Population’s unmet needs in relation to primary care in Romania- a pilot survey in County Brasov.

Background Patients’ expectations and needs for healthcare services are changing. These changes are correlated with changes in disease proles, a higher prevalence of chronic diseases, the introduction of new and innovative treatments and health technologies, and the emergence of new social and economic contexts. National health reports on Romania show that decisions in healthcare planning are not correlated with the health needs of the population. At the same time, this report shows a high degree of unmet healthcare needs of the Romanian population (related to cost, distance and waiting times), especially for low-income populations. The objective of the study was to identify the unmet needs of the population in relation to primary care medical services in the context of actual health regulations through a pilot study in a representative county in Romania. Methods The study is survey-based, and part of a health needs assessment programme commissioned by the District Health Authority to the university. A questionnaire with 21 items was designed to gather information about the structures, processes and outcomes of primary care from the perspective of the population. A total of 877 questionnaires were returned and validated. The data were analysed with SPSS version 25. Results Access to primary care was considered to be good by most of the population. Most of the settlements have a family doctor, and 80.5% can schedule an appointment on the same or the following day. Most basic medical services are provided, except for out-of-hours primary care services and cervical cancer screening. The family doctors are considered to be a reliable health resource. Conclusions Despite limitations in the practice of family medicine in Romania and therefore a narrow spectrum of services offered by primary care in general, the level of contentment of the population with this healthcare resource is still high. Barriers to access are related to the lack of some essential services, especially preventive and out-of-hours services. Unmet needs are presumably not recognised by patients due to a lack of medical culture. Further research is needed to clarify this conclusion.


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The underfinancing of the Healthcare system is one of the main causes identified by the authors of the report, but also the inefficient use of resources. Healthcare planning is merely top down and is not correlated with the health needs of the population, Romania is reporting a high degree of unmet Healthcare needs of the population related to cost, distance and waiting times, especially for the low-income group 2 .
Primary care is an important segment of the Healthcare system. In terms of health policies, it is entirely assimilated to Family Medicine. The context of practice in family medicine in Romania has certain particularities. It contains both elements favouring access and equity but also important barriers to it. One of the enablers to access is the fact that, in Romania, nearly all patients are registered with a family doctor (FD), the latter having a gatekeeping role. At this level, free consultations are offered for all insured people (more than 85%) 2 .
The uninsured have also access to a minimal package of services. The free choice of the FD is also guaranteed by the National Health Insurance Contract.
Certain barriers to the practice of FDs are present. Due to cost control policies, protocols of prescription have been used to limit the initiation of certain medication. Medication for type 2 diabetes or asthma inhalers cannot be prescribed by FDs, a referral to the specialist being needed. Other limitations are present in the reimbursement of procedures, discouraging FDs form performing them. In this context, we are registering a narrowing of the scope of care of family medicine, this one being transformed into a referral point and not an intervention one, in the system.

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The research consisted in a survey, performed in the context of a Health Needs Assessment Project commissioned by the County Council of Brasov to Transylvania University. The survey was applied to a representative sample of the population (1200) of County Brasov Romania that accounts for 634.236 inhabitants.
A theoretical sampling with mapping of all representative communities was considered. The statistical error of the sample is 3,32% for p= 95%.
In the project, we have designed a 54 items questionnaire, meant to analyse the felt and expressed needs of the population and the need to access different levels of healthcare in the past 12 months. 21 of these questions were dedicated to exploring for possible unmet health needs at the level of primary care. The questionnaire had preformulated answers that where prefiguring recognised normative aspect of care. It was self-administered. The location of delivery were FDs practices, local Councils and other places in the community. 877 questionnaires were returned and validated.
The Alpha Cronbach coefficient is 0,828 a value that has allowed us to pursue research.
Questions where grouped to explore the three dimensions of care: structure, process and outcomes of care 3 . We have also explored some patterns of relating with family medicine like the number of visits at the family doctor per year, the constancy in being registered with FD.
Data was analysed with SPSS version 25.

Results
The demographic characteristics of the sample are summarized in table1. It is to be noticed that the population over 65 is higher (18,2%) than the average of the County (15,8%) as published by the County Statistical Department. Gender distribution is favouring women, 67,2% female and 32,8% male. The level of education is as following: 11,6% have a basic education level (8 classes and under), 61,1% have graduated a high school or a professional school and 27,2% have a university background. This distribution is covering the broad spectrum of education in the community.
In terms of visits to the FD, 15,6% of patients have visited their FD once in the past 12 months and 19,8% have visited the FD for 12 times 12 months and only 3,9% more than 12 times. The study was a typical approach to Health needs assessment (HNA). HNA is recognised as a method to identify gaps in care. Health needs are various: felt needs, expressed needs, Page 7/19 normative needs 4 . All of these can be met or unmet at a certain moment, in correlation with the three dimensions: need, supply and demand. The patient is central to this equation and not always consulted.
Our study is offering the responses of a Asked if reaching their FD was a problem (in the past 6 months) 88,6% of the population answered not having had this problem and only 11,6% answered that they encountered problems. In comparison with other types of specialists, accessing FD's seems not to be a problem. Responders signalled difficulties in reaching an eye specialist (37,3% couldn't reach in the past 6 month) or a cardiologist (43,1% couldn't reach in the past 6 month).
Furthermore, the results of our study showed that only 26,6% of people could get a same day appointment with their GP. This is lower than the report of the Regional WHO office from 2009 that showed that 92,8% of people could get same day appointment with the FD 5 .
Nevertheless, our study is showing that next day appointment is possible in 53,9% of cases.
Being asked if there was an alternative doctor to see if their FD is missing, in 27,6% of cases, people affirmed that there was no other doctor to replace their FD in the community.
In only 58,6% of cases there is access to an Out-of-Hour (OOH) centre in the neighbourhood.
Opening hours of FDs offices allow most people (91,2%) to access the practice. Access to FD's office by telephone is available in 90,5% of practices.
Although in a study published in 2015 data showed only occasional access by telephone and or to an appointment system in the FDs office, this situation has changed in the past years, since the introduction of a compulsory appointment system by the National Health Insurance House (NHIH) 6 .   Access to Out-of-Hours services is a problem due to the lack of coverage in the hole territory of the County. It is a result of the fact that OOH is a service organized by FD's at their one decision, without a rigorous planning of the service by the District Health Authorities. In 27,6% of cases the FD is the only health resource in the community.
Community and school nurses are unavailable in most of the rural communities.
Person centred care and trust (  Health improvement and education ( Table 4) Results of our study are showing that most of the responders are satisfied with results of care.
Health education and medical advice is recognized to be valuable in 88,8% of cases concerning diseases and 87,7% for preventative measures.
52,3% of patients suffered from a chronic disease and 91,9% of them affirmed that they understood form medical advice of their FD how to take this medication. Questions Yes After the consultation with the FD did you feel your Health has improved? 88,2 11,8 After the consultation with your FD did you feel more informed on preventative measures? 87,4 12,6 After the consultation at your FD did you understand how to take your medication? 91,9 8,1 Availability of procedures ( Table 5) We looked at some of the procedures relevant to public health like well child, pregnancy monitoring, cervical cancer screening. Access to this service is appreciated by patients.
Despite this, data from the NHIH are showing that there is a reduces number of reported services like pregnancy monitoring and well child and cervical cancer screening.
Underreporting is one of the causes but also lack of education of the population in accessing these services.
Point of care testing like lab tests, electrocardiogram (EKG) is not recognised as an offered service in family doctor's office. The study has been approved by the Ethics Committee of Transylvania University. Consent of the patients to participate to the study was verbal and assumed through the completion of the questionnaire. The questionnaire has a heading section that is explaining the reasons of the study and is anonymous. The questionnaire was approved by the Ethics committee.

Consent for publication
Not applicable Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests
The authors declare that they have no competing interests writing and therefore is the corresponding author.
Liliana Rogozea has contributed to study design and data analysis.
Daniela Popa has contributed to questionnaire design and validation Ioana Atudorei has contributed to questionnaire design and data analysis Marius Moga has contributed to study design and data analysis.
Florin Leasu has contributed to study design and data analysis Anca Lacatus has contributed to data analysis and interpretation.