of Education and civil society organisations.
Health Literacy should be prioritised within public health policies as it has the potential to increase effectiveness across a multitude of other dimensions. A dedicated National Health Literacy Strategy should be developed to target age groups through specific communication channels and tailored health messages. It is time to progress from sporadic health education and prevention interventions towards more systematic and holistic approaches that are also adapted, as appropriate, to the high-tech and digitalised era we live in.
Priorities for vaccination:
Priorities for screening:
Economic and geopolitical shocks continue to significantly impact labour markets in Romania and globally. The war in Ukraine, consequences of the pandemic, and inflation have contributed to a global cost-of-living crisis, intensifying social unrest, with wide-ranging effects on governments, businesses, and individuals.
Romania has made notable economic progress since the early 2000s, with GDP per capita reaching over 60% of the OECD average, up from 30% in the early 1990s. However, the pandemic caused a significant GDP shock, with recovery to pre-pandemic levels by early 2021. Growth was observed in 2022, though inflation and reduced exports led to a slowdown in the third quarter.
Inflation surged to 16.76% in November 2022, driven by rising food prices, non-food goods, and services. The National Bank of Romania forecast a decrease in inflation starting in 2023. The European Commission’s economic forecast for Romania projects 2% GDP growth in the coming years, lower than previous expectations due to inflation and the ongoing war in Ukraine.
Unemployment in 2021 was 5.6%, with youth unemployment at 21%. By October 2022, the rate rose slightly to 2.96%, with a significant proportion of the unemployed having secondary education.
Health is the foundation of human capital and crucial for innovation, productivity, and Romania’s sustainable economic growth. As a developed country, growth in Romania's national income depends on a fair economy, better-paid jobs, and a workforce capable of innovation. A healthy population and an efficient, accessible health system are vital for this progress.
Romania has made significant strides in improving the quality of life through initiatives like the National Health Strategy 2023-2030, the National Vaccination Strategy, and the cancer prevention law. These efforts reflect the government's commitment to enhancing access to quality healthcare.
However, Romania faces challenges such as an aging population, an increase in non-communicable diseases, and a declining workforce due to emigration. Despite legislative advances, the health system struggles with insufficient funding, with per capita spending among the lowest in the EU.
Investing in healthcare is an investment in human capital, with proven returns in terms of improved life quality, economic growth, and productivity. For example, funding cancer services helps avoid millions of deaths and boosts economic benefits. Better use of available healthcare interventions could reduce global disease burdens by 40%. Romania has an opportunity to rebuild its economy and enhance competitiveness by focusing on prevention, access to new therapies, and increasing the number of healthcare professionals, using EU funds to improve care quality and efficiency.
Source: OECD Health Statistics 2024, Eurostat, WHO Global Health Expenditure Database
Romania should gradually increase its healthcare funding to reach the EU average of 8.4% of GDP, up from the current level of approximatively 5.2% (2025). This requires merging public and private funding effectively. Despite Romania's strong economic growth in recent years, it remains last in the EU for healthcare spending. The authorities must recognise healthcare as an investment in the country’s future prosperity, as health has a direct impact on labour productivity and indirectly influences future income through education. Additionally, Romania needs improved financing mechanisms to ensure access to innovative therapies. The "Innovation Fund" programme must be implemented adequately to provide fair access to treatments.
To address the gap between Romania and other EU countries in healthcare financing, it is essential to prioritise creating a more efficient spending process within the healthcare system, ensuring optimal use of resources alongside a gradual increase in the percentage of GDP allocated to healthcare. Healthcare contributions should be collected more efficiently, and the contribution base should be widened by eliminating exemptions. According to Law 95/2005, several categories are exempted from social contributions independently of their income level.
A proactive approach to budget estimation (through the horizon scanning process) and multiannual budgeting, which is predictable and in line with current patient needs, is vital. Furthermore, a predictable and annual adjustment of the medicines budget based on the previous year's consumption through a predictable financial mechanism to stimulate innovation is recommended.
New alternative funding solutions for healthcare should be identified, focusing on private contributions, EU funds in the next programming period, and public-private partnerships.
Until the reform of the exemptions from healthcare contributions, funds should be transferred from the state budget to cover the exempted or uninsured population, and funds collected from pharmaceutical taxes (clawback) should be reallocated exclusively to the medicines budget.
Predictability of the allocation of funding at subnational level - at the level of local/county health insurance authorities - should be ensured to provide patients with access to treatments without restrictions and prevent potentially life-threatening fluctuations in access to healthcare services of adequate quality.
Procedures should be developed to improve the allocation of funds between central and local public authorities.
Efficiency should be improved across the entire care pathway by support for access to screening and early diagnosis programmes.
Resources should be leveraged for investments to be made in health infrastructure from diverse sources (e.g., from European Structural and Investment Funds, IFIs, and the private sector, including via PPPs).
The debts of all companies (either public or private) to the healthcare fund should be recovered, and a mechanism to monitor their contribution should be put in place.
Digital tools (including electronic registries) should be introduced to create more efficiency, control, and transparency over how the healthcare budget is spent.
More specifically, in the 2022-2030 programming period, the funding of health care and public health from European Structural and Investment Funds should focus mainly on health promotion and disease prevention.
The current screening programmes should be expanded and diagnostic capacity across the country improved for diseases with the highest financial and population burdens (cardiovascular diseases, cancer, and mental health - depression).
Centres of excellence should be developed at regional level.
Continued education of medical staff should be supported, with a focus on professional and managerial skills, building capacities of health administrations and relevant public health actors.
Research and development in the pharmaceutical industry should be stimulated through partnerships between the public and private sectors, stimulating investments in clinical trials, which have a real potential of over €800 million annually, for the Romanian health system, Facilitating collaborations between the medical environment, academia, and industry is vital for innovation.
Increased efforts should be made in the field of e-health.
The Innovation Fund programme should be implemented on time according to the timelines established by the National Plan to Combat Cancer with sufficient resources to ensure its success and sustainability.
In the short and medium term, the public healthcare system should be supported by adjusting the legal framework so that public clinics and hospitals can carry out private practice for privately insured medical services. This would attract additional resources to public hospitals and enhance patient satisfaction. In the medium and long run, health system reform should entail resizing the basic health insurance package and reintroducing co-payment. These measures would protect the long-term financial sustainability of the healthcare system and help the development of the private health insurance industry
The Fiscal Environment in the Pharmaceutical Sector
The fiscal landscape has recently been characterised by frequent legislative changes that have a significant impact on the pharmaceutical industry. In addition to general taxation, the sector faces specialised taxes related to medicines, many of which have been revised in recent years.
Clawback Tax
Introduced in 2009 during the economic crisis, the clawback tax was designed as a temporary measure to address the funding deficit for reimbursed medicines. Despite several amendments, it continues to place a heavy burden on Marketing Authorization Holders (MAHs), as they are solely responsible for covering the deficit. By 2023, the tax was differentiated for two types of medicines: innovative medications (Type I), taxed at 25%, and generic or other medicines (Type II), taxed at 15%. These changes aim to improve the sustainability of the public health system and promote the introduction of new innovative medicines, while also maintaining the market for generic drugs. However, the overall health budget has remained largely unchanged in recent years, limiting the capacity to meet the growing demand for reimbursed medicines. Romania’s healthcare spending remains significantly below the EU average, raising concerns about the system's long-term sustainability. The FIC considers the clawback tax mechanism unsustainable, as it continues to negatively affect the availability of medicines and the financial health of pharmaceutical companies. In the long term, eliminating this tax could benefit both the healthcare system and the industry.
VAT and Fiscal Compliance
The clawback tax also complicates fiscal compliance by affecting both cash flow and profitability. It is a major concern in discussions surrounding VAT, as the tax burden indirectly influences companies' financial performance and operational challenges.
Minimum Turnover Tax
Since January 2024, a new minimum turnover tax has applied to companies with annual revenues exceeding 50 million euros. Set at 1% of gross revenue, this tax aims to ensure that large businesses contribute a minimum amount regardless of deductions. Pharmaceutical companies, particularly those in the wholesale distribution sector, face challenges due to this new tax, especially with reimbursed medicines that have capped prices. The government has amended pricing regulations to help mitigate the impact, but concerns remain about the sustainability of this sector, especially in critical therapeutic areas like oncology and rare diseases.
Other Tax Regulations
Large multinational groups with a consolidated turnover exceeding 750 million euros must also comply with additional tax rules, such as country-by-country (CbyC) reporting and Pillar II measures. These measures aim to enhance tax transparency and fairness, requiring companies to disclose financial and tax information for each country they operate in. The introduction of a global minimum corporate tax rate under Pillar II further complicates tax calculations, as it requires multinational groups to pay a “top-up tax” if their effective tax rate is below 15%.
R&D Incentives
Romania offers several incentives to pharmaceutical companies to foster research and development, helping them reduce costs and remain competitive. These R&D incentives are crucial in supporting innovation in the pharmaceutical sector, particularly for the development of new, high-risk treatments.
In summary, while some fiscal changes have aimed to support the pharmaceutical sector, there are still significant challenges related to taxation and budget allocation. A comprehensive reassessment of fiscal policies is needed to ensure the sustainability of Romania’s healthcare system.
Budget related
FIC considers that the reimbursed medicines budget should be readjusted to cover the real needs of the Romanian healthcare system, considering that after more than 13 years, the pharmaceutical industry continues to cover this deficit with the clawback tax. This tax has generated and continues to create adverse effects on the availability of medicines on the market. Adequate and sustainable funding of the medicines budget must be ensured to improve patients’ access to the medicines they need.
Thus, a proactive approach to budget estimation and implementation of a multiannual budgeting system is needed to ensure a sustainable budget for curative national health programmes.
Moreover, the transparency of expenditures should be increased. Annual budget adjustments based on actual consumption, and grounded in value-based procurement for both hospitals and the Ministry of Health, are needed.
The overall aim is to ensure access to treatment for patients in Romania, including existing and innovative treatments.
Clawback tax
Even though the FIC welcomes the new differentiated clawback tax as a step in the right direction, we believe that the clawback tax should be abolished entirely or at least replaced by a newly reformed clawback mechanism and that the lack of adequate budget funding for reimbursed medicines should be addressed through fair budgeting, in line with real market needs, especially as the initial context was that the clawback tax was announced as a temporary measure.
In the short term, the clawback tax should be revised to make it more predictable and less burdensome, considering that currently, there are still many court disputes generated by the lack of transparency in its calculation. Hence, it should exclude pharmacy and wholesaler margins and should be applied to the producer’s price. Further improvements could include (i) the elimination or reduction of the clawback tax for essential cheap medicines (such as medicines classified as generic medicines) or for those intended for special needs or with discontinuity risk (for the latter two categories, there is already a draft law that provides for the exemption, within certain limits, from payment of the clawback tax for marketing authorisation holders of such medicines that incur expenses involving investments made in the fields of research and development of medicine production capacities in Romania) for the population to have better access to them or (ii) the exclusion of hospital consumption from the clawback tax.
Finally, to increase transparency, the healthcare authorities should allow an independent audit of the data on which the clawback tax is calculated.
Cost-volume/cost-volume-result agreements
An immediate beneficial measure to ensure quick access for patients to innovative treatments would be the active encouragement of cost-volume/cost-volume-result agreements and the development of new facilitated access schemes. Such agreements have proven to be an efficient means of cooperation between state and private companies for the benefit of patients and should be encouraged more.
However, there is a significant need to adjust, increase, and accurately size the negotiation cap for cost-volume contracts based on actual needs (number of molecules with conditional inclusion decisions and their anticipated budgetary impact) rather than relying on historical budgeting (as the dynamics of reimbursement are not linear).
The recommendations mentioned above should also be aligned with expanding access to innovative and personalised treatments, as well as reducing the waiting time for Romanian patients to access innovative medicines by ensuring adequate funding for medicine budgets, regularly updating the list of reimbursed medicines, adhering to an updated schedule, activating and applying early facilitated access mechanisms, as well as implementing and expanding the Health Innovation Programme.
Robotic surgery is a groundbreaking innovation in modern medicine, offering unmatched precision, reduced invasiveness, and improved patient outcomes, especially in oncology where precision is crucial. It sets a new standard in healthcare by minimising post-operative risks, reducing recovery times, and improving survival rates. Widespread adoption of this technology would allow Romania to align with global best practices and elevate its healthcare system.
Moreover, implementing robotic surgery could help reverse Romania's medical brain drain by providing young surgeons with access to cutting-edge treatments, encouraging them to build careers locally. This would retain domestic talent and attract skilled surgeons who have emigrated, fostering an "inverse exodus" that would strengthen the country's medical expertise.
In the public healthcare system, robotic surgery could address key challenges like equitable access and resource efficiency. Currently, many robotic procedures are carried out in private institutions, leaving a large portion of the population without access. By integrating robotic surgery into the public sector, Romania could ensure that all patients benefit from advanced care, regardless of financial status. Additionally, the cost-effectiveness of robotic surgery, through shorter hospital stays and fewer complications, offers long-term sustainability.
The broader adoption of robotic surgery in Romania will improve care quality and position the country as a leader in medical innovation in the region. Establishing reimbursement norms and expanding robotic surgery programmes in public hospitals will help meet the growing demand for advanced treatments. With this transformative approach, Romania could enhance patient outcomes, optimise resources, and create a modern, inclusive, and efficient healthcare system.
For Enhancing Access to Innovative Medical Technologies in Romania
Implementation of Robotic Surgery into the National Cancer Plan - Robotic surgery, recognised as the most advanced surgical solution with proven benefits in oncology, should be a reimbursable service under Romania’s National Cancer Plan. Its approval will enable immediate implementation with appropriate reimbursement norms, aligning Romania with regional leaders like Bulgaria and Hungary.
Equity and High-Quality Standards in Oncological Care - Reimbursement norms will ensure equitable access to robotic surgery for all patients, regardless of income or geography, while promoting high-quality care by adopting state-of-the-art technologies and international best practices, ultimately improving survival rates and quality of life.
Expansion of Robotic Surgery Access - Romania’s current capacity includes 21 robotic surgery centres, only 3 of which are in the public sector. Reimbursement policies will increase accessibility in public institutions, boost the annual number of procedures, and bridge disparities between private and public healthcare services. The lack of a predictable reimbursement framework discourages hospitals from investing in advanced technologies, even when opportunities are available through European funding programmes. Without precise financial support mechanisms, healthcare institutions are hesitant to commit to the substantial upfront costs associated with acquiring and maintaining innovative medical equipment, limiting the adoption of cutting-edge treatments.
Infrastructure and Operational Standards – Dedicated, well-equipped robotic surgery facilities should be established across Romania’s healthcare system, adhering to manufacturer specifications and ensuring readiness through preparatory training for surgeons and surgical teams to meet operational demands. Surgeons and healthcare teams should be proactively trained to achieve certification and expertise in robotic surgery, ensuring readiness for the policy’s rollout. This preparation will balance benefits between the public and private sectors, avoiding over-reliance on private hospitals.
Defined Criteria for Participation in Reimbursement Programmes - Participation in reimbursement programmes should be limited to centres carrying out a significant number of oncological procedures annually, ensuring the attraction of expertise, or those with academic affiliations or multidisciplinary capacities, and integrating specialties such as general surgery, urology, gynecology, and thoracic surgery.
Public Awareness and Stakeholder Engagement - Targeted campaigns should be launched to educate the public and medical professionals on robotic surgery’s benefits while collaborating with policymakers, healthcare leaders, and technology providers to secure funding and drive implementation.
Data-driven monitoring and Policy Refinement - Robust systems should be established to monitor surgical outcomes, patient satisfaction, and economic impact, using data to refine policies, enhance transparency, and ensure continuous improvement in access to robotic surgery.
Romania has made significant progress in modernising its healthcare IT systems, with several key developments aimed at improving healthcare delivery. The Ministry of Health has allocated 400 million euros for the digitalisation of the National Health Insurance authority (Casa Nationala de Asigurari de Sanatate- CNAS) and over 200 hospitals, with a focus on integrating telemedicine solutions. This includes remote consultation capabilities in approximately 130 Emergency Departments, supported by the World Bank. Telemedicine has gained prominence, developing in particular during the COVID-19 pandemic, facilitating remote healthcare and enhancing collaboration among professionals.
To improve patient monitoring and security, advanced video surveillance systems have been introduced in hospitals, offering real-time monitoring and integration with medical equipment to track vital signs. Additionally, Romania has invested in robust IT infrastructure, including server data rooms, to support telemedicine and surveillance systems. Cybersecurity measures like firewalls and intrusion detection systems are also being introduced to protect patient data.
The country's digital health initiatives include the development of e-health systems to better manage patient data and improve accessibility. The digitalisation of CNAS is a priority, the aim being to modernise data management and system integration. Romania's legislative framework ensures patient privacy, with laws aligning with the EU's General Data Protection Regulation (GDPR). Patients have the right to access their medical records, enhancing trust in the healthcare system.
Romania has also introduced major e-health projects, including e-prescriptions (2012), electronic health records (2014), and the e-health card (2015). These systems are integrated into the centralised information system (SIUI). The e-prescription system, however, faces frequent malfunctions, which hinder healthcare professionals' ability to access centralised data effectively. The electronic health records project aims to store comprehensive patient information, though participation by doctors is limited to those contracted by the national health authority. Furthermore, the e-health card, though mandatory, faces implementation challenges, such as the lack of card readers in some medical units.
Looking ahead, the Ministry of Health envisions the use of e-prescriptions across the EU and the creation of a unified platform for managing patient health files. Efforts to improve cancer registries and expand their scope to cover more diseases are underway, despite challenges such as limited funding and fragmented data collection.
Romania's healthcare IT systems are poised for growth, but continued investment in infrastructure, training, and data integration is essential to overcome existing challenges and improve patient outcomes.
The FIC recommends that the healthcare authorities should adopt a Healthcare Digital Strategy, based on models from other European countries.
The current legislation still needs to be updated to ensure a legislative framework covering online communication at various levels in the healthcare system, covering each segment of activity or sub-activity.
Electronic registries should be developed and introduced as soon as possible to create more efficiency in the way financial resources in healthcare are spent, increase transparency, and gather supporting data for better healthcare policy decision-making.
The reporting requirement should be introduced as soon as possible, irrespective of whether the doctor has a contract with the national health authority. It is important that all medical records from all medical care providers should be available in the database.
Thus, further steps should be taken to implement the patient’s electronic health files project (DES), launched in 2014 and currently in a permanently offline state. In addition, negative feedback has been received from healthcare professionals and healthcare organisations concerning DES. Specifically, the electronic health file collects insufficient information from a few sources that do not hold the patient's entire medical history.
Further issues relating to maintenance and dysfunctionalities of the digital infrastructure for the e-Prescription and e-Health cards should be addressed, as the systems have not worked well. Disruptions have led to patients being unable to receive prescriptions and examinations not being registered in the system.
A 24/7 professional maintenance service is also a paramount requirement to ensure a functional system that would ease the operational burden on doctors.
Interoperability, common standards, and data sharing to private healthcare payers of medical records (rights and health expenses) should be enabled and extended to facilitate payment for medical services and medication in addition to the basic package. Thus, the adoption of patient registries should be included in the government healthcare strategy, integrated with the other e-Health tools already introduced, and should be seen as an important milestone in creating data to support healthcare policy decisions while generating more efficiency and transparency in budget resource allocation.
Ensuring adequate human resources for the Romanian health system in 2025 is of critical importance, given the current challenges facing the sector.
The Romanian health system faces significant challenges when it comes to access to medical services. While Romania has more doctors per 1.000 inhabitants compared to France, Hungary, Poland, or Belgium, for example, a major problem is caused by the high concentration of doctors in only six counties out of 41. According to the College of Physicians of Romania, more than 50% of doctors practice in counties with medical universities, while all the other 35 counties benefit from less than half the total number of doctors. The same statement indicates the need for an additional 1.400 general practitioners. This creates a significant deficit of doctors and nurses, particularly in rural areas and small urban areas.
The shortage of health specialists, which has existed for years, is demonstrated by a report issued by the Court of Accounts for the years 2014-2021. It showed that the health units subordinated to the Ministry of Health had at least 1,000 doctors less than they should. The medical specialties where there was a staff shortage were Anesthesia and Intensive Care, Psychiatry, Cardiology, Radiology, General Surgery, Physical Medicine, Emergency Medicine, Laboratory Medicine, Internal Medicine, and Gastroenterology. The situation has not changed significantly since 2021. According to the National Institute of Statistics, in 2023, there were 357 doctors per hundred thousand inhabitants. These figures place us below countries such as Bulgaria (where there are 480 doctors per hundred thousand inhabitants), Germany, Spain, Italy, Denmark, Cyprus, Lithuania, Malta, Slovakia, Finland, and Sweden.
At the end of 2023, Romania had 72,740 doctors, with over 92% working in urban areas. Despite the country as a whole having enough doctors for the population, 26 counties have only 1-2 doctors per thousand inhabitants, putting citizens' health at risk. The exodus of doctors exacerbates this issue, with many citing poor infrastructures as the main reason for leaving. A 2023 study revealed that 36% of doctors are at risk of burnout, and over half of doctors under 35 are considering leaving. The lack of medical personnel and uneven distribution hampers the shift towards effective prevention and ambulatory care. Authorities must address these issues to achieve a healthy society.
Performance-related pay should be introduced in the healthcare sector. The number of available places in medical schools should be increased to bring the training of medical professionals into line with the population’s real health needs.
The clear deficit in selected specialties should be considered when creating study places for residency studies.
The access of healthcare professionals to continuous professional development should be improved. The social importance of healthcare professionals should be acknowledged, and the role of professional associations in reforming the system should be enhanced. The healthcare system can only be reformed together with healthcare professionals.
Development of basic medical infrastructure in small urban and larger rural communities should be a strategic priority, coupled with incentives for healthcare practitioners to practice in those areas and not be attracted only by large urban areas.
The FIC recommends better training, continuous medical education, higher performance indicators, and standardised evaluation processes, which will all lead to better performance by healthcare professionals, enabling them to gain a better image, respect, and public recognition. Bearing in mind all of these elements and with the aim of contributing to the reform of the Romanian healthcare system, the FIC has continued its projects dedicated to doctors, which started in 2013 when it initiated, in partnership with the Ministry of Health, the development of several projects dedicated to medical staff in order to draw attention to the exodus of doctors, continuing with a series of courses dedicated to students and residents in the medical field. Starting from 2019, the FIC has been an active promoter of courses for hospital managers through the project Leaders for Excellence in Healthcare, organised in partnership with authorities with the aim of improving the skills and knowledge of doctors in leadership positions to adapt to the current realities and daily practices.
There is a need for national, regional, and international cooperation in developing and implementing the best policies in relation to evidence-based strategies for human resources in health. An active collaboration between health authorities, Non-Governmental Organizations (NGOs), medical societies, and trade associations is pivotal to gaining insights, developing innovative strategies, and setting out best practices and care standards. Health authorities should become more open to the expertise developed by the NGO and trade association sector. They could allow for a percentage of their programmes (especially in prevention, health education, training, and patient support) to be developed and implemented in partnership with civil society, according to national health strategies and plans, and keeping in touch with the needs of local communities.
The National Healthcare Strategy provides extensive measures designed to alleviate the impact of the migration of doctors and ultimately reverse the trend. These measures are set out in the second appendix of the strategy and should be implemented as soon as possible.
The information flow on health workers needs to be improved by adjusting the mechanism for collecting, processing, analysing, and disseminating data on human resources in health so that the planning and distribution of the workforce is carried out correctly. Furthermore, there is a need for support for human resources analysis and research activities to identify evidence-based policy options.
Europe is at a critical juncture in the development of its healthcare systems, and is facing rapidly changing health challenges. Governments and healthcare providers must prioritise disease prevention to promote healthy longevity, as the cost of inaction is high. Projections suggest that focusing on "healthy aging" could slow health spending growth and help control long-term care costs.
Romania's health performance indicators reveal significant issues. Although life expectancy has increased, it remains among the lowest in the EU, with a substantial gender gap. Preventable mortality rates in Romania are more than double the EU average, signaling weaknesses in public health and healthcare policies. The healthcare workforce crisis, i.e. the shortage of doctors and uneven distribution, exacerbates these challenges, especially in rural areas. Frequent changes in government policy disrupt healthcare planning and policy implementation, leading to inefficiencies and poor transparency.
Romania also faces systemic inefficiencies, such as bureaucratic delays and fragmented services, which hinder patient care. The slow adoption of digital technologies and underutilisation of patient data have further delayed the modernisation of the healthcare system. Moreover, Romania lags in accessing innovative medicines, with lengthy delays from approval to market availability.
The country's healthcare workforce shortage, particularly in rural areas, and the lack of leadership contribute to these problems. Furthermore, Romania conducts far fewer clinical trials than other European countries, limiting research opportunities and access to innovative treatments. Despite these challenges, there is potential for growth in areas like clinical trials, which could see significant expansion in the coming years.
Based on Romania’s health performance indicators, the following policy-focused recommendations aim to address systemic gaps and enhance healthcare outcomes:
Expansion of preventative health programmes: Investments in prevention should be prioritised to tackle high avoidable mortality rates. National campaigns should be developed to support lifestyle changes, early screening, and public education. There should be a special focus on rural areas, ensuring equitable access to prevention programmes through mobile clinics and telemedicine.
Acceleration of access to innovative medicines and devices: Regulatory and reimbursement processes should be streamlined to reduce the average time for market access from over 2 years to EU standards. Transparency, legislative predictability, and adequate finance to expand the availability of innovative treatments should be promoted.
Addressing healthcare workforce shortages and regional disparities: Incentives should be introduced, such as competitive salaries, housing benefits, and professional development for healthcare workers in underserved regions. Telemedicine should be leveraged to bridge gaps in specialist availability and investment should be made in expanding training capacities for healthcare professionals.
Stabilisation of leadership and policy implementation: Policies should be implemented to ensure minimum tenures for healthcare ministers and senior health officials to provide continuity in long-term planning. Clear national health strategies should be established with clearly defined measurable goals to insulate healthcare policy from political fluctuations.
Enhancement of system efficiency through digital transformation: The digitalisation of healthcare should be prioritised through the creation of a centralised electronic health record system to improve patient care and data utilisation. Care pathways should be integrated across primary, secondary, and tertiary services to ensure seamless coordination and minimise inefficiencies.
Boosting of clinical trial infrastructure and participation: Investment should be made in research facilities and approval processes should be simplified to attract global clinical trial sponsors. Public awareness should be raised as to the benefits of clinical trials and collaboration should take place with patient advocacy groups to improve recruitment, with the aim of tripling the number of trials by 2026.
Adoption of EU best practices and fostering of regional cooperation: Proven strategies should be learned and adopted from high-performance EU countries on preventative care, healthcare management, and innovation. Romania should collaborate with neighbouring countries to share resources and address common health challenges, leveraging EU funds to bolster infrastructure and workforce training.