Keywords

This chapter looks at health and the ways in which its post-socialist transformation has had an impact on citizenship and democracy in Romania. It adopts a political economy perspective that views citizenship and democracy as comprised not only of political dimensions, but also of social ones. Within this framework, decent wages and access to public services are fundamental to ensuring the social reproduction of citizenry and the enactment of its social rights (Marshall 1950). Diminution of these common goods potentially weakens commitment to the state, dilutes trust in public authorities, and intensifies the appeal of populist politics. In turn, struggles to extend their scope are a key engine of democratization processes (Erne et al., 2024).

We follow Marshall (1950) in considering that contemporary designs of citizenship include not only civil and political rights, but also social rights. The latter consist of “the right of the citizen to a minimum standard of civilised living,” or, in Marshall’s terms, a “living wage” (1950: 69). This standard supposes a more balanced appropriation of material assets between capital and labor; while moderating income inequalities, it also improves the overall health status of a population (Wilkinson and Pickett 2009) and thus safeguards its biological and social reproduction. While Marshall saw trade unions’ fight for the living wage as contributing to a “secondary industrial citizenship” (1950: 58), other social actors such as the government, employers, and social movements also take part in this struggle.

Social rights further include a non-wage component, that of rights to access public services, of which healthcare is likewise central to biological and social reproduction. Access to comprehensive and universal public healthcare is fundamental for palliating income inequalities, improving the overall health of the population, and enhancing citizens’ sentiment of belonging to a common social space. By contrast, if low wages combine with income inequality and deficient and unevenly distributed public services, this further removes a population from the ‘civilized’ status attached to full citizenship.

In this chapter, we disentangle the ways in which health and healthcare have become woven into changes in citizenship and democracy in post-socialist Romania. We argue that, after 35 years of post-socialist transformations, and despite recent improvements in Romania’s macroeconomic profile, the country retains an unhealthy citizenry plagued by inequalities in income and healthcare, and therefore still detached from Marshall’s civilized citizenship.

The plan of the chapter is as follows. In the next section, we show how makeover of Romania’s post-socialist political economy involved the adoption of a neoliberal and dependent development pathway (Bohle and Greskovits 2012), which steered it to a neoliberal citizenship model (Stan 2018). In the second section, we argue that Romania’s development pathway has informed changes to its healthcare system. In the third section, we explore the extent to which healthcare has been a site for contesting not only deficient health services, but more largely the country’s embrace of neoliberal citizenship and development pathway. In the fourth section, we present Romania’s record in terms of income inequalities, health status, and provision and access to healthcare at the beginning of the 2020s. The chapter ends by considering the overall impact of post-socialist transformations and healthcare reforms on Romania’s citizenship.

Romania’s Post-Socialist Political Economy

The fall of the communist regime at the end of 1989 led in 1990 to the first election in almost half a century. They brought the left-wing National Salvation Front (FSN, Frontul Salvării Naționale) to government, and its leader, Ion Iliescu, to the presidency. The same formula was kept after the second election in 1992, with FSN changing its name first to the Democratic National Salvation Front (FDSN, Frontul Democrat al Salvării Naționale) and then to the Party of Social Democracy of Romania (PDSR, Partidul Democrației Sociale din România). Despite urgent calls from the International Monetary Fund for rapid privatization and restructuring (Gabor 2011), the pace of economic transformation was initially gradual, the state maintaining ownership over public utilities and offering employees concessions on wages and work hours (Pop 2006). These concessions did not manage, however, to stem the sharp depreciation of wages and savings in the face of severe inflation triggered by the liberalization of most prices except for basic foodstuffs (Pop 2006). Moreover, the end of the central planning system set off the first wave of company closures, leading to the loss of over 1.2 million manufacturing jobs by 1996 (Neef 2002: 301–303).

The sale and liquidation of state-owned enterprises swiftly accelerated after the 1996 elections brought to power the right-wing Democratic Convention of Romania (CDR, Convenția Democrată Română) (Pop 2006), the industrial labor force dropping by an additional 424,000 already by 1998 (Neef 2002). The loss of guaranteed employment and the prolonged depreciation of income in an inflationary environment led to the impoverishment of large sectors of the population (Mureșan 1999). At the end of the 1990s, Romania’s GDP per capita was US$1600, that is, only 88% of its 1989 level (World Bank 2023), and its average monthly net wage was Euros 93.5, half of its 1989 level (Chivu 2017: 25). Many urban dwellers, mostly unemployed workers or those taking advantage of early retirement schemes (Stan and Erne 2014), sought relief by migrating to the countryside, often to practice subsistence agriculture on decollectivized land (Pasti 2006). Employment in agriculture thereby peaked at 45% of the total in 2000 (World Bank 2023). Income inequality surged, the Gini coefficient for Romania rising from 25.5 in 1992 to 30.3 in 2000 (Pasti 2006: 96).

Although in 2000 the PDSR, soon thereafter renamed the Social Democratic Party (PSD, Partidul Social Democrat), and Iliescu returned to power, Romania’s neoliberal trajectory continued even more steadfastly. Closures and privatizations of state-owned enterprises grew in number, and former industrial workers were increasingly thrust into precarious forms of employment (Poenaru 2017).

Neoliberal reform of the economy was then all but sealed when the 2004 election brought to government the center-right coalition of the National Liberal Party (PNL, Partidul Național Liberal) and the Democratic Party (PD, Partidul Democrat), with PD leader Traian Băsescu as president (Poenaru and Rogozanu 2014). Băsescu held that position until 2014, being joined between 2008 and 2012 by the center-right Democratic Liberal Party (PDL, Partidul Democrat-Liberal) cabinets of Emil Boc. Together, these political forces replaced progressive income taxation with a flat tax of 16%, lengthened the workday, eased labor and financial regulations, and endorsed additional privatizations at bargain prices (Ban 2016). These measures appeased the European Union (EU) officials who were appraising Romania’s qualifications for accession (Ban 2016), which was approved for 2007. Juxtaposed with very low labor costs and greater macroeconomic stability (e.g., lower inflation), such policies attracted foreign direct investment (FDI), which peaked in 2006 at 9% of GDP (World Bank 2023).

During the same period, the unemployment rate dropped, industrial production increased, and worker productivity rose (Murgescu 2010), while more technology-intensive products started to be exported (Haar 2010). The Balkan Tiger years of the mid-2000s did not, however, end reliance on labor-intensive, low-skilled, and low-waged work in light industries, and, despite the net average wage for the first time in 2005 bypassing the 1989 figure of Euros 199, remuneration remained extremely depressed relative to most EU countries (Stan and Erne 2014). These conditions propelled the migration of labor abroad, especially since visa requirements for the EU countries were eased in the early 2000s (Stan and Erne 2014). A jump in 2005 in the contribution of personal remittances to Romania’s GDP from circa 0.3 to 1.0% resulted from this (World Bank 2023). All these features set the country on a neoliberal dependent pathway of capitalist development (Bohle and Greskovits 2012).

The 2008 financial crisis brought the boom years to an end and saw Romania’s GDP dropping to −5.5% in 2009 (World Bank 2023). This, in turn, prompted the Romanian governments to sign several bailout-funding Memoranda of Understanding (MoUs) with the IMF and the EU (Erne et al., 2024). After the setup in 2012 of the European Semester as the EU’s constraining macroeconomic surveillance mechanism, these MoUs were accompanied by yearly country-specific recommendations (CSRs). As a result, between 2009 and 2019, the EU tasked Romanian governments with implementing a series of constraining MoU conditions and CSRs seeking to limit public expenditure. Some of these EU-backed policy prescriptions requested the government to cut public sector wages and employment numbers, which the PDL-dominated government of Prime Minister Boc did to the tune of 25% wage cuts and a 1-in-7 limit on refilling vacancies in the public sector (Stan and Erne 2016). An increase in the value-added tax from 19 to 24% burdened citizens further, as did the increased transfer of employers’ social security contributions onto workers (Ban and Rusu 2019: 11). Finally, in 2011 the Romanian government amended the Law on Social Dialogue and the Labor Code, which compromised the right to strike, trade union rights, and collective bargaining, creating thereby a more flexible labor force (Guga 2014).

The effects of these austerity policies continued even after a series of PSD-led coalition governments headed by Victor Ponta came to power starting in 2012. As much as 46% of the population was at risk of poverty or social exclusion as late as 2016, the highest rate in the EU and close to twice its average (Eurostat 2023a). Rural communities were especially hard hit with 57.8% of their residents living below poverty line (Eurostat 2023a). In 2016, income inequality rose to the second highest rate in the EU, Romania’s income quintile share ratio for disposable income reaching 7.20 in comparison to the 5.16 EU average (Eurostat 2023a). As a result, labor migration continued. By 2017, Romanian citizens residing abroad accounted for 19.7% of the country’s total working-age population, making them the largest national group within the EU that was living abroad in both absolute and relative terms (Eurostat 2020).

Following street protests sparked by the Colectiv nightclub fire tragedy in November 2015 (see section “Politicizing Healthcare”), Ponta’s PSD-led government was ousted and replaced by the technocratic cabinet of Prime Minister Dacian Ciolos. The 2016 general elections returned the PSD to power, successive cabinets led by the party thereafter cohabiting with President Klaus Iohannis (PNL), elected in 2014.

Sustained economic growth resumed by the mid-2010s, with IT, electronics, and the automotive industry undergoing a particularly robust expansion (ILO 2023). Romania’s GDP per capita level left behind its long-held bottom position in the EU to become the sixth lowest in 2021 at 74% of the EU average (Eurostat 2023a). With a number of PSD governments enacting several minimum wage increases, the latter rose in 2013–2023 at an annual average rate of 14%, the largest increase in the EU during that period (Eurostat 2023b). Romania’s minimum wage thereby moved from second lowest (at Euros 180 in 2013) to third lowest (at Euros 606 in 2022), exceeding those in not only Bulgaria but also Hungary (Eurostat 2023b). Romania’s post-austerity wage gains were nonetheless qualified. Despite a decrease in personal income tax from 16 to 10% in 2018, they translated into more modest real income growth given the shifting of contributions to social insurance entirely onto employees in the same year (Tache 2017).

At the end of 2019, the PNL returned to government as part of a series of coalitions forged with other center-right parties (most notably the Save Romania Union, USR, Uniunea Salvaţi România, under Prime Minister Ludovic Orban, and USR and the Solidarity Party, PLUS, Partidul Libertăţii, Unităţii si Solidarităţii, under Prime Minister Florian Cîţu, both representing the PNL) and, since 2021, with the PSD (under PNL Prime Minister Nicolae Ciuca and then PSD Prime Minister Marcel Ciolacu). After the Covid-19 pandemic hit the country, increased inflation rates negatively affected the previous wage gains. As such, despite a growth in GDP and wage levels, the migration of labor abroad remained significant in terms not only of numbers but also contribution to the economy. After 2017, remittances hovered at levels very close to FDI of around 3% of GDP (World Bank 2023). Yet, in 2021, agriculture still occupied 19% of Romania’s workforce (heavily for subsistence), making the country an outlier in the EU, with its 4% average (World Bank 2023). Industrial employment sat at 30% as compared to the 25% EU average, while services sat at 51% as compared to the 71% EU average (World Bank 2023). Tellingly, at the turn of the 2020s, Romania continued to be, at least by EU standards, heavily rural, 46% of its population living in rural areas (World Bank 2023).

Post-socialist transformations resulted in the neglect of public services (Ban 2016), as Romania turned from the socialist worker citizenship model to the neoliberal one (Stan 2018). Housing, education, health services, public transit, infrastructure, social benefits, research and development have been underfinanced for years (Ban and Rusu 2019). Deficient healthcare is one of the chief outcomes of dampened public expenditure. We turn to this matter in the next section.

Post-Socialist Healthcare Transformations

With its setup completed by the 1970s, Romania’s national healthcare system consisted of a comprehensive network of primary care dispensaries, outpatient polyclinics, and inpatient hospitals. Combining state-enterprise and local-authority units, the network extended from urban to rural areas. During the 1980s, healthcare suffered from general electricity and heating shortages, lack of investment in built infrastructure, as well as a scarcity of medical equipment and consumables. In this context, many patients utilized informal exchanges that involved valuable products, like foreign coffee or cigarettes, or scarce food items to access better or faster healthcare (Stan 2018). Thus, although the socialist regime had initially widened citizens’ social rights by setting up a comprehensive healthcare infrastructure, during its last decade it also undermined them under the pressure of the economic crisis as well as of its renewed attacks on women's right to abortion.

During the 1990s, post-socialist health services continued in a crisis mode, with Romania’s healthcare spending being kept below 5% of its (now dwindling) GDP. The abrupt dismantling of the socialist worker citizenship outlined in the previous section left healthcare as one of the few safety nets of which the population could avail itself in a context of massive layoffs and rising unemployment. Indeed, during their seven-year rule in 1990–1996, the social-democratic FSN/FDSN/PDSR governments left the healthcare system virtually untouched. Nonetheless, while access to public health services remained free at the point of delivery, it also came to depend more often on informal payments (widely referred to as şpaga), which now started to tilt more toward money than in-kind forms (Stan 2018).

The center-right CDR cabinets initiated the first major overhaul of the healthcare system (Stan 2018). The Law on Social Health Insurance (145/1997) led to its transformation from a national health system funded through the state budget to a contribution-based social insurance system managed by and mostly financed from a separate national health fund (Casa Naţională de Asigurări de Sănătate, CNAS). The reform introduced contractual relations between healthcare providers and the CNAS. It also instituted public healthcare coverage for ‘insured’ people, which were further divided between ‘contributing’ ones (that is, employees subjected to compulsory contributions) and several non-contributing categories of individuals (including, for example, dependent children). The law further introduced limitations on the range of services covered by social health insurance in the form of a list of services defined by the CNAS. Finally, it opened the gates to the establishment of private medical practices. National statistics registered the first private healthcare units in 1997 (Tempo Online 2023).

During 2000–2004, the PDSR/PSD government refrained from implementing major changes in healthcare except for finetuning the health insurance law. The next push came in the form of the Law on Healthcare Reform (95/2006) and a series of other measures implemented by the center-right PNL-PD government. These further commodified health services, as they allowed public healthcare units to outsource services and private hospitals and clinics to contract services with the CNAS (Stan 2018). The law further restricted access to healthcare covered by social health insurance by creating a package of basic services available to the insured population and a minimal one offered to the uninsured (Stan 2018). The latter covered primary care and healthcare for emergencies, communicable diseases, and childbirth.

The 2000s saw a gradual, yet steady, rise in private healthcare provision. By 2008, the share of private units in total ones was only 6.5% for hospitals, but as much as 91% for polyclinics, 81.6% for specialized medical centers, and 71.8% for dental practices (Tempo Online 2023). However, while primary care also started to turn private with the disbandment of socialist-era dispensaries, most family medicine or general practices effectively functioned under a public-service umbrella given that most of them contracted their services with the CNAS.

The rise in the importance of private healthcare units led to divergent pathways to access that depended on one’s socio-economic status (Stan and Toma 2019). Those in higher-skilled and higher-paid jobs availed themselves not only of speedier and better public healthcare through recourse to şpaga, but also of private healthcare in Romania and abroad. In turn, those in lower-skilled and lower paid jobs, working in subsistence agriculture or the informal sector, or the unemployed, became dependent on a chronically underfunded healthcare system in which access to the services of underpaid healthcare professionals came to be understood as largely dependent on monetary forms of şpaga that they could not afford. Save being able to draw on migrant remittances to access higher quality and more rapid healthcare, people in marginalized groups resorted to over-the-counter medicines or traditional remedies as substitutes for such care.

After the 2008 financial crisis, the EU-backed policy prescriptions tasked Romanian governments to cut not only public expenditure in general (as seen in section “Romania’s Post-Socialist Political Economy”), but also hospital spending and the number of hospitals and hospital beds. They also asked them to strengthen central control over healthcare spending, introduce performance-based funding in primary healthcare, reduce the scope of services covered by the basic services package, introduce co-payments for medical services, and establish supplementary private health insurance (Erne et al., 2024). In response, Romania’s center-right governments closed as many as 67 local hospitals and brought hospital budgets under tighter control by the Ministry of Finance. Going beyond the EU-backed mandate, at the end of 2011 President Băsescu pushed for a new healthcare law that sought to further privatize the Romanian healthcare system, most notably by placing the management of the national health fund into private hands, a change that incited street protests and two government reshufflings (see section “Politicizing Healthcare”).

At the height of the austerity period, in 2012, Romania’s public healthcare system was anew in dire straits, with wages in the healthcare sector at record low levels (Tempo Online 2023), widespread shortages of medical consumables and equipment in hospitals, ubiquitous accounts of healthcare personnel conditioning medical acts with the receipt of monetary şpaga (Stan 2018), and rising annual levels of healthcare personnel out-migration (Stan and Erne 2016). In 2013, the PSD-led government, still facing hard MoU conditionality in healthcare, introduced co-payments for medical services and wage raises in the public sector, including healthcare, which, initially, merely compensated for austerity period cuts. After the PSD returned to government in 2016, following the technocratic Ciolos cabinet, they embarked on sharp increases in healthcare sector wages. While these raises benefitted doctors more than other personnel, altogether they resulted in average net nominal earnings in health and social care rising above the average per total economy for the first time since 1991 (Tempo Online 2023). Still, proportionally lower increases for non-medical personnel and the shift of contributions exclusively onto employees (see section “Romania’s Post-Socialist Political Economy”) kept their earnings low. With Romania’s healthcare expenditure remaining between 5 and 6% of GDP, wage raises were enacted against a canvas of continuously deflated expenditure on medical consumables and equipment. These factors meant that conditions still lagged ‘Western’ standards as well as healthcare professionals’ and patients’ expectations. While the higher wages led to drops in physician out-migration (Novac 2022) and informal payments from patients (Tanasie 2023), both phenomena persisted.

After March 2020, Prime Minister Ludovic Orban’s PNL-USR government responded to the onset of the Covid-19 pandemic with a tough militaristic approach (Poenaru 2021). The PNL-USR-PLUS government that followed orchestrated a promising start to the vaccination campaign in the first half of 2021 (Stan 2021). Following several overconfident messages from President Iohannis and a relaxation of lockdown measures during the summer, by autumn 2021 the country was hit by a new pandemic wave. This proved lethal given the vaccination campaign’s focus on urban areas and rising vaccine hesitancy among the population, healthcare professionals, and public media figures (Stan 2021). The pressure that pandemic morbidity placed on hospital infrastructure tragically led to several hospital fires and patient deaths (Luţac 2021), thus highlighting the country’s obsolete healthcare infrastructure, much of which dated back to socialist times.

Romania’s healthcare reforms have not gone unchallenged. Trade unions, social movements, and street protests have played an important role in the direction these reforms have ultimately taken, as we illustrate in the next section.

Politicizing Healthcare

The first massive post-socialist protests involving healthcare were organized in 2010 in reaction to the austerity measures launched by the center-right cabinet of PDL Prime Minister Boc (see section “Romania’s Post-Socialist Political Economy”). Organized by the main trade union confederations, they included not only healthcare workers but also other public sector employees and retirees. Although impressive, the protests were largely ineffective, all of the reductions planned by the government—with the exception of pensions—ultimately being enacted. Worsening matters for the unions, the state went after several leaders involved in the protests, pressing charges of corruption against them that seemed aimed at restraining their activities (Stan 2018; Varga 2015). Concessions were also unevenly handed out to unions in order to undermine their unity, a tactic that made it easier to marginalize the unions of healthcare workers and educators (Varga 2015). A further toll was taken in 2011 when the Labor Code was amended and collective bargaining agreements were unilaterally neglected (Trif 2013).

In January 2012, Băsescu’s bid to rush a new law on healthcare reform (seen section “Post-Socialist Healthcare Transformations”) through Parliament gave rise to the most sizeable demonstrations since the 1990s. This time, however, trade unions did not participate and instead the protests brought to the streets the old socialist classes of state-enterprise workers and retirees, and members of the emergent, yet still often precarious, middle-class working for multinational corporations or international non-governmental organizations. However, their concerns were not entirely in sync, working-class participants objecting not only to the privatization of healthcare but also to the erosion of citizen rights, while middle-class activists primarily opposed corruption in the political system (Stan 2018). Despite attempts by the authorities to denigrate participants (Poenaru 2012), the protests did not relent, leading to the removal of the Boc cabinet and a slowdown in the commodification of healthcare. Two months later, in April 2012, a new wave of protests led to the fall of the PDL-led cabinet of Prime Minister Mihai Ungureanu and the appointment of the interim PSD-led government of Ponta.

Soon thereafter, in 2013, protests were carried out domestically and by the growing diaspora against the Roșia Montană mining project proposed by the Roșia Montană Gold Corporation (Wong 2013). Picketers highlighted risks the venture posed to the environment, public health, cultural heritage, and the integrity of local communities. The rallies were effective in stopping the project from going forward and some of their participants went on to organize against fracking, illegal logging, and corruption (Soare and Tufiș 2021). Nonetheless, the activists missed the opportunity to join forces with other major campaigns unfolding in 2013, namely those organized by healthcare workers.

Those protests were executed by the Coalition for Healthcare Professionals (CPS, Coaliția Profesioniștilor din Sănătate), which was established by Sanitas (the largest healthcare workers’ union in Romania, mostly representing nurses), the Romanian College of Physicians (CMR, Colegiul Medicilor din România), and other trade unions and professional associations (Stan and Erne 2016). The Coalition demanded the implementation of a sectoral collective agreement and a unitary wage scheme for public sector workers. A warning strike ultimately led the ministry to sign a sectoral collective agreement with the unions, which also met the goal of the CMR to increase the salaries of junior-level physicians. Still, it did not achieve increases for other healthcare workers and has languished awaiting agreement by employer organizations (Stan and Erne 2016).

When, two years later, the Colectiv fire tragedy provoked intense street protests, demonstrators used ‘Corruption kills!’ as the dominant slogan and the PSD government resigned shortly thereafter. The ultimate death toll of 65 (Lepădatu 2020) included not only people who perished on site but also many who later fell victim to nosocomial infections in Romania’s hospitals. Investigative journalists featured in the 2019 Oscar-nominated film ‘Collective’ showed that the likely culprit was corruption in the way public hospitals contracted disinfectants from the firm Hexi Pharma. The firm had sold diluted disinfectants to public hospitals, which further watered them down. Hexi Pharma’s public contracts for disinfectants dated back to 2005, when the center-right PNL-PD government signed the first of them. Yet this story was not what compelled protesters to take to the streets. Mostly urban and educated, the Colectiv protesters did not acknowledge the long-term politics of austerity that had curtailed resources for public hospitals, diminished democratic scrutiny over public tenders, and thus allowed private business to profit from public goods with impunity (Rogozanu 2012). Instead, the ‘Corruption kills’ slogan was a stand-in for criticism of left-wing governance, a theme that would resonate widely during the 2017–2019 anti-corruption (and anti-PSD) demonstrations.

Even so, concerns regarding the design of the healthcare system were brought back to the fore one year after the Colectiv tragedy. In 2016, Sanitas, the healthcare workers’ union, succeeded in getting the Ciolos technocratic government to increase both wages and bonuses through a strike in which 80,000 of its members participated (Adăscăliței and Muntean 2019), and the union effectively applied its negotiating tactics again to the PSD government in 2017. As we have seen in section “Post-Socialist Healthcare Transformations”, healthcare wage increases have been heavily qualified by a decrease in bonuses in the sector and the transfer of all insurance contributions to employees, and funding of the system has not proceeded in lockstep.

The wage increases and then the Covid-19 pandemic curbed healthcare-related protests. In December 2022, however, healthcare workers from across the EU, including members of Sanitas, came together to draw attention to sparse investment in public health and social infrastructure throughout Europe (Bell and Goudriaan 2022). This kind of transnational action is noteworthy given the role that the EU has played in the commodification of healthcare (as explained in section “Post-Socialist Healthcare Transformations”).

Rising inflation, the EU-wide cost-of-living crisis generated by post-pandemic developments, and Russia’s war against Ukraine led in June 2023 to Sanitas threatening the government with a strike. This was a way to put muscle into the union’s demands for wage increases for all healthcare employees, the adoption of a wage bill negotiated with the Ministry of Health, and the signing of a sectoral collective agreement (Ionescu 2023). Wanting to defuse the matter in an atmosphere of labor unrest involving a weeks-long strike in the education sector, the government rapidly agreed to raise the salaries of auxiliary healthcare workers (Bechir 2023).

While the healthcare system in Romania has undergone extensive commodification in the post-socialist period, worker and citizen activism has managed to mount resistance to it. This activism has been expressed in street protests (such as the ones organized in 2012), social movements (like the 2013 Roșia Montană movement), and trade union protests (most notably in 2010, 2013, and 2016). The tactics of the trade unions have at times included forming larger coalitions with other unions and professional organizations and establishing connections across Europe. Without question, this worker and citizen activism has had an impact. Street protests brought down several governments and occasionally even changed the pace and extent of commodification of healthcare reforms. In turn, the actions initiated by trade unions helped to produce notable wage increases in the sector. However, the effects of this activism have been limited. With significant protest energy being channeled by Romania’s educated class into the issue of corruption, trade union appeals to also consider the material underpinning of the common good of public services have echoed faintly within this class and Romania’s governments.

Health and Citizenship After 35 Years of Post-Socialist Change

What landscape does Romania offer, after 35 years of post-socialist transformations, for its population’s attainment of a living wage and a more balanced distribution of income, health outcomes, and health services? In 2021 the risk of poverty or social exclusion still encroached upon about a third of the population, but this figure was lower than a decade earlier, and the gap between it and the EU average had grown smaller (Eurostat 2023a). Yet, significant inequality remained or even worsened. While in 2021 the risk of poverty or social exclusion in urban areas stood at 16.1% (Eurostat 2023a), the figure for rural areas was a stunning 50.1%, demonstrating a sharper discrepancy than just six years earlier (Eurostat 2023a). Income inequality also persisted, in that same year Romania maintaining the highest rate in the EU (Eurostat 2023a).

Although the Covid-19 pandemic put a brake on travel globally, labor migration from Romania continued, acute evidence of the important role its citizens play in performing work essential to Western European economies (Cosma et al. 2020). This trend, in addition to a significant drop in natality since 1989 (World Bank 2023), has contributed to the aging of Romania’s population and its decline from 23.2 million in 1990 to 19.5 million in 2022, with especially steep drops occurring in some of the country’s poorer regions (Andrei 2023).

Romania’s low wage levels and elevated levels of precarity and income inequality form the background for its high rates of unhealthy coping behaviors, and ultimately its overall low health outcomes (Wilkinson and Pickett 2009). Indeed, Romania rates second highest—at 36% versus an EU average of 19%—in the proportion of adults who report heavy episodic drinking (OECD/European Union 2022: 115). It also has the highest proportion of adults in the EU who consume no fruits or vegetables in their daily diets (74% versus an EU average of 33%) and who state they engage in no physical activity (86% versus 48% for the EU), both playing central roles in 59% of adults suffering overweight or obesity, versus an EU average of 53% (OECD/European Union 2022: 119, 121, 123). No wonder therefore that Romania’s life expectancy, 75.6 years in 2019, was nearly six years behind the EU average for that year (81.3 years) despite a four-year increase since 2000 (Eurostat 2023a). The relatively high excess mortality in Romania due to the Covid-19 pandemic (OECD/European Union 2022: 93) only widened the life expectancy gap between it and the EU—in 2021, the average was 72.9 years in Romania while for the EU it was 80.1 years (Eurostat 2023a).

Furthermore, although healthy life expectancy has increased nearly every year since at least 2012, by 2019 the number, which sat at 60.2 years, still lagged the EU average by four years (Eurostat 2023a). Diseases of the circulatory system contribute particularly heavily to this difference, the resulting mortality (circa 800 per 100,000 people in 2019) being the second highest in the EU and twice the EU average (OECD/European Union 2022: 95). Additionally, in that same year, Romania exhibited the highest rate of mortality from preventable causes in general, and the third highest from treatable causes in comparison to other EU member states (OECD/European Union 2022: 14).

While Romania’s population is sicker than that of most EU member states and therefore has greater need for healthcare, at the start of the 2020s its health services landscape was patchy. In 2020, Romania’s health expenditure rose above 6% of its GDP, yet this was still far from the 10.9% EU average (Eurostat 2023a). This meant that Romania had the lowest health expenditure per capita in the EU (at 1428 Euro PPP, less than half the EU average) (OECD/European Union 2022: 129). Romania’s healthcare system lacks sufficient technological capacity. In 2019, the country had the lowest rates of CT, MRI, and PET exams per 1,000 population in the whole EU (over four times lower than the EU average), the lowest rate of mammography screenings among women (over six times lower than the EU average), and among the lowest for cervical cancer and colorectal cancer screening (OECD/European Union 2022: 161, 163, 189).

The austerity period’s assault on the public health system led healthcare provision to shift even more toward the private sector. In 2021, the share of private units in total units of each category rose to 95% for specialized medical centers, 99.8% for dental practices, 73% for specialized outpatient units, and 31.4% for hospitals (Tempo Online 2023). Significantly, the now larger private hospital sector provided only 7.3% of the total number of hospital beds in the country (Tempo Online 2023), showing that public hospitals continue to play the backstop role, with private ones skimming patients off for a profit. With most family medicine and GP practices now private but contracting their services with the CNAS, primary care provision is disproportionately concentrated in urban centers. At the start of the 2020s, only around 35% of all family physicians were based in rural areas (INS 2021: 19) although 46% of Romania’s population lived there. At the opposite pole, large and medium-sized cities attracted not only primary but also secondary and tertiary care providers and offered the higher wages patients might need for (co)payments.

As a result, access is also uneven. In 2020, an estimated 11% of the population was not insured, and therefore had access only to the minimum services package (OECD/European Union 2022: 173). The uninsured were mostly among Romania’s out-migrants, those in informal employment, the unemployed, and people from marginalized groups who lacked identity cards, such as Roma communities. Even among the insured, care might sometimes not be (sufficiently) available. In 2020, 328 communes (representing 10% of Romania’s 3,181 localities and covering 2.5% of its total population) had no family physician, and another 1,414 communes, towns, or cities (or 44% of all localities) had a deficit of one or more doctors (Petrencic 2020). The rise of co-payments and private healthcare has led to out-of-pocket payments constituting a significant part of total healthcare spending, reaching 18.9% in 2019, above the EU average of 15.4% (OECD 2021: 14). Consequently, while the proportion of the population reporting unmet medical care needs declined during the 2010s to levels closer to the EU average, the gap between people in the lowest and the highest income quintiles increased from a ratio of 3.1 in 2011 to 5 in 2022 (our calculations based on Eurostat 2023a).

Conclusion

This chapter has shown that Romania’s post-socialist neoliberal and dependent development pathway has been accompanied by a citizenship model predicated on low wages, precarious living and working conditions, reduced labor protection, rising inequalities, and insufficient support for social reproduction because of constricted social benefits and public services. Unsurprisingly, given the tight link between income inequality and social and health problems (Wilkinson and Pickett 2009), all these factors have contributed to an inordinate disease burden weighing upon Romania’s population, which has compressed its life expectancy despite recent economic expansion and growth in minimum wages. Consequently, Romania presently harbors a generally unhealthy citizenry, making access to health services ever more imperative. Despite this higher need, the gradual yet sustained commodification of its public health services since the 1990s has produced geographical disparities in the provision of services and marked inequalities along spatial and class lines in access to them.

Thirty-five years of post-socialist transformations have brought about an unequal and unhealthy citizenry substantially dispossessed of the social rights to a living wage and comprehensive and universal access to public health services. While the Covid-19 pandemic suspended austerity policies and Romania’s EU-backed National Recovery and Resilience Plan (NRRP) has committed its government to greater investment in healthcare, the commodification of health services carries on. Indeed, the funds are not earmarked for improving the public redistributive dimension of Romania’s healthcare and could therefore constitute yet another avenue for siphoning public revenue into private hands.

If this dispossession continues, Romania’s educated classes and its governments should take heed. Not only does it wear away at the health of the population, potentially stifling productivity, but it also makes populist fixes appealing, hardly a negligible matter given crucial elections in 2024. As Marshall (1950) concluded, offering collective rights to citizens—including healthcare—is essential to the lifeblood of a democratic state.