It is getting dark as I am rushing to my 6 pm appointment for an interview with Dr Ionescu, a family doctor practising in a north-western Romanian city for almost twenty years. His medical office is located on the ground floor of a one-story building, integral part of the neighbourhood of apartment buildings developed towards the end of the 1960s to meet the healthcare needs of neighbourhood residents. Approaching the entrance to ring the bell, I notice five people are waiting inside: a couple with their toddler, a man whom I deem to be much older, maybe already retired, and another man in his late twenties. Being closer to the door, the man opens it, I get in, we all say hello, and they confirm that they are queuing to see the doctor on-call at the out-of-hours primary care centre (centru de permanență). The receptionist then enters the lobby from the other hallway to tell me that Dr Ionescu can see me shortly, following his last consultation for the day. As I sit on the long bench in the hallway, I look both ways and count the doors to the other medical offices in this wing of the building (“there are 6!”), but then I stand up to skim the many pieces of paper on the wall by the doors: the daily schedule for the family doctor office, the monthly schedule with shifts at the out-of-hours centre, a poster on how to wash your hands correctly, another poster promoting vaccination, many folded A4 pages containing the patients’ rights. Few minutes pass, and I am let in an office adjoining the examination room. Dr Ionescu joins immediately after, we cover introductions and informed consent with due diligence, and then he starts by recounting how this OOH-PC centre opened twelve years ago. As he and a colleague already had their family medicine practices operating there, meeting the criteria to provide continuity of care in an OOH-PC centre for their patients was not a particularly difficult task. They were joined by four other physicians and their nurses, and so six medical teams, comprised of a physician and a nurse, could cover the monthly night shifts at the centre.

Although they have had no interruptions in providing on-call primary care every night, adapting to changing policy throughout the period to keep the centre open proved daunting at times. Last year, he had to pick up extra on-call shifts, as much as ten per month at some point, to prevent the centre from closing until they managed to find another physician to complete the team. It took over half a year, many ads on physician social media groups, and increased workloads for everyone. This challenge, he insisted, might be surprising given the location of the out-of-hours centre in one of Romania’s cities with the highest density of physicians per resident population, a city that also prides itself on its healthcare infrastructure. “The number of medicine graduates choosing a residency in family medicine has decreased a lot, and some 600 of existing [family] doctors retire per year. About 300 enrol in the residency, half of what is needed, and of these not all finish, many choosing another specialty during their residency. So the numbers are pretty grim on that side.” Then he adds: “From the start, we have no new colleagues, there are few who begin practicing and the rest are overworked. I believe the situation is even grimmer in rural areas.”

Dr Pall confirms it. She is a general practitioner who started to work in the late 1980s. Even back then, she used to take on-call shifts at a hospital in a village forty kilometres away from the city. Dr Pall coordinates the only OOH-PC centre in the rural areas of the same county, formerly located in a derelict hospital building. It is now operational in a nearby facility recently built by the village council. She is already past retirement age and has considered to stop working both in the family medicine practice and taking on-call shifts in the out-of-hours centre. However, for the time being, she has decided to keep her practice open since she could also cover here the healthcare needs of patients from a neighbouring village, on the list of another colleague who retired, leaving the residents with no primary care services.

With a stationary trend of expenditure from the social insurance scheme during the past decade (Radu et al., 2022), primary care in Romania faces numerous challenges in reaching its widest scope of providing universal health coverage. There are notable difficulties of accessibility and coverage, especially in rural areas and for different population groups that make continuity of care almost impossible (Rotar Pavlič et al., 2015; RO Ombudsman, 2021; OECD, 2021; MoH, 2022). Significant health workforce shortages have amplified during the past years, with the ageing of active physicians, outmigration, and inconsistent measures to compensate for the imminent retirement of an important share of family doctors. What are the challenges to providing out-of-hours primary care and how do the pressing issues of health workforce deficits, overburdened family physicians, and inconsistent financing for primary care shape existing disparities in coverage and healthcare access? What are the systemic causes pertaining to the existing organisational model that impede improved coverage with and accessibility of these primary care services?

The provision of medical services in out-of-hours primary care centres, outside the usual office hours of family physicians, at the end of the week, and during public holidays has received little attention in Romania. Out-of-hours primary care poses a double problem. First, as a public health issue or a service provided within the health system, out-of-hours primary care is little known apart from sparse and fragmented information. Except for the obvious examples of patients who have used the services of OOH-PC centres in different rural and urban settings when feeling sick, the awareness of the general population is limited. Local health authorities have seldom acted to systematically promote these primary care services among potential patients. The patients’ lack of awareness matches and reflects the disregard for the fragmentation of out-of-hours primary care within the health system.

Secondly, as a research topic, knowledge on OOH-PC is also limited. Data on its provision and delivery is fragmented because of year-to-year inconsistent reporting to the Romanian health authorities. The annual report of the National Health Insurance Fund for 2021 (NHIF, 2022) does not include data on OOH-PC centres, even though the previous one included financial data limited to total allocations for out-of-hours care. County-to-county data availability mostly depends on the diligence of county-level health authorities. Apart from synthetic mentions of after-hours medical services in primary care (Vlădescu et al., 2008; Scîntee & Vlădescu, 2012; Vlădescu et al., 2016; Coman et al., 2022), there have been few studies focussing specifically on the delivery of OOH-PC in Romania. An exception is a study describing the health professionals’ perspective on the activity of OOH-PC centres located in Brașov County (Lăcătuș, 2021), which acknowledges patients’ lack of information about these centres and highlights gaps in systematic data on the provision of after-hours primary care in Romania.

An exploration of out-of-hours primary care, my account here joins other attempts (Lăcătuș, 2021) at building a basis for more comprehensive research of after-hours primary care in Romania. I set out to investigate OOH-PC through a health policy and systems research (HPSR) lens (Closser et al., 2022), which accounts for the interactions between the different pillars of health systems (WHO, 2018), locating out-of-hours primary care in the wider context of the changing health system. I focus on key issues pertaining to service delivery, health workforce, financing, governance, and their interactions, as they unfold in the day-to-day delivery of after-hours primary care. This account first describes the organisation of primary care within the Romanian health system and further provides a mapping of operational out-of-hours centres in the country to highlight territorial inequalities in coverage and the resulting disparities in access.

Formerly organised according to the Semashko model where healthcare is free for all, the Romanian healthcare system underwent structural changes during the mid-1990s. General practitioners providing primary care turned from employees of the state into private practices of family medicine, and mandatory health insurance was introduced to finance healthcare. At the time, ensuring continuity of primary care was a compulsory provision in physicians’ contracts with the county-level Health Insurance Fund, in the form of 24-hour availability  patients on the lists of family doctors faced urgent issues. However, the transformation of primary care occasioned by these reforms provided no impetus to create networks of physicians that could have enabled a more effective delivery of primary care out-of-hours (Vlădescu et al., 2008). Assessing initial pilot projects to transform primary care, Vlădescu and colleagues underscore that encouraging group practices to pool the use of equipment and administrative assistance would have enabled improved coverage during out-of-hours.

Out-of-hours primary care centres were only established in the mid-2000s, as distinct entities in the health system to provide continuity of care, though lacking formal legal entity status, under the framework Law no. 263 of June 16, 2004. Under an association agreement (convenție de asociere) between two family doctors, either as an individual practice or a limited liability company (LLC), physicians can provide on-call night care if they meet certain criteria pertaining to premises, medical staff (number of physicians and nurses), medical equipment and devices. Following a positive assessment carried out by County Public Health Directorates (CPHD), the association agreements are granted a permit for operation (aviz de înființare), and physicians can start providing care in out-of-hours centres (centre de permanență). Compared with models in place in other countries, OOH-PC centres are not legal entities in the health system, and family physicians are not legally expected to provide care outside working hours.

There is only one organisational model for out-of-hours primary care provision: physicians and nurses cover shifts on a rota system to deliver care 24/7. The medical team is comprised of a physician (GP or family doctor) and a nurse, who provide primary care services in out-of-hours centres, mostly through face-to-face consultations. To cover for a month of providing care in such a centre, a minimum of seven physicians and seven nurses is required, with some exceptions for rural and isolated areas where the threshold is lowered to a minimum of five, given the health worker shortage. In terms of service accessibility, anyone facing an ailment can turn to OOH-PC centres, regardless of insurance status or registration on the physician’s list. In other words, OOH-PCCs operate on-call to ensure care in the event of non-life-threatening health problems during the hours when patients cannot see their family physicians. Services are free, and patient access is not conditioned by referral at presentation. However, if there is no OOH-PC centre in an area, no alternative arrangement is provided by the health system, but for the patient to rely on emergency services, postpone care until the next day, or self-care at home.

In an OOH-PC centre, the medical team can provide urgent/minor emergency services for acute and subacute conditions, as well as the exacerbation of chronic conditions, administer certain (basic) treatments, issue prescriptions, provide telephone advice or consultation, refer patients to other specialties, and transfer patients to emergency units, if necessary. In 2022, COVID-19 testing and vaccination against the SARS-COV-2 virus were added to the list of OOH-CP services. Within the health system, apart from ensuring the continuity of care outside the family doctors’ daily schedule, a secondary role of the on-call program provided in OOH-CP centres is relieving the emergency units of minor emergencies.

OOH-PC services are financed through direct payments. Individual practices or family medicine LLCs settle contracts with the County Health Insurance Fund (CHIF) for out-of-hours services. Physicians and nurses are paid standard hourly rates (gross 40 lei and 20 to 22 lei, respectively), and there is no per service payment, lest capitation, as in the case of family medicine for regular care. Physicians receive an additional 50 percent of their rates for utilities, but only if the facility where the centre operates is privately held, and not owned by local authorities. Each OOH-PC centre has a coordinating physician covering the OOH-PCC’s administrative duties (monthly scheduling; reporting), who nevertheless has no formal managerial or medical authority over the others practicing in the centre, except for cases where physicians doing shifts are employed in a practice owned by the coordinating physician. The coordinating role comes with a 15 percent increase to the standard hourly rate. Every practice or LLT under contract for OOH-PC services receives an additional 4 lei/hour of working after- hours to cover for the medical supplies used during on-call shifts. Nurses have no contractual relation with the CHIH, but settle contracts with either the physicians’ practices or the LLTs. Through its county-level funds, the NHIF reimburses services delivered by physicians in all the OOH-PCs operating in a given county. According to the latest NHIF annual report, total allocations to OOH-PCCs amounted to 123.771 thousand lei, representing direct transfers from the budget of the Ministry of Health (not from the health insurance fund).

After the adoption of regulations on the operating of OOH-PC centres, in the early 2010s^[1], there were 192 operational centres in rural and urban areas in 2012 (Vlădescu et al., 2016). Later, some improvements in funding^[2] led to an increase in their number, thus 379 centres were operational in 2018 (Scînteie & Vlădescu, 2023). For 2020, a number of 381 OOH-PC centres was reported, servicing a total number of 1,159,429 patients (NHIH, 2021). Last year, new criteria for the establishment and operation of OOH-PC centres in areas with a deficit in rural medical services coverage were adopted.^[3] These new regulations also brought about the closure of some OOH-PC centres in several counties during 2022. It is unclear whether these decisions were based on any assessments of local healthcare needs. Acknowledging the workforce deficit in rural/isolated areas, the mandatory minimum number of health workers was set to five,  along with the patient thresholds for operation, but only for specific isolated regions^[4]. However, no incentives were provided to support the opening of new OOH-PC centres in poorly covered areas; and per hour payments of health workers were not increased.

Official reports provide disparate data on the provision of primary healthcare by OOH-PC centres, and the available secondary data are also inconsistent. Based on secondary analysis of public health institutions’ reports containing data on the delivery of medical services that were available online, I created a database to map the territorial distribution of OOH-PC centres in the country.

Figure 1. Distribution of OOH-Cs in Romania, as of April, 2023

As of April 2023, there were 349 OOH-PCCs, the number per county ranging from 0 in Prahova to 32 in Bihor County. In over half of the counties there are under six centres per county. 68.5% of them being located in rural areas. Compared to data available for 2020, their number decreased by 9.17%, from 381 to 349. The county where the highest number of OOH-PCCs closed due to the change in regulations is Timiș, the number of centres decreasing by more than half, from 47 to 23 centres in April 2023. On the other hand, four OOH-PCCs opened in Argeș and Iași counties respectively.

The mapping shows the unequal territorial distribution of OOH-PC centres, pointing to large county-to-county disparities in patient access brought about by the neoliberal transformation of the Romanian healthcare system (Stan & Toma, 2018). This initial exploration of after-hours care in Romania describes an organisational model for OOH-PC centres that is not only cumbersome, but also disheartening for family physicians and nurses otherwise potentially willing to provide care out-of-hours on low payments, thus compensating for health worker shortages. One part of the problem is clearly the family physician shortage in numerous areas of the country (Voicu et al, 2023; Petrovici et al, 2023), another one being the variation in county health governance generated by decentralising policies. Different levels of health governance, shaped by changes in the health system, contribute to long overdue discontinuities in providing easily accessible primary care after-hours, calling for more in-depth investigation.

We would like to thank Ioana Miruna Voiculescu for her useful proofreading and suggestions to ensure style consistency and improve readability across the texts published in English.