STRENGTHS AND WEAKNESSES OF THE ROMANIAN HEALTH SYSTEM MANAGEMENT.

• Author: Popa, Ion

1. Introduction

   In the current healthcare environment, which is characterized as unpredictable, unfamiliar, ambiguous and amorphous (Peoples and Sanders, 1994, p. 1), organizations 'are confronted with challenges and uncertainty in their actions and need to be capable of adapting to new situations and environments in order to 'survive' - remain competitive and be effective.' (Baba et al., 2009, p. 33).

   'The strategic management at the level of the health system [...] aims at positioning medical units in their relation with the competitors from the external environment' (Kanellopoulos, 2012, p. 265) in order to accomplish the mission and vision of their organization. Promoting strategic management, based on rigorous diagnostic studies, SWOT analysis, market researches, ecological studies and national strategies, is becoming a necessity for both health organizations and for the health system as a whole.

   Strategic health of an organization (1) depends on how the key strengths are leveraged to exploit prime opportunities while, at the same time, minimize exposure of the critical weaknesses to the serious threats in the external environment (Mbachu and Frei, 2011, p. 278). In this context, particular importance should be given to highlighting and analyzing strengths. As shown by Nicolescu, Popa and Nicolescu (2014, p. 74), strengths are essential elements of any system that decisively determine its functionality and performance. Moreover, performance achievement through the development of strengths is faster, with less effort and resources than through eliminating/ reducing weaknesses (Nicolescu, Popa and Nicolescu, 2014, p. 74).

   The aim of this paper is to highlight the main strengths and weaknesses of health services management in Romania and the manner in which the key stakeholders relate to them, in order to formulate a series of proposals and directions for improving its performance and effectiveness. According to Popa et al. (2009, p. 84) 'stakeholders are persons or groups with an interest or a direct or emotional personal involvement in a certain organization and its performance. This category includes: managers, employees, unions, customers, suppliers, banks, etc.' Fottler et al. (1989, p. 527) generated an exhaustive list of health organizations' stakeholders, which he divided into three categories: internal stakeholders--those who operate entirely within the bounds of the organization (managers, professional and non-professional employees), interface stakeholders--those who are on the interface between the organization and its environment (e.g., medical staff), and external (suppliers, competitors, government, professional associations, patients and the local community). Taking into consideration that those who can provide the most valuable information are those directly involved, and that in order to shape a comprehensive and realistic image on the main strengths and weaknesses of the Romanian health care system management, we have chosen to analyze them from a dual perspective: that of the employees and specialists from the healthcare system, and that of the patients, who are the beneficiaries.

2. Strengths and weaknesses of the Romanian health system

   Over time, various authors have identified a number of strengths and weaknesses of the Romanian health care services, both at the organizational level and at level of the Romanian health system as a whole. For instance, Cicea, Busu and Armeanu (2011) identified among the strengths of the Romanian health care system: the relatively high number of service suppliers for each type of medical care and the existence of medical centers of excellence, which leads to an inflow of patients, regardless of the area they live in, and the implementation of hospital financing system--DRG; and among the main weaknesses: the precarious condition of the financial resources allocated to the health care system, lack of real financial and managerial autonomy, and high incidence of contagious and chronic diseases.

   An overview of the Romanian health system weaknesses, in the European context, is shaped by Euro Health Consumer Index 2013 Report, which is the seventh study made on European healthcare systems with the aim 'to select a limited number of indicators, within a definite number of evaluation areas, which in combination can present a telling tale of how the healthcare consumer is being served by the respective systems.' (Bjornberg, 2013, p. 19). Given the scores and ranks, in relation to the other European countries, we can consider that all six fields of interest from the report show weaknesses of the Romanian health system: (1) patient rights and information: rank 23-27 of 35 countries; (2) accessibility/waiting time for treatment: rank 23-30 of 35; (3) outcomes: rank 34-35 of 35; (4) range and reach of services: rank 33 of 35; (5) prevention: rank 24-28 of 35; and (6) pharmaceuticals: rank 32-33 of 35 (Bjornberg, 2013, p. 26).

   Other authors (Stanciu and Jawad, 2013) conducted an analysis of the issues facing the Romanian public health system. These referred to: (1) low wages of the medical staff, which adversely influenced the amount and quality of delivered services and caused the medical staff to migrate towards west; (2) the deficient financing of the national health system; (3) restricted access to health services; (4) the lowest consumption of medicines per capita at the purchasing power parity within the European Union.

3. Strengths and weaknesses of the Romanian health system management--pilot study

   We should mention that the present paper is the first attempt to outline, through a quantitative research, the strengths and weaknesses of the managerial component of the Romanian health system, in the view of the most important categories of stakeholders, through an inquiry-based survey.

   A similar approach has been implemented in the last six years (2009-2014) by Nicolescu, Verboncu, and Profiroiu (2010, 2011), Nicolescu et al. (2012), Nicolescu, Popa and Nicolescu (2013, 2014) which evaluated the 'health' of Romanian management, both at national and at company level, based on empirical researches which also used questionnaires as data collection tools. Among the parameters examined, an important role was given to the instrumental parameters related to strengths, respectively weaknesses of management practices.

   3.1. Methodology and limitations

   The research methodology involves the following steps: (1) research hypotheses, (2) questionnaire design, based on the independent and dependent variables necessary in order to test the research hypotheses, (3) choosing the investigated population, (4) selecting the two samples of respondents, (5) collecting and processing information (with technical support of IBM SPSS Statistics 22.0 statistical program), and (5) testing the research hypotheses (Popa, Stefan and Popescu, 2015a, p. 793).

   Taking into consideration the aim of this paper, and based on previous studies and personal empirical observations, we formulated the following hypotheses:

   H1. The perception of strengths and weaknesses of the health services management has little variation between the two categories of stakeholders.

   H2. There are no significant differences between the patients' opinion, according to their origin--from one of the eight regions, about the strengths and weaknesses of health services management.

   H3. There is a significant relationship between the respondents' opinion on the strengths of the Romanian health system management and the performance level, compared to the previous year.

   The identification and analysis of strengths and weaknesses of the Romanian health system management was based on an inquiry-based survey, which used the questionnaire as data collection tool. It was requested that from a list of strengths (Table 2) and weaknesses (Table 3) to indicate which are the first five valid ones. The list of the strengths and weaknesses used in the research include items concerning: the management system with the decisional, methodological, informational, structural and organizational subsystems, human resources management, managers, leadership, organizational culture, effectiveness, efficiency, competitiveness and sustainability, and was adapted to the peculiarities of the health system, after the one developed by Nicolescu, Verboncu and Profiroiu (2010; 2011, pp. 215-217), Nicolescu et al. (2012, pp. 216-217), Nicolescu, Popa and Nicolescu (2013, pp. 214-216; 2014, pp. 276-278), and which proved its utility in the past six years in the identification and analysis of strengths and weaknesses of the management practiced in Romania, both at national and at firms' level.

   In fact, two parallel surveys were carried out during March-April 2013, as part of a broader study on strategy and strategic management in the Romanian healthcare system. The first survey was conducted using a sample of 42 specialists and employees, from the outpatient clinic of the National Institute of Rehabilitation, Physical Medicine and Balneoclimatology. It should be mentioned that, for reasons related to the difficulty of the questions and the real possibility to provide informed answers, the studied population did not include the auxiliary staff, so the final number of persons was 74, from which we selected the 42 respondents. The sample was determined using the simple random sampling method, and a sampling frame, consisting of the employees list, which provided a guarantee of the outcome probability of 95% and a minimum acceptable error of 10.1%. From the 42 respondents, nearly half (47.6%) have worked within the organization more than 10 years, more than a third (35.7%) between 5 and 10 years, 11.9% between 2 and 5 years and only 4.8% less than 2 years.

   The second survey was done online; it was designed to outline an overall picture of the opinions of the second category of stakeholders, patients, who are the beneficiaries of health services. The main...