2021-2022 Survey Report Service Delivery Indicators Health Survey for Moldova © 2024 The World Bank Group 1818 H Street NW, Washington DC 20433 Telephone: 202-473-1000; Internet: www.worldbank.org and www.ifc.org SOME RIGHTS RESERVED. This work is a product of the staff of The World Bank and the International Finance Corporation (the World Bank Group) with external contributions. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of The World Bank’s Board of Executive Directors, or the governments they represent. The World Bank does not guarantee the accuracy of the information included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. RIGHTS AND PERMISSIONS. The material in this work is subject to copyright. Because the World Bank encourages dissemination of its knowledge, this work may be reproduced, in whole or in part, for noncommercial purposes as long as full attribution to the work is given. ATTRIBUTION. Please cite the work as follows: “World Bank Group. 2024. Survey Report: Service Delivery Indicators Health Survey for Moldova. (c) World Bank Group.” All queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H Street NW, Washington, DC 20433, USA; fax: 202- 522-2625; e-mail: pubrights@worldbank.org. Service Delivery Indicators Health Survey for Moldova – Overview of Results Table of Contents Abbreviations 9 Acknowledgments 10 Executive Summary 11 1. Introduction 15 1.1. History of Primary Health Care in Moldova 18 1.2. Motivation for the Moldova Service Delivery Indicators (SDI) Health Survey 21 1.3. How the Moldova SDI Health Survey Measures Primary Health Care 21 2. Methods 24 2.1. Survey Development 24 2.2. Description of Domains Covered in the SDI Health Survey 24 2.3. Sample Design 26 2.4. Data Collection and Analysis 27 3. Foundations 31 3.1. Care Organization 34 3.2. Systems 49 3.3. Tools 71 3.4. Workforce 74 4. Processes of Care 99 4.1. Competent Care Systems 101 4.2. Positive User Experience 130 5. Person-Centered Outcomes 140 5.1. Confidence in System 142 5.2. Financial Protection 153 6. Conclusions 158 Annexes 161 Annex A. Statistics 161 Annex B. Description of SDI Subdomains 185 Annex C. Sampling 193 Annex D. Description of Indicators 202 3 Service Delivery Indicators Health Survey for Moldova – Overview of Results Boxes Box 1. Key observations from the Moldova SDI health survey 31 Box 2. Key observations on PHC processes of care in Moldova 99 Box 3. Key observations on person-centered PHC outcomes in Moldova 140 Figures Figure 1. Organization of PHC services in Moldova 16 Figure 2. Moldova Health System Development Strategy (2008–2022) 18 Figure 3. Overview of Service Delivery Indicators domains of assessment 22 Figure 4. Proportion of facilities with emergency transport capacity, by region (%) (N = 247) 35 Figure 5. Proportion of facilities with emergency transport capacity, by facility type (%) (N = 247) 35 Figure 6. Proportion of facilities with on-site lab services, by region (%) (N = 247) 36 Figure 7. Proportion of facilities with lab on-site lab services, by facility type (%) (N = 247) 36 Figure 8. Outpatient volume per 1000 individuals in facility registered population over three-month period (median), by facility and region 38 Figure 9. Outpatient visit volume over three-month period, by disease type (median) 39 Figure 10. Proportion of required PHC services offered by facilities, by category and region 41 Figure 11. Proportion of facilities offering specialized services, by service type and region (%) (N = 247) 42 Figure 12. Proportion of facilities offering specialized services, by service and facility type (%) 43 Figure 13. Percentage of facilities offering specialized imaging and required laboratory services, by region 44 Figure 14. Registered population, by facility (count) 45 Figure 15. Proportion of facilities with transport connectivity, by region (%) 48 Figure 16. Proportion of facilities with transport connectivity, by facility type (%) 48 Figure 17. Distribution of revenue, by facility type and source (%) 50 Figure 18. Median total revenue (January-December 2020), by facility type (MDL) 51 Figure 19. Frequency of facility administrative board meetings (cumulative %) (N=197) 53 Figure 20. Proportion of facilities that shared data externally, by constituent and region (%) 54 Figure 21. Proportion of facilities that shared data externally, by constituent and facility type (%) 54 Figure 22. Proportion of Facilities Reporting Supportive supervision components (%) (N = 224) 55 Figure 23. Facility utilization of feedback data (%) 56 Figure 24. Top-five areas for facility improvement according to feedback (%) 56 Figure 25. Top-five favorable areas for facilities according to feedback (%) 57 4 Service Delivery Indicators Health Survey for Moldova – Overview of Results Figure 26. Facility management capacity components (%) 57 Figure 27. Staff performance assessment tools used by facilities (%) 58 Figure 28. Staff training selection criteria (%) 59 Figure 29. Nurse satisfaction with direct supervisor support (%) (N = 773) 59 Figure 30. Proportion of facilities with accessibility features for differently abled individuals, by region (%) 61 Figure 31. Proportion of facilities with electrification, by region (%) 62 Figure 32. Proportion of facilities with functional refrigerators for blood and vaccines (%) 63 Figure 33. Proportion of facilities with WaSH infrastructure availability, by region (%) 64 Figure 34. Water availability cascade (%) 64 Figure 35. Availability of toilets in health facilities (%) 65 Figure 36. Proportion of facilities with infection prevention and control infrastructure, by facility type (%) 66 Figure 37. Proportion of facilities with a functional incinerator, by facility type (%) 66 Figure 38. Proportion of facilities with fire safety infrastructure, by facility type (%) 67 Figure 39. Infection prevention and control practices, by facility type (%) 68 Figure 40. Proportion of measured up-to-date guideline documents observed in facilities, by facility type (%) 70 Figure 41. Proportion of available and functioning equipment, by equipment type (%) 71 Figure 42. Proportion of patients recommended for tests who received them (%) (N = 541) 72 Figure 43. Medicine availability, by service type (%) 73 Figure 44. Proportion of patients prescribed medicine during current visit (%) (N = 1,487) 74 Figure 45. PHC facility staff composition, by facility type (%) (N = 247) 76 Figure 46. Doctor absence rates (%) (N = 720) 77 Figure 47. Nurse absence rates (%) (N = 1285) 77 Figure 48. Reasons for absence, by provider type (%) 78 Figure 49. Facilities with at least one provider trained in required services, by service (%) (N = 247) 94 Figure 50. Facilities with at least one provider trained in specialized services, by service (%) (N = 247) 94 Figure 51. Percentage of women over 20 weeks pregnant who received various ANC services (%) 103 Figure 52. Clinical knowledge: Correct identification of primary treatment, by region (%) 111 Figure 53. Clinical knowledge of physicians: Correct primary diagnosis and treatment, by region (%) 115 Figure 54. Health document availability among patients, by region (%) (N = 1,499) 116 Figure 55. Patients referred for care within same facility because services needed or specialized care not available from current provider(s) or department/unit, by region (%) (N = 225) 118 Figure 56. Patients referred for care within same facility because services needed or specialized care not available from current provider(s) or department/unit, by facility type (%) (N = 225) 118 Figure 57. Provider referral frequency, by region and facility type (median) 121 Figure 58. Overall patient care and retention (cumulative %) (N = 1,496) 142 5 Service Delivery Indicators Health Survey for Moldova – Overview of Results Figure 59. Women seeking ANC at more than one facility, by region (%) (N = 38) 144 Figure 60. Women seeking ANC at more than one facility, by facility type (%) (N = 38) 144 Figure 61. Reasons patients chose multiple points of care for diabetes and hypertension (multiple select), by region (N=69) (%) 145 Figure 62. Top three challenges to patients’ access to high-quality care at facility as reported by providers, by region (%) (N = 1,276) 146 Figure 63. Top three challenges to patients’ access to high-quality care at facility as reported by providers, by facility (%) (N = 1,276) 146 Figure 64. Percentage of patients who would recommend the facility 148 Figure 65. Patients’ ratings of overall quality of facility (%) 149 Figure 66. Patients’ top reasons for choosing the facility (%) 150 Figure 67. Percentage of patients identifying area for improvement in health facilities: Top-three areas 151 Figure 68. Patients’ ratings of health care providers’ abilities and skills (%) 152 Figure 69. Patients reporting each source of money for current health care visit, among those who reported any out-of-pocket expenditure (%) (N=20) 156 Tables Table 1. Summary of facilities included in the sample frame, stratified by urban/rural and facility type 27 Table 2. Summary of fieldwork activities 28 Table 3. Response rate by study population 29 Table 4. Percentage of required PHC services offered by facilities, by region, facility type, and service type (N=247) (%) 40 Table 5. Proportion of facilities open each day of the week, by region and facility type (%) 46 Table 6. Average facility duration of operation per day, by region (hours) 47 Table 7. Provider-reported extra remuneration, by facility type 50 Table 8. Average in-kind revenue by source and facility type (MDL) (N = 112) 52 Table 9. In-kind revenue by type and facility type (MDL) (N = 112) 52 Table 10. Water supply location (%) 65 Table 11. Presence of various ICT infrastructure attributes, by region and facility type 69 Table 12. Proportion of facilities reporting availability of internet, by facility type and region (%) 69 Table 13. Median staff availability, by region and facility type 75 Table 14. Service-specific workforce availability, by region (N = 247) 80 Table 15. Service-specific workforce availability, by facility type 86 Table 16. Median years in any role in current facility, by region (median) 92 Table 17. Provider-reported time spent on training, by region and facility type 93 6 Service Delivery Indicators Health Survey for Moldova – Overview of Results Table 18. Provider satisfaction and resilience, by region and facility type 96 Table 19. Proportion of time spent across different activities (most recent week), by region, facility, and provider type (%) 97 Table 20. Workload in the most recent typical work week, by region 98 Table 21. Competent Antenatal care (%) (N = 56) 102 Table 22. Competent NCD care at current visit, by region (%) (N = 302) 104 Table 23. Competent NCD care at current or previous visits, by region (N = 302) 105 Table 24. Competent sick-child care at current visit (children less than 5 years of age) 106 Table 25. Correct diagnosis and treatment by vignette 107 Table 26. Clinical knowledge: Diagnostic accuracy, by region (%) 108 Table 27. Diagnoses selected by providers (multiple select), by vignette (%) 109 Table 28. Treatments selected by providers (multiple select), by vignette (%) 112 Table 29. Informed referral: Transfer of patient information, by region (N = 436) (%) 116 Table 30. Informed referral: Transfer of patient information, by facility type (N = 436) (%) 117 Table 31. Percent of patients who typically use current health facility for care (N=1,497), by region and facility type 119 Table 32. Referral outside facility, by region and facility type (%) 120 Table 33. Frequency of referral information sharing by providers, by region (%) (N = 471) 121 Table 34. Informed referral modality as reported by doctors, by region and facility type (%) 122 Table 35. Median number of referrals to other facilities during September–November 2021, by region and facility type 123 Table 36. Reasons for referral to another facility at higher level, by region (%) (N = 219) 124 Table 37. Reasons for referral to another facility at same level, by region (%) (n = 219) 125 Table 38. Referral: Information transfer from external facility by region 126 Table 39. Patients seeing the same provider, by region (%) 127 Table 40. Surveillance and IPC, by region and facility type (%) (N= 247) 128 Table 41. Emergency preparedness, by region and facility type (%) 129 Table 42. Proportion of facilities that conducted drills for key emergency and preparedness behaviors (%) 130 Table 43. Percentage of patients rating aspects of their experience, by region 131 Table 44. Percentage of patients rating aspects of their experience, by facility type 132 Table 45. Patient-reported provider choice, by region and facility type 133 Table 46. Provider greetings and introduction, by region 134 Table 47. Patient visits based on appointments, by region 135 Table 48. Facility-reported median wait time and consultation time, by region and facility (minutes) 136 Table 49. Patient ratings of user experience, by region (%) 137 7 Service Delivery Indicators Health Survey for Moldova – Overview of Results Table 50. Patients’ ratings of user experience, by facility type (%) 138 Table 51. Proportion of patients reporting care receipt and indicating they would return to same facility for a similar service, by visitation reason (%) 143 Table 52. Distribution of challenges to patients’ access to high-quality care at facility as reported by provider (%) 147 Table 53. Patients’ reasons for choosing this facility (%) 150 Table 54. Percentage of patients identifying various aspects of health facility as needing improvement 151 Table 55. Time to reach facility, by region (minutes) 153 Table 56. Income lost due to seeking care, by region 154 Table 57. Median costs for travel to facility and consultation 155 Table 58. Facilities not exempting patients from fees (%) (N = 45) 157 8 Service Delivery Indicators Health Survey for Moldova – Overview of Results Abbreviations AMT territorial medical association ANC antenatal care CI confidence interval ENT ear, nose, and throat EU European Union ICT information and communications technology IFA iron-folic acid IPC infection prevention and control MoH Ministry of Health (MoH) NCD noncommunicable disease NHIC National Health Insurance Company OB-GYN obstetrics and gynecology PHC primary health care PMTCT prevention of mother-to-child transmission PPS probability proportional to size SDG Sustainable Development Goal SDI Service Delivery Indicators SDSS Health System Development Strategy TB tuberculosis UTA Autonomous Territorial Unit WHO World Health Organization 9 Service Delivery Indicators Health Survey for Moldova – Overview of Results Acknowledgments The Moldova Service Delivery Indicators (SDI) health survey was prepared by the World Bank in collaboration with the Government of Moldova, under leadership of the Ministry of Health. The technical team was led by Kathryn Andrews (Health Economist) and Jigyasa Sharma (Health Economist), with contributions from Adrien Arnoux Dozol (former Senior Health Specialist), Ilie Volovei (Health Economist), Joseph Millward (Consultant), Virginia Salaru (Consultant), Ruchika Bhatia (Consultant), Juan Muñoz (Consultant), Ruben Conner (Consultant), Ghenadie Curocichin (Consultant), Inga Pasecinic (Consultant), and Olena Doroshenko (Senior Economist). The team would like to thank Harish Ram Sai (Consultant), Mahin Tariq (Consultant), and Cedric Batiano (Consultant) for their contributions to data analysis, data visualization, and report writing, as well as Harsh Sahni (Consultant) and Mahader Tamene (Consultant) for their valuable comments on the draft report. Thanks also to Richard Crabbe for editorial support. The tireless efforts of contributors to the technical working group for the Moldova SDI health survey to define the survey methodology and interpretation of results, among many other contributions, is also recognized and deeply appreciated. Contributors to the technical working group include all staff of the Ministry of Health of Moldova, representatives of PHC facilities, as well as Doina Rotaru and Maria Lefciu who represented the National Medical Insurance Company (CNAM). Further, the team would like to thank the facility managers, providers, and patients who helped make this study a possibility. The team also appreciates the work of the data collection teams at Sanigest Internacional and iData Intellegente, who supported multiple aspects of this study, most importantly managing data collection. The views expressed in this publication are those of the authors. The findings, interpretations, and conclusions herein do not necessarily reflect the views of the World Bank Group, its Board of Directors, or the countries that it represents. 10 Service Delivery Indicators Health Survey for Moldova – Overview of Results EXECUTIVE SUMMARY The Service Delivery Indicators (SDI) health survey in Moldova serves as a vital tool for assessing and benchmarking the performance of health service delivery. Its primary aim is to evaluate the quality of basic health services. This comprehensive evaluation enables both governments and service providers to pinpoint deficiencies and bottlenecks in health service delivery, monitor progress over time, and make cross-country comparisons. The widespread availability of and public awareness about SDI indicators foster engagement among policy makers, citizens, service providers, donors, and stakeholders, in turn driving efforts to enhance service quality and ultimately development outcomes. This collaborative survey was conducted by a partnership comprising the World Bank Group, the Moldova Department of Health, and the Swiss Agency for Development and Cooperation (SDC). Spanning from December 2021 to May 2022, the Moldova SDI health survey covered interviews at 247 primary health care (PHC) facilities, and further included interviews with 407 PHC physicians, 807 nurses, and 1,497 patients. The results presented in this report are not only nationally representative but also representative of the various PHC facility types and administrative divisions in Moldova, with the exception of Transnistria1. The 2021–2022 Moldova SDI health survey marks a groundbreaking milestone as the first of its kind in the Europe and Central Asia region. It also heralds a new era for SDI health studies, characterized by an expanded focus on key components of service delivery across different countries. One distinguishing feature of SDI surveys is their unique perspective on health services and specifically their focus on the experiences of service beneficiaries. The SDI survey allows for a comprehensive assessment of health service delivery by focusing on three critical domains: 1. Health service delivery foundations: This domain encompasses essential aspects such as the overall health system, organization, and availability of care. It evaluates the presence of a qualified workforce and their training, workload, and job satisfaction. Additionally, it assesses the availability of essential medicines, medical and nonmedical equipment, and supplies. The availability of information systems supporting health care is also analyzed. 1The three primary administrative divisions of Moldova include the North, Center, and South regions. For the purposes of this study, the municipalities of Chisinau and Balti were respectively considered together as a separate “urban” region, meaning that the data for the North and Center regions do not include data collected from these municipalities. Further, the Autonomous Territorial Unit of Gagauzia was considered as its own separate region. In total, the Moldova SDI is representative of these five survey regions: North, Center, South, Urban, and UTA Gagauzia. 11 Service Delivery Indicators Health Survey for Moldova – Overview of Results 2. Processes of care: In this domain, the SDI survey examines the competency of health care providers and assesses whether they possess the necessary skills and knowledge to accurately diagnose, treat, and counsel patients. It also evaluates the frequency, flow, continuity, and integration of referral systems designed to coordinate patient care effectively. Furthermore, it assesses the readiness and capacity of health facilities and workers to respond to emergencies and practice infection prevention and control (IPC). The accessibility of health services for patients, as well as the level of respect and autonomy they experience when seeking care, is also assessed within this domain. 3. Person-centered outcomes: This domain focuses on the experiences and outcomes of individuals seeking health care. It gauges patient satisfaction with the services they receive and examines factors influencing the uptake of care and patient retention. Additionally, it measures both direct and indirect costs that patients may incur while seeking health care. While many data sources offer insights into the average availability of health care components across the sector, the SDI survey offers a distinctive perspective by examining how all these vital service delivery elements come together within a single health care facility. By assessing these three fundamental domains comprehensively, the SDI survey offers a holistic view of the current status of health service delivery. This comprehensive perspective equips policy makers and stakeholders with the necessary information for making informed decisions and driving policy improvements in the health care sector. It serves as a crucial tool for enhancing the quality and effectiveness of health care services, and it ultimately benefits both health care providers and the individuals who rely on these services. Each chapter of the report is organized according to the analytical domains defined above, along with the respective subdomains and components of service delivery that have been assessed as part of each. Key findings from the survey are presented below. All estimates represent survey-weighted means, unless otherwise specified as survey-weighted medians or sums. All confidence intervals presented in the executive and chapter summaries represent 95% confidence intervals and are notated with the acronym “CI”2. Availability and quality of services On average, facilities offered 83% (CI: 80%–86%) of all mandated PHC services. The proportion of mandated services offered varied by service type and was above average for the following: noncommunicable diseases (95%; CI: 93%-97%), pediatric care (95%; CI: 92%–97%), and community health (86%; CI: 84%–88%). The proportion of mandated services offered was 2Note that in some cases, particularly for indicators representing a small subset of the survey population, confidence intervals may not have been generated due to the presence of too few observations in certain survey substrata. 12 Service Delivery Indicators Health Survey for Moldova – Overview of Results below average for the following: mental health (70%; CI: 62%–77%), infectious disease (66%; CI: 60%–72%), and OB-GYN (50%; CI: 42%–58%). Most doctors were able to provide the correct primary diagnosis and treatment for hypertension (92%; CI: 87%–98%) and diabetes (92%; CI: 86%–98%). Fewer doctors, however, were able to provide both the correct primary diagnosis and treatment options for pulmonary TB (82%; CI: 71%–93%), pneumonia (77%; CI: 66%–88%), and depression (68%; CI: 61%–76%). Availability and characteristics of health care staff Overall, 15% (CI: 12%–19%) of doctors and 13% (CI: 9%–16%) of nurses were absent on the day that the facility received a follow-up visit. The most common reasons for absence among both provider cadres were parental, medical, or earned leave and the presence of the provider in a subordinated facility that day. No providers were absent for unauthorized reasons. The median tenures of doctors and nurses observed in the study were 25 and 21 years, respectively, indicating an experienced yet aging health workforce. Nearly a quarter of doctors’ time (26%; CI: 23%–29%) and nurses’ time (28%; CI: 21%–30%) was spent on administrative as opposed to clinical tasks. Health facility infrastructure Less than a third of facilities (32%; CI: 25%–41%) had complete infection prevention and control infrastructure. While nearly all facilities had basic sanitation infrastructure such as appropriate medical waste disposal (97%; CI: 94%–100%) and improved, functional water sources (95%; CI: 90%–99%), only 56% of facilities (CI: 48%–65%) had an improved water source that was both on-premises and uninterrupted. About half of facilities (48%; CI: 39%–56%) had functioning fire safety infrastructure. Only some facilities reported having allocated earmarked funds for emergency preparedness (61%; CI: 52%–70%), having conducted fire drills (56%; CI: 47%–65%) or emergency drills (62%; CI: 53%–70%), or having undertaken structural vulnerability assessments (48%, CI: 39%–57%), despite wide availability of protocols for emergency preparedness. Most facilities had functional information technology equipment such as a telephone (97%; CI: 94%–100%) or computer (82%; CI: 76%–88%) available on the day of the interview. However, some facilities reported that they had at least one disruption to their electricity (31%; CI: 23%–39%) or internet connectivity (37%; CI: 29%–45%) over an observed three- month period. 13 Service Delivery Indicators Health Survey for Moldova – Overview of Results Most facilities with steps or inclines had a ramp (71%; CI: 63%–79%), but few had a lift (9%; CI: 6%–13%) available for differently abled patients. Less than half of all facilities had tactile flooring (42%; CI: 33%–51%), and only 14% (CI: 8%–20%) had assistive technology for visually impaired individuals or accessible toilets. Patient satisfaction with care Overall, patients were satisfied with the care that they received. Almost all patients (95%; CI: 92%–97%) reported that they would recommend the current facility to their friends, and most reported that they always or often seek care from the same facility (77%; CI: 73%–82%) and provider (86%; CI: 82%–90%). Only 20 patients (1.3%; CI: 0.6%–2.4%) reported expenditure for services, with a median cost of MDL 188; and neither travel time to facilities nor waiting times for consultation, on average, exceeded 20 minutes. That said, 24% of patients reported that they lost income as a result of seeking care the day of the survey. While the sustained investment of the Government of Moldova in its health system has certainly achieved much, opportunities still exist to improve the availability of high-quality health services, particularly for those living outside of large municipal centers like Chisinau and Balti. Key achievements highlighted by this report include high patient-reported satisfaction with care, low unexcused absence rates of PHC providers across surveyed health facilities, and both wide and high-quality provision of services for key noncommunicable diseases, particularly hypertension and diabetes. While the various infrastructural components of most health facilities were functional on the day of the interview, it quickly became apparent that disruptions to key services such as electricity, internet, and water affected a nontrivial number of health facilities. While general patient satisfaction was high, the results from this survey highlight that the experiences of some groups—persons who are differently abled and those seeking care for mental health, family planning, and infectious disease services—may be less favorable and of lower quality than the norm, particularly depending on where they ultimately seek care. Despite wide availability of emergency preparedness and response protocols and guidelines, robust IPC infrastructure, practice of emergency preparedness and response drills, and conduct of structural vulnerability assessments, there is room for improvement across many health facilities in Moldova. Key findings highlight areas for improvement, including the tendency of patients seeking care to incur opportunity costs and the aging health workforce of Moldova; but these areas also offer great opportunities for collaborative efforts with sectors outside of health, including but not limited to the education and social protection sectors. 14 Service Delivery Indicators Health Survey for Moldova – Overview of Results 1. Introduction The Republic of Moldova implemented a major effort in 2008 to provide primary health care (PHC) to its population with the design and implementation of the Health System Development Strategy (SDSS) and a National Health Policy. Reforms to the provision and organization of primary health care over time have diversified the PHC landscape in Moldova and the spectrum of services provided by family doctors. The service delivery system generally comprises a family doctor team, which includes a family physician and nurse. This system also includes public health centers, private general practitioners, and outreach services. The range of services offered in PHC is comprehensive. Moldova has made strong commitments to development, with particular emphasis on development of primary health care through its adoption of the Moldova 2030 initiative and the 2030 Sustainable Development Goals (SDGs). The Republic of Moldova’s PHC system contains several types of health facilities that operate at varying levels, including health centers (CS), health offices (OS), family doctor offices (OMF), individual family doctor offices (CI), family doctor centers (CMF), private health centers, and consultative diagnostic centers (CCD)3. Some of these facilities, such as consultative diagnostic centers and family doctor centers, are only present in large urban centers (Chisinau and Balti municipalities), while others such as individual family doctor offices primarily exist in rural areas of the country. While the Ministry of Health provides overarching management and organization of health facilities in the country, local public authorities, including those in municipalities such as Chisinau and Balti, as well as UTA Gagauzia also have a regulatory responsibility over health facilities in their territories. Figure 1 highlights the general structure of the PHC system in Moldova. This figure assumes the access of the entire population to PHC services. In rural areas with small populations, family doctor offices are opened as a substructure of the health center. In these cases, family doctor medical assistants work permanently in the family doctor office, but the family doctor from the respective health center travels to the given locality only 1-2 times a week. 3Republic of Moldova Ministry of Health, Order Nr. 988 for the approval of the rules for the organization of primary medical care, October 10, 2018. https://www.legis.md/cautare/getResults?doc_id=109177&lang=ro 15 Service Delivery Indicators Health Survey for Moldova – Overview of Results Figure 1. Organization of PHC services in Moldova Central Government Ministry of Health Other government ministries (e.g., Ministry of Defense) Nicolae Testemitanu University Clinic of State University of Primary Health Care Medicine and Pharmacy (CUAMP) Departmental PHC units 5 AMT, 12 CMF, 5 CCD, & 14 CS facilities Chisinau Municipal Health Authorities Acronyms: Privat health center National Health Insurance AMT Medical Territorial Company Association CMF CCD Consultative Diagnostic Center Balti and UTA Gagauzia Raional CS with Cl Individual Family Doctor Health Authorities subsidiary OMF and/ Office or OS CMF Family Doctor Center CS Health Center Rural CS with subsidiary OMF Family Doctor Office OMF and/or OS Local Public Authorities OS Health Office Regulatory relationship Other Raional CS with Contractual relationship subsidiary OMF, OS, and/or Cl Source: World Bank Group Types of PHC Institutions Five Medical Territorial Associations (AMT) cover the provision of both primary family medicine as well as specialized outpatient health care services across Chisinau municipality. These include 12 family doctor centers and 5 consultative diagnostic centers which provide both general and specialized care. Health centers and Family doctor offices also operate under the control of the AMTs. The AMTs also organize 14 health centers in the suburbs of Chisinau. Family doctor centers (CMF) are organized in urban localities, such as the municipalities of Chisinau and Balti, and are contracted directly by the National Medical Insurance Company. Family doctor centers include in their composition rural primary medical institutions such as health centers, family doctor offices, and health offices. Family doctor centers have capacities to provide primary medical services of higher complexity, as compared to primary medical 16 Service Delivery Indicators Health Survey for Moldova – Overview of Results institutions in rural localities. Family doctor centers organize and methodically coordinate the activity of primary medical care in their respective territory, and perform the centralization of statistical medical data, including the activity of private health centers. Health centers (CS) are usually organized in district centers or rural areas and, depending on the legal form of organization, can be public or private and are directly contracted by the National Medical Insurance Company. Health centers coordinate the activity of family doctor offices and health offices within their composition. Health centers serve at least 4,500 inhabitants; however, they can have a population of less than 4,500 in cases where the geographical location which they cover does not allow the organization of the population’s access to medical care in the health center. In such cases, the Ministry of Health and local public authorities will be informed and consulted. Private health centers can associate in groups under the guidance of family doctor centers to provide services or share resources. For health centers to operate as private practices, they must receive approval from family doctor center and local public authority that manage the territory in which they operate. Family doctor offices (OMF) are organized in rural localities with a population of 901– 3,000 inhabitants, in which, according to the state functions, 1 or 2 family doctors work respectively. These offices are permanently staffed by family doctor medical assistants but will receive visits from an assigned family doctor typically once or twice per week. Health Offices (OS) are organized in rural localities with a population of up to 900 inhabitants, where, according to state functions, only family nurses work. If two or more health offices, which are located in the same service radius and together have a population of no less than 900 - 1500 inhabitants, one position of family doctor is established. Family doctors are concentrated in health centers, where they have the necessary equipment for professional activity, but visit family doctor offices and health offices to provide medical assistance to the population on a set schedule. Individual family doctor offices (CI) operate through an individual family doctor and their team, which often includes medical assistants and other employed staff. Individual family doctor offices are usually located on the territory of the practice, which increases accessibility of the population to the family doctor at the facility premise. Individual family doctor offices provide the entire package of medical services to patients registered on the list of the family doctor who owns the practice. 17 Service Delivery Indicators Health Survey for Moldova – Overview of Results 1.1. History of Primary Health Care in Moldova Primary health care in Moldova has had an extensive history, including a number of key milestones. These milestones have been captured in Figure 2 and explained in further detail below. Figure 2. Moldova Health System Development Strategy (2008–2022) 2008 2014 2015 2016 Moldova designs Moldova signs Moldova adopts Moldova and implements the Association the UN 2030 implements a pay- the Health System Agreement with Agenda for for-performance Development the European Sustainable scheme through Strategy (SDSS) Union Development Order No. and National 1076/720 Health Policy 2017 2018 2020 2021 Moldova, in Moldova develops The Moldova Moldova, in collaboration with the Moldova Ministry of Health, collaboration with the World Health 2030 strategy, in collaboration the World Health Organization, expanding on the with the World Organization, evaluates the Moldova 2020 Bank Group, conducts the WHO success of the strategy by placing commits to STEPS survey 2008–2017 SDSS strategic priority conducting the on health Service Delivery Indicator survey Source: World Bank Group 1.1.1. Moldova Health System Development Strategy (2008–2017) The SDSS for the period 2008–20174 aimed to strengthen overall health system performance. It focused on four areas of improvement: the management of the health system; system financing and payment mechanisms for health services; provision of health services; and resource management. The SDSS was designed in parallel with and in coordination with the provisions of the National Health Policy5, providing a platform for future actions to strengthen a modern health system, with equal access to high-quality medical services for all people. 4Republic of Moldova Government, HG no. 1471/2007 regarding the approval of the Health System Development Strategy in the period 2008–2017. https://www.legis.md/cautare/getResults?doc_id=88242&lang=ro 5Republic of Moldova Government, HG no. 886/2007 regarding the approval of the National Health Policy. https://www.legis.md/cautare/getResults?doc_id=31871&lang=ro 18 Service Delivery Indicators Health Survey for Moldova – Overview of Results 1.1.2. European Union Association Agreement (2014) An important step for Moldova was its signing of the Association Agreement with the European Union (EU)6 in 2014 and its participation as a member of the EU’s Eastern Partnership. Under this agreement, Moldova undertakes to reform its domestic policies in accordance with EU laws and practices, with a particular focus on tobacco control, transfusion and transplantation, and public health protection. 1.1.3. 2030 Agenda for Sustainable Development (2015) In September 2015, Moldova adopted a historic global agenda entitled “Transforming Our World: The 2030 Agenda for Sustainable Development” (UN Resolution A/RES/70/1)7. Sustainable Development Goal 3 of this global agenda—“Ensure healthy lives and promote well-being for all at all ages”—aligns with the global commitment to develop a healthy society and protect everyone’s right to enjoy the highest standard of physical and mental health achievable. The 13 targets with 28 embedded indicators under SDG3 address major health priorities, including reproductive, maternal, and child and adolescent health; communicable diseases and noncommunicable diseases (NCDs); universal health coverage; and access to safe, effective, and high-quality medicines and vaccines. 1.1.4. Pay-for-performance introduced in Moldova (2016) In December 2016, Moldova’s Ministry of Health (MoH) signed order 1076/7208 which outlined criteria for contracting medical and sanitary institutions within the PHC system. Part of this order included mention of quarterly performance-based bonuses for facilities that achieved targets for health indicators related to services for cardiovascular disease, diabetes, cancer, tuberculosis, maternal and reproductive health, and child health. 6Association Agreement between the European Union and the European Atomic Energy Community and their Member States. https://eur-lex.europa.eu/legal-content/EN/TXT/?uri=CELEX:02014A0830(01)-20180824 7UnitedNations General Assembly, “Transforming Our World: The 2030 Agenda for Sustainable Development,” resolution adopted by the General Assembly on September 25, 2015. https://www.un.org/en/development/desa/population/ migration/generalassembly/docs/globalcompact/A_RES_70_1_E.pdf 8Republicof Moldova Ministry of Health, Order Nr. 1076/720 regarding the approval of the criteria for contracting medical and sanitary institutions within the system of compulsory medical assistance insurance for the year 2017. https://www.legis.md/cautare/getResults?doc_id=97336&lang=ro 19 Service Delivery Indicators Health Survey for Moldova – Overview of Results 1.1.5. WHO Evaluation of the SDSS (2017) The evaluation of the SDSS and National Health Policy implementations, carried out by the World Health Organization (WHO)9, showed several major areas of improvement. These included inter-sectoral collaboration to achieve health goals; monitoring and evaluation policies through a unique information system; addressing the high level of out-of-pocket payments, especially for drugs; performance indicators from the ambulatory system and the hospital system; and retaining and motivating medical staff. The evaluation indicated that the population’s broad health insurance coverage had reduced financial barriers to access, even among marginalized groups. Nearly all individuals in Moldova were registered with a PHC provider so as to enable coordination of care across the different levels of the system. Access to care across Moldova was good; however, those living in rural areas continued to face problems related to infrastructure and insurance. It remains a challenge to develop services at the PHC level in Moldova, particularly in rural areas. Additionally, the competencies, skills, and knowledge of the service providers varied, resulting in unequal care for the country’s population. At the same time, there were difficulties in coordinating primary care with other levels of health care and in providing integrated services. Patients did not often play an active role in making decisions about their health. Family doctors often referred patients to specialists even for conditions that could easily be treated in an outpatient primary health care setting. The evaluation found that patients preferred specialists because there were no long waiting lists, and medicines were reimbursed even if patients were hospitalized. Moreover, family doctors had no incentive to treat rather than refer patients to hospitals. The reduced efficiency of the PHC system had a negative impact on chronic disease management, leading to late diagnosis – failure of early detection, absence of active detection through screening. 1.1.6. National Development Strategy Moldova 2030 (2018) It should be mentioned that the Moldova 202010 National Development Strategy, approved by the Parliament in 2012, did not include health as one of the priority areas for investments. WHO later encouraged the inclusion of health as a priority in Moldova. Health was listed as a priority in the new National Development Strategy Moldova 2030, with priority given to SDGs that impact human health. Moldova 2030 also considered the experience of European Union states as well as the recommendations of the WHO and other international bodies with reference to health policies. 9Ministry of Health, Labour, and Social Protection, “Analysis of the Health System Development Strategy in the Period 2008–2017: Final Report (in Moldovan). https://msmps.gov.md/wp-content/uploads/2020/09/Analiza-Strategiei- de-dezvoltare-a-sistemului-de-s%C4%83n%C4%83tate-%C3%AEn-perioada-2008-2017-%C3%AEn-Republica- Moldova-Raport-Final-.pdf 20 Service Delivery Indicators Health Survey for Moldova – Overview of Results 1.1.7. WHO STEPS Survey (2021) The Moldova Ministry of Health, in collaboration with the WHO, conducted the 2021 STEPS, the first conducted since 201311. This survey assessed the prevalence of risk factors for noncommunicable diseases12. This study found that there was a slight increase in tobacco use but decreased prevalence of heavy drinking. While the proportion of the population that was obese remained largely similar between study years, the fraction of the population that was overweight increased. The prevalence of prediabetes was also noted as a risk factor that increased between survey years. The findings highlighted the success of PHC efforts to address NCD risk factors, but there are still concerns over the prevalence of the risk factors in the population and a need for expanded PHC efforts to address these factors. 1.2. Motivation for the Moldova Service Delivery Indicators (SDI) Health Survey The Government of Moldova, through its commitment to the Moldova 2030 and SDG 2030 initiatives, places strategic importance on health. Given the country’s rapid epidemiologic and demographic transitions, the MoH and the World Bank would like to ensure that Moldova’s health facilities are prepared for changes in the burden of disease, and that services are of good quality while being responsive to the needs of the population. The MoH also wanted to evaluate the availability, diversity, and quality of services provided at the PHC level as part of the effort to ensure universal access to health services for the country’s population. To meet these objectives, the MoH, in partnership with the World Bank, undertook planning for the nationally representative Moldova SDI health survey beginning in the fall of 2020. 1.3. How the Moldova SDI Health Survey Measures Primary Health Care The first step in measuring quality of service delivery in health is to define the concept. Quality of care, as many decades of scholarship have indicated, is a multidimensional concept. Perhaps the canonical definition was proposed by Avedis Donebedian13, who defined quality of care along three domains: structure, process, and outcomes of care. Building on this definition and other work, the Lancet Global Health Commission on High Quality Health Systems proposed an updated definition, which identifies a high-quality health system as “one that optimizes health care in a given context by consistently delivering care that 11WHO.2014. STEPS 2013: Prevalence of noncommunicable disease risk factors in the Republic of Moldova. Copenhagen: WHO Regional Office for Europe. https://extranet.who.int/ncdsmicrodata/index.php/catalog/230 12WHO.2022. STEPS 2021: Prevalence of noncommunicable disease risk factors in the Republic of Moldova. Copenhagen: WHO Regional Office for Europe. https://www.who.int/republic-of-moldova/publications/i/item/WHO- EURO-2022-6785-46551-67555 13Donabedian,A. 1966. “Evaluating the quality of medical care.” The Milbank Memorial Fund Quarterly 44 (3): 166-206. https://www.milbank.org/quarterly/articles/evaluating-quality-medical-care/ 21 Service Delivery Indicators Health Survey for Moldova – Overview of Results improves or maintains health outcomes, by being valued and trusted by all people, and by responding to changing population needs14.” The SDI health survey has a robust history of implementation but has recently been revisited to reflect the vision of high-quality health systems. This new generation of the SDI health survey is informed by the recent literature and guidance on measuring the quality of health systems, primarily that from the Lancet Global Health Commission on High Quality Health Systems. The Commission emphasized the lack of and need for measuring quality of care along three domains, namely foundations, processes of care, and quality impacts. The guiding framework of the SDI health survey (figure 3) is built on these axes, with measures organized into these three domains, as described below. The SDI framework also draws from other relevant frameworks such as the Primary Health Care Performance Initiative (PHCPI), which describes the critical components of a strong primary health care system along five key areas: systems, inputs, service delivery, outputs, and outcomes. Figure 3. Overview of Service Delivery Indicators domains of assessment PROCESSES PERSON-CENTERED FOUNDATIONS OF CARE OUTCOMES Systems Competent care systems Confidence in system • Policies and protocols • Diagnosis, treatment, counseling • Satisfaction and recommendation • Institutions for accountability • Referral, continuity, integration • Care uptake and retention for quality • Safety, prevention, detection • Management and supervision Financial protection Financing Positive user experience • Out-of-pocket costs • Physical infrastructure • Respect and autonomy • Opportunity costs Care organization • User focus • Service delivery organization • Facility connective networks • Service and case mix Workforce • Availability • Education and training Workload • Satisfaction and retention Tools • Medical equipment and supplies Source: World Bank Group • Medicines 14Kruk,M. E., Anna D Gage, Catherine Arsenault, Keely Jordan, Hannah H Leslie, Sanam Roder-DeWan, Olusoji Adeyi et al. 2018. “High-quality health systems in the Sustainable Development Goals era: Time for a revolution.” The Lancet Global Health 6 (11): e1196-e1252. 22 Service Delivery Indicators Health Survey for Moldova – Overview of Results Foundations of, or inputs to, high-quality primary care, include subdomains related to systems, care organization, workforce, and tools—critical enablers for ensuring delivery of primary care services that meet the needs and expectations of the population. These foundations are necessary pillars of a strong primary health care system yet are not sufficient alone to ensure high-quality primary health care. For this reason, the SDI health survey provides additional measurement of processes of care and person-centered outcomes. Processes of care refers to the actual delivery (or receipt) of care in a facility setting and can be assessed along two unique but interrelated subdomains: competent care systems and positive user experience. Person-centered outcomes ensure that a patient is at the “center of care,” and that patients are empowered to make decisions regarding their own health. This involves sharing all relevant information and resources with patients, so that they can consider all their choices and make an informed decision. In understanding how well the health system allows for patient-driven health care, we assess two subdomains covering confidence in the health system and financial protection. 23 Service Delivery Indicators Health Survey for Moldova – Overview of Results 2. Methods 2.1. Survey Development SDI health surveys have been developed to evaluate PHC systems across multiple countries. Recent efforts by the SDI team have included expansion of indicators to measure services and components of primary health care systems, including emergency preparedness, topical coverage of clinical vignettes, patient satisfaction, and supply chain management. The Moldova SDI health survey consisted of three primary interviewing tools: one questionnaire for health facility managers, one for providers, and a third for patients. All components of the questionnaires were reviewed by clinical experts, in partnership with the Moldova MoH, to best reflect and assess the primary health care system in Moldova. 2.2. Description of Domains Covered in the SDI Health Survey As highlighted earlier in figure 3, the Moldova SDI set out to assess primary health care across three primary domains, as described below. 2.2.1. Foundations The performance of the system is measured along the components that serve as the backbone of primary care systems: policies and protocols, institutions for accountability for quality, management and supervision, financing, and physical infrastructure. Care organization is systematically investigated along three subdomains: service delivery organization, facility connective networks, and service and case mix. Appropriate care organization, which means a balanced mix of types of facility and provider, connectivity across facilities, and case mix, is critical for optimizing resource allocation and outcomes. Availability, education and training, workload, and satisfaction and retention are four components that inform the measurement of workforce in the SDI framework. Taking a step forward in addressing human resource challenges in service delivery, the SDI health survey views health care providers as both agents and subjects of the health system and attempts to measure not just the workforce’s availability and credentials, but also factors that might be affecting their performance, such as workload and satisfaction with work. The survey also measures tools required for care delivery categorized along three groups, namely medical equipment and supplies, medicines, and information systems. 24 Service Delivery Indicators Health Survey for Moldova – Overview of Results 2.2.2. Processes of Care Three components are used to measure the competency of health care systems in delivering high-quality care: zz Diagnosis, treatment, and counseling to understand the knowledge and clinical competency of health care providers through clinical case simulations. zz Referral, continuity, and integration to understand how referral systems work and patients’ willingness to continue seeking care from the same health facility/health care provider. zz Safety, prevention, and detection to determine if practices are in place to prevent health care–acquired infections and to detect and prevent the spread of contagious diseases in a timely manner. To judge patients’ experience in receiving care, this report focuses on these components: zz Respect and autonomy – health care practices that foster the feeling of respect and autonomy in patients. zz User focus – systems in place that prioritize patients’ needs in every step of service delivery. zz Responsiveness to feedback provided by patients to facilities. 2.2.3. Person-Centered Outcomes Two components help to understand how confident patients are that the health system will provide timely and high-quality care: zz Satisfaction and recommendation – patients’ satisfaction with the various aspects of care they receive and the likelihood that they will recommend a health facility/health care provider to others based on their experience. zz Care uptake and retention – the likelihood that patients will continue to receive care at a single health facility or multiple health facilities, and the reasons for their choice. Two other components were used for assessing the various financial costs that patients bear in receiving care: zz Out-of-pocket costs. zz Opportunity costs, for example, income lost or time taken away from work in receiving care. Further details on the components measured under each subdomain of the SDI analytical framework can be found in annex B. 25 Service Delivery Indicators Health Survey for Moldova – Overview of Results 2.3. Sample Design The Moldova SDI health survey was designed to provide a nationally representative sample of health facilities, providers, and patients. The sample was drawn with the following objectives. zz To measure facility-level indicators of service delivery and quality of primary care using a nationally and subnationally representative sample of health facilities drawn with probability proportional to size based on registered population. zz To measure provider-level indicators of effort, clinical knowledge and competence, and work environment using a sample of the health care providers working within selected health facilities. zz To measure patient experience and satisfaction with care among a sample of those receiving care at the selected health facilities. To form a sample frame, a listing provided by MoH was used to determine which facilities were currently operational, provided outpatient primary care services, and were contracted by the National Health Insurance Company (NHIC). This sample frame was then stratified by facility type and the four major regions—North, Central, South, and Autonomous Territorial Unit (UTA) of Gagauzia—as well as an urban zone including the cities of Chisinau and Balti. Stratification of the sample ensured that all relevant subgroups were adequately represented. Given the different structures of care in urban and rural areas and the differences in provision of care based on facility types, we stratified the sample by facility type (Consultative diagnostic center/individual family doctor office/family doctor center/health center/family doctor office/health office/private health center) and by location (urban/rural). The strata are shown in table 1, with each row representing a stratum. 26 Service Delivery Indicators Health Survey for Moldova – Overview of Results Table 1. Summary of facilities included in the sample frame, stratified by urban/rural and facility type15 Catchment Total number Sampled Location Type of facility population of facilities facilities Consultative diagnostic center (Centrul 184,421 4 4 Consultativ Diagnostic) Family doctor center (Centrul Medicilor de 427,205 12 12 Familie) Urban Health center (Centrul de Sanatate) 275,080 24 24 Family doctor office (Oficiul Medicului de 16,151 9 9 Familie) Health office (Oficiu de Sanatate) 939 2 2 Private health center 99,367 8 8 Individual family doctor office (Cabinetul 29,462 15 15 Individual al Medicului de Familie) Family doctor center (Centrul Medicilor de 18,879 8 8 Familie) Rural Health center (Centrul de Sanatate) 1,282,390 249 54 Family doctor office (Oficiul Medicului de 909,076 620 53 Familie) Health office (Oficiu de Sanatate) 152,534 366 53 Private health center 34,657 8 8 Total   3,430,161 1,325 250 Further details on sample design and survey weights developed to account for the Moldova SDI health survey sample design are available in annex C. 2.4. Data Collection and Analysis SDI health surveys are conducted through in-person visits of enumerator teams to selected primary health care facilities. Each facility receives two visits from the enumerator team: the first is a preannounced visit when the interview with the health facility manager and with selected health care providers take place. The second is an unannounced visit during which the presence/ absence of a selection of health care providers is assessed and patients are interviewed. Some parts of the questionnaire administered to the health facility manager include validation through direct observation of the presence/absence and functioning of key infrastructure, records, equipment/supplies, and medicines. The questionnaire administered to health care providers during the preannounced visit includes in-person interviews and clinical simulation cases. The questionnaire administered to patients about their experience is completed in-person during the 15Unless otherwise stated, all tables in this report were prepared by the SDI Health Survey Team (see Acknowledgments). 27 Service Delivery Indicators Health Survey for Moldova – Overview of Results unannounced visit as patients are leaving the health facility. Additional descriptions of relevant methods are included in subsequent sections presenting survey results16. Table 2. Summary of fieldwork activities Round 1 Round 2 Round 3 Instrument and protocol Pretest in two facilities: Pilot in four facilities: testing August 13–14, 2021 September 7–10, 2021 Fieldwork staff training August 15–20, 2021 December 15, 2021 January 12 and 14, enumerators) 2022 August 21–23, 2021 (supervisors) Main data collection December 16, 2021–January January 17–30, 2022 February 24–May 4, 2022 16, 2022 Back-checks March 3–May 27, 2022 Table 2 provides an overview of the dates for the different rounds of training, testing, and data collection, which included several data quality assurance back-checks conducted in person and via telephone. Survey instruments were pretested in two facilities in August 2021; and shortly afterward – in September 2021 – they were piloted in four facilities. Training of fieldworkers occurred in August 2021, between the survey pretest and pilot. Two additional rounds of training were conducted, one in December 2021 to review changes to the tool after the pilot study and one in January 2022 to address enumerator performance as assessed through data quality assurance checks conducted by Sanigest Internacional and the World Bank team. Broadly, data were collected between December 2021 and May 2022, using computer-assisted personal interviewing (CAPI) on tablets. Two breaks occurred during data collection, the first in to observe Eastern Orthodox Christmas (January 5–16, 2022), and the second in response to restrictions on in-person activity due to a resurgence of COVID-19 across Moldova (January 31–February 23, 2022). Data quality back-checks were conducted between March and May 2022. The team carried out ongoing data quality checks during fieldwork implementation, in addition to the back-checks carried out through callbacks and revisits in 12 percent of facilities. The field team used data quality reports to follow up with supervisors and enumerators in certain cases, such as interviews with outlier values outside a normal distribution, incomplete interviews, enumerators or interviews with an above-average percentage of “don’t know” answers, and interviews for which the respondent was not the initially targeted respondent, and distribution of randomly selected questions. Additionally, responses recorded under categories other than those predetermined in the data collection tool were recoded as necessary for analysis. The enumerators were usually able to correct the value, in the case of 16Further information on methods for data collection is available from the SDI website: https://www.worldbank.org/en/ programs/service-delivery-indicators/health 28 Service Delivery Indicators Health Survey for Moldova – Overview of Results a typo) or reach the respondent to seek clarification or confirmation (in the case of provider and facility interviews). All data were subject to review by Sanigest Internacional, and a data analysis consultant employed by the World Bank Group. Data quality reports were developed and reviewed weekly by the SDI technical management team in the World Bank. The team surveyed 247 PHC facilities and interviewed 470 physicians, 807 nurses, and 1,497 patients (table 3), spending approximately two days per facility. These figures equate to 98.8 percent participation by facilities, and almost 97 percent participation by the target number of doctors and nurses. A census of private facilities was conducted, meaning that all private facilities in the sample frame were selected for interview. However, the three facilities that were not surveyed (among the 250 selected) were private facilities, and thus had no replacements available. Five additional originally sampled facilities were replaced, with consistency ensured in terms of facility type and location. Of the 2,151 eligible patients randomly selected for the interview, 660 refused, a 30 percent refusal rate. Table 3. Response rate by study population Study population Sample selected Sample interviewed Response rate PHC facilities 250 247 99% Doctors 486 470 97% Nurses 830a 807 97% Patients 2,151 1,497 70% aEstimate considering an average of two nurses per lower-level facility (172 facilities), plus the same number of nurses to be interviewed as physicians in 78 head facilities. All results presented in the following chapters were obtained using cleaned data sets and applying the relevant survey weights. Generally, the survey-weighted mean for indicators is presented, however for data that follow a non-normal distribution, survey-weighted median values have been presented. Further details on survey weights and sample size determination can be found in the sampling section (annex C). Data were cleaned and analyzed using Stata 17. Data presented in maps were visualized using the package ggplot217 in RStudio. Values for 95 percent confidence intervals are presented, where possible, in the executive summary and key results for each chapter, but these were not calculated for each table and figure in the report. Where confidence intervals are not available in chapter summaries, there were one or more strata with only one sampling unit. For these reasons, results and values presented in the report are not meant to reflect statistical comparisons but rather describe the relative frequency of results across disaggregate categories. A summary of the domains and corresponding indicator definitions is included in annex D. 17Wickham. 2016. ggplot2: Elegant Graphics for Data Analysis. New York: Springer-Verlag. See also the ggplot2 website at https://ggplot2.tidyverse.org 29 Service Delivery Indicators Health Survey for Moldova – Overview of Results Results are presented, as relevant, by region and facility type separately. Five regions and seven types of facilities are included, as listed below. All tables and graphs were produced by the World Bank Group using data from the survey. Regions 1. North. 2. Central. 3. South. 4. UTA Gagauzia. 5. Urban. Facility types 1. Health center. 2. Family doctor office. 3. Health office. 4. Individual family doctor office. 5. Family doctor center. 6. Private health center. 7. Consultative diagnostic center. 30 Service Delivery Indicators Health Survey for Moldova – Overview of Results 3. Foundations In this chapter, we present findings that assess the foundational strength of high-quality primary health care. Most data have been sourced from health facility interviews, though some have been analyzed using data collected from patients and physicians. As defined earlier, foundations of high-quality primary health care include four key subdomains: systems, care organization, workforce, and tools. Through these subdomains, we explore the strength of key pillars for high-quality primary care in Moldova, ranging from inter- facility and facility-patient connectivity to provision of required and specialized care, human resources for health, availability of clinical guidelines, and facility physical infrastructure. Box 1 highlights some of the key findings related to foundations of primary health care in Moldova. Definitions of subdomains and in-depth analysis of their associated indicators are presented in due order within this chapter. Box 1. Key observations on PHC foundations in Moldova Care organization: • On average, facilities offered 83% (CI: 80%–86%) of all mandated PHC services. The proportion of mandated services offered varied by service type, with the proportion of mandated services for noncommunicable diseases (95%, CI: 93%– 97%), pediatric care (95%; CI: 92%–97%), and community health (86%; CI: 84%– 88%) being above average. The proportion of mandated mental health (70%; CI: 62%–77%), infectious disease (66%; CI: 60%–72%), and OB-GYN (50%; CI: 42%– 58%) services was below average. • Median outpatient volume observed over a three-month period was highest for adult NCDs (254), particularly for adult hypertension (168) and diabetes mellitus (47). For mental health, adult TB, and child pneumonia, few visits were reported (median three-month outpatient volume less than 10). • Less than half of the facilities surveyed had observed emergency transport capacity (43%; CI: 35%–51%) or on-site laboratory services (28%; CI: 22%–36%). Emergency transport capacity and on-site laboratory services were most highly concentrated in the urban and UTA Gagauzia regions. • On average, 97% (CI: 94%–100%) of facilities were connected to a motorable road, and 69% (CI: 61%–77%) were within a 10-minute walk from public transport. 31 Service Delivery Indicators Health Survey for Moldova – Overview of Results Box 1. Key observations on PHC foundations in Moldova Systems: • Facilities, on average, had 85% (CI: 82%–89%) of all 5 measured clinical guidelines and 82% (CI: 76%–88%) of all 3 measured emergency preparedness guideline documents. • 75% (CI: 67%–83%) of facilities mentioned that they meet with a facility administrative board. Among those reporting that they meet with an administrative board, all meet at least once every 6 months. • 87% (CI: 80%–93%) of facilities reported having any supervisory visit in the 12 months preceding the survey. Among those facilities that did receive a supervisory visit, nearly half (48%) were considered supportive under the WHO definition of supportive supervision. • Most facilities had functional information technology equipment such as a telephone (97%; CI: 94%–100%) or computer (82%; CI: 76%–88%) available on the day of the interview, however some facilities reported that they had at least one disruption to their electricity (31%; CI: 23%–37%) or internet connectivity (37%; CI: 29%–45%) over an observed 3-month period. • Most facilities (97%; CI: 94%–100%) had appropriate waste disposal. 40% (CI: 32%–49%) had proper storage for blood or vaccines, 32% (CI: 25%–41%) had infection prevention and control infrastructure, and 48% (CI: 40%–56%) had functioning fire safety infrastructure. • While improved, functional water sources (95%; CI: 90%–99%) were widely available, only 56% (CI: 48%–65%) of facilities had an improved water source that was both on-premises and uninterrupted. • Most facilities with steps or inclines had a ramp (71%; CI: 63%–79%), but few had a lift (9%; CI: 6%–13%) available for differently abled patients. Less than half of all facilities had tactile flooring (42%; CI: 33%–51%), and only 14% (CI: 8%–20%) had assistive technology for visually-impaired patients or accessible toilets. 32 Service Delivery Indicators Health Survey for Moldova – Overview of Results Box 1. Key observations on PHC foundations in Moldova Workforce: • Overall, 15% (CI: 12%–19%) of doctors and 13% (CI: 10%–26%) of nurses were absent on the day that the facility received a follow-up visit. The most common reasons for absence among both provider cadres were parental, medical, or earned leave, or the provider’s presence in a subordinated facility that day. No providers were absent for unauthorized reasons. • The median tenure of doctors and nurses observed in the study were 25 and 21 years, respectively, indicating an experienced yet aging health workforce. • Around one in five providers, including doctors and nurses (22%; CI: 18%–26%), reported that they feel administrative tasks impede their ability to focus on direct clinical work. On average, doctors and nurses spent 63% (CI: 60%–65%) and 61% (CI: 59%–63%) of their time, respectively, providing direct care to patients. • Required services related to antenatal care, prevention of mother-to-child HIV transmission, newborn and child surveillance, health promotion and education, pediatric care, and noncommunicable disease were reported to be widely available across facilities (most specific services were available in at least 80% of facilities). Conversely, services for diagnosis and treatment of tuberculosis, HIV, reproductive health (particularly IUD insertion, pap smears, and emergency contraception), OB-GYN, and mental health were the least commonly reported by facilities. Tools: • On average, facilities had 79% (CI: 76%–83%) of measured NCD medicines, 86% (CI: 82%–91%) of measured OB-GYN medicines, 92% (CI: 89%–95%) of measured infectious disease medicines, 66% (CI: 61%–70%) of measured pediatric medicines, 63% (CI: 58%–68%) of measured vaccines, and 94% (CI: 91%–98%) of other measured medicines. • Among facilities offering the services, on average, 90% of measured lab equipment (e.g., medical spatula, syringes, clinical laboratory set) was observed, 66% of measured sterilization equipment (e.g., electric autoclave, UV lamp, hand disinfectant) was observed, and 65% of imaging equipment (e.g., X-ray, ultrasonography, EKG) was observed. 33 Service Delivery Indicators Health Survey for Moldova – Overview of Results 3.1. Care Organization This section provides an overview of facility connective network strength (emergency transport capacity, lab service availability, and pharmacy availability), service and case mix (outpatient volume by service type and provision of required and specialized services), and service delivery organization (facility connectivity to patients, facility operating hours, and registered catchment population). 3.1.1. Facility Connective Networks In many cases, service delivery can be strengthened by connective networks between health facilities that allow for between-facility communication and enable patient linkages for continued care across facilities. In some cases, facilities may be part of formal, designated networks that share staff and infrastructure or part of formal referral systems. Facilities may also be connected, in that they have systems for communicating with one another during emergencies or have an ambulance or other form of transportation on site that can link patients to other facilities, if required services are not available at the patient’s initial point of care. This component captures the existence of connective systems at surveyed facilities, with particular focus on emergency transport capacity as well as availability of laboratory services on site. Emergency Transport Capacity Figure 4 and figure 5 present the percentage of facilities with emergency transport capacity by region and facility type, respectively. Emergency transport availability refers to facility ownership of at least one motor vehicle that had fuel and authorized staff available to drive at the time of the interview. Overall, 43% of facilities have emergency transport capacity. PHC departments with the highest rates of emergency transport availability were found in private clinics (100%), health centers (80%), and family doctor centers (71%). Only 35% of family doctor offices, 25% of health offices, and 15% of individual family doctor offices had documented emergency transport capacity at the time of the survey. 34 Service Delivery Indicators Health Survey for Moldova – Overview of Results Figure 4. Proportion of facilities with emergency transport capacity, by region (%) (N = 247)18 100 100 90 80 70 60 Percent 50 50 47 41 43 38 40 30 20 10 0 Center North South Urban UTA Gagauzia Average Figure 5. Proportion of facilities with emergency transport capacity, by facility type (%) (N = 247) Health center 80% Family doctor office 35% Percent of facilities Health office 25% Individual family doctor office 15% Family doctor center 71% Private health center 56% Consultative diagnostic center 100% Average 43% Laboratory Service Availability Figure 6 and figure 7 show the percentage of facilities that offer laboratory services by survey region and facility type, respectively. Approximately one in four facilities (28%) in the sample reported availability of any laboratory services on site. The highest rates of such services on site among all facility types were in consultative diagnostic centers (100%), health centers (71%), family doctor centers (62%), and private health centers (61%). Rates of service availability were particularly low within family doctor offices (19%), health offices (9%), and individual family doctor offices (0%). 18Unless otherwise stated, all tables in this report were prepared by the SDI Health Survey Team (see Acknowledgments). 35 Service Delivery Indicators Health Survey for Moldova – Overview of Results Laboratory service availability also varied by region, with the highest concentration of service availability in urban areas of the sample (66%). Less than half of facilities in UTA Gagauzia (49%) and the North region (40%) reported laboratory service availability. Less than one in five facilities (18%) in the South and Center regions had laboratories on site. Figure 6. Proportion of facilities with on-site lab services, by region (%) (N = 247) 100 90 80 66 70 60 49 Percent 50 40 40 28 30 18 18 20 10 0 Center North South Urban UTA Gagauzia Average Figure 7. Proportion of facilities with lab on-site lab services, by facility type (%) (N = 247) Health center 71% Family doctor office 19% Percent of facilities Health office 9% Individual family doctor office 0% Family doctor center 62% Private health center 61% Consultative diagnostic center 100% Average 28% 36 Service Delivery Indicators Health Survey for Moldova – Overview of Results 3.1.2. Service and Case Mix This component captures the number and types of PHC services that were available at the facility, including availability of laboratory services. However, even where services were available at a facility, patients did not necessarily utilize them. This component also explores the availability and utilization of services to assess any potential issues of allocative efficiency. Key indicators in this component include outpatient volume (overall and by service type), availability of required and specialized services, and availability of laboratory and imaging services. Outpatient Volume Figure 8 (below) highlights the median outpatient number of outpatient visits19 per 1,000 patients in each respective facility’s registered population over a three-month period (September–November 2021). The primary purpose for presenting this information is to understand the relative care seeking patterns across different regions and facility types while normalizing these values by making them relative to the size of each facility. Considering average median outpatient volume per 1,000 patients over the 3-month period for services across regions, the Urban (902) and South (841) regions had the highest number of outpatient visits per 1,000 patients in their registered population. The highest median outpatient volume per 1,000 patients across facilities was found in consultative diagnostic centers (1,815), family doctor centers (1,101), and individual family doctor offices (835). Median outpatient volume per 1,000 patients was below average in health offices (255) and the north region (233). Further detail on outpatient visits per 1,000 registered population by service type, region, and facility type is available in annex table A.1. 19Volume of outpatient visits were collected over a 3-month period from September–November 2021. Outpatient visits refer to visits to a health facility by a patient seeking screening, preventative, diagnostic, or therapeutic services. 37 Service Delivery Indicators Health Survey for Moldova – Overview of Results Figure 8. Outpatient volume per 1000 individuals in facility registered population over three-month period (median), by facility and region Consultative diagnostic center 1815 Private health center 704 Facility Type Family doctor center 1101 Individual family doctor office 835 Health office 657 Family doctor office 717 Health center 690 UTA Gagauzia 516 Urban 902 South 841 Region North 587 Center 717 Average 701 0 500 1000 1500 2000 Number of outpatients These visits may comprise multiple patient contacts if the patient receives diagnostic or therapeutic services, examinations, or consultations from multiple health care providers during the same visit to the health facility. Additionally, as these data were observed over a 3-month period, it is possible that some of the outpatient volume count is for return visits by the same patient. It is also worth noting that some of the facility types listed (such as consultative diagnostic centers) had greater availability of specialized services such as laboratory, imaging, and surgical services as well as higher net referrals into the facility than others. Figure 9 below highlights median outpatient volume over the same period within each surveyed facility for each service type. Outpatient volume here represents median aggregate outpatient volume at facilities by disease type and is not representative of disease-specific outpatient volume for each health care worker. Figure 9 further highlights the median outpatient volume over a three-month period by disease type across facilities. This representation of outpatient volume is not normalized by patient volume, and rather reflects the service-specific median outpatient volume that facilities in the study had over the three- month period. Median outpatient volume related to adult NCDs (254), adult hypertension (168), and adult diabetes mellitus (47) were the three highest in the sample. Few outpatient visits were reported for mental health (median = 7), adult TB (median = 3), and child pneumonia (median = 1). 38 Service Delivery Indicators Health Survey for Moldova – Overview of Results Figure 9. Outpatient visit volume over three-month period, by disease type (median) Adult noncommunicable disease (NCD) 254 Adult hypertension visits 168 Childhood growth monitoring visits 47 Adult diabetes mellitus visits 41 Immunization visits 20 Mental health visits 16 Antenatal care 11 Cervical cancer screening visits 7 Adult tuberculosis (TB) visits 3 Child pneumonia visits 1 0 50 100 150 200 250 Number of outpatients visits PHC Service Provision: Required Care Figure 10 shows the proportion of all required PHC services that were offered20 on average across regions and facility types. Required PHC services are those that the MoH has mandated be available to all patients seeking care at PHC facilities in the country. These services are best outlined in the Ministry of Health order on primary health care in Moldova21 and an itemized list of service availability is available in tables 14 and 15. Approximately eight in ten required PHC services were available within surveyed facilities. The highest availability of services was in consultative diagnostic centers (96%), family doctor centers (94%), and health centers (90%), while the lowest availability of required PHC services was within health offices (76%). Regionally, availability of required PHC services was above average in the UTA Gagauzia (89%) and Center (88%) regions, and was lowest in the South (78%) region. Further detail on the proportion of required PHC services by service type, region, and facility type is presented in table 4. Overall, categories of services that had the highest proportion of services offered by surveyed facilities included noncommunicable diseases (95%), pediatric services (95%), and community health services (86%). Seventy percent of required mental health services were offered by surveyed facilities, while the proportion of infectious disease (66%) and OB-GYN services (50%) offered were the lowest in the sample. 20A PHC service being offered refers to a facility having at least one provider who can provide a designated service. For this indicator, the analysis considered the average proportion of services for which facilities have at least one provider offering that service. Further details on exact availability of services are in tables 13 and 14 in the report. 21Ministryof Health, Labour and Social Protection, Order No. 695, October 13, 2010. https://www.cidsr.md/wp-content/ uploads/2015/02/Ordin_no_695_din_13.10.2010-Cu-privire-Asistenta-med-primara.pdf 39 Service Delivery Indicators Health Survey for Moldova – Overview of Results Table 4. Percentage of required PHC services offered by facilities, by region, facility type, and service type (N=247) (%) Noncom- All re- Infectious OB-GYN Pediatric Communi- Mental municable quired diseases services services ty health health diseases services REGION Center 78 56 97 89 97 77 88 North 51 54 94 85 96 69 80 South 63 31 93 81 91 67 78 Urban 75 54 93 87 94 40 83 UTA Gagauzia 98 31 100 86 100 49 89 FACILITY TYPE Health center 83 59 99 91 96 77 90 Family doctor 63 54 97 88 96 74 84 office Health office 56 34 87 79 92 60 76 Individual family 66 54 98 92 96 77 86 doctor office Family doctor 97 71 95 95 99 57 94 center Private health 68 43 96 82 99 30 81 center Consultative diagnostic 100 100 100 97 96 50 96 center Average 66 50 95 86 95 70 83 Regionally, the proportion of infectious disease services offered by facilities was highest in the UTA Gagauzia (98%), Center (78%), and Urban (75%) regions, but below average in the South (63%) and North (51%) regions. The proportion of OB-GYN services offered was highest in the Center (56%), North (54%), and Urban (54%) regions and lowest in the UTA Gagauzia (31%) and South (31%) regions. Regarding provision of mental health services, the proportion of mental health services offered by facilities was highest above average in the Center region (77%), but at or below average in all other regions. The proportion of mental health services offered was lowest in the Urban (40%) and UTA Gagauzia (49%) regions. 40 Service Delivery Indicators Health Survey for Moldova – Overview of Results Figure 10. Proportion of required PHC services offered by facilities, by category and region Average 83 Consultative diagnostic center 96 Private health center 81 Facility type Family doctor center 94 Individual family doctor office 86 Health office 76 Family doctor office 84 Health center 90 UTA Gagauzia 89 Urban 83 Region South 78 North 80 Center 88 0 10 20 30 40 50 60 70 80 90 100 Proportion of all required services offered Across facility types, the proportion of infectious disease services offered was below average in family doctor offices (63%) and health offices (56%), but at or above average across all other facility types. Infectious disease services were universally available at consultative diagnostic centers, and nearly all infectious disease services were offered at family doctor centers (97%). The proportion of OB-GYN services offered was lowest in health offices (34%) and private health centers (43%). Similar to the findings on infectious disease service provision, OB- GYN services were universally available at consultative diagnostic centers. The proportion of mental health services offered were lowest in consultative diagnostic centers (50%), private health centers (30%), family doctor centers (57%), and health offices (60%). Provision of these services were above average across all other facility types. Generally, private health centers (81%) and health offices (76%) had the lowest proportion of mandated services offered, while the facilities with the highest proportion of mandated services available were consultative diagnostic centers (96%), family doctor centers (94%), and health centers (90%). 41 Service Delivery Indicators Health Survey for Moldova – Overview of Results Service Provision: Specialized Care Figure 11 and figure 12 highlight the ratios of facilities offering optional specialized services by region and facility type, respectively. Across the survey, about one-third of facilities (37%) offered surgical services, while slightly more than half offered services for ear, nose, and throat (ENT) (59%), ophthalmology (55%), and dermatology (59%). Overall, provision of specialized services was highly concentrated in the Center, North, and Urban regions, but sparse in the South and UTA Gagauzia regions. Provision of all specialized services was universal within consultative diagnostic centers surveyed in this study, but noticeable differences existed for other facility types. Aside from consultative diagnostic centers, provision of specialized services was highest among family doctor centers, private health centers, and health centers. Provision of specialized services was lowest within health offices and individual family doctor offices. Figure 11. Proportion of facilities offering specialized services, by service type and region (%) (N = 247) 100 90 80 72 70 69 70 66 67 67 64 63 59 59 59 60 55 51 50 46 40 37 37 37 30 26 23 20 19 16 10 7 7 0 0 Center North South Urban UTA Gagauzia Average Ear, nose, and throat (ENT) Dermatology Ophthalmology Surgical 42 Service Delivery Indicators Health Survey for Moldova – Overview of Results Figure 12. Proportion of facilities offering specialized services, by service and facility type (%) (N = 247) 100100100100 100 95 90 90 86 86 86 80 72 71 69 70 70 63 62 62 60 60 54 50 50 46 45 46 46 43 40 40 32 32 30 20 15 10 0 Health Family doctor Health Individual Family Private Consultative center office office family doctor health center diagnostic doctor office center center Ear, nose, and throat (ENT) Dermatology Ophthalmology Surgical Figure 13 highlights the proportion of facilities that offered specialized imaging such as ultrasound, medical X-ray, and advanced sonography, and required laboratory services such as basic and routine blood tests, blood donation, biochemistry, hematology, and microbiology services. Overall, only 13% of facilities in the sample offered specialized imaging services; the highest proportion of facilities offering imaging services was in the Urban region (43%). Specialized imaging services were offered by few facilities in the North (17%), South (15%), UTA Gagauzia (12%), or Center (6%) regions. Similarly, provision of required laboratory services was most common among facilities in the Urban (66%), UTA Gagauzia (49%), and North (40%) regions. Less than one in five facilities in the Center (18%) and South (18%) regions offered laboratory services. 43 Service Delivery Indicators Health Survey for Moldova – Overview of Results Figure 13. Percentage of facilities offering specialized imaging and required laboratory services, by region Imaging Laboratory North: North: 40% 17% Urban: Urban: 66% 43% Center: Center: 18% 60 6% 40 50 30 South: 40 South: UTA UTA 20 18% 30 15% Gagauzia: 20 Gagauzia: 10 49% 12% Annex table A.3 provides further detail on provision of imaging and laboratory services by region and facility type. Consultative diagnostic centers universally offered all imaging and laboratory services, and a majority of private health centers (77%) and family doctor centers (67%) provided specialized imaging services. Around six out of 10 private facilities (61%) and family doctor centers (62%) offered required laboratory services. A majority of health centers (71%) also offered required laboratory services. Provision of required laboratory services was lowest among health offices (9%) and family doctor offices (19%). A similar trend was observed for imaging service provision; only 10% of family doctor offices and 6% of health offices offered imaging services. No individual family doctor offices surveyed reported provision of imaging or laboratory services. 3.1.3. Service Delivery Organization This component aims to assess how PHC services are delivered and how facilities are situated to serve their registered populations. This section describes the types of facilities that deliver PHC; their location, including their connectivity to the population through local public transportation and motorable roads; the size of the population they serve; their accessibility to this population – the average time it takes for the registered population to reach the facility; their outreach practices; and their opening hours/hours of operation. Facility Registered Population Figure 14 highlights the population registered to each facility in the study. Registered population refers to the number of individuals who have officially registered with a family doctor at the facilities interviewed in the study. In terms of registered population, the Urban region had the health facilities with the largest population overall (median = 9,850 patients). 44 Service Delivery Indicators Health Survey for Moldova – Overview of Results Region Facilities within UTA Gagauzia had a moderate patient volume, with a median Northregistered population of 4,700 patients. The North, South, and Center regions had few health facilities Center reaching more than 100,000 people; the median registered population was under 1,500 Urban patients for each region. South Figure 14. Registered population, by facility (count) UTA Gagauzia Region Population North Center 25 000 Urban 50 000 South UTA Gagauzia 75 000 Population 100 000 125 00 25 000 50 000 75 000 100 000 125 00 Annex table A.4 further highlights registered population by facility type. The highest median facility registered population was at consultative diagnostic centers (49,780) and family doctor centers (13,720), followed by health centers (5,025) and private health centers (6,400). Other facility types had median registered populations of less than 2,500 patients. Facility Operating Hours Table 5 shows the proportion of facilities in operation each day of the week, excluding standard holidays. Nearly all facilities reported that they are open from Monday to Friday, while only about 70% reported that they are open on Saturdays, and only 1% are open on Sundays. All consultative diagnostic centers reported that they are open every day of the week. Days of facility operation during the week seemed lowest among health offices, particularly for operation on Saturdays (38%). 45 Service Delivery Indicators Health Survey for Moldova – Overview of Results Table 5. Proportion of facilities open each day of the week, by region and facility type (%) Percentage of facilities open each day of the week Monday Tuesday Wednesday Thursday Friday Saturday Sunday REGION Center 94 93 95 94 95 75 0 North 100 95 100 95 100 74 0 South 100 100 100 100 100 50 0 Urban 100 100 100 100 100 91 12 UTA Gagauzia 100 100 100 100 100 7 0 FACILITY TYPE Health center 100 100 100 100 100 87 0 Family doctor 100 100 100 100 100 79 0 office Health office 92 83 93 85 93 38 0 Individual 100 100 100 100 100 85 0 family doctor office Family doctor 100 100 100 100 100 81 24 center Private health 100 100 100 100 100 77 0 center Consultative 100 100 100 100 100 100 100 diagnostic center Average 98 95 98 96 98 70 1 Table 6 shows the average number of hours that facilities were open each day of the week. On average, facilities were open from Monday to Friday for nine hours per day; the average for Saturdays was five hours. 46 Service Delivery Indicators Health Survey for Moldova – Overview of Results Table 6. Average facility duration of operation per day, by region (hours) Monday Tuesday Wednesday Thursday Friday Saturday Sunday REGION Center 9 9 9 9 9 6 6 North 8 8 8 8 8 6 0 South 9 9 9 9 9 5 0 Urban 10 10 10 10 10 6 6 UTA Gagauzia 10 10 10 10 10 5 0 FACILITY TYPE Health center 10 10 10 10 9 6 0 Family doctor 9 9 9 9 9 6 0 office Health office 7 7 7 7 7 5 0 Individual family 9 9 9 9 9 6 0 doctor office Family doctor 10 10 10 10 10 7 6 center Private health 9 9 9 9 9 5 0 center Consultative 11 11 11 11 11 8 6 diagnostic center Average 9 9 9 9 9 6 6 Access to Facilities Regarding the time needed to reach the health facility using the most common mode of transportation in the registered population, over 82% of facilities reported that the median one-way travel time was 15 minutes by foot. Travel time was highest in UTA Gagauzia, with a median travel time of 30 minutes. Figure 15 and figure 16 highlight the proportion of facilities connected to a motorable road or within a 10-minute walk of a public transport station or stop, by region and facility type, respectively. Nearly all facilities (97%) were connected to a motorable road; the lowest proportion of facilities with such a connection was in the South region (88%). Although many facilities were connected to a motorable road, only about seven in ten (69%) were within a 10-minute walk of a public transport station or stop. Proximity to public transportation was very common among nearly all facilities in the Urban (95%) and UTA Gagauzia (100%) regions, but rates were much lower among facilities in the Center (69%), South (73%), and North (60%) regions. Facility types with particularly low proximity to public transport included health offices (49%) and family doctor offices (71%). 47 Service Delivery Indicators Health Survey for Moldova – Overview of Results Figure 15. Proportion of facilities with transport connectivity, by region (%) 100 100 100 100 100 97 95 93 88 90 80 73 69 69 70 60 60 50 40 30 20 10 0 Center North South Urban UTA Gagauzia Average % of facilities connected to motorable road % Proportion Figure 16. of facilities of facilities with public with transport transport stop/station connectivity, within a 10 minute walk by facility type (%) 100 99 97 100 100 100 100100 96 95 90 85 85 86 80 71 70 60 50 49 40 30 20 10 0 Health Family doctor Health Individual Family Private Consultative center office office family doctor center health diagnostic center doctor office center % of facilities connected to motorable road % of facilities with public transport stop/station within a 10 minute walk 48 Service Delivery Indicators Health Survey for Moldova – Overview of Results 3.2. Systems System performance is measured across several components, including policies and protocols, institutions tasked with accountability for quality, management and supervision, financing, and physical infrastructure. Some examples of key data presented in this section include presence of up-to-date clinical and operational guidelines; information on facility accountability mechanisms such as frequency and sources of facility performance feedback, feedback dissemination frequency and audience; staff performance assessment; facility- and provider-level incentives and financial accountability; and the presence of key physical infrastructure, for example, accessibility for differently abled individuals, auditory and visual privacy, and information and communications technology (ICT). 3.2.1. Financing Financing systems in health facilities have implications for facility-level and provider-level incentives, efficiency, and accountability. Information on financing at the facility level includes the sources and amount of revenue generated from the facility. Funds flowing into a facility may come from government or other sources, including private or donor sources, and may be in the form of cash or in kind. The extent to which health care providers receive payment in the form of gifts – such as from patients – or other incentives for outcomes/performance may influence staff behavior and facility functioning. This section provides information on the sources and amount of revenue generated by facilities, including procurement, in-kind resources, and incentives offered to providers. Incentives for Providers As outlined in the introductory chapter of this report, health facilities may receive quarterly financial bonuses from the National Health Insurance Company based on verified achievement of performance-based objectives. Facilities are responsible for determining how this additional funding from quarterly performance-based adjustments is distributed to facility staff for performance-related achievements. Table 7 shows the proportion of providers who reported receiving any performance incentives in the past 12 months, and the average amount of the performance incentive among those who reported receiving one. Overall, four in five providers (80%) reported that they received any performance incentives in the past 12 months. Provider-reported performance incentives were least common in health offices (57%) and private health centers (49%) and above average in family doctor centers (92%) and health centers (83%). The average performance incentive amount for providers who reported that they received an incentive in the past 12 months was MDL 4,596. Provision of gifts from patients were also captured in this study, however only two patients interviewed reported giving health care providers gifts, each valued at MDL 50, during the visit. 49 Service Delivery Indicators Health Survey for Moldova – Overview of Results Table 7. Provider-reported extra remuneration, by facility type Percentage of providers Average reported sum received as Facility type receiving any performance performance incentives in the past 12 incentives (N = 1,276) months (MDL) (N = 1,040) Health center 83 6,070 Family doctor office 76 3,936 Health office 57 4,252 Individual family doctor office 86 3,815 Family doctor center 92 6,011 Private health center 49 4,568 Consultative diagnostic center 100 7,198 Total 80 4,956 Facility Funding Sources Figure 17 and figure 18 respectively highlight the distribution of funds across different facility types by source, and the median amount of total revenue that facilities received in the 2020 fiscal year. Across all facility types, most revenue came from the National Health Insurance Company—greater than 90% among most health facility types. Median revenue varied across facility types; the highest median revenue was reported by consultative diagnostic centers (MDL 37.2 million), family doctor centers (MDL 9.9 million), health centers (MDL 2.3 million), and private health centers (MDL 1.9 million). All other facilities had a median reported revenue below MDL 1 million, and health offices reported the lowest median revenue across the study (MDL 209,651). Figure 17. Distribution of revenue, by facility type and source (%) Consultative diagnostic center Private health center Family doctor center Individual family doctor office Health office Family doctor office Health center Average Percent 0 20 40 60 80 100 National Health Insurance Company Funds Central government funds Diagnostic tests Local government funds Specialist consultations Laboratory tests Note: Values in white box highlight the percentage of revenue that came from National Health Insurance Company funds. 50 Service Delivery Indicators Health Survey for Moldova – Overview of Results Figure 18. Median total revenue (January-December 2020), by facility type (MDL) Health center 688 615 Family doctor office 209 651 Health office 688 615 Individual family doctor office 901 170 Family doctor center 1 892 000 Private health center 2 348 239 Consultative diagnostic center 9 883 963 Average 37 200 000 0 10 000 000 20 000 000 30 000 000 40 000 000 MDL In addition to direct financial revenue, facilities can receive in-kind contributions. Close to half of facilities (45%) reported that they received in-kind revenue. Within those facilities that reported in-kind revenue, the share of it in total revenue averaged 1.3%. The amount of in-kind revenue follows a pattern similar to that for direct fiscal revenue, with consultative diagnostic centers, family doctor centers, health centers, and private health centers reporting the highest median annual in-kind revenue. For most facilities , except health centers and health offices, nearly all in-kind revenue came from government sources. Health centers and health offices received larger proportions of their in-kind revenue from nongovernment sources. Table 8 and table 9 respectively highlight the sources and types of in-kind revenue received by facilities. For all facility types, medicines and supplies made up the majority of in-kind revenue, followed by medical equipment and furniture. Family doctor offices and health offices received the largest proportions of in-kind revenue from medical equipment. 51 Service Delivery Indicators Health Survey for Moldova – Overview of Results Table 8. Average in-kind revenue by source and facility type (MDL) (N = 112) Percentage Percentage Average Share of in- from from non- Facility type annual in-kind kind in total government government revenue (2020) revenue (%) source (mean) source (mean Health center 78,471 80 (62,968) 20 (15,503) 1.5 Family doctor office 7,442 93 (6,938) 7 (504) 0.9 Health office 3,714 73 (2,717) 27 (998) 1.9 Individual family doctor office 10,746 100 (10,746) 0 1.3 Family doctor center 413,768 99 (411,315) 1 (2,453) 2.9 Private health center 60,969 96 (58,427) 4 (2,542) 0.5 Consultative diagnostic center 806,842 97.7 (804,206) 0.3 (2,636) 2.7 Average 31,824 83.8 (27,944) 16.2 (3,879) 1.3 Table 9. In-kind revenue by type and facility type (MDL) (N = 112) Percentage Percentage Percentage Percentage from vehicles from medical Facility type from medical from medicines and other and general equipment and supplies nonmedical furniture supplies Health center 9 1 90 0 Family doctor office 19 1 80 0 Health office 13 0 87 0 Individual family doctor office 17 0 83 0 Family doctor center 1 2 97 0 Private health center 0 0 100 0 Consultative diagnostic center 5 8 87 0 Average 14 1 85 0 3.2.2. Institutions Tasked with Accountability for Quality This section captures the frequency of collection, review, and sharing of data on facility-level performance indicators, as well as the methods for and frequency of soliciting feedback from the population served by the facility. Additionally, it assesses the institutions and practices in place for external supervision, such as supportive supervision visits from central authorities, and the extent to which any supervisory activities adhere to the WHO definition of “supportive22”. 22World Health Organization (WHO). 2008. Training for Mid-level Managers (MLM). Module 4: Supportive Supervision (republished 2020). Geneva: WHO. https://apps.who.int/iris/bitstream/handle/10665/337056/9789240015692-eng.pdf 52 Service Delivery Indicators Health Survey for Moldova – Overview of Results Figure 19 shows the meeting frequency of facility administrative boards23. Data presented reflect the cumulative percentage for this indicator. 75% of facilities mentioned that they meet with a facility administrative board. Among the facilities that do meet with an administrative board, all reported that they have administrative boards that meet at least every six months, and many (93%) reported that their administrative boards meet once every three months. Only about one in five facilities (22%) reported that their administrative boards met at least once per month, while only 3% reported that their administrative boards met weekly. Only 1% of facilities reported that their administrative boards met more than once per week. Annex table A.5 provides further detail on the frequency of administrative board meetings across survey regions and facility types. Figure 19. Frequency of facility administrative board meetings (cumulative %) (N=197) 100 100 93 90 80 70 60 Percent 50 40 30 22 20 10 4 1 0 More than once At least At least At least every At least every per week weekly monthly 3 months 6 months Furthermore, all facilities reported having conducted quality improvement activities24 in the past 12 months with known individuals responsible, as well as reviewing quality improvement data regularly and sharing with facility management and staff. The number of facilities sharing quality improvement data with different groups did vary slightly by region and type of facility, as shown respectively in figure 20 and figure 21. Overall, most facilities reported that they shared data with external leadership (94%) and community constituents (95%). External leadership data sharing did not vary much by region but was least frequent within health offices (86%) and private health centers (83%). Sharing of data with community constituents was also relatively uniform across regions and facility types, though it was markedly lower among individual family doctor offices (69%). 23An Institution Administrative Board refers to a group of representatives of founder, National Health Insurance Company, health care providers union, and civil society organizations, who participate in decision making and work together to achieve a common goal of improving health service delivery and health outcomes. 24Quality improvement activities may include setting and tracking achievements toward targets, performance indicators, implementing decision support tools, clinical protocols, and checklists, benchmarking performance, and promoting patient engagement. 53 Service Delivery Indicators Health Survey for Moldova – Overview of Results Figure 20. Proportion of facilities that shared data externally, by constituent and region (%) 98 98 98 97 100100 100 95 95 94 95 92 89 90 80 70 60 50 40 30 20 10 0 Center North South Urban UTA Gagauzia Average % of facilities that shared data with external leadership (e.g., MoH or district health team) % of facilities that shared data with a community advisory board, community members, or patients Figure 21. Proportion of facilities that shared data externally, by constituent and facility type (%) 100 99 100 100 100100 100 98 96 95 95 94 90 86 83 80 69 70 60 50 40 30 20 10 0 Health Family doctor Health Individual family Family Private Consultative center office office doctor office doctor center health center diagnostic center % of facilities that shared data with external leadership (e.g., MoH or district health team) % of facilities that shared data with a community advisory board, community members, or patients 54 Service Delivery Indicators Health Survey for Moldova – Overview of Results When asked about quality improvement, two facilities – 0.2% of the weighted sample – reported not attaining any quality improvement targets set forth by MoH. Beyond data sharing, facilities were also asked about the frequency of supportive supervisory visits conducted at the facility within the past 12 months. Overall, 87% of facilities reported receiving a supportive supervisory visit in the 12 months preceding the survey. Supportive supervisory visits were least common among health offices; only 72% of health offices reported that they received a supportive supervisory visit. Among the facilities that received supportive supervisory visits, less than half of these visits (48%) included all components considered as supportive. Figure 22 presents the components that are included under the definition of supportive supervisory visit. Most facilities reported that during their supervisory visits, providers shared challenges and problems with their work (78%), external supervisors shared findings or issues discussed (78%), or engaged in collective problem solving about these issues (84%). The component most often lacking from supervisory visits was receipt of feedback; 61% of health facilities reported that they did not receive feedback during the supervisory visit. Generally, the highest share of supervisory visits that were supportive was reported by consultative diagnostic centers (75%) and family doctor centers (75%). Annex table A.6 provides further details by region and facility type on the proportion of facilities reporting that their supervisory visits were supportive. Figure 22. Proportion of Facilities Reporting Supportive supervision components (%) (N = 224) 100 90 84 78 78 80 70 61 60 Percent 50 48 40 30 20 10 0 Providers shared External supervisor External supervisor Health facility External challenges/problems shared findings/ engaged in collective received supervisor visit issues discussed problem solving feedback was supportive Nearly all facilities reported collecting feedback from the community in the past 12 months – only one health office located in the North did not – while 95% of facilities reported reviewing feedback data at least once per year. Figure 23 shows utilization of data collected by facilities. Nearly all facilities reported that they shared data with external leadership (93%), facility management and staff (97%), and community constituents (94%). Annex table A.7 provides further details of data utilization by region and facility type. 55 Service Delivery Indicators Health Survey for Moldova – Overview of Results Figure 23. Facility utilization of feedback data (%) 95% 93% 97% 94% Facility reviews Facility reviews feedback Facility reviews feedback Facility reviews feedback feedback data regularly data regularly data regularly and shares data regularly and shares (N=247) and shares with external with facility management with community leadership (N=236) & staff (N=236) advisory panel population, or patients (N=236) Figure 24 and figure 25 respectively highlight the top-five areas for improvement and the top-five areas identified as favorable according to feedback that facilities reported receiving from their patients. Approximately one-quarter (27%) of facilities reported that they received no feedback for improvement from those that conducted supportive supervision visits. Among those facilities receiving feedback, service and care availability was both the top area deemed in need of improvement (13%) and top area deemed favorable (24%). Other top areas needing improvement across facilities included availability and functioning of required equipment and supplies (11%), wait times for consultations (10%), facility infrastructure and cleanliness (9%), and the number of providers (6%). Facilities reported receiving positive feedback on staff respect and courtesy (18%), provider communication clarity (13%), provider clinical competence (11%), and availability of providers during operating hours (8%). Annex tables A.8 and A.9 provide further detail by facility type about areas needing improvement and areas receiving positive feedback. Figure 24. Top-five areas for facility improvement according to feedback (%) 13% 11% 10% 9% 6% Service or care Availability & Pre-consultation Infrastructure Number availability functioning of wait time or cleanliness of providers required equipment, of facility supplies, or medicine 56 Service Delivery Indicators Health Survey for Moldova – Overview of Results 100 90 Figure 80 25. Top-five favorable areas for facilities according to feedback (%) 70 60 Percent 50 40 13 30 11 20 10 9 6 10 0 Service or care Availability & Pre-consultation Infrastructure Number availability functioning of wait time or cleanliness of providers required equipment, of facility supplies, or medicine 3.2.3. Management and Supervision It is not just the broader accountability architecture that influences the quality of PHC service delivery, but also the direct management and supervision of staff members. The management and supervision domain focuses on the internal procedures and practices within a health facility that aim to review staff performance and provide feedback and support for improvement. Key indicators in this section include how often staff are provided with feedback on their performance, and what indicators and protocols are used to measure performance and conduct internal staff evaluations. Additional information is also collected on facility manager credentials. Figure 26 presents key components of facility management, including in-charge educational attainment, provider and support staff performance reviews, and use of management tools for staff performance. Approximately three in four facilities (77%) have a facility manager who holds a degree in management. Most facilities reported that they conduct provider performance reviews (91% of facilities) and support staff performance reviews (84%), and that they use tools to support staff performance (97%). Further details on these components by region and facility type can be found in annex table A.10. Figure 26. Facility management capacity components (%) 77% 91% 84% 97% Manager holds a degree Facility conducts Facility conducts support Facility uses tools to in management provider performance staff performance support staff reviews reviews performance 57 Service Delivery Indicators Health Survey for Moldova – Overview of Results Figure 27 shows the proportion of facilities that use various performance assessment tools for staff. On average, health facilities used three of the six performance assessment tools captured in the survey; the most common forms of assessment were supervisory (used by 69% of facilities), self (57%), and knowledge (53%). Facilities using the highest average number of tools were in the Urban region (4.5) and UTA Gagauzia (5.5). Among the facility types, consultative diagnostic centers and family doctor centers had the highest average number of tools used for staff performance assessment at 5.5 and 5.0, respectively. Annex table A.11 highlights use of different assessment tools across the survey regions and facility types. Figure 27. Staff performance assessment tools used by facilities (%) 100 90 80 70 69 60 57 Percent 52 53 51 50 48 40 30 20 10 0 Self-assessments Peer Supervisor or Patient Staff knowledge Clinical record assessments facility manager assessments assessments review assessments Staff knowledge assessments In addition to facility use of tools for staff performance assessment, the processes that facilities put in place to select staff for training can have a large bearing on staff performance and performance equity. Figure 28 highlights the criteria that facility managers reported that their facilities use to select which physicians receive training. Most (96%) reported that their facility uses at least one standardized method for selecting provider participation in training. More than half determine which providers receive training based on needs assessments (61%), provider specialty (for specialty-specific training) (54%), and upkeep of provider licensing and regulations (54%). Only 30% of facility managers mentioned that providers in their facility are selected to ensure that all providers receive the same training. Further detail on selection criteria for provider training can be found in annex table A.12. 58 Service Delivery Indicators Health Survey for Moldova – Overview of Results Figure 28. Staff training selection criteria (%) Training need assessment 61% Provider specialty 54% and training offered Provider licensing 54% requirements/regulations Provider interest/request 46% Provider performance 39% assessments Provider availability 34% Ensure all providers 30% receive same training At least one 96% selection criteria Figure 29 presents how satisfied nurses are with the support they receive from their supervisory family doctor. Nearly all nurses (98%) reported that they are satisfied with the support they receive from their supervisory family doctor, with little variation across regions and facility type. Satisfaction is nearly universal in all facility types aside from private health centers, where about nine in ten providers (92%) reported that they are satisfied with the support they receive from their supervisors. Figure 29. Nurse satisfaction with direct supervisor support (%) (N = 773) Average 98% Consultative diagnostic center 100% Private health center 92% Facility Type Family doctor center 98% Individual family doctor office 100% Health office 99% Family doctor office 97% Health center 98% UTA Gagauzia 100% Urban Region 97% South 96% North 96% Center 99% 59 Service Delivery Indicators Health Survey for Moldova – Overview of Results 3.2.4. Physical Infrastructure This component measures the availability and functioning of key physical infrastructure required for the daily operation of the health facility, and for its successful operation in cases of emergency. This includes the availability and functioning of infrastructure to facilitate utilization of services by differently abled populations. This includes infrastructure such as ramps, lifts, tactile flooring, toilets for clients with limited mobility, and assistive technologies for visually impaired clients. Other key infrastructure includes provisions for auditory and visual privacy for patients consulting with providers; improved, functioning, accessible, and private toilet facilities; and handwashing facilities. Other aspects are uninterrupted electricity; ambient temperature management infrastructure such as heaters and air conditioners/fans; refrigerators for vaccine and blood storage; functioning fire safety infrastructure – alarm, extinguisher; and ICT, including telephone, radio, computer, and internet. This component captures the characteristics of the infrastructure of the facility itself, not infrastructure in the surrounding area or infrastructure such as public transport required to reach the facility, and omits medical equipment, which is covered in a subsequent section. Accessibility for Differently Abled Individuals Figure 30 shows the availability of accessibility features for differently abled patients. Overall, facilities reported having about 30% of the captured accessibility features for differently abled patients (total of five components). The proportion of facilities with all five accessibility features was highest in UTA Gagauzia (62%), the South (41%), and Urban (37%) regions and lowest in the Center (22%) and North (30%) regions. This pattern generally held for availability of each specific accessibility feature. Ramps (71%) and tactile flooring (42%) were the most commonly available features across facilities. Few facilities across the sample were recorded having assistive technology for visually-impaired patients25 (14%), accessible toilets (14%), or a functioning lift (9%). Among types of facilities, consultative diagnostic centers had the highest proportion of accessibility features observed, on average (70%). Less than half of other facility types were reported as having all accessibility features. Family doctor offices and health offices had the lowest reported proportion of accessibility features for differently abled patients across facility types at 28% and 22% respectively. Annex table A.13 provides further detail on availability of accessibility features for differently abled patients by both region and facility type. 25Assistivetechnologies refer to technologies that are designed to assist those who are blind or visually impaired, such as signage with braille to help those who are blind or visually impaired to read information about the health facility or to facilitate use of amenities. 60 Service Delivery Indicators Health Survey for Moldova – Overview of Results Figure 30. Proportion of facilities with accessibility features for differently abled individuals, by region (%) 100 100 93 90 84 80 74 69 71 70 68 62 60 57 50 49 43 42 40 38 37 30 29 27 25 21 20 19 13 13 12 1414 11 10 9 5 5 5 2 0 Center North South Urban UTA Gagauzia Average Ramp (n=244) Tactile flooring Assistive technology Accessible toilet Lift (n=228) Availability of electrification and electricity-dependent infrastructure Figure 31 presents the proportion of facilities that had a functioning primary source of electricity on the day of the survey, as well as the proportion of facilities that reported having no interruptions to facility electrification over a three-month period (September – November, 2021). Nearly all (98%) facilities reported having functioning electricity the day of the interview, however nearly a third (31%) reported that they had disruptions to their electrification over the observed three-month period. 61 Service Delivery Indicators Health Survey for Moldova – Overview of Results Figure 31. Proportion of facilities with electrification, by region (%) 99 100 100 100 100 98 97 100 90 80 77 80 70 69 70 60 53 50 40 30 20 10 0 Center North South Urban UTA Gagauzia Average Functioning primary power source the day of interview Functioning, uninterrupted electricity (3 month period) One of the key infrastructural elements of health facilities includes refrigerators that can address needs to store blood and vaccines at controlled temperatures between 2–8°C. Figure 32 presents the percentage of facilities that had refrigerators observed on the day of the interview that could store blood or vaccines, as well as the functioning and temperature of the observed refrigerators. Most facilities (85%) had a refrigerator that was observed on the day of the interview designated for vaccine storage. All of these refrigerators for vaccine storage were functional and had a temperature between 2–8°C. Less than a quarter of facilities had an observed refrigerator that was designated for the storage of blood (21%). Only 3 refrigerators designated for blood storage (1%) were not functioning on the day of the interview. Overall, 20% of facilities had refrigerators designated for blood storage that were functional and had the appropriate temperature between 2–8°C on the day of the interview. It is worth noting that blood storage is not an explicit requirement of the Government of Moldova’s PHC mandate. 62 Service Delivery Indicators Health Survey for Moldova – Overview of Results Figure 32. Proportion of facilities with functional refrigerators for blood and vaccines (%) 100 90 85 85 85 80 Any refrigerator observed 70 the day of interview 60 Functional refrigerator observed on day of interview 50 Functioning refrigerator at appropriate 40 temperature (2-8 celsius) on day of interview 30 21 20 20 20 10 0 Blood storage refrigerator Vaccine storage refrigerator Water, Sanitation, and Hygiene (WaSH) infrastructure Another important component of facility infrastructure includes the availability of water, sanitation, and hygiene (WaSH) infrastructure within facilities. Figure 33 presents the availability of handwashing facilities, toilets, and improved, uninterrupted water services on- site at surveyed facilities. Nearly all facilities had at least one verified, functional handwashing facility at one point of care (99%), however only 59% of facilities had a verified handwashing facility with soap that was within 5 meters of a toilet. Most facilities (88%) reported having an improved, functional, accessible, and private toilet within the health facility premises that can be used by staff or patients. Figure 34 presents the cascade of water availability at surveyed facilities to highlight the predominant drivers of the low rate of water source availability highlighted in figure 33. Most facility managers reported having an improved water source (99%), and most facilities were also observed to have a functional, improved source of water on the day of the survey (95%). When assessed for water source availability based upon disruptions to water access, most facilities were found to have had no interruptions to their improved and functioning water source over the last three months (89%). However, facilities report relatively low rates of improved, functioning, uninterrupted water source availability on-premises (56%). Table 10 shows the distribution of water supply locations among surveyed facilities. Approximately half of water supplies were found within the facility building (48%), 13% were outside of the facility but on-premises, 19% were off-premises but within 500 meters of the facility, and 20% were off-premises and further than 500 meters from the facility. 63 Service Delivery Indicators Health Survey for Moldova – Overview of Results Figure 33. Proportion of facilities with WaSH infrastructure availability, by region (%) 100 100 100 100 100 100100100 100 98 96 99 95 90 88 84 80 70 71 72 63 61 60 59 58 56 51 53 50 Percent 44 40 30 20 10 0 Center North South Urban UTA Gagauzia Average Improved, functioning, uninterrupted, on-premises water source Improved, functioning, accessible toilet At least one point of care with functioning handwashing facility At least one functioning handwashing facility with soap within 5 meters from toilet Figure 34. Water availability cascade (%) 99 100 95 89 90 80 70 60 56 Percent 50 40 30 20 10 0 Improved water Improved, Improved, functioning, Improved, functioning, source available functioning, water uninterrupted, water uninterrupted, on-premises source available source available water source 64 Service Delivery Indicators Health Survey for Moldova – Overview of Results Table 10. Water supply location (%) Water supply location Percent Within the building 48 Outside the building but on the premises 13 Off premise but within 500 meters of the facility 19 Off premise and more than 500 meters from facility 20 Figure 35 presents the availability of different types of toilets for staff and patients. Most facility managers (88%) reported having a toilet on site, but only 39% had dedicated toilets for facility staff. Few facility managers (7%) reported that they had facilities specifically designated for females (including menstrual hygiene facilities). Further detail on this indicator by region and facility type is available in annex table A.15. Figure 35. Availability of toilets in health facilities (%) 88% 39% 7% Toilet for females Improved, functioning, Dedicated toilet (incl. menstrual accessible toilet for staff hygiene facilities) Safety and Infection prevention and control infrastructure Figure 36 highlights the availability of key infection prevention control infrastructure, including the presence of designated sites for patient isolation, a separate entrance for patients with suspected contagious disease, and physical barriers at least at one point of initial patient contact. Almost a third of surveyed facilities (28%) did not have a designated site for patient isolation and only approximately half had a separate entrance for patients with suspected contagious disease (53%) or had physical barriers in place for at least one point of initial patient contact (46%). This varied across facility types, with universal availability of these key infrastructure components in consultative diagnostic centers. Presence of each of these infection prevention and control infrastructure items was below average in health offices. 65 Service Delivery Indicators Health Survey for Moldova – Overview of Results Figure 36. Proportion of facilities with infection prevention and control infrastructure, by facility type (%) 100100100 100 95 90 90 85 80 81 79 80 75 76 70 72 68 69 70 62 60 60 53 50 50 46 46 46 Percent 40 30 26 20 17 10 0 Health Family doctor Health Individual Family Private Consultative Average center office office family doctor doctor health diagnostic office center center center Designated site for patient isolation At least one separate entrance for patients with suspected contagious disease Physical barrier at at least one point of initial patient contact Figure 37 shows the proportion of facilities that had a functional incinerator available on-site the day of the interview. Few facilities (8%) had on-site, functional incinerators observed the 100 day of the survey. Of note, all incinerators within facilities reporting them were functional the 90 day of the survey. Many facilities may outsource incineration of hazardous materials, which 80 could explain the sparce presence of on-site incinerators. 70 60 Figure 37. Proportion of facilities with a functional incinerator, by facility type (%) 50 Percent 40 30 15 20 10 10 8 10 7 6 0 Health Family Health Individual Family Private Consultative Average center doctor office office family doctor doctor health center diagnostic officer center center 66 Service Delivery Indicators Health Survey for Moldova – Overview of Results Figure 38 highlights the availability of key fire safety infrastructure within surveyed facilities, namely the availability of functional smoke detectors and fire extinguishers. Nearly all facilities had at least one functional fire extinguisher (98%), however less than half of facilities had a functional smoke detector (49%). When assessing the availability of both a fire extinguisher and smoke detector at surveyed facilities, less than half were observed having both on the day of the survey (48%). Private health centers and consultative diagnostic centers universally had both items, while availability of these items was below average in health offices (18%) and individual family doctor offices (38%). Figure 38. Proportion of facilities with fire safety infrastructure, by facility type (%) 100 99 100 100 100 100 100 100 98 97 100 90 80 71 67 70 60 55 49 50 Percent 40 38 30 20 18 10 0 Health Family doctor Health Individual Family Private Consultative Average center office office family doctor health diagnostic doctor office center center center Functional fire extinguisher Functional smoke detector While the data above have highlighted the availability of key infrastructure for safety and infection prevention and control, another key component of safety and infection prevention and control is the practices of facilities. Figure 39 highlights two key practices related to infection prevention and control, including adequate disposal of medical waste26 and regular cleaning (at least once per day) of points of care. All surveyed facilities adequately disposed of their medical waste. Most facilities also reported that they clean patient points of contact at least once daily (94%). This practice was universal at private health centers and consultative diagnostic centers and was lowest in individual family doctor offices (77%). It is worth noting that the majority of data from this study was collected during the COVID-19 pandemic, and thus infection prevention and control may have been given particular importance by facility staff during this period. 26Adequate disposal of medical waste was assessed based upon visual confirmation that infectious medical waste other than 67 at the time of the interview with the health facility. sharps was not visible or had been disposed in a protected area Service Delivery Indicators Health Survey for Moldova – Overview of Results Figure 39. Infection prevention and control practices, by facility type (%) 100 98 100 100 100 100 100 100 100 100 100 100 93 93 94 90 90 80 77 70 60 50 Percent 40 30 20 10 0 Health Family Health Individual family Family Private Consultative Average center doctor office office doctor office doctor health diagnostic center center center Adequate medical waste disposal Regular (daily) cleaning of patient points of care Consultation room features Overall, most facilities had consultation rooms with auditory and visual privacy (99% of facilities), a functional light source (98%), heater (99%), and fan or AC (98%). Availability of these features in consultation rooms was relatively uniform across regions and facility types. Annex table A.16 provides details on the availability of consultation room features by region and facility type. ICT Infrastructure Table 11 highlights the availability of various information and communications technology infrastructure across survey regions and facility types. Most facilities had a telephone (97%), computer (82%), and internet (80%) functional on the day of the interview; however, only 68% had a functioning printer. The share of facilities with internet availability was lowest among health offices (44%). Private health centers and consultative diagnostic centers universally had all ICT infrastructure items. By region, internet availability was lowest in the Center (76%) and North (76%) regions. When assessed for interruptions to internet service between the months of September to October 2021 (table 12), only 63% of facilities reported that they had functional internet that was not interrupted over the three-month period. Trends in uninterrupted internet availability were consistent with availability of internet the day of the survey across regions and facility types. 68 Service Delivery Indicators Health Survey for Moldova – Overview of Results Table 11. Presence of various ICT infrastructure attributes, by region and facility type Percentage of facilities with functional Number of functioning ICT item on day of survey infrastructure items Telephone Computer Printer Internet Mean Region Center 93 80 72 76 3.2 North 100 80 56 76 3.1 South 100 85 71 88 3.4 Urban 100 97 97 97 3.9 UTA Gagauzia 100 100 100 100 4.0 Facility type Health center 100 100 100 98 4.0 Family doctor office 100 93 79 91 3.6 Health office 91 46 20 44 2.0 Individual family doctor office 85 100 85 100 3.7 Family doctor center 100 100 100 100 4.0 Private health center 100 100 100 100 4.0 Consultative diagnostic center 100 100 100 100 4.0 Average 97 82 68 80 3.3 Table 12. Proportion of facilities reporting availability of internet, by facility type and region (%) Internet available and functioning Internet uninterrupted between Region on the day of the survey September – November 2021 Region Center 76 53 North 76 62 South 88 78 Urban 97 75 UTA Gagauzia 100 100 Facility type Health center 98 80 Family doctor office 91 72 Health office 44 32 Individual family doctor office 100 62 Family doctor center 100 71 Private health center 100 100 Consultative diagnostic center 100 100 Average 80 69 63 Service Delivery Indicators Health Survey for Moldova – Overview of Results 3.2.5. Policies and Protocols The successful operation of a PHC facility relies on adherence to operational and process guidelines, including safety and human resource protocols, and high-quality clinical care aligned with international and local clinical guidelines for patient examination/consultation, diagnosis, and treatment. While appropriate implementation of and adherence to guidelines can be difficult to measure, part of the health facility environment that enables adherence to guidelines is the availability of such guidelines for reference by staff. This section includes indicators capturing physical verification of the presence of the most up-to-date written guidelines on operations and processes such as IPC, waste management, emergency preparedness, and human resources. It also discusses clinical practice such as family planning consultation protocols, and protocols for diagnosis and treatment of hypertension and pneumonia. Figure 40 shows the proportion of clinical and IPC documents found at facilities that were up to date. On average, facilities had 85% of five measured up-to-date clinical guidelines and 82% of three measured emergency and IPC guidelines. Availability of these up-to-date guidelines was universal in health centers, family doctor centers, and consultative diagnostic centers. Only four out of five clinical guidelines were observed, on average, in family doctor offices and health offices, and 67% of measured emergency preparedness and IPC guidelines were observed in these facilities. Figure 40. Proportion of measured up-to-date guideline documents observed in facilities, by facility type (%) 100100 100 100100 100 100100 100 90 80 80 80 80 80 70 67 67 60 50 Percent 40 30 20 10 0 Health Family doctor Health Individual family Family Private health Consultative center office office doctor office doctor center center diagnostic center Clinical guidelines Emergency/IPC guidelines 70 Service Delivery Indicators Health Survey for Moldova – Overview of Results 3.3. Tools 3.3.1. Medical Equipment and Supplies This component covers the availability of functional essential medical equipment and supplies required for PHC services. Shortages of equipment or supplies can impact patient trust and continuity of care. It is worth noting that in this section, the indicators reflect the presence of at least one of each examined item. Results are not meant to capture the entire volume or depth of supply of medical equipment and supplies. Figure 41 presents the proportion of available and functional equipment at facilities across the study. A full listing of items assessed for each equipment category can be found in annex table A.17. Facilities, on average, had 93% of the 4 measured medical furniture and associated equipment, 78% of the 35 measured medical equipment items, 77% of the 22 measured special purpose articles, and 75% of the 6 measured medical instruments. Among facilities with labs on site, 90% of the 18 measured lab equipment items were available on average. In facilities offering surgical operations, only 66% of the 16 measured sterilization equipment items were available on average. Facilities stating that they offer special imaging services, on average, had 65% of the 4 measured imaging equipment items. Generally, the availability of all types of equipment was highest in the Urban and UTA Gagauzia regions. Across facility types, the best-equipped facilities were consultative diagnostic centers, health centers, family doctor centers, and private health centers. Further information on equipment availability by region and facility type is in annex table A.18. Figure 41. Proportion of available and functioning equipment, by equipment type (%) 100 93 90 90 78 77 75 80 66 65 70 60 50 Percent 40 30 20 10 0 Medical Laboratory Medical Special Medical Sterilization Imaging Furniture and Equipment Equipment Purpose Instruments Equipment Equipment Associated and Supplies (N=247) Articles (N=247) (n=117) (n=57) Equipment (n=97) (N=247) (n=247) 71 Service Delivery Indicators Health Survey for Moldova – Overview of Results Figure 42 shows the proportion of patients who reported that their provider recommended a test and that they received the recommended test. Across the sample, less than half (46%) of the respondents who were recommended tests received them. It is important to note that provision of laboratory services by PHC facilities is not required. Some patients whose providers recommended tests may have been referred to other facilities for testing. Overall, 32% of the patients who did not report receipt of tests at their current point of care reported that they were referred to another facility by their provider. Receipt of tests among those who were recommended for tests was lowest in consultative diagnostic centers (9%) and highest in individual family doctor offices (54%) and private health centers (50%). Regionally, the receipt of recommended tests among patients was above the average (46%) in the North (57%) and South (51%) regions. Figure 42. Proportion of patients recommended for tests who received them (%) (N = 541) Average 46% Consultative diagnostic center 9% Private health center 50% Facility Type Family doctor center 44% Individual family doctor office 54% Health office 39% Family doctor office 49% Health center 48% UTA Gagauzia 41% Urban 40% Region South 51% North 57% Center 39% 3.3.2. Medicines This section covers the availability of essential medicines and vaccines required for PHC service delivery. Data were collected based on direct observation of at least one available and unexpired medicine. As in the previous section, the data in this section are not meant to capture the exact volume of supply, but rather the presence of at least one item for required care. 72 Service Delivery Indicators Health Survey for Moldova – Overview of Results Figure 43 shows the proportion of medicines available27 in facilities among all measured service types. The list of medicines included are reflective of those laid out by the Ministry of Health in sections 15 and 16 of order no. 695 regarding PHC in Republic of Moldova28. Further, this figure shows the proportion of facilities that had on hand full, unexpired medicine for all measured medicines across disease types. On average, facilities had 79% of measured NCD medicines, 86% of measured OB-GYN medicines, 92% of measured infectious disease medicines, 66% of measured pediatric medicines, 63% of measured vaccines, and 94% of other measured medicines. Most facilities had all medicines for infectious disease (82%), OB-GYN (71%), and other required medicines not specific to the other listed service types (86%); however only 14% had all NCD medicines and 2% had all vaccines or pediatric medicines. Further detail on availability of specific medicines measured is available in annex table A.19. Figure 43. Medicine availability, by service type (%) 100 94 92 90 86 86 82 79 80 71 70 66 63 60 50 Percent 40 30 20 14 10 2 2 0 NCD OB-GYN Infectious Pediatric Vaccines Other Medication Medication Disease Medication Medication Medication Proportion of observed medicines available and unexpired Proportion of facilities with all medications (unexpired) Figure 44 presents the proportion of patients who were prescribed medicine during their visit to the health facility. On average, about three in five patients (61%) were prescribed medicine during their health care visit. Prescription patterns were relatively stable across regions and facility types. Prescription rates were highest for patients visiting individual family doctor offices (75%) and for patients in the North (71%) and South (68%) regions. The lowest rates of prescription were among patients who had visited a family doctor center (54%) or health office (54%), and among those who received care in the Center region (50%). 27“Available” is defined as observation of at least one full unexpired prescription. 28Republic of Moldova Ministry of Health, Order Nr. 695 regarding PHC in Republic of Moldova from 13 Oct, 2010. https:// www.cidsr.md/wp-content/uploads/2015/02/Ordin_no_695_din_13.10.2010-Cu-privire-Asistenta-med-primara.pdf 73 Service Delivery Indicators Health Survey for Moldova – Overview of Results Figure 44. Proportion of patients prescribed medicine during current visit (%) (N = 1,487) Average 61% Consultative diagnostic center 61% Private health center 66% Facility Type Family doctor center 54% Individual family doctor office 75% Health office 54% Family doctor office 59% Health center 65% UTA Gagauzia 59% Urban 62% Region South 68% North 71% Center 50% 3.4. Workforce 3.4.1. Availability This component captures the available human resources at surveyed health facilities. Key indicators in this section include the number of staff of different cadres and the number of staff providing either only outpatient care or both outpatient and inpatient care, and the number of administrative/support staff. This section outlines information on absence among providers and nurses, as well as information on the number of facilities with at least one provider offering specific services. Table 13 highlights the median number of staff across provider cadres in the survey by region and facility type. Within surveyed facilities, the median number of health care providers was three and the median number of support staff (administrative and clerical) was two; the median for overall staff was approximately five individuals. These median values were consistent across the North, Center, and South regions, but in the Urban and UTA Gagauzia regions, the number of health care providers and support staff was between four to five times that in the other regions. Similarly, the most densely staffed facilities in the sample were consultative diagnostic centers (median staff size = 196), private health centers (median 74 Service Delivery Indicators Health Survey for Moldova – Overview of Results staff size = 18), family doctor centers (median staff size = 48), and health centers (median staff size = 15). The total number of providers per population followed a similar distribution as was observed for the number of total staff across facility types. On average, there were 2.3 providers and 4.1 total staff available for every 1,000 people in the average facility’s registered population. Table 13. Median staff availability, by region and facility type Providers Total staff Health care per 1,000 per 1,000 Support staff Total staff1 providers registered registered population population Region Center 3 2 5 2.1 4.0 North 3 2 4 2.7 4.9 South 3 2 4 2.3 4.0 Urban 17 8 26 2.0 3.1 UTA Gagauzia 16 3 19 1.8 2.9 Facility type Health center 10 5 15 2.1 3.5 Family doctor office 3 2 5 2.1 3.9 Health office 1 1 3 3.8 7.4 Individual family doctor office 2 2 6 1.4 2.7 Family doctor center 5 11 48 2.1 3.2 Private health center 15 6 18 1.6 3.3 Consultative diagnostic center 103 90 196 2.5 4.6 Average 3 2 5 2.3 4.1 Notes: (1) Values in this column may differ slightly from the sum of values presented in the columns titled “Health care providers” and “Support staff,” as each column presents the survey-weighted median values were calculated independently for each population presented. Figure 45 shows the composition of staff across facility types in the survey. On average, facilities had approximately six health care providers (58% of total staff) for every four support staff (42%). Generally, this staff composition held across facility types and regions in the study. Facilities with the lowest proportion of health care providers to support staff were health offices (53% of staff); family doctor centers had the highest proportion (64%). Across regions, staff composition did not depart much from the survey average, although facilities in UTA Gagauzia had the highest proportion of health care providers to support staff (67%). Annex table A.20 shows staff composition by both facility type and region. 75 Service Delivery Indicators Health Survey for Moldova – Overview of Results Figure 45. PHC facility staff composition, by facility type (%) (N = 247) 100 90 40 39 41 36 43 43 80 47 70 60 50 40 64 60 61 53 59 57 57 30 20 10 0 Health Family doctor Health Individual Family Private Consultative center office office family doctor health diagnostic doctor office center center center Healthcare providers Other staff Figure 46 and figure 47 respectively show the absence rates of doctors and nurses in the survey. Absence was assessed based on an unannounced follow-up visit to facilities at a random interval within two weeks of initial interview. On average, 15% of doctors and 13% of nurses were absent during the follow-up visit. For doctors, absence rates were highest in health offices (46%), consultative diagnostic centers (27%), and family doctor offices (18%). No doctors were absent in individual family doctor offices during follow-up visits. Regionally, most absence rates were close to the survey average, though absence rates in UTA Gagauzia were relatively low, with only 3% of providers marked as absent on the day of the follow-up visit. Nurse absence rates were also relatively uniform across the regions and facility types, but absence rates at health offices (5%) and family doctor offices (8%) were below average. This is interesting, considering that these facility types had the highest rates of doctor absence during the follow-up visit. Like the doctor absence rates, nurse absence rates by region were lowest in UTA Gagauzia (7%). 76 Service Delivery Indicators Health Survey for Moldova – Overview of Results Figure 46. Doctor absence rates (%) (N = 720) Average 15% Consultative diagnostic center 27% Private health center 6% Facility Type Family doctor center 14% Individual family doctor office 0% Health office 46% Family doctor office 18% Health center 12% UTA Gagauzia 3% Urban 17% Region South 12% North 15% Center 17% Figure 47. Nurse absence rates (%) (N = 1285) Average 13% Consultative diagnostic center 10% Private health center 10% Facility Type Family doctor center 17% Individual family doctor office 17% Health office 5% Family doctor office 8% Health center 13% UTA Gagauzia 7% Urban 15% Region South 13% North 16% Center 10% 77 Service Delivery Indicators Health Survey for Moldova – Overview of Results It is important to understand the rate at which providers are absent, and equally important to know the reason why providers were marked as absent on the day of the follow-up interview—whether their absence was expected or not. Figure 48 shows the most common reasons for absence among family doctors and nurses. For both provider types, no providers were absent for unauthorized reasons, and the reasons for absence followed a similar pattern. The most common reason among doctors (26%) and nurses (27%) was absence for parental leave. Approximately one in four nurses were noted as absent due to earned leave (18%) or medical leave (19%); 15% of doctors reported absence for each of the same reasons. Less than 1 in 10 nurses (7%) and doctors (8%) reported absence for training or seminars. Among both doctors and nurses, 14% were absent due to their presence at a subordinate institution. Regarding reasons for doctors’ absence in health offices, presence at a subordinate institution was the most common (62%). Within PHC departments, many doctors were reported absent due to presence at a subordinate institute (19%), parental leave (22%) or earned leave (18%). Presence at a subordinate institution29 was also the top reason for doctor absence in family doctor offices (23%). Annex tables A.21 and A.22 respectively highlight the reasons for absence among doctors and nurses across regions and facility types. Figure 48. Reasons for absenteeism, by provider type (%) Off day 11% At a subordinate institution 14% Training/seminar (N=162) 8% Nurse Medical leave 15% Earned leave 15% Maternity/paternity leave 26% Sickness 1% Off day 3% At a subordinate institution 14% Training/seminar 7% (N=119) Doctor Medical leave 19% Earned leave 18% Maternity/paternity leave 27% Sickness 2% 29Subordinate institutions include those that fall under the same administrative structure that a doctor or nurse is registered to but is not the primary administrative entity. 78 Service Delivery Indicators Health Survey for Moldova – Overview of Results Table 14 and table 15 respectively show the proportion of facilities that had at least one provider who was trained to provide various required and specialized services, by region and facility type. Color coding has been added to make the values in the table easier to read and interpret, with red (<=50%), orange (51-60%), brown (61-70%), yellow (70-80%), light green (80-90%), and dark green (90-100%) denoting the proportion of facilities able to offer each service. On average across the sample, there was a low share of facilities with providers who could insert IUDs (45%) or administer emergency contraceptives (53%). Similarly, only 76% of facilities in the sample had at least one provider who could conduct a pap smear. Available provision of gynecology and obstetrics care was also low in facilities across the study, with only 56% of facilities having providers able to administer parenteral anticonvulsants and 44% able to administer parenteral oxytocin. Only half of the facilities in the survey (51%) had providers able to offer school-based health services. Availability of providers able to offer services for HIV and tuberculosis (TB) was low across the sampled facilities, with particularly low coverage of TB diagnosis via chest X-ray (51%) within facilities. Availability of psychiatry services was also relatively low; approximately seven in ten facilities offered community mental health services (71%); for management of common mental illnesses, it was 69%. Generally, the greatest availability of required services seemed to be in the Urban and UTA Gagauzia regions. Availability of specialized services, particularly laboratory and imaging services, was heavily concentrated within urban facilities. Coverage of required services was most common within consultative diagnostic centers, family doctor centers, and health centers, while availability of specialized services was most common within consultative diagnostic centers and private health facilities. The most commonly available specialized services were ENT care (54%), dermatology (56%), and ophthalmology (51%). 79 Table 14. Service-specific workforce availability, by region (N = 247) Service Delivery Indicators Health Survey for Moldova – Overview of Results Percentage of facilities with at least one health care provider trained to provide service Service/service component UTA Center North South Urban Average Gagauzia Required for PHC Oral contraceptive 83 85 74 87 100 82 pills Intrauterine contraceptive 56 40 26 59 44 45 Family planning device (IUD) Emergency contraceptive 55 52 48 62 31 53 pills Counseling on 91 86 72 87 56 85 family planning Screening Pap smear 84 74 69 79 19 76 Surveillance of pregnant 100 99 97 97 100 99 80 women Antenatal care (ANC) Surveillance Community of pregnant health women with 85 79 81 85 100 83 extra genital pathology Reproductive health HIV counseling and testing services for 98 83 88 97 100 91 HIV-positive pregnant women Infant and young child feeding 90 77 76 87 100 83 counseling for PMTCT Prevention of mother-to- child transmission (PMTCT) Nutritional counseling for HIV-positive pregnant 88 76 72 85 100 81 women and their infants for PMTCT Family planning counseling for HIV-positive 85 76 76 85 100 81 pregnant women Immunization 97 97 93 95 100 96 Newborn and child Child growth monitoring 100 97 96 97 100 98 surveillance Lactation management 100 97 97 97 100 98 Newborn examination 100 92 97 97 100 96 Safe sex practices 97 97 88 97 100 96 Personal sanitation and Community 98 100 97 97 100 99 hygiene health Harmful effects of alcohol 98 100 95 97 100 98 abuse Harmful effects of tobacco 100 100 97 97 100 99 use Health promotion and Harmful effects of substance education abuse (cocaine, heroin, glue, 99 96 97 97 100 97 and others) Harmful effects of domestic violence/gender-based 100 98 97 93 100 98 violence Demand-generation for Pap smear and cervical cancer 96 95 95 97 100 95 prevention Community-based palliative 90 86 87 62 93 87 and geriatric care School health services 52 66 30 47 12 51 Service Delivery Indicators Health Survey for Moldova – Overview of Results Acute diarrheal diseases 95 83 88 92 100 90 treatment 81 Integrated Management of Acute viral respiratory 97 98 97 94 100 97 Newborn and Childhood infections treatment Pediatric Illnesses (IMNCI) Antibiotic therapy 97 100 97 94 100 98 Pneumonia treatment 97 93 97 92 100 95 Neonatal care and 97 94 90 92 100 94 management of newborn Administration of parenteral 56 56 53 52 56 56 Gynecology and anticonvulsants obstetrics Administration of parenteral 56 51 8 55 7 44 oxytocics Service Delivery Indicators Health Survey for Moldova – Overview of Results Percentage of facilities with at least one health care provider trained to provide service Service/service component UTA Center North South Urban Average Gagauzia Diagnosis using clinical 90 69 70 78 100 78 symptoms Diagnosis by chest X-ray 68 30 47 61 100 51 Treatment 75 50 74 76 93 67 Tuberculosis (TB) Latent TB infection diagnosis 84 50 59 77 93 68 for high-risk groups Latent TB infection treatment 72 46 61 73 93 62 for high-risk groups Infectious Screening or testing of TB 77 53 71 79 100 68 disease patients for HIV Diagnosis 73 50 64 76 100 64 Counseling and support to 88 58 65 74 100 73 HIV patients HIV Voluntary screening or 70 50 59 71 100 62 82 testing of HIV patients for TB Voluntary testing and 69 56 59 75 100 64 counseling (VCT) Sexually transmitted Syphilis screening during 88 53 64 81 100 71 infections (STIs) ANC visits Risk assessment of cardiovascular diseases (e.g., heart attack and stroke) according to 100 98 97 95 100 98 package of essential NCD interventions (PEN) protocol Diagnosis of diabetes mellitus according to PEN 99 99 88 95 100 97 protocol Treatment of diabetes Noncommu- mellitus according to PEN 100 99 97 94 100 99 nicable disease protocol Diagnosis of hypertension 100 99 95 92 100 98 according to PEN protocol Treatment/refill of hypertension according to 97 99 97 92 100 97 PEN protocol Treatment of cardiovascular diseases (e.g., heart attack, stroke, and RHD) according 100 99 96 95 100 98 to standardized clinical protocols Diagnosis of chronic respiratory diseases (e.g., COPD and asthma) 99 99 88 95 100 96 according to clinical standardized protocols Treatment of chronic respiratory diseases (e.g., COPD and asthma) 100 99 97 95 100 99 according to clinical standardized protocols Diagnosis of viral hepatitis Noncommu- and cirrhosis according 92 92 85 94 100 91 nicable disease to clinical standardized protocols Treatment of viral hepatitis and cirrhosis according 92 95 85 94 100 92 to clinical standardized protocols Diagnosis of cancers according to clinical 88 90 75 89 100 86 standardized protocols Screening of cancers according to clinical 93 88 89 95 100 91 standardized protocols Management of common 76 68 66 37 49 69 Mental health mental disorders Service Delivery Indicators Health Survey for Moldova – Overview of Results Community mental health 78 70 67 42 49 71 83 Specialized services Surgical Minor surgery 43 24 4 48 19 29 Ear, nose, and 63 58 27 67 7 54 throat (ENT) Ophthalmology 67 54 16 64 7 51 Dermatology 70 62 18 58 0 56 Medical X-ray (not 3 5 2 29 12 5 including dental X-ray) Imaging Ultrasound 4 5 7 36 12 7 Advanced sonography 1 3 1 18 7 3 Service Delivery Indicators Health Survey for Moldova – Overview of Results Percentage of facilities with at least one health care provider trained to provide service Service/service component UTA Center North South Urban Average Gagauzia Blood hemoglobin (Hb) 18 33 18 63 49 26 Stool occult blood test (OBT) 9 29 10 59 49 19 Basic and routine tests Urine routine examination 16 33 18 63 49 25 (RE) Urine routine examination 16 27 15 63 49 22 (RE) – sugar and albumin Alanine aminotransferase 11 27 15 51 49 20 (ALT) Albumin 8 14 8 46 49 13 Alkaline phosphatase (ALP) 7 12 8 44 49 12 Antistreptolysin O (ASLO) 6 12 11 41 49 11 Aspartate aminotransferase 11 25 13 47 49 19 (AST) Bilirubin (average, direct, and 11 27 15 51 42 20 indirect) 84 Blood culture 5 19 7 30 44 12 Blood sugar 11 34 15 49 49 22 Blood sugar by glucometer 14 29 15 54 49 22 Laboratory Calcium 6 12 8 48 49 11 Cholesterol (average, HDL, and LDL), high-density 14 27 15 49 42 21 lipoproteins (HDL), and low- Biochemistry density lipoprotein (LDL) test C-reactive protein (CRP) 7 14 11 46 24 12 Creatine phosphokinase 7 10 10 46 24 11 (CPK) Creatinine 8 25 15 51 24 18 Gamma glutamytransferase 6 10 8 38 17 10 (Gamma-GT) HbA1c 5 17 7 43 24 12 Lactate dehydrogenase (LDH) 4 8 6 41 17 8 Liver/renal function test 6 17 11 44 42 13 PPD/Mantoux/ tuberculin 9 18 7 48 17 14 sensitivity test (TST) Protein (average and 8 20 10 48 42 15 albumin) Triglyceride level test 10 24 13 49 42 18 Urea 11 25 15 51 49 20 Uric acid 11 25 13 51 24 19 ABO blood group testing 5 5 8 45 5 8 Blood donation services Rhesus (Rh) D blood group 5 5 8 37 5 8 testing Coagulation screen 13 15 13 57 24 16 Prothrombin time, fibrinogen 5 9 11 51 12 10 Hematology Complete blood count (CBC) 15 25 18 62 49 22 Erythrocyte sedimentation 2 3 0 15 0 2 rate (ESR) Culture and ABST of all microbiological samples for 2 3 0 15 0 3 general bacteriology Fungal scraping for 2 6 3 26 0 5 microscopy Hepatitis B (HBV) serology 2 6 3 26 0 5 (ELISA) Hepatitis C (HCV) serology 1 5 1 22 0 4 (ELISA) HIV serology (ELISA) 3 13 6 28 5 9 Laboratory HIV serology (rapid) 1 3 0 23 5 3 Diagnosis of TB by rapid test 2 3 0 23 5 3 (GeneXpert MTB/RIF) Service Delivery Indicators Health Survey for Moldova – Overview of Results Diagnosis of TB using 2 3 1 22 5 3 sputum culture 85 Microbiology Diagnosis of TB using sputum smear microscopy 2 8 1 24 0 5 examination Complement fixation 1 4 3 22 5 4 reaction (RW) Syphilis serology – Treponema pallidum 3 11 5 32 5 8 hemagglutination (TPHA) Urine glucose dipstick testing 2 14 5 35 5 8 Urine ketone dipstick testing 5 11 5 32 5 8 Urine microscopy testing 3 11 5 33 5 8 Urine protein dipstick testing 1 0 2 20 0 2 Examination of malaria blood 1 0 2 19 0 2 in the thick smear Examination of malaria blood 43 24 4 48 19 29 in the thin smear Note: Red (<=50%), Orange (51-60%), Brown (61-70%), Yellow (70-80%), Light green (80-90%), Dark green (90-100%) Table 15. Service-specific workforce availability, by facility type Service Delivery Indicators Health Survey for Moldova – Overview of Results Percentage of facilities with at least one health care provider trained to provide service Service/service component Individu- Consulta- Family Family Private Health Health al family tive di- Aver- doctor doctor health center office doctor agnostic age office center center office center Required PHC services Oral contraceptive 89 88 66 92 100 76 100 82 pills (OCPs) Intrauterine contraceptive device 71 37 34 46 86 46 100 45 Family planning (IUD) Emergency 50 57 43 85 90 54 100 53 contraceptive pills Counseling on family 86 89 75 100 100 69 100 85 planning Screening Pap smear 80 85 56 92 100 76 100 76 Surveillance of 86 100 100 96 100 100 100 100 99 pregnant women Antenatal care (ANC) Surveillance of Community pregnant women 95 83 71 85 100 76 100 83 health with extra genital pathology Reproductive health HIV counseling and testing services for 99 93 80 100 100 93 100 91 HIV positive pregnant women Infant and young child feeding 95 81 75 100 100 76 100 83 counseling for Prevention of mother-to- PMTCT child transmission Nutritional (PMTCT) counseling to HIV- positive pregnant 94 77 75 100 100 76 100 81 women and their infants for PMTCT Family planning counseling for HIV- 90 77 77 100 100 76 100 81 positive pregnant women Immunization 100 99 89 77 100 100 100 96 Newborn and child Child growth monitoring 100 100 93 100 100 100 100 98 surveillance Lactation management 100 100 94 100 100 100 100 98 Newborn examination 100 100 87 100 100 100 100 96 Safe sex practices 99 97 89 100 100 100 100 96 Personal sanitation and 97 100 97 100 100 100 100 99 hygiene Harmful effects of alcohol Community 95 100 97 100 100 100 100 98 abuse health Harmful effects of tobacco 100 100 97 100 100 100 100 99 use Health promotion and Harmful effects of substance education abuse (cocaine, heroin, glue, 99 100 92 92 100 93 100 97 and others) Harmful effects of domestic violence/gender-based 99 100 95 100 100 92 100 98 violence Demand-generation for Pap smear and cervical cancer 100 98 88 100 100 100 100 95 prevention Community-based palliative 87 89 85 85 81 43 100 87 and geriatric care School health services 63 58 35 46 33 31 25 51 Acute diarrheal diseases 100 92 77 100 95 86 100 90 treatment Integrated Management of Acute viral respiratory 100 99 84 100 95 100 100 95 Newborn and Childhood infections treatment Pediatric Illnesses (IMNCI) Antibiotic therapy 97 100 94 92 95 100 100 97 Service Delivery Indicators Health Survey for Moldova – Overview of Results Pneumonia treatment 97 100 94 92 95 100 100 97 87 Neonatal care and 97 96 89 100 95 93 100 94 management of newborn Administration of parenteral 64 60 40 62 67 62 100 56 Gynecology and anticonvulsants obstetrics Administration of parenteral 54 48 28 46 76 25 100 44 oxytocics Service Delivery Indicators Health Survey for Moldova – Overview of Results Percentage of facilities with at least one health care provider trained to provide service Service/service component Individu- Consulta- Family Family Private Health Health al family tive di- Aver- doctor doctor health center office doctor agnostic age office center center office center Diagnosis using clinical 91 81 64 77 100 77 100 78 symptoms Diagnosis by chest X-ray 68 46 46 46 86 55 100 51 Treatment 82 66 56 69 95 55 100 67 Tuberculosis (TB) Latent TB infection diagnosis 86 65 56 62 95 61 100 68 for high-risk groups Latent TB infection treatment 81 55 56 62 95 39 100 62 for high-risk groups Infectious Screening or testing of TB 91 66 52 62 100 56 100 68 disease patients for HIV Diagnosis 81 61 53 62 100 85 100 64 Counseling and support to 84 71 65 85 100 76 100 73 88 HIV patients HIV Voluntary screening or 80 54 57 62 100 69 100 62 testing of HIV patients for TB Voluntary testing and 80 60 54 54 100 85 100 64 counseling (VCT) Sexually transmitted Syphilis screening during 90 68 60 85 100 86 100 71 infections (STIs) ANC visits Risk assessment of cardiovascular diseases (e.g., heart attack and stroke) 98 100 96 100 100 100 100 98 according to package of essential NCD interventions (PEN) protocol Diagnosis of diabetes mellitus 97 97 94 100 100 100 100 97 according to PEN protocol Treatment of diabetes mellitus according to PEN 97 100 97 100 100 100 75 99 Noncommu- protocol nicable disease Diagnosis of hypertension 96 100 97 100 95 100 100 98 according to PEN protocol Treatment/refill of hypertension according to 98 97 97 100 95 100 75 97 PEN protocol Treatment of cardiovascular diseases (e.g., heart attack, stroke, and RHD) according 98 100 97 85 100 100 100 98 to standardized clinical protocols Diagnosis of chronic respiratory diseases (e.g., COPD and asthma) according 97 98 92 100 100 100 100 96 to clinical standardized protocols Treatment of chronic respiratory diseases (e.g., COPD and asthma) according 97 92 83 100 100 100 100 91 to clinical standardized protocols Diagnosis of viral hepatitis and cirrhosis according Noncommu- 97 100 97 92 100 100 100 99 to clinical standardized nicable disease protocols Treatment of viral hepatitis and cirrhosis according 96 90 91 92 100 100 100 92 to clinical standardized protocols Diagnosis of cancers according to clinical 93 86 80 92 95 92 100 86 standardized protocols Screening of cancers according to clinical 92 93 85 92 100 93 100 91 standardized protocols Management of common 80 70 60 77 57 30 50 69 Mental Health mental disorders Service Delivery Indicators Health Survey for Moldova – Overview of Results Community mental health 74 78 60 77 57 30 50 71 89 Specialized services Surgical Minor surgery 45 25 20 15 81 40 100 29 Ear, nose, and 61 57 39 46 90 79 100 54 throat (ENT) Ophthalmology 67 49 40 46 86 79 100 51 Dermatology 68 57 41 62 67 70 100 56 Medical X-ray (not including 17 2 0 0 52 56 100 7 dental X-ray) Imaging Ultrasound 4 2 0 0 5 56 100 3 Advanced sonography 70 14 8 0 62 61 100 26 Service Delivery Indicators Health Survey for Moldova – Overview of Results Percentage of facilities with at least one health care provider trained to provide service Service/service component Individu- Consulta- Family Family Private Health Health al family tive di- Aver- doctor doctor health center office doctor agnostic age office center center office center Blood hemoglobin (Hb) 51 10 8 0 57 32 100 19 Stool occult blood test (OBT) 70 12 8 0 62 61 100 25 Basic and Urine routine examination routine tests 65 9 8 0 62 61 100 22 (RE) Urine routine examination 58 9 7 0 33 61 100 20 (RE) – sugar and albumin Alanine aminotransferase 35 8 1 0 33 61 100 13 (ALT) Albumin 35 5 1 0 33 61 50 12 Alkaline phosphatase (ALP) 35 5 1 0 29 52 100 11 Antistreptolysin O (ASLO) 52 9 7 0 29 52 100 19 Aspartate aminotransferase 58 9 7 0 33 61 100 20 (AST) 90 Bilirubin (average, direct, and 30 6 6 0 29 46 100 12 indirect) Blood culture 61 12 8 0 33 54 100 22 Blood sugar 62 11 8 0 38 61 100 22 Blood sugar by glucometer 34 5 1 0 29 61 100 11 Laboratory Calcium 57 11 7 0 29 54 100 21 Cholesterol (average, HDL, and LDL), high-density 38 5 1 0 33 54 100 12 lipoproteins (HDL), and low- Biochemistry density lipoprotein (LDL) test C-reactive protein (CRP) 34 5 0 0 29 46 100 11 Creatine phosphokinase (CPK) 50 8 7 0 33 54 100 18 Creatinine 27 5 1 0 29 54 100 10 Gamma glutamytransferase 25 6 7 0 19 61 100 12 (Gamma-GT) HbA1c 18 5 0 0 24 46 100 8 Lactate dehydrogenase (LDH) 31 7 7 0 29 54 100 13 Liver/renal function test 36 6 6 0 19 39 100 14 PPD/Mantoux/ tuberculin 41 6 7 0 33 54 100 15 sensitivity test (TST) Protein (average and 50 8 7 0 29 61 100 18 albumin) Triglyceride level test 56 9 7 0 33 61 100 20 Urea 56 9 7 0 33 61 100 20 Uric acid 51 9 7 0 33 61 100 19 ABO blood group testing 23 3 1 0 43 15 100 8 Blood donation services Rhesus (Rh) D blood group 23 3 1 0 33 15 50 8 testing Coagulation screen 52 6 0 0 57 61 100 16 Prothrombin time, fibrinogen 31 3 1 0 43 61 100 10 Hematology Complete blood count (CBC) 68 7 8 0 57 61 100 22 Erythrocyte sedimentation 6 2 0 0 10 15 25 2 rate (ESR) Culture and ABST of all microbiological samples for 3 3 0 0 10 23 25 3 general bacteriology Fungal scraping for 13 3 0 0 14 23 50 5 microscopy Hepatitis B (HBV) serology 13 3 0 0 14 23 50 5 (ELISA) Hepatitis C (HCV) serology 10 3 0 0 5 15 25 4 (ELISA) HIV serology (ELISA) 28 4 0 0 14 23 50 9 Laboratory HIV serology (rapid) 7 2 0 0 14 8 50 3 Diagnosis of TB by rapid test Service Delivery Indicators Health Survey for Moldova – Overview of Results 8 2 0 0 14 8 25 3 (GeneXpert MTB/RIF) 91 Diagnosis of TB using sputum 8 2 0 0 14 8 50 3 culture Microbiology Diagnosis of TB using sputum smear microscopy 13 3 0 0 14 31 25 5 examination Complement fixation reaction 10 3 0 0 10 17 25 4 (RW) Syphilis serology – Treponema pallidum 27 2 0 0 19 38 50 8 hemagglutination (TPHA) Urine glucose dipstick testing 30 2 0 0 33 31 50 8 Urine ketone dipstick testing 23 5 0 0 33 31 50 8 Urine microscopy testing 26 2 0 0 33 24 50 8 Urine protein dipstick testing 7 0 0 0 14 8 25 2 Examination of malaria blood 7 0 0 0 10 8 25 2 in the thick smear Examination of malaria blood 45 25 20 15 81 40 100 29 in the thin smear Service Delivery Indicators Health Survey for Moldova – Overview of Results 3.4.2. Tenure and Training This component measures not only the preservice education level of providers at each facility, but also the proportion of facilities with at least one provider trained in required and specialized services. This section presents the distribution of educational attainment and training of health care providers. Table 16 highlights the median tenure at the facility of the doctors and nurses interviewed as part of this study. Median tenures of 25 and 21 for doctors and nurses, respectively, highlight that Moldova seems to have an aging health workforce. Median tenure within the provider’s position is relatively consistent across regions, though slightly lower among nurses in the urban parts of the country and among doctors in UTA Gagauzia. Table 16. Median years in any role in current facility, by region (median) Doctors Nurses Region Center 26 20 North 29 23 South 31 29 Urban 19 15 UTA Gagauzia 17 22 Total 25 21 Providers reported attending training 21 days within the last year, on average. The length of these trainings was not captured, so there may be large variability in the proportion of each day taken up by training activities. For example, one provider may have attended a lunchtime training seminar for an hour or two, while another may have been in a day-long training. Table 17 shows the median number of annual leave days for continuous education and training across regions and facility types. Providers who spent an above-average number of days attending trainings were those in consultative diagnostic centers (31%), health centers (27%), and individual family doctor offices (24%). Regionally, the distribution is uniform, aside from UTA Gagauzia, where providers spent a median of 30 days attending trainings within the year. 92 Service Delivery Indicators Health Survey for Moldova – Overview of Results Table 17. Provider-reported time spent on training, by region and facility type Days of leave spent annually on continuous professional development Median Region Center 20 North 24 South 21 Urban 21 UTA Gagauzia 30 Facility type Health center 27 Family doctor office 20 Health office 14 Individual family doctor office 24 Family doctor center 20 Private health center 20 Consultative diagnostic center 31 Average 21 Figure 49 shows the proportion of facilities that had at least one provider trained in various PHC services. Most facilities in the survey had at least one provider trained in community health (99%), pediatric care (98%), OB-GYN services (90%), infectious diseases (90%), and NCD care (99%). However, as seen earlier, psychiatry service availability across facilities appeared limited (77%). Availability of providers who could offer psychiatry services was lowest within private health centers (30%) and consultative diagnostic centers (50%), as well as in the Urban (48%) and UTA Gagauzia (49%) regions. Further detail on facility provision of required services by region and facility type can be found in annex table A.23. 93 Service Delivery Indicators Health Survey for Moldova – Overview of Results Figure 49. Facilities with at least one provider trained in required services, by service (%) (N = 247) 99 98 99 100 90 90 90 80 77 70 60 Percent 50 40 30 20 10 0 Community Pediatric OB-GYN Infectious Noncommunicable Mental health disease disease health Figure 50 shows the proportion of facilities with at least one provider trained in various specialized services. Overall, provision of specialized services was moderate or low across the surveyed facilities, with around six in ten facilities reporting at least one provider on staff who could provide ENT services (59%). A similar level of service availability was observed for dermatology services (59%). Over half (55%) of facilities reported that they could provide ophthalmology services, and about a quarter of facilities (27%) reported that they could provide surgical services. Provision of specialized services varied significantly across facility types and regions; provision of each service was highest in the Urban region, followed by the Center and South regions. Specialized service provision was lowest in UTA Gagauzia. Consultative diagnostic centers universally offered specialized services, and almost all family doctor centers also offered these services. Staff who could provide specialized services were least available in individual family doctor offices and health offices. Further detail on availability of specialized services can be found in annex table A.24. Figure 50. Facilities with at least one provider trained in specialized services, by service (%) (N = 247) 100 90 80 70 59 59 60 55 Percent 50 40 37 30 20 10 0 Surgical ENT Ophthalmology Dermatology 94 Service Delivery Indicators Health Survey for Moldova – Overview of Results 3.4.3. Satisfaction and Retention Table 18 highlights the satisfaction and resilience of providers interviewed within the sampled health facilities, including the subcomponents that constitute job satisfaction. Job satisfaction was measured among nurses, while resiliency was assessed across all providers (doctors and nurses). The job satisfaction score was scaled in value from 1 to 5 for each subitem and averaged across the subscale to create the score. The median score of 4.3 indicates that nurses, in general, are moderately satisfied with their work. This degree of satisfaction seems to be uniform across facility types and regions. Nearly all nurses reported that they are given an adequate amount of support and guidance from their supervisors (98%), that they have the necessary equipment to do their jobs (90%), and that management takes action based on feedback (88%). Four in five nurses (80%) indicated that their workload is reasonable. It is worth noting that much of this survey was fielded during the COVID-19 pandemic. Provider resilience was measured for both doctors and nurses and was based on response to six questions (not shown), scaled in value from 1 to 5. Respondents were asked whether they agreed, disagreed, or were neutral toward a series of statements, including statements about their ability to recover and resume work after stressful events or difficult situations in their lives. The score from these scaled questions was then averaged to determine the overall resilience score for providers in the survey (presented in final column of table 18). Overall, providers had neutral resilience; for example, on average, they neither agreed nor disagreed with resiliency statements. This result was relatively uniform across the subsamples. Providers in consultative diagnostic centers, private health centers, and family doctor centers had above-average reported resiliency. 95 Service Delivery Indicators Health Survey for Moldova – Overview of Results Table 18. Provider satisfaction and resilience, by region and facility type Percentage of nurses who agreed with the following: Depart- Average Average Right Rea- Manage- ment amount sonable ment makes resilience nurse job provides of sup- amount necessary changes score satisfaction port and of work based on equip- (doctors score guidance expect- suggestions ment, and nurses) (N = 773) from di- ed and feed- supplies, (N = 1,276) rect su- (N = back and re- pervisor 773) (N = 773) sources (N = 773) (N = 773) Region Center 4.3 99 80 86 92 3.3 North 4.2 96 89 92 89 3.4 South 4.4 96 79 94 80 3.4 Urban 4.1 97 78 89 86 3.4 UTA Gagauzia 4.8 100 100 100 100 3.7 Facility type Health center 4.3 98 82 93 89 3.4 Family doctor 4.3 97 81 86 84 3.2 office Health office 4.2 99 88 93 95 3.4 Individual family 4.5 100 90 86 97 3.4 doctor office Family doctor 4.3 98 88 93 94 3.5 center Private health 4.6 92 97 96 86 3.5 center Consultative 4.1 100 89 100 100 3.7 diagnostic center Average 4.3 98 83 90 88 3.4 3.4.4. Workload Table 19 shows the proportion of time that doctors and nurses spent on various tasks during their work week. On average, doctors spent 63% of their time on direct patient care, and nearly a quarter of their time (26%) on administrative tasks. The remainder of their time, on average, was spent on facility management or non-clinical administrative tasks (6%) and education activities (5%). The distribution of time for nurses followed a similar trend, with nurses reporting that most of their time was spent on direct patient care (61%) and administrative clinical tasks (28%). The remainder of their time was spent on facility management or non-clinical administrative tasks (7%), or educational activities (4%). 96 Service Delivery Indicators Health Survey for Moldova – Overview of Results Table 20 presents the average number of hours worked by doctors and nurses. Working hours were similar for doctors and nurses: doctors worked a median of 42 hours per week, and nurses worked a median of 38 hours per week. Patient contacts per hour were also similar. Doctors and nurses reported seeing a median of four patients per hour worked. About one in five providers (22%) reported that nonclinical duties impede their direct clinical work; this response was likely driven by the volume of administrative clinical tasks that providers are faced with. The share of providers indicating that nonclinical duties impede their direct clinical work was highest within private health centers (31%), family doctor offices (27%), individual family doctor offices (26%), and health offices (25%); it was lowest within family doctor centers (5%). Table 19. Proportion of time spent across different activities (most recent week), by region, facility, and provider type (%) Proportion of time spent across different activities during most recent work week Facility Administrative Education Patient care management/ tasks activities administration Nurse Doctor Nurse Doctor Nurse Doctor Nurse Doctor (N = 804) (N = 471) (N = 804) (N = 471) (N = 804) (N = 471) (N = 804) (N = 471) Region Center 59 63 30 25 5 6 6 6 North 61 59 27 26 4 6 8 9 South 63 62 26 29 3 4 8 5 Urban 61 63 30 25 4 6 5 6 UTA Gagauzia 72 67 23 27 2 2 3 4 Facility type Health center 62 62 28 26 5 6 5 6 Family doctor 60 n.a. 28 n.a. 4 n.a. 8 n.a. office Health office 63 43 25 37 3 6 9 14 Individual family 61 n.a. 24 n.a. 9 n.a. 6 n.a. doctor office Family doctor 57 n.a. 31 n.a. 4 n.a. 8 n.a. center Private health 65 n.a. 30 n.a. 1 n.a. 4 n.a. center Consultative diagnostic 63 n.a. 34 n.a. 3 n.a. 0 n.a. center Average 61 63 28 26 4 5 7 6 Note: n.a. = not applicable. In some facilities only nurses were interviewed. 97 Service Delivery Indicators Health Survey for Moldova – Overview of Results Table 20. Workload in the most recent typical work week, by region Percentage of providers reporting Total hours Patient contacts that nonclinical work impedes clinical worked per hour worked duties Nurses Doctors Nurses Doctors All providers (N = 805) (N = 471) (N = 805) (N = 471) (N = 1,276) Region Center 40 43 3 3 28 North 35 40 4 4 20 South 35 42 4 4 21 Urban 38 45 4 4 20 UTA Gagauzia 35 45 3 4 4 Facility type Health center 38 42 4 4 21 Family doctor 35 n.a. 4 n.a. 27 office Health office 35 n.a. 2 n.a. 25 Individual family 35 n.a. 4 n.a. 26 doctor office Family doctor 38 n.a. 4 n.a. 5 center Private health 35 n.a. 3 n.a. 31 center Consultative diagnostic 37 n.a. 3 n.a. 18 center Average 38 42 4 4 22 Note: n.a. = not applicable. In some facilities only nurses were interviewed. 98 Service Delivery Indicators Health Survey for Moldova – Overview of Results 4. Processes of Care This chapter outlines the results of the caregiving services provided in primary health care facilities. While most of the data have been collected from physician and patient interviews during the SDI health survey, some of the observations came from the facility manager interview. As described previously, processes of care refer to the delivery or receipt of care in a facility setting. From the broadest perspective, this domain aims to understand a country’s primary health care service delivery system and gauge how competent and accessible the services are to patients. Within this domain, indicators are further assessed along two unique but interrelated categories: competent care systems and positive user experience. Box 2 highlights some of the key findings related to processes of care in primary health care facilities in Moldova. Definitions of subdomains and in-depth analysis of their associated indicators are presented in due order within this chapter. Box 2. Key observations on PHC processes of care in Moldova Competent care systems Diagnosis, treatment, and counseling: • Among patients seeking ANC, 40% reported that they received all related services (among a total possible 19 services) across all their visits. That rate increased to 70% for patients more than 20 weeks pregnant for 5 relevant services. • For NCD care, on average, 6% of patients reported receiving all of 21 measured services in their current visit and 33% across all visits (among the same 21 measured services). • Most doctors were able to provide the correct primary diagnosis and treatment for hypertension (92%; CI: 87%–98%) and diabetes (92%; CI: 86%–98%). Fewer doctors were, however, able to provide both the correct primary diagnosis and treatment options for pulmonary TB (82%; CI: 71%–93%), pneumonia (77%; CI: 66%–88%) and depression (68%; CI: 61%–76%). 99 Service Delivery Indicators Health Survey for Moldova – Overview of Results Box 2. Key observations on PHC processes of care in Moldova Referral, continuity, and integration: • In terms of health documents, nearly 82% (CI: 78%–86%) of patients had patient cards. Only 3% (CI: 2%–4%) of patients had no health documents at all. • 21% (CI: 18%–24%) of patients reported that they received a referral for further services within the same facility during their visit. The most common reason for referral among patients being referred within the same facility was because specialized services or care were not available from the initial provider they consulted with (88%, CI: 84%–93%). • Most patients (74%; CI: 70%–78%) reported that they always see the same provider. Safety, prevention, and detection: • Only some facilities reported having allocated earmarked funds for emergency preparedness (61%; CI: 52%–70%), conducted fire drills (56%; CI: 47%–65%), emergency drills (62%; CI: 53%–70%), or structural vulnerability assessments (48%, CI: 39%–57%). Positive user experience Respect and autonomy: • Across all metrics measuring respect and autonomy, facilities fare well, garnering a rating of either “good” or “very good.” • The areas receiving the lowest share of “very good” ratings were visual privacy, auditory privacy, and patient involvement, at 36% (CI: 31%–41%), 35% (CI: 30%– 40%), and 31% (CI: 26%–36%) respectively. User focus: • The mean wait time across all facilities did not exceed 18 minutes. • On average, facilities were rated between “good” and “very good” on nearly all metrics. Private health clinics and primary health care departments were rated the highest across most user-focus metrics, such as wait time and room conditions. 100 Service Delivery Indicators Health Survey for Moldova – Overview of Results 4.1. Competent Care Systems The first domain, competent care systems, grants greater insight into the quality and competence of primary health care facilities and providers in the country. To comprehensively understand quality and competence, this section provides an overview of diagnosis, treatment, and counseling quality, as well as referrals, continuity procedures, and processes for safety, detection, and prevention. 4.1.1. Diagnosis, Treatment, and Counseling This subsection reviews the knowledge and clinical competency of health care providers, specifically their ability to competently deliver diagnostic services and provide adequate treatment and counseling to patients who frequent the facility. This assessment is based on outpatient interviews and clinical case simulations. While the latter highlight the health care provider’s qualifications and processes, the former confirm the information from the patient’s perspective. Together, they enable synergy between the supply and demand sides of the data, ensuring that the results are robust. Counseling Table 21 presents the percentage of women seeking antenatal care who reported having received certain or all of 20 relevant services. This information is split into two time frames: the patient’s current visit and all visits during their pregnancy. This split follows guidance set out by the WHO on specific services that should be offered during each visit, compared to those that may be offered at specific times during the pregnancy30. Figure 51 outlines similar statistics for a subset of women who were more than 20 weeks pregnant and primarily includes procedures that are most often administered during the 2nd trimester of pregnancy to check for complications such as gestational diabetes and assess fetal development. Overall, only 40% of the women seeking ANC reported that the facility provided them with all of 20 ANC services across all their visits. For women who were more than 20 weeks pregnant, which accounts for 23 in the sample of 56 women, 70% received all of five relevant services, with a detailed distribution of receipt of each service in figure 51. For some services included in competent ANC care, the shares of women who reported receiving them were relatively low, specifically information on the side effects of iron pills (32% at this visit and 70% including any previous visit), advice on alcohol consumption (40% at this visit and 78% including any previous visit), and advice on exclusive breastfeeding (35% at this visit and 74% including any previous visit). Among those women more than 20 weeks pregnant, only 77% reported that they were informed about their blood glucose levels during their current or previous visit to the health facility, even though most (96%) reported having it checked. 30WHO. 2016. WHO recommendations on antenatal care for a positive pregnancy experience. https://www.who.int/publications/i/item/9789241549912101 Service Delivery Indicators Health Survey for Moldova – Overview of Results Table 21. Competent Antenatal care (%) (N = 56) Percentage of patients reporting receipt of service Pregnancy services This visit This or previous visit: Provider asked for maternal and child 100 100 health handbook Weighed 86 99 Informed whether weight was normal/ 88 94 higher/lower than expected Height measured* 53 86 Provider estimated delivery date* 36 83 Blood pressure (BP) measured 94 98 Informed BP was normal/higher/lower 82 99 than expected Screened for HIV* 17 77 Screened for syphilis* 19 73 Urine sample* 67 91 Blood group* 19 76 Recommended to take iron and/or folic 43 89 acid pills Informed on side effects of iron pills 32 70 Counseled on alcohol 40 78 Counseled on smoking 42 90 Counseled on physical activity 57 87 Counseled on diet 60 88 Counseled on pregnancy symptoms 70 92 Counseled on pregnancy danger signs 60 85 Advised on exclusive breastfeeding 35 74 Complete services 7 40 Note: (*) Certain services are not required at each ANC visit and may only be conducted once during a woman’s pregnancy. For the services denoted with an asterisk (*), the more informative measurement is whether the woman received the service at either the current or a previous visit. Services marked with an asterisk are not considered in the calculation of complete service provision at this visit. 102 Service Delivery Indicators Health Survey for Moldova – Overview of Results Figure 51. Percentage of women over 20 weeks pregnant who received various ANC services (%) (N=23) 96 97 90 93 100 90 77 80 70 70 60 Percent 50 40 30 20 10 0 Blood glucose Blood glucose Abdomen Ultrasound Uterine height Complete measured by information palpated performed measured services blood sample shared with patient The next four tables focus on the measurement and quality of noncommunicable disease services in the facility. Specifically, they record patients who visited the facility for diabetes or hypertension treatment and management who reported having received each specified service or all the specified services. These statistics are first shown by region, then by facility type. Both these statistics are then further segregated by the patient’s current visit and all visits (including the current visit). Table 22 outlines NCD care services for diabetes and hypertension patients by region. Table 22 shows that across all regions in Moldova, 68% of patients on average reported that providers checked their breathing and heart; 88% of patients reported getting their blood pressure measured; and only 86% reported being informed of details about their blood pressure. On average, 6% of patients received all relevant services. 103 Service Delivery Indicators Health Survey for Moldova – Overview of Results Table 22. Competent NCD care at current visit, by region (%) (N = 302) Percentage of diabetes or hypertension patients reporting service at current visit UTA Center North South Urban Diabetes or hypertension services (n = 87) (n = 106) (n = 51) (n = 17) Gagauzia Average (n = 41) Complete services 6 9 2 2 5 6 Checked breathing/heart 56 81 85 31 49 68 Examined feet 36 54 38 37 52 44 Examined eyes 34 49 51 36 36 43 Measured blood pressure (BP) 77 92 98 82 91 88 Informed BP is normal/higher/lower 76 90 98 65 91 86 than expected Glucose tested by blood sample 21 38 38 27 27 31 Received results of glucose test 94 93 92 97 93 93 Told blood sugar was normal/higher/ 32 48 40 21 44 40 lower than expected Cholesterol tested 19 23 28 8 22 22 Told blood cholesterol/lipid profile was normal/higher/lower than 90 94 96 90 100 94 expected Received results of cholesterol test 23 30 40 13 33 30 Asked medical history 37 42 46 25 56 42 Asked family history 25 32 44 16 41 33 Asked about tobacco use 21 35 21 15 34 27 Counseled on harms of tobacco use 22 27 12 15 33 22 Asked about alcohol 27 29 21 13 38 27 Counseled on harmful use of alcohol 26 29 17 15 37 26 Asked about physical activity 58 72 75 45 68 67 Counseled on physical activity 54 74 76 43 70 67 Asked about diet 53 79 81 41 75 69 Counseled on diet 50 80 88 41 79 71 Table 23 reports the extent of NCD care in the country by region, but calculates statistics based on all visits—current and previous. About a third (33%) of the diabetes or hypertension patients reported receiving all services, on average, across all the health facilities. Some services were received by comparatively smaller shares of patients, including being asked about tobacco use (54%) and alcohol use (58%) – see table 23. 104 Service Delivery Indicators Health Survey for Moldova – Overview of Results Table 23. Competent NCD care at current or previous visits, by region (N = 302) Percentage of diabetes or hypertension patients reporting service at current visit UTA Center North South Urban Diabetes or hypertension services (n = 87) (n = 106) (n = 51) (n = 17) Gagauzia Average (n = 41) Complete services 29 40 26 36 34 33 Sugar measured 94 93 92 97 93 93 Lipid profile measured 90 94 96 90 100 94 Checked breathing/heart 89 96 96 74 91 92 Examined stomach 63 81 82 77 68 74 Examined feet 64 86 57 62 56 69 Examined eyes 62 79 73 77 60 70 Measured blood pressure (BP) 92 98 98 82 98 96 Informed BP is normal/higher/lower 92 98 98 82 98 96 than expected Glucose tested 83 88 92 84 81 87 Ever received result of glucose test 88 95 90 84 91 91 Cholesterol test done 78 88 91 77 98 86 Ever received results of cholesterol test 83 92 92 77 98 89 Asked about medicines 91 98 98 84 83 93 Asked about medical history 77 93 94 86 74 86 Asked about family history 69 91 91 86 73 82 Asked about tobacco use 49 58 47 71 62 54 Counseled on harms of tobacco use 49 49 37 61 57 48 Asked about alcohol use 57 57 52 82 65 58 Counseled on harmful use of alcohol 56 57 43 72 60 55 Asked about physical activity 71 92 94 86 80 85 Counseled on physical activity 72 89 94 84 82 84 Asked about diet 74 95 94 80 88 87 Counseled on diet 75 90 94 80 88 86 Pediatric health care services is the next area examined in this section. Table 24 shows the percentage of patients visiting the facility for sick-child care who received each and all of specified services. On average, 15% of patients seeking sick-child care services reported receiving all eleven relevant services. Only half of caregivers who sought care for a sick child were informed about the child’s diagnosis. 105 Service Delivery Indicators Health Survey for Moldova – Overview of Results Table 24. Competent sick-child care at current visit (children less than 5 years of age) Percentage of all children Sick-child care services  receiving service (n = 80)  Asked age of child  97  Asked about child's symptoms  99  Asked if first or follow-up visit  81  Asked about immunization history  74  Asked about child feeding practices 74  Plotted growth  44  Informed of growth  50  Provided diagnosis 91 Counseled about child’s food/fluid intake 78  Asked about mother's health  67  All services  15  Diagnosis and treatment Health care provider capacity to correctly diagnose and treat common health conditions is integral to high-quality PHC service delivery. There are many ways to assess clinical competency – by direct observation, chart review, standardized patient, written assessments – all of which have strengths and drawbacks. The SDI health survey uses “vignettes,” which are clinical simulation cases involving two enumerators and one health care provider. One enumerator presents a clinical case and acts as the patient, and the other enumerator records the provider’s questions and actions. The provider, who is aware that this is a clinical competency assessment, asks questions of the patient enumerator (who provides standardized responses) on patient presentation and history, and requests the results of physical exam and diagnostic/screening/lab tests, to arrive at correct diagnosis, proposed treatment, and follow up. Providers are then evaluated on whether they provide the correct diagnosis/es and treatment. These clinical competency assessments capture information on both correct and incorrect responses, including the level of completeness and specificity of the diagnoses and treatments proposed. For example, some clinical cases have a primary condition, such as hypertension, plus additional comorbidities such as obesity and dyslipidemia, and analyzing the resulting data can shed light on the comprehensiveness of the provider’s assessment of the simulated case. Other clinical cases have a general diagnosis such as depression and a more specific diagnosis such as moderate depression and examining the frequency with which providers 106 Service Delivery Indicators Health Survey for Moldova – Overview of Results respond with appropriate specificity can highlight potential intervention areas. Information on common incorrect diagnoses and treatments, such as an incorrect diagnosis of diabetes type I instead of diabetes type II, or a treatment proposal that does not adhere to updated guidelines, can inform intervention and policy design to ensure providers are adequately supported with up-to-date trainings and job aids. Clinical vignette topics are selected for international comparability and country-specific disease burden and priorities, and are adapted based on each country’s clinical context and guidelines. In the case of Moldova, participating physicians from selected health facilities were each administered a random selection of two out of five available vignettes. Table 25 summarizes four attributes for each of the clinical case simulations in the health care provider survey: the correct primary diagnosis; complete, specific diagnosis; primary treatment; and complete, specific treatment. Performance has been split into primary and complete diagnoses and treatment categories to reflect real-world clinical scenarios and offer flexibility in understanding provider clinical competency most accurately. The ideal-performing provider would be able to offer all diagnoses in the complete diagnosis categories; this is often not entirely realistic in a simulated scenario and does not necessarily indicate that care by providers or their clinical knowledge are of poor quality. The distinction between primary and complete diagnoses and treatment applies primarily to hypertension and diabetes, as the complete diagnosis and treatment categories are intended to account for treatment and acknowledgement of key disease comorbidities. Table 25. Correct diagnosis and treatment by vignette Complete, Complete, specific # Primary diagnosis Primary treatment specific diagnosis treatment Hypertension, obesity, and Anti- 1 Hypertension  hyperlipidemia/dyslipidemia/ Anti-hypertensive drugs   hypertensive hypercholesterolemia  drugs and statin Metformin, oral Metformin, oral Diabetes type 2/ Diabetes type 2/diabetes biguanide, or 2 biguanide, or diabetes mellitus type 2  mellitus type 2 and obesity  sulfonylureas sulfonylureas and statin Amoxicillin or other antibiotic and 3 Pneumonia  n.a.  n.a. paracetamol or other antipyretic Pulmonary, drug-susceptible, Pulmonary, drug-susceptible, or non-specific TB (excluding or non-specific TB. Providers Referral to pulmonologist 4 drug-resistant, multi drug- penalized for selecting drug- n.a. or TB focal person  resistant, or extra-pulmonary resistant, multi drug-resistant, TB) or extra-pulmonary TB Referral to psychiatrist 5 Depression (any severity) n.a.  or Community Center for n.a. Mental Health (CCSM) Note: n.a. = not applicable 107 Service Delivery Indicators Health Survey for Moldova – Overview of Results Table 26 shows the proportion of physicians across different regions of the country who were accurately able to provide (1) the primary diagnosis of the clinical vignette; and (2) the complete and specific diagnosis/es present in the vignette. Most physicians could accurately diagnose the primary diagnosis for all cases. However, diagnostic accuracy was lowest for depression (diagnosed by 76% of all physicians on average). While the primary diagnosis did not account for the severity level of depression, the strictest grading of the clinical vignette would have posited selection of moderate depression by providers. Only 54% of providers selected moderate depression as the diagnosis for this vignette. For depression, diagnostic accuracy was lowest in the urban region (57%). Table 26. Clinical knowledge: Diagnostic accuracy, by region (%) Pulmonary Hypertension Diabetes type 2 Pneumonia Depression tuberculosis (n = 206)  (n = 121)  (n = 156)  (n = 269)  Region  (n = 188)  Complete, Complete, Complete, Primary  Primary  Primary  Primary  Primary specific specific specific diagnosis diagnosis diagnosis  diagnosis  diagnosis  diagnosis diagnosis diagnosis Center  90  58  97  47  73 81  67 78  North  96  42  100  42  88 98  92 75  South  100  46  100  52  94 71  50 81  Urban  100  47  85  42  71 97  76 57  UTA 100  30  100  100  93 100  88 82  Gagauzia  Average  96  47  97  47  83 88  74 76  Note: The vignettes for pneumonia and depression did not include secondary diagnoses. Table 27 further breaks down diagnoses provided by doctors who took part in the clinical vignettes by showing the percentage of doctors who mentioned each diagnosis. Doctors were able to select multiple diagnoses, thus the values under each vignette do not sum to 100%. Across all vignettes, the primary diagnosis was the most often cited by doctors who took part in that respective vignette. Provider scores were lower when assessed based upon complete, specific diagnosis scoring criteria for hypertension and diabetes. Provider scores for hypertension fell from 96% to 47% and from 97% to 47% for diabetes. When considering penalizations for TB diagnoses that were not clinically indicated in the vignette, including extra-pulmonary and single or multi drug-resistant TB, diagnostic scores for providers fell from 88% to 74%. 108 Service Delivery Indicators Health Survey for Moldova – Overview of Results Table 27. Diagnoses selected by providers (multiple select), by vignette (%) Percent of providers who selected Primary Complete, specific Diagnosis respective treatment Diagnosis diagnosis1 (multiple select) Hypertension Hypertension 96 Obesity 67 Hyperlipidemia/Dyslipidemia/ 61 Hypercholesterolemia Any other diagnosis/diagnoses 15 Pre-Diabetes 13 Metabolic syndrome 9 Renal artery stenosis 3 Patient does not have any disease/patient is 1 healthy Score n.a. 96 47 Diabetes Diabetes Type II/Diabetes Mellitus Type II 97 Obesity 49 Diabetes (not specific) 28 Any other diagnosis/diagnoses 8 Diabetes Type I/Diabetes Mellitus Type I 3 Score n.a. 97 47 Pneumonia Pneumonia 83 Bronchitis 14 Acute Respiratory Infection 12 Any other diagnosis/diagnoses 7 Upper Respiratory Tract Infection 1 Dehydration 1 Tuberculosis/TB 0.2 Score n.a. 83 n.a. Pulmonary Tuberculosis2 Pulmonary tuberculosis 75 Tuberculosis (non-specific) 63 Drug-susceptible tuberculosis 13 Extra-pulmonary tuberculosis 12 109 Service Delivery Indicators Health Survey for Moldova – Overview of Results Percent of providers who selected Primary Complete, specific Diagnosis respective treatment Diagnosis diagnosis1 (multiple select) Drug-resistant tuberculosis 9 Any other diagnosis/diagnoses 6 Latent tuberculosis/TB infection 3 Multidrug-resistant tuberculosis 1 Pneumonia 1 Chronic obstructive pulmonary disease 0.7 Bronchitis 0.4 Score n.a. 88 74 Mental Health Moderate depression 54 Depression (non-specific) 40 Somatoform vegetative dysfunction 20 Mild depression 16 Anxiety 16 Neurasthenia 6 Diabetes 4 Stress (acute, chronic, or adjustment stress 3 disorders) Depressive episode in bipolar disorder 1 Anemia 0.5 Hypertension 0.4 Score n.a. 76 n.a. Notes: 1. All checked options must have been selected by the provider to count for the complete diagnosis. 2. Diagnoses marked with an “x” denote penalizations for TB diagnoses that are clinically incorrect. None of the information in the vignettes suggested drug-resistance, latent infection, or extra-pulmonary TB. Figure 52 presents the proportion of physicians who correctly chose the primary treatment for each relevant vignette across the different survey regions. For this metric, most doctors were able to provide the correct primary treatment for hypertension (94%), diabetes (94%), pulmonary TB (93%), and pneumonia (92%). However, fewer doctors were able to provide the correct treatment options for depression (83%). Generally, identification of proper treatment across disease areas was highest in the UTA Gagauzia region. 110 Service Delivery Indicators Health Survey for Moldova – Overview of Results Figure 52. Clinical knowledge: Correct identification of primary treatment, by region (%) 100 100 100 99 100 97 98 96 95 94 94 93 91 92 93 93 92 91 92 90 86 88 85 85 82 83 80 78 74 70 60 50 40 30 20 10 0 Center North South Urban UTA Gagauzia Average Hypertension (n=206) Pneumonia (n=156) Diabetes mellitus type II (n=121) Depression (n=269) Pulmonary tuberculosis (n=188) Table 28 shows the distribution of clinical vignette treatments mentioned by doctors interviewed for each respective vignette. Doctors were able to select multiple treatments, so for this reason the percentages do not sum up to 100%, but rather reflect the percent of providers who mentioned a specific treatment. For clinical vignettes related to hypertension, diabetes, and pulmonary tuberculosis, the primary recommended treatments were most commonly selected by doctors. Some doctors mentioned anti-TB drugs (10%) or combination treatment (12%) when assessed for the clinical vignette on pulmonary TB. While these options are not necessarily incorrect, it is worth noting that the predominant clinical guidance for family doctors in Moldova is to refer TB patients for specialized care with a TB focal person or pulmonologist. Few providers selected Rosuvastatin (17%) or any other statins (8%), which impacted their complete, specific treatment scores for diabetes type II. While not evaluated as direct criteria for depression treatment vignette scoring, information on patient counseling was collected to assess this integral component of quality care for mental health. For example, 73% of providers advised patients to reduce stress and strengthen social relationships, 63% gave advice on engaging in daily physical activities, and 53% of providers explained the disease to the patient. 111 Service Delivery Indicators Health Survey for Moldova – Overview of Results Table 28. Treatments selected by providers (multiple select), by vignette (%) Percent of providers Complete, who selected Primary Treatment specific respective treatment treatment treatment (multiple select) Hypertension1 Indapamid (any amount or frequency) 62 Oral ACE inhibitor (e.g., Captopril, Enalapril, 54 Lisinopril, Ramipril) Statins (Rosuvastatin, Atorvastatin, 53 Simvastatin) (any amount or frequency) Aspirin (any amount or frequency) 41 Losartan (any amount or frequency) 30 Oral β-blockers (e.g., Bisoprolol, Carvedilol, 19 Metoprolol, Atenolol) Other oral diuretics (Furosemide, 15 Spironolactone) (any amount or frequency) Oral calcium channel blocker (Amlodipine, Verapamil, Diltiazem) (any amount or 13 frequency) Other oral Angiotensin-II-receptor antagonists (sartans) (Valsartan, Candesartan, 10 Telmisartan, Irbesartan) (any amount or frequency) Other treatment 10 Other Hydrochlorothiazide/thiazide like 4 diuretic Score n.a. 94 79 Diabetes2 Metformin (any amount or frequency) 94 Rosuvastatin (any amount or frequency) 17 Other treatment 15 Other statin (e.g., Atorvastatin, Simvastatin) 8 (any amount or frequency) Aspirin (any amount or frequency) 6 Insulin (any amount or frequency) 3 Other oral biguanide (e.g., Phenformin) (any 0.3 amount or frequency) Sulfonylureas (any amount or frequency) 0.0 Score n.a. 94 22 112 Service Delivery Indicators Health Survey for Moldova – Overview of Results Percent of providers Complete, who selected Primary Treatment specific respective treatment treatment treatment (multiple select) Pneumonia3 Paracetamol (any amount or frequency) 91 Amoxicillin (any amount or frequency) 86 Any other antibiotics (any amount or 8 frequency) Other antipyretics (not paracetamol) (any 14 amount or frequency) Ciprofloxacin (any amount or frequency) 3 Erythromycin (any amount or frequency) 0.8 Cotrimoxazole (any amount or frequency) 0.3 Score n.a. 92 n.a. Pulmonary Tuberculosis Refer to TB focal person 76 Refer to Pulmonologist 58 Other treatment 24 Combination therapy 12 Anti TB drugs: non-specific (any amount or 10 frequency) Paracetamol (any amount or frequency) 9 Isoniazid, rifampicin, pyrazinamide, 9 ethambutol (HRZE) Vitamin B6 (pyridoxine) 6 Amoxicillin (any amount or frequency) 3 4 tablets daily of HRZE (fixed dose 2 combination – 4FDC) for first 2 months 2 tablets daily of HR (2FDC) for following 4 1 months Macrolide (e.g., Erythromycin, roxithromycin, 0.9 azithromycin, etc.) No treatment needed 0.3 Clavulanic acid 0.0 Oxygen 0.0 Score n.a. 93 n.a. 113 Service Delivery Indicators Health Survey for Moldova – Overview of Results Percent of providers Complete, who selected Primary Treatment specific respective treatment treatment treatment (multiple select) Mental Health4 Advice to reduce stress and strengthen social 73 relationships Advice on engaging in daily physical 63 activities Explanation of the disease 53 Advice on structuring the day (e.g., 51 maintaining regular eating times) Refer to psychiatrist 51 Advice on active involvement in community 49 life Refer to the Community Center for Mental 46 Health (CCSM) Other treatment 28 Advice on stigma and misconceptions 19 Advice on self-help library intervention 12 Advice on, and schedule follow up session 9 No referral or treatment; send patient home 6 Provide written/information materials 5 corresponding to patient's age Score n.a. 83 n.a. Notes: 1. Blue coloring denotes that Statin is required for the complete treatment. 2. Blue coloring denotes that either Rosuvastatin or other statin must be selected for complete treatment. 3. Blue coloring and light blue coloring denote that one of each color group must have been selected to count as correct treatment. n.a. = not applicable Figure 53 highlights the proportion of physicians who provided both the primary diagnosis and primary treatment for each relevant vignette across the different regions in the country. On average, most doctors were able to provide the correct primary diagnosis and treatment for hypertension (92%) and diabetes (92%). Fewer doctors were able to provide both the correct primary diagnosis and treatment options for pulmonary TB (82%), pneumonia (77%), and depression (68%). 114 Service Delivery Indicators Health Survey for Moldova – Overview of Results Figure 53. Clinical knowledge of physicians: Correct primary diagnosis and treatment, by region (%) 100 100 99 100 93 94 93 92 92 91 90 90 86 88 86 80 82 80 78 77 77 75 75 70 69 70 68 68 65 60 58 55 50 40 30 20 10 0 Center North South Urban UTA Gagauzia Average Hypertension (n = 206) Pneumonia (n = 156) Diabetes mellitus type II (n=121) Depression (n = 269) Pulmonary tuberculosis (n = 188) 4.1.2. Referral, Continuity, and Integration This subsection assesses patients’ access to and facilities’ attention to health documents. Assessment of health document availability is important as they are a key component of the transfer of information for patients seeking care and facilities offering services to these patients. The analysis gauges the accessibility and functioning of referral systems in the health care facilities, along with patients’ willingness to continue seeking care from the same health facility and health care provider. Figure 54 displays the availability of health documents by region. The least common documents found among patients were their identity card or health insurance card—both found among 58% of patients. Nearly 82% of patients, on average, brought a patient card with them to the health facility. Nearly all health documents were most widely available in the South region. Very few patients on average (3%) showed up to their health appointment without documentation; this behavior was most commonly observed in the Center region (7%). 115 Service Delivery Indicators Health Survey for Moldova – Overview of Results Figure 54. Health document availability among patients, by region (%) (N = 1,499) 100 100 94 93 90 88 90 80 78 82 79 80 71 71 72 68 70 65 62 62 56 57 58 58 60 52 49 50 39 40 35 30 20 10 7 2 1 1 1 3 0 Center North South Urban UTA Gagauzia Average Patient Card Perinatal Medical Card (n = 52) Identity Card No Documentation Health Insurance Policy The next set of tables specifies patient referrals in the past three months leading to the survey. Specifically, they show the percentage of patients who thought their patient information was shared with the health facility to which they were referred, and the method through which it was shared. Table 29 segregates data by region, while table 30 segregates data by facility type. Both show that patient information is primarily transferred by patients themselves through a referral note, patient handbook, or patient card (95%). Table 29. Informed referral: Transfer of patient information, by region (N = 436) (%) Patient Patient information Patient information Patient was information was information Patient did No patient transferred was transferred was not specify information by referral Region transferred by by health transferred transfer was note/patient health facility facility staff by facility method transferred handbook/ staff over electronically staff in patient card phone (e.g., by email person by patients or fax) themselves Center 0 1 97 1 1 0 North 0 1 94 5 0 0 South 0 1 95 4 0 0 UTA 0 5 86 9 0 0 Gagauzia Urban 0 0 95 5 0 0 Average 0 1 95 4 0 0 116 Service Delivery Indicators Health Survey for Moldova – Overview of Results Table 30. Informed referral: Transfer of patient information, by facility type (N = 436) (%) Patient Patient information Patient information Patient was information was information Patient did No patient transferred was transferred was Facility not specify information by referral transferred by health transferred type transfer was note/patient by health facility staff by facility method transferred handbook/ facility staff electronically staff in patient card over phone (e.g., by email person by patients or fax) themselves Health center 0 0 97 3 0 0 Family doctor 0 1 95 4 0 0 office Health office 0 2 92 6 0 0 Individual family doctor 12 0 88 0 0 0 office Family doctor 0 0 93 7 0 0 center Private health 0 6 86 1 5 2 center Consultative diagnostic 0 0 100 0 0 0 center Average 0 1 95 4 0 0 Figure 55 and figure 56 show the proportion of patients referred to another provider within the same health facility by region and facility type, respectively. On average, the rate of referral within the same facility is around 88 percent. 117 Service Delivery Indicators Health Survey for Moldova – Overview of Results Figure 55. Patients referred for care within same facility because services needed or specialized care not available from current provider(s) or department/unit, by region (%) (N = 225) 93 95 100 84 88 90 84 77 80 70 60 Percent 50 40 30 20 10 0 Center North South Urban UTA Gagauzia Average Figure 56. Patients referred for care within same facility because services needed or specialized care not available from current provider(s) or department/unit, by facility type (%) (N = 225) 100 100 100 93 89 88 90 80 78 78 80 70 60 Percent 50 40 30 20 10 0 Health Family Health Individual Family Private Consultative Average center doctor office office family doctor health diagnostic doctor office center enter center Table 31 presents information on the percentage of patients who typically visit the facility that they were interviewed at on the day of the survey. Most patients (77%) reported that they typically visit the facility that they were interviewed at; the frequency of patients reporting this was below average at private health centers (60%), health centers (75%), and consultative diagnostic centers (72%). 118 Service Delivery Indicators Health Survey for Moldova – Overview of Results Table 31. Percent of patients who typically use current health facility for care (N=1,497), by region and facility type Percent Region Center 78 North 65 South 90 Urban 79 UTA Gagauzia 76 Facility type Health center 75 Family doctor office 81 Health office 81 Individual family doctor office 84 Family doctor center 83 Private health center 60 Consultative diagnostic center 72 Average 77 Table 32 presents the percentage of patients referred by the health care provider to another health facility and the percentage who selected the main reason why the health care provider(s) referred them to another health facility. These statistics are varied first by region and then by facility type. It is noteworthy that only 55% of referred patients in private health centers were referred because of issues with service availability. The remaining 45% were referred because the private clinic lacked the appropriate equipment or supplies for treatment. 119 Service Delivery Indicators Health Survey for Moldova – Overview of Results Table 32. Referral outside facility, by region and facility type (%) Percentage of patients referred because Percentage of patients services needed or specialized care not referred to another facility available from current health facility (N = 1,497) (N = 267) Region Center 26 85 North 21 91 South 16 96 Urban 11 94 UTA Gagauzia 13 89 Facility type Health center 17 90 Family doctor office 28 90 Health office 27 90 Individual family 19 100 doctor office Family doctor center 11 88 Private health center 8 55 Consultative 7 100 diagnostic center Average 18 89 Figure 57 shows the median number of outpatient referrals made over the course of the entire week during the most recent typical work week by region and facility type. Referral frequency is highest in the Urban region (median = 35) and UTA Gagauzia (median = 50). The median facility in the sample made 25 referrals during the week preceding the survey. 120 Service Delivery Indicators Health Survey for Moldova – Overview of Results Figure 57. Provider referral frequency, by region and facility type (median) Average 25% Consultative diagnostic center 0% Facility Type Private health center 50% Family doctor center 25% Individual family doctor office 0% Health office 32% Family doctor office 30% Health center 25% UTA Gagauzia 50% Urban 35% South Region 16% North 25% Center 25% Median number of weekly outpatient referrals Health care providers were asked how often they had received referral information for their patients in the last three months. Table 33 shows for all regions the percentage of providers who indicated that such information was shared at varying degrees of frequency. On average, most providers (79%) reported that referral information was shared with them for approximately at least 60% of their patient consultations. Referral information was shared slightly less frequently among providers in the UTA Gagauzia, North, and South regions than in others. Table 33. Frequency of referral information sharing by providers, by region (%) (N = 471) At least 20% At least 40% At least 60% Less than 20% but less than but less than but less than At least 80% of time 40% of the 60% of the 80% of the of the time time time time Center 0 1 3 11 84 North 7 8 14 9 62 South 15 10 1 7 68 Urban 3 7 4 21 65 UTA Gagauzia 10 10 46 0 33 Average 6 6 9 10 69 121 Service Delivery Indicators Health Survey for Moldova – Overview of Results Table 34 details the percentage of doctors who sent patient information to a referral facility and the method used to send patient information to the facility or health care provider. Mostly, information is sent by patients themselves (93%). Table 34. Informed referral modality as reported by doctors, by region and facility type (%) Information Unspecified Information Information Information delivered referral sent over sent delivered in by patients modality phone electronically person themselves Region Center 90 2 5 0 3 North 93 6 1 0 0 South 97 3 0 0 0 Urban 92 0 6 2 0 UTA Gagauzia 99 1 0 0 0 Facility Type Health center 94 2 3 1 0 Family 38 62 0 0 0 doctor office Health office 100 0 0 0 0 Individual family 100 0 0 0 0 doctor office Family doctor 50 0 50 0 0 center Private health 94 2 3 1 0 center Consultative 38 62 0 0 0 diagnostic center Average 93 3 3 0 1 Table 35 presents the median number of patient referrals from the health facility over three months in 2021—September, October and November. The data are further segregated by the facility level to which patients were referred—whether the level was the same as or higher than the level of the previous facility. The median facility observed in the sample referred 44 patients during the three-month period, with slightly more referrals going to higher-level facilities (median = 21) than facilities at the same level (median = 0). The largest concentration of referrals to other facilities was within UTA Gagauzia and the Urban region, and the smallest concentration was in the South region. It is worth noting that while consultative diagnostic centers had the highest median number of referrals to other facilities (514), the median 122 Service Delivery Indicators Health Survey for Moldova – Overview of Results number of referrals that they received from other facilities was nearly seven times larger (median = 3582) than their median number of referrals in from other facilities. This was also the only facility type that had a higher median amount of referrals “in” than referrals “out.” Table 35. Median number of referrals to other facilities during September–November 2021, by region and facility type Referrals from this facility to another Referrals from another facility to this (referrals out) facility (referrals in) Referrals Referrals Total Referrals to Referrals to Total from higher from same referrals higher level same level referrals level level Region Center 49 24 0 11 3 0 North 44 22 0 8 5 0 South 27 8 0 0 6 0 Urban 420 73 0 35 10 0 UTA Gagauzia 155 45 0 14 12 8 Facility type Health center 201 56 0 18 14 0 Family doctor 35 12 0 9 5 0 office Health office 26 11 0 4 3 0 Individual family 123 32 0 13 7 0 doctor office Family doctor 321 94 59 217 34 28 center Private health 216 36 0 0 0 0 center Consultative diagnostic 514 279.5 195 3582 138 1832 center Average 44 21 0 8 5 0 The two tables below present the percentage of facilities that referred patients to another facility based on specific reasons. Table 36 provides information about reasons for referrals to higher-level facilities, while table 37 provides information on referrals at the same level. Each facility manager interviewed as part of the study was asked what the top 3 reasons were for referrals out to facilities at the same and higher level facilities. The most common reason for referral to facilities of both the same and higher levels is that “services needed were beyond the scope of the referring health facility’s care mandate or the specialized care was 123 Service Delivery Indicators Health Survey for Moldova – Overview of Results available at the referred facility.” On average, just under 90% of the referrals to higher-level facilities were for this reason. For referrals to facilities at the same level, approximately one in four referrals were also made due to provider absence (25%), unavailability of necessary equipment (29%), or services being contracted out (28%). Table 36. Reasons for referral to another facility at higher level, by region (%) (N = 219) Services were Services were within the Services were Services were Services were Services within the scope of this Patient/ within the within the within the needed scope of this health patient’s scope of this scope of this scope of this were health facility's care family health health health beyond facility's care mandate, but re- facility's care facility's care facility's care the scope mandate, but the quested mandate, but mandate, but mandate, but of this the required referral this the the health needed equipment to other health facility required sup- required medi- facility’s health care was not health was too full plies were not cine was not care man- provider(s) available/ facility or available/ available/ date were absent/ stocked out/ too busy stocked out stocked out not available not func- tional Region Center 100 28 37 11 6 2 0 North 77 39 0 17 25 8 0 South 84 9 0 1 1 9 0 Urban 98 23 0 2 6 2 2 UTA 100 0 0 0 0 0 0 Gagauzia Facility Type Health center 92 24 1 9 20 4 0 Family 88 30 3 13 7 6 0 doctor office Health office 87 29 0 9 15 7 0 Individual family 100 8 0 0 0 0 0 doctor office Family doctor 100 30 0 5 0 0 0 center Private 83 44 0 26 8 0 0 health center Consultative diagnostic 100 0 0 0 0 0 0 center Average 89 28 1 11 12 6 0 124 Service Delivery Indicators Health Survey for Moldova – Overview of Results Table 37. Reasons for referral to another facility at same level, by region (%) (n = 219) The services The services need- The services The services The services needed were ed were within the needed were needed were needed were within the scope scope of the refer- within the scope within the beyond the of the referring ring health facili- of the referring scope of the scope of the health facility’s ty’s care mandate, health facility’s referring referring health care mandate, but the required care mandate, health fa- facility’s care but the need- equipment was but the required cility's care mandate or ed health care not available/was supplies were mandate, specialized providers were stocked out or not not available/ but another care was only absent/not functional at the were stocked out health facility available at this available at the referring health at the referring is contracted health facility referring health facility health facility to provide it facility Region Center 88 26 31 10 26 North 34 27 35 23 48 South 73 27 26 18 5 Urban 96 8 0 0 8 UTA 100 0 0 0 0 Gagauzia Facility type Health center 78 19 11 8 30 Family 64 33 35 20 33 doctor office Health office 55 22 37 16 22 Individual family doctor 100 0 20 0 0 office Family 100 0 0 0 14 doctor center Private 100 0 0 0 0 health center Consultative diagnostic 100 0 0 0 0 center Average 67 25 29 15 28 Note: The data presented in this table come from a multiple-choice question. Facility managers were asked how they received information about patients referred from another facility. Table 38 presents the percentage of facilities that relied on any of several specific information transfer modalities to receive information about patients from another facility. On average, 85% of the facilities depended on patients to transfer information themselves. 125 Service Delivery Indicators Health Survey for Moldova – Overview of Results Table 38. Referral: Information transfer from external facility by region No patient Transfer was Transfer was over Transfer was information was by patients phone electronic transferred themselves Region Center 11 88 1 0 North 0 89 11 0 South 0 66 32 2 Urban 0 95 0 5 UTA Gagauzia 0 100 0 0 Facility Type Health center 0 89 11 0 Family doctor 8 83 9 0 office Health office 0 90 10 0 Individual family 0 100 0 0 doctor office Family doctor 0 85 8 8 center Private health 0 54 0 46 center Consultative 0 100 0 0 diagnostic center Average 5 85 9 1 Table 39 presents the percentage of patients who continued to see the same health care provider, broken down by frequency. Across region and facility type, most patients seemed to recurringly visit the same provider, with an average rate of 88% continuing to see the same provider always or often. 126 Service Delivery Indicators Health Survey for Moldova – Overview of Results Table 39. Patients seeing the same provider, by region (%) Always Often Sometimes Rarely Never Region Center 77 14 8 1 0 North 48 27 17 9 0 South 85 11 2 1 0 Urban 83 8 2 6 1 UTA Gagauzia 82 6 7 5 0 Facility Type Health center 72 15 9 4 0 Family doctor office 69 19 7 4 0 Health office 69 17 11 3 0 Individual family 75 14 8 3 0 doctor office Family doctor center 91 4 3 2 0 Private health center 75 2 6 15 1 Consultative 78 2 15 5 0 diagnostic center Average 74 14 8 4 0 4.1.3. Safety, Prevention, and Detection This subsection reports on practices in place to prevent health care–acquired infections. It also considers facilities’ ability to detect and prevent the spread of contagious diseases and the emergency preparedness services of facilities. Facility-level infection prevention and control indicators are presented in detail in the foundations chapter of this report. Table 40 presents the proportion of facilities that report having the following protocols and infrastructural features for infection prevention and control: cases and events reported to the National Early Warning and Reporting System; at least one separate entrance for patients with a suspected contagious disease; at least one designated site for patient isolation; and points of care cleaned with disinfectants at least twice per day. Most facilities stated that they report to the National Early Warning and Reporting System (96%) and clean points of care regularly (94%). However, only half the facilities (53%) reported having a separate entrance for patients with suspected contagious diseases, and only 72% reported that they have at least one designated site for patient isolation. 127 Service Delivery Indicators Health Survey for Moldova – Overview of Results Table 40. Surveillance and IPC, by region and facility type (%) (N= 247) Percentage of facilities that report: Separate Reporting to the entrance for One designated National Early Point of care patients with site for patient Warning and cleaned regularly contagious isolation Reporting System diseases Region Center 96 48 69 93 North 98 50 75 93 South 94 63 68 97 Urban 98 80 77 98 UTA Gagauzia 93 56 100 100 Facility Type Health center 97 80 90 98 Family doctor office 96 60 75 93 Health office 98 17 50 93 Individual family 85 46 85 77 doctor office Family doctor center 100 81 95 90 Private health center 76 79 70 100 Consultative 100 100 100 100 diagnostic center Average 96 53 72 94 According to good practice, facilities need to be prepared for unforeseen conditions. The importance of this requirement was highlighted by the onset of the coronavirus pandemic. The tables below show the percentage of facilities that were prepared for emergencies as follows: had access to essential medicines, consumables, and equipment from medical buffer stores; had allocated earmarked funds; had access to backup human resources for continuity of essential health services; had defined protocols to communicate with other health facilities, affected communities, and the public; conducted emergency preparedness and response mock drills or simulation exercises in the past two years; conducted a fire drill in the past two years; and conducted structural vulnerability assessment in the last two years. 128 Service Delivery Indicators Health Survey for Moldova – Overview of Results Table 41 shows that some of these measures were more widely adopted than others. On average, roughly 90% of facilities had access to essential medicines, consumables, and equipment from medical buffer stores, and across regions and facility types, over 85% of facilities had adopted this measure. On the other hand, 48% of facilities conducted vulnerability assessments, and 61% of facilities reported having earmarked funds allocated for emergency preparedness. Table 41. Emergency preparedness, by region and facility type (%) Access to Protocols to essential communicate medicines, Allocated Access to backup with other consumables, and earmarked funds human resources health facilities, equipment from communities, and medical buffer public stores Region Center 91 55 67 85 North 90 56 75 85 South 81 74 71 83 Urban 98 77 85 91 UTA Gagauzia 93 100 100 93 Facility Type Health center 100 64 76 96 Family doctor office 87 56 73 85 Health office 84 66 66 77 Individual family 85 31 77 92 doctor office Family doctor center 95 76 86 100 Private health center 85 69 70 54 Consultative 100 100 100 100 diagnostic center Average 89 61 72 85 129 Service Delivery Indicators Health Survey for Moldova – Overview of Results Table 42. Proportion of facilities that conducted drills for key emergency and preparedness behaviors (%) Conducted emergency Conducted a Conducted structural preparedness and fire drill vulnerability assessment response drills Region Center 52 47 32 North 67 57 55 South 65 64 62 Urban 75 79 48 UTA Gagauzia 100 100 100 Facility Type Health center 63 60 39 Family doctor office 60 53 44 Health office 61 58 61 Individual family doctor office 69 46 38 Family doctor center 71 67 43 Private health center 70 62 54 Consultative diagnostic center 100 100 50 Average 62 56 48 4.2. Positive User Experience The second domain explored in this chapter is “positive user experience,” which gauges patients’ experience during their visit to a facility. First, the analysis highlights the interpersonal skills of the health care providers and seeks to understand a patient’s level of comfort during the consultation. Next, the analysis aims to measure the overall user experience during facility visits, including experience with wait times, infrastructure, and more. 4.2.1. Respect and Autonomy This subsection explores different indicators that record the patient’s review of and experience with the aspects of care provided at the health care facility. Table 43 and table 44 show different aspects of the patient’s experience and segregate it by region and facility type, respectively. Almost all patients (98–100% by region or type of facility) reported having all their questions answered during the consultation. 130 Service Delivery Indicators Health Survey for Moldova – Overview of Results In most metrics, facilities fare well, garnering a response of either “good” or “very good.” In fact, for nearly all the metrics, only a handful of patients (highest average of 1%) stated that the facility performed badly or very badly. The aspects of care with the lowest percentage of patients providing a “very good” rating included patient involvement in care (31%) and auditory (35%) and visual privacy (36%). Table 43. Percentage of patients rating aspects of their experience, by region Region Very bad Bad Moderate Good Very good Center 1 0 2 57 40 Communication North 0 0 5 49 46 South 0 0 2 70 28 Urban 1 0 3 45 51 UTA Gagauzia 1 1 4 41 53 Average 1 0 3 53 43 Center 0 1 3 53 43 North 0 0 7 52 41 Greeting and introduction South 0 0 3 56 41 Urban 1 0 6 41 52 UTA Gagauzia 0 2 8 37 53 Average 0 1 5 48 46 Center 0 0 4 59 37 North 1 0 2 64 33 Visual privacy South 0 0 2 79 19 Urban 0 1 5 57 37 UTA Gagauzia 0 0 4 47 49 Average 0 0 3 61 36 Center 0 0 4 59 37 Auditory privacy North 0 1 4 60 35 South 0 0 4 79 17 Urban 0 1 8 54 37 UTA Gagauzia 0 0 5 49 46 Average 0 0 5 60 35 Center 0 0 3 69 28 Patient involvement North 0 1 5 58 36 South 0 0 3 75 22 in care Urban 0 0 6 49 45 UTA Gagauzia 0 1 7 57 35 Average 0 0 5 64 31 131 Service Delivery Indicators Health Survey for Moldova – Overview of Results Table 44. Percentage of patients rating aspects of their experience, by facility type Facility Type Very bad Bad Moderate Good Very good Health center 0 0 4 64 32 Family doctor office 1 0 2 54 43 Communication Health office 0 0 1 49 50 Individual family doctor office 0 0 1 36 63 Family doctor center 0 1 7 37 55 Private health center 0 0 4 26 70 Consultative diagnostic center 5 0 1 31 63 Average 1 0 3 53 43 Health center 0 1 4 57 38 Family doctor office 0 0 4 51 45 Health office 0 0 1 48 51 Greeting and introduction Individual family doctor office 0 0 1 31 68 Family doctor center 0 1 11 29 59 Private health center 0 0 1 30 69 Consultative diagnostic center 2 4 11 34 49 Average 0 1 5 48 46 Health center 0 0 4 73 23 Family doctor office 1 0 2 60 37 Visual privacy Health office 0 0 3 60 37 Individual family doctor office 0 0 4 43 53 Family doctor center 0 2 7 41 50 Private health center 0 0 4 27 69 Consultative diagnostic center 0 0 0 42 58 Average 0 0 3 61 36 Health center 0 1 5 71 23 Family doctor office 0 0 3 60 37 Auditory privacy Health office 0 1 4 60 35 Individual family doctor office 0 0 11 43 46 Family doctor center 0 0 8 44 48 Private health center 0 0 5 21 74 Consultative diagnostic center 0 0 3 45 52 Average 0 0 5 60 35 Health center 0 0 4 70 26 Family doctor office 0 1 3 63 33 Patient involvement Health office 0 0 2 70 28 in care Individual family doctor office 1 0 4 55 40 Family doctor center 0 1 8 55 36 Private health center 0 0 5 34 61 Consultative diagnostic center 0 0 11 53 36 Average 0 0 5 64 31 132 Service Delivery Indicators Health Survey for Moldova – Overview of Results Table 45 investigates the autonomy patients exercised while choosing their health care provider. On average, 40% of patients reported that they were allowed to choose their PHC provider, while 58% reported being assigned a PHC provider. Autonomy was significantly higher among patients visiting private health centers, where 90% of patients reported that they chose their own PHC provider. Most patients, across all regions and facility types, reported being assigned a health care provider. Table 45. Patient-reported provider choice, by region and facility type Percentage of patients reporting: Someone in their They did not choose, They chose their PHC family chose their but were assigned a provider PHC provider PHC provider Region Center 37 1 62 North 45 0 55 South 37 1 62 Urban 53 2 45 UTA Gagauzia 40 5 56 Facility Type Health center 36 1 63 Family doctor office 44 1 55 Health office 34 0 66 Individual family doctor office 36 0 64 Family doctor center 38 4 58 Private health center 90 5 5 Consultative diagnostic center 35 8 56 Average 40 2 58 The final table in this subsection presents a unique indicator: greetings and introductions by providers during the clinical vignettes. Table 46 looks at the percentage of health care providers who greeted the patients in the clinical case simulations. On average, slightly more than half (56%) of physicians greeted and introduced themselves to the simulated patient. 133 Service Delivery Indicators Health Survey for Moldova – Overview of Results Table 46. Provider greetings and introduction, by region Percentage of providers who greeted the patient and Region introduced themselves (vignettes) Center 39 North 68 South 67 Urban 47 UTA Gagauzia 74 Average 56 4.2.2. User Focus User-centered health care systems focus on patients’ needs and preferences to ensure that they can receive high-quality care with ease. These systems anticipate various bottlenecks that can arise right from the time that a patient decides to seek care, and they design measures to address those challenges. This section presents key indicators related to user- centered care systems, with particular attention to understanding the experience of patients seeking care at health facilities. Most patients (86%) did not report any barriers to accessing the facility; 4% reported long travel times and 2% a lack of transport. Similarly, almost all patients and patient proxies31 (95–100%) reported the health care provider communicating in the preferred language of the respondent. Table 47 outlines the functioning of the appointment system within the facility. On average, 57% of patients who came to a facility had an appointment for a specific date and time. 31Patient proxies were individuals who spoke on the behalf of a patient (e.g., the parent of a child, caregiver for elderly patient) that came into the health facility and otherwise relied on another individual to support management of their care. 134 Service Delivery Indicators Health Survey for Moldova – Overview of Results Table 47. Patient visits based on appointments, by region Percentage of patient visits based on appointments Yes, was asked to visit the Yes, was given No, visited health facility after a certain a specific date/ without an time interval without mention time appointment of a specific date/time Region Center 43 11 46 North 54 6 39 South 52 8 39 Urban 71 1 27 UTA Gagauzia 72 2 26 Facility Type Health center 57 6 36 Family doctor office 44 10 46 Health office 44 12 43 Individual family doctor office 52 5 44 Family doctor center 73 2 25 Private health center 63 1 35 Consultative diagnostic center 75 0 25 Average 57 6 37 Table 48 presents the median length of time patients spent waiting for their consultation and the duration of the consultation itself (as reported by health facility managers), during regular hours for the period September–November 2021. The data are reported by region and facility. Across all regions, Urban had the shortest median wait time. No region’s median estimated wait time exceeded 15 minutes. Similarly, the median wait time did not exceed 15 minutes across facility types. Consultation times were standard, averaging around 20 minutes per patient across regions and facility types. 135 Service Delivery Indicators Health Survey for Moldova – Overview of Results Table 48. Facility-reported median wait time and consultation time, by region and facility (minutes) Wait time Consultation time Region Median Median Region Center 15 20 North 15 20 South 15 20 Urban 10 20 UTA Gagauzia 15 20 Facility Type Health center 15 20 Family doctor office 15 20 Health office 13 20 Individual family doctor office 15 20 Family doctor center 15 20 Private health center 15 20 Consultative diagnostic center 15 20 Average 15 20 Table 49 and table 50 present by region and facility type respectively the percentage of patients who rated different aspects of their user experience from very bad to very good. The indicators include the following: the time it took to travel to the health facility; how long the patient waited in the health facility after arrival and before being seen by one of the health care providers; the convenience of the facility’s hours of service; the cleanliness of the rooms inside the health facility; the physical conditions of the room inside the health facility; and the availability and functioning of equipment, supplies, and medicine at health facility. On average, facilities were rated between “good” and “very good” on nearly all metrics. On average, 19% of patients reported travel time as being “moderate.” In the Urban region, 13 percent of patients reported travel time as “bad.” On average, 16% of patients rated the availability of medicines and equipment as “moderate,” while 20% rated it as “very good.” Overall, very few patients rated any aspects as being “bad” or “very bad.” 136 Service Delivery Indicators Health Survey for Moldova – Overview of Results Table 49. Patient ratings of user experience, by region (%) Very bad Bad Moderate Good Very good Travel time Center 0 3 19 61 17 North 1 2 16 62 19 South 0 1 22 65 12 Urban 0 13 21 42 24 UTA Gagauzia 0 2 18 47 32 Average 0 3 19 57 21 Wait time Center 0 1 16 66 17 North 0 4 19 59 19 South 0 0 18 71 11 Urban 1 7 19 50 23 UTA Gagauzia 1 5 16 45 32 Average 0 3 17 59 21 Convenience of hours of operation Center 0 1 6 63 31 North 0 0 7 58 34 South 0 0 12 71 17 Urban 0 2 15 58 26 UTA Gagauzia 0 1 11 47 41 Average 0 1 9 58 32 Cleanliness of rooms Center 0 0 5 58 37 North 0 0 5 53 41 South 0 1 6 77 17 Urban 0 0 16 55 29 UTA Gagauzia 0 0 5 61 33 Average 0 0 6 61 33 Physical conditions of rooms Center 0 6 18 61 15 North 1 2 15 52 31 South 1 3 8 76 12 Urban 3 0 19 61 17 UTA Gagauzia 0 0 16 55 29 Average 1 3 15 60 22 Availability and functioning of equipment, supplies, and medicine Center 0 2 25 57 16 North 0 1 13 60 26 South 0 1 12 76 10 Urban 1 6 15 57 21 UTA Gagauzia 1 1 11 63 25 Average 0 2 16 63 20 137 Service Delivery Indicators Health Survey for Moldova – Overview of Results Table 50. Patients’ ratings of user experience, by facility type (%) Very bad Bad Moderate Good Very good Travel time Health center 0 2 21 65 13 Family doctor office 1 4 15 59 21 Health office 1 1 12 63 22 Individual family doctor office 0 4 13 58 25 Family doctor center 0 4 22 40 33 Private health center 0 1 15 54 30 Consultative diagnostic center 0 6 20 34 40 Average 0 3 19 57 21 Wait time Health center 0 2 20 62 16 Family doctor office 0 2 16 67 15 Health office 0 0 12 65 23 Individual family doctor office 0 0 25 48 28 Family doctor center 2 8 15 46 30 Private health center 0 1 15 36 48 Consultative diagnostic center 2 6 14 38 40 Average 0 3 17 59 21 Convenience of hours of operation Health center 0 0 8 68 24 Family doctor office 0 0 7 59 35 Health office 0 3 18 53 26 Individual family doctor office 0 0 5 44 51 Family doctor center 0 1 13 42 44 Private health center 0 0 6 37 57 Consultative diagnostic center 0 2 14 47 37 Average 0 1 9 58 32 Cleanliness of rooms Health center 0 0 6 67 26 Family doctor office 0 1 4 57 38 Health office 1 1 8 58 33 Individual family doctor office 0 0 6 51 43 Family doctor center 0 0 7 60 34 Private health center 0 0 1 36 63 Consultative diagnostic center 0 2 5 61 32 Average 0 138 0 6 61 33 Service Delivery Indicators Health Survey for Moldova – Overview of Results Very bad Bad Moderate Good Very good Physical conditions of rooms Health center 0 1 12 71 17 Family doctor office 1 7 14 57 21 Health office 3 10 28 43 16 Individual family doctor office 0 0 9 52 38 Family doctor center 0 0 20 54 26 Private health center 0 0 3 38 59 Consultative diagnostic center 0 0 19 51 31 Average 1 3 15 60 22 Availability and functioning of equipment, supplies, and medicine Health center 0 1 16 68 15 Family doctor office 0 1 17 62 20 Health office 0 7 29 47 17 Individual family doctor office 0 3 17 58 22 Family doctor center 2 2 12 59 25 Private health center 0 1 2 57 40 Consultative diagnostic center 0 0 10 62 28 Average 0 2 16 63 20 139 Service Delivery Indicators Health Survey for Moldova – Overview of Results 5. Person-Centered Outcomes This chapter presents findings that explore person-centered outcomes to assess whether a patient is at the “center of care.” Person-centered care involves sharing all the relevant information and resources with patients so they can consider their choices and make an informed decision. Most data have been sourced from patient interviews. To understand patients’ confidence that the health system will provide timely and high- quality care, two primary components were considered: (1) satisfaction and recommendation – patients’ satisfaction with the various aspects of care that they receive and the likelihood that they would recommend a health facility/health care provider to others based on their experience; and (2) care uptake and retention – patients’ reason for receiving and continuing care with the current or other facility. Two other components are assessed to quantify the various financial costs that patients bear in receiving care: out-of-pocket costs; and opportunity costs such as income lost and time taken away from work, which arise from seeking care. Box 3 highlights some of the key findings related to person-centered health care in Moldova. Box 3. Key observations on person-centered PHC outcomes in Moldova Confidence in system Care uptake and retention: • Among patients interviewed, 99% (CI: 99%–100%) received intended care, and 98% (CI: 97%–99%) would return for a similar service. • For antenatal care (ANC) visits, on average, 66% of women who attended two or more ANC visits had visited more than one facility for ANC services. • On average, less than 30% of patients who sought care for diabetes and hypertension visited another facility for care. The most common reasons for hypertension and diabetes patients seeking care at other facilities included lack of specialized care and lack of necessary equipment and medicines in the original facility that they visited. 140 Service Delivery Indicators Health Survey for Moldova – Overview of Results Box 3. Key observations on person-centered PHC outcomes in Moldova Satisfaction and recommendation: • Among patients interviewed, 95% (CI: 92%–97%) reported that they would recommend the facility to a friend or a relative. • On average, 37% (CI: 31%–42%) of patients rated the health care providers’ abilities and skills as very good, 59% (CI: 53%–64%) as good, and 4% (CI: 3%–5%) as moderate. • On average, 43% (CI: 38%-48%) of patients rated the overall quality of the facility they visited as very good, 52% (CI: 47%-56%) as good, and 5% (CI: 4%-6%) as moderate. • According to providers, the most common challenges for patient access to high- quality health care were long waiting times at facilities (35%; CI: 29%–41%), long travel times and distance (22%; CI: 17%–27%), and not enough health care providers (32%; 27%–38%). Financial protection Out-of-pocket costs: • The median cost to reach the facility and for the consultation was zero. • Of the 20 patients who reported expenditure for their consultation and diagnostics, the average cost was MDL 188; health insurance was the source most patients used to cover cost of the health visit. Opportunity costs: • The time needed to reach the facility across all regions and facility types did not exceed 20 minutes. • On average, 7% (CI: 4%-10%) of facilities reported that they collected revenue over the 12 months preceding the survey from direct patient fees. 141 Service Delivery Indicators Health Survey for Moldova – Overview of Results 5.1. Confidence in System 5.1.1. Care Uptake and Retention The first domain explored under “person-centered outcomes” is confidence in system. This section provides an overview of care uptake and retention—that is, the likelihood that patients receive care and continue to receive care at a single health facility versus multiple health facilities, and their reasons for doing so. Figure 58 presents overall patient care and retention indicators. Nearly all (99%) patients interviewed received their intended care during the visit. Eight percent of patients not referred elsewhere by providers nonetheless planned to seek further care from another health care provider within the same or another health care facility for the same reason they visited the facility that day; and 98% of patients who received care would come back to the facility if they needed care for a similar health concern. Annex table A.25 provides further information by survey region and facility type. Figure 58. Overall patient care and retention (cumulative %) (N = 1,496) 100 90 99% 98% 80 70 8% 60 Percent 50 40 30 20 10 0 Patients who received Patients who intended Patients who would return intended care to get second for similar service opinion Table 51 further highlights patient care and retention by reason for visitation as reported by patients. Approximately 18% of patients received a referral for further care from their provider. Intent to seek a second opinion was assessed among patients who did not directly receive a referral from their provider the day of the interview. Intent to return to the same facility for care was asked of all patients. It is worth noting that these are separate indicators and should be treated as such – they do not sum up to 100%. Trends were the same across disease types for the proportion of patients who received intended care and who would return to the same facility for similar services. A few notable aberrations are the proportion of patients who reported that they would return to the same facility for diarrhea (66%) and family planning and reproductive health services (83%). Intent to seek a second opinion was highest for dizziness or vertigo (35%), fatigue (39%), and epilepsy (100%). 142 Service Delivery Indicators Health Survey for Moldova – Overview of Results Table 51. Proportion of patients reporting care receipt and indicating they would return to same facility for a similar service, by visitation reason (%) Received Intend to get Would return for service at Reason for visit intended care second opinion the same facility (N = 1,496) (N = 1,191)1 (N = 1,496) Cough/sore throat 100 2 98 Runny nose/nose congestion 100 6 97 Fever 100 2 99 Back pain 100 9 100 Chest pain 100 19 95 Asthma/shortness of breath 100 23 93 Stomach/abdominal pain 100 15 96 Diarrhea 100 0 66 Vomiting 100 0 100 Headache/migraine 100 12 96 Arthritis/joint pain 100 14 97 Ear infection/pain/hearing 100 0 95 difficulties Eye infection/pain/vision 100 10 98 difficulties Skin infection/condition 100 0 100 Dizziness/vertigo 100 35 99 Fatigue 100 39 97 Diabetes 98 11 96 Hypertension/high blood 100 6 99 pressure Cancer 100 14 100 Pregnancy/childbirth 100 6 99 Family planning/reproductive 100 0 83 health Epilepsy/seizures/convulsions 100 100 100 Anxiety/depression/mental 100 0 100 health Routine health checkup 98 3 100 Average 99 8 98 Note: Approximately 18% of patients received a referral at their health care visit, however this question aimed to assess the proportion seeking a second opinion refers to those patients that did not receive a referral from their provider. 143 Service Delivery Indicators Health Survey for Moldova – Overview of Results Figure 59 and figure 60 show by region and facility type, respectively, the proportion of women with two or more antenatal care (ANC) visits who sought ANC care at another facility. On average, 66% of women who had two or more ANC visits visited more than one facility; the share ranged from 77% in the South region, to 67% in UTA Gagauzia and 64% in the North. The highest rates of women seeking ANC at another facility were found in individual family doctor offices (100%), private health centers (92%), and health offices (91%); rates were lower within family doctor offices (76%), health centers (63%), and consultative diagnostic centers (40%). Among women with at least two ANC visits interviewed at family doctor centers, none reported that they had sought care for ANC at another facility. Figure 59. Women seeking ANC at more than one facility, by region (%) (N = 38) 100 90 77 80 64 67 66 70 61 60 60 Percent 50 40 30 20 10 0 Center North South Urban UTA Gagauzia Average Note: Sample includes only those women who have had more than two ANC visits. Figure 60. Women seeking ANC at more than one facility, by facility type (%) (N = 38) 100 100 91 92 90 80 76 70 63 66 60 Percent 50 40 40 30 20 10 0 0 Health Family Health Individual Family Private Consultative Average center doctor office family doctor health diagnostic office doctor office center center center Note: Sample includes only those women who have had more than two ANC visits. 144 Service Delivery Indicators Health Survey for Moldova – Overview of Results Figure 61 highlight patients’ choice of facilities for treatment of hypertension and diabetes. On average, 29% of all patients who visited the health facility for diabetes or hypertension care reported also visiting other facilities for diabetes or hypertension services. Patients who sought care for diabetes and hypertension at multiple facilities were asked a multiple-select question to understand their reason for seeking care at multiple facilities. Ninety-one percent of patients who answered this question stated that they visited other facilities because specialized care and services were not available at the original facility, 10% visited other facilities because the original facility lacked required equipment, supplies, and medicines, 6% due to preference for providers who are more likely to prescribe them medicine, and 5% because the health care provider they intended to see was absent at the health facility. Figure 61. Reasons patients chose multiple points of care for diabetes and hypertension (multiple select), by region (N=69) (%) 100 100 90 80 70 60 Percent 50 40 30 20 10 10 6 5 0 Services needed or Required equipment, Preference for health care Health care provider(s) was specialized care supplies, or medicine provider(s) who are likely absent/not available at the not available at the was not available/stocked to prescribe medicine(s) health facility health facility out or not functional or treatment(s) at the health facility 5.1.2. Satisfaction and Recommendation Figure 62 and figure 63 show by region and facility, respectively, the percentage of providers reporting various barriers facing patients who seek care. The top three reasons mentioned by providers across the sampled facilities have been presented, however table 52 outlines the distribution of all responses from providers. Providers were allowed to mention multiple reasons for barriers to patient access to high-quality services. Averaging all regions, 35% of providers identified long waiting times as the biggest challenge for patients; not having enough providers at the facility was the second most common challenge (identified by 32% of providers), followed by long travel time (22%). However, 48% of providers in the Urban region and 43% in UTA Gagauzia cited not having enough providers at the facility as the biggest challenge for patients. Within facilities, long waiting times were cited by 82% of providers in consultative diagnostic centers, and 71% of providers in family doctor centers cited not having enough health care providers. Long travel times were cited in individual family doctor offices by 45% of providers, and by 34% of providers in health offices. 145 Service Delivery Indicators Health Survey for Moldova – Overview of Results Figure 62. Top three challenges to patients’ access to high-quality care at facility as reported by providers, by region (%) (N = 1,276) 100 90 Percent 80 70 60 48 50 43 38 37 40 34 35 35 32 30 28 25 26 24 27 30 22 22 20 11 10 4 0 Center North South Urban UTA Gagauzia Average Long waiting time at health facility Long travel time/distance to reach health facility Not enough health care providers Figure 63. Top three challenges to patients’ access to high-quality care at facility as reported by providers, by facility (%) (N = 1,276) 100 90 82 80 71 70 60 Percent 50 45 41 40 34 37 35 32 34 30 29 27 30 25 24 22 22 21 20 17 12 10 6 7 9 8 0 0 Health center Health office Family doctor center Consultative diagnostic center Long waiting time at health facility Long travel time/distance to reach health facility Not enough health care providers 146 Service Delivery Indicators Health Survey for Moldova – Overview of Results Table 52. Distribution of challenges to patients’ access to high-quality care at facility as reported by provider (%) Reason Percent Long waiting time at health facility 35 Not enough health providers/long delay book appt 32 Long travel time/distance to reach health facility 22 Absence of health care provider 11 No one to look after obligations at home/property 10 High travel costs to reach health facility 6 Lack of needed equipment 6 Communication gaps/miscommunication with health care provider 6 Poor facility infrastructure 5 Lack of needed medicines 4 Cost of drugs and services 3 Disrespectful/rude health care provider 1 Lack of needed supplies 1 COVID-19 Restrictions 1 Short consultation time 1 Arrival without appointment 1 Lack of information/ knowledge 1 Not enough specialists 1 Figure 64 presents patients’ recommendations for the facility by region and facility. Patients who received care were asked if they would recommend the facility to a friend or a family member. Overall, 95% of patients reported that they would recommend the facility to others for the same services they had received. A full 100% of patients at individual family doctor offices and private health centers would recommend the facility. Rates for recommendation were generally high within other facilities as well, including health centers (95%), family doctor offices (98%), health offices (95%), family doctor centers (87%), and consultative diagnostic centers (86%). The same pattern was observed within regions, where all rates for recommendation were high; the highest rates were in the South, where 99% would recommend the facility to others, followed by the North (98%), Urban (95%), Center (93%), and UTA Gagauzia (91%). 147 Service Delivery Indicators Health Survey for Moldova – Overview of Results Figure 64. Percentage of patients who would recommend the facility Center 93% North 98% Region South 99% Urban 95% UTA Gagauzia 91% Health center 95% Family doctor office 98% Facility Type Health office 95% Individual family doctor office 100% Family doctor center 87% Private health center 100% Consultative diagnostic center 86% Average 95% Figure 65 shows patients’ ratings of the overall quality of the facility they visited, ranging from bad to very good. On average, 43% of patients rated the facility as very good, 52% as good, and 5% as moderate. About three-quarters of patients (74%) rated private health centers as very good. Other facilities were rated very good by smaller shares of patients: individual family doctor offices by 68%, family doctor centers by 54%, family doctor offices by 46%, health offices by 44%, consultative diagnostic centers by 38%, and health centers by 36%. Regarding regions, 50% of facilities in the North were rated as very good, followed by UTA Gagauzia (47%), the Center (44%), the Urban region (42%), and the South (30%). 148 Service Delivery Indicators Health Survey for Moldova – Overview of Results Figure 65. Patients’ ratings of overall quality of facility (%) 5 52 43 Average Center Region North South Urban UTA Gagauzia Health center Family doctor office Facility Type Health office Individual family doctor office Family doctor center Private health center Consultative diagnostic center 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Bad Moderate Good Very good Figure 66 highlights patients’ main reasons for choosing the facility at which they were interviewed. A full distribution of reasons that patients chose the health facility is outlined in table 54. This question allowed patients to select multiple options so numbers in the figure do not sum to 100%. On average, 72% of patients reported choosing the facility where they were registered. For 36% of patients, preference was due to the location (close to work or home); 26% trusted the health care provider at the facility; and 14% made the choice based on the attitude of the health care provider at the facility. 149 Service Delivery Indicators Health Survey for Moldova – Overview of Results 100 Figure 66. Patients’ top reasons for choosing the facility (%) 90 80 72% 70 36% 60 26% Percent 14% 50 40 30 20 10 0 This is the PHC provider Location close Trust in health Health care where I am registered to home/work care provider provider attitude Table 53 provides the full distribution of reasons why patients chose a particular facility. Aside from the top reasons listed in the figures above, other common reasons that patients chose the facility they visited were due to hours (7%) and days of service (6%), service quality (7%), facility cleanliness (6%), short waiting times (4%), medicine availability (4%), and referrals (4%), among others. Table 53. Patients’ reasons for choosing this facility (%) Reason Percent This is the PHC provider where I am registered 71 Location close to home/work 35 Trust in health care provider 26 Health care provider attitude 14 The hours of service (opening and closing hours) 7 High quality services 7 The number of days services are available 6 Cleanliness of facility 6 Approachability of the health care provider 6 This PHC provider is the only available option 5 PHC provider provides a high level of privacy 5 Availability of medicines 4 Referral 4 Short waiting time in the health facility 4 Figure 67 shows the three areas most commonly identified by patients as needing improvement in the facilities where they receive care. On average, 20% of patients wanted to improve specialized services and care availability; 12% wanted improvement in overall infrastructure, amenities, and cleanliness, which includes improving disability-friendly infrastructure and having comfortable waiting areas; and 8% wanted to improve the availability and functioning of required equipment, supplies, and medicines. 150 Service Delivery Indicators Health Survey for Moldova – Overview of Results Figure 67. Percentage of patients identifying area for improvement in health facilities: Top-three areas 20% 12% 8% Specialized services Availability and functioning of Good infrastructure, amenities, or care availability required equipment, supplies, or and/or cleanliness (including medicine disability-friendly infrastructure, comfort of waiting area) Table 54 provides a complete listing of all areas identified by patients as needing improvement. Aside from the top three reasons mentioned above, other common areas that patients identified as needing improvement in facilities were related to appointment scheduling (5%), respect from staff (4%), wait or consultation times (3%), and the age of providers (45), among others. Table 54. Percentage of patients identifying various aspects of health facility as needing improvement Reason Percent Specialized services or care availability 20 Good infrastructure, amenities, and/or cleanliness 12 Availability and functioning of required equipment, supplies, or medicines 8 Appointment scheduling 5 Level of respect/courtesy from health facility staff 4 Number/age of providers/provider days of operation 4 Clear communication (listening or explaining) with health care provider(s) 3 Short waiting time in the health facility before being seen for consultation 3 Length of consultation(s) with health care provider(s) 3 Days facility is open/hours of operation 2 Clinical competence of health care provider(s) 2 Availability of health care provider(s) who are likely to prescribe medicine(s) or treatment(s) 2 Absence of health care provider(s) from the health facility during hours of operation 1 Privacy at the health facility 1 Adherence to COVID-19 protocols and/or concerns about COVID-19 safety 1 151 Service Delivery Indicators Health Survey for Moldova – Overview of Results Figure 68 shows patients’ ratings of health care providers’ abilities and skills within regions and facilities. On average, 37% of patients rated health care providers’ abilities and skills as very good, 59% as good, and 4% as moderate. No patients reported perceiving providers’ abilities and skills as bad. Overall, more than 50% of patients rated skills and abilities of providers at three facility types as very good: private health centers providers were rated very good by 63% of patients, individual family doctor offices (60%), and consultative diagnostic centers (56%). Among patients at family doctor centers, 13% rated skills and abilities of providers as moderate. Figure 68. Patients’ ratings of health care providers’ abilities and skills (%) Consultative diagnostic center Private health center Facility Type Family doctor center Individual family doctor office Health office Family doctor office Health center UTA Gagauzia Urban South Region North Center Average 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Bad Moderate Good Very good 152 Service Delivery Indicators Health Survey for Moldova – Overview of Results 5.2. Financial Protection 5.2.1. Opportunity Costs The last domain under person-centered outcomes is financial protection. The survey asked patients not only about direct costs incurred, such as for travel, services, and medicines; but also about indirect costs, such as income lost in seeking care. This insight helps to shed light on how travel time and travel cost affect access to primary health care. Table 55 shows median values for time taken to reach the facility as reported by patients. The median travel time to the facility for patients was 15 minutes. For private health center patients, it took 20 minutes to reach the facility. Overall, 22% of patients reported long travel time as a challenge to accessing services at the facility. Table 55. Time to reach facility, by region (minutes) Median time to reach the facility Region Center 15 North 15 South 15 Urban 15 UTA Gagauzia 15 Facility type Health center 15 Family doctor office 15 Health office 10 Individual family doctor office 10 Family doctor center 15 Private health center 20 Consultative diagnostic center 15 Average 15 Table 56 presents the proportion of patients who lost income when seeking care at the facility. Only six patients reported increased cost due to child or elderly care, at an average cost of MDL 160. Overall, 24% of patients reported loss of income when seeking services. Loss of income was particularly prevalent in the Center region (reported by 38% of patients), Urban region (33%), and UTA Gagauzia (31%). Within facilities, lost income was reported by 38% of patients at family doctor centers and by 31% at private health centers. The proportion 153 Service Delivery Indicators Health Survey for Moldova – Overview of Results of patients reporting income loss was lowest in the South (11%) and North (8%) regions, as well as in health offices (2%). Table 56. Income lost due to seeking care, by region Percentage of patients who lost income Region Center 38 North 8 South 11 Urban 33 UTA Gagauzia 31 Facility type Health center 22 Family doctor office 20 Health office 2 Individual family doctor office 18 Family doctor center 38 Private health center 31 Consultative diagnostic center 22 Average 24 5.2.2. Out-of-Pocket Costs Table 57 shows the median costs to reach the facility and for consultations as reported by patients who reported paying anything for the respective costs being measured. It should be noted that approximately 34% of patients reported any cost for travel to the facility and only 1% reported any cost for consultation. The median cost to reach the health facility, among those who reported spending anything, was 15 MDL. The median cost of consultations reported by patients who incurred them was 156 MDL. Travel costs did not seem to vary widely, with those patients in the North region (20 MDL) and who sought care at private health centers (30 MDL) and family doctor offices (20 MDL) reporting the highest expenditure for travel to the health facility. Consultation costs varied widely and may be predominantly explained by the relatively low amount of patients who reported spending anything for consultation. 154 Service Delivery Indicators Health Survey for Moldova – Overview of Results Table 57. Median costs for travel to facility and consultation Cost to reach the health facility Consultation cost (n=507) (n=20) Region Center 20 0 North 10 0 South 15 250 Urban 5 150 UTA Gagauzia 6 8 Facility type Health center 15 8 Family doctor office 20 1500 Health office 10 250 Individual family doctor office 10 2 Family doctor center 3 100 Private health center 30 250 Consultative diagnostic center 4 115 Average 15 156 Of the 20 patients who reported expenditure for their consultation and diagnostics, the average cost was MDL 188, and health insurance was the source most patients used to cover cost of the health visit. Figure 69 provides the percentage of patients who identified savings or health insurance as the main source of money used to pay for health care the day of the visit (including transport to the health facility, consultation, gifts, medicine, and laboratory tests). Patients were asked a multiple-choice question about which sources they utilized when borrowing money to pay for their health care, thus percentages in this figure do not sum to 100%. Overall, 28% of patients used their savings or household budget and 38% used health insurance to pay for health care visits. Most patients in consultative diagnostic centers (70%) and private health centers (66%) reported using their savings or regular household budget to pay for health care visits. By region, 55% of patients in the North reported using health insurance to cover costs. 155 Service Delivery Indicators Health Survey for Moldova – Overview of Results Figure 69. Patients reporting each source of money for current health care visit, among those who reported any out-of-pocket expenditure (%) (N=20) Average 38% 29% 4% Center 70% 18% Region North 66% 26% South 56% Urban 43% 29% 40% UTA Gagauzia 17% Health center 37% 17% 48% Family doctor office 21% Facility Type 24% Health office 54% Individual family doctor office 33% 34% 44% Family doctor center 10% Private health center 55% 15% 35% Consultative diagnostic center 29% Health insurance Savings or regular household budget Note: Patients were asked about multiple potential sources of borrowed money to pay for care, thus these data do not sum to 100%. Table 58 presents the percentage of facilities which reported collecting revenue from paid medical services in the past 12 months that require certain groups to pay for services. On average, 42% of these facilities reported patients paying for services not included in the Unique Programme of Mandatory Health Insurance. Among private health centers, 67% 156 Service Delivery Indicators Health Survey for Moldova – Overview of Results report payment by patients; the share is 64% in health centers and 60% in the Urban region. Among facilities in the UTA Gagauzia region, 64% reported patients had to pay because they were not registered at the institution. The most common reason for patients paying for services was that they were uninsured; this was the chief reason among family doctor offices (94%), health offices (67%), and in the Center region (67%). Table 58. Facilities not exempting patients from fees (%) (N = 45) Percentage of facilities where following groups pay fees Services needed by patient are Patient Patient has not included is not Patient is no referral for in the Unique registered at uninsured diagnostic tests Programme institution of Mandatory Health Insurance Region Center 29 0 4 67 North 45 0 55 0 South 0 0 59 41 Urban 32 4 60 4 UTA Gagauzia 64 0 36 0 Facility Type Health center 33 0 64 2 Family doctor office 6 0 0 94 Health office 33 0 0 67 Individual family doctor office 25 8 50 17 Family doctor center 48 0 52 0 Private health center 33 0 67 0 Consultative diagnostic center 0 0 0 0 Average 28 1 42 29 157 Service Delivery Indicators Health Survey for Moldova – Overview of Results 6. Conclusions Key findings from this survey highlight several important achievements, as well as areas where the PHC system in Moldova could improve to ensure that every citizen has access to high-quality primary health care services. The achievements—such as high patient-reported satisfaction with care, low unexcused absence rates of PHC providers across surveyed health facilities, and both wide and high-quality provision of services for key noncommunicable diseases, particularly hypertension and diabetes—highlight a key strength of Moldova’s PHC system: patients quite often receive the care that they sought. Further, few patients reported that they incurred direct costs of care; and if they did, the costs for services and transport to the health facility were low. While these achievements are worthy of celebration, several areas have also been identified for improvement in the Moldovan PHC system, as detailed below. Opportunity costs for patients seeking care Nearly one in four patients (24%) reported losing income as a result of seeking care on the day of the survey. While this is not a direct responsibility of the health facility, it reflects a health system challenge that may be attributable to other factors, such as shortcomings in employment leave policies. Addressing these concerns may require intersectoral investments and intervention. Continuity of referral systems Nearly all patients (95%) shared that they were the ones to transfer their health information to the facilities and providers they were referred to. This finding highlights the need for targeted and sustained investment in standardized referral information systems and suggests considerable scope for digital solutions. Infrastructure to support differently abled persons Most facilities with steps or inclines had a ramp (71%), but few had a lift (9%) available for differently abled persons. Less than half of all facilities had tactile flooring (42%), and only 14% had assistive technology for visually impaired individuals or accessible toilets. Availability of these infrastructural components was not uniform across survey regions or facility types, indicating that where differently abled patients seek care notably impacts their access to the infrastructure necessary for their receipt of services. 158 Service Delivery Indicators Health Survey for Moldova – Overview of Results Interruptions to key health facility infrastructure While most facilities (98%) had a functioning primary power source on the day of the interview, only 69% reported that they had experienced no interruption to electricity during the reference three-month period from September to November 2021. Similarly, 80% of facilities had functioning internet on the day of the survey, but only 63% of facilities mentioned that they had no interruptions to their internet connection during the same three-month reference period. While nearly all health facilities (95%) had a functional water source available on the day of the interview, a somewhat smaller share (about 89%) reported that they had uninterrupted water services over the three-month reference period, and only 56% had uninterrupted water services that were also on the health facility’s premises. Availability of services for mental health, family planning and cervical cancer screenings, and infectious diseases On average, facilities offered 83% of all mandated PHC services. The proportions of mandated services were below average for mental health (70%), infectious disease (66%), and OB-GYN (50%) services were below average. Only about half of the facilities in the survey reported that they have at least one provider who can provide services for IUD insertion (45%) or provide emergency contraceptive pills (53%), while 76% of facilities reported that they had at least one provider who can perform a pap smear. Diagnosis, treatment, and counseling for patients with TB, HIV, and syphilis were generally low and predominantly available in consultative diagnostic centers and family doctor centers. It will be important to ensure that Moldova focuses on improving and monitoring the capacity of family doctors to provide mental health services and screen for cervical cancer and infectious diseases such as TB, HIV, and syphilis using clinical indications, particularly since lab and imaging equipment seems to be concentrated in consultative diagnostic centers. Human resources for health While doctors and nurses spent most of their time (61% for nurses and 63% for doctors) on direct patient care, nearly a quarter of their time (28% for nurses and 26% for doctors) was spent on administrative tasks. Approximately one in five providers (22%) report that they feel nonclinical work impedes their clinical duties. Investing in nonclinical staff and shifting administrative tasks to nonclinical staff may allow providers to spend more time on direct patient care, as well as provide more space for professional development. The median tenure of doctors and nurses in their current role at their current facility was similar, at 25 and 21 years, respectively. Addressing issues of an aging health workforce, particularly in areas outside of Chisinau and Balti, will warrant particular attention as Moldova considers further investment in both the health and education sectors. 159 Service Delivery Indicators Health Survey for Moldova – Overview of Results Emergency preparedness and infection prevention and control infrastructure While many facilities had access to basic sanitation services, this survey found that many facilities did not have infection prevention and control infrastructure (such as designated entry and waiting areas for patients with suspected infectious diseases and physical barriers at points of patient presentation). Further, while protocols and guidelines for emergency preparedness were widely available, few emergency drills and structural vulnerability assessments were conducted. Management and supervisory structures Generally, health care providers (namely nurses) were satisfied with the support that they received from their manager (often the family doctor at the health facility where interviews took place). However, when health facility managers were asked about the frequency and comprehensiveness of supportive supervision visits, many stated that these visits were not comprehensive. One of the key components of supportive supervision in need of improvement is provision of feedback to health facilities from the external supervisors: only 61% of facilities reported that they received feedback as part of their most recent supportive supervision visit. Concluding remarks The ability to measure and assess PHC is a core component of health system strengthening. The SDI health survey has provided a structured approach to the measurement of PHC and presents information that is immediately relevant and actionable. While the results highlighted in the report are not meant to provide an exhaustive list of all areas of relative success and potential improvement, they do provide information that may be immediately leveraged by policy makers hoping to bolster Moldova’s PHC system. This SDI health survey has captured only a cross- sectional synopsis of Moldova’s PHC system, but the standardized nature of the survey lends itself well to future assessments of PHC in Moldova. The SDI health survey not only seeks to inform top-down approaches to primary health care and health system strengthening, but also pays special attention to person-centered outcomes. Many of these data may be pertinent to policy makers, but citizens and groups advocating for PHC strengthening in Moldova can also leverage the data presented in this study. These data and this report could ideally serve as a baseline to anchor dialogue related to PHC and health system strengthening across Moldova and the rest of the region. 160 Annexes Annex A. Statistics Table A.1. Outpatient volume over a three-month period (median), by type of service, region, and facility type Child Adult Child im- Child Cervical Total out- Antenatal growth Adult tu- non-com- Adult Hyperten- Mental muniza- pneumo- cancer patient care monitor- berculosis municable diabetes sion health tion nia screening volume ing disease Region Center 18 16 38 5 220 42 151 7 2 11 1,150 North 6 20 31 1 224 35 129 6 0 9 735 South 21 19 48 2 313 63 178 7 1 15 909 Service Delivery Indicators Health Survey for Moldova – Overview of Results 161 Urban 94 206 531 64 968 211 568 12 8 63 7,158 UTA Gagauzia 12 62 75 1 1,693 97 713 17 17 17 3,403 Facility Type Health center 40 54 180 13 796 97 480 21 5 38 2,573 Family doctor 18 21 41 1 297 50 189 7 1 13 1,046 office Health office 4 8 15 1 73 12 58 3 0 3 250 Individual family 25 25 134 15 617 89 214 34 1 19 1,692 doctor office Family doctor 72 480 774 122 2186 282 1,088 20 12 172 20,748 center Private health 47 68 485 0 932 132 580 7 15 82 3,759 center Consultative 762 826 2,589 922 10,196 2,805 5,945 1,348 21 388 79,015 diagnostic center Average 16 20 41 3 254 47 168 7 1 11 1,020 Service Delivery Indicators Health Survey for Moldova – Overview of Results Table A.2. Percentage of facilities offering required PHC services, by region and facility type Com- Infec- Psychia- All ser- munity Pediatric OB-GYN tious NCD try vices health disease Region Center 100 97 89 94 100 81 75 North 100 100 94 87 99 79 71 South 97 97 85 84 97 74 64 Urban 97 94 88 84 95 48 43 UTA Gagauzia 100 100 100 100 100 49 49 Facility Type Health center 100 100 99 94 98 84 82 Family doctor office 100 100 91 92 100 81 74 Health office 97 94 80 81 97 68 54 Individual family doctor office 100 100 85 85 100 77 62 Family doctor center 100 95 100 100 100 57 52 Private health center 100 100 86 93 100 30 30 Consultative diagnostic center 100 100 100 100 100 50 50 Average 99 98 90 90 99 77 69 Table A.3. Percentage of facilities offering specialized imaging and required laboratory services, by region and facility type Specialized imaging services Required laboratory services Region Center 6 18 North 17 40 South 15 18 Urban 43 66 UTA Gagauzia 12 49 Facility Type Health center 21 71 Family doctor office 10 19 Health office 6 9 Individual family doctor office 0 0 Family doctor center 67 62 Private health center 77 61 Consultative diagnostic center 100 100 Average 13 28 162 Service Delivery Indicators Health Survey for Moldova – Overview of Results Table A.4. Median facility registered population, by region and facility type Region Facility registered population Region Center 1,282 North 1,303 South 1,081 Urban 9,850 UTA Gagauzia 4,700 Facility type Health center 5,025 Family doctor office 1,350 Health office 426 Individual family doctor office 2,020 Family doctor center 13,720 Private health center 6,400 Consultative diagnostic center 49,780 Average 1,350 Table A.5. Facility administrative board activity, by region and facility type (cumulative %) Percentage of facilities with administrative board that met in past year: At least At least At least At least At least every three every six weekly monthly annually months months Region Center 0 5 88 100 100 North 6 43 97 100 100 South 4 26 94 100 100 Urban 9 14 95 98 100 UTA Gagauzia 0 17 100 100 100 Facility Type Health center 10 27 90 100 100 Family doctor office 0 14 93 100 100 Health office 0 30 96 100 100 Individual family doctor office 20 80 80 100 100 Family doctor center 11 17 95 100 100 Private health center 9 18 80 89 100 Consultative diagnostic center 0 0 100 100 100 Average 3 22 93 100 100 163 Service Delivery Indicators Health Survey for Moldova – Overview of Results Table A.6. Facility supervision, by region Percentage of facilities with Percentage of facilities with at least one supportive supervisory visit that covered all supervision visit in past 12 supervisory visit components (N months (N = 247) = 224) Region Center 87 45 North 86 55 South 82 40 Urban 97 65 UTA Gagauzia 100 7 Facility Type Health center 96 51 Family doctor office 90 50 Health office 72 40 Individual family doctor office 92 42 Family doctor center 95 75 Private health center 93 35 Consultative diagnostic center 100 75 Average 87 48 Table A.5. Facility administrative board activity, by region and facility type (cumulative %) Percentage of Percentage of facilities with feedback data shared with facilities that following (N = 236): review feedback data regularly Facility Community advisory External (N = 246) management and board/population/ leadership staff patients Region Center 95 93 97 94 North 99 95 95 99 South 87 92 100 83 Urban 98 86 97 97 UTA Gagauzia 100 100 100 100 Facility Type Health center 99 96 99 92 Family doctor office 94 97 98 96 Health office 94 87 94 92 Individual family doctor office 100 69 100 69 Family doctor center 100 86 95 100 Private health center 100 68 100 93 Consultative diagnostic center 100 100 100 100 Average 95 93 97 94 164 Table A.8. Community feedback about areas of improvement, by facility type Percentage of facilities that reported each area as most common feedback from registered population and/or patients (N = 247) Community feedback Individual Family Family Private Consultative Health Health family doctor doctor health diagnostic Average center office doctor office center center center office No feedback 23 32 20 54 14 15 0 27 Services or care availability 10 11 19 23 24 7 25 13 Availability and functioning of required 13 5 19 15 5 15 0 11 equipment, supplies, or medicine Service Delivery Indicators Health Survey for Moldova – Overview of Results Waiting time in the health facility before being seen 165 16 8 8 0 14 8 25 10 for consultation by health care provider(s) Good infrastructure amenities and/or cleanliness (including 4 13 9 0 10 0 0 9 disability-friendly infrastructure, comfort of waiting area) Doctor availability/ 4 4 11 0 0 0 0 6 number of providers Adherence to COVID-19 protocols and/or concerns 10 2 1 0 5 0 0 3 about COVID-19 safety Scheduling appointments 5 2 2 0 10 8 50 3 Length of consultation(s) with health care 4 0 2 0 5 15 0 2 provider(s) Table A.9. Positive community feedback, by facility type Service Delivery Indicators Health Survey for Moldova – Overview of Results Percentage of facilities that reported each area as most common positive feedback from registered population and/ or patients (N = 247) Community feedback Individual Family Family Private Consultative Health Health family doctor doctor health diagnostic Average center office doctor office center center center office Services or care availability 21 23 29 15 19 15 0 24 Level of respect/courtesy 26 15 17 23 29 7 0 18 from health facility staff Clear communication (listening or explaining) 16 13 13 0 0 8 0 13 with health care provider(s) Clinical competence of 166 11 9 14 8 29 48 75 11 health care provider(s) Availability of health care provider(s) from the health 6 12 4 23 5 0 0 8 facility during hours of operation No feedback 5 12 3 8 0 0 0 8 Good infrastructure amenities and/or cleanliness (including 7 3 4 15 5 0 0 4 disability-friendly infrastructure, comfort of waiting area) Availability of health care provider(s) who are likely 4 2 9 0 0 7 0 4 to prescribe medicine(s) or treatment(s) Days facility is open/hours 1 0 1 0 5 0 0 1 of operation Service Delivery Indicators Health Survey for Moldova – Overview of Results Table A.10. Management capacity, by region and facility type (N = 247) Percentage Percentage Percentage of Percentage of facilities of facilities facilities with of facilities where in- with health support staff using tools to charge holds care provider performance support staff a degree in performance reviews performance management reviews Region Center 81 91 83 99 North 68 93 87 95 South 79 85 78 96 Urban 89 92 91 100 UTA Gagauzia 100 93 93 100 Facility Type Health center 82 91 91 100 Family doctor office 74 94 83 99 Health office 79 87 81 93 Individual family doctor office 54 46 54 85 Family doctor center 76 100 90 100 Private health center 85 70 70 100 Consultative diagnostic center 100 100 100 100 Average 77 91 84 97 167 Table A.11. Staff performance tool(s) and criteria used, by region and facility type (N = 247) Service Delivery Indicators Health Survey for Moldova – Overview of Results Percentage of facilities that use each tool Registered Average Supervisor/ Self- Peer population/ Knowledge Clinical record number of in-charge assessments assessments patient assessments review tools used assessments assessments (mean) Region Center 48 48 79 51 49 50 3.3 North 52 46 49 41 46 39 2.7 South 78 59 76 45 65 63 3.8 Urban 76 75 85 65 76 77 4.5 UTA Gagauzia 76 93 100 93 93 93 5.5 Facility Type 168 Health center 56 47 82 71 50 44 3.5 Family doctor office 60 52 71 42 53 55 3.3 Health office 52 52 55 37 54 47 3.0 Individual family doctor office 69 54 54 38 46 46 3.1 Family doctor center 90 86 86 71 81 90 5.0 Private health center 70 69 77 63 49 62 3.7 Consultative diagnostic center 75 100 100 75 100 100 5.5 Average 57 52 69 48 53 51 3.3 Table A.12. In-service training selection criteria, by region and facility type Percentage of facilities with in-service training selection, by method (N = 247) Training Provider Provider Ensure all At least Provider Provider Provider need specialty licensing providers one specific interest/ performance availability assessments and training requirements/ receive same process request assessment offered regulations training Region Center 96 32 56 66 49 65 64 40 North 95 27 43 54 30 41 49 11 South 98 49 35 64 36 49 43 40 Urban 96 25 41 69 45 72 72 54 UTA Gagauzia 100 100 7 19 19 24 19 12 Service Delivery Indicators Health Survey for Moldova – Overview of Results Facility Type 169 Health center 100 44 57 68 44 54 69 35 Family doctor office 100 27 48 66 33 60 53 29 Health office 87 37 31 47 46 41 42 27 Individual family doctor 100 46 46 54 23 38 54 15 office Family doctor center 100 33 62 81 52 76 76 62 Private health center 83 45 46 54 32 54 55 31 Consultative diagnostic 100 50 75 75 75 75 100 100 center Average 96 34 46 61 39 54 54 30 Service Delivery Indicators Health Survey for Moldova – Overview of Results Table A.13. Accessibility of facility for people with disabilities, by region and facility type (N = 247) Percent- Percent- Per- Percentage of Percent- age of age of centage Percentage accessibility age of facilities facilities of fa- of facilities features present facilities with with a cilities with tactile as share of all with a assistive acces- with a flooring possible acces- lift technol- sible ramp sibility features ogy toilet Region Center 2 67 5 5 29 22 North 5 69 11 21 43 30 South 18 74 38 13 62 41 Urban 25 93 13 25 37 37 UTA Gagauzia 57 100 12 49 93 62 Facility Type Health center 19 85 20 31 44 40 Family doctor office 3 75 13 8 39 28 Health office 3 47 10 7 43 22 Individual family doctor office 23 85 8 38 38 38 Family doctor center 57 90 14 38 43 49 Private health center 15 100 23 25 61 45 Consultative diagnostic center 100 100 0 50 100 70 Average 8 70 14 14 42 30 170 Table A.14. Prescence of various physical infrastructure items, by region and facility type (N = 247) Percentage of facilities with the following: Improved, At least one Infection Appropriate Functional Functioning, functioning, functional prevention Functioning waste incinerator uninterrupted uninterrupted, refrigerator for and control fire safety disposal with fuel electricity on-premises blood and/or infrastructure water source vaccines Region Center 23 95 0.8 46 53 51 31 North 29 96 20 34 80 58 36 South 47 100 5 61 77 53 59 Urban 50 100 8 86 70 84 48 UTA Gagauzia 44 100 0 93 100 100 93 Service Delivery Indicators Health Survey for Moldova – Overview of Results Facility Type 171 Health center 55 97 7 71 52 64 54 Family doctor office 33 98 10 53 66 60 44 Health office 9 95 6 18 83 41 20 Individual family doctor 38 100 15 38 62 54 31 office Family doctor center 57 100 10 67 90 76 67 Private health center 39 100 0 100 79 85 60 Consultative diagnostic 100 100 0 100 100 100 25 center Average 32 97 8 48 69 56 40 Service Delivery Indicators Health Survey for Moldova – Overview of Results Table A.15. Prescence of hygiene infrastructure attributes, by region and facility type (N = 247) Percentage of facilities with the following: Toilets for females At least one Dedicated Toilets (including menstrual hand hygiene toilets for staff hygiene facilities) station Region Center 95 1 35 63 North 71 12 36 61 South 98 8 38 44 Urban 100 7 84 72 UTA Gagauzia 100 49 56 100 Facility Type Health center 97 17 69 82 Family doctor office 91 5 33 60 Health office 74 0.5 17 38 Individual family doctor office 92 31 69 92 Family doctor center 90 0 86 57 Private health center 100 39 86 100 Consultative diagnostic center 100 25 100 75 Average 88 7 39 59 Table A.16. Prescence of consultation room attributes, by region and facility type Percentage of facilities with at least one consultation room with the following: Auditory and Functional Functioning Functioning visual privacy light source heater fan or AC Region Center 100 96 98 100 North 100 100 98 100 South 98 100 100 93 Urban 98 98 100 100 UTA Gagauzia 100 100 88 100 Facility Type Health center 100 100 99 100 Family doctor office 99 100 99 96 Health office 100 95 98 100 Individual family doctor office 100 92 100 100 Family doctor center 100 100 100 100 Private health center 100 100 100 100 Consultative diagnostic center 100 100 99 100 Average 99 98 99 98 172 Service Delivery Indicators Health Survey for Moldova – Overview of Results Table A.17. List of assessed facility equipment and supplies Equipment Category Item Medical equipment Adult weighing scale Medical equipment Child weighing scale (250 g gradation) Medical equipment Infant weighing scale (100 g gradation) Medical equipment MUAC measuring tape Medical equipment Measuring tape - height board/stadiometer Medical equipment Length measurement board Medical equipment Newborn examination table Medical equipment Digital thermometer (for measuring human body temperature) Medical equipment Mercury thermometer (for measuring human temperature) Medical equipment Stethoscope Medical equipment Obstetric stethoscope Blood pressure apparatus (may be digital or manual Medical equipment sphygmomanometer with stethoscope) Medical equipment Blood pressure strap for children Medical equipment Cassolettes (medium, large) Medical equipment Mobile table for medical instruments Medical equipment Armchair / table for gynecological examination Medical equipment Pelviometer Medical equipment Otoscope Medical equipment Ophthalmoscope Medical equipment Pipette Medical equipment Ordinary portable examination lamp 173 Service Delivery Indicators Health Survey for Moldova – Overview of Results Equipment Category Item Medical equipment Gastric tube Medical equipment Guyon syringe for ear washes Medical equipment Pulse Oximeter Medical equipment Kramer splint, set Medical equipment Vision chart Medical equipment Computers information system Medical equipment Printer Medical equipment Set of eye tonometers 6-channel stationary electrocardiograph with automatic Medical equipment decoding Medical equipment 3-channel portable electrocardiograph Medical equipment Peak flowmeter for adults Medical equipment Peak flowmeter for children Medical equipment Cholesterol meter Medical equipment Neurological examination set Medical instruments Gynecological speculum Medical instruments Dressing forceps Medical instruments Anatomic Forceps/tweezers Medical instruments Surgical forceps Medical instruments Bent, straight surgical scissors Medical vascular catheters, various (elastic catheters no. Medical instruments 11, 18 etc.) Special purpose articles and objects Family doctor kit Special purpose articles and objects Garrote 174 Service Delivery Indicators Health Survey for Moldova – Overview of Results Equipment Category Item Special purpose articles and objects Garrote hemostatic Special purpose articles and objects Glass tubes Special purpose articles and objects Tubes holder Special purpose articles and objects Centimeter ribbon Special purpose articles and objects Stopwatch Special purpose articles and objects Goniometer Special purpose articles and objects Rectal tubes (mature, newborn) Special purpose articles and objects Lingual fixator Special purpose articles and objects Oral dilator Special purpose articles and objects Neurological hammer Special purpose articles and objects Set for tracheostomy Special purpose articles and objects Set for minor surgery Special purpose articles and objects Scalpel (u.f.) Special purpose articles and objects Rubber bulbs of different sizes Special purpose articles and objects Infusion stand Special purpose articles and objects Hand-washing soap/liquid soap Special purpose articles and objects Alcohol-based hand rub Special purpose articles and objects Disposable latex gloves Special purpose articles and objects Waste receptacle (pedal bin) with lid and plastic bin liner Special purpose articles and objects Other waste receptacle Laboratory equipment and supplies Medical spatula (single use) Laboratory equipment and supplies Clinical laboratory set 175 Service Delivery Indicators Health Survey for Moldova – Overview of Results Equipment Category Item Laboratory equipment and supplies Surgical needles Laboratory equipment and supplies Syringes 2ml, 5ml, 10ml etc. Laboratory equipment and supplies Infusion system Laboratory equipment and supplies Medical gauze Laboratory equipment and supplies Medicinal cotton wool (sterile, non-sterile) Laboratory equipment and supplies Non-sterile surgical gloves Laboratory equipment and supplies Sterile surgical gloves Laboratory equipment and supplies Silk in ampoules (3 sizes) Laboratory equipment and supplies Catgut in ampoules (3 sizes) Laboratory equipment and supplies Dressing packages (sterile, non-sterile) Laboratory equipment and supplies Various plasters Express diagnostic tests (blood sugar, hematuria, Laboratory equipment and supplies acetonemia) Laboratory equipment and supplies Roll adhesive tape Laboratory equipment and supplies Hypothermic package Laboratory equipment and supplies Diapers Laboratory equipment and supplies Prescriptions, medical forms Medical furniture and associated Shield equipment Medical furniture and associated Medical couch equipment Medical furniture and associated The doctor's table equipment Medical furniture and associated Medicine cabinet equipment Sterilization equipment Electric autoclave (pressure & wet heat) Sterilization equipment Nonelectric autoclave 176 Service Delivery Indicators Health Survey for Moldova – Overview of Results Equipment Category Item Sterilization equipment UV lamp for air disinfection Sterilization equipment Electric boiler or steamer (no pressure) Sterilization equipment Electric dry heat sterilizer Sterilization equipment Nonelectric pot with cover for boiling/steam Sterilization equipment Heat source for nonelectric equipment Sterilization equipment Chemical sterilization (Plasma sterilization) Sterilization equipment Cetrimide 15% + Chlorhexidine 7.5% Sterilization equipment Chlorine powder (≥ 30% active chlorine) Sterilization equipment Glutaraldehyde solution with 2% OPA Sterilization equipment Hand disinfectant solution with dispenser Sterilization equipment Hydrogen peroxide 6% (20 vol) Sterilization equipment Povidone iodine solution 5% w/v Sterilization equipment Povidone iodine solution 10% w/v for skin preparation Sterilization equipment Spirit, rectified Imaging equipment X-ray Imaging equipment Ultrasonography (USG) Imaging equipment USG with doppler Imaging equipment Echocardiogram 177 Table A.18. Equipment availability, by region and facility type Service Delivery Indicators Health Survey for Moldova – Overview of Results Percentage of equipment available and functioning in each equipment category Medical Special- furniture and Laboratory Imaging Medical Medical Sterilization purpose associated equipment and equipment equipment instruments equipment articles equipment supplies (N = 57) (N = 247) (N = 247) (N = 117) (N = 247) (N = 247) (N = 97) Region Center 76 76 76 90 87 64 58 North 79 72 77 94 95 68 68 South 80 77 77 94 84 60 58 Urban 85 84 83 97 91 72 71 UTA Gagauzia 91 61 77 100 95 69 89 178 Facility Type Health center 90 88 87 100 90 69 60 Family doctor office 80 76 76 92 87 63 56 Health office 65 62 68 88 94 60 0 Individual family doctor 85 68 76 96 0 50 0 office Family doctor center 91 93 90 99 94 70 70 Private health center 84 87 83 100 93 73 71 Consultative diagnostic 96 100 100 100 100 88 100 center Average 78 75 77 93 90 66 65 Service Delivery Indicators Health Survey for Moldova – Overview of Results Table A.19. Medicine availability by category and region (N = 247) Percentage of facilities with: At least one At least one No available Medicine observed (expired) observed (not medicine medicine expired) medicine Noncommunicable diseases Captoprilum 6 0 94 Nifedipinum 20 0 80 Magnesium sulfas 6 1 93 Furosemidum 3 0 97 Nitroglycerinum 9 0 91 Strophanthinum 22 0 77 Verapamilum 38 0 61 Salbutamolum neb 22 1 77 Salbutamolum susp 21 0 79 Aminophyllinum 10 0 90 Natrii chloridum available 1 0 99 Benzylpenicillinum 46 0 54 Diazepamum 33 0 67 Paracetamol 2 0 98 Hydrocortison/Dexametason 5 0 95 Calcium chloridum 8 0 92 Calcium gluconas 13 0 87 NaCl+KCl+Glucosum 7 0 93 Carbo activatus 9 0 91 Oxytocin available 19 0 81 Etamsylatum 8 0 92 Glucosum 5 1 94 Epinephrin 19 0 81 Atropini sulfas 20 0 80 Amiodaronum 33 0 66 Lidocaini 20 0 80 Clemastinum IJ 6 0 94 Clemastinum tabs 40 0 60 Chloropyraminum IJ 36 0 64 Chloropyraminum tabs 57 1 42 179 Service Delivery Indicators Health Survey for Moldova – Overview of Results Percentage of facilities with: At least one At least one No available Medicine observed (expired) observed (not medicine medicine expired) medicine Natrii chloridum amp 5 0 94 Papaverini hydrochloridum 4 0 96 amp Drotaverinum 11 0 88 Caffeinum 24 0 75 Nicethamidum 27 0 72 Iodine 5 0 95 Spiritus aethylicus 2 0 98 OB-GYN Magnesium sulfas 6 1 93 Oxytocin 19 0 81 Etamsylatum 8 0 92 Pediatric Benzylpenicillinum 46 0 54 NaCl+KCl+Glucosum 7 0 93 Carbo activatus 9 0 91 BCG 91 1 8 DPT 18 0 82 DPT-Hib+HepB 19 0 81 HepB 36 0 64 HPV 29 0 71 MMR 20 0 80 PCV 13 21 0 79 IPV 18 0 82 OPV 20 0 80 PVRV 89 0 11 Td 17 0 83 RV 19 0 81 Anti-Covid 19 23 0 77 180 Service Delivery Indicators Health Survey for Moldova – Overview of Results Percentage of facilities with: At least one At least one No available Medicine observed (expired) observed (not medicine medicine expired) medicine Vaccines BCG 91 1 8 DPT 18 0 82 DPT-Hib+HepB 19 0 81 HepB 36 0 64 HPV 29 0 71 MMR 20 0 80 PCV 13 21 0 79 IPV 18 0 82 OPV 20 0 80 PVRV 89 0 11 Td 17 0 83 RV 19 0 81 Anti-COVID 19 23 0 77 Infectious diseases Paracetamol 2 0 98 NaCl+KCl+Glucosum 7 0 93 Carbo activatus 9 0 91 Other diseases Natrii chloridum 1 0 99 Natrii chloridum amp 5 1 94 Iodine 5 0 95 Spiritus aethylicus 2 0 98 Note: Availability of medicine is defined as the facility having at least one observable full prescription. If there is no prescription at all, the medicine is considered unavailable. If a full prescription is available, it is then considered expired or unexpired based upon the date stamped on the product by the manufacturer. 181 Service Delivery Indicators Health Survey for Moldova – Overview of Results Table A.20. PHC staff composition by region and facility type (%) (N = 247) PHC staff composition Health care provider Other staff Region Center 56 44 North 60 40 South 58 42 Urban 60 40 UTA Gagauzia 67 33 Facility Type Health center 60 40 Family doctor office 61 39 Health office 53 47 Individual family doctor office 59 41 Family doctor center 64 36 Private health center 57 43 Consultative diagnostic center 57 43 Average 58 42 Table A.21. Reasons for doctor absence, by region and facility type (N = 119) Percentage of facilities with the following: At a Materni- Train- subor- ty/ pa- Earned Medical ing/ Sickness dinate Off day ternity leave leave seminar/ institu- leave meeting tion Region Center 10 26 14 12 2 27 5 North 0 8 6 0 3 54 6 South 0 0 35 29 0 12 12 Urban 0 27 20 14 16 6 1 UTA Gagauzia 0 100 0 0 0 0 0 Facility Type Health center 5 22 24 12 0 21 4 Family doctor office 0 15 15 15 15 23 8 Health office 0 4 0 4 0 62 8 Individual family doctor office 0 35 14 24 19 0 2 Family doctor center 0 0 0 50 0 50 0 Private health center 0 23 23 0 22 0 0 Consultative diagnostic center 2 22 18 12 9 19 4 Average 1 26 15 15 8 14 11 182 Service Delivery Indicators Health Survey for Moldova – Overview of Results Table A.22. Reasons for nurse absence, by region and facility type (N = 162) Percentage of nurses absent for the following reasons: At a Materni- Train- subor- ty/ pa- Earned Medical ing/ Sickness dinate Off day ternity leave leave seminar/ institu- leave meeting tion Region Center 7 28 21 29 0 2 4 North 0 22 9 12 0 42 0 South 2 10 29 20 0 16 9 Urban 3 27 19 19 16 6 2 UTA Gagauzia 0 100 0 0 0 0 0 Facility Type Health center 3 35 13 18 0 17 3 Family doctor office 15 0 41 37 0 0 0 Health office 0 0 0 33 0 33 0 Individual family doctor office 20 0 20 0 0 0 40 Family doctor center 3 17 19 17 31 7 1 Private health center 0 0 39 20 0 33 8 Consultative diagnostic center 0 21 39 25 0 0 0 Average 3 27 18 19 7 14 3 Table A.23. Percentage of facilities with at least one provider trained in required PHC services, by region and facility type Com- Infec- Psychia- munity Pediatric OB-GYN tious dis- NCD try health ease Region Center 100 97 89 94 100 81 North 100 100 94 87 99 79 South 97 97 85 84 97 74 Urban 97 94 88 84 95 48 UTA Gagauzia 100 100 100 100 100 49 Facility Type Health center 100 100 99 94 98 84 Family doctor office 100 100 91 92 100 81 Health office 97 94 80 81 97 68 Individual family doctor office 100 100 85 85 100 77 Family doctor center 100 95 100 100 100 57 Private health center 100 100 86 93 100 30 Consultative diagnostic center 100 100 100 100 100 50 Average 99 98 90 90 99 77 183 Service Delivery Indicators Health Survey for Moldova – Overview of Results Table A.24. Percentage of facilities with at least one provider trained in specialized services, by region and facility type Ophthalmol- Surgical ENT Dermatology ogy Region Center 46 66 67 72 North 37 64 59 67 South 16 37 26 23 Urban 51 70 69 63 UTA Gagauzia 19 7 7 0 Facility Type Health center 50 63 69 72 Family doctor office 32 62 54 60 Health office 32 46 43 45 Individual family doctor office 15 46 46 62 Family doctor center 86 95 90 71 Private health center 40 86 86 70 Consultative diagnostic center 100 100 100 100 Average 37 59 55 59 Table A.25. Patient care and retention, by region and facility type (N= 1,496) Percentage of Percentage of Percentage of patients who patients intending patients who would received intended to get second return for similar care opinion service Region Center 99 14 98 North 100 10 99 South 99 2 99 UTA Gagauzia 99 4 100 Urban 100 6 96 Facility Type Health center 99 7 99 Family doctor office 99 11 98 Health office 100 16 98 Individual family doctor office 100 2 100 Family doctor center 100 8 93 Private health center 100 4 99 Consultative diagnostic center 100 0 100 184 Service Delivery Indicators Health Survey for Moldova – Overview of Results Annex B. Description of SDI Subdomains 1. Foundations Systems Policies and protocols: The successful operation of a PHC facility relies on adherence to operational and process guidelines, including safety and human resources protocols, and high-quality clinical care aligned with international and local clinical guidelines for patient examination/consultation, diagnosis, and treatment. While appropriate implementation of and adherence to guidelines can be difficult to measure, part of the health facility environment that enables adherence to guidelines includes the physical availability in the facility of such guidelines for reference by staff. Against this backdrop, the SDI health survey includes the physical verification of the presence of the most up-to-date written guidelines on both operations/processes such as IPC, waste management, emergency preparedness, human resource guidelines, and clinical practice including family planning consultation protocols, and diagnosis and treatment of hypertension, and pneumonia. Institutions tasked with accountability for quality: Ensuring accountability for quality requires not only routine data collection by facilities on indicators capturing high-quality clinical and interpersonal care, but also frequent review, analysis, and dissemination of this information. To promote transparency and quality improvement, information on performance should be shared not only with facility management and higher-level administrators, but also with facility staff and the population that the facility serves. The SDI health survey captures the frequency with which facility-level performance indicators are collected, reviewed, and shared, and it also provides information on whom the data are shared with. The survey also measures how and how often feedback is solicited from the population served by the facility. Finally, the survey captures the institutions and practices in place for external supervision, such as supportive supervision visits from central authorities, and the extent to which any supervisory activities adhere to the WHO definition of “supportive32”. Management and supervision: It is not just the broader accountability architecture that influences the quality of PHC service delivery, but also the direct management and supervision of staff members. The management and supervision domain focuses on the procedures and practices within a health facility to review staff performance and provide feedback and support for improvement. These include measuring how frequently staff are provided with performance feedback, and using certain indicators and protocols to measure performance and conduct staff evaluations. 32WHO. 2008. Training for Mid-level Managers (MLM). Module 4: Supportive Supervision. Geneva: WHO (republished 2020). https://apps.who.int/iris/bitstream/handle/10665/337056/9789240015692-eng.pdf 185 Service Delivery Indicators Health Survey for Moldova – Overview of Results Financing: The financing systems in health facilities have implications for facility-level and provider-level incentives, efficiency, and accountability. Information on financing at the facility level includes the sources and amount of revenue that facilities generate. Funds flowing into a facility may come from government or other sources, including private or donor sources, and may be in cash or in kind. The extent to which health care providers receive payment in the form of gifts, such as from patients, or other incentives for outcomes/performance may influence staff behavior and facility functioning. Physical infrastructure: This component measures the availability and functioning of key physical infrastructure required for operation of the health facility, especially in cases of emergency. This includes the availability and functioning of infrastructure to facilitate utilization of services by differently abled populations—such as ramps, lifts, tactile flooring, toilets for clients with limited mobility, and assistive technologies for visually impaired clients; provisions for auditory and visual privacy for patients; improved, functioning, accessible, and private toilet facilities; handwashing facilities; uninterrupted electricity; ambient temperature management infrastructure—heaters and air conditioners/fans; refrigerators for vaccine and blood storage; functioning fire safety infrastructure—alarm, extinguisher; and ICT—telephone, radio, computer, internet. Care Organization Service delivery organization: This domain captures the high-level organization of care— how PHC services are delivered in the country and how facilities are situated to serve their registered populations. It includes description of the types of facilities that deliver PHC, their location—noting their connectivity to the population through local public transportation and motorable roads; the size of the population they serve and how accessible they are to this population, which is the average time it takes for the registered population to reach the facility; outreach practices; and facilities’ opening hours/hours of operation. Facility connective networks: In many cases, service delivery can be strengthened by connective networks between health facilities that allow seamless transfer of patients and information. Facility connective networks refer to systems that allow for inter-facility communication and enable health facilities to connect patients to other facilities or practitioners for further care. Facilities may be part of formal designated networks that share staff and infrastructure and/or are part of formal referral systems. Facilities may also be connected by systems for communicating with one another during emergencies, or may have an ambulance or other form of transportation on site that facilitates linkage of patients to other facilities. This domain captures the existence of these connective systems, but does not cover the performance or effectiveness of these facility networks. 186 Service Delivery Indicators Health Survey for Moldova – Overview of Results Service and case mix: This domain captures the number and types of PHC services that are available at the facility, including availability of laboratory services. Services may be available, for example, infrastructure, human resources, equipment, and supplies are present, but this does not necessarily mean that patients utilize them. This domain captures both availability and utilization, hence measuring allocative efficiency—whether facilities provide mandated services and whether these services are utilized. This domain also includes measures of outpatient volume, stratified by case type, such as births, NCD visits, and childhood immunization visits. This domain records which facilities are overburdened by particular types of cases and, therefore, what additional resources or referral patterns are required. Workforce Availability: This domain describes the de facto and de jure human resources at the health facility. It includes counts of staff of different cadres, counts of providers of different types of care such as outpatient care, inpatient care, and antenatal care, and the number of administrative/support staff. Particularly in large facilities, the number of health care providers on the staff roster may not truly reflect the number of health care providers present on a given day. This discrepancy may arise for many reasons including shift systems, on-call protocols, arrangements where health care providers perform home visits or provide care at subsidiary facilities, and the presence of individuals in management roles who have medical training but serve as facility administrators or managers who are not patient-facing. The literature33 has also indicated that staff may be absent from health facilities for unauthorized reasons, which affects performance management and accountability—this domain measures these aspects. Education and training: Beyond just the availability of staff, the distribution of educational attainment and training of health care providers has implications for quality of clinical and interpersonal care. This domain measures the preservice education level of providers at each facility, along with recent service-specific in-service trainings. Combined with information on the types and volume of cases, this domain measures whether certain trainings are being administered where needed. Workload: A high workload impacts the ability of health care providers to provide high-quality care. Overworked and burnt-out health care providers are more likely to misdiagnose, provide incorrect treatment, or not counsel patients. It is therefore essential to better understand health care providers’ workload. In low- and middle-income countries, it is common for health care providers to be involved in administrative activities like filling out insurance paperwork, managing medical supplies, etc. This role becomes even more 33World Bank. 2021. The Quality of Health and Education Systems across Africa: Evidence from a Decade of Service Delivery Indicators Surveys. Washington, DC: World Bank. https://openknowledge.worldbank.org/handle/10986/36234 187 Service Delivery Indicators Health Survey for Moldova – Overview of Results necessary in small health facilities that are run by just one or two staff members. Therefore, in measuring the workload among health care providers, the analysis accounts for both their clinical caseload and their nonclinical work. This domain also provides an understanding of how the time of health care providers is distributed across various activities. Satisfaction and retention: Individuals’ job satisfaction is closely related to their work performance and their motivation to continue to learn and grow at their workplace. For health care providers, satisfaction affects the quality of care, their interaction with patients, absence, and willingness to continue to work, especially in high-stress environments. Thus, providers’ job satisfaction affects patients’ satisfaction and influences their decisions on accessing and continuing care. There is a need to improve job satisfaction among the health care workforce to build effective, efficient, and resilient health systems. This domain measures health care providers’ satisfaction across various relevant domains, including pay/ benefit package, workload, and promotion and transfer system. Tools Medical equipment and supplies: Availability of functioning medical equipment and supplies is required to provide high-quality health care. Health care providers might not be able to diagnose and treat patients or might do so incorrectly if the health facilities do not have the essential medical items like stethoscope, syringe. When medical conditions like TB and other communicable diseases go undiagnosed/misdiagnosed, the effect on the individual and community can be catastrophic. In some cases of shortage/unavailability of essential medical supplies like syringes and gloves, providers try to optimize the current stock or reuse medical supplies that should be disposed of after single use. This can lead to hospital-acquired infections. Patients also tend to lose trust in health systems, seek care elsewhere, or not seek care at all, when they are not able to receive care due to supply shortage. This component provides a comprehensive picture of whether health facilities are stocked with essential medical equipment and supplies by making direct observations and checking for functionality. A health facility is recorded as having a given medical supply/ piece of equipment if the field team can physically verify even one such item. Medicines: This domain provides information on availability of unexpired essential medicines for PHC. Unavailability of medicines can influence patient’s behavior on care uptake and continuation. In remote areas where health facilities are the only source of affordable medicines, unavailability/shortage of medicines can keep patients from following up with the recommended treatment or can cause them to incur a high out-of-pocket expenditure, which can also impact patients’ economic well-being. If patients start considering health facilities as unreliable, they may turn to traditional sources of care, which they may deem to be more accessible and dependable. This component provides a comprehensive picture of whether health facilities have essential PHC medicines by making direct observations. This 188 Service Delivery Indicators Health Survey for Moldova – Overview of Results component also records whether the available medicines are expired to provide information not just on their availability but also on their usability. A health facility is recorded as having a said medicine if the field team can physically verify even one full prescription of that unexpired medicine. Information systems: The use of information systems to record and manage relevant data is essential for health facilities to make data-driven decisions, whether for tracking patient history or managing supply of medical items. For example, health facilities that do not use a logistics management information system or any other logistics system to manage their medical supplies are more likely to face stock-outs as it becomes difficult to manage inventory. Further, such facility-level data, when aggregated at macro level, provide important insights about the health system in the country, such as the country’s current disease burden. Having this information helps to shed light on the state of the health system and ongoing challenges and also helps in design of targeted interventions to improve the quality of health care. This domain measures various kinds of information systems used in health facilities—data reporting systems, staff trained in using these information systems, and other systems in place to share information with other health facilities and/or authorities. 2. Processes of Care Competent Care Systems Diagnosis, treatment, counseling: While inputs like medical equipment, medicines, and clinical guidelines, and basic infrastructure such as electricity and water supply, and telephone are essential to provide high-quality care, their availability does not guarantee the same. It is common for patients to receive subpar care, including misdiagnosis of medical conditions, or not to receive any care even at well-equipped health facilities. This possibility has led to a gradual shift to incorporate other measures along with availability of inputs to better understand the performance of health systems. This domain sheds light on the level of competent care provided for common medical conditions like diabetes, hypertension, and others. It also measures incompetent care like incorrect diagnosis, treatment delays, and overprescription of drugs, all of which can have harmful short-term and long-term effects. The analysis uses a two-pronged approach: to test providers’ knowledge in diagnosing and treating specific medical conditions through clinical case simulations, and to capture the actual experience of patients in receiving care for these medical conditions. This enables assessment regarding whether health care providers have appropriate medical knowledge for providing high-quality care and to capture any “know- do” gap – the gap between providers’ knowledge and their actual practice – by comparing their performance on clinical case simulations to the actual experience of patients. Clinical case simulations and the outpatient exit interview provide the means to capture other 189 Service Delivery Indicators Health Survey for Moldova – Overview of Results aspects of care quality, like whether the health care provider counseled the patient about any lifestyle change, or whether they explained the frequency and dosage of medicines. Referral, continuity, integration: This domain triangulates information from all three SDI questionnaires—facility, health care provider, and outpatient exit interview—to provide a comprehensive picture of the way referrals work within the health system, the likelihood of patients receiving care from the same health facility/provider, and the extent to which health facilities are connected to one another. For a better understanding of the referral system, the analysis reports on the number of referrals made from/to health facilities, common reasons for referrals, type of health facility from/to which referrals are made, and how patient information is transferred from/to health facilities. This information identifies gaps in the overall functioning of the referral system. For example, better guidelines and systems would need to be set up if health facilities lacked a well-defined structure to share patient information to the referred health facility. By improving referral systems, authorities can ensure that health facilities provide high-quality care according to their service mandate, and patients can navigate the health system with ease. The willingness of patients to continue to receive care from the same health facility/provider is an important measure of health systems that provide high-quality care. Such continuation of care builds provider-patient relationships, creates expectations around care, and increases the likelihood that patients will follow through with the treatment process in a timely manner. When sharing medical history with different health facilities/providers is difficult—as may be the case in low- and middle-income countries, where “central” systems that record and share such information with ease are often absent or do not function optimally—patients may experience delays in diagnosis and treatment. Safety, prevention, detection: Along with providing timely diagnosis and treatment to patients, PHC systems also need to have mechanisms and guidelines in place for early detection of an outbreak, prevention of health care–associated infections, and response to emergencies. The COVID-19 pandemic showed the importance of resilient health systems that can aid in early detection and surveillance of an epidemic/pandemic and can respond to health emergencies along with providing routine health services. This domain provides an understanding of the IPC measures in health facilities such as patient isolation room, guidelines on emergency response – for example, how to request emergency medical supplies, and preparedness against fire and natural disasters. This domain also records in- service trainings, like training on antimicrobial resistance, and disaster assessments and drills that have been conducted in health facilities. 190 Service Delivery Indicators Health Survey for Moldova – Overview of Results Positive User Experience Respect and autonomy: Along with providing timely treatment, high-quality health systems must also treat patients with respect, account for their needs and preferences, and involve them in decisions regarding their health and treatment. Whether patients seeking care feel empowered and respected, or belittled and disrespected, influences their care-seeking behavior and trust in the overall health system. Even with all the required resources and systems in place, good health outcomes would be difficult to achieve if patients refrain from seeking care to avoid a negative and disrespectful experience. This domain measures the extent to which patients are treated with respect at various stages of their consultation with the health care provider. Indicators of respectful care include whether providers greet and introduce themselves, how well providers explain things to patients, and whether providers obtain their consent before a procedure. This information from the patients’ experience is also compared to the relevant sections from clinical case simulations – for example, whether providers introduce themselves, whether they counsel the patient on medicine dosage/next steps – to highlight any gaps between providers’ knowledge and their practice. User focus: User-centered health care systems focus on patients’ needs and preferences to ensure that they can receive high-quality care with ease. Such systems anticipate various bottlenecks that can arise right from the time that a patient decides to seek care, and they design measures to address those challenges. Measurement of user-focused care includes average wait time to see a health care provider, average travel time to the health facility, and care provided in patient’s primary language. The analysis triangulates information like facility-reported hours of operation and patient-reported satisfaction with facility’s operating hours from the three surveys to identify areas that may better cater to patients’ needs. 3. Person-Centered Outcomes Confidence in System Satisfaction and recommendation: Patient satisfaction is essential for high-quality PHC systems, as it influences care-seeking behavior and hence health outcomes. Patients bypass health facilities when they are not satisfied with the care—a result that can unevenly distribute workload and patient volume across health facilities, thus disrupting the effectiveness of health systems. Patient dissatisfaction may worsen in close-knit communities, where word of mouth spreads perceptions easily, and people consider other people’s experiences and recommendations when seeking care. There are several factors such as average wait time and out-of-pocket expenditure, apart from access to health care and timely diagnosis and treatment, that impact patient satisfaction. This domain reports on the level of patients’ 191 Service Delivery Indicators Health Survey for Moldova – Overview of Results satisfaction with care and whether patients would recommend others to seek care from their provider. It also seeks to identify patients’ reasons for seeking care from a particular health facility and the areas that should be improved at the health facility. Care uptake and retention: This domain captures patients seeking care at more than one facility and their reasons for doing so. Additionally, it captures patients’ intention to return to the health facility for care—for example, pregnant women willing to give birth in the same health facility where they received ANC services. In high-quality PHC systems, patients continue to seek care at one facility unless referred to another facility. This ensures that patients do not bypass specific health facilities and that they can also seek care from providers who are familiar with their medical history, needs, and preferences. Financial Protection Out of pocket costs: Patients may face barriers or trade-offs in seeking PHC, which can reduce care utilization and have long-term economic impact, resulting in poor health outcomes. For example, patients receiving PHC at a health facility may incur costs including transport to reach the health facility itself or costs for childcare or elderly care while family members receive care. Once at the health facility, patients may pay out of pocket for consultation fees(or gifts to providers, medicines, and supplies. This domain captures out-of-pocket costs and the source of these funds, including whether patients needed to borrow money or take out a loan to pay for the services received. Opportunity costs: In addition to direct out-of-pocket costs, patients often incur opportunity costs to visit a health facility, such as lost income due to time taken off from work. These costs may be particularly burdensome for patients who work in informal labor markets and/ or do not have paid medical leave. Quantifying these costs along with the out-of-pocket expenditure enables a more accurate measure of the true financial burden of care seeking. 192 Service Delivery Indicators Health Survey for Moldova – Overview of Results Annex C. Sampling Background Primary care in Moldova was reorganized in 2010 and is described in the Order on Primary Health Care in Moldova34. This reorganization enables primary care provision by both public and private providers and includes a network of facilities at various levels. Moldova is divided into 32 raions (administrative units), with three municipalities – Chisinau, Balti, and Bender – and two autonomous territorial units, Gagauzia and Transnistria. Based on national guidance for this survey, urban areas were defined as the cities of Chisinau and Balti, while all other areas were classified as rural. The survey designated five major regions for sampling: Urban, North, Center, UTA Gagauzia, and South. Transnistria was excluded because of the difference in the organization of its health system and limited access for enumerators and survey teams. In urban areas, territorial medical associations (AMTs) play the central role in primary care provision. Chisinau has five AMTs, each consisting of two to three family doctor centers, along with 14 autonomous health centers, seven private facilities contracted by the National Health Insurance Company (NHIC), and four centers for diagnostic consultations, which also report to the AMT and were sampled. In Balti, the primary health care provider contracted by NHIC is the family doctor center Balti, with seven affiliated health centers and one family doctor office. In rural areas, primary care is provided by health centers, family doctor offices, and health offices. Health centers are larger facilities, which usually offer both inpatient and outpatient treatment and are staffed by a team of doctors. They are usually responsible for a particular catchment area, such as the surrounding locality or localities. Health centers manage smaller outlying facilities, such as family doctor offices and health offices, which offer outpatient care. Physicians may rotate between the health center and the outlying facilities on a fixed schedule. Facility Selection The first objective of the survey required drawing nationally and subnationally representative samples of facilities providing primary health care in Moldova. To qualify for inclusion, facilities had to be currently in operation and providing outpatient primary care, and had to be contracted by the NHIC. Certain facility types, including hospitals, were excluded from 34Ministry of Health, Labour and Social Protection, Order No. 695, October 13, 2010. https://www.cidsr.md/wp-content/ uploads/2015/02/Ordin_no_695_din_13.10.2010-Cu-privire-Asistenta-med-primara.pdf 193 Service Delivery Indicators Health Survey for Moldova – Overview of Results the survey, as they provide advanced care beyond the scope of the survey. Pharmacies were excluded as well, as they are not directly involved in patient diagnosis; in addition, they are not included in the PHC facility network since they are fully privatized. Three additional facilities were excluded in Chisinau: one center for diagnostic consultation, which offered only specialist care; and two family doctor centers, which were attached to a hospital and offered care only to particular groups—university students or civil servants. These facilities were excluded because they have a specialized purpose that may not reflect the average patient’s primary care experience. A full listing of facilities was provided by the MoH, of which 1,320 facilities met the eligibility criteria. To form a sample frame, this listing was stratified by facility type and the five major regions, including the South, Central, and North regions, as well as UTA Gagauzia and an urban zone consisting of Chisinau and Balti. Stratified sampling refers to dividing the sample into subpopulations and sampling separately from each of these subpopulations. This approach ensures that all relevant subgroups are represented in the sample and allows comparison of indicators across the strata. Given the different structure of care between urban/rural areas and the differences in provision of care based on facility types, stratification was done by facility type – consultative diagnostic center/individual family doctor office/family doctor center/health center/family doctor office/health office/private – and by urban/rural location. The strata are shown in table C.1, with each row representing a stratum. From the sample frame, facilities were selected within each stratum based upon probability proportional to their registered population, meaning that those facilities representing a larger proportion of the population had higher probabilities of selection into the sample than those representing smaller registered populations. The sample size for each stratum was chosen in order to minimize statistical error in estimation of facility-level indicators. This necessitated taking a census of some facility types, such as urban facilities. Among strata with more facilities, selection was done using probability proportional to size (PPS) sampling, based on the registered population of each facility, which increased the likelihood of sampling facilities with a larger population. PPS sampling helped ensure that the facilities selected were representative of the care available to the entire population. The facilities within each stratum were sorted by region (North/Center/South) and by raion, creating an implicit stratification that ensured that the geographic distribution of the sample was representative. The total number of selected facilities in each stratum is shown in table C.1, and a geographic breakdown is shown in table C.2. The sample consisted of 250 facilities, and the full sample frame is shown for reference. It was designed to facilitate detection of a difference in availability of medicine or other facility-level variables of at least 10 percentage points in urban versus rural facilities with 95% confidence35. 35This is based on 0% standard error in the urban census and 5.3% standard error in the rural PPS sample. 194 Service Delivery Indicators Health Survey for Moldova – Overview of Results Table C.1. Summary of facilities included in the sample frame, stratified by urban/rural and facility type Registered Total number Sampled Location Type of facility population of facilities facilities Consultative diagnostic center (Centrul 184,421 4 4 Consulativ Diagnostic) Family doctor center (Centrul Medicilor de 427,205 12 12 Familie) Health center (Centrul de Sanatate) 275,080 24 24 Urban Family doctor office (Oficiul Medicului de 16,151 9 9 Familie) Health office (Oficiu de Sanatate) 939 2 2 Private health center 99,367 8 8 Individual family doctor office (Cabinetul 29,462 15 15 Individual al Medicului de Familie) Family doctor center (Centrul Medicilor de 18,879 8 8 Familie) Health center (Centrul de Sanatate) 1,282,390 249 54 Rural Family doctor office (Oficiul Medicului de 909,076 620 53 Familie) Health office (Oficiu de Sanatate) 152,534 366 53 Private health center 34,657 8 8 TOTAL 3,430,161 1,325 250 195 Service Delivery Indicators Health Survey for Moldova – Overview of Results Table C.2. Sampled facilities by raion Individual Consultative Family Family family Health Health Raion diagnostic doctor doctor Private Total doctor center office center center office office Anenii Noi 3 2 1 1 7 Balti 7 1 8 Basarabeasca 1 1 Briceni 1 1 2 1 5 Cahul 2 2 2 3 9 Calarasi 1 2 1 1 5 Cantemir 1 2 2 5 Causeni 1 2 2 1 6 Chisinau 4 12 17 8 2 8 51 Cimislia 5 1 1 3 10 Criuleni 1 1 2 4 Dondiuseni 1 2 0 3 Drochia 2 1 1 1 5 Dubasari 1 2 1 4 Edinet 1 2 1 4 Falesti 1 2 4 7 Floresti 2 3 3 8 Glodeni 2 1 3 Hincesti 3 2 2 1 8 Ialoveni 2 4 2 2 10 Leova 1 1 1 3 Nisporeni 1 2 2 5 Ocnita 2 1 3 Orhei 2 4 3 2 2 1 14 Rezina 1 1 1 1 4 Riscani 1 1 3 5 Singerei 2 1 5 8 Soldanesti 3 0 2 5 Soroca 2 2 2 6 Stefan Voda 1 2 1 4 Straseni 3 2 1 6 Taraclia 2 1 1 4 Telenesti 2 3 5 UTA Gagauzia 4 1 5 Ungheni 3 2 4 1 10 Total 4 15 20 78 62 55 16 250 196 Service Delivery Indicators Health Survey for Moldova – Overview of Results Health Care Provider Selection The second objective for the SDI health survey was to measure providers’ effort, clinical knowledge and competence, and work environment. The goal was to select a simple random sample of the health care professionals who routinely provide primary care. In Moldova, only physicians are licensed to provide clinical diagnostic and therapeutic services, while nurses perform health promotion, disease prevention, counseling, medical manipulations, vaccination, documentation, and application of emergency care/measures until the arrival of the doctor. Although both physicians and nurses were invited for a provider survey, sampling for the two cadres was done separately, and the content of the survey was also different for each. Physician Sampling To obtain a sample of physicians, a sample frame was created using the full list of doctors provided by the Ministry of Health, where each physician was mapped to the head medical facility (reporting facility, usually a health center) that the physician was assigned to. In Moldova, all physicians are mapped to one head facility, but they may offer services (for instance, a few days per week) at the lower-level facilities (for example, health offices or family doctor offices) affiliated with the head facility. The sample frame was drawn from 78 health facilities that were selected for the facility survey. All physician interviews took place at the head facility, and the survey team had to make necessary arrangements in consultation with the facility manager/in-charge, at least 10 days in advance, to ensure that all selected doctors were at the head facility on the day that the enumerators visited the facility to conduct provider interviews. The final sample frame consisted of 770 physicians from 70 facilities; provider-level information was unavailable for an additional eight health centers. This sample frame allowed the estimated target number of physicians to be interviewed at each selected facility prior to the enumerator visiting the facility. This innovation, as opposed to using an arbitrary target/cutoff threshold for the number of providers, enabled sample selection to increase statistical efficiency—minimize sampling error36. To balance the trade- off between statistical precision and logistical constraints such as interview length and enumerator time, the sample size of physicians to be interviewed was calculated using an assumption that up to four interviews would be completed per day. A total of 486 doctors were sampled to provide a margin of error of 2.5% on provider-level indicators. During survey implementation, enumerators aimed to interview doctors at each facility, using the following protocol: 36Sampling error at the provider level was estimated at 2.5% across all facilities. The sampling error ranged between 0% and 35% per facility, depending on the number of physicians in each facility and the number interviewed. The overall confidence in provider-level estimates depends on both the facility-level and the provider-level sampling error. 197 Service Delivery Indicators Health Survey for Moldova – Overview of Results • The total number of doctors, N, from each head medical facility was indicated in the provider-level sampling Excel document. Approximately 10 days prior to arriving at the facility, the survey team worked with the facility in-charge to confirm or adjust the full roster and arrive at the correct N, including only doctors who were actively providing outpatient care. • Upon the team’s arrival at the facility, the previously selected number, n, were randomly pulled from the revised roster. This list of doctors was scheduled for interviews, and the enumerators worked with the facility to find appropriate times to interview each doctor individually. Doctors that chose to opt out of the survey were replaced. Enumerators continued interviewing doctors, with the goal of reaching n doctors. As part of the provider survey, physicians were assessed on their clinical competence using clinical vignettes, which aimed to measure the diagnostic ability, treatments, and behavior of providers by simulating an interaction with a potential patient. The SDI health survey in Moldova used five clinical vignettes, and each physician was requested to participate in two randomly selected vignettes. Vignette selection was done randomly, as there was no prior evidence that supported differential performance of providers across the various disease categories covered by the current list of vignettes used in Moldova. Nurse Sampling The SDI health survey interviewed primary care nurses at the 250 selected health facilities. At the 172 lower-level facilities, all nurses on duty were interviewed, as each facility was generally served by one to three nurses. At the 78 higher-level facilities, the total number of nurses interviewed was the same as the total number of physicians selected for an interview. A simple random sample of nurses was drawn from within each facility at the higher-level facilities, as nurses are not mapped to the physicians but to the facility directly. Nurses received a shortened version of the provider questionnaire, which excluded the clinical vignettes. A total of 830 nurses were sampled, assuming two nurses per lower-level facility and the same number of nurses as doctors at higher-level facilities. Patient Selection The third objective of the SDI health survey was to measure patients’ experience of and satisfaction with care using a simple random sample of patients availing themselves of care at the 250 selected health facilities. Patients were enrolled upon exiting the facility. The survey implementation team used the protocol below, which was based on the collaboration of an interviewer, a patient handler, and the administrative staff, and which started before the beginning of the workday. The steps are as follows: 198 Service Delivery Indicators Health Survey for Moldova – Overview of Results • Anticipate the total number, N, of patients who will arrive to be seen by doctors at the facility in the workday. Most patients in the Moldovan context arrive by appointment, not spontaneously, so this estimate is based on the number of appointments in a day. • Define the number, n, of interviews that the interviewer can be expected to conduct in the workday. For instance, if the facility is open for health appointments for six hours and appointments take 30 minutes on average, then n = 12. • Compute the sampling step, s = N/n, rounding to an integer. • Recruit patients after consultation upon their exit of the facility. • Determine the serial number, f, of the first patient to be interviewed as a random integer between 1 and s. The patients to be interviewed will be those with serial numbers, f, f+s, f+2s. The protocol was designed to select a simple random sample from among all incoming patients. Some survey practitioners could consider it too laborious and complicated because it required the collaboration of two fieldworkers – the interviewer and the patient handler – and the anticipation of the total number of patients who would arrive at the health facility, which implies contacting the facility managers before the workday begins. Facility managers could thus be tempted to ask the interviewer to simply start interviewing the first outgoing patient, and then the next outgoing patient as soon as the first interview was complete. However, this alternative is vulnerable to several selection biases that can seriously affect the credibility of the study, namely: • Interviewer subjectivity when selecting the next outgoing patient, especially when multiple patients exit the facility simultaneously. • Differential nonresponse depending on various patient-related circumstances such as need to leave the facility after the appointment or, more importantly, satisfaction with the appointment. • Exclusion of the incoming patients who abandon the facility before being treated, possibly discouraged by long waiting times. • The demonstrated intrinsic tendency of this alternative to select the patients whose appointments take longer. The sampling strategy for patient recruitment was the same for all levels of facilities, but to reflect the services offered at the different levels of facility, the questionnaire used at the 199 Service Delivery Indicators Health Survey for Moldova – Overview of Results lower-level facilities was a shortened version of that used in the higher-level facilities. Survey Weights Given the multi-respondent nature of the SDI survey, weights were developed at multiple levels, depending upon how certain units of observation were nested within existing entities. For example, facilities were selected based upon probability proportional to their size (registered population); thus, the probability of selecting a facility (fi) is as follows: where n = total number of selected facilities; mi = registered population of facility i; = total registered population of the stratum (this is equivalent to the sum of the registered population for each facility in the stratum); and t = total number of facilities successfully interviewed in the stratum. Selection of providers was dependent upon the probability that a given provider’s facility was selected for interview. With this in mind, the probability of selecting a provider in a given facility (pi)37 was determined as follows: where n = total number of eligible providers in facility i; s = number of providers selected in facility i; t = number of providers successfully interviewed in facility i; and fi = probability of selection for facility i. The above provider weight is meant to serve as a means to adequately weight the selection of providers for the provider survey interview. However, part of the weight, ( ), overlaps with the potential absence of providers in the facility on the day of the interview. Thus, weighting for the provider absence indicator at the facility must exclude this term and be weighted as follows for the probability of a provider being selected (ai): where n = total number of eligible providers in facility i; s = number of providers selected in facility i; t = number of providers successfully interviewed in facility i; and fi = probability of selection for facility i. 37Note that selection of nurses followed the same protocol as selection of providers. Requisite information on the number of eligible nurses, selected nurses, and successfully interviewed nurses was needed to calculate these weights. 200 Service Delivery Indicators Health Survey for Moldova – Overview of Results Selection of patients was similar to selection of providers, though rather than being based upon a preexisting roster, patient selection was based upon a sampling fraction developed using the expected patient volume in the facility. Thus, the probability of selecting a patient in a given facility (pti) is expressed as follows: where n = number of patients presenting on the day of interview in facility i; s = number of patients selected in facility i; t = number of patients successfully interviewed in facility i; and fi = probability of selection for facility i. Survey weights were calculated as the inverse probability of selection, as follows: Facility = 1/fi Providers = 1/pi Patients = 1/pti Note that the weight for nurses was also the inverse probability of their selection. Probability of selection for nurses followed the same procedure as that for providers in (pi). Additional Notes Some strata were surveyed in their entirety (i.e., every facility within the stratum was selected for interview). In these cases, each facility had a probability of selection equal to 1. However, it was important to ensure that these facilities were weighted for potential nonresponse by calculating the following portion of the facility probability equation for any strata where all facilities were selected but any were not successfully interviewed: 201 Annex D. Description of Indicators Service Delivery Indicators Health Survey for Moldova – Overview of Results Domain Domain Domain level 3 Indicator name Definition Numerator level 1 level 2 Foundations Care Facility Emergency % of facilities with at least 1 vehicle present and Number of facilities that own a organization connective transport functional at the time of the survey (vehicle, four-wheeled motor vehicle or networks capacity functional, driver) vehicle operational from facility that has fuel and authorized staff to drive at time of visit Foundations Care Facility Lab on site % of facilities with laboratory services provided Number of facilities providing at organization connective on site least one laboratory service networks Foundations Care Service and case Outpatient Patient volume—outpatient total past 3 months Patient visits September– organization mix volume November 2021 Foundations Care Service and case Outpatient Visits by service type (NCDs, growth monitoring, Patient visits by type (ANC, child organization mix volume by etc.) immunization, child growth service monitoring, TB, NCD, adult diabetes, hypertension, mental 202 health, child pneumonia, cervical cancer screening) Foundations Care Service and case Fraction of % of facilities able to provide each service (and Number of facilities that were organization mix required services all services together) required at PHC level for able to provide each (and all) offered, by each of these service categories: community type(s) of service required at PHC category health, pediatric, OB-GYN, infectious diseases, level between September and NCD, psychiatry November 2021 Foundations Care Service and case Fraction of % of facilities able to provide each service (and Number of facilities that were organization mix nonrequired all services together) NOT required at PHC level able to provide each (and all) services offered, for each of these service categories: surgical, specialized service(s) between by category ENT, ophthalmology, dermatology September and November 2021. Foundations Care Service and case Fraction of % of facilities able to provide each lab service Number of facilities that were organization mix required labs (and all services together) required at PHC able to provide each (and all) offered, by level for each of these lab categories: basic and laboratory service(s) required at category routine tests, biochemistry, blood donation PHC level between September and services, hematology, microbiology November 2021. Domain Domain Domain level 3 Indicator name Definition Numerator level 1 level 2 Foundations Care Service and case Fraction of % of facilities able to provide each imaging Number of facilities that were able organization mix required imaging service (and all services together): medical X-ray, to provide each (and all) imaging offered ultrasound, advanced sonography service(s) between September and November 2021 Foundations Care Service delivery Facility Average of facility registered population size Total number of registered organization organization registered population population Foundations Care Service delivery Facility opening Distribution of opening days + hours (duration % of facilities open each day of organization organization hours of hours open) the week Average hours open per day (by day of the week) Foundations Care Service delivery Facility service % of facilities that experienced recent service Number of facilities that closed organization organization closures closures on a day other than Sunday or for a government holiday between Service Delivery Indicators Health Survey for Moldova – Overview of Results September and November 2021 203 by reason Foundations Care Service delivery Connectivity Distribution of average one-way time to reach Average one-way time to each organization organization (travel time) the health facility using the most common mode facility by mode of transportation of transportation in the registered population Foundations Care Service delivery Connectivity to % of facilities connected to motorable road Number of facilities connected to organization organization motorable road motorable road Foundations Care Service delivery Connectivity % of facilities with public transport station/stop Number of facilities with a public organization organization (public transport) within a 10-minute walk transportation station/stop within a 10-minute walk Foundations Systems Financing Visits with gifts % of visits with any gifts provided to health care Number of patients that provided staff gifts to health care provider(s) during the visit Foundations Systems Financing Value of gifts Distribution of value of gifts to providers Average amount of estimated provided value of gift provided to health care providers during visit Foundations Systems Financing Provider- % of providers receiving any performance Number of health care providers reported extra incentives that received a performance remuneration incentive in the past 12 months Service Delivery Indicators Health Survey for Moldova – Overview of Results Domain Domain Domain level 3 Indicator name Definition Numerator level 1 level 2 Foundations Systems Financing Provider- Average remuneration beyond set salary Average reported money received reported extra received in past year (provider-reported) as performance incentives in past remuneration 12 months Foundations Systems Financing Revenue sources Fraction of total revenue from NHIC, central Average revenue in 2020 by government funds, local government funds, source paid consults, paid diagnostic tests, paid laboratory tests, and other funds Foundations Systems Financing Total revenue Total revenue from insurance, government, Total revenue in 2020 patients (country-specific relevant categories) (over 12 months) Foundations Systems Financing Revenue from Total in-kind revenue (over 12 months) Total in-kind revenue in 2020 in-kind Foundations Systems Financing Fraction of in- Fraction of in-kind revenue from government vs. Total in-kind revenue from kind by source nongovernment sources (over 12 months) government sources in 2020 Total in-kind revenue from 204 nongovernment sources in 2020 Foundations Systems Financing Fraction of in- Fraction of in-kind revenue by type (vehicles, Total in-kind revenue by type in kind by type medical equipment, etc. per country-specific 2020 (vehicles and furniture and codes) (over 12 months) nonmedical equipment; medical equipment; furniture; medicines and supplies) Foundations Systems Institutions for Active % of facilities with administrative board that met Number of facilities where the accountability for community in past year; distribution of number of meetings administrative board met at least quality advisory board once in the past 12 months Number of facilities where the administrative board met constantly, weekly, monthly, every 3 months, every 6 months, and annually Foundations Systems Institutions for Any quality % of facilities having conducted quality Number of health facilities that accountability for improvement improvement activities over past 12 months identified responsible individual quality with known individual responsible for quality improvement activities Domain Domain Domain level 3 Indicator name Definition Numerator level 1 level 2 Foundations Systems Institutions for Facility quality % of facilities that review quality improvement Number of facilities that reviewed accountability for improvement data regularly quality improvement results at quality data use least annually Foundations Systems Institutions for Facility data % of facilities with quality improvement data Number of facilities that shared accountability for sharing: external shared with external leadership such as MoH or quality improvement data with quality leaders district at all, regularly external leadership or governing authorities at least annually Foundations Systems Institutions for Facility data % of facilities with quality improvement data Number of facilities that shared accountability for sharing: internal shared with facility management and staff at all, quality improvement data with quality staff regularly facility management and staff at least annually Foundations Systems Institutions for Facility data % of facilities with quality improvement data Number of facilities that shared accountability for sharing: shared with community advisory board/ quality improvement data with the quality community population/patients at all, regularly administrative board, registered population or patients Service Delivery Indicators Health Survey for Moldova – Overview of Results Foundations Systems Institutions for Quality % of facilities attaining any quality improvement Number of facilities that attained 205 accountability for improvement any performance indicator in the quality targets in place past 12 months Foundations Systems Institutions for Facility % of facilities with at least one supportive Number of facilities with one or accountability for supervision visits supervision visit in past 12 months; distribution more supervision visits in the past quality of number of visits 12 months Foundations Systems Institutions for Facility Facilities reporting supportive supervision Number of facilities whose accountability for supervision is visits that included sharing challenges, issues supportive supervision visit quality supportive identified, collective problem solving, AND included sharing challenges, written feedback issues identified, collective problem solving, AND written feedback Foundations Systems Institutions for Any feedback % of facilities having collected feedback from Number of facilities that sought accountability for collection from community in past 12 months feedback from their registered quality community population and/or patients in the past 12 months Foundations Systems Institutions for Facility feedback % of facilities that review feedback data Number of facilities that reviewed accountability for data use regularly population feedback at least quality annually Service Delivery Indicators Health Survey for Moldova – Overview of Results Domain Domain Domain level 3 Indicator name Definition Numerator level 1 level 2 Foundations Systems Institutions for Facility feedback % of facilities with feedback data shared with Number of facilities that shared accountability for data sharing: external leadership such as MoH or district at all, results of feedback from the quality external leaders regularly community with external leadership or governing authorities at least annually Foundations Systems Institutions for Facility feedback % of facilities with feedback data shared with Number of facilities that shared accountability for data sharing: facility management and staff at all, regularly results of feedback from the quality internal staff community with groups within the health facility at least annually Foundations Systems Institutions for Facility feedback % of facilities with feedback data shared with Number of facilities that shared accountability for data sharing: community advisory board/ population/patients results of feedback from the quality community at all, regularly community with the administrative board, registered population, or patients at least annually Foundations Systems Institutions for Improvement Most common community feedback about Frequency for the first 75% of the accountability for community area(s) of improvement for the health facility most common feedback about 206 quality feedback types (frequency of different feedback) area(s) of improvement the health facility received from its registered population and/or patients Foundations Systems Institutions for Positive Most common community positive feedback Frequency for the first 75% of the accountability for community about the health facility (frequency of different most common positive feedback quality feedback types feedback) about the health facility received from its registered population and/or patients Foundations Systems Management and Management % of facilities with management capacity: Number of facilities where the supervision capacity any of/all of management degree, in-service in-charge holds a degree in training, review in past 12 months management Foundations Systems Management and Facility conducts % of facilities with health care provider Number of facilities where supervision performance performance reviews in past 12 months (any) supervisor(s) held individual reviews (clinical meeting(s) with health care providers) provider(s) to review their performance Domain Domain Domain level 3 Indicator name Definition Numerator level 1 level 2 Foundations Systems Management and Facility conducts % of facilities with support staff performance Number of facilities where supervision performance reviews in past 12 months (any) supervisor(s) held individual reviews (support meeting(s) with support staff to staff) review their performance? Foundations Systems Management and Tools to % of facilities using at least one tool and defined Number of facilities that used at supervision support staff criteria to support staff performance; type of least one tool to assess health performance tool(s) and criteria used care provider or support staff performance Foundations Systems Management and Tools to Type of tool(s) and criteria used Number of facilities that used supervision support staff each of the tools to assess health performance care provider or support staff performance Foundations Systems Management and In-service % of facilities with a transparent method of Number of facilities that use at supervision training selection selecting people for training; distribution of least one of the defined processes selection criteria to determine which health care Service Delivery Indicators Health Survey for Moldova – Overview of Results provider(s) receive in-service 207 training Foundations Systems Management and In-service Distribution of selection criteria for selecting Number of facilities that used supervision training selection people for training each of the different processes to determine which health care provider(s) receive in-service training Foundations Systems Management and Providers' % of providers satisfied with their supervisors Number of providers that received supervision satisfaction with in terms of the support and guidance received the right amount of support support from from them and guidance from their direct supervisors supervisor. Foundations Systems Physical Accessibility of Proportion of attributes in place for patients Number of attributes each facility infrastructure facility for people with disabilities (ramp, lift, tactile flooring, has for patients with disabilities with disabilities assistive technologies for visually impaired, toilet accessible for people with limited mobility) Service Delivery Indicators Health Survey for Moldova – Overview of Results Domain Domain Domain level 3 Indicator name Definition Numerator level 1 level 2 Foundations Systems Physical Service % of facilities with infection prevention and Number of facilities with all infrastructure readiness: control infrastructure (physical barriers where infection prevention and control infection patients present, separate waiting area for infrastructure verified: physical prevention contagious patients, designated site for patient barriers where patients first isolation, beds spaced 1m apart, at least 1 present themselves, separate patient consultation room has environmental entrance for patients with a ventilation, container for soiled linens, suspected contagious disease, appropriate waste disposal (defined under designated site for patient numerator), hand hygiene (defined under isolation, appropriate waste numerator) disposal (infectious medical waste other than sharps is not visible or waste is disposed in a protected area), one point of care has at least one functional hand hygiene facility. Foundations Systems Physical Waste disposal % of facilities demonstrating appropriate waste Number of facilities with infrastructure disposal: segregated using correct color-coded appropriate waste disposal 208 bins; sharps, infectious, noninfectious, chemical, (segregated according to color, radioactive waste all disposed of safely and all types of waste are either not visible or in protected area) Foundations Systems Physical Functional % of facilities with functional incinerator with Number of facilities with at least infrastructure incinerator fuel/functional power source one incinerator that is functional, and power/fuel source for at least one incinerator is available Foundations Systems Physical Functioning % of facilities with at least one functioning Number of facilities with a infrastructure telephone telephone (can be landline, mobile, or functional landline telephone, smartphone) mobile phone, or smartphone Foundations Systems Physical Functioning % of facilities with functioning computer Number of facilities with at least infrastructure computer one computer functional Foundations Systems Physical Functioning % of facilities with functioning printer Number of facilities with at least infrastructure printer one printer functional Foundations Systems Physical Functioning, % of facilities with functioning, uninterrupted Number of facilities with infrastructure uninterrupted internet (no interruptions in last three months) functioning internet that did not internet experience any interruptions of internet access during September, October, November 2021 Domain Domain Domain level 3 Indicator name Definition Numerator level 1 level 2 Foundations Systems Physical Information and Number of functioning information and Average number of functioning IT infrastructure communications communications technology infrastructure items infrastructure items technology (of phone [any type], internet, computer, printer) Foundations Systems Physical Fire safety % of facilities with functioning fire safety (alarm Number of facilities with infrastructure infrastructure + extinguisher available + functioning) functioning fire safety items (at least one functional fire alarm/smoke detector and fire extinguisher) Foundations Systems Physical Functioning, % of facilities with functioning, uninterrupted Number of facilities with infrastructure uninterrupted electricity (from any source) with secondary functional main source of electricity with (backup) source (meaning: functioning today, no electricity, no interruptions backup interruptions in past three months, functioning between September and secondary source) November 2021, and at least one functioning secondary source of electricity Service Delivery Indicators Health Survey for Moldova – Overview of Results Foundations Systems Physical Water % of facilities with improved, functioning, Number of facilities with available 209 infrastructure uninterrupted, on-premises water source water source located on premises (functioning today, no interruptions in last three that have not experienced months, on premises) interruptions between September and November 2021 Foundations Systems Physical Toilets % of facilities with functioning improved, Number of facilities with at infrastructure functional, accessible, private toilets least one improved, functional, accessible, and private toilet within the premises in functioning condition for use by staff and patients Foundations Systems Physical Female toilets % of facilities with improved, functional, Number of facilities with at infrastructure accessible, and private toilet designated for least one improved, functional, females only that has menstrual hygiene accessible, and private toilet facilities designated for females only that has menstrual hygiene facilities Foundations Systems Physical Toilets for staff % of facilities with improved, functional, Number of facilities with at infrastructure accessible, and private toilet designated for staff least one improved, functional, only accessible, and private toilet designated for health facility staff only Service Delivery Indicators Health Survey for Moldova – Overview of Results Domain Domain Domain level 3 Indicator name Definition Numerator level 1 level 2 Foundations Systems Physical Hand hygiene % of facilities with at least one toilet that has Number of facilities with at infrastructure at least one functional handwashing facility least one toilet with at least one with water and soap within 5m of the toilet; functional handwashing facility and at least one point of care has at least one with water and soap within 5m of functional hand hygiene facility the toilet; and at least one point of care has at least one functional hand hygiene facility Foundations Systems Physical Consultation % of facilities with at least one consultation Number of facilities that have at infrastructure room with visual room with auditory and visual privacy least one consultation room with and auditory auditory and visual privacy privacy Foundations Systems Physical Light source % of facilities with at least one patient Number of facilities with at least infrastructure consultation room that has a functional light one patient consultation room source that has a functional light source Foundations Systems Physical Temperature % of facilities with availability of functioning Number of facilities with at least infrastructure control for cold heater in patient consultation rooms one patient consultation room 210 weather with at least one functional heater Foundations Systems Physical Temperature % of facilities with availability of functioning fan Number of facilities with at least infrastructure control for hot or AC in patient consultation rooms one patient consultation room weather with at least one functional AC unit Foundations Systems Physical Refrigerator % of facilities with least one functional Number of facilities with at infrastructure (blood or vaccine refrigerator (with temperature within least one refrigerator available storage) appropriate range as measured during survey) and functioning for the storage of blood and/or vaccines with recorded temperatures of 2–8°C Foundations Systems Policies and Clinical Physical presence of up-to-date guidelines for Number of clinical guidelines protocols guidelines efficient working of the health facility: % of available in the health facility clinical guidelines present Foundations Systems Policies and Guidelines for Physical presence of up-to-date guidelines for Number of emergency/IPC protocols emergency efficient working of the health facility: % of guidelines available in the health preparedness emergency/IPC guidelines present facility and IPC Foundations Tools Medical Test availability % of patients prescribed laboratory test(s) who Number of patients that received equipment and report receipt of all tests prescribed laboratory test(s) supplies Domain Domain Domain level 3 Indicator name Definition Numerator level 1 level 2 Foundations Tools Medical Equipment % of equipment available + functioning Number of equipment items in equipment and availability (wherever required) in each equipment category/block that are available supplies category defined (medical equipment, medical and functional at time of visit instruments, special-purpose articles and objects, lab equipment and supplies, medical furniture and associated equipment, sterilization equipment, imaging equipment) Foundations Tools Medicines Patient-reported % of patients prescribed medicine at the health Number of patient prescribed medicine facility on day of visit medicine prescription Foundations Tools Medicines Medicine % of facilities with available and unexpired Number of facilities where all availability medicines in each of the different categories medicines in each category are (oral medicines and injections, vaccines) available (at least one observed and unexpired) Foundations Workforce Availability Provider seen % of patients reporting seeing provider out of Number of respondents who Service Delivery Indicators Health Survey for Moldova – Overview of Results all interviewed patients received care by at least one 211 health care provider during their visit Foundations Workforce Availability Active health Number of health care providers in place and Average number of active health care providers providing services, averaged over past three care providers at the health ("effective staff days facility providing diagnostic or roster") therapeutic services, examinations, or consultations to patients over the past three most recent completed days Foundations Workforce Availability Support staff Number of support staff Average number of other staff working at the facility Foundations Workforce Availability Total staff Total staff Average number of providers and other staff working at the facility Foundations Workforce Availability Overall facility Overall facility staff composition: active health Distribution of active health care staff composition care providers vs. support staff providers and support staff Foundations Workforce Availability PHC staff Fraction of PHC staff composition: active health Fraction of health care provider vs. composition care providers and support staff other staff Service Delivery Indicators Health Survey for Moldova – Overview of Results Domain Domain Domain level 3 Indicator name Definition Numerator level 1 level 2 Foundations Workforce Availability PHC providers % of sampled (from roster) PHC providers NOT Number of doctors or nurses not NOT present at at the facility providing care on the day of present at facility at the time of health facility the unannounced visit (previously the overall the unannounced visit (overall % "absenteeism" metric) absence) Foundations Workforce Availability Provider absence Distribution of reasons for absence of PHC Number of doctors or nurses reasons providers on the day of the unannounced absent per reason on the day of visit (include both authorized reasons + the unannounced visit unauthorized reasons and be sure to present what % is unauthorized) Foundations Workforce Availability Service-specific % of facilities with at least one health care Number of facilities where at least provider who routinely provides each service one health provider routinely (same as services list—where "required" and “not provides each service and service required” are reported separately by category) component Foundations Workforce Availability Provider Number of years in the current position and Average number of years in the retention (proxy) facility current position at the facility 212 Foundations Workforce Education and Distribution Average annual days of leave spent on Number of days spent by training of time spent continuous professional development providers attending continuing on continuing education medical education Foundations Workforce Education and Service-specific % of facilities with at least one health care Number of facilities with at least training training provider who has been trained in last two years one provider having been trained in each service (same as services list—where in each service category in the "required" and “not required” are reported past two years separately by category) Foundations Workforce Education and Professional Distribution, by cadre, of professional degrees Number of doctors or nurses training training who attained each of the relevant professional degrees Foundations Workforce Satisfaction and Job satisfaction Distribution of responses to job satisfaction sub- Number of doctors responding to retention items each job satisfaction sub-item Foundations Workforce Satisfaction and Resilience Brief Resilience Scale—BRS survey Number of doctors responding to retention documentation on how to analyze results of each resiliency scale sub-item resilience Domain Domain Domain level 3 Indicator name Definition Numerator level 1 level 2 Foundations Workforce Satisfaction and Provider Average number of providers leaving past year, Number of providers who left the retention vacancies proportion of positions vacated in past year facility in the past year Foundations Workforce Workload Time distribution Time spent by provider on different activities: Average time spent by provider across different providing care to patients, administrative clinical in different activities (providing activities tasks, education activities, facility administration, care to patients, administrative and other activities clinical tasks, education activities, facility administration, and other activities) Foundations Workforce Workload Total hours Distribution of total hours worked past week Average total hours of work in worked providers' most recent typical work week Foundations Workforce Workload Provider Patient load: average per hour worked Average patient contacts per hour outpatient load worked during the most recent (hourly) typical work week Foundations Workforce Workload Provider Patient load: average, minimum, maximum per Average, highest, and lowest Service Delivery Indicators Health Survey for Moldova – Overview of Results outpatient load day worked number of outpatients seen in a 213 (per day) given day during the most recent typical work week Foundations Workforce Workload Satisfaction Distribution of provider responses to "Do you Number of providers who feel like with clinical vs. feel that your nonclinical work gets in the way of their nonclinical work prevents nonclinical work your clinical work?" them from being able to complete their clinical work effectively Person- Confidence Care uptake and Choice of ANC % of women seeking ANC at more than one Number of women who visited centered in system retention facilities facility among those who have 2+ ANC visits any other health facility/facilities outcomes for antenatal care during this pregnancy Person- Confidence Care uptake and Reasons for Distribution of reasons for visiting more than Number of women who had each centered in system retention choice of ANC one facility for ANC for this pregnancy reason for visiting more than one outcomes facility facility for ANC for this pregnancy Person- Confidence Care uptake and Choice of NCD % of patients who have visited other health Number of patients who have centered in system retention facilities facilities for NCD care visited any other health facility/ outcomes facilities for diabetes and/or hypertension care Service Delivery Indicators Health Survey for Moldova – Overview of Results Domain Domain Domain level 3 Indicator name Definition Numerator level 1 level 2 Person- Confidence Care uptake and Reasons for Distribution of reasons for visiting more than Number of patients who selected centered in system retention choice of NCD one facility for NCD care each reason for visiting more than outcomes facility one facility for diabetes and/or hypertension care. Person- Confidence Care uptake and Unmet need for Patients reporting no receipt of intended care Number of patients that did not centered in system retention services on the out of all interviewed patients receive services during their visit outcomes day of interview Person- Confidence Care uptake and Patients Patients intending to seek care at another Number of patients who plan to centered in system retention intending to get facility for the same concern out of those not visit another health care provider outcomes second opinion referred elsewhere ("plan to attend another within the same or another health health care provider or department/unit within facility for further care for the this health facility or another health facility for same reason they visited the further care for the same reason you visited the facility that day health facility today") Person- Confidence Care uptake and Intention to % of patients who would return to this facility Number of patients who would centered in system retention return for similar health concern come back to the same facility 214 outcomes if they needed care for a similar health concern Person- Confidence Satisfaction and Provider view Distribution of top challenges for patients’ Number of providers who selected centered in system recommendation of patient providers identify each challenge category for outcomes challenges patients accessing or receiving care at the facility Person- Confidence Satisfaction and Recommend % of patients who would recommend facility Number of patients who would centered in system recommendation facility recommend facility to a friend or outcomes family member who needed the same service they received that day Person- Confidence Satisfaction and Overall quality Patient rating of overall quality of facility Frequency of rating of overall centered in system recommendation rating ("Taking everything into account, how would quality of facility outcomes you rate the quality of care you received at this health facility?") Person- Confidence Satisfaction and Reasons for Distribution of responses to "Why have you Frequency of response to why the centered in system recommendation choosing this chosen this PHC provider?" patient chose this PHC provider outcomes facility Domain Domain Domain level 3 Indicator name Definition Numerator level 1 level 2 Person- Confidence Satisfaction and Top thing to be Distribution of responses to "What is the top Frequency of selection of each centered in system recommendation improved thing that could be improved in this health response to what could be outcomes facility?" improved in the health facility Person- Confidence Satisfaction and Patient-reported Distribution of responses to "Overall, how would Frequency of different ratings of centered in system recommendation skills and abilities you rate the skills and abilities of the health the skills and abilities of health outcomes of health care care provider(s) at this health facility to address care providers in this health center provider [your/the patient’s] health concerns and needs?" to address health concerns and needs Person- Financial Opportunity costs Time to reach Median time to reach facility Median time it took patient to centered protection facility reach facility from home outcomes Person- Financial Opportunity costs Lost income to % of patients with lost income due to health Number of patients with lost centered protection health care care services income due to the time it took to outcomes visit the health facility Person- Financial Opportunity costs Increased % of patients with increased childcare or elder Number of patients who had to Service Delivery Indicators Health Survey for Moldova – Overview of Results centered protection dependent care care costs due to health care services pay for childcare or elder care 215 outcomes costs due to because of visit to the health health care facility Person- Financial Opportunity costs Dependent care Median and average costs incurred by patients Average cost for childcare or elder centered protection costs due to on dependent care care to visit the health facility outcomes health care Person- Financial Out-of-pocket Cost to reach Median and average cost to reach facility Median cost to travel to the health centered protection costs facility facility for everyone who attended outcomes the visit Person- Financial Out-of-pocket Cost of gifts for Median cost of gifts given to health care Cost of gift (in Moldovan Lei) centered protection costs providers providers outcomes Person- Financial Out-of-pocket Cost of Average cost of consultation and diagnostics Average cost of consultation and centered protection costs consultation lab outcomes Person- Financial Out-of-pocket Borrowing Distribution of sources of money to pay for Number of patients who selected centered protection costs money for health current health care visit (including travel) each source of money used to outcomes care pay for health care the day of the visit (including transport to the health facility, consultation, gifts, medicine, and laboratory tests) Service Delivery Indicators Health Survey for Moldova – Overview of Results Domain Domain Domain level 3 Indicator name Definition Numerator level 1 level 2 Person- Financial Out-of-pocket Patients not Groups of patients not exempt from paying fees Number of facilities in which each centered protection costs exempt from group of patients has to pay for outcomes fees services provided at the facility Processes of Competent Diagnosis, Competent ANC Fraction of interviewed patients visiting facility Number of ANC patients who care care systems treatment, care: this visit for ANC receiving each (and all together) of received each (and all together) counseling the following for THIS visit for this pregnancy: of the specified services for the provider asked for maternal and child health current visit and pregnancy handbook; weighed; informed whether weight was normal/higher/lower than expected; height; blood pressure measured; informed BP was normal/higher/lower than expected; recommended to take IFA; informed on side effects of IFA; counseled on alcohol; counseled on tobacco; counseled on physical activity; counseled on diet; counseled on pregnancy symptoms; counseled on pregnancy danger signs; advised on exclusive breastfeeding 216 Processes of Competent Diagnosis, Competent Fraction of interviewed patients visiting facility Number of ANC patients who care care systems treatment, ANC care: entire for ANC receiving each (and all together) of received each specified service counseling pregnancy the following for this or a previous visit for this (and all together), during this or pregnancy: provider asked to see maternal previous visit for this pregnancy and child health handbook; % of women who report: provider estimated delivery date; weighed; informed whether weight was normal/ higher/lower than expected; height; blood pressure measured; informed BP was normal/ higher/lower than expected; screened for HIV; screened for syphilis; urine sample; blood group; recommended to take IFA; informed on side effects of IFA; counseled on alcohol; counseled on tobacco; counseled on physical activity; counseled on diet; counseled on pregnancy symptoms; counseled on pregnancy danger signs; advised on exclusive breastfeeding Domain Domain Domain level 3 Indicator name Definition Numerator level 1 level 2 Processes of Competent Diagnosis, Competent ANC Among women who are at least 20 weeks Number of ANC women at least care care systems treatment, care: services pregnant, % women visiting facility for ANC 20 weeks pregnant who reported counseling required for receiving each (and all) of the following for this blood glucose measured by blood pregnancy at or a previous visit for this pregnancy: blood sample; informed blood glucose least 20+ weeks glucose measured by blood sample; informed was normal/higher/lower than blood glucose was normal/higher/lower than expected; palpate abdomen; expected; palpate abdomen; ultrasound; uterine ultrasound and uterine height height Processes of Competent Diagnosis, Competent NCD At THIS visit for diabetes or hypertension, % Number of diabetes or care care systems treatment, care: this visit of patients who report: checked breathing/ hypertension patients who counseling heart; examine feet; examine eyes; measure received each (and all together), BP; informed BP is normal/higher/lower than for THIS visit, of the specified expected; glucose test; ever received result of services glucose test; ever told glucose was normal/ higher/lower than expected; asked about tobacco use; counseled on harms of tobacco Service Delivery Indicators Health Survey for Moldova – Overview of Results use; asked about alcohol; counseled on harmful 217 use of alcohol; asked about physical activity; counseled on physical activity; asked about diet; counseled on diet Processes of Competent Diagnosis, Competent NCD At this or previous visit for diabetes or Number of patients who report, in care care systems treatment, care: entire care hypertension, % of patients who report: checked this or previous visit for diabetes counseling duration breathing/heart; examine stomach; examine or hypertension, receiving each feet; examine eyes; measure BP; informed BP and all of the specified services is normal/higher/lower than expected; glucose test; ever received result of glucose test; ever told glucose was normal/higher/lower than expected; cholesterol test; ever received results of cholesterol test; ever told cholesterol was normal/higher/lower than expected; asked about medicines; asked about medical history; asked about family history; asked about tobacco use; counseled on harms of tobacco use; asked about alcohol; counseled on harmful use of alcohol; asked about physical activity; counseled on physical activity; asked about diet; counseled on diet Service Delivery Indicators Health Survey for Moldova – Overview of Results Domain Domain Domain level 3 Indicator name Definition Numerator level 1 level 2 Processes of Competent Diagnosis, Competent NCD Fraction of interviewed patients visiting facility Number of diabetes or care care systems treatment, care: this visit for diabetes/hypertension care receiving each hypertension patients who counseling (and all together) of the following for THIS visit received each (and all together), for this condition: examined with stethoscope; for THIS visit, of the specified feet; examined eyes; BP taken; informed BP services normal/higher/lower than expected; glucose test by blood sample; received results of glucose test; told blood sugar was normal/higher/lower than expected; cholesterol test; received results of cholesterol test; told cholesterol was normal/ higher/lower than expected; asked medical history; asked family history; asked about smoking; counseled on smoking; asked about alcohol; counseled on alcohol; asked about physical activity; counseled on physical activity; asked about diet; counseled on diet Processes of Competent Diagnosis, Competent NCD Fraction of interviewed patients visiting facility Number of diabetes or 218 care care systems treatment, care: entire care for diabetes/hypertension care receiving each hypertension patients who counseling duration (and all together) of the following for this or a received each (and all together), previous visit for this condition: examined with for THIS or PREVIOUS visit, of the stethoscope; examined stomach; examined feet; specified services examined eyes; BP taken; informed BP normal/ higher/lower than expected; blood sample; received results of blood sample; told blood sugar was normal/higher/lower than expected; cholesterol test; received results of cholesterol test; told cholesterol was normal/higher/lower than expected; asked medical history; asked family history; asked about smoking; counseled on smoking; asked about alcohol; counseled on alcohol; asked about physical activity; counseled on physical activity; asked about diet; counseled on diet Domain Domain Domain level 3 Indicator name Definition Numerator level 1 level 2 Processes of Competent Diagnosis, Competent sick Fraction of interviewed patients visiting facility Number of patients who visited a care care systems treatment, child care for sick child care receiving each (and all facility for sick child care received counseling together) of the following for this visit: asked each (and all together) of the age of child; asked about child's symptoms; specified services this visit asked if first or follow-up visit; asked about immunization history; asked about growth; asked about feeding; informed on diagnosis; counseled on feeding; asked about mother's health Processes of Competent Diagnosis, Competent Fraction of interviewed patients visiting facility Number of patients who visited care care systems treatment, nutrition-related for sick child care for child under six months a facility for sick child under six counseling care, children receiving each (and all together) of the following months who received each (and under six months for this visit: plotted growth; asked about all together) of the specified growth; asked about feeding when not sick; services this visit counseled on feeding; counseled on exclusive breastfeeding Service Delivery Indicators Health Survey for Moldova – Overview of Results Processes of Competent Diagnosis, Competent Fraction of interviewed patients visiting facility Number of patients who visited 219 care care systems treatment, nutrition-related for sick child care for child six months to two a facility for sick child six months counseling care, children years receiving each (and all together) of the to two years who received each between six following for this visit: plotted growth; asked (and all together) of the specified months and two about growth; asked about feeding when services this visit. years not sick; counseled on feeding; counseled on continued breastfeeding Processes of Competent Diagnosis, Confidence in Among patients prescribed medicine, % of Number of patients who care care systems treatment, medicine (in patients reporting (each, and all together): reported (each, and all together): counseling terms of how to thoroughly explained how to take medicine; thoroughly explained how to take, side effects, informed on side effects; confident in take medicine; informed on side administration) administering medicine effects; confident in administering medicine Service Delivery Indicators Health Survey for Moldova – Overview of Results Domain Domain Domain level 3 Indicator name Definition Numerator level 1 level 2 Processes of Competent Diagnosis, Clinical Vignette-average performance in indicating Number of providers who selected care care systems treatment, knowledge: PRIMARY diagnosis correctly the right diagnosis by case: counseling primary Case 1: Hypertension diagnosis Case 2: Diabetes type 2/diabetes mellitus type 2 Case 3: Pneumonia Case 4: Pulmonary tuberculosis smear positive Case 5: Moderate depression Processes of Competent Diagnosis, Clinical Vignette-average performance in indicating ALL Number of providers that selected care care systems treatment, knowledge: all diagnoses correctly the right diagnosis by case: counseling diagnosis Case 1: Hypertension, obesity & hyperlipidemia/dyslipidemia/ hypercholesterolemia Case 2: Diabetes type 2/diabetes mellitus Type 2 & obesity Case 3: Pneumonia 220 Case 4: Pulmonary tuberculosis smear positive & drug-susceptible tuberculosis/TB Case 5: Moderate depression Processes of Competent Diagnosis, Clinical Vignette-specific and average performance in Number of providers who selected care care systems treatment, knowledge: indicating correct treatment the correct treatment by case: counseling primary Case 1: Indapamid & statins treatment (rosuvastatin, atorvastatin, simvastatin) (any amount or frequency) Case 2: Metformin & rosuvastatin Case 3: Amoxicillin, paracetamol, expectorant Case 4: Prescribe anti-TB drugs or refer to a specialist Case 5: Treatment (nonpharmacological)/ psychoeducation and counseling Domain Domain Domain level 3 Indicator name Definition Numerator level 1 level 2 Processes of Competent Diagnosis, Clinical Vignette-specific distribution of treatment Number of providers who selected care care systems treatment, knowledge: (correct + incorrect) each type of potential treatment counseling treatment by cases Processes of Competent Diagnosis, Clinical Vignette-specific and average performance in Number of providers who care care systems treatment, knowledge correct diagnosis + treatment together selected the correct diagnosis and counseling treatment by case Processes of Competent Referral, Health document % of patients with any type of health document; Number of patients with any and care care systems continuity, availability frequency of each type of document each type of health document: integration patient card, identity card, health insurance policy, perinatal medical card handbook Processes of Competent Referral, Informed referral: Among patients having referral in past three Number of patients who thought care care systems continuity, past & type of months, % reporting (for last referral) how their patient information was integration documentation they think their patient information was shared shared with health facility to which they were referred Service Delivery Indicators Health Survey for Moldova – Overview of Results (including if the information was not shared at 221 all) Processes of Competent Referral, Reasons for Distribution of frequency of reasons for referral Frequency for each reason for care care systems continuity, referral within to another provider/department within same referral to another health care integration facility facility (“Why do you think [you/the patient] provider or department/unit were [was] referred to another health care within this health facility provider or department/unit within this health facility?”) Processes of Competent Referral, Referral outside For today's visit, % of patients referred to Number of patients referred by care care systems continuity, facility another health facility health care provider to another integration health facility Processes of Competent Referral, Reasons for Distribution of frequency of reasons for referral Frequency for each reason for care care systems continuity, referral outside to another facility (“Why do you think the health referral to another health facility integration facility care provider(s) referred [you/the patient] to another health facility?”) Processes of Competent Referral, Facility is usual % of patients who typically use this health Number of patients who visit this care care systems continuity, source of care facility for care health integration facility often or always when seeking care Service Delivery Indicators Health Survey for Moldova – Overview of Results Domain Domain Domain level 3 Indicator name Definition Numerator level 1 level 2 Processes of Competent Referral, Provider referral Average number of referrals providers report Average number of outpatient care care systems continuity, frequency making; % of providers who do not know how referrals made over the course of integration many referrals they make the entire week during the most recent typical work week Number of providers who did not know how many referrals were made Processes of Competent Referral, Provider- Distribution of how often patient information Frequency with which provider care care systems continuity, reported was sent to health facility to which provider received information about the integration frequency referred patient patient and/or the patient’s of referral contact with the health care information provider in the last three months sharing Processes of Competent Referral, Provider- Distribution of ways that patient information Frequency of ways that patient care care systems continuity, reported was sent (“What was the most common way that record and the referral ticket were integration informed referral patient information (such as patient history and sent to the facility or health care 222 modality the reason for referral) was sent to the health provider to which patient was facility or health care provider to which you referred referred the patient?”) Processes of Competent Referral, Referrals out Number of referrals out Number of patient referrals from care care systems continuity, the health facility in September, integration October, November 2021 Processes of Competent Referral, Referrals out: Distribution by frequency or percentage: Average number of outpatient care care systems continuity, same level number of referrals to higher level and same referrals from the facilities to integration level of health facilities a higher-level health facility or same-level health facility Processes of Competent Referral, Reasons for Distribution of most common reasons for Frequency of reason for referral to care care systems continuity, referral out referral FROM this facility TO another facility another facility integration Processes of Competent Referral, Referral: Distribution of modalities of patient information Frequencies of modalities of care care systems continuity, information transfer from this facility to receiving facility; % patient information transfer integration transfer out no patient information transferred Domain Domain Domain level 3 Indicator name Definition Numerator level 1 level 2 Processes of Competent Referral, Referrals in Number of referrals in Number of patient visits that care care systems continuity, were referred from another health integration facility Processes of Competent Referral, Reasons for Distribution of most common reasons for Frequency of reason for referral care care systems continuity, referral in referral TO this facility FROM another facility from another facility integration Processes of Competent Referral, Referrals in: Distribution by frequency or percentage: Average number of outpatient care care systems continuity, same level Number of horizontal referrals in, from same- referrals from higher-level or integration level facilities, from higher-level facilities same-level health facility to the facility Processes of Competent Referral, Referral: Distribution of modalities of patient information Frequencies of modalities of care care systems continuity, information transfer to this facility from referring facility; % patient information received from integration transfer in no patient information transferred referring facilities Processes of Competent Referral, Patients seeing % of patients reporting they often see the same Number of patients reporting they care care systems continuity, the same provider out of all patients often see the same health care Service Delivery Indicators Health Survey for Moldova – Overview of Results integration provider provider always or often 223 Processes of Competent Safety, Surveillance: % of facilities testing and reporting notifiable Number of health facilities that care care systems prevention, testing + diseases to central authorities report cases/events according to detection reporting the National Early Warning and Reporting System Processes of Competent Safety, IPC separate % of facilities with separate waiting areas for Number of facilities with at least care care systems prevention, waiting room patients with contagious diseases one separate entrance for patients detection with a suspected contagious disease Processes of Competent Safety, IPC patient % of facilities with one designated site for Number of facilities with at least care care systems prevention, isolation patient isolation one designated site for patient detection isolation Processes of Competent Safety, IPC cleaning % of facilities with point of care cleaned Points of care cleaned with care care systems prevention, record regularly disinfectants at least twice per day detection Processes of Competent Safety, Medical supply % of facilities with access to essential medicines, Number of facilities with access to care care systems prevention, guidelines consumables, and equipment essential medicines, consumables, detection in case of an emergency and equipment from medical buffer stores in case of an emergency Service Delivery Indicators Health Survey for Moldova – Overview of Results Domain Domain Domain level 3 Indicator name Definition Numerator level 1 level 2 Processes of Competent Safety, Space/infra % of facilities with protocols to repurpose beds Number of facilities with specified care care systems prevention, guidelines + protocols to repurpose facility spaces + protocols detection protocols to erect external spaces Processes of Competent Safety, Financing % of facilities with guidelines/protocols for how Number of facilities that have care care systems prevention, guidelines to request, receive, and use additional financing allocated earmarked funds for detection during emergencies emergency Processes of Competent Safety, Human resources % of facilities with guidelines/protocols for Number of health facilities that care care systems prevention, guidelines revising staff hours + increasing staff numbers + have access to backup human detection creating temporary staff housing resources for continuity of essential health services in case of an emergency Processes of Competent Safety, Risk % of facilities with guidelines/protocols for Number of facilities that have care care systems prevention, communication communication with staff within facility + defined protocols to communicate detection guidelines between facility and authorities + between with other health facilities, facility and other facilities + between facility and affected communities, and public registered population 224 Processes of Competent Safety, Surge capacity % of facilities that have conducted simulations/ Number of facilities that care care systems prevention, preparedness drills on managing surge capacity have conducted emergency detection preparedness and response mock drills or simulation exercises in the past two years Processes of Competent Safety, Fire safety: % of facilities where an assessment of facility's Number of facilities that have care care systems prevention, assessment and vulnerability to fire risks and a drill/simulation conducted a fire drill in the past detection drill/simulation on fire safety and prevention have been two years conducted Processes of Competent Safety, Preparedness: % of facilities where an assessment of facility's Number of facilities that care care systems prevention, natural vulnerability to natural disasters and weather conducted structural vulnerability detection disasters and events and a drill/simulation on safety assessment in the last two years weather events: procedures in the event of a natural disaster assessment and and/or weather event have been conducted drill/simulation Processes of Positive user Respect and Patient-reported Patients reporting all questions were answered Number of patients that reported care experience autonomy questions during consultation out of all patients all their questions were answered answered during their consultation Domain Domain Domain level 3 Indicator name Definition Numerator level 1 level 2 Processes of Positive user Respect and Patient-reported Distribution of "Rate the experience of being Frequency of rate the experience care experience autonomy respect greeted and talked to respectfully by the health of being greeted and talked to care provider(s)" respectfully by the health care providers Processes of Positive user Respect and Patient-reported Distribution of "Rate the experience of how Frequency of rate the experience care experience autonomy communication clearly health care provider(s) communicated/ of how clearly health care explained things to you" provider(s) communicated/ explained things to you Processes of Positive user Respect and Patient-reported Distribution of "Rate the ease with which you Number of patients that choose care experience autonomy provider choice could see a health care provider(s) of your their PHC provider choice " Processes of Positive user Respect and Greetings and % of providers who greeted the patient and Number of providers who greeted care experience autonomy introduction: introduced themselves in ANY of the clinical the patient and introduced provider vignettes that were administered themselves in at least one of the vignettes Service Delivery Indicators Health Survey for Moldova – Overview of Results Processes of Positive user Respect and Greeting and Distribution of patients' experience (ranging Frequency of patients' experience 225 care experience autonomy introduction: from very bad to very good) of being greeted of being greeted and talked to patient and talked to respectfully by the health care respectfully by the health care provider(s) providers Processes of Positive user Respect and Visual privacy Distribution of patients' experience (ranging Frequency of patients' experience care experience autonomy from very bad to very good) of how their visual of how their visual privacy was privacy was respected respected Processes of Positive user Respect and Auditory privacy Distribution of patients' experience (ranging Frequency of patients' experience care experience autonomy from very bad to very good) of how their of how their auditory privacy was auditory privacy was respected respected Processes of Positive user Respect and Patient Distribution of patients' experience (ranging Frequency of patients' experience care experience autonomy involvement in from very bad to very good) of how well health of how well health care provider(s) care care provider(s) involved them in decisions involved them in decisions about about their care their care Processes of Positive user User focus Challenges in Distribution of challenges/barriers patients Frequency of reported challenges/ care experience accessing the faced in accessing this facility (“What challenges, barriers reported in accessing the facility if any, do you face in accessing this health facility facility?”) Service Delivery Indicators Health Survey for Moldova – Overview of Results Domain Domain Domain level 3 Indicator name Definition Numerator level 1 level 2 Processes of Positive user User focus Visits based on % of visits based on appointments of all patients Number of visits based on care experience appointments appointments Processes of Positive user User focus Patient-reported Median time waited, and % of patients waiting Median time spent waiting at the care experience wait time over N minutes if national threshold is defined health facility after arrival and before being seen by one of the health care providers Processes of Positive user User focus Communication % of patients receiving care in their primary Number of patients reporting care experience in primary language health care provider(s) primarily language communicated in their preferred language Processes of Positive user User focus Facility-reported Estimated average wait time (asked across all Average estimated waiting time care experience estimated wait services) for a patient who has come for time a patient visit during regular hours between September and November 2021 Processes of Positive user User focus Facility-reported Estimated average consultation time (asked Average consultation time with 226 care experience estimated across all services) a health care provider for a consultation time patient between September and November 2021 Processes of Positive user User focus Fees visible to % of facilities where fees are posted visible to Number of facilities where fees care experience patients patients are posted visible to patients Processes of Positive user User focus Patient-reported Distribution of average travel time to reach Average travel time to reach care experience travel time facility (“How long did it take you to reach this facility from home health facility today?”) Processes of Positive user User focus Patient-reported Distribution of "How would you rate the amount Frequency of the rating of the care experience rating of travel of time it took to travel to this health facility?" amount of time it took to travel to time this health facility Processes of Positive user User focus Patient-reported Distribution of "How would you rate the amount Frequency of the rating of the care experience rating of wait of time [you/you and the patient] waited in this amount of time the patient waited time health facility after arrival and before being seen in health facility after arrival and by one of the health care provider(s)?" before being seen by one of the health care providers Domain Domain Domain level 3 Indicator name Definition Numerator level 1 level 2 Processes of Positive user User focus Patient-reported Distribution of "How would you rate the Frequency of the rating of the care experience rating of duration of [your/the patient’s] being greeted amount of time that the patient duration of visit and talked to respectfully by the health care was greeted and consulted by the provider(s)?" health care provider they saw on the day of the interview Processes of Positive user User focus Patient-reported Distribution of "How would you rate the Frequency of the rating of care experience convenience convenience afforded by this facility’s hours of convenience afforded by the of hours of service, that is, the days this health facility is patient in the facility’s hours of operation open and its hours of operation?" service Processes of Positive user User focus Patient-reported Distribution of "How would you rate the Frequency of rating of the care experience cleanliness of cleanliness of the room(s) inside this health cleanliness of the rooms inside rooms in the facility, including the waiting room(s), this health facility health facility patient consultation room(s), and toilet(s), if applicable?" Processes of Positive user User focus Patient-reported Distribution of "Overall, how would you rate the Frequency of rating of physical Service Delivery Indicators Health Survey for Moldova – Overview of Results care experience physical physical conditions of the room(s) inside this conditions of the room inside this 227 conditions of health facility, including the waiting room(s), health facility rooms in the patient consultation room(s), and toilet(s), if health facility applicable?" Processes of Positive user User focus Patient-reported Distribution of "Overall, how would you rate Frequency of rating of availability care experience availability and the availability and functioning of equipment, and functioning of equipment, functioning supplies, and medicine at this health facility?" supplies, and medicine at health of equipment, facility supplies, and medicine in the health facility