6. Romania: A growing international medical education hub

Marius Ungureanu
Babeș-Bolyai University
Karolina Socha-Dietrich
OECD Health Division

For international medical students, the attractiveness of Romanian medical

schools has increased since the country’s accession to the European Union in 2007, as they offer diplomas with EU-wide recognition for relatively low tuition fees and living costs. At present, nearly all medical schools offer programmes in English and/or French, taking up around 30% of the total teaching capacity. The internationalisation of medical education in Romania has taken place in the absence of any formal national strategy. Rather, medical schools have developed their own strategies to attract international students as a way to generate additional income, to be able to recruit and retain academic staff and to develop their infrastructure. Although Romania has become increasingly attractive for international medical students, owing to poor working conditions and relatively low salaries, the country’s health system is not attractive as a workplace, and most international medical graduates leave after obtaining their first degree.

    

The statistical data for Israel are supplied by and under the responsibility of the relevant Israeli authorities. The use of such data by the OECD is without prejudice to the status of the Golan Heights, East Jerusalem and Israeli settlements in the West Bank under the terms of international law.

6.1. Introduction

Since Romania’s accession to the European Union (EU) in 2007, the country’s medical schools have significantly intensified efforts to open or expand the capacity of medical programmes in foreign languages, targeting international medical students (that is, students who leave their country of origin to study medicine abroad). In the academic year 2018/19, nearly all medical schools (10 out of 13) in Romania offered long-cycle programmes (six years) in English and/or French, along with the programme in Romanian.

While in the past the Romanian medical schools attracted international students mainly from non-EU countries, such as the neighbouring Republic of Moldova, more recently an increasing number of citizens of the EU and OECD countries – for example, France, Germany, Israel, and Sweden – have decided to pursue their medical education in Romania. These students intend to return to their home countries on graduation to complete postgraduate training and start to practise as physicians there.

Romania thus provides the international medical labour market with much-needed medical graduates and, in turn, receives additional funding to spend on its medical education system. However, decisions on how many domestic and international students are admitted to the different medical schools in Romania are based solely on their training capacity, without much (if any) consideration given to the current and future health needs of the population. There is an urgent need to establish a formal medical workforce planning process in Romania, linking decisions on the number of students admitted to all medical programmes (Romanian and English/French) with current and projected future demand for doctors. There is also a need to address the fact that, owing to poor working conditions and relatively low salaries, the country’s health system is not attractive as a workplace to either domestic or international medical graduates.

Against this background, this chapter describes findings from a case study on the internationalisation of medical education in Romania – in particular, its dynamics, magnitude, and main drivers, as well as its potential impact on the medical education system and national medical workforce. The discussion relates to international medical students enrolled in long-cycle programmes; it does not include medical students visiting Romania temporarily (for one or two semesters) as part of the EU’s international student exchange programmes.

The study was undertaken in 2018 and is based on key-informant interviews with representatives of main policy actors in the education and health sectors in Romania – including government departments, regulatory bodies, professional associations, and medical schools (see Annex Table 6.A.1 for a complete list of interviewees’ institutional affiliations) – in addition to a literature review. Furthermore, information on push and pull factors behind decisions to pursue medical education in Romania was obtained from a sample of international medical students.

6.2. Nearly 30% of new-entrant places in medical schools in English- and French-language programmes

Romania has 11 public and 2 private medical schools. In total, they produce a relatively high number of medical graduates: 22.2 medical graduates per 100 000 population in 2016 – a greater number than in nearly all OECD and EU countries, and much higher than the OECD average of 12.5 in 2016 (Figure 6.1).

Figure 6.1. Number of medical graduates per 100 000 population, OECD and EU countries, 2006 and 2016
Figure 6.1. Number of medical graduates per 100 000 population, OECD and EU countries, 2006 and 2016

Note: There are no medical graduates in Luxembourg. In Denmark, the data refer to new doctors receiving an authorisation to practise (resulting in an over-estimation if it includes some foreign-trained doctors).

Source: OECD Health Statistics 2018, https://doi.org/10.1787/health-data-en.

 StatLink https://doi.org/10.1787/888933970627

In the past decade, the medical education system in Romania has undergone significant internationalisation. In particular, the country’s medical shcools have intensified their efforts to either open or expand the capacity of medical programmes taught in English or French. As a result, in the academic year 2018/19, 10 of the 13 medical schools in Romania offered long-cycle programmes in English, and 4 of these 10 also offered the programmes in French, along with the programme in Romanian. In Romania, a long-cycle programme in medicine is six years in duration.

Accordingly, while the total annual number of places for new medical students increased by nearly a fifth between 2011/12 and 2018/19 (from 5 250 to 6 121), the capacity in foreign-language programmes increased by 75% (from 995 to 1 740, of which 76% or 1 330 places were in the English programmes and another 410 in the French programmes) (Figure 6.2). This also means that the proportion of places in foreign-language programmes increased from 20% to 30% in the same time span. The number of new-entrant places in the Romanian programme grew only slightly; in the 2018/19 academic year it even shrank by around 1%, for the first time since 2011/12.

Figure 6.2. Trends in the number of new-entrant places in medicine in Romania – all programmes and Romanian, English, and French programmes, 2011/12 to 2018/19
Figure 6.2. Trends in the number of new-entrant places in medicine in Romania – all programmes and Romanian, English, and French programmes, 2011/12 to 2018/19

Source: Compilation based on numbers published in the annual government decree on the nomenclature and specialisation in tertiary education in Romania.

 StatLink https://doi.org/10.1787/888933970646

The changes in numbers of the new-entrant places available in the Romanian and international programmes vary by medical school (Figure 6.3):

  • The largest medical university in Romania – the University of Medicine and Pharmacy Bucharest – expanded its annual new-entrant capacity in the English programme from 200 to 300 (+50%) between 2011/12 and 2018/19, thereby maintaining the largest English-language programme in the country. During the same period, the annual new-entrant capacity in the Romanian programme decreased from 1 500 to 1 266 (-16%), resulting in an overall reduction of capacity. Only the much smaller medical school in Constanţa experienced a similar reduction in overall capacity.

  • The second and third largest medical schools – in Cluj-Napoca and Iași – doubled the annual new-entrant capacity in their English programmes and increased the capacity in their French programmes by 50% between 2011/12 and 2018/19. Just behind the much smaller private medical school in Arad (where the proportion is 50%), these two schools now have the largest proportion of foreign-language capacity, at around 40%. The combined capacity of the English and French programmes in the medical school of Cluj-Napoca is the largest in the country. This school also increased the capacity of its Romanian programme, making it the fastest-growing medical school in the country.

  • In the medical school in Târgu Mureș, the annual new-entrant capacity of the English programme increased from 50 to 150 between 2011/12 and 2018/19. The English programme accounts now for 35% of the school’s capacity.

  • Three medical schools that did not offer any international programmes in 2011/12 – Craiova, Oradea, and the private medical school in Bucharest – have since opened programmes in English, offering between 45 and 100 new places in the 2018/19 academic year.

  • The three smallest medical schools – in Sibiu, Brasov, and Galaţi – do not offer any foreign-language programmes (for more detailed data see Annex Table 6.A.2).

Figure 6.3. Trends in the numbers of new-entrant places by medical school, Romania, 2011/12 and 2018/19
Figure 6.3. Trends in the numbers of new-entrant places by medical school, Romania, 2011/12 and 2018/19

Note: P indicates a private medical school.

Source: Compilation based on numbers published in the annual government decree on the nomenclature and specialisation in tertiary education in Romania.

 StatLink https://doi.org/10.1787/888933970665

6.2.1. A large share of international medical students come from Israel and EU/EFTA countries

In 2017, foreign-born students accounted for 5.4% (25 022) of the total number of students in all tertiary education institutions in Romania. According to the Executive Agency for Higher Education, Research, Development and Innovation Financing (UEFISCD), 6 890 international students originated from other EU or European Free Trade Association (EFTA) countries and 18 132 from non-EU/EFTA countries (UEFISCD, 2017[1]). Of the EU/EFTA students in all fields of study, nearly a third (31%) come from France, followed by Germany (18%) and Italy (12%).

Among all the international students, 55% (3 789) from EU/EFTA countries and 26% (4 753) from non-EU/EFTA countries enrolled in medicine. Data that would allow identification of the specific nationalities of the latter are not available at the national level. Of all non-EU/EFTA students in medicine, dentistry, and pharmacy together, the largest group comes from Israel, followed by Moldova and Tunisia. A quarter of the Moldovan students study in campuses of Romanian universities located within Moldova (UEFISCD, 2017[1]).

Additional information obtained from the University of Medicine and Pharmacy Cluj-Napoca – hosting the largest programme in French – confirms the presence of a large number of French students, with 870 registered to study medicine in 2018/19. At the University of Medicine and Pharmacy Târgu Mureș, the largest group of international students is from Germany, followed by Italy and Sweden. At the University of Medicine and Pharmacy Craiova, international students from Israel make up by far the largest group, followed by Greece (Table 6.1. ).

The data provided by the three universities suggest that the distribution of international students by nationality might vary among the medical schools, indicative of a degree of specialisation in their marketing strategies (for further discussion see Section 6.4).

Table 6.1. Top five nationalities of international students – Universities of Medicine and Pharmacy Târgu Mureș and Craiova, 2018/19

University of Medicine and Pharmacy Târgu Mureș

University of Medicine and Pharmacy Craiova

Country

Number of students

Country

Number of students

Germany

202

Israel

131

Italy

75

Greece

43

Sweden

44

Italy

28

Finland

25

United Kingdom

20

Israel

16

Syrian Arab Republic

17

Note: These numbers include the number of students in the English programmes at the departments of medicine and of pharmacy.

Source: Personal communication with the universities’ authorities.

 StatLink https://doi.org/10.1787/888933970684

Moreover, information available on Swedish students pursuing medical education in all Romanian medical schools indicates that the number is sizeable but decreasing, at 325 in 2015/16, 251 in 2016/17 and 222 in 2017/18 (Swedish Board of Student Finance, 2018[1]) (see also Figure 2.2 in Chapter 2).

6.3. Admission rules, tuition fees, education and training pathways for international and domestic students

6.3.1. Medical schools enjoy significant autonomy in their decisions on student intake

Every year, each medical school states its preferences on the intake of new medical students – both domestic and international – in an application to the Romanian Agency for Quality in Higher Education (ARACIS). The Agency is an independent institution responsible for the assessment of the didactic capacity, with the aim of ensuring an adequate quality of the tertiary education in Romania.

Following a comprehensive individual assessment by ARACIS, which involves an evaluation of human and material resources, the maximum number of new entrants is determined separately for every medical school and programme – Romanian, English, and French. Medical schools can also apply for an evaluation of their didactic capacity by another independent accreditation agency, in Romania or abroad, as long as it is registered in the European Quality Assurance Register for Higher Education. Following the assessment, the maximum numbers of new entrants to medical programmes are endorsed annually in a government decree.

These maximum numbers do not need to be attained, however. Indeed, some medical schools decide to admit fewer students as part of their marketing strategies to signal a higher quality of education.

It is worth noting that neither the Ministry of Health nor medical associations are formally involved in the process of determining the number of new medical student entrants. More importantly, there is no formal mechanism linking the decision on the maximum number of new entrants to medicine studies with future demand for doctors – as estimated, for example, by the health needs of the population.

6.3.2. The Ministry of Education subsidises places in the Romanian programme

Generally, for students enrolled in the Romanian programme, medical schools receive a per capita subsidy from the Ministry of Education, meaning that these students do not face any tuition fees or other student levies. The competition for these subsidised places is open to Romanians and to all other nationals of EU/EFTA countries. In practice, however, there is a language barrier to access: the process begins with an exam in Romanian, including questions on biology, chemistry, and/or physics.

Students enrolled in the English or French programmes, including any Romanian nationals, pay tuition fees. The annual fees are decided by each university and range from EUR 3 150 to 6 000 (euros) for the public universities. Tuition fees in the two private medical schools are higher, at EUR 6 250 and 7 000, respectively (Table 6.2).

Table 6.2. Annual tuition fees in English/French programmes in Romanian medical schools (EUR), 2018/2019

Medical school

Annual tuition fee (EUR)

Bucharest

6 000

Brasov

4 000

Cluj-Napoca

5 000

Constanta

5 000

Craiova

5 000

Galati

4 000

Iași

5 000

Oradea

4 800

Sibiu

3 150

Târgu Mureș

5 000

Timișoara

4 500

Private Medical School Arad

6 250

Private Medical School Bucharest

7 000

Source: Compilation based on information from the medical schools.

 StatLink https://doi.org/10.1787/888933970703

The programmes in English and French are open to nationals of any country, with candidate selection based on high-school performance. The admission process is organised separately by each university, with the number of places available for each programme announced publicly at least six months prior to admission. The admission of successful candidates from non-EU/EFTA countries is further subject to acceptance by the Ministry of Education.

Medical schools strive to optimise the admission process for international applicants. The University of Medicine and Pharmacy Târgu Mureș, for example, offers “early admission”, which allows international candidates to apply before completion of the final high-school exam and secure a conditional acceptance, pending the exam and its result.

Part of the income from tuition fees is used to offer scholarships to international medical students: of all international student fees charged by tertiary education institutions in Romania, 5% are redirected to the Ministry of Education, which offers a number of scholarships each year. Moreover, some medical schools have created additional scholarship funds for international medical students. At the University of Medicine and Pharmacy Cluj-Napoca, for example, in the first semester of the academic year 2018/19, close to 20% of the students in the French programme received merit-based scholarships ranging from EUR 1 000 to EUR 1 250 per month. These largely cover the monthly costs of living, including accommodation costs.

6.3.3. Domestic and international students follow the same medical education and training pathways

The medical education in Romania covers six years of study, followed by three to seven years of (specialist) residency training. All international students in Romanian medical schools are required to master the Romanian language by the end of the second year of their medical studies, in view of the relatively large share of “hands-on” education in direct contact with patients, which starts in the third year of the programme. The residency training is organised exclusively in Romanian, so applicants need to submit proof of Romanian language proficiency.

During their postgraduate training, residents are employed in designated public healthcare institutions and continue to participate in training activities organised at the universities, the costs of which are borne by the Ministry of Health. The competition for residency placements is open to all medical graduates – domestic and international – of Romanian medical schools, as well as international medical graduates from other EU/EFTA countries. Moreover, international medical graduates from non-EU/EFTA countries can take part, subject to approval from the Ministry of Education.

The competition for residency training is strong. The number of available posts has traditionally been lower than the number of new medical graduates from the Romanian programme alone: in recent years, 10-15% lower, although in 2018 the number of positions advertised matched the number of these graduates. Furthermore, residents already pursuing their training often choose to re-enter the competition in the hope of getting a better ranking that would allow them to choose another specialty. Within the pool of available residency posts, international medical graduates can also compete for a limited number of posts, for which the university-related costs are subject to charges.

The number of residency posts is fixed by the Ministry of Health and is communicated to the Ministry of Education, which includes it in the annual government decree. The Ministry of Health does not use any formal evidence-based mechanism in this process. It often simply updates the numbers based on ad hoc consultations with the medical schools.

In 2017, international medical graduates in residency represented 4% of the total number of trainees/residents (688 of 16 950). Most of the residents were nationals of Tunisia (19%), Morocco (17%), and Moldova (7%). No EU country had more than ten residents pursuing postgraduate training in Romania in 2017 (Ministry of Health, 2018). Interviews with representatives of the medical schools suggest that the numbers of foreign-born residents pursuing their postgraduate training in Romania have risen over the past five years. At the University of Medicine and Pharmacy Iași, for example, the number increased from 1 resident in 2014 to 16 in 2018. According to the university’s representatives, this can be explained by recent efforts to improve the quality of training in residency, with an increased focus on giving residents a more active role in treating patients.

6.4. Drivers of internationalisation of medical education in Romania

6.4.1. Internationalisation of medical schools as part of general internationalisation efforts in higher education

The international aspirations and efforts of the medical schools also take place within the broader context of the internationalisation of the tertiary education system in Romania. Although a comprehensive national policy for the internationalisation of higher education is lacking, a strategic framework has been in place since 2015. This was developed through the Human Resource Development Operational Programme, with EU funding support ( (UEFISCDI, 2015[2])]). The project, entitled “Higher Education Evidence Based Policy Making: A Necessary Premise for Progress in Romania”, has produced a series of analyses and recommendations for decision makers at the national level as well as for universities (Box 6.1). The final project report suggests a series of objectives and related activities, but without matching them with a timeline, numerical targets, or a budget.

Box 6.1. Recommendations of the “Higher Education Evidence Based Policy Making: A Necessary Premise for Progress in Romania” project

Recommendations from the 2015 project report addressed to national decision makers in the education sector included calls to:

  • design and adopt a comprehensive national policy for internationalisation of higher education, in line with existing EU reference documents, accompanied by an appropriate legal framework and efficient operational structures for implementation

  • collect information and statistical data on the higher education system as a whole, as the foundation for policy making for internationalisation and for higher education in general

  • remove legislative and bureaucratic barriers to internationalisation and mobility, including by simplifying the procedure for accreditation of foreign-language programmes.

Recommendations addressed to universities included calls to:

  • create internationalisation strategies through a comprehensive consultation with the university community and incorporate these into overall institutional strategies

  • enhance the internationalisation of curricula

  • promote mobility opportunities for students and staff, supported by the university's own resources

  • develop a coherent and comprehensive mechanism for collecting nationally standardised data and information, consistent with international practices.

Source: (UEFISCDI - Executive Agency for Higher Education, Research, development and Innovation Financing, 2015[2]).

Apart from this initiative, internationalisation is a component of the “Educated Romania” (“România Educată”) initiative, developed by the Department of Education and Research of the Presidential Administration and launched in December 2018. A working group has been established within this project to foster the internationalisation of higher education in Romania (Presidential Administration, 2018[3]).

6.4.2. Push and pull factors for international students: limits on access in home countries, low tuition fees, and EU-wide recognition of medical diplomas

As with health professional mobility, push and pull factors underlie the international students’ decisions to pursue medical education outside their home countries. For many international medical students, especially nationals of EU countries, the main push factors are the numerus clausus policies that limit access to the medical education in their home countries. As for the reasons that draw those who decide to study abroad to the Romanian medical schools in particular, the main pull factors mentioned by the international students interviewed include:

  • relatively low tuition fees compared to their home countries or other countries offering medical education programmes in English;

  • relatively low living costs, especially compared to other EU countries;

  • recognition of medical diplomas throughout the EU – for international students from non-EU/EFTA countries; a degree from a Romanian medical school opens access to the entire EU medical labour market;

  • relatively easy-to-achieve admission standards, i.e. absence of a written admission exam, since the admission is based on high-school grades.

Medical schools frequently tailor their international study offer to nationals of a selected country. The University of Medicine and Pharmacy Cluj-Napoca, for example, concentrates on potential students from France (Box 6.2). It is the second largest medical school in Romania but hosts the largest French programme. In 2017/18, 80% of the students enrolled in this programme came from France.

Box 6.2. French programme at the University of Medicine and Pharmacy Cluj-Napoca

The medical school Cluj-Napoca has offered a programme in French since 2000. In 2018/19, it had more than 1 600 international students, including around 1 000 francophone students, of whom 870 were French nationals. While some of the French students (with Romanian origins) were enrolled in the Romanian programme, most were in the French programme, where they accounted for 80-90% of students.

According to representatives of the school, the medical education model it has adopted is based on the French model. Over time, many members of the faculty in Cluj-Napoca have been trained in France, thus importing knowledge and procedures.

To signal its commitment to the quality of education, the school took the decision not to increase the intake of students to the number allowed by ARACIS. Presently, it accepts 150 new students into the French programme annually of the maximum allowance of 180 students.

The school is also a member of the Conférence Internationale des Doyens et des Facultés de Médecine d’Expression Française – an international network of French-speaking medical faculties and part of the Agence Universitaire de la Francophonie.

With the aim of facilitating the return of the French students to France and preparing them for the entry exam for residency training (the épreuves classantes nationales), the school entered into dialogue with a number of institutions in France involved in the organisation of the exam. This includes Grenoble University (which manages the Système Informatique Distribué d’Évaluation en Santé platform), the French Rectors’ Conference, and the French Medical Schools’ Deans Conference.

Source: University of Medicine and Pharmacy Cluj-Napoca (2019).

6.4.3. International students as an additional source of income for medical schools

In a poorly funded educational system (OECD, 2017[4]), international students represent a significant source of additional income for medical schools in Romania (see Table 6.2). As discussed earlier (Section 6.3.1), however, medical schools cannot admit an arbitrarily high number of international students because of the ceilings set in an independent assessment of each school’s teaching capacity by ARACIS.

Moreover, the international programmes are part of the schools’ efforts to attract and retain qualified staff, thus addressing the emigration of medical personnel from Romania (see Section 6.5). Indeed, a significant share of the additional income is used to offer extra pay to the staff involved in the international programmes, usually in the form of paid over-time. Student-oriented internationalisation also creates opportunities for other types of international collaboration, most frequently in the area of research; this also contributes positively to the attractiveness of a career as a medical educator in Romania.

Representatives of the medical schools also stressed that internationalisation is an effective tool for stimulating professional development of the academic staff in general, as it creates a positive environment in which new courses can be developed and expands faculty interest in new areas, such as new specialties or teaching methods.

6.4.4. Further impetus for internationalisation from competition between medical schools

Apart from the financial gains, medical schools perceive international programmes as positive contributions to their reputations and visibility at the national and international levels. This often leads to improved rankings – again, nationally and internationally.

Consequently, the competition between schools provides additional stimulus for internationalisation. To signal an internationally oriented strategy, medical schools, for instance, can apply for external evaluations by international accreditation bodies such as the European University Association or the European Medical Schools’ Association. Significant efforts are also undertaken to establish close partnerships with universities in other EU countries as well as in Asia and North America.

The competition extends to the international level, with schools opening campuses in other EU countries. One example is the University of Medicine and Pharmacy Târgu Mureș, which plans to open a campus in Germany (Box 6.3).

Box 6.3. University of Medicine and Pharmacy Târgu Mureș to open a medical campus in Germany in 2019/20

For the University of Medicine and Pharmacy Târgu Mureș, internationalisation is a key strategic objective. It dedicates more than a third of its teaching capacity to the programme in English (see Figure 6.3 above). The majority of international students came from Germany in the academic year 2018/19 (see Table 6.1. above).

The university reports high demand from international applicants, with around three candidates for each available place in the English programme in 2017. To address this demand, in particular from students in Germany and surrounding countries, the university plans to open a branch in Germany. According to an announcement made by the university’s Chancellor in December 2018, the campus will open in Hamburg in the academic year 2019/20 and will train 150 students annually in an English-language programme.

Source: University of Medicine and Pharmacy Târgu Mureș (2019).

6.5. Growing numbers of international medical graduates but low retention

The findings of this study suggest that the internationalisation of medical schools not only brings additional funding but also promotes the quality of medical education, in particular through staff retention and development, as well as through competition among the Romanian universities. However, owing to poor working conditions, notably a high workload – related to low staffing norms and hiring freezes, a weak infrastructure, and the correspondingly weak professional development opportunities – and relatively low salaries, the country’s health system is not attractive to either international or domestic medical graduates.

There is no systematic record of the career paths of the international graduates of the Romanian medical schools, but all interviewed stakeholders share the perception that the majority do not consider Romania as a place to practice. Indeed, while postgraduate training is equally open to domestic and international medical graduates, the share of foreign-born medical graduates in residency training is low – it stood at 4% of all residents in 2017, much lower than the 20% of places available in foreign-language programmes in Romanian medical schools in 2010/11, i.e. six years earlier.

Data from some of the students’ countries of origin further confirm that international students return home to complete their postgraduate training. In 2017 in France, for example, among all medical graduates of international universities attending the exam for entry to postgraduate training, the most numerous group were French nationals (133 of 328), the majority of whom (110 of the 133) had obtained their first medical degree in Romania (CNG, 2018). Moreover, graduates from non-EU/EFTA countries are legally required to obtain Romanian citizenship to be allowed to practise, which might be an additional discouragement from pursuing postgraduate training and eventually a career in Romania.

Many Romanian doctors have also left the country to practise abroad – predominantly in Western Europe – as indicated by data from the destination countries (Table 6.3). In particular, Romania’s accession to the EU in 2007 created new migration opportunities (Vlãdescu et al., 2016[5]). Furthermore, in student surveys carried out in some medical schools, the majority (85%) of Romanian students reported their intention to search for postgraduate training and employment abroad on graduation or completion of their training (Suciu et al., 2017[6]).

Between 2015 and 2018, the Romanian health sector experienced the lessening of some of the austerity measures implemented during the previous decade, which included a salary cut of 25% and budget constraints on hospital staffing. Physicians’ salaries have increased in several stages since 2015, and for some medical specialties the salaries doubled in 2018. Nevertheless, the staffing norms in public healthcare institutions remain low and/or are still subject to a hiring freeze.

There is no source of data within the country to establish the exact magnitude of the exodus or possible returns of doctors trained in Romania. This limits the capacity to assess the effectiveness of any retention initiatives. Official data regarding physician outflows are limited to the number of requests for certificates of conformity/good standing issued by the Romanian Ministry of Health/College of Physicians for doctors intending to practise medicine in other countries of the EU. These certificates, however, are only evidence of an intention to emigrate and physicians might obtain such certificates more than once.

Discussions with stakeholders revealed a lack of co-ordination (or any clear strategy to establish a co-ordination mechanism) between the Ministry of Education and the Ministry of Health with regard to medical workforce planning and management. The main problem is the lack of continuity in the government, which results in frequent changes in policy directions in the education and health sectors.

The National Health Strategy 2014-2020: Health for Prosperity is the current strategic document to guide the development of the Romanian health care system (Ministry of Health, 2014). In the analysis that informed the development of the strategy and the associated action plan, the challenges related to human resources for health (massive outflows, geographic shortages) were recognised as factors jeopardising people’s access to high-quality health care services. In order to address this, the strategy includes as a specific objective the implementation of sustainable policies for human resources for health. Since the adoption of the strategy, however, little has been done to operationalise this objective. In 2016, through a whole-of-government approach, the National Action Plan for Human Resources for Health was developed, with broad consensus from labour unions and professional associations. Its main objectives were to improve human resources for health governance, consolidate data flows about health professionals for better planning and strengthen research efforts to generate evidence for policy making, but approval of the plan is still pending.

In 2017, the Ministry of Health created the Human Resources for Health Centre, with the aims of improving medical workforce planning and management as well as of facilitating the return of doctors who have left to practise abroad. The Centre was still not fully operational at the end of 2018, however. The Ministry also embarked on an effort to develop a national registry of health professionals based on data available in professional colleges. The general objective of the registry is to improve the management of data pertaining to health professionals in Romania in order to improve the evidence base for health workforce planning. The register is expected to be deployed by 2020.

Table 6.3. Number and share of doctors trained in Romania in annual inflows of foreign-trained doctors to selected EU countries, 2006-17

Country

Annual inflow of doctors

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

Belgium

Foreign-trained (number)

204

418

459

400

504

665

684

481

558

566

500

598

of which trained in Romania (number)

2

126

132

153

146

178

122

108

90

108

76

53

trained in Romania (%)

1%

30.1%

28.8%

38.2%

29%

26.8%

17.8%

22.4%

16.1%

19.1%

15.2%

8.9%

France

Foreign-trained (number)

-

-

-

-

-

1 578

1 435

1 515

1 732

1 676

1 503

1 330

of which trained in Romania (number)

-

-

-

-

-

457

402

364

339

333

308

253

trained in Romania (%)

-

-

-

-

-

29%

28%

24%

19.6%

19.9%

20.5%

19%

Germany

Foreign-trained (number)

-

833

934

1 071

1 426

1 900

2 225

1 964

1 730

1 530

1 430

-

of which trained in Romania (number)

-

54

71

103

244

403

579

404

286

244

251

-

trained in Romania (%)

-

6.5%

7.6%

9.6%

17.1%

21.2%

26%

20.6%

16.5%

15.9%

17.5%

-

Ireland

Foreign-trained (number)

-

-

-

-

683

855

783

832

871

1 777

1 819

1 685

of which trained in Romania (number)

-

-

-

-

83

150

131

124

179

194

185

122

trained in Romania (%)

-

-

-

-

12.1%

17.5%

16.7%

14.9%

20.5%

10.9%

10.2%

7.2%

Netherlands

Foreign-trained (number)

140

151

166

205

226

158

177

94

138

163

-

-

of which trained in Romania (number)

-

5

11

7

11

6

8

7

-

14

-

-

trained in Romania (%)

-

3.3%

6.6%

3.4%

4.9%

3.8%

4.5%

7.4%

-

8.6%

-

-

Norway

Foreign-trained (number)

1 208

1 215

1 179

1 287

1 309

1 300

1 603

2 310

1 304

1 281

1 325

1 505

of which trained in Romania (number)

13

24

15

32

21

26

43

78

56

60

65

59

trained in Romania (%)

1.1%

2%

1.3%

2.5%

1.6%

2%

2.7%

3.4%

4.3%

4.7%

4.9%

3.9%

Sweden

Foreign-trained (number)

661

764

821

770

810

739

754

864

940

891

-

-

of which trained in Romania (number)

25

52

56

32

46

65

83

71

116

107

-

-

trained in Romania (%)

3.8%

6.8%

6.8%

4.2%

5.7%

8.8%

11%

8.2%

12.3%

12%

-

-

Switzerland

foreign-trained (number)

1 798

1 798

1 984

1 924

1 892

2 015

2 179

2 519

2 123

2 183

2 355

2 268

of which trained in Romania (number)

9

12

17

26

27

21

21

41

53

51

52

53

trained in Romania (%)

0.5%

0.7%

0.9%

1.3%

1.4%

1%

1%

1.6%

2.5%

2.3%

2.2%

2.3%

United Kingdom

Foreign-trained (number)

6 156

5 056

5 022

4 960

5 945

5 189

5 951

5 459

5 939

4 980

5 649

6 331

of which trained in Romania (number)

87

175

233

254

677

449

292

276

276

216

237

212

trained in Romania (%)

1.4%

3.5%

4.6%

5.1%

11.4%

8.6%

4.9%

5.1%

4.6%

4.3%

4.2%

3.3%

Source: OECD Health Statistics 2018, https://doi.org/10.1787/health-data-en.

 StatLink https://doi.org/10.1787/888933970722

6.6. Conclusions

Romanian medical schools are internationalising to expand and grow. Over the past decade many have been able to attract a growing number of international students by developing their programmes in English and French, while maintaining relatively low costs of studies and having the advantage of offering medical degrees that are recognised across the EU.

This internationalisation seems to have contributed positively to the quality of medical education in Romania. The universities have embarked on improvement processes in efforts to appeal to international students and to be competitive in relation to other medical schools in the country and abroad. Moreover, through curriculum changes driven by international students’ needs and infrastructure improvements to allow more international students to be enrolled, national students have also benefited from the modernisation of medical schools.

However, the internationalisation of medical education is a growing activity that is mainly happening in parallel with the traditional role of medical schools of training new doctors to serve the needs of the Romanian population. It does not contribute directly to achieving health systems goals, in particular with regard to ensuring adequate medical workforce levels:

  • For international students, Romania is an attractive location for obtaining a first medical degree, particularly if they cannot obtain it in their own countries because of numerus clausus policies or other capacity constraints, but it is not attractive for completing postgraduate specialty training and pursuing a career. Many Romanian medical graduates and doctors share this view and want to pursue their careers abroad owing to poor working conditions in the country.

  • Decisions on how many domestic and international students are admitted to the different medical schools in Romania are based solely on their training capacity, without much (if any) consideration given to the current and future health needs of the population. Over the past five years, the growth in numbers of students admitted to Romanian medical schools has only occurred in the English and French programmes, with zero growth in the Romanian programme. If the demand for doctors increases in Romania in the years ahead, the pool of Romanian medical graduates will not have kept step; and they – despite many voicing their intention to leave – are more likely to remain and practise in the country than international graduates.

There is an urgent need to establish a formal medical workforce planning process in Romania, linking the decisions on the number of students admitted to medicine in all programmes (Romanian, English, and French) with the current and projected future demand for doctors. This model should become a basis for co-ordination between the medical education sector and the health sector, with the view of ensuring that domestic needs for doctors are met.

Internationally, there is a need for more refined data collection that would allow monitoring the international mobility of doctors to distinguish between international and domestic graduates of Romanian medical schools. While the emigration of Romanian graduates and doctors to other countries can be considered a “brain drain” for Romania, this is not the case for international students who pay the full cost of their studies while doing their degrees and who, in most cases, do not intend to stay in Romania after graduation.

References

[4] OECD (2017), “The Romanian education system”, in Romania 2017, OECD Publishing, Paris, https://dx.doi.org/10.1787/9789264274051-5-en.

[3] Presidential Administration (2018), , http://www.presidency.ro/ro/romania-educata.

[6] Suciu, S. et al. (2017), “Physician migration at its roots: a study on the emigration preferences and plans among medical students in Romania”, Human Resources for Health, Vol. 15/6, http://dx.doi.org/http://dx.doi.org/10.1186/s12960-017-0181-8.

[1] Swedish Board of Student Finance (2018), .

[2] UEFISCDI - Executive Agency for Higher Education, Research, development and Innovation Financing (2015), Internationalisation of tertiary education (Cadrul strategic pentru internaționalizarea Învățământului Superior din România), https://bit.ly/2DrCSFz.

[5] Vlãdescu, C. et al. (2016), Romania: Health system review. Health Systems in Transition, WHO.

Annex 6.A. Institutional affiliations of the interviewees
Annex Table 6.A.1. Institutional affiliations of the interviewees

National institutions

Ministry of Health

Ministry of Education

Executive Agency for Higher Education, Research, Development and Innovation

Presidential Administration Department of Public Health

Presidential Administration Department of Education and Research

Romanian College of Physicians

Human Resources for Health Centre

National School of Public Health, Management and Professional Development

National Association of Medical Schools' Deans

Local institutions

Carol Davila University of Medicine and Pharmacy Bucharest

Iuliu Hatieganu University of Medicine and Pharmacy Cluj-Napoca

University of Medicine and Pharmacy Târgu Mureș

Faculty of Medicine and Pharmacy Oradea

Gr. T. Popa University of Medicine and Pharmacy Iași

Groups

Romanian medical students in Cluj-Napoca

International medical students in Cluj-Napoca

Annex Table 6.A.2. Trends in the maximum allowed number of new-entrant medical students, by medical school and programme in Romanian, English and French, 2011/2012 to 2018/2019

 

2011/2012

2012/2013

2013/2014

2014/2015

2015/2016

2016/2017

2017/2018

2018/2019

 

RO

EN

FR

RO

EN

FR

RO

EN

FR

RO

EN

FR

RO

EN

FR

RO

EN

FR

RO

EN

FR

RO

EN

FR

Bucharest

1 500

200

0

1 500

200

0

1 500

200

0

1 500

200

0

1 266

250

0

1 266

250

0

1 266

300

0

1 266

300

0

Brasov

100

0

0

100

0

0

100

0

0

100

0

0

100

0

0

100

0

0

100

0

0

100

0

0

Cluj-Napoca

330

100

120

330

100

120

330

200

120

330

200

120

550

200

120

550

200

180

550

200

180

550

200

180

Constanţa

250

125

0

250

125

0

250

125

0

250

125

0

250

125

0

225

125

0

225

125

0

225

125

0

Craiova

290

0

0

320

50

0

320

50

0

320

50

0

320

50

0

320

50

0

320

50

0

320

50

0

Galaţi

50

0

0

50

0

0

80

0

0

80

0

0

80

0

0

80

0

0

80

0

0

80

0

0

Iași

550

100

100

550

100

100

550

150

150

550

150

150

550

150

150

550

150

150

550

200

150

550

200

150

Oradea

100

0

0

100

50

0

140

50

0

140

50

0

140

100

0

140

100

0

150

100

0

150

100

0

Sibiu

120

0

0

120

0

0

120

0

0

120

0

0

120

0

0

120

0

0

150

0

0

120

0

0

Târgu Mureș

240

50

0

240

50

0

240

50

0

270

100

0

270

100

0

270

150

0

270

150

0

270

150

0

Timișoara

525

100

40

525

100

40

525

100

40

525

100

40

525

100

40

525

100

40

525

100

40

525

100

40

Arad P

75

40

20

75

40

20

75

40

20

75

40

20

100

60

40

100

60

40

100

60

40

100

60

40

Bucharest P

125

0

0

125

0

0

125

0

0

125

0

0

125

0

0

125

0

0

125

45

0

125

45

0

Total

4 255

715

280

4 285

815

280

4 355

965

330

4 385

1 015

330

4 396

1 135

350

4 371

1 185

410

4 411

1 330

410

4 381

1 330

410

Yearly total

5 250

5 380

5 650

5 730

5 881

5 966

6 151

6 121

Note: RO = Romanian-language programme; EN = English-language programme; FR = French-language programme; P = private medical school.

Source: Compilation based on numbers published in the annual government decree on the nomenclature and specialisation in tertiary education in Romania.

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