This report was conducted as part of the project ”Help to help Ukraine” implemented by FONPC with the support of CARE – a global confederation that has been fighting against poverty and social injustice for over 75 years, through a programme coordinated and implemented at national level by the SERA Romania Foundation (a non-governmental, non-profit, private organization that has been working for 26 years in the field of child protection and the promotion of children’s rights in Romania) with the support of FONPC (The NGOs Federation for Children).
The view as described in this document is that of the authors and does not reflect necessarily the view of the organisations supporting the study.
Founded in 1997, FONPC exists together with and for its members, comprising 65 NGOs, for the benefit of children and the community. It is guided by the principles and statutory provisions and it promotes the following values: identity/ autonomy of members, effectiveness in communication and action, democratic decision-making, solidarity, openness, trust, mutual respect, equity, consistency/ continuity, partnership, transparency, participation and involvement. In order to achieve its objectives, FONPC works in close partnership with donors, funders, local and national authorities and non-governmental organisations, international organisations, European institutions, the civil society, the community and other actors involved in promoting respect for children’s rights.
The Federation has the role of monitoring children’s rights, influencing public policies in all sectors of children’s rights: education, social, health, justice, etc.
The projects developed by FONPC over the years have aimed to support NGOs but also direct professional beneficiaries, such as children and families. The 65 member NGOs within FONPC are independent organisations which have signed the common Charter of Values and a statute, as well as given rise to a strong common voice.
The Federation of Child Protection NGOs- FONPC and its members provide humanitarian support to people affected by the conflict situation in Ukraine. FONPC has started a process of monitoring and coordinating FONPC members in order to act in a coherent and complementary way during this period. FONPC members are providing humanitarian assistance to children and families who have fled Ukraine and sought shelter in Romania. Through coordination with public authorities, FONPC and its members come to meet the needs of Ukrainian refugees.
In order to ensure the necessary resources for children and women leaving Ukraine, and to provide them a safe space, FONPC and its members make available material and human resources. Some of FONPC’s member teams and volunteers operate on the ground at border crossings to provide immediate support to children and families in need, who have been traumatized by the experience of war and losing their homes. Other FONPC members have grouped together to receive refugees in centres/spaces set up throughout the country (Bucharest, Vaslui, Ploiești, Satu-Mare, Galați etc).
Since the beginning of the war, Romania has received and hosted thousands of refugees. FONPC’s member NGOs have made available resources and have offered support to every person in need.
These NGO activities are an essential contribution to ensuring the observance of the human rights of refugees and other migrants, including the right to be treated with dignity and respect, access to health and education services, adequate food, shelter and care, the right to freedom of expression and security, to seek asylum, and the right to protection from torture and other ill-treatment and from refoulement and collective expulsion.
The FONPC team has focused its efforts on coordinating and fundraising actions so that NGOs on the ground can carry out their work.
At the same time, FONPC is part of the Working Group „Children and Youth”, organized by the Ministry of Family, Youth and Equal Opportunities through the National Authority for the Protection of Children’s Rights and Adoption. The aim is to contribute to the implementation of Romania’s National Refugee Response Plan.
The Federation actively participates in the meetings of the Strategic Coordination Group for Humanitarian Assistance (at the level of the Prime Minister’s Office, under the coordination of a Secretary of State).
We collaborate with the General Inspectorate for Emergency Situations, the Department for Emergency Situations, the Red Cross, UNICEF, the General Directorates for Social Assistance and Child Protection, the Chancellery of the Prime Minister, NGO Platforms.
On 24 February 2022, Russia launched a military aggression against Ukraine, causing millions of people to flee the war and seek refuge in EU countries (including Romania and Poland) and the Republic of Moldova.
The war in Ukraine has created a humanitarian catastrophe: 14 million Ukrainians have been displaced since the start of Russia’s invasion of Ukraine. The UN High Commissioner for Refugees estimates that this is the fastest and largest displacement of people in decades.
It is also estimated that over 7 million people have been internally displaced, with many more stranded in the combat zone, who are unwilling or unable to leave due to military action.
According to the UNHCR, by 6 December 2022, 4.8 million refugees from Ukraine were registered for temporary protection or similar arrangements in the EU.
So far, the EU has allocated €523 million for humanitarian assistance to help civilians affected by the war in Ukraine. This includes €485 million for Ukraine and €38 million for the Republic of Moldova. EU Member States alone have made available almost €957 million.
By means of this funding, citizens within Ukraine’s borders and those who have fled to neighbouring countries receive aid in the form of:
So far, more than 13.5 million people have benefited from humanitarian assistance in Ukraine thanks to the EU and other donors. This funding is part of the €1 billion support package pledged by the European Commission to address the most pressing humanitarian needs both inside and outside of Ukraine.
With the outbreak of the armed conflict in Ukraine, the European Commission began coordinating its largest ever operation through the European Civil Protection Mechanism, which the Member States activate in case of a major humanitarian disaster. Through this mechanism, any country in the world can request assistance when an emergency exceeds its disaster response capabilities. Depending on the nature of the disaster, this aid can take different forms, such as:
- search and rescue operations
- extinguishing forest and urban fires
- medical assistance
- medical equipment and pharmaceuticals
- water purification
- temporary emergency shelters
- safe repatriation of EU citizens
To date, assistance through the EU Civil Protection Mechanism amounts to €443 million.
In addition, the UN mechanisms for coordinating humanitarian assistance in the event of major disasters have also been activated simultaneously in states that have requested international assistance, including Romania, – needs and assistance plans have been described in detail in the Regional Refugee Response Plan (RRP) and FLASH Appeal and the Ukraine Humanitarian Response Plan (HRP). These mechanisms were recalibrated in October 2022. According to UN OCHA reports, the $1.85 billion request for humanitarian assistance for refugees ($226 million for Romania) was funded in proportion of 50.7%. Of the $935 million, the European Commission contributed 3.3% through two funding instruments, a modest contribution compared to the United States (32%).
In the case of the Regional Refugee Plan, no more detailed analysis is provided on the proportion of these funds reaching civil society compared to the part given to the UN or, bilaterally, to the governments of refugee-receiving countries, or how much of these funds reached particular sectors (e.g. health), as opposed to reports for the allocation of humanitarian funds to Ukraine, where the UN and other multi-lateral organisations received $2.1 billion of the $3.85 billion allocated, of which only 0.15% went to Country Pooled Funds for those responding to needs on the ground level. Also, only 0.01% of the funds were directed to national organisations (NGOs and civil society) and 0% to local organisations. Only 7% of funds went to health and medical services (https://fts.unocha.org/appeals/1103/summary). At the same time, many donors, including the European Commission, contribute to both mechanisms and it is not clear from the documents whether the same funds were reported more than once (i.e. 16% of the funds meant for the Regional Refugee Plan came from the UNICEF regional office as part of a multi-donor fund).
The 27 EU countries plus Norway, Turkey, North Macedonia and Iceland have provided in-kind aid ranging from medical supplies and shelter to vehicles and power generation equipment. Items were delivered directly to Ukraine and through existing logistics networks in Poland, Romania and Slovakia.
By 18 October, some 70,400 tonnes of equipment had been delivered.
More than 13 million people have received some form of humanitarian aid in Ukraine, thanks to the EU and its donors.
More than 8.9 million people have received food assistance, and another 8.6 million have benefited from medical interventions and equipment, 3.9 million in cash aid and 6.4 million in critical protection services.
In addition, almost 5 million people have regained access to drinking water and critical sanitation and hygiene services.
Moreover, as Ukraine is facing a huge need for medical supplies, the EU has made available its rescEU strategic reserve, a new European pool of resources, which includes a fleet of water bombers and helicopters, medical evacuation planes, as well as a stockpile of medical supplies and on-site hospitals to deal with health emergencies. According to the European Commission, in early August, more than 1,000 Ukrainian patients were evacuated by the EU through its civil protection mechanism to receive medical care in hospitals in Europe.
The patients were transferred to 18 countries: Germany, France, Ireland, Italy, Denmark, Sweden, Romania, Luxembourg, Belgium, Spain, Portugal, the Netherlands, Austria, Norway, Lithuania, Finland, Poland and the Czech Republic. Recent operations include the transfer of 2 patients to the Czech Republic on 3 August and the evacuation of 15 patients to Germany, 4 patients to the Netherlands and 2 patients to Norway.
The research report „Access to health care in Romania for Ukrainian refugees” aims to analyse the response offered by Romania, through its public institutions and non-governmental organisations, to Ukrainian refugees facing health problems. It aims to analyse the support offered to refugees, the resources available to the Romanian medical system and organisations, and the coping situation of those who had fled the war and had met with medical problems in Romania.
II. Methodological premises
The present study comprises a methodology adapted to emergency situations, constantly changing, by taking into account the fact that no preliminary detailed studies have been carried out so far. The purpose is to obtain as clear and real a picture as possible of the access to health services for the people who have fled to Romania from Ukraine since the beginning of the conflict.
The study also provides relevant information on the funds that central public authorities have used to support beneficiaries of temporary protection or persons in transit in Romania starting with the outbreak of the crisis in Ukraine until December 2022, as well as the number of beneficiaries of these services, the type of funds used and how they had been spent.
The view as described in this document is that of the authors and does not reflect necessarily the view of the organisations supporting the study
This analysis has the following specific objectives:
1. To present the needs of Ukrainian citizens related to the health sector and identify the challenges they face.
2. To analyse the degree to which the state and private health services in Romania can be accessed and identify opportunities for improving the access to these.
3. To analyse the financial resources used so far by state institutions to address the challenges faced by Ukrainian citizens, beneficiaries of temporary protection.
Structure of the analysis
The methodology of this study includes three components: desk research, data analysis and qualitative analysis.
The first part of the study comprises a desk research analysis, namely a review of documents and other relevant studies conducted to date. In this respect, the normative acts directly related to the subject of the study are presented.
In the second part of the study, existing statistical data are analysed to present the number of Ukrainian citizens accessing health services at national level, the number of inflows and outflows of Ukrainian citizens, as well as the financial resources spent so far, etc.
The third part of the study contains a qualitative analysis of testimonies collected from Ukrainian citizens who are beneficiaries of temporary protection, and from Romanian professionals who are involved in supporting refugees, both in public services and in non-governmental organisations. Data were collected from eight interviews. Among the interviewed persons, there is also the president of the Romanian Coalition of Chronic Disease Patient Organisations, who is also the vice-president of the European Patients Forum, the manager of the Bucharest – Ilfov ambulance service and the head of the Public Relations Office of DGASMB – General Directorate of Social Assistance of the Municipality of Bucharest,
The analysis tool used in this part of the study is the semi-structured interview, which contains a set of questions for Ukrainian citizens who have taken refuge in Romania and a set of questions for Romanian citizens who directly support them and who are involved in ensuring their access to health care. Interviews were conducted with people from the health sector, NGOs involved in supporting Ukrainian refugees in Romania and 3 Ukrainian beneficiaries of temporary protection measures. The common set of questions also covered issues such as access to a family doctor, access to pharmaceuticals and treatments, including those for chronically ill people, bureaucratic aspects of the health system, types of funds invested, etc.
In the last part of the study, we analysed the situation of the allocated funds and the way they were distributed through the documents received from public institutions and organisations, which were asked to provide information on the financial resources allocated, their type, the number of beneficiaries, etc. These institutions include: the General Secretariat of the Government, the Ministry of Health, the Ministry of Internal Affairs, the Ministry of Investment and European Projects, the Ministry of Labour and Social Protection, the Ministry of Family, Youth and Equal Opportunities, the Ministry for Development, Public Works and Administration, the National Health Insurance House, as well as non-governmental organisations involved in supporting Ukrainian refugees. The letters sent to public institutions were prepared and sent on the basis of Law 544/2001 on access to information of public interest. The questions in the address refer to the funds received, the sources of the funds and how they were allocated.
The results of the study provide an overview of the access to health services in Romania, as well as recommendations for improving access to health services for beneficiaries of temporary protection, including a picture of the funds mobilised in Romania for these services.
III. Description of the current situation
According to the data centralized and communicated by the General Inspectorate of Border Police, from 10 February 2022 (pre-conflict period) to 5 January 2023, 3,250,347 Ukrainian citizens entered the territory of Romania. On 1 January 2023, 106,786 citizens from Ukraine who had obtained some form of protection were registered in Romania, out of more than 3.2 million who have entered the country since the beginning of the armed conflict.
Rights under the temporary protection system include residence permits, access to the labour market and housing, healthcare and access to education for children.
With its unprecedented mobilisation, Romania admirably managed the wave of refugees coming from Ukraine in the early months of the war. Against an extremely strong emotional background, the first model of exemplary mobilisation was set by the population, from the moment the first groups of refugees arrived. But the successful management of such a large-scale crisis would have been impossible without the rapid and effective involvement of the government, local authorities, civil society and the private sector.
The complexity of the mechanism created by the Romanian state to provide assistance to Ukrainian refugees who transited or settled as refugees in Romania consisted of direct services offered through public institutions, coordinated with additional assistance offered by the civil society and the Romanian population, and the extra resources collected by the international community through the EU Civil Protection Mechanism (activated for member states) and through the UN coordinated Regional Refugee Response Plan (RRP and Flash Appeal – which is activated for any international response where a state requests international assistance).
According to the Romanian Government, in 2022, more than 106 million euros were paid from public funds for the accommodation and feeding of refugees through the 50/20 programme, representing a daily expenditure of more than 352,000 euros. Of this money, Romania has only received a first tranche of €39.1 million of EU aid to cover the costs of meals and accommodation for Ukrainian refugees.
The total funding received from the government and all partners involved in managing the refugee situation is estimated to exceed half a billion euros so far.
In its Regional Plan for Refugees, the UN also estimates that the states which have received refugees will need about $1.8 billion to supplement services provided through public funds (Romania estimated a need of $239,858,526). The demand has been funded at 50.7% in 2022, but no funds have yet been allocated for 2023 needs. Also, data on allocation per country, per sector or beneficiary entity (government, civil society, UN or international agencies) are not available.
Out of the more than 3.2 million Ukrainian citizens who have crossed the borders in the last 12 months, more than 2.5 million have received direct support from the Romanian Government or its partners. There are currently over 107,000 Ukrainian citizens who have chosen to stay in Romania, of which more than 47,000 are children. (…) More than 500 million euros have been allocated from the state budget and international partners, 6 ministries are involved in the National Plan for the Medium and Long-Term Measures, more than 20 laws have been amended and adopted for the management of displaced persons from Ukraine, more than 1,500 local authorities and 300 NGOs are involved in providing direct support to refugees from Ukraine.
A sample analysis of funding allocations across various type of non-state actors (NGOs, UN etc), shows only a fraction of the overwhelming funding that went to the response reached local and national NGOs first responders, across all sectors. Since the beginning of the crisis in Ukraine up until the end of April 2022, the member organisations of The Federation of Child Protection NGOs- FONPC have supported a total of almost 380,000 refugees, investing a total of more than 6 million Euros. An overwhelming number of donations or funds has been received (16 organisations out of 22) in the form of private funds or allocations given by international NGOs (including grants), without any direct budget allocated by local or central authorities, the European Union. This situation also reflects the reported trend in the allocation of resources received for the Ukraine crisis HRP (details for the regional refugee plan are not available), where only 0.01% of the funds reported through the international assistance coordination mechanisms reached national organisations, and 0% to smaller local organisations, which were „implementing partners” of the UN and international organisations.
CARE international, a 75-year-old global INGO working to fight poverty and social injustice in the world, with a specific focus on the empowerment of women and girls, works side-by-side communities and local CSO partners to understand the root causes of poverty and find innovative, locally led solutions. When the crisis in Ukraine started CARE decided to respond to the needs of Ukrainian refugees in Romania and Moldova through their local partner SERA Romania Foundation (a non-governmental, non for profit, private organization), with whom they had been working for over 20 years in a truly localized approach. An additional 32 local partners were selected for the implementation of programs under the CARE/SERA contracting, a good proportion of which are FONPC members. CARE also supported FONPC to further strengthen the capacity of the local partners, undertake the advocacy initiatives and support the programme in general. So far the programme has reached 80,411 refugees in Romania, 3,414 in Moldova, and 66,054 conflict affected people in Ukraine (through cross boarder activities) by December 2022.
The main focus of the CARE and local partners response programs has been towards protection and fulfilling the basic needs of refugees. The majority of refugees entering Romania and Moldova are women, children and the elderly. This has meant that protection of vulnerable refugees has become a focus of our work in Romania and Moldova. The main response activities around protection have been;
– Dissemination of information and referrals: Ensuring that refugees get access to social services critical to ensuring that refugees are safe and supported within host countries, including Romania and Moldova.
– Child protection and safe spaces: The provision of safe spaces for children and vulnerable persons mean that refugees are supported within a secure environment. This has included supporting the registration of Ukrainian children in the Romanian social services system so that they have access to the benefits and social security as host community children do.
– Mental health and psychological support: After the traumatic experience of war, and potentially the loss of loved ones and their homes, it is important that refugees receive psychological support so that they are better able to deal with the impact of the war, as well as to reduce the mental trauma caused by the conflict.
– Reduction of human trafficking risks: By providing safe and secure transportation and information about services for refugees entering into Romania in the initial surge of displacement, we have been able to reduce the propensity of human trafficking for refugees.
Additionally, the CARE and local partners response has focused on providing basic needs to refugees either crossing the border or staying in a host community such as Romania or Moldova. Many refugees who enter the country often did not have the basic necessities to maintain a healthy and secure lifestyle. By not only providing refugees with safe refuge through our protection activities, but also providing basic needs such as food and non-food items – the response ensured that the basic needs of refugees in the immediate aftermath of the war were covered.
For health specifically, official data released by the Romanian Government shows that since the beginning of the war in Ukraine until the beginning of 2023, 19,594 Ukrainian refugees received medical assistance and 3,170 were hospitalized. Of these, 4,590 were transported by ambulance to hospitals.
On vaccination, the government report registers 462 children vaccinated against polio and another 444 against measles – first dose. Also, more than 1,000 elderly people sought social services.
Access to health services has been extended to Ukrainian refugees with temporary protection status. WHO, in partnership with the Government and other parties, has identified 24 family health clinics which are refugee-friendly. Those clinics receive help with language interpretation, registration, referral and financial support for refugee registration and service provision.
Legislative provisions – Legislative and policy framework
Given that Ukraine is not yet an EU Member State, immediate access for Ukrainians fleeing the war, let alone their integration, would not have been possible without immediate intervention on the legal framework to amend and correct several normative acts.
Romania has established a clear decision-making and coordination structure to enable agencies with different law enforcement and operational liabilities at all levels of government to plan, coordinate and interact effectively on the scene in response to the humanitarian refugee crisis.
From the first day of the conflict, a high-level decision-making Task-Force was set up at Government level, under the coordination of the Prime Minister, followed by an operational Task Force, called the „Ukraine Commission”, headed by the Head of the Prime Minister’s Chancellery and set up to oversee the activities of the ministries involved in the management of the refugee influx in all areas of intervention.
Also at the level of the Prime Minister’s Chancellery, the Strategic Coordination Group for Humanitarian Assistance, headed by a State Counsellor, has been established to provide the strategic framework for humanitarian response and to facilitate cooperation between agencies and partners at national, European and international level.
Romania’s response to the refugee crisis is structured on two levels of intervention: the first response, emergency assistance, and the second response, protection.
The first response, emergency assistance, is basically Romania’s emergency response and intervention for newly arrived refugees from Ukraine. The Department for Emergency Situations (DSU) of the Ministry of Internal Affairs led the operations in this phase, consisting of the deployment of resources and capacities at the main border crossing points on the way into the country, the provision of humanitarian transports, emergency shelter, food, basic medical assistance, etc.
The efforts undertaken by the Department for Emergency Situations have been complemented by legislative and administrative work at the level of other ministries within the Romanian Government, which have issued a large number of legislative acts to meet the emergency needs of refugees.
Local authorities have also coordinated their efforts with government agencies, developing their own operational plans based on local needs assessments.
The public effort was strongly supported by Romanian civil society, international non-governmental organisations, UN agencies and private actors. In parallel to the system created by the Romanian state, the UN under UNHCR leadership has also activated the thematic cluster system (protection, health services, basic needs, education and right to work), which is a platform for the allocation of funds received through RRP and Flash Appeal to UN agencies and international and local partners (28 active NGOs). Although the original intention was for the cluster system to be integrated into the Romanian state coordination system, in reality they operated with little integration in the early months of the Ukraine crisis response. Consultations for the 2023 plan have been initiated, however, while the UN provides a detailed report on funds allocated through the Ukraine Humanitarian Response Plan (UKraine HRP), there is no data available on the spending of funds received for refugees through the RRP for the inter-agency overall response (except individual UN agency specific activities).
The second response, the EU Civil Protection mechanism, is a mechanism developed to ensure medium and long-term protection and inclusion measures for Ukrainian refugees who choose to live in Romania.
- Thus, on 27 February 2022, just three days after the outbreak of the war, the Government adopted the Emergency Ordinance No. 15/2022 on the granting of humanitarian support and assistance by the Romanian state to foreign citizens or stateless persons in special situations from the area of armed conflict in Ukraine. This normative act created the legal framework for the provision of humanitarian support and assistance by the Romanian State to foreign citizens or stateless persons in special situations, coming from the area of armed conflict in Ukraine, in a similar way to the one applied to asylum seekers in terms of food, medical assistance, clothing and hygiene.
- In order to facilitate access to health services for Ukrainians who have fled the war, on 2 March 2022, the President of the National Health Insurance House issued ORDER No. 127 amending and supplementing the Order of the President of the National Health Insurance House No. 1.549/2018, which established the procedure by which foreign citizens or stateless persons in special situations from the area of armed conflict in Ukraine can access health services on the territory of Romania.
Procedure for Ukrainian citizens to access medical services in Romania
On the basis of the border crossing document accepted by the Romanian state, foreign citizens or stateless persons coming from Ukraine benefit from medical services, medicines, sanitary materials, medical devices and services included in the national curative programs, the same as the insured persons in Romania.
The healthcare providers to whom these persons turn send to the health insurance company, by any electronic means of communication, a copy of the document on the basis of which the person in question will be added to the Single Integrated Information System (SIUI), by assigning a unique identification number classified in a new category created specifically for the computerized registration of these persons, having the code 426, called „Foreign citizens or stateless persons in special situations coming from the armed conflict in Ukraine, entering Romania and not applying for a form of protection, according to Law no.122″. /2006 and who are not beneficiaries of the Convention ratified by Decree no.165/ 1961”.
„We need to provide the necessary medical care to these hard-pressed people, even if it means extra effort. The processing for the assignment of the unique identification number will be done in a very short time, that is why we recommend to doctors that when they provide medical services to a Ukrainian refugee, first of all they should send the health insurance company the necessary documents in electronic format, so that by the end of the consultation they will receive the unique identification number necessary for the registration in the SIUI of the medical service provided,” said Adela Cojan, interim president of CNAS.
● In view of the adoption on 4 March 2022 of Council Implementing Decision (EU) 2022/382 establishing the existence of a mass influx of displaced persons from Ukraine within the scope of Article 5 of Directive 2001/55/EC and having the effect of introducing temporary protection, it was decided to manage Ukrainian refugees in an integrated system and to avoid difficulties in supporting them, further amendments to primary legislation were necessary. Thus, on 7 March 2022, the Government adopted Emergency Ordinance No. 20/2022 on amending and supplementing certain legislative acts and establishing certain measures for humanitarian support and assistance.
This new normative act introduced new measures to provide support and humanitarian assistance to children, adults, people with disabilities and all Ukrainians coming to Romania, establishing solutions to ensure the rights to education, health, work, child protection, protection of people with disabilities. Emergency Ordinance No 20/2022 also includes measures to facilitate and encourage civil society, the private sector and individuals to continue making donations for the benefit of Ukrainian refugees, and international organisations to have a simpler mechanism for collaboration.
The main regulations of Emergency Ordinance No 20/2022:
- Ensuring border flow
- Extending the possibility of paying maintenance entitlements to situations where foreign nationals or stateless persons are hosted by private persons.
- Ensuring the right to education thus:
- Child protection
- Protection of persons with disabilities
- Health care
- Foreign citizens and stateless persons, who come from the area of armed conflict in Ukraine and do not apply for a form of protection in Romania according to the Asylum Law, receive free medical assistance and appropriate treatment for emergency situations through the national emergency medical assistance system. Medical services are provided in temporary camps for accommodation and humanitarian assistance or in accommodation facilities established by emergency committees.
- Ukrainian refugees are included in the national public health programmes to receive medicines and appropriate medical care.
- Regulations to simplify and facilitate people’s access to health services, such as access to the basic package of services is granted without a referral.
- Right to work
- Mechanism for the settlement of humanitarian assistance services provided by the Romanian state.
- Six working groups have been set up within the Strategic Coordination Group for Humanitarian Assistance, established under the Prime Minister’s Office to provide the strategic framework for humanitarian response and to facilitate cooperation between agencies and partners at national, European and international level. The measures proposed by them were included in the National Plan of Measures on the Protection and Inclusion of Displaced Persons from Ukraine, beneficiaries of temporary protection in Romania, a document approved by the EMERGENCY ORDINANCE no. 100/ 29.06.2022. The National Plan includes a variety of key interventions in six key areas: employment, health, education, housing, children and youth and vulnerable persons and aims to provide an integrated package of protection measures for Ukrainian refugees during the period of temporary protection and its extension.
- DECISION No 367 of 18 March 2022 on the establishment of certain conditions for ensuring temporary protection, as well as for amending and supplementing certain normative acts on the situation of foreigners.
- DECISION 337 /2022 on granting free of charge services and facilities for the transport of foreign citizens or stateless persons in special situations from the area of armed conflict in Ukraine.
- DECISION No. 336 of 11 March 2022 on the establishment of the mechanism for settlement from the budget of the County Inspectorates for Emergency Situations/Inspectorate for Emergency Situations Bucharest-Ilfov which include expenses for food and accommodation of foreign citizens or stateless persons in special situations, coming from the area of armed conflict in Ukraine, hosted by natural persons, as well as for the allocation of an amount of money from the Budgetary Reserve Fund available to the Government, provided for in the State Budget for 2022, for the supplement of the budget of the Ministry of Internal Affairs.
- DECISION no. 315/2022 for the approval of the maximum amount of accommodation costs in the accommodation facilities established by the county/urban committees for emergency situations for foreign citizens or stateless persons in special situations who come from the area of armed conflict in Ukraine and who do not apply for a form of protection according to Law no. 122/2006 on asylum in Romania, as well as for the allocation of an amount from the budgetary reserve fund available to the Government, provided for in the state budget for the year 2022, to supplement the budget of the Ministry of Internal Affairs.
- ORDER no. 3.325 of 2 March 2022 on the completion of the Annex to the Order of the Minister of Education no. 5.140/2019 for the approval of the Methodology on academic mobility of students.
- Emergency Ordinance No. 100/2022 on the approval and implementation of the National Plan of Measures on the Protection and Inclusion of Displaced Persons from Ukraine, beneficiaries of temporary protection in Romania, and for the amendment and correction of some normative acts.
IV Information on access of displaced persons from Ukraine to health services in Romania
4.1 Official data on Ukrainian refugees’ access to health services in Romania.
The official estimates of the government display an amount of more than half a billion euros, spent in 2022 from government funds (state budget) and from funds allocated by UN agencies and institutional partners involved in managing the refugee situation. More than €106 million has been paid from public funds for accommodation and food for refugees through the 50/20 programme, representing a daily expenditure of more than €352,000, but there are no exact figures on the cost of medical services and treatment provided to Ukrainian citizens so far.
Moreover, the official data that have been provided to FONPC do not reveal any information regarding access to health services in the public and private system. The National Health Insurance House (CNAS) explained in its reply to FONPC that, despite the claim for two existing health systems, one public and one private, in reality there is only one health system, composed of public and private facilities.
Thus, health insurance companies conclude contracts for the supply of medical services, medicines and medical devices with both public and private units, without discriminating on account of their form of ownership. At the same time, a person wishing to benefit from self-financed medical services, i.e. outside the social health insurance system, may apply to both a public and a private unit.
Basically, the CNAS talks about two systems of financing medical services, one public, through the social health insurance system, and one private, from the patient’s own financial sources, with the mention that in some cases these financing systems complement each other (for example, in the case of compensated medicines).
Medical units in contractual relations with the health insurance companies report to the latter only the medical services, medicines and medical devices that are subject to settlement by the health insurance companies, which is why the CNAS is not able to track the number of services/medicines/devices provided to patients outside the social health insurance system, and, therefore, the number of beneficiary patients.
According to the data centralized by the Ministry of Health, until mid-November almost 11,000 citizens from Ukraine were admitted to medical units in Romania, almost 14,000 were admitted into the Emergency Reception Units (UPU) and 868 were registered with chronic diseases.
Regarding the situation of admissions of Ukrainian refugees in Romania, a total of 10,699 admissions were registered in the period April – November 2022, with the most being registered in May (3,266) and June (1,434). Of these, 5,822 adults and 4,877 children requiring care in medical facilities.
Complementing these data, the “Report on Romania’s efforts and achievements in the field of humanitarian assistance to refugees, children’s rights and other vulnerable categories for 2022” mentions that 3,170 Ukrainians benefitted from prolongued hospitalisation.
The situation of admissions per month:
4.1.2. Admissions into the Emergency Room (ER)
The situation of admission into the ER, recorded by the Ministry of Health, shows that from March to mid-November 13,917 Ukrainian citizens developed medical problems that brought them to an emergency unit. The highest number of admissions into the ER, over 2,000, were recorded in March (2,498) and April (2,322).
Out of the nearly 14,000 people, 2,769 needed admission, with most cases recorded in March (516), April (474) and May (383).
Also, out of the total number of Ukrainian refugees who came to the ER, most of them, 9,808, arrived by personal transportation and 4,109 were transported by ambulance.
By the end of the last year, the government report mentioned 19,594 admission of Ukrainian citizens to the ER.
The situation of admissions into the ER of Ukrainian Citizens:
|Coming to the ER|
|By ambulance||By own transport||Admitted||TOTAL|
4.1.3. Chronically ill patients
Chronic diseases are conditions that last for long periods of time and their symptoms are relieved by treatments recommended by medical specialists. Some conditions require long-term treatment and appropriate medical monitoring (e.g. diabetes, arthritis, hypertension).
Between March and November, 868 Ukrainian citizens were registered with chronic conditions requiring medication and professional monitoring.
The situation of the chronically ill patients
4.1.4. Situation regarding access to emergency medical services in Bucharest – Ilfov
Between 23 February and 8 December 2022, the Bucharest – Ilfov Ambulance Service provided medical assistance to 3,374 people from Ukraine, 1,881 of whom adults over 18 years of age and 1,493 children.
When it comes to emergencies, 81% were code yellow and code red emergencies, with the highest proportion being code yellow, i.e. 2,703 people.
„There are diabetics, there are people with heart or cardiovascular diseases, there are people with oncological diseases who need help, there are people with neurological diseases, so there are people who demonstrate the whole range of reasons for which ambulances are usually called in Romania”. (Dr. Alis Grasu, manager of the Bucharest-Ilfov Ambulance Service)
671 more people requested at-home consultations during that period.
4.1.5 Health services used by vulnerable people (disabled children, physically and sexually abused people, etc.)
The Government report – “Romania’s response to the humanitarian refugee crisis 2022” shows that 13,782 Ukrainian children were referred to specialized services, including health and social assistance, and 4,993 children were registered with the General Directorates for Social Assistance and Child Protection (DGASPC).
287 persons with specific needs received protection assistance and 199 children are currently part of the special protection system.
In addition, 32,025 Ukrainian refugees received information about available protection services related to gender-based violence (GBV), sexual exploitation and abuse.
The report “Barriers and Bridges – Communication and Information Exchange in the Ukrainian Refugee Community in Romania, on Women’s Health Services, including Sexual and Reproductive Health Services (SRHR)” states that „refugees asked where they could find such clinics and doctors, whether they were free or for had to be paid for, etc. Information was incomplete or hard to find, and some pregnant women returned to Ukraine to give birth there”.
Regarding free psychological help for refugees, including children and seniors (information about special telephone lines, doctors, language barriers, etc. is missing), the same report points out that „the needs of the disabled people revolved in general around the recognition of their disability. The refugee centre in Iași (Nicolina) announced that the disability status issued in Ukraine is not valid in Romania, and refugees with disabilities (and their caretakers) have to obtain a new certificate in compliance with the Romanian procedures (a new medical commission)”
The report „Waiting for the sky to close: The Unprecedented Crisis Facing Women and Girls Fleeing Ukraine”, published in September 2022, following a partnership between VOICE and HIAS as part of a six-country assessment in the region, conducted a 10-day rapid assessment in Romania to assess the needs of women and girls affected by the war in Ukraine and the needs of women’s rights organisations and groups responding to this emergency. They reported high risks of being trafficked; lack of access to means of living and cash assistance; and inconsistent access to reliable information and services.
The assessment also highlighted protection concerns related to sexual exploitation and abuse (SEA) and unsustainable housing (which often increases the risk of labour exploitation). In general, the report notes, forcibly displaced people in Romania lack access to services to combat gender-based violence, reproductive health services, mental health and psychosocial support services (MHPSS), and legal services and information. In addition, Roma and LGBTQIA+ communities are met with discrimination and additional protection concerns.
The same report shows that forcibly displaced people face language barriers to accessing GBV and reproductive health services, and those in private accommodation face additional barriers to accessing services. For those housed in NGO-run centres, NGOs either provide access to GBV services or can facilitate access to these services. Some women’s rights organizations (not affiliated with shelters) noted that they provided limited services for PWDs and/or were prepared to provide these services. They mention the need to have appropriately trained translators or Ukrainian/Russian speaking therapists on their teams.
4.2. Funds allocated to the National Health Insurance House from the state budget for humanitarian support and assistance
In order to complete the picture on the provision of health services to war-affected Ukrainian citizens, the resources allocated and the sources of funding, FONPC also approached the National Health Insurance House (CNAS).
From the answer received it appears that in the CNAS budget for 2022, approved by Law no.317/2021 on the state budget for 2022, funds amounting to 26,448,000 RON have been provided for the implementation of the provisions of GEO no. 15/2022 on the provision of support and humanitarian assistance by the Romanian state to foreign citizens or stateless persons in special situations from the area of armed conflict in Ukraine, as amended and supplemented. By November, from the approved budget provision, funds amounting to 15,528,850 RON have been allocated per Health Insurance House for medical assistance granted in the period March – September 2022, to the afore mentioned persons.
At the same time, in its answer, the institution stated that it did not receive any non-reimbursable external funds for the medical assistance of refugees from Ukraine, the financing of this assistance being provided exclusively through transfers from the state budget to the CNAS budget, through the Ministry of Health.
CNAS also stated that, according to GEO no. 15/2022, persons from the area of armed conflict in Ukraine benefit from the package of services provided for in the framework contract on the conditions for the provision of medical assistance, medicines and medical devices under the social health insurance system and its implementing rules, as well as medicines, medical materials, medical devices and medical services included in the national curative health programmes, like Romanian insured persons, without payment of the social health insurance contribution, the personal contribution for medicines provided in outpatient treatment and with exemption from the co-payment.
CNAS confirmed that Ukrainian patients were provided with medical services on the main levels of health care, i.e. family medicine services, outpatient clinical specialist medicine services, outpatient paraclinical medical services, day and continuous hospitalisation services, dental medicine services and pharmaceutical services.
During the research, we also tried to find out how many Ukrainian citizens used public health services and how many of them were treated privately, but CNAS said that it could only provide information on the number of displaced persons from the area of armed conflict in Ukraine who received medical services paid for by the social insurance system in Romania, not having data on the number of refugees who received medical services funded from other sources or offered pro bono, given the large mobilization of civil society in our country for supporting them. Thus, according to the CNAS e-records, by 31 October 2022, more than 6,000 people displaced to our country because of the war in Ukraine had received medical services paid for by the Romanian social health insurance system.
4.3 Access in the health system as reflected in the reports of NGOs and international organisations
Access to medical facilities and medicines, challenges in registering with a family doctor, unfamiliarity with the Romanian language, problems in finding family doctors who accept Ukrainians, inconsistent procedures for registering with a family doctor from county to county, inability to obtain compensated prescriptions, lack of information about the full list of free or paid medical services are the main issues identified by non-governmental and international organisations in their reports and studies to understand how support can be better targeted.
The Federation of Child Protection NGOs – FONPC conducted a self-administered questionnaire to analyze the needs of refugees from Ukraine temporarily settled in Romania. Data collection took place from 2 to 9 September 2022 and a computer-assisted web interview methodology (a rapid method of data collection based on a standardized questionnaire via the internet) was used and, in total, data was collected from 513 respondents. The purpose of this survey was to collect responses from Ukrainian citizens, refugees living in Romania, in order to assess their needs for the upcoming months. The survey consisted of six questions, and each question allowed respondents to assess their needs in relation to the most common actions in their lives – access to health care, education, accommodation/transport, labour market, etc. The survey used a five-point Likert scale to measure needs as follows: 1 – not at all important; 2 – not very important; 3 – moderately important; 4 – important; 5 – very important. The survey results helped identify new needs and priorities seven months after the outbreak of war.
As regards access to health services, the FONPC analysis report found that this is the most pressing issue for Ukrainian citizens. This question explored their access to and perceptions of the different needs they might have in relation to health services, in particular access to specialised treatment for chronic diseases, gynaecological and mother and child services, general medicine, testing laboratories, therapy and specialised services (e.g. physiotherapy, psychological, behavioural therapy, etc.).
Access to specialist treatment for chronic diseases is not at all important for 9% of respondents; it was identified as slightly important for 11% of respondents, of moderate importance for 16% of respondents, important for 12% and very important for 52% of respondents.
Approximately 6% of respondents say that access to gynaecological or maternal and child health services is not at all important, 7% say these services are slightly important, 14% say they are moderately important, 14% consider them important and 59% of respondents consider them very important. Less than 1% of respondents (n=3/513) considered that access to general medical care is not at all an important need for the upcoming months. 4% of respondents say that access to general medical services is slightly important, 7% say this is of moderate importance, 10% think it is important, and the vast majority, 79% (n=405/513) of respondents think that access to general medical services is very important. Similarly, access to medical laboratories is equally important among Ukrainian citizens. Only 2% of respondents said that this need is not at all important to them, 5% answered that it is a little important, 11% said that it is a need of moderate importance, 18% answered that it is important and the majority, 64% of respondents, said that access to these services is very important. Finally, the responses received regarding the need for access to therapy and other specialised medical services (e.g. physiotherapy, psychological therapy, behavioural therapy, etc.) varied. 16% of respondents said that these services are not at all important to them, 10% considered it a slightly important need, 15% considered it moderately important, 12% considered these services important and 47% of respondents considered it very important.
For the open-ended question, respondents provided detailed information on the challenges they face in accessing healthcare as follows:
- Challenges in registering with a family doctor because many family doctors do not want to register Ukrainian citizens. As a result, this limits the ability of refugees to get medicines for chronic diseases since these medicines require prescriptions. In addition, not registering with a family doctor leads to another challenge – refugees cannot benefit from (at least partially) compensated medicines;
- Due to limited services there are challenges in accessing rehabilitation centres for children or adults with disabilities (e.g. services such as speech therapy, behavioural therapy for children diagnosed with autism, physiotherapy for people recovering from injuries or other chronic illnesses, etc.);
- Limited capacity to receive consultations and treatment from specialist doctors (the most common specialisations requested were paediatricians, dentists, diabetologists and ophthalmologists).
These data show a shift in the priority of needs identified by refugees compared to a study done by SERA, FONPC, FONSS, PLAN International and CARE in May 2022, where access to health services was less prioritized than the need for basic goods (food, hygiene supplies, etc.), transportation or housing, but respondents reported similar barriers to accessing services. Also, a vulnerable group for whom protection services did not have clear connections with specialised health services were people who had suffered physical and sexual violence (SGBV) or had been trafficked.
The International Organization for Migration (IOM) has conducted a report based on 10,097 valid questionnaires collected between 25 March and 10 October 2022. The data was collected in Brașov, Bucharest, Constanța, Galați, Huși, Iași, Maramureș, Suceava and Tulcea.
In terms of access to healthcare, the IOM report notes that the advice and information teams noted in the first two months that healthcare issues were not frequently raised by Ukrainian refugees as they expected to return to Ukraine shortly. Instead, it has now become an increasingly important issue, especially for chronic patients who need access to medication and consultations with specialist doctors.
The IOM therefore notes that access to medical facilities and medicines remains a priority need for Ukrainian refugees in Romania, and the main barrier to access doctors and treatment is not knowing the language. The report states that a limited number of Ukrainian refugees speak Romanian or English and, as a result, consulting a doctor is impossible without a translator.
In this context, there are testimonies from translators and data collectors at border crossings that some Ukrainian refugees return to Ukraine for short periods of time just to get medical assistance.
To the question „Do you have access to a health clinic where you are in Romania?”, asked by IOM representatives in August-October 2022, 4% of respondents in Bucharest answered no, 10% in Iași, 14% in Galați, while the percentage of those in Constanța who answered no was 43.
When asked the same question, 76% of Ukrainians in the capital said that they have easy access to health services, while 20% said that access is difficult. In Constanța, 49% said they had easy access and 7% said it was difficult. In Galați, 44% said they had no problems getting healthcare in a clinic, while 42% said it was difficult, and in Iași more than half of them (53%) said they were satisfied and 37% said access was difficult.
To the question „Do you have access to a hospital where you are in Romania?” the proportion of negative answers was as follows: 4% in Bucharest, 11% in Iași, 16% in Galați and 50% in Constanța. 82% of refugees in Bucharest answered the same question that they had easy access and 15% that access was difficult.
In Constanța, while half of those surveyed said they did not have access to a hospital, 36% said they had no problems and 14% said that getting healthcare in hospital was difficult.
In Galați, 42% of those who completed the questionnaire said they were satisfied with access to a hospital, while a further 42% said it was difficult, and in Iași half of those who responded said they had easily accessed medical services in a hospital, while 39% said they encountered difficulties.
„There is great variability in access to health clinics and hospitals from county to county. The majority of those living in Bucharest have no difficulty accessing healthcare in Romania, while a significant proportion of those in counties near the border with Ukraine, such as Constanța, Galați and Iași, have difficulty obtaining healthcare. According to information gathered from qualitative interviews, Ukrainians in these counties overcome these difficulties by crossing the border from time to time to see their doctor and ensure continuity in their healthcare. The limited access to health services in Constanța has been addressed by the establishment of an integrated community centre in September 2022, which also houses general practitioners and translators,” the IOM report said.
The same issues regarding refugees’ access to health services in Romania were also raised in the report Bridges & Barriers , produced by the Romanian Independent Journalism Centre in collaboration with representatives of the Internews humanitarian team, to see how information is communicated and exchanged in Ukrainian communities in Romania.
In terms of access to healthcare, the report shows that most refugees have problems finding family doctors who accept Ukrainians, mainly because of the language barrier.
„Humanitarian agencies have published lists of Ukrainian/Russian-speaking family doctors, but refugees have found that they are no longer relevant. Humanitarian agency staff also mentioned that many doctors are unaware of the existence of various translation apps and, as a result, are hesitant to see patients who do not speak Romanian. Some refugees in Bucharest said they could not register with a family doctor because they did not have residency papers.”
Ukrainians believe that many of the problems also arise because of the differences between the health systems in Ukraine and Romania.
„Many refugees mentioned that they don’t understand how the Romanian medical system works.”
The Bridges & Barriers report reveals that refugees say they do not have information about the full list of free or paid healthcare services, and the information they do get is very often based on the personal experiences of other refugees and has a high degree of variability.
„Most refugees know that the emergency medical system is free. Vaccination of children and adults, including for Covid-19 – where they can get vaccinated, how registration works, what is the vaccination scheme in Romania, etc. Medical prescriptions – how to get prescriptions, what medicines are available and free, what facilities are available to refugees with chronic diseases, what treatments can replace medicines not available in Romania (e.g. produced in Ukraine).”
Official and clear information is also lacking for women’s health services, including sexual and reproductive health services (SRHR). Refugees have asked where they can find such clinics and doctors, whether they are free or charged, etc.
„Information is incomplete or hard to find, and some pregnant women have returned to Ukraine to give birth there.” (Bridges & Barriers Report)
UNICEF ROMANIA, another international organisation that has been intervening in Romania since the outbreak of the war in Ukraine, notes in a report on its actions in support of Ukrainian refugees, published in late 2022, that multi-service centres, known as Blue Dot centres, were developed at the beginning of the crisis in cooperation with local authorities and partners such as UNHCR to provide refugee children and their families with a safe space and vital services such as protection, counselling and playgrounds.
In terms of access to health services, to meet the immediate needs of refugees, especially people and children with disabilities, UNICEF has provided access to essential services, including vaccinations and life-saving medicines. Mother and infant spaces have been created in Blue Dot centres as well as in transit and placement centres to provide safe places for breastfeeding and childcare.
To date, 95,000 parents and carers have received health-related information, including information on infant and young child nutrition. More than 16,000 Ukrainian women and children have benefited from access to primary health care through UNICEF-supported mechanisms.
A total of eight Blue Dot centres have been operational in Romania, most of them near the borders with Ukraine and Moldova. Since the start of the refugee action, 230,000 children and women have had access to these services in Blue Dot centres. More than 16,000 children and carers have accessed psychosocial and mental health support services and more than 3,000 children and women have benefited from GBV risk prevention and other prevention or response interventions.
As of February 2022, an estimated 700,000 Ukrainian children have crossed the border into Romania and the Border Police and local child protection authorities have identified and provided protection to nearly 5,000 unaccompanied or children separated from their families by the end of December.
V. Identify the main difficulties faced by refugees from Ukraine when accessing health services in Romania
Beyond the official data that the central authorities have recorded and transmitted, in order to understand the need for health care in Romania of Ukrainian citizens and how they manage to benefit from it, we tried to get a picture of this phenomenon by obtaining information directly from the ground level, from doctors, volunteers, representatives of NGOs or patients’ organizations and even from Ukrainian patients treated in Romania.
Following discussions with those involved in supporting refugees and with refugees from Ukraine who have directly faced medical problems and have had to turn to the Romanian health system, a number of problems have been identified that require both legislative interventions and especially financial support from the public authorities.
In parallel, FONPC asked several member organisations, involved in supporting refugees since the beginning of the war in Ukraine, to explain the main challenges they faced, what worked and can become an example of good practice and what solutions they identified to facilitate access of Ukrainian citizens to the health system in Romania.
While refugees avoid talking openly about their situations, volunteers and representatives of non-governmental organisations, who have been trying for almost a year to address the difficult situations that a citizen fleeing war and arriving in a foreign country can find themselves in, point to a whole series of drawbacks.
As a general observation from the analysis of the interviews and information provided by NGOs and others directly involved in supporting refugees, patients in Ukraine are reluctant to talk about the problems they have or how they have been supported to overcome them. When they do agree to talk, however, they speak in positive terms about their experiences in Romanian hospitals/clinics, have no complaints about the way they were treated, and generally admit to being pleasantly surprised by the way their problem was handled.
„I came to Romania to wait for the papers from Chișinău to go to Austria for treatment after a cancer operation. (…) I did all the investigations here and I will stay in Romania for the time being. I had the operation last December, in Ukraine, and now I need the follow-up procedures, the isotope radiation, which I did here. I did the first operation in Ukraine, before the war started, the second operation was supposed to be in April, but because the war started it couldn’t be done, and I was operated here, at Parhon Hospital, in August. I reached out to the UNHCR organization and they looked up which clinics could help me. The doctor here said that for now it’s going well and I don’t need any more treatment. I also sent the medical documents to my doctor in Kiev, because I wanted to know his opinion, and his opinion was the same, that I don’t need another round of treatment. I am happy that I ended up here, that I ended up in the hands of people who helped me.” (A.D., patient from Ukraine)
„I came to Romania on 14 March 2022. The first medical problem was with my child. She had dental problems, she had a toothache. (…) I also had health problems. I got sick during the weekend, I had acute pain in my throat, and I didn’t know where I could go. I turned to the volunteers, and they in turn suggested that I go to the doctors at the North Station. There I got help.” (O.M., patient from Ukraine)
The main difficulties that refugees from Ukraine reported when they had to access a medical service were lack of information and not speaking Romanian.
Obtaining the simplest information on the existence of the nearest hospital or doctor can become an extremely complicated problem for a Ukrainian refugee who does not speak Romanian or any other international language. Then, understanding how the Romanian medical system works and the procedure they have to go through in order to be registered with a doctor raises new obstacles that are impossible to overcome without a translator.
Finally, not being able to communicate with the doctor creates equally big problems, and in a serious medical situation can even cause life-threatening problems for which the doctor could be accused of malpractice.
At the same time, the inability to communicate clearly with the patient force many doctors to turn down Ukrainian refugees, as poor communication puts them in a position where they cannot help them if there is no translator to ensure that highly accurate information about the patient’s current and past health problems is conveyed.
A study in New Zealand shows that language barriers prevent refugees from understanding differences between health systems or health care delivery procedures, including the risk of not understanding the dosages of prescribed medication.
„My child was the first to have medical problems. She had dental problems, she had a toothache. The difficulty was that I don’t speak Romanian, and my English is very bad. I couldn’t call the reception of a dental clinic and tell them about my problem (…) The worst was when I arrived at the emergency room and I couldn’t explain what was hurting me and what the doctors could help me with, so I wouldn’t have any more pain. They put me on an IV and I was in so much pain that I was crying and they didn’t understand why. It’s quite a sensitive area here they put the drip in, it hurt a lot. It took about 10 minutes to explain through signs before they understood me and when they took the IV out, I felt better. I felt so bad I couldn’t even type on google translate. (…) In Ukraine, in the city where I live I have a family doctor, I have access to any specialist doctor I need, but here I don’t know how and to whom to turn to in case of need, and this stresses me out. People from organisations tell me that I can only get medical help after I register with the organisation or get a job, which offers me medical insurance and with the help of which I can access any specialist doctor I need” (O.M., patient from Ukraine).
In fact, not only patients but also doctors have admitted that most of the time when they arrive in hospitals or when the ambulance arrives at their accommodation, communication is done through Google translate.
„We don’t have any translator, they usually don’t speak English and we make due with our phone on google translate.” (Dr. Claudiu Rădulescu, Ambulance Service Bucharest Ilfov, general practitioner, emergency doctor)
„I have an acquaintance in Ukraine who has a much more serious diagnosis than I did.
I told him my experience. I told her that there is an organisation that can help them. (…) in times of war, moving in a foreign country with knowing the language is very difficult.” (A.D., patient from Ukraine)
„Refugees face two problems: first – registration within Romania’s health system, because without medical insurance doctors cannot see patients. The second is that most of them came to Romania without their medical records, and not speaking Romanian they can’t get along with the doctor.” (Maria Fedorova – Ukrainian citizen, representative of Amurtel Romania Association)
The inability to communicate in Romanian or an international language prompted the organisations’ representatives to help. The solutions identified by the NGOs were to call on volunteers to accompany patients, sometimes funds were found to pay for such translators. A solution would be for each local community to have a mobile team of translators that hospitals could call on if needed.
The NGOs called out to the Romanian state and international organisations, as well as European institutions, to mobilise funds to provide at least one translator for emergency services.
Another solution would be to include basic information on talking to doctors in education modules for children and adults. Therefore, both at school and in Romanian language courses for refugees, this module on health services should be included. The existence of dictionaries that include this type of conversation would also be very useful.
“Difficulties in accessing certain medical services, either because of their cost or because of language barriers. Project specialists identified clinics offering free services and translators accompanied them to consultations.” (SCOP Timișoara)
„Another problem encountered is the lack of translators for Russian-Romanian that could facilitate Ukrainian people’s access to medical and social services. For example, the total lack of at least one translator in the state hospitals, taking into account that every day citizens of Ukrainian origin arrive there for medical treatment/consultations.” (Bethany Social Services Foundation’s Community Centre for Children and Families in Ukraine team)
„One of the biggest challenges for both refugees in need of services and those helping them is the language barrier! Considering that we are talking about medium and long term support, one of the solutions is to start intensive language learning programs, supported by the state, and another solution, would be the creation of a mobile team of translators (at least in big cities) that can be requested by refugees when they need to turn to different services/institutions.” (Profilaxis Timișoara Medical Aid Foundation)
”Lack of access to information/ reduced access/ misinformation/ language barrier (…) information is vast and dense, just like navigating the medical system. It’s hard to translate, literally and figuratively, to foreigners when Romanian citizens also have difficulty navigating the bureaucratic hodgepodge.” (Rădăuțiul Civic Association)
„Many of the refugees cannot access medical services because of the language barrier, and our organization helps them to get in touch with other NGOs and register with the doctor.” (Amurtel Romania Association)
„Translating medical records is another anguishing process, as medical protocols in Ukraine and the Commonwealth of Independent States are largely different from the protocols used by EU member states. Thus, we have encountered such situations where, after we have ensured the authorised translation of the medical file, the doctors in Romania decided that the whole set of investigations and tests had to be repeated in order to establish a treatment scheme that would follow the EU protocols, as the patient’s file in Ukraine was based on different procedures and treatments, not recognised in the European area.” (ASSOC Baia Mare Association)
Apart from the lack of knowledge of Romanian, an equally pressing problem is the lack of funds for the purchase of medicines, for medical investigations or for the translation of medical documents.
From the analysis of data received from NGOs and interviews with people in Ukraine, it appears that the latter were able to benefit from medical services if they had the support of NGOs, which helped them both with translation, including translation of some medical documents, and with the purchase of medicines. It is important to stress that especially people with chronic illnesses, disabilities or who have experienced physical or sexual abuse are in urgent need of medical services (medical consultations and specific treatments) and long-term care. There is therefore an urgent need to mobilise funding and to facilitate their access to services: translation, funding for consultations, medical and other specific treatments, including hospitalisation.
„Why did I turn to volunteers? Because I didn’t have the money to go to a private clinic or to buy the necessary medication. At the North Station, the doctor’s consultation and the medicines were given to me for free.” (O.M., patient from Ukraine)
„For people suffering from serious illnesses, who do not have enough financial resources, in times of war, moving to a foreign country with an unknown language is very difficult, and they face various doubts and fears”. (A.D., patient from Ukraine)
„IOM Romania (International Organization for Migrants), as long as it had funds, helped people who needed medical assistance, but at the moment the waiting list is very long. (…) I don’t know the exact number, but there are enough. Especially patients with chronic diseases who need specific medicines, for example insulin-dependent diabetics, patients with chronic thyroid disease who need hormones, disabled people who have had their disability certificate expire and need to extend it. (…) Refugee medical records are in Ukrainian, and in order to be understood by Romanian doctors, they have to be translated, which involves significant costs.” (Maria Fedorova – Ukrainian citizen, representative of Amurtel Romania)
The registration of patients from Ukraine with the family doctor, although theoretically a solved problem from a legislative point of view, things work only partially, in practice according to data received by FONPC. Theoretically, people from Ukraine who have a temporary residence permit can go to any service provider, i.e. family doctor, doctor in a polyclinic that has a contract with the Insurance House or hospital doctor. They should log on to the website of the National Health Insurance House (CNAS) and generate a unique code in our health insurance system under which they can be treated like any other Romanian citizen. In reality, doctors either fail to generate the unique code from the CNAS platform, or they appear as invalid on the list of the doctor they have registered with, and the latter is unable to settle the costs of any prescriptions issued or referral notes.
Another issue that seems to have been overlooked is the time allocated to a family doctor for a consultation, i.e. 15 minutes, and the number of consultations that such a doctor can make per day, as set out in the Framework Contract regulating the conditions for the provision of healthcare, medicines and medical devices, technologies and assistive devices under the social health insurance system for the years 2021 – 2022:
„The total number of points reported for medical services provided by family doctors with their own lists, corresponding to a 35 hours/week schedule and a minimum of 5 days per week, may not exceed for the activity carried out the number of points resulting according to the work schedule, taking into account the following:
– the average time/consultation in the doctor’s office is 15 minutes;
– an average working time of 5 hours/day for consultations in the office, established in accordance with the provisions of Article 1(1)(a) of the Directive. (2) (a) (3);
For a work program of 5 hours per day for consultations at the clinic, where payment is made by medical service rate, an average of 20 consultations per day calculated over a quarter is taken into account, but not more than 40 consultations per day. – maximum 3 home visits per day but no more than 42 consultations per month. In these conditions, if the doctor has 15 minutes for a consultation and translation is needed to understand the patient, the allocated time doubles. The second aspect concerns the calculation of the average of 20 consultations per day that the doctor can bill. In other words, even if the family doctor makes an effort to see extra patients, he would be in a situation where the services would not be reimbursed.
The biggest obstacle we faced when we started supporting Ukrainians who needed medical care was the difficulty in registering them with a family doctor. The first aspect that needs to be clarified is why this registration was and is necessary. Although everyone has access to emergency medical services, in many cases these services are not sufficient given the conditions patients suffer from. Many Ukrainians suffer from chronic conditions, are classified as disabled, and many children need vaccinations. Treatment and periodic medical care are necessary for these people, and this set of services is not offered by the emergency medical service. Thus, the only way to ensure it is through registration with a family doctor in Romania. Unfortunately, the number of family doctors is too small in relation to the population in Romania, which leads to the overloading of doctors and even the refusal to register Romanian citizens.” (The Baia Mare Association)
„Unfortunately, the legislation that came into force in March 2022, which allows doctors under contract with the CNAS to request the reimbursement of consultations for refugees, has not changed the situation very much. On the one hand – for doctors – the legislation does not clearly state how and with what documents from the patient/refugee the consultation must be justified. On the other hand, from a practical point of view, the law allocates to a consultation the same remuneration and time as for a Romanian – speaking patient, losing sight of the detail of translation – which practically doubles the consultation time. The law also does not provide for resources to ensure translation, which remains the responsibility of the doctor or the patient. Thus, even if some NGOs solve the problem of translation, doctors prefer to offer only occasional „pro bono” consultations rather than juggle with the CNAS’s reimbursement. In Timișoara, the Profilaxis Medical Centre, with the support of the Profilaxis Medical Aid Foundation, has accepted the challenge of paying the CNAS for consultations offered to refugees from the very first month, and is probably one of the few private medical establishments to do so. Around 500 refugee patients have crossed the threshold of the Profilaxis Medical Centre, most of them with frame diseases, who need regular assessment and prescription, but also newborns who have entered the national free vaccination programme. Here the management team has appointed a family doctor who consults all refugees, and provides referrals to other specialist doctors or compensated prescriptions for the chronically ill. (Profilaxis Medical Aid Foundation Timișoara)
Faced with dead-end situations, with patients in need of medical consultation and treatment, which were impossible to obtain without a family doctor who could take care of them, NGO representatives had to increasingly access emergency services, aware that they were overburdening both ambulance services and staff and resources in emergency units.
„The big problems are drugs, health system, because we don’t have access to the health system except in emergencies. (…) Family doctors are not able to generate their unique code. The problem is not that the doctors refuse to see them, for there were even some doctors who wanted to help. Both in Râmnicu Vâlcea and in Băile Olănești, they helped, but trying to generate the patients’ code they did not succeed and eventually they got fed up. You know how it is, nobody works for free. I guess that’s it too.” (Rebenciuc Foundation volunteer, which cares for 700 refugees from Ukraine)
„Reluctant attitude coming from the community/family doctors/refusal of the latter to put them on patient lists. There are few doctors who register patients from Ukraine, even though their status here is regulated by national legislation and European directives etc. In the case of the lucky ones, someone or they themselves (the educated ones who inform themselves) pay their insurance, even though they shouldn’t, and are listed as insured in the health system. (…) There are GPs who prefer the non-employed patient, but who has an employed spouse or child and could co-insure them, to pay for their insurance, after so much time they still do not apply/understand the mechanism of co-insurance, and do not enrol until the non-employed person comes with proof of insurance payment.” (Rădăuțiul Civic Association)
„System errors in the database at the level of the County Health Insurance House. In these cases clinics could not enter the assigned Identification Number. We also had a case that was not identified in the database of the County Health Insurance House, although it was registered with the family doctor. This is the case of a child suffering from epilepsy. The family doctor could not issue her a prescription because she was not in the database.” (SCOP Timișoara)
„First of all, one of the challenges was the lack of Russian-speaking family doctors who were willing to provide medical services. This made it impossible for Ukrainians to access the ‘compensation’ system for prescriptions or medical consultations, and they had to pay 100% for every medical service they needed.” (Bethany Social Services Foundation’s Community Centre for Children and Families in Ukraine team)
„The difficulty is that the family doctor cannot officially see Ukrainians because they do not exist in the national health insurance system. And there is no legal basis for the family doctor to register them in the system. In this case there are 2 solutions. The first – hospitalization, by calling the emergency, the second through NGOs that have international funding, and offer access to medical services in private clinics. But at the moment the funding of many organisations is exhausted.” (Amurtel Romania Association)
Lack of funds to buy medicines or perform medical investigations is another major problem identified by the qualitative analysis.
The inability to register with a family doctor also makes it impossible to obtain a compensated prescription or a referral for tests or other medical investigations. In the first phase of the humanitarian crisis, the mobilisation of civil society was aimed at securing essential medicines for the chronically ill, for whom continued treatment was vital. Subsequently, the needs became more and more diverse and the funds available to international organisations became insufficient.
Getting Ukrainian patients who could not register with their GPs into emergency care was only an insignificant first step in solving their medical problems, as any further treatment or further investigations required money. Therefore, NGO representatives had to find, once again, ways to support these costs.
Initially, various private clinics provided some investigations free of charge, funds were obtained from international organisations to cover the costs of treatment and medical services, networks of support services – public institutions, NGOs, private services – were created at local level to help, but the prolongation of the war and the increase in the number of refugees, or refugees in need, meant that these funds were increasingly scarce and waiting lists were getting longer.
„We have a member organisation within COPAC which is based in Iași, which is very close to the area where the wave of immigrants was very high and the first thing they did was to collect pharmaceuticals that could be used by those who needed them, being patients with chronic diseases, who had to continue their treatment and who couldn’t find solutions, especially in the first minutes, when we didn’t know exactly what to give them and how to coordinate them. (…) We have colleagues from the Diabetes Patients Association who collected and donated medicines, and I mean insulin, I mean those blood glucose tests, those machines, consumables, things that could be used by people with diabetes to continue their treatment or to monitor their disease. (…) The transplant colleagues, likewise, took patients who needed dialysis, who needed treatment, being transplant patients, and directed them to university centres and to dialysis centres and many of them, including haemophilia colleagues, tried to provide treatment, including accommodation, to those who came into the country. (…) In fact, that was the most important thing, that these patients didn’t interrupt their treatment and put their lives at risk.” (Radu Gănescu, President of the Coalition of Patients’ Organisations with Chronic Diseases – COPAC, Vice-President of the European Patients’ Forum)
„In the last 2 months our organization has managed to help about 250 people to get to the doctor. (…) But at the moment the funding of many organisations is exhausted. Some are on the waiting list. People with disabilities, whose disability certificate has expired, those who need to see the dentist (getting to the dentist is a big problem), people who need surgery, or expensive investigations, because they need hospitalisation but don’t have access to the health insurance system. All these cases are on the waiting list, only some are in the settlement stage.” (Amurtel Romania Association)
„At the moment, the clinics with which we have collaborated offer free treatment and consultations in a very small number according to medical specialties. In the first months, the Regina Maria clinic offered free consultations to Ukrainians, and all that was left for us to do was to provide translation and funds to pay for prescribed medicines in cases where the sick people could not afford it. The ASSOC Association, with the financial support of the FDSC, through the „In a Good State” programme, carried out a 4-month project which also had a component covering the costs of medical services and treatments. At the time, many requests were for dental treatments, as almost no clinics covered these treatments and interventions free of charge. Drug treatments for many other conditions were also provided, as well as consultations other than dental.” (ASSOC Baia Mare Association)
„All the prescriptions have to be bought by someone, because there are people who come from war zones, they have no home, they have nothing. So they actually came with their clothes on. (…) We take them to emergencies. We stay with them in the emergency room for 4 hours, 5 hours, as long as it takes to stay there until they are given a prescription, and with the help of good people, because I personally have no chance of being able to support them financially, I have come to ask everyone, both those I know and those I don’t know, to buy them a prescription. There are also a few foundations that have offered and helped us buy prescriptions for those we go to the emergency room with and give them treatment. But it’s clear that this won’t go on forever. Everyone buys one prescription, two, three four, but they are expensive. That’s not going to be a solution we’re going to rely on.” (Rebenciuc Foundation volunteer, who cares for 700 refugees from Ukraine)
„A network of support services – public institutions, NGOs, private services – was set up in Timisoara from the very first days of the war, which worked very well during the more than 10 months of the war. The Profilaxis Medical Aid Foundation joined this network, providing medical services. Over time, some partners have withdrawn, others have remained „on the barricades”, identifying solutions and funding to ensure the transition from an immediate to a long-term humanitarian response to the Ukrainian refugee crisis.” (Profilaxis Medical Relief Foundation Timisoara)
„The specialists in the project identified clinics offering free services and the translators accompanied them to consultations. If no clinics offering free services were identified and the beneficiaries could not cover the costs of the consultations, they were offered financial support. Some of the medical services that are difficult to access for refugees from Ukraine in Timisoara include: dental medical services – only emergency services can be accessed free of charge, all we could do in this case was to provide translation of consultations, facilitate access to dental X-rays, facilitate access to dental clinics near their homes; access to CT scan – in order to benefit from this medical service, refugees from Ukraine have to wait 6 months; neuropsychiatry and physiotherapy medical services – children who need these medical services are put on a very long waiting list. ” (SCOP Timișoara)
„Mobilization on providing medical treatments and interventions was the salvation of Ukrainian citizens who came with various frame diseases, or found out right after coming to Romania that they have cancer, diabetes or other untreatable diseases.” (Bethany Social Services Foundation’s Ukrainian Community Center for Children and Families team)
The NGO effort to help refugees get the medicines they need has been joined as far as possible by doctors. Not infrequently, when they were called through the 112 system for consultations, in addition to the occasional interventions, they would leave them some of the medicines they had in their kit, just enough to last them until they could get treatment from pharmacies.
„We also did treatment, lowered blood pressure and even left them some of our medication and prescribed the prescription so they could buy it later. Even in children, if we are talking about antithermics, we left our suppository, we also left the prescription.” (Dr. Claudiu Rădulescu, Ambulance Service Bucharest Ilfov, general practitioner, emergency doctor)
One serious problem we want to highlight in this review is the situation of babies who cannot be vaccinated.
As regards the vaccination of children, the Government Report on Romania’s efforts and achievements in the field of humanitarian assistance to refugees, children’s rights and other vulnerable groups for the year 2022 mentions that 462 Ukrainian children have been vaccinated against polio and another 444 with the first dose of measles vaccine.
Also, the list of facilities for refugees from Ukraine published by the Romanian Government states that „All children from Ukraine on the territory of Romania, including those who do not apply for protection under the Asylum Law, (…) have the right to a health assessment in educational establishments, and if they are not vaccinated they can benefit from the vaccination scheme according to the National Vaccination Programme run by the Romanian Ministry of Health”.
This situation is all the more delicate in the context that since the beginning of the humanitarian crisis there has been talk of Ukraine reporting low vaccination coverage of diseases that had been eradicated in the country, such as measles, polio and diphtheria.
„We even have cases of measles in children, especially since Ukraine was a country with poor vaccination coverage and many communicable diseases, some with very serious potential, which have not existed in Romania for a very long time, I mean a variant of polio due to a modified vaccine virus, as happens in countries with poor vaccination coverage, or even diphtheria. So we are following all these elements, we have to improve all the time the collaboration with the Inspectorate for Emergency Situations in order to know where there are such agglomerations of people coming to Romania, so that we can offer them this first medical assistance, plus testing for various communicable diseases, including infection with the new coronavirus and vaccination not only against COVID, but for all the communicable diseases included in the national programme is possible”. (Minister of Health, Alexander Rafila, 25 March 2022).
Representatives of non-governmental organizations, however, point out that vaccination of children can only be done through the family doctor, and if registration is not possible, vaccination cannot be done either. Such a situation was reported to us in Valcea county.
„We have big problems with having 56 unvaccinated babies. We have a newborn baby whose mummy said to me yesterday: ‘Alina, please come with me to the vaccine’. I don’t want to scare them, to tell them that we don’t have a chance, and I’m talking to them because I don’t have any other option now. (…) They accept the Romanian vaccination scheme without any problem. (…) The problem is that we don’t have a family doctor and vaccines are only given by a family doctor. I have looked into it and there is no other option. There is only the paid one, which is pointless to consider because we don’t have the funds to buy the vaccines for the children. We barely manage to buy them formula milk, pampers, hygiene products, and that’s as much as we can. The IOM has helped us, foundations have helped us, but again, nothing is forever.” (Rebenciuc Foundation volunteer, which cares for 700 refugees from Ukraine)
„They can be done for free, because we can ask for the doses from the Public Health Department (DSP). For the vaccination service I don’t think we get paid. Since we don’t have a Romanian CNP, we can’t report them to the DSP. Thus people acted pro bono when there were vaccine doses available. In Bucharest there was no problem with that, but in the rest of the country many colleagues complained that there was simply no vaccine, it didn’t matter whether someone was Romanian or Ukrainian, they didn’t have enough doses in general.” (Raluca Zoitanu, family doctor and president of the National Federation of Family Doctor Employers, in an interview with PressOne)
Solutions identified by NGOs
Beyond the problems that inevitably arise in such a tense moment, such as the one created by the state of war, the huge mobilization of the Romanian authorities, the Romanian civil society, the private sector and the international organizations that joined hands to provide an urgent humanitarian response is in itself perhaps the best model of best practice. As the government report on Romania’s involvement in supporting people fleeing war shows, more than 1,500 local authorities and 300 non-governmental organisations are involved in providing direct support to refugees in Ukraine. Everyone involved in this humanitarian response has at least one model of good practice that can be multiplied to improve support to those in need.
● Collaboration between central and local authorities and civil society
The humanitarian response for refugees in Ukraine has been effective even when situations seemed intractable, thanks to the fact that at such a critical juncture central and local public authorities, non-governmental organisations and the private sector have teamed up. By working together, all those who can help, solutions to what seemed to be extremely difficult problems were found, sometimes in a very short time.
This kind of collaboration has also worked in the medical field. This has enabled medical clinics to be set up overnight at border crossings and support networks to be developed locally so that chronically ill people in Ukraine could continue their treatment even though they had not been able to register with a doctor, patients with serious problems could be operated on or have the medical investigations they needed even though they were not paid for.
Such mobilization, which made possible medical treatments and interventions, meant the salvation of Ukrainian citizens who came with various frame diseases, or found out even after coming to Romania that they had cancer, diabetes or other incurable diseases.
However, more efforts are needed to integrate the international aid that has been channelled through the UN platforms to further support the services available to refugees and to direct more of these funds to organisations and civil society that actively contribute to the National Plan for Refugees.
● Psychological support for adaptation to the new environment
„The free psychological support offered by most NGOs is of paramount importance in regulating and balancing the mental and emotional health of people who have experienced trauma and strong emotions, imbalance or material loss. The psychological support offered also aims to facilitate faster and more functional integration and increase motivation to live effectively and with purpose.” (Bethany Social Services Foundation’s Ukrainian Community Centre for Children and Families team)
● Ensuring translation in interaction with state institutions / hospitals / medical clinics
„Another method used by the institutions, and which has proven effective, is to employ a person with Russian/Ukrainian language skills to accompany Ukrainian citizens to various public/private institutions, as they play a key role in facilitating their integration into the Romanian social context, as well as into the structure and way the social/health/economic system operates in Romania.” (Bethany Social Services Foundation’s Community Centre for Children and Families in Ukraine team)
Since the outbreak of the armed conflict, the EU has expressed its full solidarity with Ukraine and the Ukrainian people, providing coordinated humanitarian, political, financial and material support.
The Council of the European Union notes the concrete steps taken by the EU to help the refugees, including:
– a temporary protection mechanism for people fleeing war
● €523 million in humanitarian aid
● civil protection support to Ukraine, the Czech Republic, Moldova, Poland, Slovakia and the United Nations High Commissioner for Refugees (UNHCR)
● financial and technical support for Member States hosting refugees
● border management support for EU countries and the Republic of Moldova
On 29 June 2022, the Commission also presented the FAST-CARE (Flexible Assistance for Territories) proposal in response to the European Council conclusions of May 2022, which called for new initiatives to support millions of refugees fleeing the war in Ukraine, including through support to neighbouring countries.
On 15 September 2022, MEPs adopted simplified rules for the use of EU regional funds to address the consequences of Russian aggression against Ukraine.
The FAST-CARE rules further simplify the procedures for Member States to use financial resources to address the consequences of Russia’s invasion of Ukraine. The new rules provide for additional pre-financing of €3.5 billion in 2022 and 2023. Given that refugees can change location several times, the location requirement has been removed. Member States are also now allowed to declare expenditure for projects already implemented related to the needs of refugees and can also obtain, until mid-2024, 100% EU funding for projects promoting the socio-economic integration of third-country nationals. For these projects, at least 30% of the amount must be granted to local authorities and civil society organisations working in local communities.
Despite the adoption of these simplified rules, we have not been able to identify any organisations or institutions that have benefited from FAST-CARE funding. We have requested an official point of view from the European Commission Representation in Bucharest, but at the time of finalising this report we have not received a response.
Also, as a contributing member of the funds allocated through the UN-coordinated Regional Refugee Plan (RRP) and FLASH Appeal, the European Commission and contributing Member States have a responsibility to ensure that the funds have been implemented with impact and that sufficient resources have been channelled to community partners supporting government efforts, but no data was found on allocations to health services or civil society organisations.
What the Romanian authorities say about EU funds allocated to support citizens in Ukraine
In an attempt to get an overview of the needs of Ukrainian refugees arriving in Romania and the resources available to meet them, FONPC asked several public institutions (ministries and government agencies) to report whether they have received additional funds, for what purpose and how they were allocated.
Please note that requests for data were sent to the General Secretariat of the Government, the Ministry of Health, the Ministry of Internal Affairs, the Ministry of Labour and Social Solidarity, the Ministry of Family, Youth and Equal Opportunities, the Ministry of Investment and European Projects, the Ministry of Development, Public Works and Administration, the National Public Health House, the Public Health Directorate in Bucharest, as well as to a number of private clinics, the latter of which refused to provide data on medical services provided to citizens of Ukraine.
A compilation of the responses received from public authorities shows that although most are involved in dealing with the various problems faced by people who have fled war, these activities have been supported with funds from their own budgets. The only ministry with direct responsibility for administering temporary protection measures for Ukrainian refugees who do not seek some form of protection in Romania and which has received external funding to support them is the Ministry of Internal Affairs, which amounts to €39.1 million.
The Ministry of Internal Affairs
The Ministry of Internal Affairs (MAI) has informed FONPC that by the beginning of August 2022, the Directorate for Non-Reimbursable External Funds (DFEN) of the central apparatus of the MAI, in its capacity as Managing Authority for Home Affairs, has signed two financing contracts with the European Commission, for a total amount of 39.1 million euros, of which 12.1 million through the Asylum, Migration and Integration Fund (FAMI) and 27 million through the Border and Visa Management Instrument (BVI).
„On 11 and 12 August 2022, €39.1 million was paid into the accounts of the Ministry of Internal Affairs and on 19 October, DFEN sent the European Commission the final reports signed at Managing Authority level for the two contracts (FAMI and IMFV). The funds will be used on the basis of the principle of non-cost related financing and the purpose of the emergency assistance is to cover the budgetary effort of the EU Member States most affected by the refugee crisis in Ukraine, i.e. expenditure related to the reception of Ukrainian citizens under the terms of the Decision on temporary protection of 4 March 2022 and for activities related to border control and facilitation of border crossing at the relevant external borders of the EU. The Financing Contract for the project Improvement of accommodation conditions for refugees from Ukraine, financed from the Norwegian Financial Mechanism – Bilateral Fund (100% GRANT), in the amount of 2,457,100 RON, was also signed, with the beneficiary being the General Inspectorate for Emergency Situations (IGSU). It should be noted that in the period 24.02.2022 – 08.11.2022, 4,390 asylum applications by Ukrainian citizens were registered and 83,428 residence permits were issued.
At the same time, we mention that the funding mechanism was established on the basis of Government Emergency Ordinance No 15/2022, as amended, Government Decision No 336/2022, as amended, Government Emergency Ordinance No 100/2022 or Government Decision No 367/2022, as appropriate,” MAI states.
The mentioned institution also said that the amounts allocated to the Ministry of Interior until the moment of formulating the answer requested by FONPC, from the Budget Reserve Fund available to the Government for the support of foreign citizens or stateless persons in special situations who come from the area of armed conflict in Ukraine and who have not requested a form of protection under the Law no. 122/2006 on asylum in Romania are 395,890 RON, as follows:
Government Decision No 315/2022: 207,890 RON;
Government Decision No 336/2022: 18,000 RON;
Government Decision no. 494/2022: RON 45,000 RON;
Government Decision no. 799/2022: 95,000 RON;
Government Decision no. 1033/2022: 30,000 RON.
The Government of Romania, through the Decisions of the National Committee for Emergency Situations, provided the following materials to Ukraine:
– By DECISION No. 8/2022 – various types of medicines (11,900 pcs. analgesics, 12,000 pcs. anti-inflammatories, 10,000 pcs. antibiotics) and 7,340 litres of disinfectant;
– By DECISION No 10/2022 – 44 005 kg/litres of food, 4 000 pieces of household goods and 1 000 tonnes of fuel;
– By DECISION No 11/2022 – 11 type A and B ambulances;
– By DECISION No 14/2022 – 311,436 litres/tonne of fuel;
– By DECISION No 17/2022 – 180 kg medical products – human immunoglobulin;
– By DECISION No 21/2022 – disposable Tyvek contaminated area protective coveralls – 600 pieces, Tyvek contaminated area chips – 600 pairs, Brown reusable radiation protection coveralls – 130 pieces, Latex contaminated area protective gloves – 4000 pairs, personal dosimeters with alarm facilities – 200 pieces, portable gamma flowmeters – 50 pieces;
– By DECISION No 25/2022 – 385,000 surgical masks, 39,936 visors and 8,150 coveralls.
Subsequently, on 28 December 2022, the Government adopted a new decision supplementing the budget of the Ministry of Internal Affairs by 56.7 million RON for the settlement of expenses for food and accommodation of citizens from the area of armed conflict in Ukraine hosted by individuals.
The supplement to the budget of the Ministry of Internal Affairs was made for the settlement, in December, of food and accommodation expenses for about 27,000 foreign citizens or stateless persons from the zone of armed conflict in Ukraine, hosted by natural persons.
„The money represents financial support of 20 RON/person hosted/day for food and 50 lei/person hosted/day for accommodation. This is in line with the payment schedule set by GD no. 336/2022. The amount is allocated from the Government’s Reserve Fund and represents commitment and budget appropriations to finance the expenditure provided for in Article 1(10) of GEO 15/2022 on the granting of humanitarian support and assistance by the Romanian State to foreign citizens or stateless persons in special situations from the area of armed conflict in Ukraine”, reads the communiqué sent by the Government at the end of last year. In the same communiqué,
The Government noted that, against the background of the prolonged conflict situation in Ukraine, it allocated funds amounting to 335 million RON, representing humanitarian support and assistance to foreign citizens or stateless persons from the area of armed conflict in Ukraine.
At the same time, in view of Article VIII of the Government Emergency Ordinance no. 20/2022 on amending and supplementing some normative acts, as well as for establishing some measures of humanitarian support and assistance, for granting humanitarian support and assistance to foreign citizens or stateless persons in special situations, coming from the area of the armed conflict in Ukraine, the General Inspectorate for Emergency Situations of the Ministry of Internal Affairs has collected from donations, so far, the amount of 217000 RON.
MAI also mentioned that the General Inspectorate for Emergency Situations is currently implementing the following grants signed with the European Commission:
● „Grants for an action” Romanian Shelter Capacity (RO-SHELT) (130.595.000 RON).
● ECHO/RESP/EXT/SUB/2022/869439/UARO2 (2.400.570 euros).
The Ministry stated that, according to Article 2(1) of GD No 315/2022, accommodation costs for foreign nationals or stateless persons in special situations who come from the area of armed conflict in Ukraine and who do not apply for a form of protection according to Law No 122/2006, are paid by the county inspectorates for emergency situations, under the terms of the law, to central or local public institutions or authorities, public or private economic operators and to associations or foundations.
Analysis of EU support to Romania during the Ukraine crisis – The Ministry of Investment and European Projects
The Ministry of Investment and European Projects (MIPE) has provided further details on the external funds allocated to support refugees from Ukraine who have arrived in Romania, as well as their origin, in response to a request from FONPC.
The representatives of MIPE mentioned that on 18.03.2022 the Government Decision no. 367/2001 on the establishment of certain conditions for ensuring temporary protection, as well as for amending and supplementing certain normative acts in the field of foreigners, published in the Official Gazette of Romania no. 268/2022, entered into force. The normative act issued at the proposal of the General Inspectorate for Immigration, for the application of the Council Decision of the European Union implementing Decision (EU) 2022/382 of 4 March 2022 on the existence of a mass influx of displaced persons from Ukraine within the meaning of Article 5 of Directive 2001/55/EC, lays down the concrete conditions for ensuring temporary protection of displaced persons on the territory of Romania and establishes the categories of persons who may benefit from this status.
The competent institution(s) that has/have the competence to establish and grant temporary protection measures or any other form of adequate protection to the categories of persons referred to in Art. 1 of Government Decision no. 367/2002 shall also have the legal competence to provide specific activities to ensure the basic needs and immediate support to persons granted temporary protection or any other form of adequate protection, namely basic necessities referred to in Art. 1 para. (1) (a) to (c) of Government Emergency Ordinance No 15/2022, as amended.
For the purposes of the above, the competent institution(s) having the competence to establish and grant temporary protection measures or other forms of protection appropriate to the categories of persons referred to in Article 1 of GD no. 367 /18 March 2022 will access financial support for partial settlement from the POCU, based on the unit cost established by Regulation (EU) 2022/613 of the European Parliament and of the Council of 12 April 2022 amending Regulations (EU) No 1303/2013 and (EU) No 223/2014 as regards the increase of the pre-financing from REACT-EU resources and the establishment of a unit cost, in accordance with the eligibility rules and European and national rules applicable to the Operational Programme and in accordance with the amounts approved by the European Commission for these types of measures.
Thus, the financial resources identified from the savings generated by the projects completed and/or ongoing at the level of the Human Capital OP, in the amount of approximately 100 million euros, will be reused to finance support and humanitarian assistance measures by the Romanian state to foreign citizens or stateless persons in special situations, coming from the area of the armed conflict in Ukraine, according to the eligibility rules communicated by the European Commission and in accordance with the provisions of the national legislation in force. As a result of the identification of these savings, the Human Capital OP (HCOP) was amended by creating a new priority axis (PA 9) with a value of €100 million.
The amount of expenditure that can be settled on a unit cost basis, allocated under the Human Capital Operational Programme 2014 – 2020, is 585,255 thousand lei, equivalent to 118,427 thousand euro at the InforEuro exchange rate of July 2022, of which the European Union contribution is 494,190 thousand lei, equivalent to 100,000 thousand euro corresponding to a percentage of 84.44%, and the national contribution is 91,066 thousand lei, equivalent to 18,427 thousand euro, corresponding to a percentage of 15.56%. MIPE specifies that the amounts allocated for this purpose represent savings identified in the budget execution of the POCU and not additional allocation from the European Union.
As regards the launch of the call for projects and the implementation of AP 9 POCU, these steps will be carried out following the procedures and mechanisms applicable to projects with European funding, at the pace and under the conditions that the potential beneficiaries of these actions will prepare mature projects and ensure compliance with the eligibility of expenditure.
Also, in the context of the humanitarian refugee crisis in Ukraine, grant opportunities have been identified through the EEA and Norway Financial Mechanisms, as follows:
– € 500,000 for „Improvement of accommodation conditions for refugees in Ukraine” – accommodation containers, heaters, stackers:
– The grant contract was signed on 09.08.2022 between IGSU and MAI – based on NCP/donor approval of 22.03.2022;
– PNC made the pre-financing payment (€500,000) on 12.09.2022; OP transferred to IGSU the amount of €500,000 on 13.10.2022.
– 330.000 euro through the Romanian Social Development Fund, which will support the work of two NGOs – Federația Filantropia and Asociația ASSOC which will provide food, accommodation, consigliere, medical services for refugees and interventions to prevent human trafficking in the context of the refugee crisis:
– ASSOC Association – the funding contract was signed on 20.05.2022, FRDS transferred the advance to ASSOC on 15.06.2022 (the amount transferred is € 96.073,78)
– Philanthropy Federation – the financing contract was signed on 18.08.2022, FRDS transferred the advance to Philanthropy on 09.09.2022 (the amount transferred is 103.385,41 euro)
– 100,000 euro from the bilateral fund available under the Research Programme, to provide humanitarian support through 2 partner universities in the programme (Danube University of Galati and Stefan cel Mare University of Suceava), namely to cover daily food and accommodation costs (utilities, cleaning services, security, etc.). The funding contracts with the 2 universities were signed on 14.04.2022. The Programme Operator transferred the advances, according to the funding contracts, on 02.05.2022. Both contracts had a completion date of 30.11.2022.
So far, UEFISCDI has disbursed 90% of the advance, with the remaining 10% to be disbursed after approval of the reports submitted by the 2 universities.
– €2 million for the Active Citizenship programme (FDSC) by increasing the allocation to 3 open calls (revolving type). 26 projects entered the technical and administrative evaluation phase on 15.11.2022:
– 2 projects under Call 1.1 – Civic participation on the crisis in Ukraine
– 6 projects under Call 4.1 – Human rights awareness and equal treatment for refugees from Ukraine
– 18 projects under Call 6.1 – Support for refugees from Ukraine.
Analysis of EU support to Romania during the Ukraine crisis – The Ministry of Family, Youth and Equal Opportunities (MFTES)
Following FONPC’s request, the Ministry of Family, Youth and Equal Opportunities (MFTES) stated that the central apparatus did not receive any European funding, nor was there any expenditure to support refugees from Ukraine through services or benefits managed by MFTES.
„However, based on requests from the General Inspectorate for Emergency Situations (IGSU), buildings belonging to the heritage of certain student cultural houses – subordinated to the MFTES (such as the Tei Student Cultural Sports Complex and the Student Cultural House in Craiova) have been used to host Ukrainian refugees, with the resulting costs being provided from the IGSU budget,” the MFTES explained.
Ministry officials also said they had no direct information regarding external funding of subordinate institutions, but FONPC’s request was submitted to the National Authority for the Protection of Children’s Rights and Adoption, which forwarded:
„In order to give a response, we addressed the General Directorates of Social Assistance and Child Protection of the counties / sectors of Bucharest, with the request to communicate the amounts spent by these institutions to support refugee children from Ukraine.
According to the information centralized at national level, based on the data received from the above mentioned institutions, so far the DGASPCs have spent 6415.36 RON for the support of Ukrainian children.
With reference to questions 2-5 we would like to point out that our institution has so far not received any non-reimbursable external funds to be used for the purpose of supporting refugees from Ukraine”.
The Ministry of Labour and Social Solidarity
The Ministry of Labour and Social Solidarity stated that it has no direct powers in the administration of temporary protection measures for Ukrainian refugees who do not apply for a form of protection in Romania, as the coordination of these measures is the responsibility of the Ministry of Interior, through its subordinate institutions: the General Inspectorate for Emergency Situations (IGSU) and the General Inspectorate for Immigration (IGI).
In this context, the Ministry of Labour and Social Solidarity explained that social assistance benefits are granted only to persons who have international protection, i.e. refugee status or subsidiary protection, and that these rights are conditional for foreign citizens or stateless persons on establishing domicile or residence on Romanian territory, under Romanian law.
„We would like to mention that in the area of social assistance benefits no non-reimbursable external funds were used in the context of the crisis in Ukraine. As mentioned above, the right to social assistance benefits is guaranteed in Romania, without any kind of discrimination, for all Romanian citizens, as well as for citizens of other states or stateless persons, who have their domicile or residence in Romania, and the payment of the rights granted is borne by the state budget”, the reply sent by FONPC.
The institution also states that according to the provisions of Article 20 of Law 122/2006 on asylum in Romania, the recognition of refugee status or the granting of subsidiary protection entitles the beneficiary to receive social assistance under the conditions provided by law for Romanian citizens. Also, persons who have refugee status or benefit from subsidiary protection have the right to benefit, upon request, from a monthly non-refundable allowance for a maximum period of 12 months if, for objective reasons, the person lacks the necessary means of subsistence. The amount of the non-reimbursable monthly allowance is 568 RON per month *approximately €113) for each family member, including children. The funds needed to grant the monthly non-reimbursable aid are provided from the budget of the Ministry of Labour and Social Solidarity through the National Agency for Payments and Social Inspection (ANPIS) and the county agencies for payments and social inspection. According to ANPIS data, in 2022, 516 applications for monthly non-refundable aid for people with refugee status were registered, for which an amount of 2,124,097 RON was paid.
The National Agency for Employment
Since the early days of the conflict in Ukraine, the National Agency for Employment (ANOFM), an institution under the coordination of the Ministry of Labour and Social Solidarity, has been involved in supporting those refugees who have declared their desire to stay and work on Romanian territory.
„For all the measures and actions undertaken, ANOFM used its own human and financial resources.
The Romanian language courses for Ukrainian citizens, organized so far, involved a financial effort of 16365 RON, from ANOFM budget.
Also, our institution did not receive any non-reimbursable external funds, therefore other partners of ANOFM did not access such funds either. ”
The Employment Agencies of the counties that have common border crossing points with Ukraine have regularly sent representatives to border crossing points and refugee centres to inform and advise Ukrainian citizens.
The National Agency for Employment (ANOFM) also provides labour market measures for Ukrainian citizens under the same conditions as for Romanian citizens; it provides free services to Ukrainian citizens registered with ANOFM, namely: information and professional counselling, job mediation, vocational training, assessment and recognition of professional skills obtained in non-formal or informal contexts, EURES support services.
The Ministry of Development, Public Works and Administration
In its reply to the FONPC, the Ministry of Development, Public Works and Administration stated that: it could not allocate funds to support refugees from Ukraine as it has no budget allocated for this purpose, it did not receive non-reimbursable external funds in the context of the crisis in Ukraine, nor was it involved in providing emergency aid, as the Ministry of Internal Affairs is the only institution that manages refugees from Ukraine and the financial aid provided by the Romanian state.
Conclusions and recommendations
In any crisis caused by the outbreak of war, governments, the private sector and international humanitarian organisations/agencies must provide a rapid and robust humanitarian response. Romania, as Ukraine’s neighbouring country, has been and remains one of the first destinations for Ukrainians fleeing conflict. Clearly, in response to the crisis caused by the war in the neighbouring country, Romania has taken a lot of steps to ensure that refugees have access to accommodation, food, financial assistance, social protection and basic needs. However, in many areas there are still things that are not working or that need adjustment or improvement, and the medical sector and access to services provided through it are in this situation.
Given that the shortcomings found do not only concern patients in Ukraine but also the health system, the conclusions and recommendations have been structured separately.
The main problems Romania faces in order to intervene effectively in the Ukraine crisis:
● Lack of funds for tests or for purchasing prescription drugs – lack of funds for health services in general.
● Increasing financial pressure on the budget of the National Health Insurance House, given the growing population and the costs being borne exclusively by internal funds.
● Romania has made a huge financial effort without having a base or reserve fund to cover these costs.
● Lack of transparency regarding the funds allocated by the European Commission to Romania and other countries involved in the Ukraine crisis;
● Lack of transparency in the reporting of allocations through the Regional Refugee Plan and FLASH Appeal, including allocations made to local and national civil society partners.
● Insufficient funds allocated by the UN and EU to civil society organisations providing services to refugees in Ukraine, relative to needs.
● Initiate discussions at the level of the European institutions on the settlement of urgent and other types of services, apart from accommodation and meals for Ukrainian citizens who have the right of temporary residence in Romania. Integration of refugees requires ensuring access to the full range of services, including medical, and host countries must be supported through UN and EU mechanisms.
● Call for European and international support (through the Regional Refugee Plan and the FLASH Appeal) to support patients in Ukraine by allocating a share to go to the medical systems of the supporting countries.
● Measures to provide non-reimbursable funds to support the costs of various types of health services for refugees.
● Allocation of funds by the European and UN Institutions that can be accessed by NGOs providing humanitarian assistance.
● National legislation to be recognised at European level in order to allow the Romanian health system to pay for services provided to Ukrainian citizens.
● Transparency in reporting on allocations and on the impact of funds allocated through the Regional Refugee Plan and FLASH Appeal, including allocations made to local and national civil society partners.
● Integration of national and UN-facilitated coordination systems for international assistance, with dedicated funds for civil society organisations providing additional health services (e.g. Country Pooled Funds);
● Facilitate discussions and reflections with relevant organisations and actors in other Member States involved in refugee programmes to harmonise and institutionalise successful practices.
● Urgent advocacy activities and efforts to promote and ensure equitable access to healthcare for Ukrainian citizens who have settled in Romania.
● Temporary or medium and long-term integration measures to ensure independent living in Romania for Ukrainian refugees.
● Flexible, coherent legislation in line with the needs of Ukrainian citizens.
Main issues of the healthcare system in Romnia:
● Language barrier – unable to get along with Ukrainian patients without a translator;
● Poor access of refugees to health services due to fear of doctors being accused of malpractice in case of wrong advice due to language barrier;
● Difficulties in registering with the family doctor;
● Differences in health systems between the two countries;
● Vaccination in general, vaccination of children in particular to avoid epidemics or pandemics that would endanger children’s lives;
● Suffocation of the Romanian health system if the number of patients were to increase in a pandemic context and subsequently in an epidemic alert context and if the human resource is the same;
● The inability of family doctors to receive patients from Ukraine due to fears about the settlement of medical expenses;
● The inability of Ukrainian refugees to receive free prescriptions due to the fears of family doctors regarding the settlement of prescriptions or referral tickets for Ukrainian patients;
● Increased pressure on Emergency Care Units (UPU) and increasing requests to the 112 emergency system.
● Allocation of resources to solve translation problems. Given that we are already talking about medium and long term support, we recommend that at the level of each local community there should be a mobile team of translators that hospitals/medical staff can call upon in case of need, that funds should be mobilised to provide at least one translator for emergency services.
● There is also a need to include basic information on conversing with doctors in education modules for children and adults and to consider the possibility of publishing dictionaries to facilitate such discussions.
● Improve legislation to make it clearer and more attractive to GPs and in line with the reality on the ground level, i.e. take into account that the duration of a consultation requiring translation doubles.
● Allocate funds to ensure translation of medical documents/consultations.
● Identify and remedy problems that prevent family doctors from generating the unique code in the Single Integrated Information System (SIUI) to be able to take patients from Ukraine.
● Transparency when it comes to the clinics refugees can go to for consultations and medical services. We consider it necessary to draw up a complete list of free or fee-for-service medical services for Ukrainian refugees. The list should include data on the type of services, available clinics, locations, available doctors, etc.
● Find an alternative solution for vaccination of babies if they cannot be registered with a family doctor. To this end, the authorities must ensure a sufficient number of vaccine doses.
● Factual compensation for prescriptions and medical tests, not just theoretical, by ensuring access to a family doctor or by establishing a procedure to ensure that family doctors who fail to enter Ukrainian patients into the CNAS platform are compensated for their prescriptions and medical services.
Report conducted by Elvira Gheorghiță
FONPC Supervisors: Daniela Maria Boșca, Rodica Corina Andrei and Valentina Mîrza
 Romanian Government, Report on Romania’s Response to the Ukrainian Refugee Crisis, 13 January 2023
 Romanian Government, Report on Romania’s Response to the Ukrainian Refugee Crisis ,13 January 2023
 Ukraine: 2022 Flash Appeal Funding Snapshot – 16 January 2023
 Romanian Government, Raportul privind eforturile și realizările României în domeniul asistenței umanitare a refugiaților, al drepturilor copilului și al altor categorii vulnerabile pe anul 2022 (The report on Romania’s efforts and achievements in the field of humanitarian assistance to refugees, children’s rights and other vulnerable categories for the year 2022), 13th January 2023, page 25
 Romanian Government, Raportul privind eforturile și realizările României în domeniul asistenței umanitare a refugiaților, al drepturilor copilului și al altor categorii vulnerabile pe anul 2022 (The report on Romania’s efforts and achievements in the field of humanitarian assistance to refugees, children’s rights and other vulnerable categories for the year 2022), 13th January 2023, page 25
 Raportul Guvernului – Răspunsul României la criza umanitară a refugiaților 2022 (Government Report- The Romanian Response to the refugee humanitarian crisis 2022)
 SERA, FONPC, FONSS, PLAN, CARE , Rapid Gender Analysis Brief – Ukrainian Refugees in Romania, May 2022
 Ordinul nr. 1068/627/2021 din 29 iunie 2021 privind aprobarea Normelor metodologice de aplicare în anul 2021 a Hotărârii Guvernului nr. 696/2021 pentru aprobarea pachetelor de servicii şi a Contractului-cadru care reglementează condiţiile acordării asistenţei medicale, a medicamentelor şi a dispozitivelor medicale, tehnologiilor şi dispozitivelor asistive în cadrul sistemului de asigurări sociale de sănătate pentru anii 2021 - 2022 (Government Order-no. 1068/627/2021 of June 29, 2021 regarding the approval of the Methodological Norms for the application in 2021 of Government Decision no. 696/2021 for the approval of the service packages and the framework contract that regulates the conditions for the provision of medical assistance, medicines and medical devices, technologies and assistive devices within the social health insurance system for the years 2021 - 2022)
 Declarația ministrului Sănătății, Alexandru Rafila, 25 martie 2022 /Declaration of Health Minister, Alexandru Rafila, 25th of March 2022
 Guvern: 56,7 milioane de lei pentru decontarea cheltuielilor cu hrana şi cazarea refugiaţilor proveniţi din Ucraina (Government: 56.7 million lei for settlement of food and accommodation expenses of refugees from Ukraine)