Financial Sustainability Of Public Hospitals. Alternative financing models and operational cost efficiency

Abstract

BACKGROUND: The financial sustainability of public hospitals represents
one of the most pressing challenges facing the Romanian healthcare system.
Romania allocates approximately 6.0–6.3% of gross domestic product to
healthcare, compared to a European Union average of 10.9%, generating a
recurring cycle of structural underfunding: undersized weighted case tariffs,
supplier arrears, depreciated infrastructure, and large-scale emigration of
qualified staff.
METHODS: This article is based on a 97-page scientific work consisting of
a mixed-methods integrated study combining a scoping review of international
literature (Preferred Reporting Items for Systematic reviews - extension for
Scoping Reviews) with a comparative panel analysis based on official secondary
data. The sample comprises five County Emergency Clinical Hospitals: Bihor/
Oradea, Cluj-Napoca, Târgu Mureș, Constanța and Iași/Saint Spiridon, for the
period 2022–2024. Data sources include annual hospital activity reports, Joint
Order of the Ministry of Health and National Health Insurance House no.
1018/528/2025 (Annex 23A - data on diagnosis-related groups), NHIH and
National Institute of Statistics reports, and international references from the
OECD and ECDC.
RESULTS: The share of personnel expenditure increased from 58–64% in
2022 to 65–67% in 2024, approaching the critical threshold of 70%. The case mix
index ranges from 1.57 (CECH Constanța) to 2.25 (CECH Târgu Mureș), without
corresponding tariff adjustment. The weighted case tariff of CECH Bihor (1,854
lei in 2024) is 13.5% below the sample average. CECH Cluj-Napoca demonstrates
that operational efficiency and clinical quality can coexist: in-hospital mortality of
1.78%, patient satisfaction of 97.96%, and a case mix index of 2.22 in 2024.
CONCLUSIONS: Structural underfunding - not managerial inefficiency -
is the primary cause of the sustainability crisis. Centralised procurement
(estimated savings 20–35%), DRG tariff reform, and energy performance
contracts (energy savings 30–50%) are the interventions with the highest
composite impact–speed–feasibility score. The paper proposes the Trifocal
Financial Sustainability Model and a decision matrix with 13 recommendations
addressed to national policymakers, supervisory authorities, and hospital
management.