ANALYSIS OF THE ROMANIAN HEALTH SYSTEM FROM THE PERSPECTIVE OF THE NUMBER OF HOSPITALS

: The paper presents aspects about the indicators related to the health system in Romania. The indicators considered were: the number of hospitals by type of ownership (public and private) and by development regions of Romania, time evolution (for period 1990-2021) followed by the detailed analysis on the year 2021 of the healthcare staff, represented by the number of physicians (dentists excluded), and of the resident population at January 1 st 2021. The data used for the analysis was obtained from the National Institute of Statistics. From the results of the research, it is worth noting the division into three large categories of areas according to the number of hospitals, respectively: the developed area, the partly developed area and the undeveloped area.


Introduction
Romania, like other developing EU countries, has many areas related to health that still need to be improved (Todor et al., 2021).A recent study shows that the evolution and performance of health systems are technology and digitally dependent ideals (Tudor et al., 2022).However, in order to be able to implement the technological part and develop the system, infrastructure is needed in the first phase.And the infrastructure refers to the number of hospitals and the proximity to the patient.At the same time, in the case of Romania, health policies and, therefore, the quality and quantity of medical services have registered major changes (Cigu and Cigu, 2022).There are other studies that have focused on a certain field of medicine and that have showed that there is a shortage of hospitals in Romania.According to one of the research studies, "in the country, there are only four intervention centres involved in the Acute Myocardial Infarction program for localities with a population of 2,500,000 people.Only one of them, the Institute of Cardiology, is public, the other three are private centres.New public centres should be built involving prestigious specialists in the field."(Simionescu, 2019).
Starting from these data, the present study aimed to make an analysis of the health system in Romania by assessing the number of hospitals, which will highlight the major deficiencies of the health system in the country.Comparing the data on the number of hospitals per population and per number of Physicians, the strong need to pay attention to this extremely important and vital system will be demonstrated, in a clear way.

Methodology
This study uses official information from the All these statistical data are presented in the following analysis, using tables and graphic representations made by the authors to enhance understanding and facilitate follow-up and evaluation.

Results and discussion
Table 1 shows the evolution of the number of hospitals in Romania over time, for the total number and for the types of ownership (public and private).Overall, from the evolution of the recorded data, the positive evolution of the number of hospitals can be observed for the period 1990-2021.However, there were also short periods when the number of hospitals decreased year-on-year, such as: 1993 recorded 433 hospitals, and the following year (1994) only 415.The sharpest decrease was recorded in 2017, when there was a drop from 576 (the maximum number recorded for the entire period analysed) to 515 in 2018.Then a period of recovery and growth followed again, reaching 535 in 2021.
The analysis of the data recorded for the privately owned hospitals shows that, in the first period (1990)(1991)(1992)(1993)(1994)(1995)(1996)(1997), there were no such hospitals in Romania.Then, for the period 1998-2021, this number increased constantly year-on-year, from 2 private units in 1998, to 168 private units in 2021.Most probably, this phenomenon will not stop here, as it can be seen there is a high demand for private healthcare services in the market (Marin-Pantelescu and Hint, 2020).
Studies show that the reasons why Romanians choose private hospitals instead of public ones range from better conditions, quality of services offered, high performance equipment, consultations, treatments and intervention facilities, to the professional staff (Romania Journal, 2022).
The number of public hospitals has fluctuated over the recorded period, the main reason being the updating of regulations and legislation, which has had direct and immediate consequences on the medical system in Romania (Ministry of Health, 2010).
Up to this point, the study presented the analysis of the number of hospitals in Romania, by types of ownership.However, their sum is not so easy to analyse, which is why the paper continues with the presentation of the number of hospitals by counties for the year 2021.As it can be observed in Table 2, for the year 2021, in Romania, the county with the most hospitals is Bucharest, the capital and largest city of Romania."It is described as the cultural, financial, entertainment, and media centre in the country with a significant influence in Eastern and South-Eastern Europe as well" (Wikipedia, 2023).As it can be observed, Bucharest, the capital, had 76 hospitals in 2021, of which 50 are public and 26 private.
The capital is followed by Cluj with 36 hospitals (19 public and 17 private), where there is an almost equal percentage between the two forms of ownership, Iasi with 29 hospitals (19 public and 10 private), Prahova with 25 (15 public and 10 private) and Brasov with 24 hospitals (13 public and 11 private), where an almost equal balance can be noticed between public and private hospitals.On the opposite side, Covasna, Botoșani, Dâmbovița, Ialomița and Mehedinți counties have only 4 hospitals each.It is interesting that there are no private hospitals in these regions.
In order to highlight the counties where the most hospitals are located, the graphic representation (Figure 1) of the total number of hospitals, per counties, in Romania, in the year 2021, was performed.The graphical representation, marked with dark blue, shows the areas from Romania with the highest concentration of hospitals, while the lightest green shows the areas with the fewest hospitals (Covasna, Botoșani, Dâmbovița, Ialomița and Mehedinți counties).
For a more impactful image of the health system in Romania, the number of hospitals, physicians (dentists excluded) and resident population are then presented by development region for the same year analysed.Dark blue shows the areas where there is a large number of hospitals, while light green shows the region with the fewest hospitals (West Region).In the end, the analysis carried out succeeded in dividing Romania's development regions, according to the number of hospitals in 2021, into 3 categories:  The developed area according to the number of hospitals where the regions are included: Bucharest-Ilfov and North-West;  The partly developed area according to the number of hospitals where the regions are included: North-East, Center and South -Muntenia;  The undeveloped area according to the number of hospitals where the regions are included: South-East, South-West-Oltenia and West.

Conclusions
The paper analyses the Romanian health system from the perspective of the number of hospitals.For this analysis, data from the Tempo database of the National Institute of Statistics were used.As it appears from the study, there is a positive evolution of the number of hospitals for the period 1990-2021.However, there were also short periods in which the number of hospitals decreased from one year to another.The sharpest decrease was recorded in 2017, when there was a drop from 576 hospitals (the maximum number recorded for the entire analysed period) to 515 in 2018.Then a period of recovery and growth followed again, reaching 535 in 2021.
According to the division by counties, for the year 2021, the most hospitals in Romania are located in Bucharest, which is the capital of the country and where 76 hospitals can be found (50 public and 26 private).The capital is followed by Cluj (36 hospitals), Iasi (29 hospitals), Prahova (25) and Brasov (24 hospitals).The smallest number of hospitals are located in: Covasna, Botosani, Dambovita, Ialomita and Mehedinti -areas where there is no private hospital.
A division of the development regions of Romania was carried out, depending on the number of hospitals in: Developed areas, Parlty developed areas and Undeveloped areas according to the number of hospitals.
In conclusion, there is a lack of new hospitals development in Romania.This is evident from the campaigns among politicians who promote the construction of new hospitals in the country (Sittings of the Chamber of Deputies of April 20, 2022).Unfortunately, there have been no state-built hospitals in recent years, and furtermore, their number is decreasing every year.However, there is also an example of good practice in this field of hospitals in Romania.The NGO "Dăruiește Viață", which is building the First National Children's Hospital for Cancer, Severe Illnesses and Trauma exclusively from donations (Dăruiește Viață, 2023).
Following the study carried out and based on the results obtained, the conclusion is that the Romanian Ministry of Health should take immediate measures; in the same way, the whole political class should support more actions in the field of health in Romania, primarily by creating and developing the necessary infrastructure.

Fig. 1 .
Fig. 1.Image of graphic representation of hospitals in Romania on the map, in 2021 by counties Source: Made by the authors with Datawrapper based on data provided by the National Institute of Statistics http://statistici.insse.ro/(accessed on April 2, 2023)

Fig. 2 .
Fig. 2. Image of graphic representation of hospitals in Romania on the map, in 2021 by development regions Tempo database of the National Institute of Statistics.A series of indicators are considered:  The number of hospitals in Romania in the period 1990-2021, by type of ownership;  The number of hospitals in Romania by type of ownership and counties for the year 2021;  The number of hospitals by development regions of Romania for the year 2021;  The number of physicians (dentists excluded) by development regions of Romania for the year 2021;  The number of resident persons on January 1, for the year 2021, by development regions of the country.According to the specifications mentioned by the National Institute of Statistics, the following limitations of the terms are mentioned: procedures of modern medicine.Physicians plan, supervise and assess the implementation of care and treatment plans by other health care services providers, coordinate the medical training and research activities.-In Romania the dentist profession is exercised by natural persons holding an official qualification in dentistry, members of the College of Dentists of Romania.Monitoring and controlling the exercise of the dentist profession is done by the College of Dentists of Romania and the Ministry of Public Health" (Tempo, Healthcare staff, by categories, development regions and counties, 2023). Resident population -"usually resident population represents all persons of Romanian nationality, foreign or stateless who have their usual residence in Romania" (Tempo, Usually resident population at January 1 st 2021, 2023).

Table 1
The evolution of the number of hospitals in Romania in the period 1990-2021, by types of ownership Source: Made by the authors based on data provided by the National Institute of Statistics http://statistici.insse.ro/(accessed on April 2, 2023)

Table 2
The record of the number of hospitals in Romania by ownership and counties for the year 2021 * the data are expressed in numbers Source: Made by the authors based on data provided by the National Institute of Statistics http://statistici.insse.ro/(accessed on April 2, 2023)

Table 3
Presentation of statistical data on the development regions of Romania for the number of hospitals, physicians (dentists excluded) and resident population for the year 2021