Recommendations
1.3. Health system
EVOLUTIONS: +1 SITUATION: +1 PERSPECTIVES: 0
Source: “Activity of the health system”, Scientifi c Practical Centre of Public Health and Sanitary Management, 2006
Figure 4 Comparison of maternal mortality rate per 100 thousand live births
15 Law of the Republic of Moldova no.123-XV of 18.03.2003 (repealed in 2006).
Development of human capital the local public authorities, exceeding a
lit-tle bit the resources provided by donors as humanitarian aid (2,7%). Aft er the legisla-tive amendments regarding the local public administration, operated in 2006, public medico-sanitary institutions found them-selves in an uncertain situation, the local administrations actually do not have any responsibility for the management of rayon hospital funds16. In the context of the inter-nal resource defi cit, a great part of expen-ditures meant for the rehabilitation of pri-mary health care institutions were covered by World Bank investments. In July 2007, the Government of the Republic of Moldova and the International Development Associ-ation concluded the agreement on funding of the Health Services and Social Assistance Project, Moldova.
According to the Law on mandatory health insurance17, the citizens of the Re-public of Moldova got equal possibili-ties in obtaining timely and quality health care within the limits of the provisions of the Unifi ed Programme (basic package of health care services). However, a higher achievement of the objective related to uni-versal access and adequate quality of heath services faces a series of impediments: defi -cit of primary healthcare personnel in rural areas, old medical equipment in rayon hos-pitals, inadequate conditions of buildings, continuation of problems related to the fi -nancing of medico-sanitary institutions and insuffi cient implementation of information technologies. As a result, the coverage rates for primary health care services constitute less than 65% in some rayons (Cantemir, Rezina, Falesti, Cimislia).
Presently, a great part of the total num-ber of insured population (75%) does not have access to health care at home, included in the Unifi ed Programme18. Th e National Health Insurance Company does not ensure the provision of such services because of the absence of commissioning criteria and of a regulation on functioning of home care pro-viders and it also lacks a costing regulation (see also SOCIAL PROTECTION POLI
CIES). It is estimated that about 25000 suf-fering patients lack palliative care at home every year, more than 60% of them live in rural areas19. At present, home care services are preponderantly off ered by NGOs funded
exclusively by foreign donations20. A verita-ble public-private partnership in the health protection system is not established so far.
Th ere are about 120.000 persons with mental disabilities (3% of the population, percentage situated within the European av-erages) registered in the Republic of Moldo-va. A slow but constant tendency is observed with regard to the increase of morbidity, es-pecially in the contingent of young people.
Th e modern system of health care in case of psychic diseases envisages development of community centres for mental health, but these just begin to appear in our country.
Th e system of patients’ referral makes more complicate the planned admission in specialized departments (endocrinol-ogy, neurol(endocrinol-ogy, rheumatol(endocrinol-ogy, cardiology), where the waiting list is about 3-6 months.
Patients can be hospitalized only in cases of emergency. Th us appears a vicious circle, where lack of access to planned admission leads to disease worsening, situation which requires emergent admission and which in turn makes the absence of beds for planned
16 Laws of the Republic of Moldova no.436, no.437 and no.438.
17 Law of the Republic of Moldova no.1585 of 30.04.1998.
18 Decision of the Government of the Republic of Moldova no.1480 of 25.12.2006 on the approval of the Unifi ed Programme of mandatory health insurance for 2007
19 “Assessment of palliative care needs in the Republic of Moldova”, So-ros-Moldova Foundation, 2007.
20 http://www.cordaidpartners.com/English/Health_and_Wellbeing/
Projects/Project_details/Reform_of_community_care_systems_in_
republic_of_Moldavia.aspx?mId=10537&rId=76.
Source: „The Activity of the health system”, Scientifi c Practical Centre of Public Health and Sanitary Management, 2006
Figure 5 Global incidence of tuberculosis in the Republic of Moldova (1997-2006) per 100 thousand persons
Development of human capital
admission more acute. Th us the risk of com-plications increases and appear conditions for non-formal payments within the system.
During the last years the absolute number of doctors and medical personnel of medium level continued to increase. However the pos-itive dynamic is based on the personnel from republican health care institutions, while provision of health personnel to the munici-pal and rayon institutions indicates a certain involution, stimulating a series of negative social phenomena (see URBAN MOLDO
VA, INTERNAL MIGRATION). In the mu-nicipal hospitals we have today 47,5 medical personnel of medium level per 10 thousand inhabitants, compared to 60,7 medical per-sonnel per 10 thousand inhabitants in 2002.
It appeared a slight decreasing tendency of the number of family doctors (2031 persons in 2006 compared to 2066 in 2005)21, deter-mined also by specialists’ leaving.
Risks
Poor performances in improvement of main health indicators, especially of infan-tile and maternal mortality, worsen the neg-ative demographic rate. Although not reach-ing epidemic proportions, the evolution of such diseases like AIDS and Tuberculosis is alarming22, creating signifi cant economic and social risks. Th eir spreading could cause a decrease of the economic growth rate and an increase of health expenditures, generated by activities related to care provided to suf-fering people. Th e dependency ratio could increase, undermining the fi nancial stability of the social protection system, especially in the conditions when fertility is already very low (section BIRTH RATE AND MOR
TALITY RATE CRISIS). At the same time, this could lead to the increase of the number and level of poverty of single-parent house-holds and of those lead by old people which take care of orphan children, whose parents deceased because of AIDS.
Despite the registered progresses in the Republic of Moldova during the past years,
the health protection system’s functioning could be aff ected by a series of risks. It is not excluded that during the following 3-4 years, the Republic of Moldova would face a defi cit of medical personnel. Essential improvement of medical personnel remu-neration in the neighbour countries makes these countries very attractive destinations for emigration of doctors and nurses from Moldova. Aft er Romania’s accession to the EU, many doctors from this country had al-ready left the health system to work in west-ern countries.
Th e mandatory health insurance system implies also a series of risks related to non-collection of contributions to the manda-tory health insurance in the set quantum and terms. Th e accessibility of services for poor people continues to be low, because of man-datory payment of services which are not in-cluded in the Unifi ed Programme of manda-tory health insurance (see LIVING STAN
DARDS). Absence of real competitiveness for the service providers and non-applica-tion, except for primary health care, of a per-formance incentive system, by stipulating it in the contracts with NHIC, constitute essen-tial causes for low quality of health services.
More than 60% of the funds continue to be used for the maintenance of hospitals which services oft en include treatment of minor pathologic conditions23. At the same time, curative health care services continue to be preponderantly fi nanced in the disadvantage of preventive medicine programmes.
At present, the pressure of public medi-cal-sanitary institutions increases in order to revise the tariff s for health care services which were “frozen” during 2004-200724. Th is situation creates inevitably premises for increase of contributions to mandatory health insurance and of the health insurance policy’s price, the fi nancial consequences are to be endured by the population.
Governmental policies
A certain infl uence on the promotion capacities of health policies had the double reformation during 2004-2006 of the Minis-try of Health. Th e last reorganisation oper-ated in November 2007 off ered the ministry a structure to correspond to the priority activity directions. Aft er the Government approved the National Health Policy25 in
21 “Health of the population of the Republic of Moldova in 2006”, Natio-nal Scientifi c Practical Centre of Preventive Medicine, Chisinau, 2007.
22 “Prevention of AIDS crisis in Eastern Europe and Central Asia”, World Bank, 2003.
23 Expertise of inpatient health care quality provided to insured persons, Curierul medical (Medical Courier), no. 5, p. 56-60, Chisinau 2007
24 Order of the Ministry of Health of the Republic of Moldova no.76/2004.
25 National Health Policy, http://ms.gov.md.
Development of human capital 2006, the Ministry of Health forwarded to
the Parliament for approval the draft Health System Development Strategy for 2007-2012 with an action plan, focused on directions like increase of the Ministry’s capacities in terms of policies and regulations, health promotion; making more effi cient the use of available resources; improvement of health services quality and effi cacy.
Th e Public Health Reform Project in Moldova26 implemented under the control of the Ministry of Health by the consortium of EPOS Health Consultants/GVG/HMTC and funded by the European Union has con-tinued the process of health system decen-tralization by increasing the Centres of Fam-ily Doctors’ autonomy level in pilot regions.
Based on the preliminary project’s results and at the insistence of the World Bank, the Government engaged to ensure separation of primary health care centres from rayon hospitals from 1 January 2008. Th is would contribute to increase the responsibility of family doctors and local authorities for re-source management.
In order to keep the medical personnel within the system in 2006 a series of facili-ties were introduced `for young specialists with medical background, employed (espe-cially in rural areas, where the situation is very diffi cult, see chapter RURAL MOL
DOVA) according to the repartition made by the Ministry27. As a result of provision of these facilities, about 80% of the graduates of residential studies in 2006 accepted to be employed according to the Ministry’s repar-tition scheme.
In order to increase the quality of health services and to make them more effi cient, the Government approved in 2005-2006 a series of national programmes. Th e Nation-al Programme on control and prevention of Tuberculosis for 2006-2010 has as objective the stabilization of Tuberculosis epidemic situation. Presently, the Automated Infor-mation System for monitoring and evidence of patients with Tuberculosis is being tested at the national level. However, the logistics and social information and education ac-tivities remain to be underdeveloped and without a fi nancial coverage.
Th e National Programme on Control and Prevention of Diabetes Mellitus
“Mold-Diab” for 2006-201028 puts more stress on the prevention activities in early detection of diabetes. Today, laboratory investigations for diabetic patients are free of charge. Th ere have been developed treatment standards, which can be applied in medical practice.
Th e National Programme for Preven-tion and Control of HIV/AIDS and STIs (sexually transmitted infections) for 2006-2010 envisaged to continue implementation of Global Fund grant for fi ghting AIDS, Tu-berculosis and Malaria for 2003-2008. Th ere have been strengthened the capacities for diagnostic, treatment and prevention of the abovementioned infections, implemented educational programmes for general popu-lation, young people and groups of people with an increased infection risk. In this con-text, it is worth mentioning the beginning of a good cooperation between governmen-tal institutions and civil society (see CIVIL SOCIETY).
Activities of the National Programme on control of viral hepatitis for 2006-2010 are partially covered by the Immunisation Programme including children up to 17 years old. As a result of implementation of actions to fi ght viral hepatitis, the morbidity reduced by 2,4 times, including the morbid-ity caused by viral hepatitis A (by 3 times).
Th e Republic of Moldova has achieved the objectives set by World Health Organisa-tion for signifi cant decrease of morbidity caused by hepatitis B. In order to carry out the immunisation programme, the Ministry of Health issued an order with a detailed ac-tivity plan for 2006-2010 and distributed it to all public medico-sanitary and preventive medicine institutions.
Th e National Programme on blood transfusion safety and self provision of san-guine preparations for 2007-2011 was also adopted and it is being in the initial imple-mentation phase, the National Programme on healthy lifestyle promotion for
2007-26 http://www.healthreform.md/ru/.
27 These facilities include free of charge dwelling, provided by the au-thority of local public administration for the period of activity in that locality or coverage of renting expenses; unique indemnities provi-ded by the Ministry in the amount of 30 thousand MDL for doctors and 24 thousand MDL for medical personnel of medium level, which are paid by 7,5 thousand and 6 thousand respectively after the ex-piration of the fi rst month and further at the end of each year of activity; monthly compensation provided by the Ministry for the cost for 30 KW of electrical power, one cubic meter of wood and a ton of coal per year.
28 Decision of the Government of the Republic of Moldova no.439 of 26.04.2006.
Development of human capital
2015, the National Programme on eradica-tion of disturbances caused by iodine defi cit until 2010 and a series of other special pro-grammes. Th e Programme on promotion of quality perinatal health care services for 2003-2007, focused on most diffi cult fi elds of perinatal health care – to apply the tech-nologies suggested by the programme, to re-duce maternal, perinatal and early neonatal mortality rate by 30%, the mortality-and-birth rate29 from 7,2 to 5 per 1000 of new-borns during 2003-2007.
Recently the National Programme on healthy lifestyle promotion for the period of 2007-2015 was approved. A promising start for the improvement of situation in the fi eld could be considered the event that took place on 11 May 2007, when the Parliament ratifi ed the Framework Convention on To-bacco Control, taking over the responsibil-ity for its implementation in order to protect health of population. Th e Concept on opti-mization and modernization of the hospital sector and specialized health care is under development30.
Th e improvement of health system legal framework continues to align to the inter-national norms. Th e Law on patient rights and responsibilities31 and the Law on medi-cal practice32 were adopted. But because of delay in adopting other laws and regulations which would ensure functioning of the stip-ulated provisions, the respective documents can not be fully applied. Th e Regulation of the individual Commission for medical pro-fessional expertise and Instructions on the patients’ participation in taking decisions meant to increase and improve patient pro-tection are under development. In this con-text, according to doctors’ opinion, a lack of balance has been produced in favour of
pa-tients. Th e much waited laws on malpraxis33 and the doctors’ league could re-establish this balance, although their implementation will take some time.
Taking into account the necessity to im-prove people’s access to health services, the Government included in the National De-velopment Plan (2008-2011) the aspect of extending the coverage of population from rural area and poor people with mandatory health insurance by reducing contributions of people from rural areas. Th ere exist cer-tain non-clarities with regard to the achieve-ment of this objective, related to the fact that about 40% of working age population from rural areas are not formally employed.
Th ere began a series of activities on im-provement of the situation in the fi eld of mental health. Th e Republic of Moldova ad-hered to the Declaration on Mental Health, signed by the European countries in 2003 and engaged to align to modern standards of psychiatric health care. However, a well defi ned plan appeared only in 2007 at the same time when the National Programme on mental health was approved34. A network of mental health community centres is going to be established within this programme.
Th e Programme will be implemented with allocations from the state budget (500 mln.
MDL for the period 2007-2011), and about 30% of the necessary funds are to be covered by international donors35.
Recommendations
In order to effi ciently carry out the Na-tional Health Policy we consider that it is necessary to implement a series of short-term and long-short-term policy recommenda-tions:
Clear delimitation of competences of the state institutions and local public administration for effi cient management of sanitary system and eff ective transfer of competences, attributions and responsibilities from the Ministry of Health to local public administration. Increase of local public administration responsibility for mana-gement of public health problems at local level can be ensured only if a performance evaluati-on mechanism would be applied into practice.
Community NGOs shall be actively involved in monitoring of performances. At the same time, it is necessary to strengthen the control capacity of the Ministry of Health over the public health objectives, activities and structures.
29 Mortality rate is equal to the ratio between number of dead births and number of live births during a certain period (as usually, one year) on a certain territory.
30 The decision of the College of the Ministry of Health of 02.03.2006
“On the activity of the Ministry of Health in 2005 and strategic deve-lopment directions for 2006”.
31 Law of the Republic of Moldova no.263 of 30.12.2005.
32 Law of the Republic of Moldova no.264 of 23.12.2005
33 The notion of malpraxis implies incorrect or inadvertent treatment applied to a patient, which can cause him/her prejudices related to the degree of aff ection of the physical or psychical capacity, con-sequence of some gaps of professional training, lack of experience, therapeutic or diagnostic abilities.
34 National Mental Health Programme for 2007-2011 launched at 11.05.2007.
35 With fi nancial support of Swiss Agency for Development and Coope-ration on 24 May 2007 in Ungheni took place the inauguCoope-ration of the Community Mental Health Centre, the second one after the fi rst one was established in Buiucani sector, municipality of Chisinau.
Development of human capital
Development of a set of standards to make the management of health system resources effi cient.
An important direction in this sense is to ensure decisional and fi nancial transparency, which im-plies informatization of the system of health care institutions, development of Ministry of Health portal and urgent implementation of clinical protocols and treatment practical guides. A fi rst step would be the implementation of Integrated Healthcare Information System (its cost estima-ted at $83 mil. for the period of 2007-2009). Im-provement of the quality of health services can be ensured on the basis of some national stan-dards for quality management. Achievement of these objectives implies combining the training of qualifi ed managers for the health system with the use of already existent potential of specialists trained in the fi eld of public health and their pla-cement in key jobs.
Extension of mandatory health insurance to increase the access to quality health services is timely only in the conditions of continuous monitoring of the process in order to not com-promise the system’s fi nancial sustainability.
Development of voluntary health insurances within NHIC in parallel with strengthening the company’s capacity for management of contracts with medico-sanitary institutions
will enlarge the range and quality of health care services.
To keep the medical personnel within the sys-tem it is necessary to increase their salaries, to apply incentive methods (higher compensations at repartition, bonuses to the salary, adequate working conditions), operated depending on personal eff orts.
Increase of competitiveness for health care ser-vices could be achieved by supporting the deve-lopment of private health sector and adopting the Law on private health care.
Health and healthy lifestyle promotion actions should be based on much bigger resources, as well as on large involvement from the behalf of nongovernmental entities.
Convergence with the EU health standards shall also impose the increase of the GDP per-cent allocated to the health sector. Pressures on public fi nances will decrease only together with the introduction of voluntary health insurances on a large-scale. At the same time it is necessary to create a reserve health fund, meant for major emergency cases and to co-fund priority projects in the health system.