Report No. 32354-ECA Review of Experience of Family Medicine in Europe and Central Asia (In Five Volumes) Volume V: Moldova Case Study May 2005 Human Development Sector Unit Europe and Central Asia Region Document of the World Bank Contents Acknowledgments ........................................................................................................................................ ix Executive Summary ...................................................................................................................................... x 1. Introduction....................................................................................................................................... 1 1.1. Objectives of the study and methodology......................................................................................... 1 1.2. Primary research................................................................................................................................ 2 The evaluation framework................................................................................................................. 1 1.3. 1.3.1. Qualitative research............................................................................................................ 2 1.4. Primary HealthCare Facility and PhysicianTask Profile Surveys ................................................... 2 1.4.1. PHC Provider Facility Survey ............................................................................................ 4 1.4.2. Survey of TaskProJiles ofFamily Physicians ..................................................................... 4 1.5. Secondary Research.......................................................................................................................... 4 1.5.1. Literature review................................................................................................................. 5 2. The challenges faced inthe Early part of the transitionBY THEHealth System inMoldova .........6 2.1. Background....................................................................................................................................... 6 2.2. Economic changes and increasingpoverty........................................................................................ 6 2.3. Declining HealthExpenditures ......................................................................................................... 8 2.4. Worseninghealthindicators .............................................................................................................. 9 2.5. Excess infrastructure and human resources.,................................................................................... 14 2.6. Inequities inhealthexpenditure and outcomes ............................................................................... 16 2.7. Inefficient service provision............................................................................................................ 17 2.8. Low levels ofpay for healthpersonnel ........................................................................................... 18 2.9. Access barriers to the healthservices andnegative perceptions ofthe health system .................... 20 3. Healthreforms and key legislative changes .................................................................................... 22 3.1. Health Sector Strategy..................................................................................................................... 22 3.2. Organizational changes ................................................................................................................... 23 3.3. Development of a State-GuaranteedMinimumPackageof Services.............................................. 25 3.3.1. Immunization program ...................................................................................................... 25 3.4. Health systemfinancing before the introductiono f mandatory healthinsurance ........................... 26 3.5. Health systemfinancing after the introductionof Mandatory Health Insurance............................. 28 3.5.1. Out ofpocket Payments .................................................................................................... 30 3.5.2. External Funding .............................................................................................................. 31 3.6. Resourceallocationand provider payment systems ........................................................................ 31 33 4. 3.7. Rationalizationof the hospital sector .............................................................................................. KeyDevelopments inPrimary HealthCare.................................................................................... 36 4.1. Development o fHumanResources inPrimary HealthCare........................................................... 36 4.1.1. Trainingof family physicians and nurses ......................................................................... 36 4.1.2. Training of Health Managers ............................................................................................ 39 4.1.3. ContinuingMedical Education ......................................................................................... 40 4.1.4. 4.2. Incentives for humanresources....................................................................................................... 40 Family Medicine Association ............................................................................................ 40 4.3. Organization o f Primary Health Care Providers.............................................................................. 40 4.3.1. Types of Primary Health CareProviders ......................................................................... 40 4.3.2. Access to Primary Health Care......................................................................................... 41 4.4. RefurbishmentofPHC Centers....................................................................................................... 41 4.5. Utilization of PHC services............................................................................................................. 42 4.6. Guidelines........................................................................................................................................ 43 ... 111 5. Primary HealthCare Service Delivery: Facility Survey ................................................................. 44 5.1. Range of services provided ............................................................................................................. 44 j11. . . Urban and rural comparison .............................. :............................................................. 44 5.1.2. 45 5.2. Availability of equipment.,.............................................................................................................. Comparison by reform status ............................................................................................ 46 5.2.1. Urban and rural comparison ............................................................................................ 46 5.2.2. 48 5.3. Immunization services..................................................................................................................... Comparison by reform status............................................................................................ 49 5.3.1. Urban and rural comparison ............................................................................................ 49 5.3.2. Comparison by reform status ............................................................................................ 49 5.4. Family Planning.............................................................................................................................. 50 5.4.1. Urban and rural comparison ............................................................................................ 50 5.4.2. 5.5. Essential drugs................................................................................................................................. 50 Comparison by reform status............................................................................................ 50 5.5.1. Urban and rural comparison ............................................................................................ 50 j5.2. 51 Task profile of doctors working inprimary healthcare.................................................................. . 6. Comparison by reform status ............................................................................................ 52 6.1. Use of medical equipment ............................................................................................................... 52 6.1.1. Comparison by urban-rural status.................................................................................... 52 6.1.2. Comparison by reform status............................................................................................ 53 6.2. Application of medical techniques.................................................................................................. 54 6.2.1. Comparison by urban-rural status.................................................................................... 54 6.2.2. Comparison by reform status ............................................................................................ 55 6.3. Firstcontact managementof commonly encounteredconditions ................................................... 56 6.3.1. Comparison by urban-rural status.................................................................................... 56 6.3.2. Comparison by reform status............................................................................................ 59 6.4. Health promotionanddisease prevention....................................................................................... 61 6.4.1. Comparison by urban-rural status.................................................................................... 62 6.4.2. Comparison by reform status............................................................................................ 62 6.5. Chronic disease management.......................................................................................................... 64 6.5.1. Comparison by urban-rural status.................................................................................... 64 6.5.2. Comparison by reform status............................................................................................ 64 6.6. Job satisfaction ................................................................................................................................ 65 6.6.1. Comparison by urban-rural status.................................................................................... 65 6.6.2. Comparison by reform status ............................................................................................ 66 7. Findingsofthe qualitativeresearch................................................................................................. 68 7.1. PHC reforms andperceived benefits............................................................................................... 68 7.1.1. Increased user satisfaction. ............................................................................................... 68 7.1.2. Improved access to health services................................................................................... 68 7.1.3. Namedphysician to take care of health problems of the individual andfamily ...............69 Continuity of care.............................................................................................................. 68 7.1.4. 7.1.5. Comprehensivehealth services ......................................................................................... 69 7.1.6. Increased awareness of rights........................................................................................... 69 7.1.7. Enhanced engagement of thepolicy makers and cross learning ...................................... 69 7.1.8. Efficient care delivery and use of resources ..................................................................... 69 7.1.9. Improvedfirst-contact and gate keepingfunction of PHC level ....................................... 70 7.2. Barriers to change and development of PHC ....................................... ,.................................... 70 7.2.1. Legal and administrative barriers..................................................................................... 70 7.2.2. Low salaries ...................................................................................................................... 70 7.2.3. Increasedpapenvork and bureaucracy ............................................................................. 7~ iv 7.2.4. DifJiculty attracting doctors to rural areas....................................................................... 71 7.2.5. Poor image of family medicine because ofproblems with retrainingprogram ................71 7.2.6. Resistancefrom hospital specialists.................................................................................. 72 7.2.7. Inadequate referral and counter-referral mechanismswith high referral rate to secondary care 72 7.2.8. Accreditation ..................................................................................................................... 72 7.2.9. Fear of the unknown and crossing boundaries ................................................................. 72 7.2.10. Nostalgiafor the old times ................................................................................................ 73 7.2.11. Poor communication ......................................................................................................... 73 7.2.12. Top-down approach .......................................................................................................... 74 7.2.13. Lack of incentives.............................................................................................................. 74 7.2.14. Punitive culture................................................................................................................. 74 7.2.15. Poor appreciation of PHC andfamily medicine ............................................................... 74 7.2.16. Low managerial capacity at rayon level ........................................................................... 75 7.3. Critical success factors andenablers............................................................................................... 75 7.3.1. Economic crisis ................................................................................................................. 75 7.3.2. Creating an enabling environment.................................................................................... 75 7.3.3. Supportfrom theHealth Insurance Company................................................................... 76 7.3.4. Structural changes that accompanied the FM model........................................................ 76 7.3.5. 76 International support ........................................................................................................ Effective and sustained communication ............................................................................ 7.3.6. 76 7.3.7. 8. KeyAchievements of PHC Reforms............................................................................................... A visible and articulated strategy...................................................................................... 77 78 8.1. Organizational andregulatory changes .......................................................................................... -78 8.2. Financing, resource allocation, andprovider payment systems...................................................... 78 8.3. Service Provlsion............................................................................................................................. . . 79 8.4. Resource Generation ....................................................................................................................... 79 9. Challenges That remainto be addressed......................................................................................... 80 9.1. Expandingthe role andcompetenciesof the PHC team ................................................................. 80 9.2. Balancing innovationwith standardization ..................................................................................... 80 9.3. Incentives ........................................................................................................................................ 81 9.4. Equity and allocative efficiency ...................................................................................................... 81 9.5. Developinghumanresourcecapacity to manage strategic change ................................................. 81 9.6. Integration, continuumof care, and referral systems ...................................................................... 81 9.7. Communicatingthe reforms............................................................................................................ 82 9.8. Balancingpower betweenthe primary and secondary levels.......................................................... 82 9.9. Monitoring, evaluation andanalytic capacity.,................................................................................ 83 9.10 Sustainability ................................................................................................................................... 83 10. LessonsLearned.............................................................................................................................. 84 10.1. Critical success factors for sustaineddevelopment of PHC............................................................ 84 10.2. Being Strategic ................................................................................................................................ 84 10.3. Managingstrategic change.............................................................................................................. 84 10.4. Levelof Intervention....................................................................................................................... 85 10.5. Appropriate governance structures.................................................................................................. 85 10.6. Responsiveness................................................................................................................................ 85 10.7. Branding Family Medicine.............................................................................................................. 85 10.8. Incentives ........................................................................................................................................ 86 10.9. Communication............................................................................................................................... 86 10.10. Holistic Approachto Reforms......................................................................................................... 86 10.11. Monitoring and Evaluation.............................................................................................................. 86 V 10.12. Exit Strategy.................................................................................................................................... 86 11. Appendix ......................................................................................................................................... 87 11.1. Annex 1:Methodology-Framework for analysis.......................................................................... 87 11.2. Annex 2: Provider facility survey.................................................................................................... 89 11.3. Annex 3: Nivel Task Profile Instrument......................................................................................... 90 11.4. Annex 4: Decree on responsibilities of the family physician.......................................................... 91 12. References....................................................................................................................................... 97 vi FIGURES Figure 1: Frameworkfor Analyzing HealthSystems................................................................................... 1 Figure 1. PopulationGrowth (annual percent) 1990-2002) ......................................................................... 6 Figure 2. GDP Growth (annual inpercent terms) 1990-2002...................................................................... 7 Figure 3. Total, public andprivate healthexpenditure as apercentageof GDP .......................................... 8 Figure4. Life expectancy at birth.............................................................................................................. 10 Figure 5. Infant and under five mortality (1995-2002) .............................................................................. 10 Figure6. Incidenceof gonorrhea andsyphilis basedonofficial notifications........................................... Figure7. Tuberculosis incidence................................................................................................................ 12 . . 12 Figure 8 Incidence of cardiovascular illness ............................................................................................. . 13 Figure 9. Incidence ofmalignant neoplasms.............................................................................................. Figure 10. Number of children with disability (per 1,000 children aged 14years andunder)..................13 14 Figure 11 Number o f doctors per 1,000 populationinurbanand rural areas............................................ . 15 Figure 12. Number of nurses per 1,000 population(urban and rural) ........................................................ 15 Figure 13. Per capita healthexpenditure (in2000, inMoldovanLei)........................................................ 16 Figure 14 Infant mortality by region......................................................................................................... . 17 Figure 15. Number of ancillary staffper 1,000 population........................................................................ 19 Figure 16. Decline innumber of doctors and nurses inurbanand rural areas (percent, 1995 to 2001).....19 Figure 17. Organizationofhealthsystemat district level.......................................................................... 24 Figure 18. Financingflows inMoldovanHealth System: Before introductionof MHIand administrative reforms in2004 ........................................................................................................................................... 27 Figure 19. Allocation of the public sector budget prior to HealthInsurance Reforms .............................. 28 Figure 20. Allocations inPHC as a percentageof total government healthbudget................................... 32 Figure21. Number ofhospitals inMoldova .............................................................................................. 33 Figure22 Number ofhospitalbeds (total andper 10,000 population) ...................................................... 34 Figure 23 Number of admissions per 100people and average length of stay per admission.................... .. 35 Figure 24. Hospital capacity utilization ..................................................................................................... 35 Figure 25. Total number of doctors and nurses (OOOs)1995-2001 ............................................................. 36 Figure26. Number of family doctors inMoldova ..................................................................................... 37 Figure27 Number of family doctors......................................................................................................... 37 Figure28 Number of visits to family physicians ...................................................................................... .. 42 Figure 29 Number of referrals to secondaryand tertiary care................................................................... 43 Figure32 Frequency ofmanaging commonpediatric conditions ............................................................. .. 57 Figure 33. Frequency of managing common gynecological conditions ..................................................... 57 Figure34. Frequency ofmanaging commonadult conditions ................................................................... 58 Figure 35. Frequency o f managing common adult conditions inwomen .................................................. 58 Figure36 Frequency o fmanaging commonpsychosocial problems ........................................................ 59 Figure37 Frequency o fmanaging commonpediatric conditions ............................................................. .. 59 Figure 38. Frequency of managing common gynecological conditions ..................................................... 60 Figure39 Frequency o fmanaging commonadult conditions ................................................................... 60 Figure40 Frequency o fmanaging commonadult conditions inwomen .................................................. .. 61 Figure41. Frequency of managing commonpsychosocial problems ........................................................ Figure42 Percentageof doctors providing family planning services,-antenatal, and intrapartum care....61 . 62 Figure43. Percentageo f doctors providinghealtheducation advice on smoking, diet, and alcohol in special sessions............................................................................................................................................ 63 Figure 44. Proportionof family physicians providing antenatal, intrapartum, and family planning services (by region) ................................................................................................................................................... 63 Figure45 Percentof family physicians involved inmanaging conditions that were oftenmanagedin . PHC............................................................................................................................................................. 64 vii Figure 46 Percent o f family physicians involved in managing conditions that were frequently managed . in PHC......................................................................................................................................................... 65 Figure47. Percent o f doctors interested injob and who find real enjoyment (by urban and rural location) ..................................................................................................................................................................... 66 Figure 48. Percent o f doctors who feel effort and reward do not correspond and who may take a non- medicaljob .................................................................................................................................................. 66 Figure49. Percent of doctors interested injob and who find real enjoyment (by reform status) ...............67 Figure 50. Percent o f doctors who feel effort and reward do not correspond and who may take a non- medicaljob .................................................................................................................................................. 67 TABLES 3 Table 1b. Location o f districts and reform status......................................................................................... Table la: Number o f facilities. physicians. and patients surveyed (by location) ......................................... 3 Table 2. Estimate o f Private Sector Health Care Expenditures.................................................................. 31 Table 3. Frequently provided essential PHC services.. .............................................................................. 44 Table 4. Less frequently provided essential PHC services......................................................................... 45 Table 5. Services with statistically significant urban-rural difference in provision levels......................... Table 6 Frequently provided essential PHC services ................................................................................ . 45 45 Table 7. Less frequently provided PHC services ....................................................................................... 46 Table 8. Services with statistically significant difference inprovision levels between advanced and less- advanced reforms ........................................................................................................................................ 46 Table 9. Essential equipment found to be frequently available.................................................................. 47 Table 10. Essential equipment found to be infrequently available............................................................. 47 Table 11. Essential equipment with significant urban-rural differences inavailability ............................. 48 Table 12. Essential equipment with significant differences inavailability ................................................ 48 Table 13. Essential equipment with differences in availability (statistically not significant) .................... Table 14 Difference in availability o f equipment not frequently possessed by PHC centers ...................48 . 49 Table 15. Availability o f vaccines .............................................................................................................. 49 Table 16. Availability o f family planning materials .................................................................................. 50 Table 17. Availability o f essential drugs (Statistically significant difference) .......................................... 50 Table 18. Availability o f essentialdrugs (Statistically no significant difference) ..................................... 51 Table 19. Availability o f drugs by reform status........................................................................................ 51 Table 20 Equipment usedby family doctor or staff inthe PHC center..................................................... . 52 Table 21. Equipment used by family doctor or staff inthe PHC center (rural >urban) ............................. 52 Table 22. Urban rural differences in infrequently used equipment............................................................ 53 Table 23. Equipment used by family doctor or staff inthe PHC centers situated inadvanced or less- advanced reform regions ............................................................................................................................. 53 or less-advanced reform regions.................................................................................................................. 54 Table 24. Equipment infrequently used by family doctor or staff inthe PHC centers situated in advanced ... V l l l ACKNOWLEDGMENTS This report reviews the experience of family medicine in Moldova. It is part of a study comprising 5 volumes that reviews the experience o f family medicine infour countries inthe Europe and Central Asia Region (ECA) -- Armenia, Bosnia and Herzegovina, Kyrgyz Republic, and Moldova. The report reviews the experience, draws lessons, and establishes an evidence-base for detailed analysis. The study presents best practices for policy dialogue and future investments by the Bank and other financial institutions. The detailed case studies compare these countries and draw common themes and issues. Comparisons are made with best-developed or existing models inthe OECD and other ECA countries that have already undertaken family medicinereform. The report was financed by a Dutch Trust Fund. It was prepared by a team led by Rifat Atun (Imperial College) and included Viorica Berdaga (UNICEF), Lilia Turcan (UNICEF), Svetlana Stefanetz (UNICEF), Evelina Cibotaru, and Alisher Ibragimov (Centre for Health Management, Imperial College). UNICEF Moldova office providedco-financing and technical support to the Moldova Case Study, as part of a larger collaborative researchproject. The Task Profile I n s t m e n t was designed by Wienke Boerma. The study was prepared under the leadership of Betty Hanan. Kees Kostermaans and Juan Pablo Uribe were the peer reviewers. Valuable comments were provided by Betty Hanan, Joana Godinho, Victor Volovei, and Mikhai Ciocanu. Annie Milanzi and Anna Goodman helpedto prepare the document for publication. i x EXECUTIVESUMMARY INTRODUCTION 1. The objectives of the study were to review the experience of family medicine in Europe and Central Asia (ECA), present best practices, and make recommendations for policy dialogue and future investments. 2. The study employed primary and secondary research, using both qualitative and quantitative methods of inquiry and usedproprietary framework of analysis and instruments to explore key changes in policies, regulations, organizational structures, financing, resource allocation, provider payment systems, service provision, and human resources. The impact of family medicinereforms was analyzed. 3. Moldova inherited a health system based on the Soviet Semashko Model characterized by: centralized planning; hierarchical administrative organization; a very large provider network dominated by hospitals and tertiary provider units; parallelhealthsystems for lineministries and large organizations; poorly developed PHC level fragmented by tripartite delivery model which provided services separately for adults, men and children, as well as a large number o f vertical programs delivered by narrow- specialists; absence of family physicians at the PHC level, which lacked gate keeping function; a surfeit of hospitals and human resources concentrated inthe capital Chisinau; an inequitable resource allocation systembasedon historic activities and inputs-and favored large hospitals inurbancenters at the expense of rural areas; line-item budgeting of provider units and salary basedpayment systems which encouraged inefficiency and discouraged improved performance; strict care delivery protocols not based on current evidence whch encouraged excessive referral to secondary care level; highly curative and disease focused services (partly attributable to the nature of medical training) with limited health promotion or prevention, and; a system which allocated users to doctors and prevented them from exercising choice or meaningfully participating inthe healthproductionprocess. 4. Decoupling from the Soviet Union led to rapid economic decline. Between 1993 and 1999 the GDP declined by 60 percent. By 2000, the GDP per capita was US$353.50 with almost 90 percent of the population living on less than U S $1.00 per day. Inthe transition period, level of funding to the health sector declined substantially-creating a substantial funding gap between the levels of financing needed bythe healthsystemandthe resourcesavailable. 5. Low funding levels from the public sector and low salaries of health professionals resulted in many health professionals leaving the health sector-particularly inrural areas-substantial inequities, emergence of rent seeking behavior, and informal payments which acted as a barrier to many citizens to accessinghealthservices. 6. Early inthe transition period populationhealth indicators worsened, and then recovered to levels witnessed in 1990. 7. Government of Moldova sought to reform the health system to address key problems, namely: Organizational complexity; excess infrastructure and human resources; allocative inefficiency and inequities in financing; inefficient service provision; limited incentives and low pay levels for health personnel. X KEY ACHIEVEMENTS: ORGANIZATIONALAND REGULATORY CHANGES 8. The Law on Health Protection was adopted in 1995, and in 1997 the Moldovan Government approved a Health Sector Strategy for the period 1997-2003. The Strategy aimed to address structural inefficiencies, reduce human resources, and improve financing of the health sector, and identified as key objectives: (i) 'addressing health issues' as a priority; (ii) and solidarity; (iii) equity establishing effective structures and processes to implementing and monitoring National Health Policy; (iv) establishing inter sectoral programs with broad consultation, consensus, andcommunity participation. 9. Despite a resource-constrained environment, Moldova has achieved significant milestones with PHC reforms. 10. Key laws and regulations have been developed to create an enabling environment for FM and PHC reforms. FamilyMedicine i s recognized as a specialty inLaw. 11. The tripartite systemof pediatric, women's, and adult clinics have been consolidated into unified PHC centers providing services for all citizens. 12. The scope and content of PHC services have been articulated in law and defined in detail inthe State GuaranteedBenefits Package. 13, A large number ofPHCcentershave beenrefbrbished with support fromthe WB HIP 14. Users have been giventhe freedom to choosetheir family physicians. 15. There has been a remarkable rationalization of the hospital sector: the most substantial among the FSUcountries. 16. Financing, resourceallocation, and providerpayment systems. 17. Mandatory Health Insurance with co-payments has been introduced, thus creating a transparent environment as regards payments to health service providers. A key achievement of the reforms i s the establishment of a Single Payer System, which allows integration of state and local budget revenues with MHIF contributions to fund the Basic Benefits Packageunder the Mandatory Health Insurance Fundfor the insured and those inexempt categories. A HealthInsurance Company, with Territorial Branches, has beenestablished and i s now acting as the purchaser ofhealth services. 18. New provider payment methods, basedon a simple per capita mechanism, have been successfully introduced to remunerate PHC centers according to agreed contracts between the Health Insurance Company and the rayonhealthauthority. 19. Moldova has been particularly successful in increasing the proportion of health system funding allocated to PHC and has specified in Law that 35 percent of the public health expenditure should be allocated to the PHC level. xi SERVICE PROVISION 20. A State Guaranteed Basic Package has been introduced for the entire population regardless of their insurance status and enrollment. Citizens not covered under the MHIscheme have access to the Basic Benefits Packageunder the MHIF. 21. There i s excellent coverage of immunization and reasonably well spread provision of basic PHC services inall regions, but significant inequities persist. 22. The task profile survey shows statistically significant difference in the application of medical techniques, use o f equipment when delivering PHC services, provision of healthpromotion services, and management of first contact and chronic conditions by family physicians in advanced reform areas as compared with those inintermediate and early reformareas. 23. There is evidence from the qualitative researchthat the new model i s welcomed by the users and health professionals who identify many benefits which, among others, include the user-centeredness of the modeland havinganameddoctor, user choice, and the more comprehensive nature of the FMmodel. RESOURCE GENERATION 24. A critical mass ofFMspecialists andnurses hasbeentrainedinshort-course retrainingprograms. KEY CHALLENGESAND RECOMMENDATIONS 25. There has been good progress with the FMand PHC reforms inMoldova, but this progress needs to be sustainedand acceleratedto addressthe many challengesthat remain. 26. The retraining programs have been successful inrapidly scaling up FM inMoldova, but they are too short to convert narrow specialists into generalist family physicians. Existingtraining programs need to be extended and further strengthened to produce family physicians of higher competence and to counteract criticisms leveledby narrow specialists and opponents of reforms at FMinstitutions. 27. Countrywide standards on scope and quality of services have succeededinestablishing minimum quality standards and basic-level PHC services as compared with OECD countries. The scope and content of services provided inPHC settings inMoldovaare still basic, and there i s muchroomfor expanding the scope of services provided in PHC. Current contracts introduced by the HIC and the BBP-MHIF will help enhance equity by providing a uniformpackage of services to the whole country. Muchwork needs to be done inthe next few years to further institutionalizethis system. To further develop PHC over time, there needs to be a move toward more flexible contracting based on performance. However, such a shift will require: significant analytical and execution capacity at the HIC robust information systems at the PHC level; enhancedchoice o f users; andexpanded managementcapacity. 28. Major inequities inaccess to services and funding exist. The next phase of reforms should place an emphasis on enhancing equity by changing resource allocation mechanisms to take into account poverty andhealthneeds. 29. The presence of narrow specialists at PHC centers is a source of inefficiency and a barrier to developing PHC as it adversely impacts on first contact, continuity, and the comprehensive functions of PHC. All narrow specialists at the PHC level should be trained as family physicians, and their roles should be modified so that they practice family medicine. xii 30. Limited incentives and poor salary levels of FM specialists are two major problems that need addressinginthe immediate term. There needs to be a much stronger indicationthat FMi s valued on par with hospital specialties. 31. There are no incentives to achieve a substantial secondary-to-primary shift, thus limiting the ability of the PHC level to develop extended primary care and move beyond a gate keeping role. Furthermore, limitedvertical integration hinders development of continuumof care. 32. Implementing PHC reforms is a complex strategic change process, and there i s insufficient managerial capacity to accelerate the pace of development. It i s necessary to rapidly develop a critical mass of middle and senior level managersand healthprofessionals to act as change agents. 33. As with the other countries inthis study, there is a lack of systematically collected data at the PHC level that can be analyzed to demonstrate key reform objectives have been achieved. The PHC component of the M&E system at the Institute of Public Health and Management needs to be enhanced and analytic capacity expanded to regularly analyze data and to generate timely information to inform decisions. 34. The benefits of a family medicine centered PHC system are not adequately communicated to citizens and health professionals. Although, the WE3 HI'has significantly invested in communication and advocacy activities, more investment is neededto improve communicationbetween and within levels of the healthsystem and with the public to rectify misperceptions of family medicine. 35. The power among the health service providers rests with the hospital sector. Recent administrative reform, which has recentralized power in the hands of the rayon hospital director, at the expense of PHC providersthat were autonomous, i s a retrograde step and needs to be reversed. CRITICAL SUCCESSFACTORS 36. The study has identified a number of critical success factors. These include: Being strategic by allowing regional and inter-country cross learning and lesson sharing; Investing in not just technical inputs but management of change; Simultaneously working at policy, strategy and operational levels; (iv) Appropriate governance structures; Maintaining responsiveness to the changing context; Branding and image buildingto improve the status of FM specialists, as compared with narrow-specialists; Improved incentives for continual improvement; Improved communication between and within levels of the health system and to the public; Developing a holistic approach to reform, and; Having an agreed-upon exit strategy. ... Xlll 1. INTRODUCTION 1.1. OBJECTIVES OF THE STUDY AND METHODOLOGY 1. The objectives of the study were to review the experience of family medicine' in Europe and Central Asia (ECA), present best practices, and make recommendations for policy dialogue and future investments. The countries inthe study included Armenia, Bosnia and Herzegovina, Kyrgyz Republic, and Moldova. Inaddition, a desk study was conducted on Estonia. 1.2. THEEVALUATIONFRAMEWORK 2. Kutzin suggests a three-step approach to evaluating healthreforms, describing: (i) contextual key factors driving reform; (ii) the reform itself and its objectives, and (iii) process by which the reform the was implemented.2To these three further steps can be added: (1) describing the changes introducedby the reforms; (2) analyzing the impact of these changes on health system objectives and goals, and (iii) establishmg whether the reforms have achieved the policy objectives. 3. The evaluation used a framework to analyze key changes in health system elements and objectives inrelationto primary healthcare (PHC). This i s shown inFigure 1.3 (See annex 1) Figure 1: Framework for Analyzing Health Systems I /- J ~~ Satisfaction 4. This framework builds on that developed by Hsiao4 and identifies four levers, available to the policy makers and managers in health systems. Management and modification of these levers enables policy makers to achieve different intermediate objectives and goals. The `organizational arrangements' lever refers to the policy environment, stewardship function, and structural arrangements in relation to funding agencies, purchasers, providers, and market regulators. Financing and resource allocation levers refer to resource collection, pooling, allocation, and the mechanisms and methods used for paying health service providers. The `provision' lever refers to the `content', i.e. the services provided by the health sector rather thanthe structures within which this `content' i s delivered. The intermediate goals identified in the framework - equity, technical and allocative efficiency, effectiveness and choice are frequently cited by others as end goals inthemselves. However, inthis framework efficiency, equity, effectiveness, and choice are taken as means contributing to attainment o f the health sector's ultimate goals of health, financial riskprotection, and user satisfaction. 1 5. This framework was used to analyze key changes in health system elements and intermediate goals. An important finding of the literature search and country visits was the lack of systematically collected data at the PHC level. Therefore, primary researchwas undertaken to generate original data to complement secondary researchfindings. 1.3. PRIMARYRESEARCH 6. Primary research was comprised of three elements: (i) Qualitative research; (ii) Primary Health Care Facility Survey; (iii)PhysicianTask Profile Survey 1.3.1. Qualitativeresearch 7. Qualitative research involved 100 key informant interviews, including 28 policy makers and managers (of which 4 were nurses) as well as 68 doctors and 4 nurses currently in practice. Thirty o f these doctors were from urban areas, and 38 were from rural areas. Three of the remaining four nurses were from ruralpractices, and one was from anurbanpractice. 8. The interviews explored the perceptions of key informants regardingthe goals and objectives of the reforms, changes in structures and processes, critical success factors, barriers, and enablers that influenced the introduction and diffusion of Family Medicine reforms, major achievements, and lessons learned. 9. A semi-structured questionnaire was specifically developed for the study for face-to-face, in- depth interviews o f key informants. The questionnaire was piloted, and theniteratively refinedinthe four countries studied. 10. Purposive sampling was used over two stage^.^ An initial set of key informants were purposively identified for the first stage of the study and interviewed. The data emerging from the initial set of interviews were analyzed to identify key emerging themes, which were explored further using a refined and shortened questionnaire to allow in-depth exploration o f some of the key themes emerging from the initial set of interviews.6 The second stage also employed `purposive sampling' with `snowballing' to capture a multi-level multi-stakeholder sample of key informants, representing the key stakeholders involved inPHC reforms inbothpolicy development andimplementation from urbanandrural areas. 11. The analysis informed the detailed case study by capturing information on key structural and process changes, issues related to design and implementation of PHC reforms, the drivers and barriers to reform, the factors influencing the establishment o f an enabling environment for change, and the lessons learned. 1.4. PRIMARY HEALTH CARE FACILITY AND PHYSICIANTASKPROFILE SURVEYS 12. These two elements of primary research were done concurrently to explore changes in service delivery and practice of family physicians as a result of the PHC reforms and training of physicians as family medicine specialists. It was not possible to do a pre- and post-interventionstudy as there were no data or baseline studies that analyzed service delivery patterns and physicianpractices before the reforms and after the introduction of changes. 13. We undertook two cross-sectional studies simultaneously: (i) Primary Health Care Facility survey, and; (ii) Physician Task Profile survey. 2 14. Each of the instruments was adapted to the context of Moldova and translated to Romanian and Russian. Local research teams were trained inthe use and application of the instruments. Data analysis was undertaken at Imperial College. 15. We used purposive sampling to provide a diverse sample. Nine districts were selectedbased on geography and the relative stage of development of PHC care reforms, including three districts each from the Northern, Central, and Southern parts of the country. Ineach district, urbanand rural PHC centers were surveyed. Eachdistrict has a large PHC center which serves the whole town, and rural PHC centers serve the population who live invillages. Sixty eight centers were surveyed and 163 doctors working in these centers were interviewedby a team trained inthe use of the instruments. We also interviewed 561 patients who attended these centers on the day the surveys were undertaken. The surveys were undertakenjointly by UNICEF, who also used the survey to interview a further 821 patients to explore their views onprograms supportedby UNICEF. (Tables l a and lb) Table la: Number offacilities, physicians, and patients surveyed (by location) I Northern I N o I Central I N o I Southern I N o I Aggregate I Total 1 Urban I Facilities I 3 IFacilities I 3 IFacilities I 3 IFacilities 9 Doctors 26 Doctors 16 Doctors 33 Doctors 75 Patients 176 Patients 126 Patients 132 Patients 434 16. Thirty centers and 62 doctors were surveyed from four districts at the advanced stage of PHC reforms (Floresti, Glodeni, Anenii Noi, and Hincesti). Thirty centers and 86 doctors were surveyed from four districts at the intermediate stage of reforms (Edinet, Stefan-Voda, Comrat and Cahul), and a further eight centers and 15 doctors were surveyed from one district at the early stage of reforms (Telenesti - Table lb). Table lb. Location of districts and reform status Districts Geography Reform Status Doctors Centers interviewed surveyed Edinet North Intermediate 21 8 Floresti North Advanced 16 8 Glodeni North Advanced 19 8 Anenii Noi Centre Advanced 11 6 Hincesti Centre Advanced 16 8 Telenesti Centre Early 15 8 Stefan-Voda South Intermediate 18 8 Comrat South Intermediate 25 7 Cahul South Intermediate 22 7 3 1.4.1. PHCProvider Facility Survey 17. This component of the primary researchuseda facility survey instrument developed specifically for the study. The instrument drew on guidance and methodologies developed by the World Bank on facility surveys' and on a number of internationally available facility surveys. The instrument was developed by the research team and refined following discussions with collaborators in Bosnia and Herzegovina, Kyrgyzstan, and Moldova to ensure appropriateness to the local context. Then, they were piloted ineacho f the four countries includedinthe study. 18. The instrument comprises sets of questions to capture information on: (i) characteristics general of PHC facilities and the population size served; (ii) scope of services; (iii) organization of services; (iv) availability and composition of PHC staff, availability of essential emergency drugs, availability of equipment and services; (v) comprehensivenessof services; and(vi) quality of services. 19. A summary ofthe elementsofthe instrumentis attachedinAnnex 2. 20. The instrument was coded and a computer program was written in Access@ for data entry and analysis. We performed statistical analysis (descriptive statistics and T-Test) to test for observed differences. 1.4.2. Survey of TaskProfiles of Family Physicians 21. The second component of the primary researchwas a cross-sectional survey of family physicians to explore their `Task Profiles' using a validated instrument developed by the NIVEL Group in the Netherlands.8 The instrument, previously tested and validated in 32 European countries, i s available in several languages, including Russianand other Slavic languages. It enables collection of detailed data on the preventative, promotive, and curative services provided by family physicians as well as their skills, knowledge base, attitudes, and workload. The latter of which i s captured by use o f a seven-day workload diary, The instrument was obtained from the author, Dr. W Boerma ,and with his kindpermission used inthe study, A summary ofthe instrument is showninAnnex 3. 22. The survey of the Task Profiles o f Family Physicians aimedto identify the scope and availability of services and the skills of doctors working at the PHC level. It also aimed to identify similarities and differences between FM specialists and non-specialist GPs. 23. The instrument was tested in the four study countries and modified to ensure contextual sensitivity. The instrument was coded and a data collection and entry program developed in Microsoft Access. Datawere transferred to SPSS@for statistical analysis. 1.5. SECONDARY RESEARCH 24. Secondary research comprised of two elements: (i)a review o f international and in-country published literature to ascertain key legislative changes related to the reforms and to identify changes in financing, resource allocation, provider payment systems, organizational changes and regulation, and service provision; and (ii)analysis of cross-sectional andlongitudinal data onhealthindicators. 4 1.5.1. Literature review 25. The literature review consisted of desk research of published articles in peer-reviewed journals, supplemented by documentary analysis of published reports, key legal instruments, and policy documents, World Bank Publications (including aide memoires), country HITS published by the European Observatory onHealth Systems Research, andother relevant studies.' 5 2. THE CHALLENGESFACEDINTHE EARLYPARTOF THE TRANSITIONBY THE HEALTHSYSTEMINMOLDOVA 2.1. BACKGROUND 26. Moldova declared its independence from the Soviet Union in August 1991. It i s a landlocked country borderedby Romania and Ukraine and covers a landmass of 338,000 sq. km. It has a population of 4.3-4.5 million. Inthe last decade, Moldova has experienced a negative population growth.'' (Figure 1) Figure 1. Population Growth (annual percent) 1990-2002) 0 -9 05 - -0 1 -se ,-015 5 -02 -2 -0 25 I0 -03 L -9 35 -0 4 -0.45 1 I Year Source: World Bank, 2004 27. Moldova has a rich mosaic of ethnic groups comprising ethnic Romanians (around 67 percent), Ukrainians and Russians (25 percent), Gagauz Turks (3.5 percent), and others, including Jewish and Bulgar residents. 2.2. ECONOMIC CHANGES AND INCREASINGPOVERTY 28. Between 1993 and 1999 the GDP declined by 60 percent. By 2000, the GDP per capita was U S $353.50 with almost 90 percent ofthe populationlivingon less than U S $1.OO per day." 29. The World Bank estimated that by 2000, per capita GDP was only 40 percent of that in 1990,'* lower than around 50 percent o f the rest of the FSU countries, and about 75 percent for Central and Eastern Europe. Moldova's GDP was 40% o f what it had been in 1990, lower than the GDPs of close to half of the other FSU countries, and about 75% of (or 25% lower than) the (average) GDPs for Central and EasternEurope.13Economic growth resumed in2000 after a decade of decline inthe GDP (Figure 2). 6 Figure 2. GDP Growth (annualinpercentterms) 1990-2002 I O , I -35 1 I Year -GDP Growth (annual %) Source: World Bank2004 30. Following a decade of severe economic decline, Moldovan GDP rebounded by more than 25 percent over the period 2000 to 2003. Strong growth continued in 2004. Growth inMoldova has been strongly pro-poor. Poverty rates have fallen from 71 percent of all households in 1999 to 37 percent in 2003. 31. The primary source of the recent growth performance has been a strong surge in final consumption. The increase in consumption has been fuelled by the large inflow of workers' remittances and wage and pension increases. Investment has remained low and net exports are significantly negative. 32. Notwithstanding the recent growth, Moldova i s the poorest country in Europe with a Gross National Income o f US$59O.l4The GDP per capita, at purchasing power parity, in2004 was estimated to be US$ 1,800.15 Moldova was among the last of the FSUeconomies to returnto positive GDP growth, and the GDP level i s still around 40 percent of the pre-independence levels.16 Early in the transition years, Moldova sought external financing to overcome the economic shocks and to begin a program of structural adjustment. Today, Moldova remains highly indebted. In2000, the present value of debt-to- GDP ratio reached90 percent.17 33. Rapid and substantive decline in GDP created significant poverty among the population and in particular the population from rural villages." The World Bank estimates that in2000, almost 88 percent of households had incomes below subsistence levels, while 53 percent had incomes of less than half the subsistencelevel." A household budget survey undertaken in2000 showed that around 40.5 percent of all householdshad monthly incomes under the poverty line.20In2002, the poverty level was estimated to be 50 percent of the population21,although other studies estimate this figure to be higher. For instance, the 2001World Bank Dynamic Poverty Study (May 2001Unpublished) showed that the incidence of poverty had increasedfrom 50 percent in 1997 to almost 70 percent in 1999, thereafter declining to 65 percent at the endof 2000.22 34. The worsening economic conditions also led to a widening o f inequalities. Between 1998 and 2001the Gini coefficient was 0.4.23 7 2.3. DECLINING HEALTH EXPENDITURES 35. The reduced economic activity and the consequent decline in the GDP adversely impacted on Government budget allocations to the health sector, which experienced a substantial decline inthe period 1993 to 2003. 36. Between 1994 and 1997, the Moldovan Government's financial contributions to the health sector amounted to around 6 percent of the GDP, while the total health expenditure was around 8.3 percent of the GDP?4 In 1996, the amount of funds allocated by the Government to the health sector fell to 3.8 percent of the GDP. In 1999, following the economic crisis, which saw a 6.5 percent decline inthe GDP, the State expenditure on the health budget was reduced by 35 percent from 4.3 percent of the GDP to 2.9 percent of the GDP, while the total expenditure fell from 7.2 percent to 5.3 percent of the GDP. In2000, the Government expenditure on the health sector amounted to 2.9 percent of the GDP (and 17 percent of the State budget), further declining to 2.8 percent in 2001. Inthe same period, the total expenditure on healthfell to 5.1 percent ofthe GDP. (Figure 3) Figure 3. Total, public and private health expenditure as a percentage of GDP I 8.3 -- n 8 0 7.2 5.3 5.2 5.1 .- -1t 4 7 3 3 a2 g 2 ! O i i 1997 1998 1999 2000 2001 Public Private Source: World Bank Data, 2004. 37. According to the November 2003 World Bank Health Policy Note for Moldova, inthe ten-year period since 1993, budgetary spending on health care has declined 62 percent inreal terms since 1993.25 By 2000, it represented 100 lei, or US$10 per capita. As a percentage of GDP, Moldovanpublic sector health expenditure is just below the world average (3.2 percent of GDP) and above the average for low income countries (2.4 percent of GDP). It i s on par with the Eastern European and Central Asian Region's average of 4.4 percent.26The situation is actually worse than in other countries, however, because only 65 percent of public funds are actually available to purchase health care services. Thirty- five percent must go towards clearing up arrears incurred in the past. The decline in public funds for health care services has resulted inan increase ininformal payments and the introductionof a formal set of user fees and private financing. According to household surveys and informal estimates, private out- of-pocket spending i s estimated to double total health care spending by contributing another US$10 per capita. 8 38. The financial constraints faced by the sector are further exacerbated by the fact that not all the funds allocated to the health system are always received by the MoH, and budget sequestration is not unusual. Further, a substantial proportionof the public funds (35 percent of the total) are actually usedto pay for debt arrears, and only 65 percent of the total budget i s available to purchase healthcare service^:^' However, with the introduction of Mandatory HealthInsurance,these debt arrears arebeingcancelled. 39. The decline inhealth expenditures has meant that the Government has had difficulty meeting its obligations to fully finance a minimum package of services for its citizens, maintaining the extensive infrastructure, andpayingthe salaries ofhumanresources employed inthe healthsector. The low funding levels from the public sector and low salaries of health professionals led to the emergence of informal payments, which acted as a barrier to many citizens wishing to access health services. A household survey carried out by UNICEF in 1997 showed that 33 percent of those surveyed could not access health services because o f lack of funds.28 2.4. WORSENING HEALTHINDICATORS 40. The transition adversely affected the healthof the population. The healthsystem faces the burden of a dual epidemiologicalprofile, characterized by diseases of poor countries like infectious diseases, and diseases of rich countries like cancer and cardiovascular diseases. Poverty, alcohol, and tobacco are the key determinants inthe health of most Moldovans. Morbidity and mortality from these factors account for a sizeableburdenon society and onthe economy. 41. In1995, Moldova was onthe verge of a public healthcrisis. Life expectancy was declining and sexually transmitted infections (STIs) were reaching near epidemic proportions. However, Moldova has made steady progress since the mid-1990s in reversing the decline in life expectancy and in restoring health status to levels unseensince before the economic crisis. The most substantial reversals are interms of life expectancy, which increasedfrom 65.9 years in 1995 to 67.4 years in2000. (Figure 4). 9 Figure4. Life expectancy at birth 1990 1991 1992 1993 1994 1995 1996 1997 1996 1999 2000 2001 2002 i I Female +Averaae Male Source: Department o f Public Health andManagement and World Bank Statistics 2004 42. According to preliminary figures from the Department of Public Health and Management, infant mortality rate, which was 18.3 per 1,000 live births in 2002, has declined to 16 per 1,000 live births.29 (Figure 5) In2000, maternal mortality ratio per 100,000 live birthswas estimated to be 36. Figure 5. Infant and under five mortality (1995-2002) I 0 1990 1991 1552 1953 1594 1995 l9SS 1997 1998 1955 2000 2001 2002 2003 2004 Source: Department ofPublic Health and Management and World Bank Statistics 2004 (2004 preliminarydata) 43. Key public health challenges lie with communicable diseases, inparticular tuberculosis (TB) and HIVIAIDS, where the situationis worsening. 44. Estimates of HIV incidence and prevalence are a cause for concern and show a more than 25-fold increase in prevalence to reach 0.2 percent among adults of the 15-49 age group, rankingfourth in the CIS.30According to UNAIDS/WHO estimates, in 2001, the number of people in Moldova living with 10 HIV/AIDS (PLWHA) was 5,500. Of these, 2,000 have been officially diagnosed and 50 are under treatment. Young people under 30 years of age constitute about 70 percent of those infected. Without an effective control program, the HIVIAIDSprevalence i s projected to reach 1.9percent bythe beginning of 2011.31HIV infection i s currently concentrated in the intravenous drug user (IDU) population, and intravenous drug use currently remains the main mode of HIV transmission, accounting for 82 percent of all reported cases in2001. There is a change inepidemiologicalpattems. The proportionof IDUs among newly detected HIV cases declined from over 80 percent in 2000 to less than 55 percent in 2003, suggesting that sexual transmission has become an important transmission route and that, as inUkraine and Russia, the epidemic, which has been concentrated in risk groups, is spreading to the general population. 45. Pregnant women constitute an important group affected by HIV/AIDS. According to the latest available statistics, the share of women infectedwith HIV/AIDSgradually increasedfrom 24.3 percent in 2000 to 37.9 percent in 2003. Since 1989, 78 HIV+ pregnant women have been registered by the Ministryof Health. Until2003, around one to three cases of HIV+pregnant women were identifiedper annum. However, following the introduction of universaltesting of pregnant women for HIV,the number of newly detected HIV cases increasedto 12 cases in2003 and to over 40 cases inthe first nine moths of 2004. This increase reflects the spread of HIV beyond the risk groups in Moldova to the general population. 46. The populationof injecting drug users (IDU) i s estimated at 50,000, and this number i s estimated to be growing at 30 percent per annum.32Most of the I D U s are not registered drug users. Hence, estimating true incidence and prevalence levels i s fraught with difficulty. However, according to statistics from the Centre for Public Health and Management, in 2003, the prevalence of drug users was 155 per 100,000 population. In 2004 this figure had increased to 173.8 per 100,000-an annual increase of 12 percent. 47. A worrying trend is the rapid and substantial rise in the incidence and prevalence of sexually transmitted illness. The number of cases of syphilis increased almost thirty fold from 7.1 per 100,000 in 1989 to 200.1 per 100,000 in 1999. The number o f new cases of common STIs (syphilis, gonorrhea, chlamydia, and trichomoniasis) was estimated in2001 to be around 239,000 per year. The expansion of commercial sex work (CSW) and trafficking of women are contributing to this explosion in sexually transmitted illnesses, which increases the likelihood of sexual transmission of HIV. The officially notified cases of STIs are much lower than the estimates of incidence, whch are thought to be four to five times the officially notified rates, which show a decline in syphilis but a continuing and substantial increaseingonorrhea levels (Figure6). 11 Figure 6. Incidence of gonorrhoea and syphilis based on official notifications 100, I 90 .- 3n + 70 60 0 9 8 50 r 40 a, 30 E 9 20 10 0 2000 2002 2003 2004 nGonorrhea Syphilis I Source: Department ofPublic Health andManagement (2004 estimates) 48. In the period 1990 to 2002, the incidence of tuberculosis more than doubled (according to officially notified new cases), although estimates put the current incidence to be almost 50 percent higher thanthe officially notified cases (Figure 7). Figure 7. Tuberculosis incidence I 160, I 120 100 80 60 40 20 n 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 I 10Tb incidence(noldied)m18lncldence(eslmled)nSeries3 Source: Department of Public Health and Management and (Estimated from World Bank Statistics 2004 andWorld BankTBHIV Project PAD) 49. The most dramatic increase of tuberculosis was registered inchildren. In2004, as compared with 2003, the number of officially registeredtuberculosis cases inthis group doubled. 50. Given the increase in the incidence and prevalence of tuberculosis, STIs, IDUs, and expanding commercial sex work, a rapid increase inHIV/AIDSand an evolution from concentrated to a generalized epidemic is likely. 12 51. Although Moldova has worsening communicable disease problems, it has gone through demographic and epidemiological transition, and chronic illnesses are prevalent. Between 2000 and 2004, the incidence of cardiovascular illness increased by almost 80 percent to reach 170 per 100,000 population (Figure 8). Similar trends are observed for neoplasms, which inthe same period increasedby 20 percent (Figure 9). Figure 8. Incidence of cardiovascular illness 1 180I 1 2000 2002 2003 2004 Source: Department of Public Health and Management Figure 9. Incidence of malignant neoplasms 1 200, -as 180 P -7- 160 8 140 L 120 -E8 100 B 80 C C FI .F 60 40 g.- U 20 C - 0 2000 2002 2003 2004 Source: Department o f Public HealthandManagement 52. Another source of concern i s the increasing number o f children with disability, which has increased60 percent between 1993 and 2001 (Figure 10). 13 Figure 10. Number of childrenwith disability (per 1,000 childrenaged 14years and under) 02+ 1993 1994 1995 1996 1997 1998 1999 2000 2001 Source: DepartmentofPublic Health and Management 53. Notwithstanding these improvements, Moldovan health indicators continue to lag considerably behindother European and Commonwealth of Independent States (CIS) countries, and greater efforts will beneededfor Moldovato meet the MDGtargets 2.5. EXCESS INFRASTRUCTUREAND HUMANRESOURCES 54. As with other post-Soviet countries, at independence Moldova inherited a centralized health systembasedonthe Semashko model. The model was characterized by anextensive infrastructure with a curative focus anda largenumber of healthprofessionals. 55. As inother post-Soviet countries, parallel health services for railways, prisons, and the ministries of defense, interior, and education existed. These services consume around 10 percent of the central government fundingfor health.33 56. In1994,there were 305 hospitals with42,000 beds, amounting to 116hospitalbedsper 10,000 population. In the same year there were 37.9 physicians and 104 nurses and midwives per 10,000 population, a high figure when compared with the countries of the former Soviet Union (FSU) and the Central and Eastern European Region. However, these averages masked huge inequities in the distribution of infrastructure and human re sources with an excess inurbanareas and cities and relative absence inrural areas. It was estimated that, in2002, around 15 percent of rural areas were not covered by doctors.34 57. For instance, as regards number of doctors per capita population, there was a ten-fold difference betweenurbanand rural areas (Figure 11). 14 Figure 11. Number of doctors per 1,000 populationinurban and rural areas -- I I 8 Urbar i Rural 1995 1996 1997 1998 1999 2000 2001 Source: Department o f Public Health andManagement Annual Statistics 2002 58. A similar pictureexisted for the number ofnurses but this difference was less marked, with a four fold difference inthe numbers per 1,000 population (Figure12). Figure 12. Number of nursesper 1,000 population(urban andrural) 180, I 140 a P g 120 80 Rural E C 1995 1996 1997 1998 1999 2000 2001 Source: Department ofPublic Healthand Management Annual Statistics 2002 59. Despite the large overall number of medical professionals inthe country, there have not been any major reductions inmedical school admissions. 60. Although there i s a large hospital and PHC infrastructure, most of the buildings are in poor condition. A survey of four large family doctor centers, (serving a population of around430,000 people), six health centers (serving a population of 68,000) found poor infrastructure quality and work environment and inadequate equipment levels (except for a few that had been refurbished as part of the WB HIF ~roject).~' 13 2.6. INEQUITIES INHEALTHEXPENDITUREAND OUTCOMES 61. Although information i s limited, the 2001 UNICEF household survey highlighted critical aspects related to the financial fairness of the Moldova health system. (Ref) The main findings of the survey included: (i) poor households have more limited access to health care services, reflected in the total number of visits to outpatient clinics and hospitals by income level, (ii) households pay a much poorer higher percentage of their income for health care and the differences are exacerbated over time, (iii) average out-of-pocket expenditure for hospitalization is more than three times the average household income. The study highlightedthe potentially catastrophic nature of expenditure for hospital care and the need to develop a financial risk pooling mechanism that mitigates risk among the poorest population. It also underlined that the above three factors combine to create a barrier to access for the poorer households, with consequent decline inhealthoutcomes for the poor and a widening healthgap. 62. Regional and socioeconomic inequities existed for resource allocation, service utilization, morbidity, and mortality. Resource allocationto local governments is not needbasedand follows historic patterns. Further, the proportion of local government funds allocated to health care varies. Health expenditures, as a proportion of total local government spending declined from 28 percent, inthe period 1993-1997, to an average of 22 percent in2000-but it rangedbetween 17to 28 percent byregion.36Not surprisingly,in2000, per capita health expenditure betweenregions variedtwo fold (Figure 13). Figure 13. Per capita health expenditure (in 2000, inMoldovan Lei) 140 3 5 120 -8 s 100 I ' Source: Departmento fPublic Healthand Management 63. Similarly, infant mortality rates between some regions also varied by almost two fold (Figure 14). 16 Figure 14. Infant mortality by region 64. Despite an excess of human resources, these were not equitably distributed, with a ten-fold difference inthe per capita number of doctors and four-fold difference inthe per capita number of nurses inurbanandruralareas37(Figures 11and 12). 2.7. INEFFICIENT SERVICE PROVISION 65. Moldova inherited a health system based on the Soviet Semashko Model characterized by: (i) centralized planning; (ii)hierarchical administrative organization; (iii)a large provider network dominated by hospitals and tertiary provider units; (iv) parallel health systems for line ministries and large organizations; (v) poorly developed PHC level fragmented by a tripartite delivery model, which provided services separately for adults, men and children, as well as a large number of vertical programs delivered by narrow specialists; (vi) absence of family physicians at the PHC level, which lacked a gate keeping function; (vii) a surfeit of human resources concentrated in urban areas; (viii) an inequitable resource allocation system based on historic activities and inputs rather than on need or poverty, which favored large hospitals inurban centers at the expense o f rural areas; (ix) line-item budgetingof provider units and salary-based payment systems that encouraged inefficiency and discouraged improved performance; (x) strict care-delivery protocols not based on current evidence, a circumstance that encouraged excessive referral to the secondary-care level; (xi) highly curative and disease focused services (partlyattributable to the nature of medicaltraining) with limitedhealthpromotion or prevention, and; (xii) a system which allocated users to doctors and prevented them from exercising choice or meaningfully participatinginthe healthproductionprocess. 66. For consumers, health services were provided free of charge, and there was little individual responsibility for health. 67. Performance, interms of productivity of facilities, satisfaction o f patients, or quality o f care was not considered a factor when financing provider institutions. Managers could maximize their budgets by 17 reporting as many full beds as possible and minimize their costs by admittingpatients who required little care. Under this system, there was no accountability for performance. 68. These factors created inappropriate incentives to retain unnecessary beds, to admit patients with little or no need for hospital care for periods of lengthy hospitalization, and to invest little effort to improve quality, appropriateness, or efficiency of services. There existed no incentives also to encourage public health, healthpromotion, or PHC. 69. The vertical programs, as in other post-Soviet countries, operated without good linkages with other related programs. For instance the linkages betweennarcology, tuberculosis, and STI services were poor, andthe services were not effective intargeting riskpopulations. 70. The primary care level had limited involvement inmanaging common chronic andcommunicable disease problems and acted as a referral level rather than as an effective gatekeeper. It was not effective inmanagingcommonconditions at the PHClevelto resolve problems. 2.8. LOWLEVELS OF PAY FORHEALTHPERSONNEL 71, Salaries, paidto physicians and middle-level medical staff, are determined according to the "Law on Remuneration of the Republic of Moldova," and levels reflect years of service, qualifications, and position held rather than performance. The Law does not provide incentives to encourage improved performance or provisionof highquality services. 72. In2000, teachersanddoctors earnedaroundUS$20-30 permonth.38In2000, the averagesalary for physicians was US$30 per month, and that for other healthpersonnel averaged US$24 per month. In the transition period, the wage differentials between the public and private sectors widened, with consequentmovement o f many public sector staffto the private sector.39 73. The erosion of real salaries, arrears with payment o f salaries, and failure to link salary levels with group and individual performance i s a major weakness inthe system. While there have been efforts to reduce salary arrears and to increase wages, structural problems in the salary scales have not been addressed and remain a barrier to achieving any meaningful changes to salary levels. 74. Low salaries and lack of incentives have led to low motivation levels and have encouragedrent seeking behavior. Informal payments have increased substantially. It has led to erosion of public confidence inthe health sector and healthprofessionals and also adversely affected the quality and scope of services delivered. Many health professionals have left the health sector or emigrated abroad. Although, this natural wastage has helped address the presence of excess human resources, most of those who have left are ancillary staff and nurses who are difficult to attract and retain as they have few other means of generating additional income (Figure 15). 18 Figure 15. Number of ancillary staff per 1,000 population 50 1 ` i 45 40 #.-35 30 C 25 n 5 20 2 15 10 5 0 1995 1996 1997 1998 1999 2000 2001 2002 1 I Year Source: Department ofPublic Health and Management 75. While the attrition inthe number of health professionals inthe health system alleviated some of the excesses inthe healthsystem, it created significant problems inrural areas. The decline inthe number of health professionals working in rural areas was much higher than that observed inurban areas. For instance, between 1995 and 2001 the number of doctors inurban areas declined only 5.6 percent, while the number inrural areas declined by around 25 percent. The decline for nurses inrural areas was more dramatic, with a decline of 37 percent as compared with 19 percent inurbanareas (Figure 16). Figure 16. Decline innumber of doctors and nurses inurbanand ruralareas (percent, 1995to 2001) 40 35 g 30 25 5 20 5 5 15 H : lo 5 0 Source: Department o fPublic Health and Management 19 2.9. ACCESSBARRIERS TO THE HEALTH SERVICES AND NEGATIVE PERCEPTIONS OF THE HEALTHSYSTEM 76. A number of studies identified that high cost was a major barrier to accessing health care. Particularly for the poor population, unofficial payments actedas a deterrent. 77. A health survey conducted in 2001 showed that the majority of the population was not satisfied with the infrastructure of healthfacilities. On average, only 13 percent of the populationwas 'completely' or 'very satisfied' with the current healthcare system, and 84 percent believed it should be changed.40 Despite an excess capacity of health care facilities, there was inadequate access coverage in all of the judets surveyed, with significant regional variation. On average, 55 percent of those visiting their family doctor and 46 percent of patients visiting a specialist paid for the consultation. The survey found that although good communication existed between patients and doctors, patient complaints and needs were not taken into account with healthservice decision^.^^ 78. Two Public Opinion Surveys have been done in2002 and 2003. These surveys of 1,200 citizens and a smaller number of in-depth interviews with experts were financed by the World Bank and implemented by the Center for Public Opinion Research "Moldova Modem$, in 200242and by the Academy of Sciencesof Moldova: Institute of Philosophy, Sociology and Law in2003.43 79. Many findings from surveys of the users in 2002 and 2003 were similar. In2002, around 44 percent of the respondentswere aware of the health reforms, while in2003 this number had increasedto 60 percent. 43, 44 80. Most respondents mentioned the strengthening of the primary medical services and investment in health education (on healthy lifestyles) preventive care as priorities for the health care sector. Introducing the institution of family doctors was generally acceptableto the respondents. Although many respondents do not have a clear understanding o f the role o f family doctors, a large proportion supported the idea of having a family doctor as they felt a family doctor would provide more personal care with continuity for the person and the family.433 In2002, creation of the institution of family doctors was supported by 55 44 percent of the respondents while in2003, this figure had increasedto 61 percent.43 81, Inthe 2003 survey, 12 percent of the respondentswere satisfied with the quality of medical services; 46 percent "generally satisfied"; 28 percent "more or less satisfied"; and 10 percent "not satisfied at 82. Both surveys found that unofficial payment of doctors, nurses, and other medical personnel was widespread42343 with over than half of respondents in 2003 acknowledging that they had "unofficially paid'' their physicians and other health professionals. Around half of those surveyed in 2003 were in favor of "official" user fees to substitute for the unofficial payments, although 48 percent felt that in addition to official user fees they would have to pay unofficial charges. An overwhelming majority (77 percent) of the people surveyed in2003 expressedthat they did not "have a permanent doctor" to consult with or follow a course of treatment free of charge.44 83. Poverty and difficult living conditions were identified as the most important problems o f the Moldovan society as well as the risingprices, increasing crime rate, and unempl~yment.~~, 44 Inthe 2003 survey, corruption was also identified as a major problem.44Although health in general and subject matters such as HIV/AIDS inparticular were not main concerns of the society, respondents spoke of the "womanizing" of poverty, referring to the diminishing capacity of women to pay for medical services. Highprices were identifiedasthe mainbarrierto healthservicesandmedicines. Manyofthe respondents were not able to affordto pay for prescriptions.43344 20 84. In2002, one third of those interviewedfelt that the healthsystemshouldbereformed along lines of Western countries, while a similar proportion wished to see the Soviet health system rein~tated.~~In 2003, althoughthe proportion wanting reform inline with systems inWestern countries had remained the same, the proportion o f people wanting a return to the Soviet health system declined to 22 percent.44A large proportion of respondents disapproved hospital closures as they felt that the savings would be channeled elsewhere rather than reinvested to improve the health system. Many respondents favored building small hospitals and health centers in each district. The survey found that, generally, the population was pessimistic about the reforms, with 53 percent doubting that the situation would improve.43'44 85. A group o f experts surveyed in2002 all agreed that the health system should be reformed, but there was disagreement regarding the direction and content of reforms. A frequently expressed concern was the low level of training of family physician^.^^ 21 3. HEALTHREFORMSAND KEYLEGISLATIVE CHANGES 3.1. HEALTH SECTORSTRATEGY 86. The Law on Health Protection was adopted in 1995.44This established the platform for subsequentLaws and Decreesto reformthe health system. 87. In 1997, the Moldovan Government approved a Health Sector Strategy for the period 1997- 2003.45 The Strategy aimed to address structural inefficiencies, reduce human resources, and improve financing o f the health sector. It also identified.as key objectives: (i) `addressing health issues' as a priority; (ii) equity and solidarity; (iii)establishing effective structures andprocessesto implementing and monitoring National Health Policy; (iv) establishing inter-sectoral programs with broad consultation, consensus, and community participation. The Strategy identifiedthe major areas of development: Organizational and Structural Changes: (i)development of PHC, (ii) developing a family medicine centered model with a named doctor responsible for citizens health, (iii) establishing effective interface between PHC and secondary care, (iv) creating incentives for increased health promotion and preventive activities, (v) enhanced management of human resources, (vi) introduction of care guidelines, (vii) decentralization to improve local management of services and increased user participationwith definition of the rights of the users, (viii) restructuringof the hospital network, (ix) improvement o f resource allocation mechanisms to develop alternative service provision models. Modifications to financing system: (i)organization and introduction of compulsory health insurance; (ii) decentralization with autonomous provider units that will be contracted to provide services; (iii) change resource allocation from line-item budgetingto one based on per capita mechanisms; (iv) transfer of managemento fparallel health systems to Ministryof Health; and (v) allocating State funds to cover vulnerable groups andpriority nationalprograms. Reform of the education and training system for medical staff: (i) changing training curricula in line with best developed practice; (ii) introducing continuing medical education; (iii) reforming medical specialties. Pharmaceutical reform: (i) introducing rational prescribing; (ii) developing pharmaceutical policies and regulations for medicines management.46 These themes were developed into the "five pillars" o f the health reform strategy and articulated inthejoint Government of Moldova/World BankHealth Investment FundPr~ject.~'These pillars were: (i)restructuring the network of medical services, inparticular redistributingresourcesfromtertiary medical care (where there i s overcapacity) to primary care; (ii) strengthening the primary health care network by establishing an efficient network o f family physicians; (iii) legalizing illegal payments, eliminating payments for unnecessary or excessive medical services, especially those which burden the poor population; (iv) creating a package of medical services in line with budgetary resources, with an emphasis on primary health care; and (v) centralizing health system financing to improve distribution of fundsbetweenlevels. 22 90. Between 1998 and 2000, the Government issued a number of Decisions and Decrees that were followed by the Ministry of Health Orders to operationalize the Health Sector Strategy for 1997-2003. These legislative acts formed the basis for the reforms. The PHC reform established the State Hygiene and Epidemiological Service (SHES) for the country. A Government Decree in 1997 promoted structural and organizational changes to establish a new PHC system. It createdthe specialty of Family doctor and the post of family doctor (Annex 2) and PHC nurse. Further,it introduced the principle of free choice of family doctor, and recommended the development of necessary normative acts for the creation and development of PHC and family medicine. The same Decree introduced a per capita payment system for PHC providers, replacing line-item budgetinge4* 91 , Between 1998 and 2002, there were 54 regulations issued by the Council of Ministers regarding PHC.49 Responsibility for managing PHC, hospitals, and emergency services (with the exception of Republican Hospitals and Research Institutes) was delegated to the judet/municipality/TAU administrative authorities (councils), to be financed both directly from the state budget and fi-om local budgets. The regulations stipulated that 35 percent of the local health budgets (27 percent of the government health expenditure) should be allocated to PHC, with 45 percent to hospital services, 15 percent to emergency services and 5 percent to specialist hospitalservices. 92. Severalregulations relatingto restructuring of the hospital sector were passedinthe same period, These required the Ministry of Health and the Judet Health Authorities to initiate hospital rationalization and health sector restructuring to reduce hospital expenditures and releaseresources to invest inPHC. A medium-termrestructuringplanwas agreedbetween the Ministry of Health and Judets Health Authorities which required the judets to reduce the number of hospitals and to halve the number of hospital beds (MoH Directive December 1998). 93. The Government also elaborated and approved a ten-year Hospital Restructuring Plan for hospitals inChisinauMunicipality and for RepublicanFacilities. This RestructuringPlan was established as one of the conditions for disbursement o f the third tranche of the Structural Adjustments Credit providedby the InternationalMonetary Fund(IMF). 94. In1999,the Government approved regulations that changedthe resource allocation methodto rayons fromhstoric budgetsto a per capita budget allocation, adjusted for age and sex, to achieve amore equitable resource allocationreflecting localneeds. 95. In1998,the Parliament enacteda Law to introduce MandatoryHealth Insurance to provide an extra budgetary financing source for the health system based on a salary tax of 2 percent from the employee and 2 percent from the employer (see section oncompulsory health insurance). 3.2. ORGANIZATIONAL CHANGES 96. Betweenthe declaration of independence(1991) and 1999,Moldovawas divided administratively into 40 rayons and 10 towns. 97. In1999,theadministrative boundarieswere rearranged. Healthsystemdecentralization beganin 1999 with changes in public governance arrangements that aimed to regionalize government adrmnistration. The Law on Local Public Administration in199950established 11 regional administrative units comprising 10 counties uudets), one metropolitan area (the city of Chisinau), and the territorial autonomous unit (TAU) of Gagauzia. The judets were given increased responsibility and scope for regional planning and administration, including health. The regional health authorities were made responsible for paying regional health services, with support from the central government budget and 23 local tax revenues. However, inadequate tax revenues at the local level and low government transfers made it difficult for the regional health administration to implement decentralization and the new local- level arrangements. Inthe judet administrative structure, local health budgets were allocated directly to PHC units, sectoravjudet hospitals, and emergency services and managed autonomously by each o f the units(see figure 17). 98. The Public Administration Law 123/2003 enacted in 2003 and Government Decisions 688 and 689 of June 2003 developed a new public administrative structure based on 32 rayons, 3 municipalities, and 2 territorial and autonomous unit^.^^,^^ In line with the new Law and Government Decisions, the Minister of Health issued Regulation 190 regarding the new structure of the health care system at the rayon and municipal levels.53 The new regulations abolished the judet structure and stipulated that health services should be reorganized into one legal entity composed of rayon hospitals, primary health care, emergency and ambulatory specialist services, with separatebudgets for eachof the different services, but managedbythe rayonChief Doctor. Figure 17. Organization of healthsystem at district level Informaticsand Hospitalspecialist statistics departments Main specialist maternaland child health Technical services Main specialist Pharmaceutical assistance Mainspecialist nedical techniques 99. There are now 32 districts, 3 municipalities, and 2 territorial autonomous units. The new territorial structure places the entire budget and income from the Health Insurance Company contract in the hands of the rayon Chef Doctor. Under this new unified structure, PHC units no longer operate as separate legal entities, but are accountable to the rayon hospital's Chief Doctor, who administers and i s responsible for the budget of the PHC centers, emergency services, hospitals, and specialist services. The health funds are transferred from the Health Insurance Company and local government to the rayon hospital administration. The rayon chief physician then allocates the funds to the sub-units s/he directly manages, but i s requiredto comply with M O H budgeting norms, which stipulate allocation o f 35 percent of resourcesto PHC, 15 percent to emergency services, and 50 percent to hospital services. However, the funds are not ring fenced. Rayon hospitals cannot increase the number of beds without approval from MOH. Hospitals inrayons with populations of less than 90,000 provide services infive basic specialties, while hospitals in larger rayons provide more extensive services for their population and for those from smaller neighboring rayons. 24 100. The contract with the Health Insurance Company (HIC) allowed the rayon chief physician to reallocate up to 25 percent of the PHC budget for hospital care, creating a risk of sequestration of the PHC budget for the benefit of hospital services, which occurred in some rayons.54This clause was changed in2005, following discussions duringthe World Bank Mission inJune 2004. The new contract does not allow for sequestration, and now sub-accounts for PHC are possible. 3.3. DEVELOPMENTOF A STATE-GUARANTEED MINIMUM PACKAGEOF SERVICES 101. A key achievement is the establishment of a Minimum Package of Services for the whole population of Moldova. Article 36 of the Constitution of the Republic of Moldova guarantees free minimumprovisionofhealthcare services to the population. However, the Constitution does not define what this `minimum' amount should be. The "Basic Law on Health Care," enacted in 1995, followed by the "Law Regarding the Minimum Package o f Free Medical Assistance Guaranteed by the State," introduced in 1999, defined the responsibilities of the State as regards healthcare and defined a basic set of health services for which the State has the responsibility to finance. The MinimumPackage includes: (i)Primary health care services provided by a general practitioner/family doctor in an ambulatory care unit or at home; (ii) Consultative services provided by physician-specialists inpolyclinics and hospitals (when patient i s included on the list of GP/FD and i s referred by the GPFD); (iii) Limited range of diagnostic tests and elementary investigations conducted inambulatory laboratories (when prescribed by the GPED); (iv) Immunization (through National Immunization Program); (v) Urgent and emergency services for life-threatening situations; (vi) Hospital care for treatment of tuberculosis, mental disorders, oncology, asthma, diabetes, AIDS and "social related-diseases," and a number of other infectious diseases. 102. At the endof2000, UNICEF launchedthe PHCRehabilitationProject inHincestiwith the aimof testing the financial andtechrucal feasibility of implementing a model of PHC based on a clearly defined package of services supported by treatment protocols. The pilot covered a population of 130,000 people and implemented an essential service package based on 50 cost-effective priority interventions and a package of 109 drugs. The evaluation of the pilot showed that the project was successful inmeeting its three objectives o f increasing: (i) accessibility, efficacy, and quality of healthcare services in the the primary care sector by implementing the Basic Package of Services, Essential Drugs Policy, and health care guidelines, and by developing Emergency Services; (ii) the efficacy and efficiency of health service by rationalizing PHC structures, strengthening PHC management, and streamlining health service funding; (iii) community involvement in health services planning, organization, and evaluation. The evaluation o f the pilot Project showed that at a cost of around U S $3 per capita per annum, it was possible to access basic PHC services, including pharmaceuticals and ancillary services, and that this was affordable to the local health administration. The Basic Package provided good coverage against the main causes of illness in Moldova and led to the improved service utilization and health status o f the covered population. However, it was difficult in the pilot to mobilize resources for a community financing scheme.55 3.3.1. Immunization program 103. The first National Immunization Program (NIP) o f Moldova for the period 1994-2000 was developed and adopted by the Government in 1994. The NTP was able to reach its targets with the technical and financial assistance of UNICEF, WHO/EURO, EU, Japan, and the USA.56 104. The Government adopted a second Immunization Program (2001-2005) in 2001 which put in place an enabling environment to develop an effective National Immunization Program integrated into 25 PHC delivery with guaranteed funding for the NP from the State budget and disease reductiontargets in accordance with the WHO EuropeanRegion. 57 105. Moldova has been able to achieve excellent immunization coverage for children. As a result, in the year 2000 Moldova was certified polio free. An assessment of quality of immunization delivery services conducted in 2001 by the National Center of Preventive Medicine with financial support of WHO Euro showed that immunization services were fully integrated into PHC. The assessment found the National Immunization Program provided good service at every level, with equal accessibility for urban and rural populations and good cold chain facilities. However, a lack of financing by the national and local authorities adversely affected logistical support to the NIP, especially in relation to transportation of vaccines, records keeping, andmaintainingcold chain equipment5* 106. A Multiple Indicator Cluster Survey (MICS) of 11,592 households done in 2000 by UNICEF identifiedthat immunization coverage among children 15-26months old was 94 percent inrural areas, 86 percent inurban areas, and 74 percent inTran~nistria.~~ 107. Inline with WHO'SEuropean Region's goal of eliminating measles by 2007 and reducing the incidence of congenital rubella syndrome (CRS) to 4 per 100,000 live births by 2010, the Republic of Moldova has developed a national plan for measles elimination, mumps and rubella control, and CRS preventionfor 2002-2007. The planincludes: (i) a measles/ rubella (MR) vaccination catch-up campaign and rubella vaccination for women of childbearing age; (ii) introduction of two doses of MMR vaccination at the ages of one and six years; and (iii) implementation of surveillance for rash-fever illnesses and CRS. By the end of April 2003, 99 percent of 8-19 year-old persons and 96 percent of university students 20-23 years old were immunized with combined measles/ rubella vaccine. Seventy- eight percent of women of childbearingage (20-29 years old) received monovalent rubellavaccine.60 108. A Health Facilities Assessment undertaken by UNICEF in 2001 in several regions found an improvement inthe immunization system delivery between 1999 and 2001, but 48.4 percent of facilities had experienced stock-outs of vaccines; 42 percent had an irregular supply o f MMR vaccine with 22.6 percent lacking vaccine for more than 3 months. All facilities had vaccine carriers with ice packs for vaccine transportation and had working refrigerators. Vaccines were stored correctly in 97 percent of facilities, and temperaturewas recorded twice a day in96 percent of facilities. 3.4. HEALTH SYSTEM FINANCING BEFORE THE INTRODUCTION OF MANDATORY HEALTH INSURANCE 109. Prior to the introduction of the MHI, financing o f the health sector was derived from four principal sources: (i) revenues from general taxes; (ii) taxes; (iii) fees (formal out-of-pocket local user payments madebypatients directly at the point of service); and; (iv) externalfunding(Figure 18). 26 Figure 18. Financingflows inMoldovan Health System: Before introductionof MHIand administrative reformsin2004 0" "IPOII., Bud$* Population Hospital primary care center , care centers Source: Cercone JA. Moldova Health PolicyNote. The World Bank, 2003. 110. The sector was funded principally through general taxation, collected at the district level. Local governments (district or municipal) signed agreementswith the Ministryof Finance regarding the level of funds to be allocated to the district level health system. Surplus funds were retained by the Ministry of Finance and passedto the Ministry of Healthto administer as the state (or "republican") budget.61 111. Decree 420 of the Ministry of Health (1998) stipulated that 35 percent of the local health budget should be allocated to PHC. Inreality, hospitals have receivedup to 80 percent of local healthbudgets.62 Actual allocations to PHC have reachedabout 30 percent. . 112. Revenues from national level general taxes were used to finance the Ministry of Health. The amount of funds allocated centrally to the Ministry of Health was determined annually according to the "Annual State Budget of the Republic of Moldova," approved by the Parliament. The M o H used its budget to pay for national vertical programs such as immunization, mental health, tuberculosis and HIV control, the republican hospitals, National Centre for Preventive Medicine, the Institute for Mother and Child Health, and research centers managed by the Ministry o f Health. The Ministry of Health also funded the Centre for Public Health and Management (CPHM), which employs around 50 staff, including statisticians and epidemiologists, and collects and provides on a regular basis annual reports and statistics on the Moldovan Health System. The expenditure for these programs and institutions accounted for 90 percent of the M o H funds. The remaining 10 percent of the M o H budget was used to finance parallel health services managed by the Ministry o f Interior (including the penitentiary system), the ministry of defense, and the railways. A parliamentary Committee on Health and Welfare monitoredthe activities of the Ministryo f Health. 113. In terms of administrative structure, between 1991 and 1999 Moldova was divided into 40 districts (rayons) and 4 municipalities. The Law on Local Public Administration enacted in 1999 established 11 Judets (regions or counties). Responsibility for planning, financing, and managing local primary health care, secondary care services provided at district and regional hospitals (comprising 27 certain inpatient services specified in the minimumpackage), and emergency services was delegated to the 11 regional health authorities. These regional health administrations reported to the Ministry of Health. The Judet health administration allocated the local health budget to four main areas: (i) hospital inpatient services (45 percent of total); (ii) primary health care (35 percent); (iii) emergency services (15 percent); and (iv) certain specialist services such as ophthalmological services (5 percent). Each of these departments was an administratively autonomous budget holder with responsibility to the regional health department and, through them, to the Ministry of Health. Each department had a director, and their budgets were ring-fenced (Figure 19). Figure 19. Allocation of the public sector budget prior to Health InsuranceReforms I I I I I Governmentof Moldova Local Government Health system funds from publicsources 40%0f funds 60%of funds Ministry of Health RegionalHealth Department Parallel health Republican hospitals Research institutes \ S%offunds I 114. However, since 2004, the public administrative structure of Moldova has changed along with healthsystemfinancing and administration(See section on organizational changes). 3.5. HEALTH SYSTEM FINANCING AFTER THE INTRODUCTION OF MANDATORY HEALTH INSURANCE 115. In1998, the Law onMandatory HealthInsurance was enactedto introducefinancing from social insurance and to move to a mixed system of financing.63Government resolutions in 2002 enabled the creation of 11 territorial branches of the Health Insurance Company (HIC) and defined the contract between the HIC and health care providers on the basis of volume of activities for Basic Benefit Package of HealthCare Servicesunder the Mandatory Health Insurance (BBP-MHI) andprices basedontariffs set bythe MOH..6465 The costing methodologyis inaccordancewith Government Resolutions.66 116. In2002, the Government Decision enabled piloting of the CHI inthe Hincesti district for a six- month period from July to December 2003.67 Mandatory Health Insurance was successfully piloted, Duringthe pilot the MHIcontributions were established as a 2-percent payroll tax for the employers and employees in the rayon. The MHI contributions for pensioners, children, students, and the officially registered unemployed were established to equal 169.68 lei (12.8 USD) for half a year, and the total 28 amount of public fhding o f the rayon health care system increased by 1.8 times. The PHC center in Hincesti became a part o f the rayonhospital after the mergingof all healthcare institutions into one legal entity. At start of the pilot there was an approximately 40-percent deficit in the number of family physicians in the rayon. With introduction of the MHI ths deficit was partly corrected by employing physicians in residency training. During the first three months of the pilot, the workload of PHC increasedby 35,000 additional visits to the PHC physicians, and the proportion of visits by rural citizens increased from 42 percent in year 2002 to 73 percent in year 2003. Inthe same period, the number of ambulance visits decreased substantially in comparison with the same three-month period in 2002.68 However, it appears that the State Guaranteed Minimumpackage was larger than the benefits package included inthe Basic Benefit Packa e of Health Care Servicesunder the Mandatory Health Insurance, an anomaly that needs to be addressed.f 9 117. InDecember 2003, the Government passedaregulationdefiningservices to be covered bythe Mandatory Health Insurance and available only for the insured population. In addition, 21 national programs, available to all Moldovan citizens regardless of insurance status, were identified. The national roll-out be an in January 2004 with appropriate modifications to the Law on Mandatory Health Insurance.."> 71, 72 Changes inthe Law also make it possible for individuals or legal entities to establish 'medical institutions'to contract with the Health InsuranceCompany or its territorial branches.73 118. The contributions are now set on a payroll tax of 2 percent of monthly salary payable by the employee and 2 percent payable by the employer.74MHI covers those who are permanently employed (defined inthe Law as holders of Labor Cards). Inaddition, contributions are made from the state budget for unemployed persons, including students attending vocational training, full-time university students, and disabled persons. Transfers from local government budgets cover children under the school age, children inprimaryand secondary education, those officially registered as unemployed, andpensioners. 119. The benefits for the insured were stipulated in the Government Resolution that defined BBP- MHI,which includes: (i) emergency pre-hospital medical assistance; (ii) medical assistance; (iii) primary specialized ambulatory medical assistance; (iv) stationary medical assistance; and (v) other services relatedto medical assistance.75 120. The services stipulated in the BBP-MHI and the contracts between the HIC (and its territorial branches) and the providers follow the Government-approved MinimumPackage of Services, which was changed to include: "(i) anti-epidemic prophylactic measures and medical services within the national programs stipulated in the state budget; (ii) pre-hospital medical assistance, in case o f major medico- surgical emergencies that endanger the life of the person; (iii) general practitioner-provided primary medical assistance, which i s comprised of clinical examinations (subjective and objective), with recommendations for examinations and treatment; (iv) medical assistance, stipulated inthe BBP-MHI.76 121. The PHC services delivered by the FM specialist according to the HIC contract include: "supervision of baby's growth; immunization according to the vaccination calendar; preventive examinations for adults and family planning; pre-natal care, supervision o f pregnant women, and post- natal care of women, including providing pregnant women with iron medication that i s 100 percent compensatedwhen prescribed by the family doctor; interventions incase o f illness, including the volume of healthcare servicesprovidedbythe family doctor (health care innew cases of illness and acute state of chronic diseases); interventions, including preventive, in the cases o f frequently met diseases; and surgical emergencies provided by the primary health care entity in the health care institutions and at home; ambulatory examination for certaincategories of patients; supportingactivities." 29 122. The HIC agrees to an annual contract with the rayon administration with pre-specified price and volume o f services to be provided. PHC providers are paid according to a per capita contract, and hospitals are paidper dischargedpatient andper case for emergencies. 123. Since the introduction of the MHI, inthe frit three months of 2004 the number o fPHC visits was about 2,900,000, an increaseof over 20 percent as compared with the same period in2003.77 124. While many of the FSUcountries have attempted to introduce healthinsurance schemes, success has been limitedS7*Moldova i s attempting to use MHIas an instrument to improve efficiency and quality of health services rather than as a means to raise all health system financing, realizing that in the transition years, health financing needs to be mixed and from several sources. At present, income from MHI is low and financing comes predominantly from general and local taxes and out-of-pocket expenditures. Healthinsurance i s being usednotjust as a tool to mobilize resources, but also as a catalyst for change. Implementation of MHI i s progressing well. Revenues continue to closely follow projections. As part of a healthinsurance basedmodel, the Government has approved the basic package of services for 2005, which have expandedinscope incomparison with 2004. The package now includes the services of narrow health specialists and dentists as well as financial subsidies for drugs for patients with hypertension. For the uninsured, the Government has allocated 30 million Lei to cover in-patient and specialized out-patient treatment of patients who suffer social diseases, such as TB, oncological illnesses, psychiatric diseases, HIV/AJDS, etc. 125. The World Bank mid-termreview for the Health Investment FundProject indicatedthat the new territorial structure placed the entire budgetkontract inthe hands of the rayon chief physician and left the PHC budget at risk of potential sequestration. Sequestration by the rayon directors was allowed under the insurance contract (up to 25 percent of the PHC budget for hospital care). Indiscussions with the HIC Director, the June World Bank mission received assurances that the next version of the contracts would eliminate the clause that allowed for potential sequestration of PHC funds. Following this intervention, the 2005 contracts were amended to the effect that did not allow the Chef of the Rayon Hospital to use funds from PHC for hospitals. In addition, the 2005 contracts provide for allocation of resources on different bank sub accounts (hospital, PHC, etc). 3.5.1. Out of Pocket Payments 126. Private expenditure for health comes from three sources: (i) unofficial payments to health care providers; (ii) user charges; and (iii)expenditure onpharmaceuticals. 127. The decline inpublic financing of health care has been substituted with an increase in informal payments and the introductionof a formal set of user fees. 128. User payments were introduced in 1999 and apply to certain services and pharmaceuticals not covered under the MinimumPackage guaranteed by the State. Formal user charges were introduced to create transparency with payments to providers (in an attempt to reduce informal payments made to providers) and also to raise additional sources o f funds for the health sector to partially offset the diminishedfunding fromthe public sector. 129. Out-of-pocket payments have been increasing since 1992 and now exceedpublic expenditure on the health sector. In1998, a household expenditure survey done by the Department of Statistics showed household expenditures of 4.2 Lei per capita per month (amounting to 184 million Lei per year and 2 percent of GDP) and about half as much as the public sector expenditure on health.79However, a household survey carried out byUNICEF in 1996 showed that households spent around 9.9 Lei per capita 30 per month on health (amounting to a total of 440 million lei per annum and equaling public sector expenditure - see Table 2)." Table 2. Estimateof Private Sector HealthCare Expenditures Average monthly health care 4.0 4.2 9.9 15.2 I Total estimated private sector 175.3 184.1 439.4 220 expenditure on health (million lei) 1 DOS: Household Expenditure Survey carried out by the Department of Statistics. UNICEF 1996: "Accessibility of Health Services and Evaluationof Expenditureson Healthinthe Republic of Moldova", UNICEF, 1997. UNICEF 2000: BerdagaV, Stefanet S, Bivolo. Access o f the Population ofthe Republic OfMoldova to Health Services. UNICEF. Chisinau, Moldova. 2000. 130. By 2000, average per capita out-of-pocket (OOP) expenditure was 15.2 Lei per month per household, amountingto around 220.million Lei and 50 percent of the total health expenditure in2000.81 Around 80 percent of the OOP expenditure was for pharmaceuticals, 12 percent for investigations, 6 percent for consultation, and 3 percent for transport. Evidence from the UNICEF household surveys indicate that the increase inhousehold out-of-pocket spending has had a larger negative impact on poor and low-income households, consuming a larger portion of their household income and causing them to forgo neededcare.82 131. According to informal estimates of out-of-pocket expenditure, private financing i s likely to double total healthcare spendinginthe 2004-05 financial year by contributing a further US$lO per capita. 3.5.2. External Funding 132. Extemal funding i s also a significant source o f funding for the health sector. In 1999, the World Bank approved a new Country Assistance Strategy for the Republic of Moldovawith a second structural adjustment loan. The World Bank Health Investment FundProject, to develop ahealth sector centered on PHC, began in2001. The Project i s funded by a World Bank credit o f U S $10 million, complemented by a U S $10 million grant from the Government of the Netherlands and co-financing of U S $1.6 million by the Moldovan Government. The Project has established a 'Health Investment Fund' to upgrade emergency and PHC centers and to reduce excess capacity inthe hospital sector. The health sector also receives project-based funding and assistance from the European Union, UK DFID, Japanese InternationalCooperation Agency, SIDA,UNICEF, UNDP, UNFPA, the Global Fund, and WHO. There are severalNGOsthat are active inMoldova, including, the InternationalRedCross andthe Open Society Institute. 3.6. RESOURCE ALLOCATION AND PROVIDER PAYMENT SYSTEMS 133. An important achievement of health reforms is increased resource allocation to the PHC level. The proportion of health expenditure allocated to PHC has gradually increased from 10 percent o f the total government health expenditure in 1999 to 26 percent in2003, while hospital expenditure declined in proportionto this increase(Figure 20). Figure 20. Allocations inPHC as a percentage of total government healthbudget 1997 I998 1999 2000 2001 2003 ` Source: Department o f Public Health and Management 134. Prior to the establishment of the HIC and contracts, rayon hospitals received budgets from local governments according to inputs and activities such as the numbers of staff, bed days, and outpatient visits. Republicanhospitals received their budgets from the MOH. PHC providers were paid according to a weighted per capita adjusted for age and gender. Since 2004, the regional healthadministration has a contract with the HIC stipulatingvolume of services to be provided. 135. The territorial purchasers of the HIC contract with hospitals are paid according to block volume of services based on the number of cases and performance indicators regarding quality, user satisfaction, and organizational change. 136. Hospitals can levy additional charges for services not included as part of the State Guaranteed Package of Services (as specified inthe "Law regarding MinimumPackage of Free Medical Assistance Guaranteed by the State") on a fee-for-service basis at prices set by the M O H in accordance with the "Regulation onFee for Health Services." 137. The HIC and its territorial branches allocate 35 percent o f the funds available for routine health care to PHC. This total sum divided by the number o f persons insured (and those covered by State and local funding) gives the amount of funds available per insured person entitled to PHC services. The contract for PHC services i s signed with the rayon health authorities and allocations are made on a per capita basis. There i s no risk adjustment. The capitation amount paid i s based on the number of insured persons on the family doctor's list multiplied by the per capita rate, and i s paid monthly in arrears. The contract with PHC providers stipulates attainment of certaintargets andperformance indicators inrelation to: observation of the development o f children under five; implementation of a vaccination program; regular preventive checks o f adults; and detection, treatment, and supervisionof patients with chronic and social diseases (tuberculosis, cancer, cardiovascular diseases, diabetes, hepatitis and cirrhosis, HTV/AIDS). The insured persons have the right to change their family doctor after being registered for three months. 32 3.7. RATIONALIZATION OF THE HOSPITALSECTOR 138. The hospital sector has significant excess capacity inMoldova. When health spending began to fall, revenues were insufficient to maintain such an extensive network. Reduced health care funding, excess utility costs, and large arrears made it impossible to sustain such an infrastructure. Studies that explored rationalization opportunities concluded that significant capacity could be eliminated without adverse effect on healthcare de1ive1-y.'~ 139. Several regulations relating to restructuring of the hospital sector were issued between 1998 and 2000 to rationalize the hospital sector. These regulations required the Ministry of Health and the Judet Health Authorities to initiate hospital rationalization and health sector restructuring to reduce hospital expenditures and release much needed resources to invest in PHC. A medium-term restructuring plan, agreedto by the Ministry of Healthandjudet Health Authorities, required thejudets to reduce the number of hospitals and to halve the number of hospitalbeds (MoH Directive December 1998). The Government also elaborated and approved a ten-year Hospital Restructuring Plan for hospitals in Chisinau Municipality and for Republican Facilities. This Restructuring Plan was established as one of the conditions for disbursement of the third tranche of the Structural Adjustments Credit provided by the International Monetary Fund (IMF). Between 1995 and 2002 the number of hospitals (including Republicanfacilities) declined from 265 to 65 (Figure 21). Figure 21. Number of hospitalsinMoldova 1 300 , I 250 ~ 200 L P m 5 150 z 100 50 1 0 1995 1998 1999 year2000 2001 2002 1 Source: Department of Public Healthand Management Statistics 140. Inthe sameperiodthenumber of bedswas reducedfrom42,000 to 22,000 (Figure22). 33 Figure22. Number of hospitalbeds (total andper 10,000 population) 140 41963 120 100z P I 80 BVI 60 n a? z 15000 5 2s5 40 20 0 1995 1998 1999 Year2000 2001 2002 Source: Department of Public Health andManagement Statistics 141. The annual savings resultingfrom closures of facilities are estimated to be aroundUS$ 10 million (equivalent to 25 percent of total health spending), andthese savings have been used for reducing arrears, increasing allocations to primary care, increasing salaries, and improving availability of materials and supplies.84 142. In2002, a comprehensive restructuring plan was approved for the Municipality of Chisinau, including the Municipal andRepublicanfacilities. This plan, however, has not yet been implemented. 143. The number of hospital admissions between 1995 and2000 declined inline with reducedhospital capacity. Inthe same period the average length o f stay fell from 16.4 to 11.9 days per admission (still very highby European standards, but inline with FSUcountries - Figure23). 34 Figure 23. Number of admissions per 100 people and average length of stay per admission 25 20 23.5 C 18 .a 4a 20 16 z8 a 14 7 15 v) a 12 '0 .-5 v) 10 f 0 .E 10 v) 8E 8 d L 6 $ 5 4 z s 2 0 0 1990 1995 1996 1997 1998 1999 2000 ___IAdmissions Der 100 DODUlatlOfl +ALOS Source: WHO RegionalOffice for Europe Health for All Database. 144. However, the hospitalutilization levels are still low, suggestingthat further substantial reductions incapacity canbe achievedwithout adverselyaffectingservice delivery (Figure24). Figure 24. Hospital capacity utilization 90 80 70 - 6 0 p! e 9 >, C g 40 a :: 030 20 10 0 1990 1995 1996 1997 1996 1999 2000 Source: WHO Regional Office for Europe Health for All Database. 35 4. KEYDEVELOPMENTSINPRIMARYHEALTHCARE 4.1. DEVELOPMENTOFHUMAN RESOURCESINPRIMARYHEALTH CARE 145. Moldova uses central planning to determine health workforce requirements. The Human ResourcesUnitinthe Ministry of Healthis responsible for determining human resourcerequirements. 146. Moldova has an excess of doctors and nurses, although the numbers have been declining due to low salaries and emigration(Figure 25). As demonstrated earlier inthis report, significant inequities exist ingeographic distributionofdoctors andnurses, andthe decline hashitthe ruralregions particularlyhard. It is difficult to attract doctors and nurses to-and to retain them in-rural areas and this remains one of the major challenges facedby the Health SysteminMoldova. Figure 25. Total number of doctors and nurses (000s) 1995-2001 54 45 _.( Doctors I 1995 1996 1997 1998 1999 2000 2001 Source: Department ofPublic Health and Statistics 147. Although the total number of doctors has been declining, the proportion trained in family medicinehas increased. 4.1.1. Trainingof family physiciansand nurses 148. According to data from different sources, the number of family physicians in Moldova ranges between 2,000 and almost 4,000. However, many statistics do not distinguishbetween therapeutists, general practitioners with no specialist training infamily medicine, andthose retrainedinfamily medicine (Figure 26). 36 Figure 26. Number offamily doctors inMoldova 1 500 450 I 4oo - s2250 TI O n t#200 5 150 z 'I ~ 0 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 I Pnmary Specialisation Through intemship Residency ~ ~ Source: Faculty ofFamily Medicine, StateUniversity 149. According to the Department of Public Health and Management, in2002 there were 2,143 family doctors (Figure 27). Figure27. Number of family doctors ---- 1995 1996 1997 1998 1999 2000 2001 2002 Source: Department ofPublic HealthandManagement statistics 150. The family doctor training programbegan inMoldova in 1996. The Faculty of Family Medicine was established at the State Medical University in 1998. A Chair inManagement Training and Public Health was created in 2000. Two model family practices were established in Chisinau and have been used as training practices. The FM Chair has 15 faculty including four associate professors and eight assistantprofessors. It has strong support from the State University 37 151. The Faculty has been providing four different training programs for family physicians: (i) A three-year specialist residency program in family medicine; (ii) four-month retraining course, which A started in 1998; (iii)four-week retrainingcourse, which started in2003 and i s supported by the World A Bank, and (iv) short-term thematic courses supportedbyUNICEF since 1998. 152. Between 1996 and 2001 the Faculty provided `some training' in family medicine to over 2,000 doctors in residency and short course programs and was selected by the World Bank in 2003 as the implementingagency for the retrainingof PHC doctors infamily medicine. 153. Between 1998 and 2004, the UNICEF Moldova office provided short courses on mother and child health issues (antenatal care, immunization, child growth and development monitoring, Integrated managemento f Childhood Illnesses) to over 7,000 family doctors and nurses. 154. In2002, internationaltechnicalassistancewas used,withfinancingfromthe WorldBankHealth Investment FundProject and UNICEF, to develop a curriculum for the training of trainers program (TOT) and to train FM and family nurse trainers. A four-week training program was designed comprising: (i) Participatory teaching techniques (e.g., subjective objective assessment plan (SOAP), adult learning, problembased learning (PBL), role-plays, and case stories); (ii) organizational skills; and (iii) role of the the family doctor/family nurse. 155. certificate^.^^ The FM and family nurse trainers trained A total o f 34 FMtrainers and 20 family nurse trainers were trainedinthe TOT programand given in the TOT program also worked with the international consultants to develop a retraining curriculum to retrain doctors working in PHC in FM. Initially, an 18-week-long retraining course was developed to train 750 family physicians and 1500 family nurses. However, due to lack of funds, this programwas scaled down to four weeks. Inaddition, UNICEF provided financial support for two additional weeks o f training on integrated management of childhood illnesses (IMCI), antenatal care (ANC), and supervision of healthy childdevelopment (SHCD), thus extendingthe training to six-weeks. UNICEFfinanced development ofthe curriculum, remuneration for trainers as well as the subsistence and travel costs of all the trainees trained in the program for the additionaltwo weeks. 156. The four-week element ofthe training comprises four modules: Module I- Concepts of primary care include history taking, consultation skills, prevention, national immunization program, diagnostic shlls, assessing disability, managing drug abuse and violence. Module I1- Syndromic managementand clinical and examination skills, antenatal care, minor surgery, cancer screening, and antibiotic use. Module I11- Teamwork, conflict management, managing common acute emergencies. Module IV- Managing specific illnesses such as heart failure, gastrointestinal problems, diabetes, complicated pregnancy, asthma, urinary tract infections, care of elderlypatients. 157. With support from the WB Health Investment FundProject (HIFP), five regional FM Training Centers were established (in Orhei, Balti, Lapusna, Ungheni and Cahul) and rehbished. The centers were provided with appropriate educational materials and visual aids to enable training to take place. The rehbishment and equipping of the UniversityFamily Practice Training Centre was equally financed by the WB HIFP and the State Universityof Medicine and Pharmacy. 158. The State University of Medicine and Pharmacy was contracted in2003 with financing from the Bank to implement the training program. Doctors and nurses are being trained in the six-week short course retraining program (four-weeks of FM and family nursing and short courses of IMCI, ANC, 38 SHCD, and CGDM) in groups of 15 and 25, respectively. A total of 30 groups o f Family physicians and 60 groups o f nurses will be trained in five regional training centers and the University Family Practice Training Centre inChsinau. 159. By April 2005, 750 physicians and 1,500 nurses were retrained in the FM and family nursing retraining program.86 Evaluation of the training thus far indicates high satisfaction among participants. Pre and post tests have shown the significant impact of the training. 160. There are several concems regarding training and family: (i) The short nature of the training; (ii) The lack of career structure for graduates of FM programs; and (iii) inadequate incentives for FM The physicians. 161. It has beenestimatedthat around 20-30 percent of family medicine graduates go backto work in posts in hospitals. To address the problem of low salaries and incentives, the M O H has developed new guidelines stipulating a mechanism for wage calculations, which will allow for wage increases in2005, especially for GPs inrural areas, where there i s an acute shortage of staff. MOH is confident that these changes will go a long way toward solving staff shortages in rural areas (personal correspondence Ms. BettyHanan, WorldBank Task Team Leader for Moldova). Residencyprogram in Family Medicine 162. A three year residencyprogramwas establishedin1997. The programcomprises: Year 1: (i)Family Medicine inspecialized centers such as university clinics and FMtraining centers; (ii) Intemalmedicine (25 weeks); (iii) Pediatrics (16 weeks) Year 2: Sub specializations such as endocrinology, obstetrics and gynecology, dermatology, tuberculosis, infectious diseases, hematology, emergency medicine, imaging. Year 3: Sub specializations such as dermatology and 32 weeks of family medicine with a large proportiondedicatedto rural medicine. 163. The programis changing with the introductiono fthree months ofFMtraining inYear 2 and three months of compulsory rural practice inYear 3. 4.1.2. Training of Health Managers 164. International technical assistance was used, with financing from the World Bank Health Investment FundProject, to develop a TOT curriculum and to train 26 trainers inhealthmanagement. 165. The TOT programconsisted of four modules, each lasting one week and comprising: (i) general health management; (ii) quality management; (iii) financial management; (iv) business planning and teaching / training method~logies.'~ 166. The trainers trained inthe TOT programwere involved ina working group establishedto develop a training curriculum to train 200 healthmanagers. The nationwide training of healthmanagers has been designed to upgrade the management skills o f health administrators, especially in the context of the nationwide implementation o f MHI, which i s completely changing the system's modus operandi. The 39 curriculumfor training of healthmanagersincluded: (i) general andhumanresource management; (ii) strategic planning; (iii) quality management; and (iv) financial managementand accounting. total 167. The training of health managers, implemented by the State University of Medicine and Pharmacuetics, began in2003. The training i s co-financed by the Soros Foundationof Moldova and the Open Society Institute of New York (OSI). The initial target of 200 managers was increased to 300 health managers (comprising rayon chief physicians, deputy chef physicians, managers of PHC institutions, and hospital managers who will be trained in 12 groups of 25). The objective of training i s to upgrade management skills of health administrators to enable implementation of the health reforms, and inparticular the healthinsurance scheme. ByApril2005,200 healthmanagershadbeentrained.88 168. Inaddition, UNICEF Moldova, inclose partnership with CDC-Atlanta, has provided support to the development of training curricula and materials on Management of Mother and Child Health Programs with elements of Total Quality Management, Evidence Based Medicine, Epidemiology, and surveillance systems in public health. Between 2001 and 2004, more than 100 health care managers receivedtraining onthe above-mentioned issues. 4.1.3. Continuing Medical Education 169. CME i s governed by regulations on revalidationand the Health Law. It consists of a total of 450 hours accumulated over five years andneeds to be done by every doctor to progress inthe healthservice. 4.1.4. Family Medicine Association 170. The FMAssociation of Moldova was established in2000 and held its first congress inthe same year. The Association i s supported by the WHO, and has had activities/projects supported by UNICEF and the Sores Foundation. 4.2. INCENTIVES FORHUMANRESOURCES 171. A Government Resolution, which came into force on 01 January 2004, also changed the procedure for salary calculation at public health institutions. This Resolution indicates the maximum rates of compensation for employees at public health institutions agreed upon by the Ministry of Health, the National Health Insurance Company, and the SFinFitatea Trade Union. It also proposes that the executives of the public healthinstitutions involved inthe MHIsystem allocate 50 percent ofthe revenues accumulated from chargeable medical services to remuneration of health professionals by increasing pay levels, giving additional pay in the form of bonuses, and providing monetary assistance based on performance, complexity and quality of work.89 4.3. ORGANIZATION OF PRIMARYHEALTH CARE PROVIDERS 4.3.1. Types of Primary Health Care Providers 172. PHC network consists of four types o f PHC providers: (i) for Family Medicine, basedon Centers the former district polyclinics and often serving large populations of over 50,000; (ii) Health Centers, based on former SVAs (selkskiye vranchnii punkt); (iii) Family Doctor offices based on former rural 40 ambulatories covering populations over 1001, and; (iv) Health posts for family doctors' assistants for villagedareas with populations of less than 1000. 173. There are 190 Centers for FamilyMedicine, Health Centers, and Family Doctors offices managed by the regional health authorities. Inaddition, there are PHC centers managedby other ministries and privateenterprises. 174. Regions are divided into family doctor sectors, eachwith apopulationof 1,000-1,800 people. 4.3.2. Access to Primaiy Health Care 175. Most Moldovancitizens have good geographic accessto PHC services. A household survey done in2000 byUNICEFto assess level of access to healthservices found that 87 percent ofhouseholds were at a distance of less than 5 km and needed less than one hour to reach the nearest PHC facilities." There was an urban-rural difference ingeographic access: Around 93 percent of the urbanand 82 percent o f the rural households were situated within less than 5 km of a PHC center. Additionally, 79 percent of rural patients, as compared to 93 percent of urban patients, were able to reach a PHC center in less than an hour. Close to two thirds (65.6 percent) of patients from rural areas walked to the PHC centers, as compared with 58 percent from urban areas. 176. Although all Moldovan citizens are entitled to Guaranteed Minimum Basic Health Services, significant financial barriers to health care exist. 177. The UNICEFhousehold survey in2000 found that because of financial barriers, 15.3 percent of households had `total' and 40.1 percent had `low' inaccessibility to health services. Accessibility varied with education, socioeconomic status, and place of residence. Vulnerable population groups were the most adversely affected: 72.8 percent of households were headed by someone with a low educational level; 71.6 percent were from the poorest percentile and 58.6 percent were from rural areas with low accessibility due to unaffordable services. The survey identified that 33.5 percent of the population were not financially protected against eventual health problems with lower socioeconomic groups (47.9 percent) and rural (41.3) less protected. 91 178. Just over half of the households surveyed (50.6 percent) had adequatefinancial access to services in a case of emergencies, but 30.4 percent of the respondents mentioned that, because of financial barriers, they had to postpone a necessary medical consultation. Of those who were able to access medical care, 18.5 percent were unable to purchase the treatment prescribed because of financial reasons.92 4.4. REFURBISHMENTOF PHC CENTERS 179. A number of PHC centers havebeenrefurbishedwith financing fromthe WB HIFP. The Health Investment FundComponent of the World Bank Project i s being implementedinthree phases. The first phase targeted PHC facilities; the second addressedPHC and emergency care; and the third phase i s also targeting PHC and emergency care. 180. Inthe first phase, healthcenters from Chisinau Municipalityand PHC units from Central Judets (Balti, Ungheni, Lapusna, Tighma, and Taraclia) were selected for refurbishment and equipping through competitive and transparent selection of sub-projects. In the second phase, additional competitive mechanisms were put inplace and transparent criteria were established to select regions that were invited 41 to submit restructuring and investment proposals. In particular, priority was given to rural areas with lower access to health benefits. PHC centers with three or more family physicians covering populations of four to five thousand were selected across the country. Under phase two, equipment valued at EUR 1 million was deliveredby the end of July 2004. Delivery of equipment under a third lot was completed in November 2004. Forty-five ambulances were delivered inApril 2004, and 30 new ambulances are to be deliveredby the first quarter of CY05. 181. Intotal, 280PHCfacilitieswill berefurbishedintwophases, withsupport fromthe WB HIFP.93 Bymid2003, rehbishment of 55 PHC facilities, selectedinthe first phase, was completed. Subsequent field visits and focus group sessions undertaken at the end of 2003 have demonstrated increased satisfaction among users and health professional^.^^ By the end of 2004, 50 more PHC facilities were rehabilitatedwith substantial improvement to conditions for the FMteam and the users.95 4.5. UTILIZATIONOF PHC SERVICES 182. The utilization of PHC services, as measured by the number of visits to family physicians, increased by 17 percent between 2000 and 2002, thereafter declining to a level observed in2000 (Figure 28). Figure 28. Number of visits to family physicians 12 I 2000 2002 2003 2004 Source: Department of Public Health and Management statistics 183. Between 2000 and 2002, the number o f referrals from PHC to secondary and tertiary services increasedby 10percent (Figure 29). 42 Figure 29. Number of referrals to secondary and tertiary care 600 ,I I 553 500 zr - 400 $ 300 r L P 5 200 z 100 0 c 2000 2002 I Source: Department ofPublic Health andManagement statistics 4.6. GUIDELINES 184. To date, very few evidence-basedguidelines and protocols have been developed, except for those relating to IMCI, antenatal care, and child growth and development monitoring developed with the support of UNICEF and with gooduptake inthe PHC pilot inthe Hincestiregion. 185. The WB HIF Project i s providing support to the MOH to develop clinical protocols for most common illnesses. The Clinical Protocol Specialist has been working with local experts since early October 2004. Working Groups have beenestablishedto work under the guidance of the consultant. The groups are to select priority diseases for which Treatment Protocols should be developed. A questionnaire was prepared and transmitted to all hospitals to review the situation on the use of clinical protocols. Diseases will be selected on the basis of their major impact on morbidity, mortality, and cost of services. 43 5. PRIMARYHEALTHCARE SERVICEDELIVERY: FACILITYSURVEY 186. The PHC facility survey explored five areas: (i) of services provided; (ii) range availability of equipment; (iii) use of clinical guidelines; (iv) immunization services; and (v) essentialdrugs. 187. The analysis initially compared urban and rural PHC centers. The analysis was then repeated comparing PHC centers inadvancedversus less-advanceddistricts. 5.1. W G E OF SERVICESPROVIDED 5.1.1. Urban and rural comparison 188. Most o f the basic services were frequently (90-100 percent) provided inboththe urban and rural PHC centers surveyed. Although almost all of these services were less commonly provided in rural centers, the differences were not sigmficant (Table 3). Table 3. Frequently provided essential PHC services Hepatitis 100 97 Tuberculosis 100 95 Diarrhea 100 95 Acute Respiratory Illness 100 100 Home visits 100 100 Ambulance service 89 90 Family Planning 100 92 Health education andprevention clinic 100 97 189. Several services (e.g., minor surgery) typically provided at the PHC level inEuropean countries were infrequently provided. There were urban and ruraldifferences that were not significant (Table 4). 44 Table 4. Less frequently providedessentialPHC services I rIntrapartum Service I Urban(%) I Rural(%) care I 44 I 33 II STIs 78 78 Minor surgery 44 50 Hospitaladmission privileges 44 22 Patient observation as a day case 78 75 Laboratory 78 57 190. Immunization services were more likely to be provided inrural centers, and this difference was statistically significant. Incontrast, HIV services were more likely to be providedinurbancenters, which were much more likely to have pharmacy services. These differences were statistically significant (Table 5). Service Urban (YO) Rural(%) Urban-Rural Sig. (2-tailed) difference (O h ) Immunization 89 100 -11 0.009 HIV 100 55 45 0.009 Pharmacy 100 52 48 0.000 5.1.2. Comparisonby reform status 191. Although most of the essential PHC services were more frequently provided inadvanced reform regions, these differences were statistically not significant (Table 6). Table 6. Frequently provided essential PHC services I Service IReform(YO) Low reform(YO) 1 I General consultation 100 1 98 immunization 100 98 Nutrition clinics 100 95 Antenatal care 88 98 Postpartum care 100 100 Diabetes 88 98 HVpertension 100 98 Heart disease 100 97 Mental Health 88 II 90 98 ~ Hepatitis 88 Tuberculosis 100 95 Acute Resuiratory Illness 100 100 STIs 88 77 FamilyPlanning 88 93 Health education andprevention clinic 100 97 Nursing care 100 90 Home visits 100 II 100 I u l a n c e service 1 100 I 89 1 45 192. Differences between advanced and less-advanced reform regions were observed in the level of service provision for a number of less fi-equently performed services, but these differences were statistically not significant (Table 7). Service Reform (YO) Low reform (YO) Intrapartum care 63 31 HIV 75 59 Minor surgery 63 48 Patient observation as a day case 88 74 193. Interestingly, a number of services were significantly more likely to be provided inless-advanced reform areas (Table 8). Table 8. Services with statistically significant difference in provision levels between advanced and less-advanced reforms II Reform I I I I (%II Lowreform MeanDifference Sig. (2-tailed) (%) (Yo) Pediatric consultation 75 98 -23 0.0019 Asthma 63 98 -36 0.0000 Diarrhea 63 100 -38 0.0000 194. This may be because the retraining o f family in the cohorts working in less-advanced reform areasbenefited fromtraining inUNICEF-sponsored I M C Iprograms. 5.2. AVAILABILITY OF EQUIPMENT 5.2.1. Urban and rural comparison 195. A large percentage o f basic equipment-the kindone would expect to find inPHC centers-was present inmost o fthe centers surveyed (Table 9). 46 Equipment Urban(%) Rural(%) Refrigerator 100 88 Stethoscope 89 98 Sphygmomanometer 89 72 Tonometer 100 98 Thermometer 100 100 Dressing kits 89 87 Examination table 89 88 Svatula 89 93 Tape meter 100 97 Adult scale 89 65 Measuring bar on wall 78 68 Disposableneedlesand syringes 89 90 Intravenous line 89 95 Sight chart 78 73 Child scale 89 100 196. Some essential pieces of equipment-the kindone would expect to findina PHC facility-were infrequently (<60 percent) found in the PHC centers surveyed. Although there were urban and rural differences, these were statistically not significant (Table 10). Table 10. Essential equipment found to be infrequently available 197. Reflex hammers and ECGs were more likely to be found in urban centers; in contrast, simple minor surgical equipment was found more often inrural centers. (Table 11) 47 Table 11. Essential equipment with significant urban-rural differencesinavailability 1 Equipment I Urban (YO) Rural (YO) MeanDifference ( 1 1 O h ) I Sig. (2- I tailed) Reflex hammer 78 32 46 0.01 ECG 89 45 44 0.03 Obstetric stethoscope 67 93 -27 0.03 Kidneybasin 33 73 -40 0.05 Spongebowl 67 92 -25 0.03 5.2.2. Comparisonby reform status 198. For almost all the equipment frequently available, there was a difference betweenmore- and less- advanced reform districts, with the PHC centers inthe advanced-reform districts more likely to possess the equipment. This difference was statistically significant for expensive equipment such as ophthalmoscopes and otoscopes (Figure 12), but for other equipment the difference was not statistically significant. (Table 13) Equipment Reform (YO) Low reform (YO) Difference ( O h ) Significance (p) Ophthalmoscope 100 38 87 0.000 Otoscope 88 36 51 0.005 Floor lamp (surgical) 50 7 43 0.001 Table 13. Essential equipment with differences inavailability (statistically not significant) 48 199. There was also a difference in the availability of equipment that was infrequentlypossessedby the PHC centers. This equipment was likely to be possessedby PHC centers inmore advanced reform districts, but the difference was statistically not significant (Table 14). Table 14. Difference inavailability of equipment not frequentlypossessed by PHC centers I Eauiument I Reform(%) ILowreform(%) Catheter set 63 39 Kidneybasin 75 67 5.3. IMMUNIZATION SERVICES 5.3.1. Urban and rural comparison 200. Triplevaccine and oral polio were equally present inalmost all the facilities surveyed. However, urban facilities were more likely to have measles, tetanus, and BCG vaccines. The difference, inthe case of the latter two, was statistically significant (Table 15). Table 15. Availability of vaccines Vaccine Urban (YO) Rural(YO) Difference (YO) Significance @) DTP 100 100 0 Polio 100 98 2 0.32 Measles 100 73 27 0.08 Tetanus 89 77 12 0.05 f B.C.G. 89 28 61 0.00 5.3.2. Comparisonby reform status 201. Tetanus vaccine was statistically more likely to be available in PHC centers situated in reform regions (p<0.05); however, statistically no difference was observed for DTP, OPV, measles, andBCG. 49 5.4. FAMILYPLANNING 5.4.1. Urban and rural comparison 202. There was a statistically significant difference in the availability of family planning materials, which were invery low availability inthe rural areas (Table 16). Urban (YO) Rural ( O h ) Difference (%) Significance @) Condoms 89 27 62 0.00 Oral contraceptives 100 23 77 0.00 Injectable contraceptives 44 2 42 0.00 IntraUterine Device (IUD) 89 8 81 0.00 5.4.2. Comparison by reform status 203. Injectable contraceptives were more readily available inPHC centers situated inadvanced reform districts, and this difference was statistically significant. There was no statistically significant difference inthe availability ofcondoms, oralcontraceptives, andIUDs. 5.5. ESSENTIAL DRUGS 5.5.1. Urban and rural comparison 204. There was a marked difference in the availability of essential drugs in urban and rural PHC centers, with urban centers more likely to possess them. These differences were statistically significant for several drugs, but not so for others (Tables 17 and 18). Table 17. Availability of essentialdrugs (Statistically significant difference) Drugs Urban (%) Rural (YO) Sig. (2-tailed) Adrenaline 100 93 0.045 Insulin 89 23 0.000 Metoclopromide (antiemetic) 100 38 0.000 Metronidazole 89 43 0.010 50 Table 18. Availability of essential drugs (Statistically no significant difference) Penicillin G 78 52 I Atropine I 100 I 80 I Hydrocortisonelprednisolone 100 97 Aminophylline 100 97 Syntocinon or ergometrine 78 53 Frusemide 100 97 Rehydration salts 89 87 Antihistamine 10 98 Paracetamol 100 98 Penicillinor ampicillin 89 77 Co-trimoxazole 100 75 Iron and Folic Acid 100 75 5.5.2. Comparisonby reform status 205. Although there were differences inthe availability of essential drugs, with more PHC centers in the advancedreform district likely to possess these drugs, the differences were statistically not significant (Table 19). Table 19. Availability of drugs by reform status Antihistamine 100 98 Co-trimoxazole 100 75 IronandFolic Acid 100 75 Gliceryltrinitrate 0 15 51 6. TASK PROFILE OFDOCTORSWORKING INPRIMARYHEALTHCARE 6.1. USE OF MEDICAL EQUIPMENT 6.1.1. Comparisonby urban-rural status 206. Doctors working inurban areas were statistically more likely to use or have access to diagnostic or therapeutic equipment on site in their health centers used by their colleagues. However, these were infrequently used (50 percent or less), except for the ECG machine (77 percent inurban centers). These levels are lower than what would be expectedinPHC centers inEurope (Table 20). Table 20. Equipmentusedbyfamily doctor or staffinthe PHCcenter 207. Doctors working inrural areas were more statistically likely to use or have on site equipment for minor surgery (Table 21). Equipment Urban (%) Rural (%) Significance (p) Suture set 23 38 4.1E-02 set for minor surgery 15 39 5.6E-04 52 Table 22. Urban rural differences ininfrequently used equipment 1Equipment I Urban(%) I Rural(%) 1 I Otoscope I 44 I 35 I protoscope bloodglucose test set ophthalmoscope audiometer peak flow meter 17 eye tonometer 29 31 urine catheter 17 30 6.1.2. Comparison by reform status 209. For most diagnostic and therapeutic equipment, there was a statistically significant difference in the use or access on site by family doctors working inPHC centers situated inadvanced reform regions (Table 23). Table 23. Equipment used by family doctor or staff inthe PHC centers situated in advanced or less-advanced reform regions 210. Doctors inPHC centers situated inadvancedreform regions were also statistically more likely to use or have on-site access to equipment that was very infrequently used (Table 24). There was statistically no difference inX-ray, audiometer, and cholesterol meter use. 53 Table 24. Equipment infrequentlyused by family doctor or staff inthe PHC centers situatedinadvanced or less-advanced reformregions advanced intermediate low significance (p) Defibrillator 27 6 0 0.00 Protoscope 10 0 0 0.01 Sigmoidoscope 8 0 0 0.02 gastroscope 26 0 0 0.00 6.2. APPLICATION OF MEDICALTECHNIQUES 6.2.1. Comparison by urban-rural status 211. Most of the medical techniques used in the surveyed were 'seldomhever' applied by family physicians (in 80 percent or more of the cases). These included: cryotherapy; applying a plaster cast; removal of a sebaceous cyst; resection of ingrowing toenail; removal of rusty spot from cornea; insertion of IUD; excision of warts; maxillary puncture; and myringotomy of the eardrum. There was no statistically significant difference inthe applicationfrequency of these medicaltechniques. 212. Some medical techmques, such as fundoscopy, applying a plaster cast, or joint injection separate, were used 'occasionally', 'usually', or '(almost) always' by family physicians in30-40 percent of the cases. However, there was no statistically significant difference between family physicians from urbanand rural PHCcenters. 213. Three procedures (wound suturing, strapping an ankle, and setting up an intravenous infusion) were seldomusedby family physicians. Wound suturingand settingup an IV infusionwas more likely to be done by family physicians in rural areas, whereas strapping an ankle was more often done in urban centers (Figure 30). These differences were statistically significant (p