Patient Perception and Ethical Trade-Offs in Resource Allocation: A Qualitative Study with Conceptual Simulation in a Romanian Municipal Hospital

Background/Objectives: Municipal hospitals in transitional health systems operate under structural resource constraints that complicate managerial decision-making and shape patient perceptions. This study examines how patients interpret resource allocation and evaluate the ethical and legitimacy consequences of alternative strategic priorities. Methods: A qualitative research design was employed using semi-structured patient interviews. Participants were recruited using purposive sampling based on predefined inclusion criteria: age over 18, hospitalization for digestive symptoms, undergoing diagnostic investigations, and provision of informed consent. Thematic analysis identified key expectation domains related to technological modernization, workforce capacity, infrastructure, and relational communication. These themes were translated into core governance variables and integrated into a conceptual simulation model comparing three allocation scenarios: technological investment, human resource expansion, and status quo preservation. Results: Findings show that patient evaluations extend beyond satisfaction to include distributive fairness, symbolic modernization, and institutional legitimacy. Simulation findings suggest that technological investment strengthens symbolic legitimacy and perceived equity but may increase workload and fiscal exposure; workforce expansion enhances relational justice and operational stability yet leaves modernization gaps; and status quo preservation maintains short-term fiscal balance while risking gradual legitimacy erosion. Conclusions: The study demonstrates that satisfaction metrics alone are insufficient for governance evaluation. Integrating ethical analysis, organizational legitimacy theory, participatory input, and systems thinking provides a structured framework for assessing resource allocation trade-offs in resource-constrained municipal hospitals.