Annals of Dunarea de Jos University of Galati Fascicle I.

Economics and Applied Informatics Years XVII no2/2011 ISSN 1584-0409 www.ann.ugal.ro/eco

ChallengesofUsingCosteffectivenessAnalysis inRationalizingHealthCarePublicSpending
AncatefaniaSAVA
A R T I C L E I N F O A B S T R A C T

Articlehistory: Accepted1June2011 Availableonline30June2011 JELClassification I10,H51,D70,D61 Keywords: Healthcare,Publicspending, Prioritysetting,Costeffectiveness analysis

Theaimofthisstudyistoaddressthechallengesofusingcosteffectivenessanalysis(CEA)by decisionmakers in rationalizing health care public spending. Firstly, it presents a brief literaturereviewonthenecessityofusingcosteffectivenessanalysis.Also,thepaperfocuses on ways of measuring health outcomes and costs, analyzing the evolution of public expendituresonhealthcareafter1990inRomania,incomparisonwiththoseoftheEuropean MemberStates,inmonetaryterms,butalsoonthebasisofsomeinternalefficiencyindicators. Eveniftherearemanylimitationsconcerningtheimplementationofthisanalysisandmany studies labeled as CEAs in the healthcare literature often offer only partial program evaluation, basing only on resource costs, CEA is helpful and necessary in setting priorities whenchoicesmustbemadeinthefaceoflimitedresources. 2011EAI.Allrightsreserved.

1.Introduction Publicspendingonhealthcareisofmajorimportanceinimprovingthehealthofthepopulationandhas becomeaconstantlyrisingcomponentoftotalgovernmentspending.Increasingtheamountsofpublicfunds allocatedtohealthcaremustalsobecorrelatedwiththeeffectivenessoftheiruse. This paper underlines the implications of using costeffectiveness analysis in rationalizing health care publicspending.Thus,thepaperbeginswithareviewoftheliteraturethatadvocatesforusingthisanalysis in order to increase the effectiveness in public expenditure on health care and also highlights the main methodological barriers that may be encountered. The next paragraph looks on how to calculate the cost effectiveness ratio, insisting on defining outcomes and also on the indicators which measure health care expenditures(healthcarepublicspendingasapercentageofGDPandhealthcarepublicspendingpercapita). Intermsofpublicexpenditure,thepaperpresentsananalysisoftheirdynamicsfortheperiod19912010,at EuropeanUnionlevel,emphasizingthechangesduringthisperiod.Thelastparagraphaimsatananalysisof qualitativeindicatorsoftheRomanianhealthsystem,comparedtothesituationatEuropeanlevel,takinginto accountdataonhumanandtechnicalresourcesandinformationonhospitalpatientsandthetreatmentsthey receive. 2.Literaturereviewonthenecessityofusingcosteffectivenessanalysis Measuring effectiveness of health care programs funded with public money has become a concern for policy makers in recent years. As Elizabeth McGlynn [1, 19] noted, from the consumer perspective, health care decisionmaking is a multiattribute problem. Consumers do not take into account only cost and quality, but also other factors such as location, convenience, amenities, transportation, etc. In order to influencedecisionmaking,theremustbedevelopedweightsforthesethings.Itisalsoimportanttotakeinto accountthequalityimplicationsofmeasurement,whichincludesmeasuringtheeffectofqualityreportingon thesegmentofconsumerdecisionmaking. Musgrove[12]talksaboutatleastninedifferentcriteriarelevantfordecisionsaboutpublicspendingon healthcare,someofthemincludingeconomiccriteria,suchas:publicgoods,externalities,catastrophiccost and costeffectiveness; others ethical reasons, like: poverty, horizontal and vertical equity and the rule of rescue;andotherspoliticalconsiderations,asthedemandsbythepopulation. A technique which measures the incremental or marginal economic cost per unit of health care gained amongdifferentinterventionsforthesameconditionwithoutattemptingtomonetizethehealthcaregainis costeffectivenessanalysis.

DoctoralSchoolofEconomics,FacultyofEconomicsandBusinessAdministration,AlexandruIoanCuzaUniversity,Iai,Romania.Emailaddresses:sava.anca@yahoo.com(Anca StefaniaSava).

 Asitisknown,healthcareisnotapurepublicgood,becauseprivatepurchasersarewillingtopayforit,so thatcosteffectivenessshouldalsobeusedinordertochoosewhichserviceswithexternalitiesdeservetobe financedpublicly.Thus,publicfundsshouldfinancepublicandsemipublicgoodsthatarecosteffectiveand forwhichdemandisinadequate. Forthecatastrophiccost,whichcannotbepaidbysomeonewhoisnonpoor,thereisarequirementtobe financed publicly, as the populationcannotallow it, so that costeffectiveness needs to be separately taken intoaccount. Whereaspovertyisnotcorrelatedwithcostsoroutcomesofhealthcarethereseemstobenorelationship with costeffectiveness, even though are sometimes compatible criteria doing something to improve the healthofthepoorhasabetterthanaveragechanceofalsobeingcosteffective[12,12]. The difference between equity and effectiveness is achieved through horizontal and vertical equity criteria.Accordingtohorizontalequity,peoplewithequalhealthproblemsshouldreceiveequaltreatment.In thiscase,theonlyvariableisthecostofintervention.Whilethecostofinterventionisthesameornearlythe same for patients with similar problems, horizontal equity and costeffectiveness are perfectly compatible. Unlike, in the case of vertical equity, there are introduced two variables: the effectiveness of different treatments (meaning the improvement in health from an intervention) and the severity of different health problems(todomoreforthosewithworseproblems),whichmeansthatthecostismuchhigherthanforany otherintervention,sothatlesscosteffectiveness. The rule of rescue represents a choice for keeping a person alive for long enough, and in good enough health, based on a triage between those who survive through medical intervention, those who will die anywayandthoseinbetween.Intheseconditions,theeffectjustifiesthecost. Theproblemofprioritysettinginthefieldofhealthcarehasalsobeenrevealedinasurveymadeinfour countries(UnitedKingdom,Germany,UnitedStatesandIndia)byTheEconomist(2009),whichshowsthat health care is the second most important issue in terms of government priorities ahead of education, the environment,crime,defenseandhousing,whilethemostimportantissueswereeconomyandcreatingjobs. Bloom [2] conducted a direct survey with questions about healthcare (use of specific benefit/risk and benefit/costtechniques,resultsanddecisionoutcomes,plusotherbenefit,risk,andeconomicdata),for2001 2002,inFrance,Sweden,UnitedKingdom,andtheUnitedStates,andshowedthatanyformaleconomiccost effectiveness, cost benefit or cost utility analysis in whether to accept, pay for, or reject new interventions were used occasionally (only 51% of private payers used costeffectiveness analyses or costbenefit analyses). Also, the study shows that economic outcomes were rarely available when needed, and most decisionmakerswerenotknowledgeableenoughtoevaluatethequalityofmethodsanddataused.According tothestudysresults,tworespondentsfrom104notedthatSwedenwouldrequireformalbenefit/cost(like cost/qualityadjusted lifeyear) analyses, after acceptance based on benefit/risk, for all pharmaceuticals within the next 2 years (in 1975, Sweden became the first countryto make a public decision in healthcare based on formal economic evaluation in deciding to accept and pay for computerized axial tomography scans),whiletheUnitedKingdom,OntarioandAustraliaalreadyhavetheserequirements[2,332]. Also, National Business Group on Health expressed its position on a major increase in comparative effectivenessresearch,asitwillimprovequalityandleadto betterpatientoutcomes,patientswillbemore engaged and make more informed decisions about their health care, physicians and other health professionals will have better information to consider treatment options, will reduce unnecessary and duplicativecareandleadtomoreefficientcare,willhelpeliminatedisparities[14,23]. A focus group research among United Kingdom health authorities, conducted by Hoffman et al. [10], showed that decision makers generally recognized the usefulness and necessity of published economic evaluations in their decisionmaking processes. The negative points of the findings were related with the: generalizabilityofstudies(ifstudiesfromtheUnitedStatesevaluationsareapplicabletoaUnitedKingdom context),focusonnarrowquestions,theneedforaqualityscoringsystems(whichcanactasafilterandcan identifyhigh/lowqualitystudies)etc.Thestudyalsorevealsfactorsthatmightencouragedecisionmakersto make more use of economic evaluations: the appraisal of studies by a trusted source, the need for more flexibilityinhealthcarebudgetsandmoredetailedexplanationsofthepracticalrelevanceofstudysresults [10,72]. Theapplicabilityofstudiesintheprioritysettingprocessisaffectedbycertainmethodologicalbarriersto the use of costeffectiveness analysis [11]: differences between countries in health care infrastructure, defined as treatments and health care facilities, differences in the availability of certain technologies; incidence of disease (if it is higher, the immunization programs are more costeffective in populations); generalizability; perspective of the analysis; relative prices or costs; incentives to health care professionals andinstitutions;targetpopulation;uncertaintyaboutcostsandoutcomes;portfolioofprograms;timeliness and accessibility of findings. In what concerns costs and outcomes necessary for computing the cost effectivenessratio,thereareuncertaintiesaboutthetruenumericalvaluesoftheparametersusedintheratio andpossiblevaluesinotherpopulationsthantheonethestudyappliesto;thecorrectmethodforcombining theparametersofthemodel;thesubjectivejudgmentoftheanalyst.
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 As a conclusion of the above mentioned, costeffectiveness is considered an important tool in order to increase the effectiveness of using public spending on health care. Even if limited, the analysis attests the indisputablecontributionofthismethodindesigningaproject,inachievingimprovedresultscomparedwith projectsthatdonotimplementitandalso,provestobeausefulguideforpublicpoliciesaimedatprioritizing healthcarespending. 3.Methodology Ihaveuseddescriptivemethodsinordertopresentthechallengesofusingcosteffectivenessanalysisin rationalizing health care public spending. I have chosen to make comparisons between Romania and EuropeanUnionMemberStatesconcerningtheindicatorsthatmeasuretheoutcomesandpublicspendingon healthcare,highlightingtheeconomicandsocialdevelopmentdifferences.Thestatisticaldatausedwerethe oneprovidedbyEurostatdatabaseandtheRomanianStatisticalBreviary. 4.Challengescomputingcosteffectivenessratio 4.1.Measuringbenefitsofusinghealthcareservices Itisknownthatanincreaseinhealthspendinghasasdirectlybenefitimprovingthehealthofpopulation, but indirectly, it leads to economic benefits by reducing absenteeism from work, also it increases the economicproductivity,giventheextendofproductivelife,increasedlifeexpectancyandreducedpremature mortality.Eurostatoffersdataonstructuralindicatorsonhealth,suchas:healthylifeyearsinabsolutevalue at birth, life expectancy in absolute value at birth, healthy life years at 65 in percentage of the total life expectancyetc.Forexample,forfemales,in2008,healthylifeyearsinabsolutevalueatbirthrecordedthe highestvalueinMalta,71.9yearsandattheoppositewasSlovakia,with52.3years.ForRomania,thevalue was62.6years.Acosteffectivenessanalysisprovidesasingleratio,theincrementalcosteffectivenessratio thatreflectsthedifferenceinthecostsofinterventionsdividedbythedifferenceintheirhealtheffectiveness or clinical outcomes. According to the existing studies which apply costeffectiveness analysis, health outcomes are defined in various ways, such as cataracts removed, lifeyears gained, cases of diseases prevented, qualityadjusted lifeyears (QALYs), disabilityadjusted lifeyears (DALYs), healthyyears equivalents(atheoreticallysuperioralternativetoQALYs),improvedfunctionalstatusorqualityoflife.The measurerecommendedbythePanelonCostEffectivenessinHealthandMedicineishealthrelatedquality adjustedlifeyears(QALYs). Analternativemeasureonhowmuchayearoflifeisdiminishedifapersonsuffershealthlimitationsis thequalityadjustedlifeyear,whichassignsaweightranging from0,whichrepresentsdeathto1,meaning perfect health, corresponding to the patients quality of life, for each period. Qualityadjusted lifeyears provideacommoncurrencytoassessthebenefitsorburdensthatpatientsexperienceintermsofqualityand quantity of life. DALY represents the sum of the present value of future years of lifetime lost through prematuremortalityandthepresentvalueofyearsoffuturelifetime,adjustedfortheaverageseverityofany mentalorphysicaldisabilitycausedbydiseaseorinjury[11,27].Theconceptwasintroducedin1993bythe WorldHealthOrganizationandtheWorldBankandsincethenhasbeenusedfortworelatedpurposes[4,2]: tomeasuretheburdenofdisease,theextenttowhichprematuredeathsanddisabilitiescausealossofhealth statuscomparedtoeveryoneslivingtooldageingoodhealthandtheotheroneistocomparethevalueof health interventions that have multiple or different health outcomes occurring at different ages. Gaining a DALYthroughahealthinterventionreducestheburdenofdisease.UsingDALYsincosteffectivenessanalysis requires using relevant cohort life expectancies, a panel for population, state all the assumptions used to calculateit,presentarangeofDALYestimatesandalsototestthesensitivityofcosteffectivenessratiosto changesintheassumptionsusedtocalculateit[7,329]. Whenmeasuringcosteffectivenessanalysisinnaturalunits,itappearcertainlimitations,astheprograms compared must have the same objective, so that it does not offer any information about the importance of otherobjectiveoveranother. 4.2.Measuringhealthcareexpenditures Cost plays an important role in health care decisions, representing an important criterion if an intervention has merit. Health care systems everywhere are faced with the problem of limiting growth in spendingonhealthservices,whilstensuringthattheirpopulationhasaccesstoappropriatecare. In the health care sector, many studies based on data for both developed and developing countries showed that income is the major determinant of the populations health status, while health care public spending as a percentage of GDP, as well as the share of public outlays in total health care spending, are seldomsignificantfactorsinexplainingcrosscountrydifferentialsinhealthindicators[6].Studiescarriedout fordevelopedcountriessuggestthatthereisapositive,albeitweak,relationshipbetweenpublicspendingon health care and premature mortality, in a sample of OECD countries. Also, there are differences in costs between developed and developing countries, related with population ageing. Ageing increases the risk of chronic and degenerative diseases this is why healthcare systems will need to be adjusted to account for these factors. In less developed countries, it is talking about the socalled demographic bonus, a
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phenomenonwhichmeansthatpeoplewhogeneratetheincometopayformedicalcarewillincrease,evenas the number of elderly grows because of the drop in the number of children. For example, developing countriessuchasIndia,areexportingtheirdemographicbonustotherichworldthroughahugelevelofout migration,accordingtoDr.JulioFrenk,deanoftheHarvardSchoolofPublicHealth[15,14]. Ontheotherhand,indevelopedcountries,accordingtoOECD,inthenextyearseconomicgrowthcouldbe cut by onethird because of changes related to ageing. At the same time, more people over 65 years mean morevotersover65years,whowillbeanxioustoprotectstateprovisionsfortheirretirementandcare. Itshouldbeidealthatcosteffectivenessanalysisincludedirectcosts(suchasdoctorsornursestimeand suppliesused)aswellasindirectcosts(suchasaportionof administrativecosts).Inwhatconcernsdirect cost,itincludesallcostsdirectlyrelatedtothehealthcareinterventionunderconsideration,directmedical costssuchcostsofdrugs,testsandproceduresandsalariesofnursesanddoctors,butalsodirectnonmedical costs such as cost of transportation of patients. On the other hand, indirect costs measure the impact of diseasesorconditionsonproductivity.Often,healtheconomistsusegrossearningstoestimateindirectcosts. Table1presentsthedynamicsofpublicexpenditureforhealthasapercentageofGDP,fortheperiod19912010.

Table1.DynamicsofpublicexpendituresforhealthasapercentageofGDPduring19912010

Countries/Time EU(27) EU(25) EU(15) Belgium Bulgaria CzechRepublic Denmark Germany Estonia Ireland Greece Spain France Italy Cyprus Latvia Lithuania Luxembourg Hungary Malta Netherlands Austria Poland Portugal Romania Slovenia Slovakia Finland Sweden UnitedKingdom 1991 : : : 5.8 : : 6.7 5.8 : : : : : 6,5 : : : 5.0 : : : : : : : : : 6.7 : 5.3 1995 : : 6.0 6.1 : 5.9 6.5 6.3 4.8 5.7 3.8 5.3 7.3 5.,3 2.4 3.4 : 4.9 5.8 3.9 3.7 7.7 : 5.4 2.4 : 5.1 6.2 6.2 5.5 1998 : : 6.0 6.2 2.9 5.8 6.4 6.1 4.4 5.4 3.9 5.2 7.2 5.6 2.7 4.1 : 4.8 5.2 4.6 3.8 8.3 : 6.0 2.6 : 5.4 5.8 6.2 5.4 2000 : : 6.0 6.3 3.6 5.7 6.6 6.2 4.3 5.5 3.9 5.2 7.1 6.0 2.6 3.9 4.1 4.1 4.9 4.9 3.7 8.2 : 6.2 4.2 6.4 5.2 5.7 6.1 5.7 2001 : : 6.2 6.5 2.5 6.0 6.8 6.3 4.1 6.1 4.6 5.1 7.2 6.3 2.9 3.2 4.7 4.8 4.8 5.1 3.9 6.9 : 6.5 4.1 6.6 4.9 5.9 6.5 5.9 2002 6.2 6.3 6.3 6.5 5.3 6.2 7.0 6.4 4.2 6.5 4.5 5.2 7.5 6.3 3.1 3.7 4.3 4.7 5.4 5.7 4.2 7.0 4.4 6.5 4.1 6.5 5.0 6.2 6.8 6.2 2003 6.4 6.4 6.5 7.0 5.9 6.4 7.1 6.5 4.1 6.7 4.7 5.2 7.8 6.3 3.4 3.4 4.3 4.8 5.7 6.0 4.4 7.4 4.3 6.7 3.5 6.5 6.5 6.5 7.0 6.3 2004 6.5 6.5 6.6 7.1 5.2 7.3 7.1 6.1 4.0 7.0 4.7 5.5 7.8 6.7 3.1 3.5 4.2 5.1 5.4 6.1 4.4 7.3 4.2 7.0 3.2 6.4 4.7 6.6 6.7 6.7 2005 6.6 6.6 6.7 7.1 5.4 7.2 7.2 6.2 4.1 6.7 4.9 5.7 7.9 6.9 3.1 4.3 4.9 5.2 5.6 6.4 4.4 7.4 4.4 7.2 3.4 6.3 4.8 6.9 6.7 6.9 2006 6.6 6.7 6.8 6.9 4.0 7.2 7.3 6.2 4.2 6.7 5.3 5.7 7.8 7.0 3.1 4.9 4.6 4.6 5.6 6.4 5.8 7.5 4.6 6.7 3.3 6.3 5.8 6.9 6.6 7.1 2007 6.6 6.6 6.7 6.9 4.1 7.1 7.5 6.1 4.4 7.0 5.4 5.7 7.8 6.8 2.9 4.3 4.6 4.4 4.9 5.8 5.9 7.6 4.5 6.6 3.7 5.9 6.4 6.6 6.6 7.1 2008 6.8 6.8 6.9 7.4 4.5 7.2 7.8 6.3 5.2 7.8 5.6 6.1 7.8 7.1 3.0 4.6 5.0 4.4 4.9 5.4 6.0 7.7 5.1 6.3 3.8 6.1 6.9 7.0 6.9 7.5 2009 : : : 8.0 4.4 8.0 8.8 6.9 5.6 8.9 6.0 6.7 8.3 7.5 3.3 4.7 5.6 5.0 : 5.5 : 8.2 : 7.1 4.4 6.8 7.8 8.0 7.4 8.5 2010 : : : : : : 8.4 : : : : : : : : : : : : : : : : : : : : : : :

Source:Eurostatdatabase

As shown in table 1, the dynamics of public health expenditure in GDP has not experienced significant changes during 19912010, the average for the European Union Member States remained around 6%. The shareofpublicspendingonhealthcarehasbeengrowingduring1990s,inperiodsoffiscalconsolidation. There are some differences from one European Member State to another, depending on the level of economic development, but also ontax reform policies of public authorities. In 2009, for countries such as Cyprus,Bulgaria,Romania,thelevelofpublicspendingforhealthcarewasatfairlylowlevels(3,34,4%of GDP),comparedto8.9%inIreland,8.8%inDenmark,8.5%intheUKor8.3%ofGDPinFrance. AccordingtoTheAgeingReportfrom2009oftheEuropeanCommission[5,28], publicexpendituresin the EU27 are projected to grow by 1.5 percentage points of GDP (to 8.2% of GDP in 2060), due to the combinedimpactofageing,potentialimprovementsinhealthstatusandtheeffectofchangesinthenational income.Forindividualcountries,theincreasesrangefromlessthanonepercentagepointsforcountriessuch asLatvia(0.6%ofGDP),Cyprus(0.6%ofGDP),Bulgaria(0.7%ofGDP)andSweden(0.8%ofGDP),tomore than3percentagepointsofGDPforMalta(3.3%ofGDP). Compared with the situation in Europe, in Romania weights are significantly smaller (table 1), EU27 averagein2008was6.8%ofGDP.SourcesforfinancingpublicexpenditureonhealthcareinRomaniaare: theNationalUniqueHealthInsuranceFund(themainsourceofhealthfinancinginRomania),Statebudget, nongovernmental expenses, foundations, etc., as well as external sources. The analysis conducted by the RomanianPresidentialCommissionin2008emphasizedthreemajorissuesconcerningthefinancingofthe
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health system in Romania: a very low level of resources allocated to health, insufficient sources and inappropriate ways of raising funds for health, arbitrary using and inefficient and inequitable allocation of resources[16]. Smaller size of the public financing of health care in Romania is confirmed by public expenditure per capita, an indicator which places us almost at the end of the ranking in Europe, with 238.33/per capita (2009),justaheadofBulgaria,with200.33/capita(2009),whiletheEU27averagewas1,751.25/capita (2009),asresultsinTable2.

Table2.Dynamicsofpublicexpendituresforhealthpercapitaduring19912010()

Countries/Time EU27 Belgium Bulgaria CzechRepublic Denmark Germany Estonia Ireland Greece Spain France Italy Cyprus Latvia Lithuania Luxembourg Hungary Malta Netherlands Austria Poland Portugal Romania Slovenia Slovakia Finland Sweden UnitedKingdom 1991 : 952.6 : : 1428.9 1064.9 : 614.80 70.21 : : 1102.91 : : : 1263.79 : : : : : 284.13 : : : 1350.95 : 791.35 1999 : 1467.3 48.6 322.3 2077.5 1509.8 187.78 1330.41 484.32 757.86 1627.75 1129.22 381.19 113.24 : 2027.38 224.54 445.16 913.06 2090.19 : 703.96 56.67 680.83 193.35 1377.61 1700.62 1339.90 2000 : 1554.6 61.2 343.0 2147.3 1547.0 191.61 1518.49 495.45 823.00 1697.51 1257.63 386.53 140.28 144.39 2080.72 244.40 548.13 978.26 2131.18 : 776.06 75.69 695.51 213.24 1467.91 1838.32 1544.36 2005 1481.19 2050.55 160.58 706.49 2756.47 1690.89 338.55 2645.,23 867.20 1198.66 2165.25 1692.58 557.15 241.59 297.26 3409.80 494.93 766.39 1381.68 2184.17 283.29 1049.87 124.04 907.44 346.31 2059.35 2225.96 2121.45 2008 1707.67 2393.65 210.29 1027.42 3305.02 1893.75 626.80 3181.42 1180.69 1458.18 2378.01 1871.74 653.90 464.49 476.63 3622.99 515.76 770.19 2129.06 2632.71 481.15 1026.96 249.70 1127.76 824.11 2453.55 2487.77 2221.26 2009 1751.25 2531.94 200.33 1046.66 3553.47 2009.45 578.48 3179.44 1254.31 1552.19 2451.97 1891.71 691.83 388.10 439.18 3885.11 465.22 783.59 2362.76 2695.50 417.84 1121.25 238.33 1191.18 905.13 2566.13 2334.50 2152.50 2010 : : : : 3621.98 : : : : : : : : : : : : : : : : : : : : : : :

Source:owncalculationsaccordingtoEurostatdatabase

Analyzing the dynamics of public health spending per capita, expressed in euro, we find the same differencesbetweendevelopedanddevelopingcountriesfromtheEuropeanUnion.Countriesthathavespent the most per capita over the period were Denmark (in 2010, 3621.98/capita), Luxembourg (in 2009, 3885.11/capita), Ireland (in 2009, 3179.44/capita), Austria (in 2009, 2695.50/capita), Netherlands (in 2009, 2362.76/capita), while Bulgaria has allocated for health amounts between 48.6 and 200.33 per capita. 4.3.Measuringhealthcarenonexpendituresdata AccordingtoEurostatdatabase[18],informationonhealthcarecanbedividedintotwobroadgroupsof data: health care data on human and technical resources and outputrelated data that focus on hospital patients and the treatments they receive. The available data shows that in 2008, the highest number of physiciansper100,000inhabitantswasrecordedinAustria(458.5)andLithuania(370.6).ForRomaniathe valuewas221.5practicingphysiciansper100,000inhabitants. The most commonly used measure of the utilization of hospital services is the hospital discharge of in patients,anindicatordefinedastheformalreleaseofapatientfromahospitalafteraprocedureorcourseof treatment. The highest number of hospital discharges, in 2008, was recorded in Lithuania (93,525.8 dischargesper100,000inhabitants,inpatients),followedbySlovenia,with67,837.0dischargesper100,000 inhabitants,inpatients.Attheopposite,thenumberofthehospitaldischargesofinpatientswasrelatively low in Malta and Cyprus (below 20,000 per 100,000 inhabitants), which may be due to patients travelling abroadinordertoreceivespecialisttreatment.ForRomaniatherewere4,765thousandsin2008.According totheRomanianStatisticalBreviary[17]itiscalculatedanindicatorofthenumberofimpatientsinhospitals, whichincreasedfrom5,025thousandin2000to5,374thousandsin2008. Diseasesofthecirculatorysystemaccountedforthehighestnumberofhospitaldischargesin2008inthe vastmajorityofcountriesforwhichdataareavailable,oftenwithupwardsof3,000dischargesper100,000 inhabitants.Fordiseasesoftherespiratorysystem,ahighernumbersofdischargesper100000inhabitants wererecordedinBulgaria(3,033.9,in2008),followedbyRomania(3,026.0,in2008).InSpain(3,587.2in patients per 100,000 inhabitants, 2008) and France (3,750.8 inpatients per 100,000 inhabitants, in 2008) thereweremoredischargesfrompregnancies.
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 Afunctionofhospitalefficiencyistheaveragetimespentinhospital,aswellasthetypeoftreatmentsthat are on offer. The average length of stay in hospital was generally longest for those patients suffering from cancerorfromcirculatorysystemproblems.InRomania,accordingtoRomanianStatisticalBreviary[17],the number of hospital days decreased from 8.8 days in 2000 to 7.6 days in 2008. In Europe, according to Eurostat database, in 2008, France (6.1 days, Reunion), Cyprus (6.4 days), Bulgaria (6 days) reported the shortest average stays in hospital. At the opposite, some of the longest average stays for diseases of the circulatory system were recorded in Finland (16.3 days), Czech Republic (around 13 days) and Germany (around11days). Also,anotherindicatoristhenumberofhospitalbedsper1,000inhabitants.InRomania,basedondata fromtheStatisticalBreviary[17],thisindicatorhasbeendecliningsince1989,from206,908beds(8.9per 1,000inhabitants)to166,817beds(7.4bedsper1,000inhabitants)in2000and137,016beds(6.4per1,000 inhabitants)in2008.InEurope,in2008,thehighestnumberofbedsper1,000inhabitantswasregisteredin Bulgaria(7.9beds). 5.Conclusions The research literature indicates an increasing interest on using costeffectiveness analysis by decision makersashealthcarecostsarerisingandmustbekeptundercontrol.Accordingtothisanalysis,healthcare outcomes are measured in terms of: cataracts removed, lifeyears gained, cases of diseases prevented, qualityadjustedlifeyears(QALYs),healthyyearsequivalentsetc. Wemustrecognizethefactthathealthcaresectormarkethasmultipleimperfectionsanditisimportant to analyze spending considering the burden of disease and also the need for resources. Thus, I have also presentedanoverview ofthe public expenditures onhealth careat the European countries, in comparison withthoseofRomania.TherelativeimportanceofthefundsallocatedtohealthcareintheEuropeanUnion hasbeenconsideredonthebasisofsomeindicatorsofefficiency,suchas:thenumberofphysicians,diseases, hospitaldischargeofinpatients,theaveragetimespentinhospital.ForRomaniathereisaseriousconcern, due to the fact that many doctors leave country, which represents a braindrain of medical staff that puts patients at risk. Health is one of the most valuable assets, an individual first class priority and must be recognizedasanationalpriority.Eveniftheapplicabilityofthisanalysisislimitedbycertainmethodological barriers,itprovestobeausefulguideforpublicpoliciesaimedatprioritizinghealthcarespending.
Acknowledgements ThisworkwassupportedbythetheEuropeanSocialFundinRomania,undertheresponsibilityoftheManagingAuthorityfor theSectoralOperationalProgrammeforHumanResourcesDevelopment20072013[grantPOSDRU/88/1.5/S/47646].

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