Measuring Patients’ Perception and Satisfaction with the Romanian Healthcare System

: Measuring patient satisfaction of healthcare service quality represents a signiﬁcant element of a healthcare’s system (HS) overall evaluation. It is the starting point for creating policies in national healthcare. The purpose of this paper was to evaluate Romanian patients’ perception and satisfaction of the quality of the national HS as a whole and of its components. Exploratory and descriptive research was used. Data were collected through face-to-face interviews with Romanian patients, based on a questionnaire. Out of the 2305 respondents, 83% used the Romanian HS in the past 12 months and 58% of the respondents did not trust the system. The accommodation, food, and other facilities of Romanian hospitals were perceived as being at a low level. One third of the respondents were unsatisﬁed and very unsatisﬁed with respect to the overall impression of the Romanian HS. In addition, our research found a statistically signiﬁcant relationship between conﬁdence in the HS, age, and gender, and also between the overall impression on the HS, age and income.


Introduction
Competition at a global level requires the implementation of sustainability, viewed as an important strategy in the service industry. Sustainability-related issues are of paramount importance and consequently the implementation of sustainability in one's company has become a common desire [1,2]. When defining sustainable development, it is necessary to highlight how to make development meet present needs, while not influencing the capability of future generations to satisfy their own needs [3]. A stronger pressure has been exerted during the last decades upon organizations to focus not only on financial performance, but also on sustainability and accountability in business performance [4]. From this viewpoint, any company aims at focusing on sustainability, from environmental, social and economic performance perspectives [5].
The World Health Organization defined health not just as the absence of disease or infirmity but as being as being a state of well-being from a physical, mental and social point of view. Healthy people have a productive life from a social and economic standpoint [6,7]. Health is a fundamental right of low level of satisfaction with Romanian HS as being: the additional costs due to the poor financing of the HS; long waiting times due to the small number of specialists; accommodation facilities and conditions, and the attitude of medical or auxiliary personnel [29,30,[34][35][36]. Francu and Francu found that Romanian patients mainly complain about accommodation, lack of medicines in hospitals, and the long waiting time in the ambulatory system [37].
It is generally agreed that measuring patients' satisfaction represents a support in achieving sustainability of the HS together with other indicators. Most previous researches analyze and measure either patients' satisfaction or patients' confidence in the HS. The present study brings together and evaluates simultaneously the assessment of patients' satisfaction and the confidence in the Romanian HS.

Design
The main focus of the current study is to better understand the perceptions and satisfaction of patients with the healthcare system in Romania.
For this study the following research objectives were formulated: 1.
identifying the patients' level of confidence in the Romanian healthcare system; 2.
identifying the appreciation level of the conditions in the hospitals from Romania; 3. identifying correlations between the main demographic variables of the respondents (independent variables) and two dependent variables: confidence in the HS and overall impression of the Romanian HS.
Descriptive research is commonly used to identify status, reflect a general overview, characterize and offer information about the actual phenomenon on the market representing a foundation for problem solving [38]. A descriptive cross-sectional study was conducted to identify the factors that influence patients' satisfaction. The investigation was also used as a research method for data collection, in the form of face to face interviews with Romanian patients. Data were collected between 2017 and 2018.

Sample and Settings
The healthcare system is free of charge in Romania. Thus, all population can benefit from these services. Given the sensitivity of health data and the main purpose of our research-to evaluate the overall impression and confidence in the HS-our research considers to collect data from patients detached from a particular consultation environment, where the service was provided.
As the aim of a study is mainly exploratory and descriptive, the present research uses the snowball sampling technique [38][39][40]. This sampling technique offers practical advantages such as having the social networks of identified participants that can provide an ever-expanding set of potential contacts [39][40][41]. Sampling continues until data saturation [42]. Snowball sampling is a more formal methodology that allows inferences to be made about a population of individuals who have been difficult to count by descending methods such as household surveys [39][40][41].
Sample calculation using G*Power version 3.1.9.2 [43] for a small correlation (r < 0.1, using the Cohen rules) reveals a minimum sample size of 800 for a power ≥ 0.8 is considered acceptable.
The collection process resulted in a total of 2305 valid questionnaires that constitute the size of our research sample. For a sample size of 2305 respondents, the power is about 0.95.
The questionnaires were voluntarily implemented by second year students from the Faculty of Business, Babes , -Bolyai University, enrolled in a marketing course. They split the questionnaires out into groups of friends and families, considering various categories of respondents' age and residence, who have accessed health services from different medical specialties [42]. The participation in the interview was voluntary and the perceptions and attitudes recorded during the interviews were used only for the purpose of the present paper. Participants were informed in the questionnaire briefing what are the research objectives and their rights to privacy and confidentiality and protection of personal data. Thus, the participants understood that by filling in the questionnaire they give their written consent to take part in the research and understand their rights. They were given the possibility to withdraw at any time during the filling in of the questionnaire. The present research collected only non-identifiable patient information. All data are anonymized.

Data Collection
Quality represents the customers' overall impression of services [44]. Service quality assessment is a cognitive judgement [45]. The quality perception reflects an attitude considering comparison between expectations and received services [46]. Reichheld and Sasser stated that in order to obtain customer satisfaction it is important to fulfil the promise, generating confidence [47].
There is no universal measurement instrument for the overall impression with HS. That is why the satisfaction level with HS is determined indirectly considering its determinants.
An 18 questions questionnaire was designed and administered to get insights on the perceptions and attitudes of Romanian patients about the healthcare system. Structured (multiple choice and scale questions concerning importance) and unstructured questions (for occupation and residence) were used [38,41,48].
The questionnaire had two parts. The first part evaluates the main factors that influence patients' level of satisfaction with the Romanian healthcare system. It contains the basic information for the research such as: the contact frequencies of the healthcare system, the confidence in the Romanian HS, the overall impression about the HS, the perceived quality of the medical services, the perceived attitude of the medical personnel etc. The second part has six other questions used to create the socio-demographic profile of the respondents (age, gender, education, occupation, monthly average income and residence of the respondents).
The questionnaire was pretested by business administration undergraduates before administering it to a representative sample. The aim was to find out if the questions are clear enough, clearly understood, in the right order and the provided answers are sufficient and detailed enough. The fill in time was also determined. The questionnaires were administered during face-to-face interviews performed by students. Students were trained on how to administer the questionnaire. The 4-h long training tackled aspects of implementation and data collection.
In this marketing research just part of the data collected were used. Items were scored on a 5-point Likert scale (1-very poor, 5-very good) [38] evaluating the accommodation conditions, food, medical equipment, facilities/equipment, confidence in doctors and nurses, care quality provided and doctors and nurses attitudes. Table 1 contains descriptive statistics of the above scores and also the Cronbach's Alpha coefficient [41,48].
The reliability analysis was evaluated through Cronbach's Alpha coefficient [38,41,48]. The obtained values are over 0.8 thus highlighting the used scales had a good internal structure.
The positive values point out the agreement of all the items with the scale, while the obtained values suggest a close relation of the items.
The external validity of the questionnaire is based on the analysis of the linear correlation coefficient [38,41,48]. Table 2 shows convergent relations between scales and items.  Correlation coefficients are statistically highly significant, ranging from acceptable to very good. The question referring to occupation was eliminated from the study because the majority of the respondents confused the occupied position/function with the occupation. Also, with one exception, the respondents have an urban residence.

Data Analysis
Data was entered and managed with Microsoft Excel (Microsoft, Edmonton, KY, USA, 2010). SPSS (v 15) (IBM Corporation, Armonk, New York, NY, USA, 2006) was used for the statistical analysis. The qualitative data was described by using (absolute and relative) frequencies. The acceptable error threshold was α = 0.05 [38,41,48].
The relationships between qualitative data was evaluated by using the Chi-square test. The Kendall correlation coefficient for the ordinal qualitative variables with more than 25% equal values was calculated. In the case of gender the point biserial correlation coefficient was used. In order to estimate Sustainability 2020, 12, 1612 6 of 16 the correlation coefficients (with α = 0.05) significance tests were performed and for the empirical interpretation Colton rules were used [38,41,48].

Ethics
As this paper represents an evaluation of the perceptions and satisfaction of patients concerning the HS, considering that their participation in the study was entirely voluntary, patient information was not identifiable, and no medical research was conducted, ethical approval was not required. Table 3 presents the classification data of the respondents. The study investigated how often the patients used the healthcare system. In the last 12 months, 63% of the sample used the Romanian HS 1-3 times and 20% used it more than 3 times. Almost a fifth of respondents did not use the health system in the last year ( Figure 1).

Distribution on Confidence and Impression Regarding Romanian HS
Although 58% of respondents do not trust the Romanian HS, interestingly, 36% have high confidence in it ( Figure 2). Even if the percentage of those who trust the HS is lower compared to those who do not, greater attention should be paid to identifying and analyzing the reasons and Never 17%

Distribution on Confidence and Impression Regarding Romanian HS
Although 58% of respondents do not trust the Romanian HS, interestingly, 36% have high confidence in it ( Figure 2). Even if the percentage of those who trust the HS is lower compared to those who do not, greater attention should be paid to identifying and analyzing the reasons and factors that determine trust or mistrust.

Distribution on Confidence and Impression Regarding Romanian HS
Although 58% of respondents do not trust the Romanian HS, interestingly, 36% have high confidence in it ( Figure 2). Even if the percentage of those who trust the HS is lower compared to those who do not, greater attention should be paid to identifying and analyzing the reasons and factors that determine trust or mistrust. The majority of Romanian patients (82.51%) consider in the case of illness, only the physicians' opinion. The research shows the importance of specialist opinion compared to other sources of information and influence, such as alternative medicine (7.07%) and friends' advice (5.2%) (Figure 3). The majority (almost 80%) of respondents that consider opinions other than their doctor's seem to have a low and very low level of confidence in the Romanian HS.
The majority (almost 80%) of respondents that consider opinions other than their doctor's seem to have a low and very low level of confidence in the Romanian HS.
The majority of Romanian patients (82.51%) consider in the case of illness, only the physicians' opinion. The research shows the importance of specialist opinion compared to other sources of information and influence, such as alternative medicine (7.07%) and friends' advice (5.2%) (Figure 3). The majority (almost 80%) of respondents that consider opinions other than their doctor's seem to have a low and very low level of confidence in the Romanian HS.  The research also investigated the opinion of people regarding complementary services to the healthcare system. Regarding the conditions and facilities offered in Romanian hospitals most respondents appreciate the accommodation, food, and other facilities in hospitals as being poor, but the majority appreciate the medical equipment ( Figure 4). Seventy-three point nine-nine percent are not satisfied with the food, 60.26% with the facilities, 59.39% are not satisfied with the accommodation and 49.08% withe the medical equipment offered by the Romanian HS.   The majority (almost 80%) of respondents that consider opinions other than their doctor's seem to have a low and very low level of confidence in the Romanian HS.
The research also investigated the opinion of people regarding complementary services to the healthcare system. Regarding the conditions and facilities offered in Romanian hospitals most respondents appreciate the accommodation, food, and other facilities in hospitals as being poor, but the majority appreciate the medical equipment ( Figure 4). Seventy-three point nine-nine percent are not satisfied with the food, 60.26% with the facilities, 59.39% are not satisfied with the accommodation and 49.08% withe the medical equipment offered by the Romanian HS. The research also investigated the opinion of people regarding complementary services to the healthcare system. Regarding the conditions and facilities offered in Romanian hospitals most respondents appreciate the accommodation, food, and other facilities in hospitals as being poor, but the majority appreciate the medical equipment ( Figure 4). Seventy-three point nine-nine percent are not satisfied with the food, 60.26% with the facilities, 59.39% are not satisfied with the accommodation and 49.08% withe the medical equipment offered by the Romanian HS. Thirty-nine percent of respondents are satisfied and very satisfied with the overall impression of the Romanian HS, while 34% are unsatisfied and very unsatisfied ( Figure 5). Most respondents did not have an opinion about the healthcare system or did not wish to express it. This result highlights the sensitivity of the subject or the indifference and lack of confidence in the Romanian HS of the respondents. 17  Thirty-nine percent of respondents are satisfied and very satisfied with the overall impression of the Romanian HS, while 34% are unsatisfied and very unsatisfied ( Figure 5). Most respondents did not have an opinion about the healthcare system or did not wish to express it. This result highlights the sensitivity of the subject or the indifference and lack of confidence in the Romanian HS of the respondents.

Associations between Different Analyzed Variables
Using the Kendall correlation coefficient, point biserial correlation coefficient and Chi-Square test, the study investigated various associations between analyzed variables. The results are presented in Tables 4 and 5.

Associations between Different Analyzed Variables
Using the Kendall correlation coefficient, point biserial correlation coefficient and Chi-Square test, the study investigated various associations between analyzed variables. The results are presented in Tables 4 and 5. The correlations between the confidence in the HS and the variables in Table 4 are weak even though the ones with age and gender are statistically significant. The research reveals a statistically significant relationship between confidence in the healthcare system and the age (p < 0.001, Chi-Square-24 df) ( Figure 6), and gender (p < 0.001, Chi-Square-8 df) (Figure 7), a negative not statistically significant relationship between confidence and education and a negative not statistically significant relationship between confidence and income.   Considering the overall perception (Table 5), the study demonstrated a statistically significant relationship between the overall impression of the Romanian HS and age (p = 0.023, Chi-Square-30 df) (Figure 8), no relationship between impression and gender (p = 0.58, Chi-Square-10 df), no relation between impression and education (p = 0.116, Chi-Square-25 df) and a negative statistically significant relationship between overall impression and income (p = 0 < 0.001, Chi-Square-20 df) (Figure 9).  Considering the overall perception (Table 5), the study demonstrated a statistically significant relationship between the overall impression of the Romanian HS and age (p = 0.023, Chi-Square-30 df) (Figure 8), no relationship between impression and gender (p = 0.58, Chi-Square-10 df), no relation between impression and education (p = 0.116, Chi-Square-25 df) and a negative statistically significant relationship between overall impression and income (p = 0 < 0.001, Chi-Square-20 df) (Figure 9).  Also, the majority of those respondents that are neutral with the healthcare system have high confidence in it, but most with low confidence are either satisfied and very satisfied or unsatisfied and very unsatisfied. The study demonstrated a strong statistically significant relationship between overall perception and confidence (p < 0.001, Chi-Square-12 df) (Figure 10).  Also, the majority of those respondents that are neutral with the healthcare system have high confidence in it, but most with low confidence are either satisfied and very satisfied or unsatisfied and very unsatisfied. The study demonstrated a strong statistically significant relationship between overall perception and confidence (p < 0.001, Chi-Square-12 df) (Figure 10). Also, the majority of those respondents that are neutral with the healthcare system have high confidence in it, but most with low confidence are either satisfied and very satisfied or unsatisfied and very unsatisfied. The study demonstrated a strong statistically significant relationship between overall perception and confidence (p < 0.001, Chi-Square-12 df) ( Figure 10).

Discussion
Several studies on patients' satisfaction and the increasing interest in patients' experience among social scientists [49] began when medicine became marketable. In this respect, many studies at the national and international level are made by official authorities and also by researchers.
Starting from a pilot study, a more in-depth investigation was performed on a statistically representative sample in order to identify the perceptions and behaviors of the Romanian patients concerning the healthcare system. Information about demographic characteristics was correlated with how often patients contacted the Romanian healthcare system in the last year. For example, 9.93% from those under 40 years old never used the HS. Regarding the gender of the investigated respondents, 35.14% of the feminine sample contacted the system 1-3 times. With respect to the income, the study reveals that only 2.55% of the respondents with higher level of income (over 3500 lei) used the healthcare system more than 3 times.
The study reveals that in the last 12 months, 17% of the sample never used the Romanian HS. Sixty-three percent (63%) of the sample used the healthcare system more than once and 58% of the respondents do not have confidence in the HS. An interesting and useful result of the study can be considered the high confidence in the system (36% of the investigated population), that majority used the HS more than once.
Different studies showed that the healthcare outcome depends on patients' satisfaction [50,51]. The satisfaction is improved by the attitude and behaviour of medical staff [52]. Besciu shows that over 72% of the Romanian patients are satisfied with the attention paid by the doctor, and over 60% of the interviewees trust the doctor to whom they referred [53].
Patients' adherence to treatment is associated to a higher degree of satisfaction and also to confidence in medical care [54,55]. The interest and involvement of medical staff lead to increasing patients' confidence in the HS [56]. According to our results, the majority of the patients (82.51%) take into account the doctors' opinion when ill. The study reveals the importance of the specialists' opinion compared to other sources of information and influence such as alternative medicine (7.07%) and friends' advice (5.2%).
Regarding the level of satisfaction, our study reveals that only a little over a third of our respondents are satisfied (20%) or very satisfied (19%) by the Romanian HS. In a study conducted in China, in 14 public hospitals, it is showed that patients' satisfaction level is high (Cronbach's alpha was 0.949) [28]. In another study developed in Bangladesh a high level of satisfaction with health services was found (score 4.17 from 5.0, Cronbach's alpha was 0.93) [57].

Discussion
Several studies on patients' satisfaction and the increasing interest in patients' experience among social scientists [49] began when medicine became marketable. In this respect, many studies at the national and international level are made by official authorities and also by researchers.
Starting from a pilot study, a more in-depth investigation was performed on a statistically representative sample in order to identify the perceptions and behaviors of the Romanian patients concerning the healthcare system.
Information about demographic characteristics was correlated with how often patients contacted the Romanian healthcare system in the last year. For example, 9.93% from those under 40 years old never used the HS. Regarding the gender of the investigated respondents, 35.14% of the feminine sample contacted the system 1-3 times. With respect to the income, the study reveals that only 2.55% of the respondents with higher level of income (over 3500 lei) used the healthcare system more than 3 times.
The study reveals that in the last 12 months, 17% of the sample never used the Romanian HS. Sixty-three percent (63%) of the sample used the healthcare system more than once and 58% of the respondents do not have confidence in the HS. An interesting and useful result of the study can be considered the high confidence in the system (36% of the investigated population), that majority used the HS more than once.
Different studies showed that the healthcare outcome depends on patients' satisfaction [50,51]. The satisfaction is improved by the attitude and behaviour of medical staff [52]. Besciu shows that over 72% of the Romanian patients are satisfied with the attention paid by the doctor, and over 60% of the interviewees trust the doctor to whom they referred [53].
Patients' adherence to treatment is associated to a higher degree of satisfaction and also to confidence in medical care [54,55]. The interest and involvement of medical staff lead to increasing patients' confidence in the HS [56]. According to our results, the majority of the patients (82.51%) take into account the doctors' opinion when ill. The study reveals the importance of the specialists' opinion compared to other sources of information and influence such as alternative medicine (7.07%) and friends' advice (5.2%).
Regarding the level of satisfaction, our study reveals that only a little over a third of our respondents are satisfied (20%) or very satisfied (19%) by the Romanian HS. In a study conducted in China, in 14 public hospitals, it is showed that patients' satisfaction level is high (Cronbach's alpha was 0.949) [28]. In another study developed in Bangladesh a high level of satisfaction with health services was found (score 4.17 from 5.0, Cronbach's alpha was 0.93) [57].
In accordance with another study realized in Romania, our research, reveals that the most satisfied patients are: older, with a low level of education or with low incomes [58].
Popa, Drugus , , Leasu, et al. noticed [29], our study reveals that the conditions and facilities offered in the Romanian hospitals are perceived at a low level concerning the accommodation, food and other facilities. Only medical equipment was positively appreciated by the majority. Opposite to our study, Meng, Li, Zhang, et al. showed that the service organization and facilities is placed on the second place out of five (the Cronbach's alpha of service organization and facilities was 0.878) [28]. Like our results, another study regarding Romanian patients' satisfaction showed that the quality of attention and care increase the satisfaction level even the healthcare resources are less [31,33,58]. The differences between the group of satisfied and dissatisfied investigated respondents in respect with the overall impression of the Romanian HS are not revealing, even if more are satisfied. Also, a significant percentage (27%) are indifferent to Romanian HS.
Our study reveal that more than half (58%) of the respondents are not confident with the Romanian HS, but this result is better compared to previous study of Sarbu and Zanfir that highlighted a percentage of 93.85 as unconfident Romanian respondents [59].
The study demonstrates a strong statistically significant relationship between confidence in the healthcare system and the age and gender of the respondents. The confidence in Romanian HS increases with age. Women have greater confidence than men in Romanian HS. Also, taking into account the overall impression, the research demonstrated a statistically significant relationship between the overall perception of the Romanian HS and age and a negative statistically significant relationship between overall impression and patients' income. Romanian patients are more satisfied with the HS as they age and as income level increases, they become slightly dissatisfied.
Similarly, in Iran, Mahaorlouei, Akbari and Lankarani showed that young people are dissatisfied with the HS [60]. Also, some studies indicated that the population with high income are less satisfied by the HS compared to people with a smaller income [60][61][62].
The obtained results are aligned with findings of other studies carried out in Romania, emphasizing the need of the HS to adapt to the increasing expectations of the patients and the relationship between patients' satisfaction and the quality of healthcare services [27,31,32,37].

Conclusions
One important strategy in the service industry that gives a boost to global competition in the field is sustainability. Today, the healthcare industry has begun embracing sustainability more aggressively. Patients' satisfaction in using healthcare services becomes an important tool in devising healthcare service quality, access improvement and monitoring.
The present study regarding patients' satisfaction in the context of ensuring a Romanian sustainable healthcare system has several limitations. The most important one is related to sample consistency. Although the results cannot be generalized to the entire population, they offer important insights into the perceptions of Romanian patients. It can be noticed that the respondents are part of the business administration student's social network, almost all from urban areas, not always representative of the Romanian population. Another important limitation refers to the fact that 17% of the respondents have set opinions about the healthcare system in Romania, although they did not used it in the last 12 months. The limits above can become a topic of further research. Given that recently the salaries of HS employees in Romania have increased considerably and that large investments have been made in equipment in most hospitals, it would be interesting to replicate the study to analyze whether patients' perceptions have changed. The present research offers a support in understanding, evaluating and improving the services offered by the Romanian healthcare system. Our results can bring a valuable contribution to further studies on patients' satisfaction that can be improved by a more in-depth approach, but also offer practical implications and managerial recommendations especially for authorities and related institutions and private businesses in their planning for further development. Like other previous studies highlighted [53], the following recommendations that can improve the level of patient satisfaction could be formulated for the policy-makers: increasing the financing of the HS, including the level of salaries of doctors, the development of medical emergency structures, as well as the professionalization of the management of health units.