Health Research in Romania

Prepared by Dr. Virgil Paunescu

Bucharest, 2000
Acknowledgements

The author acknowledges the valuable contribution to this case study by Professor Dr. Mihai
Zamfirescu, President of the Romanian Academy of Medical Sciences. Also other sources of
information were used such as: the database of the Human Resources Department of the
Ministry of Health of Romania, data from the National Health Statistics Centre, the 1998
report on "Horizon 2000" the research program of the National Agency for Sciences,
Technology and Inventions and reports of the WHO Liaison Office, Bucharest.

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 Medical Research in Romania

1. Research networks

If we try to describe medical research in Romania in the past 10 years, we have to take as
the starting point of our review the year 1989, with its political changes and the structures as
they existed at at that moment. The political and economic reforms, which came after 1989,
induced changes that affected medical research too, both research policies and resources.

The economic crisis led to important cuts in financial resources and means, but it also
contributed to restructuring the previously highly institutionalized research facilities. The
result was decentralisation of many research facilities. Some were closed down; the
remainder were revamped as new institutions, governmental or non-governmental
organizations, funded by the State or from various other sources.

It became clear that merely ensuring funds for research was not enough to ensure its
effectiveness. There was a need for a clear policy in the field that would also bring about a
change in mentality within the research community. The scientific community should accept
the fact that not everything that can be financed and researched should be researched, and
that every research result should have a purpose, should be needed for something or should
be requested by somebody. There has to be a real need for research. This should lead to the
development of new technologies or more advanced techniques, should generate more
valuable knowledge for society as a whole, for progress and welfare.

The main body of medical research in Romania is organized in a number of research

institutes and several special units. Their staff and supporting activities are derived from
clinics and hospitals all around the country, under the authority of the Ministry of Health
and/or the Ministry of Education. It should be stressed that there are in fact four tiers of
research units in this field:
• A number of research institutes and research units under the direct responsibility
of the Ministry of Health;
• A complex medical research network belonging to the medical and
pharmaceutical universities, as stated above in Bucharest, Iasi, Cluj, Tirgu-Mures,
Craiova, Timisoara etc., involved in systematically teaching a number of
specialties to medical students, with a six-year curriculum approved by the
Ministry of Education;
• Another group of units also involved in medical research, supported by the
National Agency of Science, Technology and Innovation (NASTI), organized by a
medical committee, as part of a central research college;
• And last but not least, the Medical Section of the Romanian Academy, doing
fundamental research in a number of subsidiary, dependent biological and
medical institutes.

These four research networks, which are practically independent of one another, developed
gradually during the 20th century. The staff of the respective medical specialties belongs,
either to the academic/university domains, or to the NASTI. NASTI was the last one to
appear, namely after the 1989 revolution for freedom and political independence, evolving
from the level of a general directorate in the Ministry of Education to a Ministry of Research.
Later on the Ministry of Research was restructured to become the above-mentioned National
Research Agency which is now the main coordinating and financing body of research in
Romania, including medical research.

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Government policy on research is implemented through NASTI, in the framework of its
National programme called "Horizon 2000". The programme has four main objectives:

i. Achievement of an efficient and safe infrastructure;

ii. Improvement of the industrial competitiveness and technological and industrial
integration into the EU norms and standards;
iii. Environmental protection and quality;
iv. Increasing the Romanian participation in international scientific co-operation.

2. Research funding

It can be observed that medical research is not explicitly mentioned within the main
objectives, but can easily fit in. The major consequence of this can be seen in the figure
describing the allocation of NASTI funds by research theme:

NASTI funds allotment for research themes (%)

standards 40

new materials
biotechnology 35
health
urbanism 30
basical sciences
flight, space 25
umanistic sciences
regional development 20
defense
informatics
15
transportation
agriculture
10
environment
risk assessment
5
energy
natural resources
0
industrial technologies

Only 2.17% of the whole NASTI budget was allotted to medical research activities. Annually
NASTI receives from the Government about 0.2% of the GDP. The highest amount was
allocated to industrial technologies, agriculture, basic sciences and urbanism. Some of the
high allocation fields are priorities within research objectives, but some of them are due to
structures that existed prior to 1989, such as huge independent research institutes.

NASTI aims to support the cross-sectoral nature of research activities within the “Horizon
2000" programme by creating a flexible, horizontal approach to the use the funds. Despite
the flexibility, the pressure on the State budget and the transition period affected the national
programme by financing mainly projects already running or those resulting from international
governmental cooperation.

The system of fund allocation can be summarised as follows:

NASTI gets advice from an Advisory Committee. The Committee members are
nominated for a 6-year mandate by the ministries and the Romanian Academy,
for what is an honorary position.

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 NASTI funds allotment (%) to the specialised
commissions
16 ecology
energy
14 inovation
machine construction
12 metalurgy
electronics

10
chemistry
textile industry

8 transportation
communication, iformatics

6
agriculture
construction
medical research
4
physics
biology
2
recycling
socio-economics
0
flight, space

Those nominated are well-known scientist or persons with high academic

degrees, and receive no remuneration for their work on the committee.
There are a number of subcommittees (specialised commissions) according to
the various specialities. The Subcommittee for Biomedicine and Pharmacy has
27 members selected by the Advisory Committee.
The Subcommittee:

Ø evaluates the need, the number and the priority of research projects;
Ø establishes the framework for their objectives;
Ø calls for project proposals;
Ø evaluates the proposed projects and forwards them to the Advisory
Committee;
Ø the agreed objectives are distributed to the research institutes for
choosing the themes;
Ø The proposed projects, evaluated by the subcommittees are subject to
approval by the Advisory Committee. Once approved, the projects are
financed by NASTI.

The funds allotted to the specialised subcommittees are along virtually the same lines as the
research topics, where machine construction, electronics, chemistry, agriculture and physics
are the main priorities. The Subcommittee for Medical Research received 2.17% of the NASTI
budget. This could lead us to the conclusion that medical research is not among the high
priorities area of NASTI. The place of medical research within NASTI is also illustrated in the
following figure:

Fields of medical research financed by National Agency

for Sciences, Technology and Inventions (NASTI)
Total amount allotted for medical research: 2.17 %

prevention and control

9%
2%
operational programms

14%
pharmacology
47%
classical medical
techniques
immunology,
oncology, AIDS
14% other

non-conventional
11% 3% technologies
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According to NASTI, in 1998, the whole research field in Romania involved 36,302 people, of
whom 20,450 were highly qualified. They are employed in 503 research facilities. Of these 22
are National Institutes of Research, 14 are facilities belonging to the Romanian Academy and
39 are under the authority of Ministry of Education.

The same source states that the number of staff involved in research decreased by 30% in
1998 compared to 1997. The decrease was higher (34.2%) within the number of highly
qualified personnel. The decrease was due to the year on year budget deficit, lack of
research requests from social and economic sites, restructuring and reform of research
institutes towards production, services or trade activities.

3. Evaluation criteria

The evaluation criteria of the projects for financing followed the NASTI guidelines:
• Long-standing allocation (to ensure continuity);
• Development of various fields in EU;
• Requests from ministries to finance strategic studies ;
• Support for basic research.
There were selected projects to support and foster international programmes, like COST,
INCO-COPERNICUS, NATO, TEMPUS, EUREKA, PECO, or bilateral agreements such as with
France, Spain, Japan, Greece and Belgium. The complex multidisciplinary character of
projects should be stressed, which explains the differences in funding allocations between
research topics and specialized subcommittees.

The criteria could also explain, to a certain extent, the fund allocation for medical research,
which has several sources:
i. National Agency for Science, Technology and Inventions (NASTI) (previously organised
as a Ministry) receives yearly about 0.2% of GDP. The mechanism for financing medical
research was described above;

ii. Ministry of Health - through national health programmes - direct financing of some
institutes, which have research departments or activities - salaries for researchers The
health care reform introduced new ways of financing health care services and
restructured the classic hierarchy of the health sector. The Ministry of Health's budget is
dedicated mainly to public health issues. The financial resources are directed to the
institutes within the framework of the national health programmes. All these
programmes have research components. The salaries for the staff involved are covered
also from this source;

iii. Romanian Academy Grants (State budget) - project targeted. The Romanian Academy
as budget holder, distributes research grants to specific projects;

iv. Collaboration between research institutes and foreign partners;

v. Foreign sources (mainly EU);

vi. A few private sources - mainly sponsorships related to participation of specialists in

various congresses, not clearly directed towards a research project.

In summary, the financial resources for medical research in Romania can be illustrated in the
following chart:

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 Finance resources

State Budget

Foreign sources Private sources

(mainly EU) sponsorships

Ministry of Health National Agency for Science Romanian Academy

regular budget NASTI (Grants)

National Programms for Health Institutes for Medical Sciences Research project Research project

Research project Research project

4. Romanian Academy of Medical Sciences

Moreover, there is a central NGO, The Academy of Medical Sciences, acting as consultant and
advisor to the same Ministry of Health, which enjoys a high degree of autonomy in
conducting medical research in close relations with the university clinics in the main
Romanian cities.

The Romanian Academy of Medical Sciences is an independent institution financed by the

Ministry of Health, the Romanian Academy and its members. It has an advisory role with
NASTI, the Romanian Academy, Ministry of Health and Ministry of Education. It also fulfils the
role of Subcommittee for Bio-ethics for the Ministry of Health.
This high-level body of medical specialists was founded by Professor Daniel Danielopolu, a
cardiologist born in 1883, and former Minister of Health in the thirties and at the same time
member of the Romanian Academy. The Academy had its origins in 1934 by an Act of
Parliament, and was, from the outset, the highest medical organized body, a sort of
"noblesse" of the medical non-governmental profession.

Later, after the Second World War that destroyed and reshaped so many institutions among
the states of the world, it was "absorbed" by the communist regime, and only after the 1989
revolution was it promoted to its former leading position. From its vantage point, the
Academy was successful in encouraging and sustaining an active research life, with a
systematic approach to the main fields of medicine, that could be summarized as follows:
• Nurturing a number of traditional epics of Romanian research: for example
anatomy, physiology, cardiology, endocrinology, gerontology, neurology, virology
and bacteriology, as well as modern informatics, public health research and
environmental hygiene, health management etc;
• Keeping a breast with new developments in medical science around the world
and helping to incorporate its effective use in research institutes and clinics;
• To provide a satisfactory level for a combination of adequate instruction and
support for the creation of a new medical school for an active body of research;
• And thus, to contribute to the creation of an "elite of career researchers", to be
grafted onto new, well-adapted structures of "excellence".

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In fact, all these actual objectives were reflected in a deeper understanding of modern
physiology, further assuring the quality of medical procedures, in the spirit of European "good
clinical and laboratory practice" that aimed at orienting, finalizing and accomplishing medical
research.

As far as better promoting and, thus, safeguarding an active scientific life is concenrned, as
well as adequately entertaining the "speculated " outcome of medical research, it was a
question of overcoming the problems of publishing scientific results or up-to-date reviews in
various fast developing fields of interest, as well as extensive and constant use of "Internet".

Some achievements were published by the NASTI in its 1998 report, which reflect mainly the
research activities funded through it's "Horizon 2000" programme. There were 55 institutions
involved in medical research activities, mobilizing a staff of 700 people, of whom 410 were
highly qualified personnel.

Human resources in medical research

projects financed mainly by NASTI

1800
1600
1400
1200
1996
1000
1997
800
600 1998

400
200
0
no. of research personnel no.of high qualified research
personnel

5. Human Resources in medical research

There were a number of 54 projects that could be grouped as follows according to financial
allocation criteria:

47,04%, 2,56%, 10,51%, 14,24%, 13,85%, 9,45%.

Preventing Operational pharmacology classical Immunology, Non-
and control programs medical oncology, conventional
techniques AIDS technologies

The priorities of medical research were formulated in accordance with the general health
indicators of Romania and with the health priorities of the Ministry of Health. They focussed
on prevention and control of chronic diseases, infectious diseases, immunology, AIDS,
oncology research, Romanian drugs, medical equipment and software for health care
services.

The figures and table presented above, list the human resources and institutions involved in
research funded by NASTI. The financing process was project targeted. Apart from that, the

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regular budget of the Ministry of Health supports the salaries of researchers in 29 medical
research institutions. There are 3 categories of such research facilities:

i. 13 research institutes with beds - premises, structure and management are linked
to university clinics;
ii. 11 research institute without beds - their focus is mainly on public health;
iii. 5 research centres - linked also to well recognized clinics.

Human resources of the MoH

Year 1996 1997 1998
Category of Total With Withou Total With Withou Total With Withou
personnel resear t resear t resear t
ch title resear ch title resear ch title resear
ch title ch title ch title
Total 2357 685 1672 2419 872 1547 2483 816 1667
Biologist 321 204 117 311 195 116 273 156 117
Chemist 221 144 77 231 149 82 214 130 84
Biochemist 54 32 22 59 39 20 57 35 22
Pharmacist 98 39 59 75 36 39 64 33 31
Doctor 1663 266 1397 1743 453 1290 1875 462 1413

This table shows the dynamics of research personnel, employees of the Ministry of Health
from 1996 -1998. As compared to the figures of the NASTI report, the number of research
staff of the Ministry of Health increased during past years, instead of decreasing as a result of
budget constraints.

There are differences between the categories of personnel in terms of number and trends.
Doctors represent more than 70% of the staff. Their number increased by 300 in three years.
It is common knowledge that there are no incentives for research activities, and salaries of
researchers are the same as for other doctors. Th only real explanation for this important
increase in the number of doctors in research is to be found in the role, structure,
organisation and management of research institution. As mentioned before, 18 institutes out
of 29 are linked to hospitals and/or university clinics, so that the majority of the doctors are
likely to provide health care services.

The downward trend in research personnel, as mentioned by the NASTI report, can be
observed only among biologists and pharmacists. The growing importance of modern
technologies has led to a decrease in the number of biologists, while pharmacists left for the
private sector where the free market of pharmaceuticals has created new career development
opportunities for pharmacists.

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The following chart clearly shows the differences between the categories of personnel
employed as researcher in the research network of the Ministry of Health:

6. Scientific events

Researchers, employees of the ministry of health

2000

1800

1600

1400 Biologist
1200

1000 Chemist
800

600 Biochemist
400
200 Pharmacist
0
Total With Without Total With Without Total With Without Doctor
research research research research research research
title title title title title title
1996 1997 1998

Regardless of the financing sources, all medical research activities are strongly linked to
scientific events and publications. The importance of the events and publications, and the
way in which the scientific and professional community receives them, can be seen in the
following figures:

Scientific events (1998)

ecology
energy
machine construction
metalurgy
electronics
chemistry
textile industry
transportation
informatics
agriculture
urbanism
medical field
physics
biology
defense
recycling
socio-economics
flight, space

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The figure shows that the medical field is in third place among research fields in Romania as
far as scientific events are concerned. As compared with the other figures related to financing
medical research, we can observe the high ranking of medicine and pharmacy. The
conclusion can be drawn that there is a huge demand in this field, demand for research,
demand for information, demand for up-to-date knowledge in this field.

7. Publications

The same conclusion emerges from the next figure on publications. Again, the medical field
holds third place after agriculture and physics.
The large number of publications reflects the demand for knowledge and information among
health professionals.
Health care reform introduced a lot of changes that needed to be assessed, evaluated and

Publications
1400
1200
1000
800
600
400
200
0
ecology energy machine construction metalurgy
electronics chemistry textile industry transportation

informatics agriculture urbanism medical field

physics biology recycling socio-economics
flight, space
reshaped to produce new tools for health workers to do their job. There is a need for
research on the outcome of these reforms and their impact on the health status of the
population. The differences between figures on financial allocations and research results,
such as events and publications, should be considered by NASTI in setting criteria for the
distribution of funds.

8. Recent achievements

We can describe in brief a number of most noteworthy results obtained during the last 10
years in a series of the most representative medical research institutes in Romania:
• The National "Victor Babes" Institute for pathology and biomedical sciences,
interested mostly in anatomy pathological and functional studies on biochemical,
hormonal and genetic alteration in various vital organs and tissues, oriented
towards the "apostosis phenomenon", based on the dynamics of applied
immunoenzimatic immunohistochemistry, and molecular biology investigations;
the genetic molecular analysis of HLA alleles, associated in pre-oncogenic
proliferative processes, on the basis of HLA1 and HLA2 genotyping. And too the

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 mechanism of action of all-trans-retinoic acid in the induction of reemission in
acute panmyelocite laukemia;
• The "Stefan Nicolau" Institute of Virology of the Romanian Academy persuing
fundamental studies on Human Immunodeficiency Virus, as well as on epidemic
hepatitis viruses (A, B, C, D, E);
• The "Contacuzino" Institute of Immunology, microbiology and epidemiology on
modern and rapid "fingerprinting" molecular methods in epidemic infections
produced by particularly aggressive strains of microbes in the Enterobacteriaceae
Family; Streptococcus pneumoniae, Brucella, Toxoplasmosis, as well as on other
enteroviruses, to obtain remarkable active new specific immunomodulatory
products, based on fundamental studies in the cellular and hormonal arms of
immunological processes, as major changes in natural factors of body resistance
to microbial and viral inversion mechanisms and their particular
immunomodulatory aspects autoimmunity and immunodeficiency;
• The "Nicolae Simionescu" Institute for cellular biology and pathology especially
on fundamental processes of irreversible glycosilation of proteins and their role in
the interaction with endothelial cells in experimental diabetes;
• The "Paulescu" nutritional and metabolic pathology studies on multiparametric
electronic system in the early diagnosis of diabetic somato-sensititive neuropathy;
• The National Institute of Chemical and Pharmaceutical research on new
biologically active synthetic products belonging to the fluoro-kinolones;
• The "Parhon" Institute of Endocrinology on hypophysal and epiphysal
neurohormones in the diagnosis of glandular tumors and a most comprehensive
National Program for the prophylaxis and adequate multifunctional treatment of
osteoporosis, constructing also a national incidence and prevalence indicator,
based on the combined use of Dexa, absorption and radiogeometry of bone
structures;
• Most remarkable progress obtained by using a new bio-adapted product
"biovitroceramics" Ponetti in orthopedy, traumatology in bio-osteoblast implants
and prostheses as well as in dentistry in the efficient control of paradontopathies;
• New surgical techniques in the field of laparoscopic surgery, in hepatic
transplantation and original procedures based on virtual electronic models in
neurosurgery;
• Special social-medical programs on an active community care of the elderly,
geriatric palliatology and total community care for the old terminal patient etc.
and detection of special aspects immuno-endocrine integration and chrono-
biology of aging;
• Institute of Public Health and Institute for Mother and Child Care were focused
their research activities towards infant mortality, nutrition and Iodine deficiency.

A brand new research complex of the National Research Programme was initiated recently
and development is under way on the basis of converging population studies. It contains five
main lines of activities:
• Fundamental research oriented towards a better understanding of pathological
mechanisms in promoting multisectoral and multidisciplinary research, connecting
biotechnology and information;
• Development of scientific knowledge in children and adolescents, as well as geriatric
research medical care with a number of other domains, such as biophysics,
biochemistry, into pathology, with a view to obtaining an adequate prophylaxis in
reducing the multifactoral causes of some high morbidity and mortality indicators;
• Organizing a transplant network across Romania, together with the management of a
bank of organs and tissues;
• Creating new efficient strategies of a fundamental character in trying to better control
pathological processes and risk factors with chronic and degenerative consequences
that induce high morbidity, such as diabetes mellitus, mental disorders, cancer, etc.;
• Obtaining new medical equipment and appropriate technologies in medical care, in
search of the best technological transfer possibilities, based also on specific medical

12
 information networks for their rapid and efficient introduction in current use, thus
ensuring a better life and health status for the population.

9. International cooperation

One of the key issues to achieve the objectives of the research policy is international
cooperation. Despite the fact that a lot of medical research activities were conducted with
international support, as compared to other research fields, international cooperation in
medical research is rather poor. This could be explained by the main objectives of NASTI and
by the poor resources allocated to research. On the other hand, other sources of funding for
research, such as the private sector and the pharmaceutical industry, were mainly directed
towards sponsoring the participation of Romanian scientists in various scientific events
around the world. Due to the regulations in force for the past 10 years, the local drug
industry could not support any research activities. Prices of their products were strongly
regulated by the State, and they were not allowed to include research and development costs
in the production cost. This policy had a negative effect on research related to the locally
produced medicines.
Electronics, ecology, physics and agriculture are fields where international collaboration was
the most important pillar of research activities.

International collaboration
200

150

100

50

ecology energy machine construction

metalurgy electronics chemistry
textile industry transportation informatics
agriculture urbanism medical field
physics biology recycling
special programms

10. Conclusions

§ Romania has an important medical research potential within a network of researchers

and auxiliary personnel of its institutes and universities. More than 60% of them are
highly qualified scientists with academic and scientific degrees;

§ Medical research in Romania is financed form 6 main sources, such as the State budget
through the National Agency for Science, Technology and Inventions, Ministry of Health,

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 Ministry of Education and the Romanian Academy; international cooperation, intersectoral
cooperation and private sources;

§ The State allocation for research represents 0.2% of GDP, a percentage considered very
poor. By way of comparison, the entire health care budget for the last 5 years was
around 3% of GDP annually. It is widely recognized that health care in Romania is
chronically under-financed, a fact reflected in health indicators;

§ The funds allotted to medical research were far below the estimate of NASTI’s specialized
subcommittees;

§ There is a downward trend in staff involved in research. In fact, there is a passive

restructuring of all research facilities and institutions due to the shortage of financial
means. In the long run this could have a negative effect unless there is a policy or a
reform framework for this field;

§ There is a lack of use of research findings in the economy and in health care. This could
be explained by the lack of a research market and by massive import of products and
technologies, as a side effect of the policies of the 80's;

§ The gap between the need and demand for research becomes more and more
significant;

§ There is a need for coordination in order to avoid overlapping, to ensure synergy and to
identify new ways of collaborating;

§ Romania has no definite, widely accepted policy on medical research. Medical research
does not cover the needs of health policy developments and of the health development.
Reform of medical research structures directed towards the better use of existing means
is needed, as well linkage to demand, improving international cooperation and the flow of
information;

§ The Government should regard medical research as a priority among other research
activities. Medical research as a priority could contribute better to the achievement of the
objectives set by NASTI within the overall targets of the Government, such as EU
accession and building the welfare state.

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