The camera pans jerkily over a hospital bed before honing in on the burn victim’s head. Under a plastic tube stretched across his charred, blackened ear, a group of white fly larvae are writhing in an open wound. This is no horror film, but footage secretly filmed inside Bucharest’s top burns unit.

The images were recorded shortly before the patient’s death in the intensive care unit at the Clinical Emergency Hospital of Plastic Surgery and Burns in Bucharest, the only hospital in the Romanian capital that specialises in treating serious burns. They were leaked to news website tolo.ro in July by anaesthetist Camelia Roiu, who said there was another identical case in the hospital. “These are the conditions in which the patients are treated in this hospital and they need to be changed,” she told tolo.ro.

Roiu initially kept her identity secret and says that since publicly admitting she recorded the images she has been sent to various disciplinary commissions. She also claims to have been victimised by her colleagues, writing in a Facebook post that she is being deprived of necessary medical equipment and some surgeons have asked not to work with her.

Roiu has also revealed she was one of the whistleblowers after the Club Colectiv tragedy, informing the media that many of the people saved from that fire in the night club in November later died from infections contracted in hospital. “Those young people died in a biological bomb, because of hospital-acquired infections,” she said back in December.

The Colectiv tragedy led to mass protests when it was revealed that the club’s owners had violated fire safety regulations. The fire, which ultimately led to the deaths of 64 people, showed how bad the consequences of a corrupt system can be. It also revealed another terrifying aspect of the Romanian healthcare system: hospital-acquired infections, which caused the deaths of many who were saved from the fire. Roiu’s statements raised a wave of support among Romanians, many of whom have signed an online petition asking for her to be protected.

Under-reported

Hospital-transmitted infections are clearly a problem in Romania, but nobody knows the true extent of the problem, as only 10 Romanian hospitals participated in the last survey on this issue. Romania currently reports healthcare-associated infection rates of just 2.8%, well below the EU average of over 5%, indicating substantial under-reporting, professor Karl Ekdahl, part of a team of European Centre for Disease Control (ECDC) experts who visited Romania in early July, said in an interview with bne IntelliNews.

Ekdahl, who heads the ECDC’s public health capacity and communication unit, believes the system discourages hospital administrators from reporting the true figures. “Under the present legislation, hospitals should have less than 2% infections and that is not an incentive to report higher figures,” he says.

With mounting public outrage following the Colectiv tragedy, more light is now being shed on the system. The problems and the shortcomings of the public healthcare sector, many times denied by hospital managers and politicians, are starting to surface.

Ask any Romanian about their relationship with the public healthcare sector, and they will immediately mention the corruption in the system, the bribes they usually have to pay for services which should be provided free of charge, the lack of medicine in the hospitals and the fact that it is a usual practice to be given a list of medicines to buy yourself if you are hospitalised, as well as the improper conditions in hospitals and clinics, lack of beds and so forth.

To a large extent these are problems common across the Central and Eastern European region. “The other former Warsaw Pact countries had essentially similar public healthcare systems with similar kinds of problems, though they have dealt with them in different ways,” says Brendan Melck, senior analyst at IHS Markit Life Sciences.

Melck points to the low level of public healthcare funding as the root of the problem; a 2014 OECD survey showed funding in Romania as a percentage of GDP was among the lowest in the EU. Low salaries for state employees encourage corruption, from the routine small payments made to doctors to larger-scale corruption in the public procurement system.

A few months after the Colectiv scandal brought down prime minister Victor Ponta and his government, a journalistic investigation by Gazeta Sporturilor newspaper revealed that sub-standard disinfectants supplied by Hexi Pharma to most Romanian hospitals possibly contributed to the deaths of the Club Colectiv victims. The scandal also led to the resignation of health minister Patriciu Achimas Cadariu. Hexi Pharma owner Dan Condrea committed suicide the day before he was due to speak to prosecutors, leaving many questions unanswered.

“Money for healthcare actually went into the pockets of companies that supply medicine or materials. The market in healthcare products sold to state hospitals is rigged, a lot of money is siphoned off,” Roxana Wring of the opposition Union Save Romania party tells bne IntelliNews.

And the revelations keep on coming. It was recently revealed that one woman died at the Hospital of Plastic Surgery and Burns after she had been given a transfusion using the wrong blood group, and another patient is in a serious condition at another Bucharest hospital due to the same medical mistake.

Fresh blood

Managing the healthcare sector is probably the biggest challenge of the technocratic government led by Dacian Ciolos. After Cadariu’s resignation, Ciolos appointed the head of the finance minister’s office, Vlad Voiculecu, as health minister. Voiculescu is known in the country for his charitable activities in the healthcare sector, such as the launch of the so-called Cytostatics Network in 2008, which is a group of more than 400 volunteers from around Europe who brought drugs that were not available in pharmacies to the country free of charge. He also set up Magicamp, a camp for children suffering from cancer at his parents’ house in Dambovita county.

Although his intentions and drive are admirable, change takes time – and time is what Voiculescu does not have. Romania is expected to hold general elections this autumn, in which the technocratic government is likely to be replaced by a new political one.

In a recent interview with Capital magazine, Voiculescu said that his ministry is working on a plan to build new hospitals. “Until the end of my mandate, I hope we have an investment plan for the next five years. We are working on a study which will show us what we need and where,” the minister said.

He added that the problem of hospital-acquired infections is well-known among medical personnel and if all punitive measures were to be applied, 80% of Romanian hospitals would have to be closed, which is an unrealistic option and would send the country into crisis.

The health ministry declined to comment to bne IntelliNews on the measures taken so far in order to avoid similar cases in which sub-standard products come to be used in hospitals.

Observers say there is a visible commitment on the part of the technocratic government to make reforms. According to Ekdahl, “the Ministry of Health is aware that there is an issue with healthcare associated infections in Romania, and there is now a high political commitment to try and embrace this issue.”

However, Romania has consistently failed to take advantage of external funding for the sector. Romania has €150mn in European funds earmarked for building three regional hospitals, but the government has to map the services needs by the end of the year. “In fact, we have several months to do what has not been done in years and you can’t get European money without this document,” Voiculescu told Capital.

Back in March 2014, the World Bank approved a €250mn loan to Romania for health sector reform. “The World Bank programme was signed in 2014 and not a eurocent has been drawn so far. I can assume... that drawdowns will start this year,” Voiculescu said.

In fact, according to Ekdahl, simple and relatively cheap measures such as the introduction of hand sanitizers in hospitals could have dramatic results. He calls for alcohol dispensers to be made available close to patients and for a hand hygiene awareness campaign among healthcare workers. “This could save lives,” he says. A similar campaign rolled out in UK hospitals helped to reduce the spread of drug-resistant MRSA infections.

Although one of the issues in Romania’s healthcare scandal is the supply of substandard products, Ekdahl believes a culture of hand hygiene would still be beneficial. “It is self-evident that if you are working in a hospital setting, working with patients, you should have good products, but at the same time it's important that this event should not stop or delay the implementation [of a hand hygiene campaign],” he says.

These and other measures proposed to the health ministry by the ECDC “could be done relatively cheaply if there is a will” and would result in “tremendous change”, says Ekdahl, though he acknowledges that, “In a country like Romania, you also have the problems of too few isolation rooms and over-crowding in hospitals, but that is a much bigger issue.”

Wring also believes a change in approach is as important as building new hospitals. “Doctors and nurses leave the healthcare system because they are underpaid and conditions are so grim,” she says. “We also need to invest in preventive medicine. Currently, politicians don’t look at health as an area of strategic importance,” she warns, citing the failure of Romania’s first attempt to introduce a ban on smoking in public places.

Going private

As the public healthcare sector faces more and more problems, private healthcare providers are expanding at a fast pace. Moreover, the ongoing scandals in the public sector are bringing them more customers.

“Our activity has not been affected by the disinfectants scandal, as we do not use these products. On the contrary, we have seen an increase in the number of patients who have chosen private hospitals to public ones exactly because of this,” Mihai Marcu, president of MedLife managing board, tells bne IntelliNews. The company had served over 450,000 corporate clients across the country at the end of the first quarter of 2016, a record on the private medical services market.

IHS’ Melck points to the expansion of private healthcare services in fellow CEE countries, and forecasts a similar trend in Romania. “If there is an over-burdened and underfunded state healthcare system, then people will look to the private sector as a kind of escape valve,” he says. “In Poland and Hungary, private healthcare providers are increasingly offering services that are within the reach of a growing number of people, including those with not particularly high salaries. Romania has the potential to be very similar.

MedLife is now expanding. The company announced on August 4 it had acquired a 90% stake in Centrul Medical Panduri medical centre and plans to borrow €20mn for new acquisitions. It is currently negotiating five new acquisitions, of which one is relatively large. In the second half of the year, MedLife plans to open two new clinics, in Brasov and Ploiesti, increasing its network to 35, Marcu adds.

Another private healthcare firm, Medicover, is also bullish about the Romanian market. “There is no denying that Romania currently offers numerous business opportunities, in many sectors. Foreign investors’ interest in the country is also increasing,” says Adrian Peake, general director of Medicover Romania. “The local private medical services market continues to be in a full process of development and consolidation. The annual growth rate of this market is of approximately 12%.”

The company, which has been present in Romania for over two decades, plans to continue its expansion with the opening of at least three new clinics per year. It opened four new clinics in the first half of 2016 alone. “We are a long-term investor here and will continue our local development, where we estimate that we will register significant increases from year to year. This is partly due to the significant expansion potential in all areas of the country,” says Peake.

MedLife and Medicover are not the only private operators planning to expand. Romania's second largest private medical services provider, Regina Maria, announced on June 22 it had invested €700,000 in a new clinic in the southern city of Pitesti. The company has been on a buying spree over the past few months as it seeks to expand its national network. In May, Regina Maria acquired the Dr. Grigoras medical centre in western Romania and in April took over Helios medical centre in the south western city of Craiova. In March, it bought Ponderas hospital in Bucharest and signed a €15mn agreement to develop its first hospital in the city of Cluj Napoca.

As Romanians become better informed about the shortcomings of their health system, and their disposable incomes rise, the expansion of the country’s private healthcare providers is a trend that will only continue.