Editorials |
A new year, a new era: Romania and Bulgaria join the European Union
Martin McKee1, Dina Balabanova1 and Andreea Steriu2
1 European Centre on Health of Societies in Transition, London School of Hygiene and Tropical Medicine. Isle of Man
2 Department of Home Affairs Isle of Man
Correspondence: Martin McKee, European Centre on Health of Societies in Transition, London School of Hygiene and Tropical Medicine, e-mail: martin.mckee{at}lshtm.ac.uk
The New Year celebrations on the 31st of December 2006 were unusually noisy in Bucharest and Sofia. At last, two and a half years later than their central European neighbours, and six months later than originally envisaged because of concerns about the pace of reform of criminal justice systems and measures to tackle corruption, Romania and Bulgaria joined the European Union.
Accession is likely to bring further economic growth.1 But will health also improve? Life expectancy at birth is at the bottom of the European Union league although in Bulgaria, and a little more unsteadily in Romania, it has been increasing rapidly since the late 1990s.2 However it cannot be assumed that this progress will continue. Rapid gains in life expectancy seen in Hungary in the years leading up to its accession have since slowed markedly while, in both Latvia and Lithuania, life expectancy in 2005 was lower than in 2004.
What then must be done to ensure that health does continue to improve? In particular, how can both countries ensure that no one is left behind as the economy grows? A large proportion of the population in both countries remains either below the poverty level or vulnerable to becoming so.3,4 Some groups are especially disadvantaged. Both countries have large Roma populations who, for centuries, have largely been excluded from mainstream society. Despite the requirement imposed by the accession process to address their needs, and the commitment of heads of government to join in the ‘Decade of Roma Inclusion’ programme,5 their health (and economic) status remains very poor, with high levels of both communicable and non-communicable diseases. They suffer from poor access to health services, both geographical, with poor provision of facilities in Roma communities, and administrative, with difficulties obtaining the documentation necessary to enrol in health insurance systems.6
Looking ahead, there is the potential for a new underclass to emerge, as migrants move from neighbouring countries to replace those who have moved abroad. The population of Bulgaria has fallen by over 1 million since 1990, while the decline in Romania is twice as great. Both countries have close linguistic ties to neighbouring countries, Moldova in the case of Romania, and Macedonia in the case of Bulgaria. Indeed, anyone with a grandparent or parent born on Moldovan territory before 1940, when it was forcibly incorporated into the USSR, is entitled to Romanian citizenship, although the imposition of a residence requirement by the Romanian authorities has made the process much more difficult.7 There is a danger that their semi-legal status will drive these migrants into hazardous and low-paying jobs with little social protection.
Another concern is the situation of people in rural areas. Rural parts of both countries are very poorly served by basic services, such as electricity, piped water, and sewerage.8,9 Rural settlements are aging rapidly and agricultural restructuring has reduced the traditional forms of employment, while new ones are not emerging, in part because of the weak infrastructure.
While policies are needed that will address the social and economic determinants of disease, there is also much to be done to improve the care that is provided to people when they become ill. Both countries experience high death rates from causes that are amenable to effective health care, such as cerebrovascular disease and cervical cancer. Indeed, during the 1990s, amenable mortality actually increased in Romania at a time when it was declining elsewhere in central and eastern Europe.10 In both countries, health system reform has been difficult. Many facilities are obsolete. Informal payments remain widespread, deterring those in need of care but, equally importantly, acting as an incentive to professionals to resist change.11 Currently, access to high-quality prevention and care remains problematic for a large proportion of the population. Looking ahead, there are concerns about the potential loss of young health professionals seeking employment abroad.
There are many challenges ahead for both countries. Yet accession to the European Union also brings many opportunities. Already, the requirements of the aquis communitaire have ensured that legislation in areas, such as health and safety, food standards, and tackling discrimination has been strengthened substantially. Both countries have also benefited from pre-accession financial support. However, over the next decade, both will receive substantial additional financial support in the form of cohesion and convergence funds. These are expected to be, in the years 2007–2013, 
17 billion in the case of Romania 12 and 6 billion for Bulgaria.13 This poses two challenges. The first, given the existing high level of corruption in both countries, is to ensure that the money is spent effectively. The second, which is a challenge to the public health community, is that it is spent in ways that enhance health.
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1 ICEG EC & Corvinus. SEE Monitor No 11-12, 2006. (2006) (ICEG EC & Corvinus, Budapest).
2 World Health Organization. Health for All database. (2007) (WHO, Copenhagen).
3 Zamfir C. (2001) Poverty in Romania. (CASPIS, Bucharest).
4 Quintanilla R. Bulgaria. (2005) The road to successful EU integration—the policy agenda. (World Bank, Washington DC).
5 The Decade of Roma Inclusion: Challenging Centuries of Discrimination. Open Society News, Summer-Fall 2005. URL: http://www.soros.org/resources/articles_publications/publications/osn_20051011/osnroma_20051011.pdf (accessed 31 January 2007).
6 European Roma Rights Centre. (2006) Ambulance not on the way. (ERRC, Budapest).
7 URL: http://news.bbc.co.uk/1/hi/world/europe/6268853.stm (accessed 31 January 2007).
8 Dumitru M, Diminescu D, Lazea V. (2004) Rural development and the reform of Romania agriculture. (Romanian Centre for Economic Policies, Bucharest).
9 World Bank. Bulgaria: Survey on rural development needs. (2004) (World Bank, Washington DC).
10 Nolte E, Shkolnikov V, Scholz R, McKee M. (2004) Progress in health care, progress in health? Patterns of amenable mortality in central and eastern Europe before and after political transition. Demographic Res Special Collection 2:139–62.
11 Balabanova D and McKee M. (2002) Understanding informal payments for health care: the example of Bulgaria. Health Policy 62:243–73.[CrossRef][ISI][Medline]
12 European Commission. (2006) Inforegio factsheet. (European Commission, Romania.Brussels).
13 European Commission. (2006) Inforegio factsheet. (European Commission, Bulgaria. Brussels).
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