Romania Case Study – Increasing Access to Reproductive Health Services and Supplies by Getting the Incentives Right

December 8th, 2016 | Viewpoint


Like many Eastern European countries in the early 1990s, Romania had a history of low contraception use and a high rate of abortion. A decade of fitful reform yielded modest improvements. Starting in 1999, progress accelerated dramatically thanks to a number of critical and complementary interventions; a national health insurance scheme, the privatization of health providers, extensive policy change, training to enable more providers to offer family planning services, and a heavy focus on rural access. The interventions also built public demand for modern contraceptives, and changed how contraceptives were supplied in both public clinics and in private pharmacies.

Between 1999 and 2004, Romania showed a significant increase in contraceptive prevalence rate (CPR) among women of reproductive age in union, from 29.5 percent in 1999 to 38.2 percent in 20041. The change in CPR was particularly dramatic in rural areas, with an increase of over 12 percentage points (20.9% to 33.0%) in the same period. This coincided with a decrease in the total abortion rate (number of abortions a woman would have during her lifetime), and a reduction of 36.8 percent in abortion-related maternal mortality.

Figure 1: Trends in Contraceptive Prevalence Rate, Total Fertility Rate, and Total Abortion Rate among Women in Union, 15–44 years (Romania Reproductive Health Survey 1993, 1999, 2004)

One of the drivers of this success was the right mix of expanding access to contraceptive services and supplies—especially in rural areas—and incentivizing providers to offer high quality services. Reproductive health services were expanded beyond the narrow purview of gynecologists to include general practice physicians (GPs), who received training. Health reforms encourage GPs to contract with the National Health Insurance House (NHIH) to provide a package of preventive health services under a flat capitation fee. Private providers leased public clinics in rural areas, and were paid by the NHIH based on their client enrollment. Contraceptive services were additional; providers received a fee for service paid by the NHIH for each client they served. Because clients were allowed their choice of providers and could enroll in any clinic, providers were rewarded for the quality of their services by attracting and retaining clients. For family planning, quality of services included not only appropriate counseling and screening by the physician, but also availability of a range of modern contraceptive methods, which were provided free to low-income clients.

Figure 2: National Coverage with Trained Family Planning Providers, December 2005 Compared to September 2001 (baseline)

Getting these incentives right, and expanding access to reproductive health services in rural areas and disadvantaged communities including the Roma and among youth, yielded remarkable changes in contraceptive prevalence and reduction in abortion in just five years.

Romania’s success in increasing access to and use of modern contraceptives and  lowering the rate of abortion has continued; by 2013, modern CPR in rural areas had reached 54 percent, and the abortion rate has continued to decline.

Figure 3: Relation between Modern Contraception (rural) and Abortion Rate in Romania2


Part One: To Achieve Universal Health Coverage, Get the Incentives Right

1 Gasco, Merce, Christopher Wright, Magdalena Pătruleasa, and Diane Hedgecock. 2006. Romania: Scaling Up Integrated Family Planning Services: A Case Study. Arlington, Va.: DELIVER, for the U.S. Agency for International Development.
2 Gasco, Merce. 2016. “Family Planning in Romania: An update after 6 years of donors’ withdrawal.” Presented at the 2016 International Conference on Family Planning in Bali.

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