Depoliticizing Care: Neoliberal Reforms and the Displacement of Responsibility in Romanian Healthcare
Over the past three decades, Romania's healthcare system has undergone a series of transformations under the influence of international financial institutions, EU alignment pressures, and domestic structural constraints. While framed as technical improvements, these reforms followed a distinct neoliberal logic that gradually privatized care, transferred responsibilities to individuals, and silenced both professional and civic resistance. This commentary explores the epistemic and institutional dynamics through which healthcare reforms were legitimized, highlighting the role of depoliticized language, technocratic oversight, and the absence of collective agency. Drawing on World Bank documentation, media discourse, and isolated instances of resistance, I argue that the Romanian case exemplifies the political costs of structural silence in public health governance.
From the early 1990s to the present, Romania's health system has transitioned from a state-run, centralized model to a hybrid structure increasingly reliant on public-private partnerships, performance-based financing, and technocratic oversight. These reforms, often presented as modernization or alignment with EU standards, reflect a deeper ideological shift: the neoliberal reimagining of care as a contract, not a right.
The 1991 Health Rehabilitation Project (World Bank Loan 3409-RO) initiated this trajectory. It promoted decentralization, user fees, and a logic of cost recovery. Follow-up projects throughout the 2000s and 2010s, such as APL1 and APL2, consolidated this vision by embedding DRG-based hospital payments, rationalization of hospital networks, and policy instruments designed to attract private actors into the healthcare landscape. Reforms emphasized efficiency, disbursement, and quantifiable performance, while equity, labor conditions, and the lived experience of patients were marginalized.
Public reaction remained subdued. Even during acute moments—like the controversial 2011 reform draft which sought to privatize emergency services—resistance was triggered more by the perceived threat to national icons (e.g., the SMURD system) than by a broader critique of market-driven healthcare. Dr. Raed Arafat's temporary resignation ignited protests, but these ultimately failed to generate a sustained public debate about the commodification of health.
Within professional communities, critique was fragmented. Physicians like Florin Chirculescu, writing for CriticAtac, called out the erosion of public hospitals and the burden placed on individual practitioners. The Romanian College of Physicians (CMR) occasionally issued warnings about systemic collapse due to underfunding, uneven distribution of staff, and aging workforce demographics. Yet such statements remained discursive, rarely tied to demands for structural redress or mobilization.
Labor unions, too, largely avoided confronting the political roots of the crisis. Federations like Sanitas focused on wage disputes and working hours, without articulating broader claims for systemic equity or redistribution. Their silence can be read not only as opportunism, but also as evidence of the narrowing of political imagination within professional advocacy.
Meanwhile, health reforms continued under the banner of results-based financing and resilience. The 2020 Program-for-Results (PforR) operation tied funding to performance outcomes, extending the logic of managerial accountability while maintaining the invisibility of care work’s affective, social, and political dimensions.
This trajectory raises the question: Who is responsible when someone dies due to lack of access to care? The design of the reform architecture ensures that no one actor can be held accountable. The result is a diffusion of responsibility that masks structural violence. Patients are redefined as consumers; health professionals as contractors; and the state as regulator rather than guarantor.
In this sense, Romania's health reform is not simply a case of institutional transformation—it is a case of epistemic erasure. By replacing political debate with managerial oversight, and by framing inequality as inefficiency rather than injustice, the system effectively silences those who suffer most from its dysfunction.
Yet resistance does exist, even if muted. Discursive interventions by physicians, isolated protests, and journalistic investigations into hospital closures and inequities form a fragile but crucial counter-memory. They remind us that reform is never neutral—and that the stakes of silence are, quite literally, life and death.
References:
World Bank (1991–2024) health reform documents (summarized in thematic matrix)
Chirculescu, F. (multiple essays), CriticAtac
Stan, S. & Erne, R. (2021). Cross-border care and transnational responsibility
Holmes, S. (2013). Fresh Fruit, Broken Bodies
Peck, S. (2025). "Doubly exploited": Migration and labor agency
CMR Press Release (2024)
Wiener, A. (2024). Interview, SpotMedia
Rafila, A. (2024). Statements reported in Digi24
Trif, A. (2013). Romania. Transfer: European Review of Labour and Research, 19(2), 227–237. doi:10.1177/1024258913480600
Neoliberal Citizenship and the Politics of Corruption: Redefining Informal Exchange in Romanian Healthcare" by Sabina Stan
Adăscăliței D, Muntean A. Trade union strategies in the age of austerity: The Romanian public sector in comparative perspective. European Journal of Industrial Relations. 2019;25(2):113-128. DOI: https://doi.org/10.1177/0959680118783588.
"Is Migration from Central and Eastern Europe an Opportunity for Trade Unions to Demand Higher Wages? Evidence from the Romanian Health Sector" (Sabina Stan & Roland Erne, 2016);
Costanza Galanti’s PhD thesis (2023): "The Struggle for Healthcare under the European Union’s New Economic Governance Regime. Trade Union and Grassroots Mobilisations in Response to Healthcare Commodification in Italy and Romania (2008 – 2022).