CONSULTING SERVICES FOR THE DEVELOPTMENT...

CONSULTING SERVICES FOR THE DEVELOPTMENTOF THE REGIONALIZATION PLAN

Final Report

This document is presented to the Ministry of Health of the Republicof Moldova

June, 2013

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Consulting Services for the development of the Regionalization Plan

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This Report is the final deliverable under the RegionalizationPlan consultancy carried by Sanigest Internacional under anengagement with the Ministry of Health of the Republic ofMoldova.

Sanigest Internacional 2013This document is a formal publication by Sanigest Internacional and the Copyright andownership of the materials and documents prepared by The Firm and approved by theMinistry of Health will be submitted to the Ministry of Health...

Comments and questions regarding this report:We welcome all communications regarding this Report and the Project in general. They maybe addressed to the Team Leader (James A. Cercone, [email protected]).

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Acknowledgements

This work is the product of a team effort that integrates international and nationalcontributors from all levels of the healthcare system. It was prepared by a Sanigest Team ledby James A. Cercone, with inputs from Claudio Meirovich, Orvill Adams, Gunter vonLeoprechting, Fabian Hernandez, Silvia Molina, Martin Darcy, Michal Pothuis and RodrigoRodriguez-Fernandez. Sanigest Internacional would like to express our deep gratitude to allthe people who have contributed to this report.

The consultants would like to thank Andrei Usatii for his leadership. Rodica Scutelnic for hercollaboration and key insight within the project. Svetlana Cotelea and Oleg Hincu for theirinitial ideas and comments which shaped the structure and content of this document. Theauthors would also like to thank participants from PAS, including Andrei Mosneaga andGhenadie Turcan for their insights. The following hospital directors provided essential inputsfor the analytical phase of this assignment; Spitalul raional Briceni, Director ClaudiaVeltman, Spitalul raional Donduşeni, Director Veaceslav Casian, Spitalul raional Drochia,Director Tudor Cojocaru, Spitalul raional Edineţ, Anatolie Director Guţu, Spitalul raionalOcniţa, Director Feodor Iurcu and Spitalul raional Rîşcani, Direcor Gheorghe Roşu.

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Acronyms and Abbreviations

CIS Commonwealth of Independent StatesCNAM Compania Nationala de Asigurari in Medicina (national health insurance

company)CVD Cardiovascular DiseaseDALY Disability Adjusted Life YearDRG Diagnosis Related GroupsEU European UnionENT Ear Nose and ThroatFSU Former Soviet UnionFTE Full Time Equivalent EmployeesGIS Geographical Information SystemGOM Government Of MoldovaHIF Health Insurance FundHNA Health Needs AssessmentICD International Classification of DiseasesIMR Infant Mortality RateMHSP Moldova Health Service PlanMMR Maternal Mortality RateMOH Ministry of HealthNCD Non-communicable DiseaseNHIC National Health Insurance CompanyOHI Obligatory Health InsurancePCU Project Coordination UnitPHC Primary Health CareRHA Regional Health AuthoritySWOT Strengths, Weaknesses, Opportunities and ThreatsWHO World Health Organization

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Table of Contents

ACKNOWLEDGEMENTS..................................................................................................... II

ACRONYMS AND ABBREVIATIONS ................................................................................... III

EXECUTIVE SUMMARY..................................................................................................... IX

1. INTRODUCTION..................................................................................................... 1

2. CONSULTANCY SERVICES FOR THE DEVELOPMENT OF THE REGIONALIZATION PLAN3

3. HUMAN RESOURCES FOR HEALTH ......................................................................... 63.1. Introduction .................................................................................................................. 63.2. Supply and Demand for Health Human Resources ...................................................... 83.3. Planning Specialist Services ........................................................................................ 113.4. Strategies for Underserviced Rural Areas................................................................... 123.5. The Situation in Moldova Northern Region................................................................ 163.6. Retraining.................................................................................................................... 213.7. Age Distributions of the Present Professional Workforce.......................................... 223.8. Transfer and Recruitment........................................................................................... 263.9. Short term interventions ............................................................................................ 263.10. Longer term interventions .......................................................................................... 273.11. The Adjustment of the Health workforce................................................................... 273.12. Training Plan for the four Districts of Briceni, Ocnita, Edinet and Donduceni ........... 283.13. Facilitating the transfers staff to the new inter rayon hospital in Edinet .................. 30

4. PHARMACY ......................................................................................................... 324.1. Physical access ............................................................................................................ 324.2. Financial access........................................................................................................... 344.3. Overview ..................................................................................................................... 374.4. International Interventions......................................................................................... 424.5. Proposed Solutions ..................................................................................................... 454.6. Key Success Factors..................................................................................................... 48

5. EMERGENCY SERVICES......................................................................................... 525.1. Financing & Budgeting ................................................................................................ 525.2. Legislation ................................................................................................................... 535.3. Availability and spreading of ambulance care ............................................................ 535.4. Response time............................................................................................................. 555.5. Process flow ................................................................................................................ 555.6. Technology.................................................................................................................. 56

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5.7. Requests by profile ..................................................................................................... 575.8. Cooperation with other partners................................................................................ 585.9. Situation in the Northern region ................................................................................ 585.10. Ambulance response time .......................................................................................... 595.11. Personnel: ................................................................................................................... 605.12. Recommendations ...................................................................................................... 61

6. PALLIATIVE CARE AND OTHER CHRONIC CARE SERVICES ...................................... 636.1. Changing disease patterns .......................................................................................... 646.2. Complex needs in chronic care ................................................................................... 646.3. Integrated care pathways ........................................................................................... 656.4. Long term care ............................................................................................................ 666.5. End-of-life care............................................................................................................ 676.6. Terminal care .............................................................................................................. 676.7. Supportive care........................................................................................................... 676.8. Disease stage............................................................................................................... 68

7. GOVERNANCE ISSUES .......................................................................................... 69

8. STRENGTHENING SERVICES.................................................................................. 728.1. Improving transportation to improve access ............................................................. 73

9. NOMENCLATURE TRANSITION............................................................................. 76

10. CHANGE MANAGEMENT...................................................................................... 79

11. PUBLIC PRIVATE PARTNERSHIPS DISCOURSE AND STRATEGY ............................... 8311.1. Project Description ..................................................................................................... 8311.2. Current Scope ............................................................................................................. 8411.3. A PPP Rationale........................................................................................................... 8411.4. Strategic and Project Specific Risks ............................................................................ 8511.5. Political Support.......................................................................................................... 8511.6. Funding Sustainability................................................................................................. 8611.7. Fiscal Risk .................................................................................................................... 8711.8. Lack of Implementing Capacity in the Public Sector................................................... 8811.9. Legal Framework......................................................................................................... 8811.10. Domestic Market Capacity.......................................................................................... 8911.11. Economy and Finance ................................................................................................. 8911.12. Project Risks ................................................................................................................ 9011.13. Risk evaluation ............................................................................................................ 9111.14. Affordability ................................................................................................................ 9516.1. Project Income / Demand Assumptions ..................................................................... 96

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30.1. Procurement Strategy................................................................................................. 9830.2. Procurement Options ................................................................................................. 9930.2.1. Discounted cash flows..........................................................................................................................10230.2.2. Results ..................................................................................................................................................10330.2.3. Sensitivity analysis................................................................................................................................108

30.3. Soft Market Testing................................................................................................... 10830.4. Procurement Plan ..................................................................................................... 10930.5. Delivery Arrangements ............................................................................................. 112

31. IMPROVING LABORATORY SERVICES ................................................................. 114

32. RENOVATE VS. REBUILD .................................................................................... 11732.1. Phased Approach ...................................................................................................... 11832.2. Planned Scope of Services ........................................................................................ 119

33. SAVING LIVES .................................................................................................... 12133.1. Quick wins ................................................................................................................. 124

34. RECOMMENDATIONS ........................................................................................ 128

35. REFERENCES ...................................................................................................... 131

ANNEX ......................................................................................................................... 1341. Emergency service personnel for the northern region ............................................ 1342. Characteristics of Northern region emergency care services................................... 13535.1. Proposed financial configuration model................................................................... 1363. Characteristics of Northern region emergency care services II................................ 1374. Mortality before arrival and in the presence of the team........................................ 1385. Details the equipment required by functional area for the new hospital……………….

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List of Tables

Table 1 : Traditional approaches to estimate requirements for HR for health .........................7Table 2 Evidence-based interventions to improve retention in rural and remote areas bycategory of intervention ..........................................................................................................14Table 3 Rating of Interventions to redress rural and remote disparities of health workers...15Table 4 Physician Benchmarks per 100,000 various sources ..................................................17Table 5 DGA Partners USA specialist per 100,000 ...................................................................19Table 6 Planned Redistribution of Physician Staff in Northern Region ...................................21Table 7 Age Distribution of Professionals in Northern Region ................................................23Table 8 Specialist needed in the next 3 years..........................................................................24Table 9 presents an outline of the elements of the training plan ...........................................29Table 10 Total number of pharmacies and subsidiaries. Republic of Moldova (2003-2010)..33Table 11 Total number of pharmacies by location and type. Republic of Moldova (2010) ....34Table 12 Total pharmaceutical expenditure within total health expenditure and publicpharmaceutical expenditure within total pharmaceutical expenditure (%). Republic ofMoldova (2003-2010) ..............................................................................................................35Table 13 International cumulative pharmaceutical mark-ups, public and private sectors.(2008) .......................................................................................................................................36Table 14 Pharmacy mark-ups, public and private sectors. Republic of Moldova. ..................36Table 15 Emergency care budget in Moldova .........................................................................52Table 16 Emergency teams to 10 thousand population 01.04.2013.......................................53Table 17 Regional Ambulance Services and dispatch centre ..................................................54Table 18 Ambulance equipment..............................................................................................57Table 19 Emergency servicer request by specialty profile ......................................................57Table 20 Emergency response for northern region.................................................................59Table 21 Ambulance response time ........................................................................................59Table 22 Ambulance personnel ...............................................................................................60Table 23 Number of Calls.........................................................................................................60Table 24 Palliative Care in Germany 2011 ...............................................................................64Table 25 Palliative care in France 2007 ...................................................................................64Table 26 Advantages and disadvantages of different governance structures ........................70Table 27 Aspects of care that distinguish conventional health care from people-centredprimary care.............................................................................................................................72Table 28 Nomenclator for Rayon Hospitals in the four rayons northern region ....................76Table 29 Distribution between the Responsible Risks in PPP Projects ...................................92Table 30 Spatial characteristics of zone hospital ....................................................................95Table 31 Total investment estimates for Edineţ......................................................................95Table 32 Average cost per case (MDL)....................................................................................97Table 38 Terms of Long Term Debt Financing (MDL) ............................................................102Table 39 Equity Cash Flow from project by Option (MDL million) ........................................105Table 40 Average project revenue and cost per Option (MDL million).................................107Table 33 Indicative Timescales (From Decision to Use PPP) .................................................111Table 34 Governing th Process-Gateway Review ..................................................................112

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Table 41 Laboratory assessment based on European standard 2010...................................114Table 42 Cutting back on unneeded testing ..........................................................................115Table 43 Quick wins for the northern region ........................................................................125

List of Figures

Figure 1 New Level of Services...................................................................................................1Figure 2 Supply and demand .....................................................................................................9Figure 3 Age distribution northern region...............................................................................24Figure 4 Number of pharmacist per 10,000 people. ...............................................................32Figure 5 Supply Chain for medicines and supplies in the public sector: Main issues atRepublic of Moldova ................................................................................................................38Figure 6 Physical flow of medicines and supplies in the public sector, Republic of Moldova.39Figure 7 Information and physical flow of drugs by postal distribution in rural areas for thepublic sector, Republic of Moldova. ........................................................................................48Figure 8 Emergency care process flow algorithm....................................................................56Figure 9 Separating acute and chronic care services in Moldova ...........................................63Figure 10 Patients are seen at the level of care they need .....................................................66Figure 11 Change management components..........................................................................79Figure 12 The change process and its layers ...........................................................................80Figure 15 Availability Payments by Option (MDL mil) ...........................................................104Figure 13 Competitive Dialogue Process for Hospital Procurement .....................................110Figure 14 Procurement option process ................................................................................111Figure 16 Condition cost relationship....................................................................................117Figure 17 Two phased approach............................................................................................119Figure 18 Range of services within the new facility ..............................................................120Figure 19 Improving standards of care will help save lives in Moldova ................................121Figure 20 Years of life lost to stroke ......................................................................................123Figure 21. Stroke care within the northern region ................................................................124

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Executive SummaryExecutive Summary

This is the fourth consultancy report for the development of the Republic of Moldova'sregionalization plan. In this final instalment of a four part series, Sanigest addresses allremaining issues regarding “system reform” within the regionalization strategy for thenorthern region. The issues are presented the following chapters:

Human resources for health Pharmacologcical services Emergency services Palliative care and other chronic care services Governance issues Strengthening services Change management PPPs

Human resources for health- The delivery of effective, high-quality healthcare in thereorganized model will depend in large part on the availability of appropriate healthpersonnel of all types. Many factors are involved in ensuring that the population has accessto the appropriate health personnel. There are a number of approaches to planning thehealth workforce. These approaches reflect different values and require different levels ofinvestment in data collection and analysis. Sanigest describes step-by-step the approachutilized in Moldova within the context of the regionalization plan. The strategy also takesinto consideration economic constraints and effective demand for services.

Pharmacological services-The chapter will focus on facilitating equitable access tohealthcare services, specifically to medicines. To achieve equitable access, both the physicalavailability of the drugs within a reasonable travelling time and distance, and the financialcapability of purchasing them are required. The chapter presents a set of internationalinterventions that have been executed in various countries providing a myriad of possibleoptions for the Republic of Moldova. The section concludes with a set of recommendationsbased on international best practice regarding such issues related to over-the-countermedicines, consumption, distribution, infrastructure, and access in general.

Emergency services-This section describes the current situation in Moldova regarding theemergency care sector's financing and budgeting. It also discusses issues related tolegislation, personnel, and access to ambulance care services. The chapter reportsambulance response times in the northern region and general process flows between callcentres and actual response teams. The report also covers request by specialty highlightingcurrent usage per service. The chapter concludes with a set of recommendations onimproving the current situation in the northern region, including ways to improve the criticalpathway for patients.

Palliative care and other chronic care services- Previous reports developed by Sanigest forMoldova's Ministry of Health have highlighted the importance of separating chronic andacute care in the northern region and the description of services at each level . This chapter

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focuses on palliative care as well as a description of other forms of chronic care that will bemade available within the proposed Chronic Care Centres in the northern region.

Governance issues- The chapter on governance advocates for the establishment of a stronggoverning mechanism to help the realization of the regionalization strategy. A solidgovernance structure will ensure that all parties involved in the transition are provided witha clear path toward a better healthcare system in the northern region. Sanigest proposes ahybrid governing structure.

Strengthening services- The response of the health sector and societies to the challengessuch as transitioning burden of disease and shifting levels of care has been slow andinadequate. This speaks to both an inability to mobilize the requisite resources andinstitutions to effect change as well as a failure to either counter or substantially modifyforces that resist change, namely: a disproportionate focus on specialist hospital care;fragmentation of health systems; and the proliferation of unregulated commercial care. Thischapter outlines the issue of how to strengthen essential services within the northernnetwork, particularly primary health care and transport.

One of the key elements for enabling “system reform” within the regionalization strategywill be the creation of incentives that encourage hospitals to work collaboratively todevelop new approaches and solutions in response to inter-hospital system reform.Increasingly, northern rayon leaders will need support in developing solutions which mayinvolve significant reconfiguration and networking of services across organisationalboundaries. The latter of which may currently be perceived as a “loss” to a particularorganisation. Anotther key theme of the proposed design principles is the empowerment ofstaff to work across organisational boundaries if they are to be able to provide essentialpatient-led care

Change management- In the northern region, there has been a recognized need for systemchange to support the delivery of safe and high-quality care. Awareness of the reactions tochange will help the healthcare manager responsible for the change process respondappropriately to the expressed concerns. Understanding the reasoning behind thesereactions occur may assist the leader to introduce change in a manner that anticipates,acknowledges, and responds to concerns. Sanigest presents key aspects of changemanagement that will need to be planned in conjunction with the development ofinfrastructure and be executed to ensure a smooth and efficient transition.

PPPs- In this chapter, Sanigest presents an illustrative model highlighting how a real PublicPrivate Partnership (PPP) could work for the proposed inter-rayon Edinets hospital. A moreextensive full modeling would be required at a later stage as a feasibiltiy study to verifyassumptions presented within the model. Because models of care develop rapidly, it isconceivable that a facility that is modern and fit-for-purpose on opening can be out-of-dateand unsuitable within a number of years, certainly before the building has outlived itsphysical value. In order to protect the facility against this service redundancy, it is essentialthat the proposed development is future proofed. This is achieved by introducing flexibilityinto the design and, also importantly, into any longer term service contracts or agreements.The PPP model, in addition to providing the finance for the project and managing the risksof delivery, can also satisfy both of these requirements.

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Overall, we propose that national and local policy should clearly support the innovative localregionalization model for service reconfiguration, and recognise both the benefits ofcontestability and choice in certain routine services. We highlight the importance of well-integrated specializes, chronic and emergency care networks in providing guaranteed accessto high-quality care. Networks will need to develop greater organisational and financial“muscle”, and the concepts laid out above provide an organisational vehicle by which toachieve this goal. However, clearer governance and accountability mechanisms for clinicalnetworks must also exist in tandem to the before mentioned changes. Care should be takento ensure that future refinement of financing models and guidance progressively supportsthe more effective operation of managed clinical networks in key service areas.

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1. Introduction

The Government of the Republic of Moldova established the reconfiguration of thehealthcare provider network as a priority within the Programme of activities for 2011-2014– “Restructuring of the public hospitals network based on the principles of economicefficiency and provision of secure and qualitative healthcare services, in conformity with theGeneral National Hospital Plan”.

The plan corresponds to the best practices in the organization of hospital medical assistanceand outlines the overall framework under which the hospital reform should beimplemented. The key objectives cited by the plan include: (i) Adequate access (geographic,financial) to services; (ii) Provision services of high-quality; (iii) Effective collaboration andcoordination between all levels of hospital medical assistance, as well as other medicalservices (primary medical assistance and emergency medical assistance); (iv) Increasedefficient use of resources (financial, institutional, human); and (v) Satisfaction of patientsand community participation.

In order to promote the plan's implementation, the current Government Resolution aims tooutline the main elements to be applied in the initial phase of hospital networkstrengthening intended for the Northern Region of Briceni, Donduşeni, Edineţ, Ocniţa andBalti. This region has been selected for implementation based on the population size andrepresentative characteristics, making it an excellent initial implementation location.

The Hospital Network Strengthening aims to address a number of challenges that thepopulation faces and the legacy of the hospital-centric healthcare system developed from1960 to 1980. Sanigest has carried out the regionalization strategy based on a populationbased service approach that best fits Moldova’s current situation for the northern region.The Sanigest population based service planning approach seeks to understand and plan forthe health needs of the target population as a whole, and to implement and evaluateinterventions to improve the health or well-being of that population. In Sanigest’sapproach to care delivery, individual patient care is provided within the context of the localculture, health status, and health needs of the entire northern population of which thatpatient is a member. When planning care for a population, as distinct from caring for anindividual member of that population, health services are accountable for measuringoutcomes for all members of the targeted population, including those who may not, for avariety of reasons, access services, within the northern region. This is largely whatdifferentiates Sanigest’s population based planning models from traditional, individualpatient-centred service plans and/or models.

By thinking in terms of whole populations at the planning stage, services will synergize toimplement systems and processes of care that will lead to improved outcomes for wholepopulations of patients, as well as for individual members of those populations. Based onthis process, our initial baseline assessment has emphasized the clear need to separateacute and chronic services within the region and help plan establish the profile of servicesfor each level of care as seen in figure 1.

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Figure 1 New Level of Services

Specialized long-term care Palliative services Assisted living

Cardiovascular care unitNeuro-geriatric unit

NeurophysiologyNeurology

Neuropathology and OcularPathology

Neuropsychology

Convalescent unitPalliative care unit

Cancer unitPain Service (Pain

Management)

Residential UnitDay Case Unit

Briceni, Donduşeni, and Ocniţa

Services Technology InfrastructureSurgery Emergency

ICU Medical unitStroke Unit

Labor and DeliveryPaediatric Laboratory

Maternal etc.

CatheterizationlaboratoryEndoscopy

ImagingAmbulatory SurgeryFunctional diagnosis

etc.

Number of beds-120m2 per bed-150

Edineţ

●Specialized acute care

Stroke unit andInterventional cardiology

●Urgent Care Centre 24/7

●Long term chronic care

●Assisted living

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Neuropsychology



Management)






Maternal etc.



etc.


Edineţ





●Assisted living

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Neuropsychology



Management)






Maternal etc.



etc.


Edineţ





●Assisted living

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These two levels of care will work together as a streamlined flow of care. Patients whorequire integrated services and true service integration will need to grow upwards fromclinical practice and innovation. Service redesign and reconfiguration for the northernregion will be firmly embedded in a culture that places patient safety and quality first at alltimes.

The overarching regionalization strategy reflects the local condition (including needs,resources and capabilities). Local decision-makers have been included within the planningprocess that proposes the reconfiguration of services (within the overall goal of maintainingthe highest possible quality of care by all service changes). The Ministry of Health mustempower local commissioners and providers to act flexibly, and should not attempt toenforce the regionalization approach but to empower local decision-makers to takeownership of the new model of care.

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2. Consultancy services for the development of the Regionalization plan

Sanigest worked together with the Ministry of Health of Moldova to provide a strategic tooland detailed Framework Plan for the regionalization of specialized and highly specializedhospital care. Based on this plan, it will be possible to implement the Policy Roadmap forMoldova and establish the common administrative health management system ofmonoprofile hospitals, primary health care decentralization, and implementation of qualitymanagement system in all health facilities.

The following chapter provides a detailed description of where to find all expected Services,Tasks and Deliverables within the numerous reports produced during the consultancyservices carried out by Sanigest.

Sanigest products: -Initial report, Inception Report, Intermediary Repor,t Final report

description of an accurate estimate of the beds with different profiles that are

needed including the long term care and rehabilitation beds-Inception Report

flow of patients in the referral system within the area of health- Intermediary Report

cooperation mechanism with emergency and primary health care, and a business

plan for each hospital- Final report

the analysis and review of Regionalization Framework Plan to optimize the number

of health areas and develop in detail its organizational structure- Inception Report

Intermediary Report, Final report

patient referral mechanism- Intermediary Report

recommendations on enhancing the operation of Hospital Administration Councils-

Final report

framework regulation of the hospital facilities- Intermediary Report, Final report

implementation of quality and performance management system in all health

facilities- Intermediary Report, Final report

the implementation of population screening programs at the primary health care

level for non-communicable disease control- Intermediary Report

geographical location and communication infrastructure- Inception Report

existing hospital infrastructure- Inception Report, Intermediary Report

capacity and quality of health care provided in health facilities in selected regions-

Inception Report, Intermediary Report, Final report

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comfort / satisfaction of patients and medical staff with reference to health services-

Inception Report, Intermediary Report

links, including the contractual ones and collaboration with other health facilities

(hospitals, Family Doctor Centres, Health Centres, etc.).-Intermediary Report

inadequate medical devices and real needs according to European standards-

Intermediary Report

capacity of pharmacies located within hospitals to respond to real needs and

requirements- Final report

ensure the staffing with medical personnel of different profiles and covering the real

needs-Inception Report, Final report

updated legal norms and standards governing the institutions and services

concerned-Intermediary Report

contractual relations with the National Health Insurance Company, based on which

the health services are rendered- Intermediary Report

provide to the Client 3 detailed and well-reasoned scenarios, which will include

approximate costs for their implementation and regionalization of hospital services-

Intermediary Report

Cost-effective use of existing facilities with further development solutions and

possible alternative options for future hospital infrastructure, including the green

space-Intermediary Report

Alternative options for the use of targeted hospital buildings- Intermediary Report

Cost-effectiveness and future costs (capital and maintenance costs) for the proposed

development alternatives- Intermediary Report

Estimate economic benefits, the reimbursement rate and duration of investment-

Intermediary Report , Final report

Following the selection and approval by the Client of one of the 3 scenarios, the

development coordination and completion of a detailed Plan of Actions for the

regionalization of hospital service- Intermediary Report , Final report

the rendering of impatient, day care and outpatient services- Intermediary Report

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detailed plans for upgrading the capacity of hospitals in Briceni, Donduşeni, Ocnita

and Edineţ- Inception Report, Intermediary Report, Final report

description of planning and operation of specialised transport services for patients

within the radius of this region- Final report

comprehensive plan for staff training, with the estimation of training needs; areas of

training; the number of medical personnel of different levels to be trained, training

plan development, estimated costs- Final report

identify opportunities (minimum 3) for Public-Private Partnership (PPP). For each

opportunity, in accordance with Law on PPP No. 179 of 2008 a feasibility study with

the identification of the PPP object and its objective shall be developed, being

provided the economical - technical arguments for PPP projects; general conditions

for PPP- Intermediary Report, Final report

estimate the costs for infrastructure and endowment with necessary medical devices

to modernize hospitals in Hincesti, Cimislia, Leova and Basarabeasca-- Intermediary

Report

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3. Human Resources for Health

3.1. Introduction

Major changes are taking place in the health care delivery system of Northern Moldovabased on the regionalization proposals presented earlier by Sanigest and approved by theMinistry of Health. Work to date has included an assessment of need, prioritization ofservices and plans for reorganization of the public delivery system into an inter-rayonhospital in Edinet that will serve all four districts. Rayon hospitals in three districts will beconverted into chronic care centres (CCC). This large reorganization will involve a set ofspecific challenges, which are discussed later in this report.

The delivery of effective, high quality health services in the reorganized model will dependin a large part on the availability of appropriate health personnel of all types. There aremany factors that will have an impact on ensuring that the population has access to thehealth personnel they require to improve their health condition. There are a number ofapproaches to planning of the health workforce. These approaches reflect different valuesand require different levels of investment in data collection and analysis. Table 1 presents acomparison of the accepted traditional approaches to HR planning for health. In resources-poor countries, it is necessary to consider the economic constraints and to develop plansbased on the effective demand for services. This requires, at the very least, data about therelative needs of the population and mechanisms for setting priorities about which needsare to be met and with which order within a budget constraint.

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Table 1 : Traditional approaches to estimate requirements for HR for health

Method forHRH

requirementsDescription Assumptions Advantages Limitations

Needs-based

Estimates futurerequirements basedon estimated health

deficits of thepopulation

Projects age/ andgender/specific“service needs”based on service

norms and morbiditytrends

Converts projectedservice needs to

personsrequirements usingproductivity norms

and professionaljudgment

All health care needscan and should be

metCost-effective

methods to addressthe needs can be

identified andimplemented

Resources are usedin accordance with

needs

Has the potentialof addressing the

health needs of thepopulation using a

mix of HRIs independent ofthe current healthservice utilization

Is logical,consistent with

professional ethics,easy to understandIs useful for someprograms such asprenatal and child

careIs useful for

advocacy

Ignores the questionof efficiency inallocation of

resources amongother sectors

Requires extensivedata

If technologychanges, it requires

norms updateIs likely to project

unattainable serviceand staff targets

Utilization-based (or

demand/based)

Estimates futurerequirements basedon current level of

service utilization inrelation to future

projections ofdemographic profiles

Current level, mix,distribution of health

services areappropriate

Age and sex-specificrequirements remain

constant in thefuture

Size anddemographic profile

of the populationchanges in wayspredictable by

observed trends inage and sex specificrates of mortality,

fertility andmigration

Economicallyfeasible targets

due to no or littlechange in

population/specificutilization rates

(assumed)

Requires extensivedata

Overlooks theconsequences of

“errors” arising fromthe assumptions

proving to be invalidProduces a “statusquo” projection,

since futurepopulation segmentsare assumed to have

similar utilizationrates as base year

segments

Healthworkforce topopulation

ratio

Specifies desiredworker-to-

population ratio

Often based oncurrent best regionratio or a reference

country, with asimilar but

presumably moredeveloped health

sector

Quick, easy toapply and tounderstand

Provides no insightinto personnel

utilizationDoes not allow to

explore interactionsbetween numbers,mix, distribution,productivity and

outcome

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Method forHRH

requirementsDescription Assumptions Advantages Limitations

Base yearmisdistribution willlikely continue in

target year

Service target-based

Sets targets for theproduction and

delivery of specificoutcome oriented

health servicesConverts thesetargets into HR

requirements bymeans of staffing and

productivitystandards

It assumes that thestandards of each

service covered arepracticable and canbe achieved within

the timescale of theprojection

Relatively easy andunderstandable

Can assessinteractions

between variables

Potentially unrealisticassumptions

Source: Sanigest Internacional

The approach used in planning specialist supply in Northern Moldova uses a combination ofneeds based and utilization based approaches for the entire region. Physician to populationratios have been developed for the entire region based on a professional assessment ofneeds using realistic scenarios for the areas. Specific approaches are described in theIntermediate Report on mobilization (April 2013). Demand (utilization) estimates for thezone were developed by Sanigest consultants using the existing utilization rates in the 4rayons and international population based estimates of expected demand. Based on theseestimates, expected rates of ambulatory surgery, average length of stay and occupancyrates, the consultants developed a profile of the expected utilization and beds required.Standards by specialty were then used to project the number of specialists needed for theentire population and then distributed to the hospital and CCCs according to the level ofcare required

3.2. Supply and Demand for Health Human Resources

The number of medical doctors, nurses, dentists and other health care providers that areavailable to provide services to their populations vary across countries. These numbersdepend on the way that services are organized, the cost of services and the effectiveness ofthe planning systems. The planning of HRH is separated into two distinct but relatedcomponents, Supply and Demand, as per the following diagram:

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Figure 2 Supply and demand


The concepts governing the supply side are the ones that most are familiar with becausethey are concerned with education and training – the production of workers for the healthsystem. The supply side essentially covers three areas: the inputs into the system, the lossesfrom the system, and the use of the health workers in the system. The factors that form partof the supply therefore include:

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the current stock of health workers, their age-sex profiles and the degree to whichthey are engaged in delivering health services (full-time, part-time, employed,unemployed, underemployed, gender);

the type of work they are licensed or certificated to do compared to what they areactually doing;

the availability of education and training places; the availability of suitable candidates; the availability of educators and trainers; entrants to the system, graduates from the different medical and related fields; losses from the system (attrition due to death, change of occupation, retirement,

migration);

The effective supply of a particular category of health worker could be increased if there isroom for productivity gains, allowing increased service output per worker. This may beachieved through the organization of work, the use of incentives, or the matching of skillsand competencies to the functions and tasks to be performed.

The Demand side of HR planning is more complex than that of the supply1 side since itrequires data on current and expected utilization of services. Demand is sensitive to priceand therefore methods of health finance will have major impacts on effective demand. Inpublic systems where governments finance health services and patients do not face pricerationing; demand will depend on perceived needs, population education levels and publiceducation to ensure that target populations are aware of the importance of priorityinterventions. Mental health is an example of this point: mental health services have beenidentified as a priority in Northern Moldova but care seeking behaviour often is less thanoptimal due to perceived stigma or cultural restraints that limit the demand for mentalhealth care.

Correctly assessing the necessary human resources required to deliver appropriate healthservices therefore requires starting from data on what exists and what is possible in termsof the organization and management of the workforce, something easier said than done inmany countries. Patterns of entry and attrition, the enabling factors and barriers, and thelikely utilization of services have to be understood before supply and demand estimates canbe made. This will depend on a relatively complete data base of health workers and a solidhealth services management information system. Where the latter does not exist, plans canbe made based on professional opinions about optimal patterns of care. This appears to bethe approach adopted by Sanigest in the Northern Region.

1 Markham B, & Birch S, 1997, 2 Back to the future: a framework for estimating health-care human resourcesrequirements”, CJONA, vol. Jan – Feb

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3.3. Planning Specialist Services

There are different approaches to the planning of specialist services which incorporateelements of the models outlined above. An example of a supply model is the ‘SWAG” modelthat has been used by the National Health Service in the United Kingdom. This modelfocuses on fully trained specialists and uses the following variables for which they havedata:

Current numbers of specialists Current and predicted future ratio to whole time equivalent (WTE) Expected specialists qualification dates of registrars in training Anticipated delays in those dates Distribution of training time of future recruits Direct international recruitment The percentage overseas doctors who stay Wastage rates Retirement rates Numbers converted from non-consultants Additional training opportunities planned2

The UK approach uses actual data and estimate where the data is not collected routinely.Small scale surveys are used as a basis for the estimates.

The Australian Medical Workforce Advisory Committee (AMWAC)3 uses a similar approach.The workforce is counted and described in terms of demographic characteristics. Workparticipation is described usually in terms of number of hours worked on average per week.This is cross tabulated by sex and age. Head counts can be modified by hours worked tocreate a full-time equivalent (FTE) ‘effective’ workforce. Modeling of the specialistworkforce focuses on three components:

1. A detailed profile of the current workforce, new entrants to the workforce and lossesto the workforce

2. A supply trend based on predictive analysis; and3. A requirements trend also based on predictive analysis

The results of the analysis provide a set of strategic actions which include:

Adjust education and training intake; Increase participation rates;

2 rcpsc.medical.org/publicpolicy/imwc/uk_physician_workforce_planning_JudyCurson.pdf

3 Australian Medical Workforce Advisory Committee, Specialists Medical Workforce Planning in Australia –AMWAC Report 2003-1, May 2003

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Reduce workforce loss; Encourage workforce re-entry (for shortages) or early exit (for surpluses); Adjust net migration Encourage adjustment in workforce productivity; Improve workforce distribution; Re-design workforce tasks to vary combination of skill mix and professions; or Influence consumer behavior.

3.4. Strategies for Underserviced Rural Areas

Distribution of Health WorkersWhen applying an acceptable standard of FTE based on populations, we often see that thereis a significant imbalance between urban and rural areas. This situation is particularly acutefor specialists. Many countries are faced with trying to provide specialist services to rural orremote regions of their countries with varying degrees of success and the situation inMoldova is not distant from other countries. This is a challenge faced by countries at alleconomic levels. An evaluation of relevant strategies was conducted by the World HealthOrganization. The evaluation identified the following interventions:

Rurally located medical school; Rurally relevant curricula and rural clinic placements; Multifaceted education interventions; Continuing medical education; Compulsory service; Bonding schemes; Financial incentives; Professional support – including outreach services and Tele-health.

Table 2 below presents a review of evidence-based interventions to improve retention inrural and remote areas. The literature suggests that single initiatives are not likely to beeffective. It is necessary to employ a set of initiates that will be suited to the specificsituation. In Canada, The Specialist Section of the Society of Rural Physicians of Canadarecently published a policy statement which is consistent the global evidence as identifiedby the World Health Organization. Seven recommendations that could apply to the contextof the northern region are:

1. Integrate all rural/regional specialists with their respective medical schooldepartments. The suggested responsibility is the medical schools. In Moldova, theresponsibility should also be the medical school.

2. Make all education opportunities in medical school departments available to ruralpractitioners. The suggested responsibility is the medical schools.

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3. Clinical traineeships – Regulatory bodies in conjunction with medical schools shouldhave the responsibility. In Moldova the most effective organization is probably thelocal and national governmental health organizations.

4. Opportunity clearing house – In Moldova this responsibility could be shared betweenthe Ministry of Health, Regional Health Authority and the Medical Associations.

5. Locum Physicians – These are physicians who are willing to work as short – termreplacement physicians – The responsibility for developing a roster of thesephysicians should be the Ministry of Health. The Ministry could develop a LocumProgramme with the necessary incentives.

6. Financial and other incentives to assist in recruiting and retraining specialistphysicians in rural areas. These incentives to assist in recruiting and retrainingspecialist physicians in rural areas (for example, access to education opportunities,grants, retention fees, tax benefits). This is the responsibility of the central and localgovernment and their agencies.

7. Recognize the contribution of rural specialists. This responsibility can be sharedbetween the levels of government and the medical schools.4

Consistent with the WHO evaluation, the Rural Specialist Society in Canada believes thatsingle interventions are not sufficient to attract, recruit and retain physicians in rural andremote areas.

4 Specialists Section of the Society of Rural Physicians of Canada, Canadian Journal of Rural Medicine(2012;17(1).

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Table 2 Evidence-based interventions to improve retention in rural and remote areas by category ofintervention

Category of Intervention Examples

Education

Students from rural backgrounds Health professional school outside of major

cities Clinic rotations in rural areas during studies

Curricula that reflect rural health issues Continuous professional development for

rural health workers

Regulatory

Enhance scope of practice Different types of health workers

Compulsory workers Subsidized education for return of service

Financial incentives Appropriate financial incentives

Better living conditions Safe and supportive working environment

Professional and personal support

Outreach Career development programmes

Professional networks Public Recognition measures

Source: Carmen Dolea, WHO

www.samss.org

Wilson et.al (2009)5 in their review of interventions for rural and/or remote practicecategorize the interventions into five areas and most importantly rate them in-terms ofevidence on their impact. The categories are selection, education, coercion, incentives andsupport.

5 N. Wilson, I.D. Couper, E. De Vries, S. Reid, T.Fish, B.J.Marais., ‘A critical review of interventions to redressinequitable distribution of health care professionals to rural and remote areas’, The Internal Electronic Journalof Rural and Remote Health Research, Education Practice and Policy (2009). http://www.vrh.org.au

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Table 3 Rating of Interventions to redress rural and remote disparities of health workers


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In The Republic of Moldova, there is a rural recruitment and retention strategy for newmedical and pharmaceutical graduates. The strategy is multifaceted, combining regulatoryand financial incentives. Judgment No. 1345 – 30.11.2007 provides for the following:

Young specialists are required to work for three years in public health careinstitutions

Compensation for housing is provided by the local public authority 30, 000 lei is provided for doctors and pharmacists 24, 000 lei is provided for middle level medical and pharmacist personnel – payable

the 1st of each month, 7500 lei, and 6000 lei respectively and then at the end ofeach year of service

In addition monthly compensation is provided for energy in the form of 30 kw ofelectricity, the cost of an annual cubic meter of wood and a ton of coal including gasfor heating.

This rural strategy can be considered to a strong strategy because it is multifaceted andincludes national and local government authorities. To meet the needs of the NorthernRegion, this strategy must be combined with education strategies and some of the otherstrategies discussed above.

3.5. The Situation in Moldova Northern Region

Sanigest has developed a detailed plan for physicians and dentists in the Northern Regionbased on population based standards for each specialty. The standards have beendeveloped using several factors:

The first step was get a clear picture of the utilization rates and disease patterns andtrends in the northern region. This was done by examining diagnostic related group(DRG) rates for each specialty for the region.

The level/capacity of services that would be available at each level was defined,working in consultation with central authorities as well as face-to-face interviewswith directors of rayon hospitals and focus groups/workshops with specialist in theregion.

Disease burden was also included as another input in the calculation of standards.Multiple sources were consulted in order to benchmark physician availability basedon international standards as seen in table 4 and 5, but in many cases where nointernational standards were available such as TB specialist, MRTB and XRTB etc.Rates based on previous reports and specialist consultations were used to estimateactual demand for specialist.

Population projections based on migration, birth, and mortality rates for the regionwere used as opposed to current population numbers.

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Table 4 Physician Benchmarks per 100,000 various sources

Supply Benchmarks Per 100,000 Population

DGAPartners

Specialty Weiner(Kaiser)1

Weiner(U.S.Supply)1

Solucient20032

Longshore +Simmons1995Base3

Low High OtherStudies

Natl.Supply

Primary CareSpecialties

Family Practice 12.7 30.2 22.5 10.2 15.1 17.6 33.3 22.6

General Paediatrics 15.3 19.0 13.9 13.1 12.0 14.0Geriatric Medicine 2.6Internal Medicine 27.6 43.5 19.0 24.7 20.9 24.4

Medical SubspecialtiesAllergy/Immunology 1.0 1.2 1.7 1.3 1.1 1.6 2.3 1.1Cardiology 2.9 6.6 4.2 2.6 4.0 6.5 7.1Dermatology 2.4 3.1 3.1 2.3 2.2 2.7 3.8Endocrinology 1.2 1.2 0.8 0.7 0.9 1.7Gastroenterology 2.1 3.4 3.5 1.6 2.0 3.5 3.8Haematology/Oncology

2.0 1.1 1.1 1.9 1.7 1.2

Infectious Disease 0.9 1.2 0.7 0.7 0.8 1.9Nephrology 1.3 1.7 0.7 0.7 0.7 0.9 4.

02.4

Neurology 1.7 3.6 1.8 1.3 2.2 3.8

4.1

Physical andOccupational Medic

1.1 1.5 0.7 0.7 2.8

Psychiatry 5.7 13.5 5.7 4.1 4.0 4.7 20.3

12.6

Pulmonary Disease 0.9 2.5 1.3 1.1 1.1 1.6 3.6Rheumatology 0.9 1.1 1.3 0.5 0.5 0.9 1.

01.5

Surgical Specialties 6

CardiothoracicSurgery

0.8 1.7

Colorectal Surgery 0.5General and VascularSurgery

5.8 10.6 6.0 5.7 16.7

Neurosurgery 0.8 1.5 0.6 0.6 1.3 1.6Obstetrics/Gynaecology

10.1 13.1 10.2 10.3 11.5

Ophthalmology 3.6 6.2 4.7 5. 8.3

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Supply Benchmarks Per 100,000 Population

4Orthopaedics 4.1 6.9 6.1 4.8 4.6 6.6 6.

08.1

Otolaryngology 2.5 3.0 2.8 2.8 2.8 3.1 3.2

2.6

Plastic Surgery 1.0 2.1 2.2 0.4 0.4 0.7 2.3Urology 2.5 3.4 2.9 2.5 2.5 3.0 2.4

Hospital-BasedSpecialties

Anaesthesiology 6.4 11.6 5.5 9.2

12.6

Emergency Medicine 7 2 6.9 12.3 5.4 10.4

6.9

Hospitalist 0.7 2.7Intensivist/CriticalCare

1.2 0.7

Pathology 2.3 4.1 2.4 3.7Radiology 5.3 9.5 6.4 1.

12.6

Paediatric SpecialtiesMedicine

PaediatricGastroenterology

0.26

PaediatricCardiology

0.20 0.50

PaediatricHaematology/Oncology;

0.55

PaediatricNeurology

0.59

Surgery 0.32PaediatricNeurosurgery

0.06

PaediatricOtolaryngology

0.17


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Table 5 DGA Partners USA specialist per 100,000

Specialty DGABase

DGALow

DGAHigh

Primary Care SpecialtiesFamily Practice 17.6 15.8 19.4General Paediatrics 13.9 12.5 153Geriatric Medicine 2.6 2.3 2.9Internal Medicine 21.1 19.0 23.2

Medical SubspecialtiesAllergy/Immunology 1.3 1.2 1.4

Cardiology 4.1 3.7 4.5Dermatology 2.6 2.3 2 9Endocrinology 1.2 1.1 1.3

Gastroenterology 2.8 2.5 3.1Haematology/Oncology 1 7 1 5 1.9Infectious Disease 1.0 0 9 1.1Nephrology 1.0 0.9 1.1

Neurology 2.3 2.1 2.5Physical and OccupationalMedicine

1.1 1.0 1.2

Psychiatry 5 7 5.1 6.3Pulmonary Disease 1.3 1.2 1.4Rheumatology 0.9 0.8 1.0Surgical Specialties 1

Cardiothoracic Surgery 1.3 1.2 1.4Colorectal Surgery 0.5 0.4 0.5General and Vascular Surgery 5.9 5 3 6.5Neurosurgery 0.8 0.7 0.9Obstetrics/Gynaecology 10.3 9.3 11.3Ophthalmology 4.5 4 1 5.0Orthopaedics 5.8 5.2 6.4Otolaryngology 2.8 2.5 3.1Plastic Surgery 1.2 1.1 1.3Urology 2.6 2.3 2.9Hospital-Based SpecialtiesAnaesthesiology 6.8 6.1 7.5Emergency Medicine 7.1 6.4 7.8Hospitalist 2.7 2.4 3.0Intensivist/Critical Care 1.0 0.9 1.1Pathology 2.5 2.3 2.8Radiology 5.3 4.8 5.8Paediatric SpecialtiesMedicine

Paediatric Gastroenterology 0 2 0.2 0.2Paediatric Cardiology 0.4 0.4 0.4PaediatricHaematology/Oncology

0.6 0.5 0.7

Paediatric Neurology 0.6 0.5 0.7Surgery 0.3 0.3 0.3

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Specialty DGABase

DGALow

DGAHigh

Paediatric Neurosurgery 0.1 0.1 0.1Paediatric Otolaryngology

1 Trauma surgery is included in the numbers forgeneral surgery, neurosurgery, and orthopaedicsurgery.


The plan is ambitious and targeted to requirements over the next five years, based on anassessment of need. The degree of workforce adjustment will be considerable given plansoutlined in current planning documents. Table 6 shows the extent to which adjustments willbe required.

The redistribution plan will involve a major redistribution of staff, with many physicians whoare now working in rayon hospitals being transferred to the regional hospital in Edinet.Almost 35% of the existing workforce (192 of 473) have been identified as surplus based onthe standards. Over 158 additional professionals will need to be recruited from outside theregion or from a relatively small pool of new medical graduates to meet the specialty needs.

The specialties with a surplus of five or more are as follows:- Radiology (7)- Neurology (5)- Occupational Medicine (6)- Gastroenterology (8)- Clinical Pharmacology- and Therapeutics (18)- Health Management (20)- Epidemiology (35)- Family Medicine (75)

A careful assessment of the capability and willingness of persons in these groups to takeretraining will have to be made.

Applying the population-based standards discussed above, results in many specialtiesidentified as in need of new recruited (hired) physicians. The specialties that requireadditional five or more physicians are as follows:

- Cardiology (14)- Geriatric Medicine (7)- Paediatrics (21)- Ophthalmology (6)- Long-term care (5)- General Psychiatry (10)- Psychotherapy (9)

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- Psychogeriatric (7)- Clinical Neurophysiology (7)- Rehabilitation medicine (8)- Obstetrics & Gyn (6)- General Surgery (9)- Trauma & Ortho Surg (6)-

These shortages will be aggravated by the numbers that will be retiring in the next fewyears.

Table 6 Planned Redistribution of Physician Staff in Northern Region

PresentNumber

Transfer toEdinet

Transfer toCCCs

Physician Staffin Surplus

Stay in PlaceNew Hiresrequired

472 140 0 192140

158.5

Source: Calculated from Sanigest Mobilization sheet. Moldova Stands 2 21 2013.xlxs

3.6. Retraining

In a number of the post-Soviet countries, there is much experience with the retraining ofnarrow specialists as family physicians (Georgia, Kyrgyzstan). There is less experience,however, in the retraining of family physicians as specialists. There are lessons that can belearned from these programmes and retraining and re-entry programmes for physicians inthe USA and Canada. The following are suggested steps that can be taken to improve theeffectiveness of the retraining programme:

1. Trainers and mentors must be identified and trained because retraining adultphysicians is different from training new young residents;

2. The retraining courses must be designed and fully approved by the appropriatebodies;

3. The trainers should be members of the medical faculty and have access to thesupports of the medical school (library, simulation centre, etc);

4. There must be practical settings for training that are linked to the medical school;5. The retraining programme should have a continuing education component;6. The retraining programmes should be adequately funded.

Provision should be made to provide the physician going through the retraining withsufficient income so that they are willing to engaged in retraining. Retraining can beattractive to a number of physicians who will see it as an opportunity to do somethingdifferent and contribute to the improvement of their healthcare system.

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It will be more difficult for some specialist groups that are in surplus to be retrained. Theremust be rigorous assessment of the core education, and practice of these groups and thefeasibility of retraining in shortage specialties. Priorities must be selected a retrainingprogrammes designed to fill these. Cardiology, Paediatrics and Geriatric Medicine are goodcandidates as priorities because they would address the key health burdens of the region.

3.7. Age Distributions of the Present Professional Workforce

The age distribution of the present workforce is shown in Table 5 and Figure 3. At present17.6% of professionals are 65 and over and another 16.9% are in the 60-64 age range.Physicians can be expected to reach peak levels of productivity between the ages of 40 and59. Approximately 56% of professionals in the Northern Region are in these age ranges. Lessthan 10% are aged 25 to 39, when they can be expected to increase their productivity infuture years.

The Northern region data indicate that there are major challenges to be faced if the regionis to have a workforce of sufficient size to serve the population in the next five to ten years.The number of physicians 60 and over equal the numbers classified as redundant in Table 7.Plans developed by Sanigest anticipate hiring 183 new physicians to meet the specialists’needs in the region to provide services planned for the new hospital and CCCs. Physicians inthe next two age groups (55-59 and 50-54) will be moving into an age range where theirproductivity may decline.

Planning implications of these age distributions are:1. Decisions will need to be made about selective retention of physicians who exceed

retirement age. Practice beyond retirement age is prevalent in the region and thistendency should be understood when making decisions about whether or not tooffer continued employment or transfer to these physicians.

2. The potential for retraining, and the economic and professional costs and benefits ofretraining for physicians who are in higher age groups should be explored.

3. The willingness to transfer or retrain may decline once physicians have exceededcertain age thresholds. The numbers who may not wish to transfer or retrain are notpossible to predict in advance and planning activities should include a study of thispossibility.

There are many doctors working beyond retirement age. Health authorities acknowledgethat this is an important issue in-term of the actual numbers and also the potential negativeimpact on quality and patient safety. While it is to be expected that this practice willcontinue in the next 3-5 years (because there is a need) it is critical that provision be madeto address those specialties that will be at ‘high risk’ because of their numbers at and abovethe retirement age and the number that will be at retirement age in the next 2-3 years asseen in table 8. It is also possible that some physicians that are currently working aboveretirement age will chose to retire if they are not comfortable with how the reconfiguration

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will affect them. Hospital authorities must ensure that continuing medical educationprogrammes are made available to all physicians and physicians working beyond retire ageshould be encouraged to participate in them.

Table 7 Age Distribution of Professionals in Northern Region

Age Number PercentEdinet Bricini Ocnita Donduceni Total

25-29 1 3 0 1 5 1.1%30-34 2 2 2 1 7 1.5%35-39 18 7 3 4 32 6.8%40-44 20 7 10 7 44 9.3%45-49 30 10 7 10 57 12.1%50-54 30 21 21 13 85 18.0%55-59 20 18 22 19 79 16.7%60-64 27 21 15 17 80 16.9%65-69 14 10 10 18 52 11.0%70+ 13 8 5 5 31 6.6%Total 175 107 95 95 472 100.0%


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Figure 3 Age distribution northern region


Table 8 Specialist needed in the next 3 years

Specialty

Currentdeficit/surplus

acording tostandards

Danger ofnot

meetingstandardsdue to age

in twoyears

Medical Specialities 4.25Accident and Emergency -5Anaesthetics (including Intensive Care) -1.5 √Cardiology -14Child and Adolescent Psychiatry -2.5Dermatology 3.25 √Endocrinology and Diabetes Mellitus -0.75Gastroenterology 8.5Geriatric Medicine -1.75Infectious Diseases 2 √Medical Oncology 3.25Neumo 4Neurology 4.75Nuclear Medicine -2.5 √Occupational Medicine 6Renal Medicine -0.5 √

0

10

20

30

40

50

60

70

80

90

25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70+

Num

ber

Age Distribution - Northern Region Physicians

Donduceni

Ocnita

Bricine

Edinet

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Specialty



Danger ofnot


in twoyears

Rheumatology 1 √Pediatric 0Paediatrics -6.5Neonatology 0.25Paediatric Surgery 1 √Obstetrics and Gynaecology -6Surgical Specialties -75.75General Surgery -8.5Trauma and Orthopaedic Surgery -6Cardiothoracic Surgery -1 √Neurosurgery -1 √Ophthalmology -5.75Oral and Maxillo Facial Surgery -2ENT 3Plastic Surgery -3.25 √Urology -2.25Long-term care -14TB 2.75Narcology 1.5 √Others -6.25Mental Illness and Disabilities 0General Psychiatry -10Forensic Psychiatry -1.25Psychotherapy -2 √Old Age Psychiatry -2Learning Disabilities NAPathology and Radiology -10 √Chemical Pathology -3.75 √Clinical Genetics -1Clinical Neurophysiology -0.5Clinical Pharmacology and Therapeutics 18Clinical Radiology 7 √Hematology 1Histopathology -1 √Immunology -0.5

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Specialty



Danger ofnot


in twoyears

Medical Microbiology & Virology -1 √Health Management 20.75Internal med -1.5 √Epidemio 34.75Fam med 75Fisiotherapy 0.25Dentistry -1.5Rehabilitation -1.25 √


3.8. Transfer and Recruitment

Transfer of existing professionals to Edinets will require a plan that takes into accountmatching skills to planned service departments and professional considerations such asopportunities for peer support and continuing medical education. Living arrangements andopportunities for families in the form of schools, recreation and cultural activities shouldalso be part of the plan. Participation of those to be transferred in designing plans for thetransfers should be part of the process in order to ensure a cooperative reorganization.Incentives, both monetary and non-monetary, should be considered.

Recruiting and retaining medical specialists to the Northern Region of Moldova will requirepolicies and a set of interventions. There must be short term (less than one year), mediumterm (1-3 years), and longer term interventions (More than 3 years). In view of the relativelylarge number of new hires required (183 or 39% of the present workforce), strategies will berequired to recruit physicians from other regions and to attract potential medical graduatesin the future. Recruitment from other regions might best be approached as part of anational plan for healthcare reorganization. If the opportunity permits, planning forrecruitment should be done in conjunction with the national Department of Health.

3.9. Short term interventions

As discussed above the Ministry of Health working with local authorities have in place amultifaceted scheme for new medical graduates to work in rural areas. This scheme can beused to supply more new health personnel to the Northern Region. In addition a similarscheme to attract physicians from urban areas can be put in place in the short – term ifthere is agreement among the key government stakeholders. Such a scheme, combinedwith training opportunities may be attractive to younger urban general physicians.

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3.10. Longer term interventions

Attracting potential medical students to the region will require a carefully designedprogramme that will include the following:

Long Term – Introducing potential medical students to the benefits of rural practice.This will need the participation of physicians practicing in rural areas, the medicalschool, a representative of the regional health authority and local business peoplethat can talk about the important role that the specialist can play and how thecommunity can support them.

Clinical rotation in rural settings can be a medium term intervention. It will requirepolicies by the Ministry of Health, and the Ministry of Education will enable themedical school to organize rural teaching settings and to evaluate the studentsbased on their rural experience. Clinical rotations will require the training of teachersand clinical supervisors in rural clinical supervision and evaluation. The health facilitymanagers and the local health authorities must also be involved in developing therural clinical rotation programme.

It is recommended that a Task Force led by a senior Ministry of Health official be chargedwith determining the feasibility of these set of interventions and their economic costs.

3.11. The Adjustment of the Health workforce

The implementation of the Network Reconfiguration within the Regional Strategy requiresthe labour adjustment of health workers. The potential adjustment can contribute toincreasing the productivity of health workers in the Northern Region. Where a surplus ofhealth workers exists, strategies to take them out of the workforce can be designed. Thesestrategies can include the following:

Early retirement with compensation. There are 80 doctors aged 60 to 64, who willreach retirement age within five years. There are an additional 83 doctors aged 65or older.

Where the specialty is in surplus and the doctors have more than five years toretirement, a strategy of retraining can be considered and proposed to theperspective candidates. This is complex because it will require the development ofappropriate curricula, evaluation methods and theoretical and clinical training sites.In the Northern Region, many careful assessments of the potential for retrainingshould be made and strategies to attract qualified persons into retraining programsdeveloped.

Labour adjustment must be governed by the Labour Code of the Republic of Moldova, No.154-XV from 28.03.2003. Chapters II, III, IV and V address the contract of the individual. Thelaw does not address the collective dismissal, change of contract, for economic or other

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reasons. The Law on Civil Service, No. 443 – XIII of 04.05.1995, modified in 2002, also willgovern changes in health workforce as a result of changes in contracts.

Adjustment to health workforce must be planned and managed carefully with theinvolvement of the appropriate stakeholders. The need for socially responsible restructuringis strongly encouraged by the European Centre for the Development of Vocational Training.The Centre suggests that there must be strategies for career guidance, to help theredundant worker to find other employment, ensure fairness in the application of thereduction in-force. Other initiatives should include trained advisors and a clearing house ofjob information for potential job seekers.

It is recommended that a Task Group with legal representation be created to determine thefeasibility of different labour adjustment strategies.

3.12. Training Plan for the four Districts of Briceni, Ocnita, Edinet and Donduceni

Training plans for the health workforce must be guided by principles that are agreed to bythe stakeholders. The key principles of the regionalization strategy can be used as the basis:

Provision of patient care which is tailored to the needs and is of appropriate scopeand quality;

Achieving better patient safety; Achieving better patient care outcome; and Improving efficiency through reducing duplication and maximize use of human,

financial, infrastructure and other health care resources to provide health careservices.

The training plan development and implementation should be guided by a Training AdvisoryCommittee or Board which will have responsibility to recommend the training plan anddevelop criteria for the selection of trainees. The Committee/Board should agree onindicators of quality and measures of outcome of the training programme. A trainingsystem to realize the regionalization strategy could have five functions:

1. To improve existing staff skills;2. To develop new capacities;3. To improve planning of new service methods;4. Continuing professional development (competencies, life-long learning);5. To help to implement change in service delivery structure and organization.

The training plan should have three foci: managerial, enabling competencies, and specifictechnical skills. The development of the training process begins with first a comprehensivetraining needs assessment and second, the development of a strategic training plan torealize the objectives of regionalization strategy.

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Table 9 presents an outline of the elements of the training plan

TargetGroup

TrainingNeed

Type oftraining

LearningObjective

CourseTitle

CourseDescription

Modeof

TrainingDuration Provider Cost

The implementation of the reconfiguration strategy will require a broad range of skills andcompetencies in managerial, supporting and medical staff. The managerial areas of trainingwill include:

Health personnel management; Financial management; Materials management; Coordination and management of referrals; Financial management; Contracting; and Materials management.

In addition the magnitude of the changes will require the guidance of a core group whohave change management skills and are able to assist managers in building relationships andintroducing new approaches to work.

The enabling areas of training will include:

Change management; Project management; and Communications skills

Detailed training plans must be developed after a rapid needs assessment. It is envisioned,however, that the training approaches for managerial and enabling skills and competencieswill be short course modules which will use small group training methods, case studies andon-the job experiential training. The duration of the courses should be no-longer than 4weeks delivered in two week segments. A process for on-going support by trainers will bedeveloped and used for continuing development. Participants who demonstrate high abilitywill be identified and trained as trainers.

The re-training of medical personnel is much more complicated and will require a detailedanalysis of the respective curriculum to determine the base training of the group beingretrained and the theoretical and clinical areas in which they will need new knowledge,technical skills and competencies. The first steps must include the development ofcurricula, the training of tutors, and clinical supervisors in the specialties identified aspriority.

This process requires policy direction, agreement and commitment of the medical school,clinical training bases (commitment of the hospital directors) and adequate funding. An

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accelerated programs could be developed and be ready for re-training in six months withcommitted leadership and support from Ministry of Health, Medical Associations and LocalAuthorities. The Consultants working closely with the Training Advisory Committee/Boardcan prepare a comprehensive training plan in six weeks. A focus group approach can beused as the instrument to determine the training needs. It is believed that this would bemore effective than training needs survey.

3.13. Facilitating the transfers staff to the new inter rayon hospital in Edinet

The effectiveness of the new inter rayon hospital in Edinet will depend on strategies thatwill encourage the transfer of healthcare providers. Retention strategies must accompanyrecruitment strategies. A critical set of retention strategies are categories in studies as‘working and living conditions’6. This group of strategies include: infrastructure, safe andsupportive living and working environment, housing conditions, availability oftransportation, social involvement in the community, communication, access to internet,etc. Each of these factors contributes to a health worker’s decision locate and stay in a ruralor remote area. Some studies have found that when health workers live close to or on-sitethe facility in which they work they feel that they are able to serve their clients better anddo not have to contend with long commutes to and from work. Hence, appropriately builtand furnished housing close to the place of work can be a strong supportive incentive. Thishas been recognized by the Authorities in Moldova in the recruitment of new graduates forrural practice. It is suggested that the provision of accommodation should be considered asone strategy in encouraging health workers from the other northern rayons to work inEdinet.

Transportation, its availability and affordability is often a barrier for health workers whowould otherwise be willing to work in a health facility within a reasonable travel distance.Some health workers may be willing to travel two to four hours daily if the means oftransportation is comfortable, affordable and safe. It is recognized that there are timesduring the year when the weather acts to prohibit travel. It is suggested, however, that thefeasibility and viability of providing transportation to the inter rayon hospital for healthworkers who reside in the other three rayons be studied and a workable strategydeveloped.

Health workers are also reluctant to work away from their family because they are not ableto ‘easily’ communicate with their family. To address this it is important that the inter rayonhospital have the communications capacity to allow health workers to communicate withtheir families. This can be accomplished through the provision of internet access to the staffand their families. Access to communications should be considered as part of a package ofincentives.

The literature also suggests that health workers often feel isolated when they have to workoutside of their own communities. The inclusion of new health staff in local activities is a

6 World Health Organization, ‘Increasing access to health workers in remote and rural areas through improvedretention – Global Policy Recommendations, WHO, 2010

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powerful retention incentive. This can include activities such as sports, cultural activities andeducational activities. It is important that the new recruited doctors, nurses and othertechnical staff be oriented into their new work and social environment. It is suggested thatan orientation program which recognizes the importance of social orientation bedeveloped and implemented for newly recruited health workers to the inter rayonhospital.

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4. Pharmacy

The chapter will focus on facilitating equitable access to healthcare services, specifically tomedicines. For this to be verified it is required both the physical availability of the drugswithin a reasonable travelling time and distance, and the financial capability of purchasingthem.

4.1. Physical access

Starting with the first potential barrier to equitable access, when comparing the density ofpharmacist in the Republic of Moldova with other European countries, in Figure 4 it can beseen that the country lies almost exactly at the European average, according to the latestavailable WHO data.

Figure 4 Number of pharmacist per 10,000 people.

Source: WHO Health Statistics (2012)

However, the physical coverage of pharmacies across the country is not homogeneous, witha clear concentration in Chisinau and in the north, where population density is higher. In therural areas, there are pharmacies associated to some, but not all, primary health centres.Where a pharmacy exists, it is attended by either a family doctor, or a nurse, and holds areduced assortment of medicines. This is actually an exception to the law that requires anactual pharmacist to be in charge of dispensing drugs of any type. According to our deskreview, and in agreement with the anecdotal experience accumulated during this study, at

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the rayon level antibiotics as well as injectable medication are often sold over the counterwithout a prescription. Furthermore, nurses and pharmacist also seem to dispenseprescription only medications both at the primary care level and in the public sector.

A good proxy to pharmacies’ physical proximity is to use the percentage of catchmentpopulation farther than 5km to the PHC (some of them, it must be remembered, without apharmacy), which is 25.5% in the urban areas, and 35.2% in the rural areas. Furthermore, anassessment of road quality communicating the primary health-care facilities with theircatchment area has shown that a very low percentage (9%) had decent (asphalt or gravel)roads, and a number of villages do not have regular public transport to the local healthfacility. These will undoubtedly pose an access barrier, requiring the availability of findingsome means of transportation, and therefore adding time and cost to the process ofobtaining care and/or medication of any type (even over-the-counter) in the rural areas,especially in the south.

Therefore, it is not surprising that the household studies have found that use of medicineshappens more frequently in urban centres (38.2%) vs. in rural areas (30.9%). It should alsobe mentioned that almost half the population (45.2%) uses medicines without aprescription.

This pattern is also influenced by people’s distrust on the diagnosis accuracy and suspectedprescribing bias influenced by pharmaceutical interests. Unfortunately, there is no recentpublished evidence relating prescription practices and clinical outcomes in the Republic ofMoldova.

The physical barrier aspect has been, however, improving lately. According to data from theMinistry of Health, in 2007 there were 179 villages with PHCs without the presence of apharmaceutical service, whereas now that number has decreased almost 60% to a figure of107 villages without a pharmacy in 2012. See Table 10.

Table 10 Total number of pharmacies and subsidiaries. Republic of Moldova (2003-2010)


Having said that, outside of the urban concentrations only one-in-three pharmacies is notassociated to a hospital or PHCs (Table 11) and no data is available regarding the presenceof pharmacies in primary health-care facilities without a doctor[3].

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Table 11 Total number of pharmacies by location and type. Republic of Moldova (2010)


In absolute numbers it is clear that progress have been made in increasing the number ofvillages with some type of pharmacy. However, compounding the problem is the fact thatactual (essential) drugs availability in many of the country’s pharmacies appears to beproblematic: according to the latest WHO data, the availability of key medicines wassuboptimal in both public (51%) and private (58%) pharmacies. Eight essential medicines (of50 studied) had 30% or less availability in public or private outlets and only 10 medicines (allgenerics) had availability over 80%.

This fact was not confirmed by the anecdotal evidence gathered during this study, buthaving a sufficient amount of drugs in stock to serve the demand is an inescapable step toserve the patients needs. A more comprehensive study should demonstrate whether stocklevels are generally insufficient, and apply a root-cause analysis to establish the necessaryremedies to improve the situation.

4.2. Financial access

Access to emergency and primary care is universal regardless of insurance status and so areservices connected to key public health issues such as HIV infection and AIDS, TB andimmunization. The package of benefits available under health insurance covers specializedoutpatient and hospital care and a very limited range of pharmaceuticals. For those withoutinsurance coverage, these services are paid in full as OOP payments. OOP payments aremade up of informal payments and direct fee-for-service payments; there are no officialuser fees or co-payments for services covered under medical health insurance, althoughthere is a sliding scale of co-payments for any pharmaceuticals covered. Informal paymentsoccur at almost all levels of the system, but they are much more widespread for inpatientcare.

A substantial share of the population is not covered by the NHIC, with user’s perception ofthe cost-effectiveness value of health insurance for primary health care and outpatientspecialized care coverage to be very low. This is especially true for self-employed peoplewith low incomes. Household survey data from the NBS indicate that health insurance washeld by 79.7% of population in 2008 and 74.0% in 2010[3].

The largest share of expenditures is related to direct payments for diagnostic tests,prescribed medicines and most of all pharmaceuticals, as there is only a very limitedpackage of compensated medicines. Depending on the price of the product, the NHIC willreimburse 50%, 70%, 90% or 100% of the cost. The list of compensated medicines is revisedon an annual basis and approved by the Ministry of Health, with CNAM spending 150 million

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Moldovan lei, or 4.3% of their executed expenditures on that activity. Additionally, theamount spent by the MoH facilities in drugs amounted to 373.2 million Moldovan lei, whichin this case represents 10.9% of their total executed expenditures. Regardless of this, publicfunding only covering 28% of total expenditures and meanwhile, total pharmaceuticalexpenditure as a percentage of total health expenditure has doubled from 17.8% in 2003 to34.2% in 2010[3]. See Table 12

Table 12 Total pharmaceutical expenditure within total health expenditure and public pharmaceuticalexpenditure within total pharmaceutical expenditure (%). Republic of Moldova (2003-2010)


A recent study reviewing the availability and affordability of medicines found the cost ofmedicines to be significantly higher in the Republic of Moldova when compared tointernational prices, with patients paying 30–40% more for most generics sold in both publicand private sectors[6].

In 2011, a survey on medicine prices, availability, affordability and price components wasconducted by local experts with WHO support; The final price of all pharmaceutical productsin the Republic of Moldova is derived by adding to the fixed manufacturer price a wholesalemark-up of up to 15%, a retail mark-up of up to 25% and VAT at 8%.

The survey revealed that patients paid about double for brand names than they pay forgenerics, and that most of the generics sold were about 35% higher in price than the lowestpriced generics. Most standard treatments are not affordable for people with low wages,particularly for the treatment of psychosis, schizophrenia, Parkinson’s disease and ulcerativecolitis. However, in 2011, the wholesale mark-ups were just below 15% in both sectors,while the pharmacy mark-ups were about 20–25%, apart from the public sector in ruralareas where it was 14–15%. The following Table 13 compares the cumulative mark-up formedicines in other low- and middle-income Countries. Consequently, the greatestcontributor to the final price is the manufacturer’s selling price. Of the medicines that wereprocured by the Health systems in Republic of Moldova public sector, 75% were at about 3.5times the international reference price.

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Table 13 International cumulative pharmaceutical mark-ups, public and private sectors. (2008)


Finally, the following Table 14 depicts the different cumulative mark-up in the public andprivate sector, at both rural and urban areas:

Table 14 Pharmacy mark-ups, public and private sectors. Republic of Moldova.


Regardless of the generally smaller cumulative mark-ups, average prices in privatepharmacies have been found to be 10% lower than those in the public pharmacies.

The Ministry of Health is committed to tackling this issue in a comprehensive way, includinginitiatives to change the current centralized public procurement mechanisms.

According to household surveys conducted in 2008 and 2010, 25.4% of respondents in 2008and 19.2% in 2010 did not access primary or specialized outpatient health care whenneeded.

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4.3. Overview

The supply chain involves every stage from planning and procurement to the final deliveryof the product. For the purpose of this study, the discussion will mostly focus on onesegment in the supply chain – distribution – and solutions to alleviate the physical barrier toaccess to drugs in the rural areas. In the upcoming discussion, distribution does not simplyrefer to the transportation of goods but encompasses ordering, transportation and logisticsmanagement for distributing goods from the manufacturer to their final outlets.

Distribution systems may be fully publicly owned, or rely on a fully private system with apayment mechanism for covering the publicly generated operations costs. Most OECDcountries have chosen a fully privatized system, in which the public role is restricted toregulations and contracting of the used services. This is not the case in most low- andmiddle-income countries, as they typically rely on a publicly owned and operated centralwarehouse, and a mix of public distribution using their own vehicles and private supplyagencies vehicles. In some cases, Public-Private Partnerships or para-statal agencies arecreated to serve the drug demand (e.g. Tanzania, Uganda, Zambia), or the distribution issimply subcontracted to an international agency as done in Malawi, where they decided tosubcontracted the full supply chain, including procurement, storage and distribution[2].There is, however, no consensus on which system is better suited for each set of conditions.The system in place in the Republic of Moldova is closest to fully private system, and it isknown as a Direct Distribution system, shown in Figure 6 and explained in detail later.

The following Figure 5 depicts the different steps involved in a full supply chain, thereforereferring not only to the physical flow of goods, but also the flow of information (e.g.forecasting) and funds (e.g. Pricing). After a fast assessment of the supply chain ofpharmaceuticals for the public system in the Republic of Moldova, the graph shows in redthose areas that does not seem to be working in alignment with the stated objective (i) ofthe MoH to provide adequate physical and financial access to services. Most of thoseproblematic areas are mentioned along the study, but special mention must be made to theforecast, that is pivotal to the design of a resource-efficient supply chain. In the case of theRepublic of Moldova, the forecast is based on historical figures of drug consumption,instead of actual (i.e. real time) drug needs. The difference may be very significant, takinginto account that drug access faces important barriers that will skew the consumptionfigures towards drugs that are physically available and more economical to purchase(perhaps influenced by the co-payment scheme) instead of what is truly needed. The adventof mobile, paperless technologies have opened the door to systems that gather informationremotely in real time, so that the managers of the supply chain are now able to receive allphysician prescriptions as they are produced, and take the necessary actions to ensure thatdrugs are available when needed, where needed, and at an economic price due to theminimization of supply chain inefficiencies. In a conversation with the Medicines Agency, itsDirector pointed out that currently there is a paperless prescription and tracking pilot beingrun by one distributor, which seems an excellent opportunity to test and consequentlymove the supply chain in that direction.

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Figure 5 Supply Chain for medicines and supplies in the public sector: Main issues at Republic of Moldova


Problems in the distribution step are a major cause of stock-outs, but bottlenecks at anyother step in the supply chain may be to blame, including supply shortages at themanufacturer, wholesaler or distributor; poor forecasting and ordering processes; or legal,political or financial constraints. As mentioned in the Introduction, additionally to thephysical barrier to access, in the case of the Republic of Moldova, affordability of accessappears to pose a formidable obstacle for a significant proportion of the population,especially those dwelling in rural areas. As abovementioned, the main culprits appear to behigh procurement costs and an insufficient co-payment scheme even for the insuredpatients. Measures to resolve these should be studied, but they lie outside the scope of thepresent study.

Different from most developed countries, the Republic of Moldova pharmaceutical marketdoes not distinguish between over-the-counter and prescription medicaments, requiring the

Programming

•List of Essential Drugs•Clinical Guidelines•ForecastingMethodology

•Reactive (historical consumption) VS.•Proactive (actual demand, in real time)Budgeting

•Matching (funds available, national health priorities)•PrioritizationPurchasing

•Bids (open competitive vs. longstanding contract)•Price, delivery time, quality controlWarehousing

•Warehouse network optimization•Facilities Owned, Rented, or OutsourcedDistribution

•Physical Access (distance, availability) VS.•Financial AccessRational use

of drugs

•Clinical guidelines enforcement•Patient's health awareness and access.

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•List of Essential Drugs•Clinical Guidelines•Forecasting•Reactive (historical consumption) VS.•Proactive (actual demand, in real time)

•Matching (funds available, national health priorities)•Prioritization•Bids (open competitive vs. longstanding contract)•Price, delivery time, quality control

•Warehouse network optimization•Facilities Owned, Rented, or Outsourced•Physical Access (distance, availability) VS.•Financial Access

•Clinical guidelines enforcement•Patient's health awareness and access.

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intervention of a pharmacist for the purchase of either. The following discussion, therefore,is applicable to both classes of products.

The following illustration describes the physical flow of drugs and medical supplies for thepublic health system in the Republic of Moldova.

Figure 6 Physical flow of medicines and supplies in the public sector, Republic of Moldova.


On the left-hand side is the path followed by the pharmaceuticals purchased through apublic tender, issued under the supervision of MoH’s Medicines Agency, in agreement withthe regulation on the Procurement of Medicines and other medical products for necessitiesof medical services. The selected companies sign contracts which, among other conditionsregarding drug quality, delivery, penalties for delays, etc. include a clause specifying thatquantities can be changed by +/- 30% without a change in price. There is no centralwarehouse, and all distribution is done directly by the tender bid winners following demandfrom the different public health facilities. According to the conversations sustained duringthe visits organized for the preparation of this report, even if there seems to exist anestablished scheduled ordering. In fact, MoH facilities order “as needed”, with noconsiderations for consolidating orders in order to decrease distribution costs to tender-bid-winners. Notwithstanding the above, the small size of the country and the presence of alarge private pharmaceutical sector seem to compensate for that. In fact, none of the twodistributors interviewed, admittedly major players in the Moldova market, found that to bea problem.

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Imported medicines arriving from well-established companies (ICH, GMP) are submitted to afast-track quality control process, only requiring a handful of days to be cleared for sale inthe market. However, those purchased from unknown and/or uncertified manufacturers aresubjected to a full quality control analysis, and takes a maximum of 40 days for thoseproducts to be cleared for sale in the country. Surprisingly, the Medicine Agency doescharge below its cost for these laboratory analyses, introducing a market distortion thatcreates an incentive for insufficiently funded importers that keep small stocks, which maycause drug shortages and/or stock-outs. This not only fuels the importer marketfragmentation verified in Moldova, which implies smaller purchasing power and translatedin higher drug prices, but also financially weakens the Medicines Agency. The impairment ofthe Medicines Agency has broad implications including many facets of the pharmaceuticalmarket such as the regulation of medicines pricing in the public and private sector, theirparticipation on the elaboration of Standard Treatment Guidelines, and the supervision ofpharmaceutical services of the public and private sector.

All the drugs and medical supplies procured and distributed following this path are free-of-charge, including the rural doctors “kit”, which contains some basics and are distributed upto the CMF extra-budgetary as above-explained.

The hospital visited (Edineţ Rayonal Hospital), a medium size tertiary facility with around400 beds, with a ~75% occupancy, had no supply problems. The main pharmacy hadadequate space (albeit the facilities were very old), and the products were well organized inshelves with clear labelling. Stock cards were not used, but the use of a proper IT pharmacymanagement system and the relatively low volumes allowed for a smoothly run operation.They work under a purely “pull” system, with periodic (monthly) ordering that targets astock level equivalent to ~45 days of average demand for most medicines and supplies, butwith rational variations taking into account the drug life-saving potential, price, and fragility.They also kept a small stock of the most common medicines in each department equivalentto ~3 days of overage demand. The small size of the country allows for same-day delivery incase of emergency, and at least in the case of the facility visited, that mechanism is veryseldom used. The information gathered by the IT system is shared only once a year with thecapital. This is not ideal especially in light of the connectivity opportunities available, but hasworked “well enough” for their needs so far.

Coming back to Figure 5, on the extreme right-hand side, the “orange” arrow represents thesituation found in urban areas, in which a distributor (or its private pharmacy brand) rentsspace in a public health facility and manages its service. There, all products are paid out-of-pocket by patients, with some co-payment effective for those listed drugs in the insurance’sco-payment list mentioned in the previous section. To all effect, this is a private pharmacylocated within a public facility, and therefore will not be further considered in this study.

Finally, at the centre of the Figure 6, all “purple” objects depict facilities dealing with ruralpopulations. The “green” arrow represents direct purchasing from private distributors, andevery rayon establish their business links and contracts with them. The absence ofprocurement specialists, smaller purchasing power, and potential opportunities for

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corruption makes this arrangement non-ideal. Accordingly the latest available WHO studyindeed found that prices in the private sector are more affordable than in the public sectorby some margin. This finding corroborates with the anecdotal experience we gatheredduring the preparation of this study[6].

The CMF department of supply medicines and medical devices was established in 2007aiming to extend the availability of medicines to underserved rural areas. The system worksby appointing a “responsible” health-worker (officially a nurse, though sometimes familydoctors) to the management of a small stock of drugs kept in the health facility. This personthen retains 5% of all sales as compensation. New regulations from November 2012contemplate the pharmacist to carry a range of suitable products covering different pricepoints. However, the success of such a regulation in decreasing the out-of-pocketexpenditure will be conditioned upon availability. All things being equal, and consideringthat maximum pharmaceutical retail mark-up is capped at 25% in the Republic of Moldova,this arrangement should give access to less expensive drugs to patients than thosepurchased through private channels as the cumulative mark-up is significantly smaller.However, and as above-mentioned, this is not the case due to the more expensiveprocurement prices contracted by the CMF extra-budgetary office. Moreover, the systemhas inherent perverse incentives in place for the person responsible of those small stocks, topush for an overconsumption of drugs and especially the most costly items. If this system isreplaced by an alternative that still requires healthcare workers to manage these local(rural) medicine stocks, the incentives should be designed so that they do not promotebehaviours that will have a negative impact on the public health, as they currently do.

The Ambulatory Clinic visited, Edineţ Centrul Medicilor de Familie (CMF), could also beconsidered of average size among those that represent the Rayon’s most important healthcentre. It has 60 family doctors (plus a number of specialists) and treats between 700-1000patients daily. The operations of its CMF internal pharmacy, which supplies free drugs foremergency patients and the like, is identical to that of the above-mentioned hospital, andalso faced no supply problems.

There is another pharmacy depending directly on the clinic, albeit self-financed. The CMFextra-budgetary sells to the public but most importantly supply to the rest of health facilitieslocated in the rayon, which in this case comprises 35 villages. Depending on theirequipment, personnel and catchment size, these rural health centres are classified indecreasing order of size as:

CS - Health Centre (Centru de Sanatate)

OMF - Family Doctor Office (Oficiul Medicului de Familie)

PM - Health Post (Punct Medical – associated to a CS/OMF)

These will, in principle, only hold a small stock of basic drugs under the management of aresponsible health worker if there are no private pharmacies in the area. Typically, themanager of these small dispensing points travels weekly or biweekly to the CMF extra-

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budgetary office to pick up what she/he needs to re-stock and to fulfil any patient requestafter having made a call on the previous day to make sure all her/his order will be fulfilled.This is especially important since, at least in this case, the stock held at the CMF extra-budgetary office was extremely limited, probably worth less than a week of averagedemand. This system's work is supported by the distributor’s same-day delivery policy, andmay be rooted in the long cash-to-cash cycle times of their business operations. The systemis dependent on the small-stock manager working on credit, not clearing her/his balanceuntil the sales are made, and that she/he returns to re-stock. That would also be the time atwhich she/he is paid the 5% commission.

Again, all the system follows a pull-logic. One exception is insulin, which is centrally“pushed” up to the rayon's CMF, where the patient must go to get the prescriptionanyways. The other exceptions are psychotropic drugs, which are tightly regulated andcannot be obtained by the system described above, and HIV/TB that are distributedseparately.

4.4. International Interventions

The following section describes a selection of interventions successfully applied to improvethe access to healthcare services in other resource-constrained settings. The interventionwill be briefly described, including the location and initial conditions (problem) faced, thereasoning and methodology to tackle the issue at hand, and the results and lessons learnedafter implementing the intervention.

Experience A: Fuel Africa/PHD Pharmaceutical Distribution (South Africa)

PHD (formerly Fuel Africa) is a manufacturer-independent distribution service based inSouth Africa[10]. The problems of distribution in Africa, where distances are long andinfrastructures are lacking are well known. Compounding the problem, private hospitals hadsmall stock-in-hand, and relied on same day or next day delivery to serve their demand. PHDtook advantage of the opportunity and started offering smaller pharmaceutical importers inSouth Africa to take care of the distribution, estimating that by consolidating a handful ofservices the operations would be more efficient and therefore economical. The servicesproved to be a success given their understanding of the needs in the pharmaceuticalindustry of a quality controlled and dependable distributor that could reduce the importer’soperating costs. Today PHD supports a wide client base of multi-nationals, donor and publicsector organizations in Sub Saharan Africa. It is Africa’s leading healthcare supply chaincompany, and has now become the largest specialist pharmaceutical warehousing anddistribution infrastructure on the African continent.

PHD experience has shown how changes to the logistics and inventory management systemcan reduce pharmaceutical costs by 15 – 30% for consumers. The learning from thisexperience could be directly applied to both solutions Rx2 and Rx3.

Experience B: Improving maternal health by Contractual Management (Pakistan)

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The health sector in Sindh, Pakistan faced a number of problems, including a high burden ofdisease, both communicable and non-communicable, and low utilization of the healthfacilities in rural areas. In an effort to improve delivery of basic health services in remoteareas, the government of Pakistan contracted the management of lower level healthfacilities with a group of government managers in an unusual model that employs themanagers of an NGO, granting them decisive authority[11]. The experience turned out to bevery positive: the initiative dramatically increased utilization of services at facilities, andresulting that the area progressed from having the largest under-five mortality, to being theleader in postnatal care in Pakistan. Secondly, and very significantly for the Republic ofMoldova situation, the increased accountability designed in the system, together with theflexibility to make management decisions including hiring and transfers, did enable the newmanagers to improve availability of medicines and supplies, and improve providerperformance through increased monitoring. The learning from experience B could bedirectly translated to both solutions Rx2 and Rx3.

Experience C: Increasing access to underserved populations by innovative managementschemes (Guatemala)

In 1997 the government of Guatemala faced the challenge of extending the coverage with apackage of basic health services to 3 million people living in rural, impoverished, andprimarily indigenous communities. This ambitious challenge presented an excellentopportunity to experiment under controlled conditions with three different deliverymodels[12]:

i. Direct mode.- Contracting nongovernmental organizations (NGOs) to directly provideservices;

ii. Mixed mode.- Contracting NGOs to act exclusively as financial managers for the MoHhealth service providers. In this arrangement the contractors had the autonomy tocontract additional personnel, and purchasing by-passing the slow-inefficient publicprocurement system. This is similar to the above-described Experience B;

iii. Traditional mode.- MoH retained the management of the health posts and increasedthe resources available.

Efforts were made to apply these three different solutions to areas that were statisticallysimilar, and following the implementation household and provider surveys based on semi-structure interviews were used to investigate the level of success of the differentmanagement modes, in terms of increasing access, patient satisfaction and overallefficiency.

Strictly speaking from a public health perspective, the results shown that women andchildren in areas served by the mixed model (ii.) had significantly better key healthindicators when compared to the traditional model. Results for those served by the directmodel (i.) were similar to the traditional model (iii.), although these communities werelocated much farther from health facilities, and the programs had not been running for aslong. Users tended to report greater satisfaction with the new models. Focusing on the

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logistic perspective, the provider survey found that the NGO-based models (i.; ii.) aregenerally more productive than the traditional model; however, they are more costly, andresults on economic efficiency were mixed.

Along the process an initially unsophisticated system of contracting and provider selectionevolved into a more transparent, performance-oriented, and decentralized system ofdecision making for new and existing contracts that appears to have been largely successful.The study concluded that contracting basic healthcare may be an effective strategy toreduce health inequities in other country contexts where access to health services isinadequate which perfectly applies for the present document. Contracting brought a serviceimprovement (and consequently better health outcomes) and increased efficiency, in areasof weak capacity, even if cost was sometimes higher. A different study in Cambodia andBangladesh[13] did also find better outcomes and costs under a Direct Cost contract mode,but that may be related to the better overall healthcare system in Guatemala.

The learning from experience C could be directly translated to both solutions Rx2 and Rx3.

Experience D: Meta-study (International)

A study published in The Lancet[14], one of the world's leading general medical journal,studied examples of contracting with non-state entities for improving healthcare delivery. Aespecially significant sub-set of six of those studies are particularly applicable for theRepublic of Moldova situation, and the results shown that in all cases the contractors weremore effective than the government, on the basis of several measures related to bothquality-of-care and coverage of services. In the studies reviewed, the differences betweencontractor and government performance tended to be large (e.g. median coverageimproved between 5-20%), and the conclusion pointed that contracting can increasecoverage, even in poor, remote areas. With the resources and the explicit responsibility,many contractors were willing and able to work in difficult areas that had previously beenunderserved. The results are in line with those discussed in Experience B, & C, and thereforesupport the feasibility of both solutions Rx2 and Rx3.

Experience E: Merck Sharp & Dohme and DHL corporate social responsibility activity(International)

River Blindness is an eye and skin disease caused by a worm, and about 90% of the diseaseoccurs in Africa. The incidence is very significant, and in some West African nations thedisease had blinded communities, including about 50% of men over the age of 40 years. Thedisease has motivated a population movement away from the fertile river valleys to settle inless productive upland country, and hence the annual economic losses were estimated, inthe 1970s, at US $30 million[15].

In a joint effort to improve this dire situation, a pharmaceutical company and a logisticscompany decided to combine their core capabilities to ensure rapid and flexible delivery of

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the medicine, in what has become the largest on-going medical donation program inhistory. On the pharmaceutical side of the agreement, Merck Sharp & Dohme (MSD)generously supplies the treatment (Mectizan) free to 35 countries in the Middle East, Africaand Latin America. On the logistical side, DHL[16] has signed up to offer at-cost shipping ofthe treatment from MSD's facility in Clermont-Ferrand, France. Supplies of the medicine arecarried out to endemic countries through DHL's air express services. DHL Middle Eastregional director declared that the company “is committed to this project and others like itthat can make a difference to people's lives.” MSD has expanded the program to offertreatment against lymphatic filariasis (elephantiasis), another parasitic disease, in Yemenand Africa where the disease co-exist river blindness. Regarding DHL, the worldwide deliverycompany provides refrigerated space in their warehouses and offers their plane and truckfleets to distribute vaccines and bed nets to remote areas of Kenya[17].

The learning from experience D applies mainly on the logistic side of the story, showing thatcompanies with a strong logistic component such as packaging or beverage companies, maybe interested in offering space at a reasonable price for an intervention that it is wellaligned with their corporate social responsibility programs. This is a possibility that shouldbe explored with regards to Rx4.

Experience F: Reaching the “last mile” (International)

In the most remote settings, distribution networks break down in the “last mile” withimpassable roads and isolated villages. Because these areas tend to have the worst povertyand health indicators as well, it is particularly important for EHP systems to overcomedistribution barriers in the ‘final mile.’ Lessons can be learned from private companies in theconsumer goods business, which have successfully increased reach in these markets throughcreative local solutions. Coca-Cola, for example, invested in local entrepreneurs to develop anetwork of ‘manual distribution centres’ that deliver Coke products by foot and cart topreviously inaccessible villages.

Companies with similar distribution routes as EHPs can help to reduce overhead costs andlogistics infrastructure for EHPs by providing space for EHPs in their warehouses or on theirtransport fleet. UNILEVER, Proctor & Gamble, and other personal care and foodstuffmanufacturers are ideal candidates to collaborate with EHP systems because they alreadysuccessfully operate in the villages that are most difficult to reach for EHPs.

Several companies have already developed these partnerships. Exxon Mobil distributes freeinsecticide-treated bed nets to pregnant women and mothers at many of their gas stationsacross Ghana and Zambia

On the same lines as Experience D, this is a possibility that should be explored with regardsto solution Rx4.

4.5. Proposed Solutions

All the options described will focus on increasing physical availability, and will not betackling financial availability, which is also an important consideration and should be studied

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following some of the lines mentioned in this report, i.e. improvement of procurementprices and revision of the co-payment scheme. Moreover, all solutions described below willbe applied on the supply side of the issue, as this is what is traditionally considered therealm of the logistics. However, the importance of demand side interventions should not beunderestimated[19]. If patients, in one hand, understand the benefits (including theeconomics) of good health and they follow the advice of physicians that, on the other hand,prescribe correctly following clinical guidelines, those actions will have a tremendous impacton the pharmaceutical market, making even remote locations more attractive for privatepharmacies to serve, and making demand more predictable. Furthermore, these changeswill facilitate the optimization of their logistics, which will be finally translated in both betterphysical availability and better prices. The dramatic returns to increased health awarenessand acceptance of simple techniques related to health and hygiene in developing countrieshave been well documented.

OTCs should be de-regulated, as it is the case in Europe, US, middle income countries suchas Jordan, etc. and made available at convenient stores and filling stations so that access isfacilitated for people in geographically constrained areas, and especially those that live inareas where there is no primary health centre. The reasoning behind this policy is that OTCdrugs are regarded as being in principle safe medicines for minor ailments, and can be usedin conditions in which a physician might not prescribe a drug at all.

Prescription medicines, as follows:

Rx1. CMF pharmacies with networks in villages are maintained, but purchasesthrough national tender-bid-winners.

This mechanism should only affect the final price of medicines, which shouldbecome more affordable. The improvements will be rooted on the greater MedicinesAgency purchasing power due to the larger volumes purchased nationally, and byavoiding corruption opportunities pursuing the application of stricter procurementpractices based on the World Bank procurement Guidelines for Goods and forConsulting Services. The distribution will remain dependent on the health workerresponsible for stock keeping, but her/his incentive should no longer be linked tosales, and a system based on the catchment population is suggested.

Rx2. CMF-network supplied by a private provider, under centrally negotiatedconditions of price, availability, etc.

This solution maintains the negotiation of the Rayon’s CMF with privatedistributors, but under the supervision and rules defined by the Medicines Agency. Asof today, the cumulative mark-ups for medicines in the public sector are lower thanthose in the private sector (especially in the rural areas), but still prices are higher inthe public sector. Accordingly, a good monitoring on procurement prices as abovedescribed should warrant more affordable medicines in the public sector, and amonitoring system to ensure that the rules are obeyed should be implemented. The

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contract should establish a “license” fee proportional to the catchment area, fromwhich the incentive to the person responsible for stock keeping should be paid (see amore detailed discussion below). This amount should be calculated for each CMF overtheir estimated volume of sales, in itself related to burden of disease, and taking intoaccount most of the sales will be prescribed by family doctors. For the privateprovider, the business will still be profitable, with the ceiling defined by thecumulative 40% profit (15% wholesale + 25% retail) achievable by the traditionalprivate service channels.

Rx3. CMF-network managed by a private provider creating a PPP: i.e. rentalspace is offered at the healthcare facilities, conditioning availability, etc.

This solution extends to the conditions presented in the previous solution, so thatthe private provider will be responsible for managing the stocks available in thosehealth facilities that currently offers them, and also to study the possibility to extendthem to other potentially interesting areas. This arrangement will require the privateprovider to ensure the distribution of the medicines and supplies, and to keep areasonable stock in each facility in agreement with their catchment population. Aback-of-the-envelope calculation using data from Edineţ Rayon gives a rough averageof ~US$0,094 ~US$0,124 monthly compensation per person living in the catchmentarea under the current system. We would propose a system that maintains the level ofeconomic incentive, but based on a per-capita basis. The compensation shouldbalance whether the responsible person is in charge of picking-up the items andmaintaining the minimum stock (Solution Rx 2) or relies on the private provider, asproposed in this solution. Regardless, in both Rx 2 and Rx 3 solutions the responsibleperson is still in charge of collecting “special” orders from patients, and stock keeping.Hence, economic compensation will still be necessary.

Rx4. Stock at health facilities is eliminated, and medicines are distributeddirectly to patients (e.g. by post).

This solution represents the most radical departure from the current status quo,and will result in the elimination of the small stocks of medicines held in some of thepublic rural health facilities. From an economic point of view, this is the only solutionthat will re-establish a purely competitive pharmaceutical market, hence promotingfairer conditions for the private providers to become more efficient. The system willrequire that (rural) prescriptions are communicated to the provider, and should alsocontemplate safety checks so that medicines will only reach the intended patient.Alternatives, many of them free-of-charge based on mobile technologies aboundtoday[20], such as: sms for life that uses mobile phone, short message service, andelectronic mapping technologies to accurately track and support review of reportedweekly stock levels in Tanzania; m-track, which employs text-based messaging to trackdisease outbreaks and medication supplies in Uganda; Stop the Stockouts deployedFrontlineSMS in a number of partnerships to map drug availability; or UNICEF use of

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RapidSMS a monitoring, data collection tool and communication tool that allows bothquantitative and qualitative data through SMS forms and bulk SMS messaging forinventory management. A study should be commissioned to select what option will bethe best suited for the Republic of Moldova needs and constraints. The distributioncould be done by using the postal service or a private packing company, paying specialattention during the negotiations to ensure that the chosen contractor will meet theappropriate chain of custody and special transportation requirements. Figure 7depicts how this solution would operate: the final distribution to patients will becontracted to the postal service or a private packing company depending on themarket reality in each rayon, always ensuring that the medicines are handled safely totheir recipients.

Figure 7 Information and physical flow of drugs by postal distribution in rural areas for the public sector,Republic of Moldova.


4.6. Key Success Factors

Essential to the success of the initiatives to improve the pharmaceutical supply chain inunderserved and rural areas in the context of the regionalization plan is the commitment ofthe governing body and senior managers of the Ministry of Health and its partnerorganizations, to ensure a proper implementation of the pilot tests rayons and to releasethe necessary resources to undertake the task. Once the pilots have been completed, it

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would be the time for analysing the experience, and study both the positive and negativelearnings. An additional study is recommended to define how many pharmaceutical servicepoints are truly necessary in the currently underserved areas. The following areas should beinvestigated:

Population distribution and demographics, ideally complemented by burden ofdisease.

Current consumption data of the CMF pharmacies in the catchment area Infrastructure (road, transportation, technology…) data and other relevant data.

Once completed, the results from this study will help in deciding where the pharmaceuticalservice points are most needed, and the learnings from the chosen pilots could be appliedto the best suited solution of those proposed at a national level.

In common for all the options presented, an awareness campaign directed to educatepatients to the benefits of proper use of medicines is recommended, to ameliorate the factthat patients in constrained settings do not have access to a pharmacist. Posters and flyersshould be made available at the health centres serving these populations, and the healthpersonnel trained to give sound advice to patients. Furthermore, the creation of a freephone number for pharmaceutical advice available at all times would be an excellent tool inprogressing towards better public health outcomes in Moldova.

Another important area is to ensure that patients get effective medicines from any of theproposed solutions. The enforcing of an effective monitoring and pharmacovigilance systemshould be put into place to protect the public from counterfeit, ineffective and/or harmfulmedicines that do not comply with current regulations.

More specifically to the different solutions presented:

Regarding the access to OTCs, the solution relies on the existence of a sufficient number ofPoint-of-Sales to have a positive impact. This will vary from site to site and depend on theireconomic landscape.

Focusing on the proposed solutions for prescription medicines:

Rx1. CMF purchases through national tender-bid-winners.For availability to improve, the first obstacle is to calculate a reasonable forecast,

so that estimated quantities are incorporated on the national tender, and the bidwinners can plan their demand appropriately, and hence, serve the orders as received.This seems perfectly feasible given that sales data exists. The person responsible formaintaining the stock should be compensated for her/his efforts through incentivesthat are aligned to public health outcomes and not to his monetary compensation: analternative has been described that would work in the proposed lines, by linking themonetary amount to the population of the catchment area. The compensation shouldalso factor in the fact that the “last mile” distribution relies on the same person thatoversees stock keeping.

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Rx2. CMF-network supplied by a private provider.This solution is based on the existence of private providers interested in becoming

the supplier to each rayon’s CMF under the described conditions of the contract.Moreover, it would require an effective monitoring system on procurement prices tooffer affordable medicines in the public sector, at least no more expensive than in theprivate sector. The same comments regarding the compensation of the personresponsible for managing the stock of medicines at the health centres apply.

Rx3. CMF-network managed by a private provider creating a PPP.This alternative is an extension of the previous solution, in which the contractor is

not simply a supplier but the responsible for managing the stocks at the health centresthat includes them. This will effectively offer private providers a Point-of-Sales in thoserural areas, which should represent an attractive opportunity for private providers. Forinstance, in conversation with the Director of Sanfarm-prim, he stated very clearlytheir interest in becoming the providers of these areas under the conditions describedin this solution.

Rx4. Medicines distributed directly to patients.This solution requires the existence of an effective system of linking the

information regarding the prescription (medicine need) with the patient (medicinerecipient). Ideally this should be done by using some type of electronic prescription,which can be easily sent to the contracted distributor. Some alternatives have beenbriefly mentioned on the solution description, but many others may be designed, andin today’s connectivity reality, it should pose no problem to find a system that fulfilsthe needs as discussed. Once the distributor has the information, it will use theirlogistical system to pick-up the desired drug from the corresponding tender-bid-winner or pharmaceutical wholesaler, and introduce that product on their distributionroutes so that it should reach the patient within 24hr-48hr after the prescription waswritten. These operations will create a digital invoice so that periodically (for instance,monthly) the tender-bid-winners can invoice both the post and the insurance for theoutstanding payments, including the cash collections by the postal service from thepatients upon delivery. Therefore, the implementation of Rx4 requires:

Creation of a system in which the relevant real-time information on drugdemand is shared with each contracted distributor. This will be facilitated bythe use of electronic prescriptions.

Require all tender-bid-winners and (major) pharmaceutical wholesalers toserve the contracted distributor, and receiving periodic payments.

Contract a distributor that is able to sustainably and safely reach the currentlyunderserved population, for a price that does not make medicinesunaffordable. This should ideally be within the 25% pharmaceutical retailmark-up.

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Finally, it should be mentioned that the problems faced the Republic of Moldova to improveaccess to underserved patients will evolve in time in unison with the changing populationpatterns, which includes a decreasing but aging population, and a probable decrease in thenumber of people living in very remote areas. All of the proposed solutions have thecapability of respond to these changing patterns, and therefore be not only a temporarysolution as long as the always changing economic market forces do not introduce moreaffordable alternatives.

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5. Emergency Services

Emergency Departments are vital components of local urgent care networks, deliveringacute and emergency care, in close coordination with ambulance services, walk-in services,GP out-of-hours services and other emergency intervention services

Emergency care in the Republic of Moldova marks its beginning as a system on 4 September1944 with the first rescue station in Chisinau. The rescue station began its work with acarriage with two horses; serving serious patients in their homes or in public places. Thecurrent Emergency medical service structure includes: National Scientific and PracticalCentre of Emergency Medicine, 4 zone stations of Emergency care (composed of 43substations located in municipalities and Rayonal centres, and 88 points for emergency care,located in rural areas).

5.1. Financing & Budgeting

Emergency care is covered by the national health insurance company and is free-of-chargefor the entire population. The national health insurance company pays a fixed amount ofmoney per capita. That amount is 92.41 lei, which is about 5.6 euro. The budgets for 2011and 2012 are as follows:

2011 – 303,125,819 lei (approximately 24,245,215 USD or 18,664,517 Euro)

2012 – 318,208,018 lei (approximately 25,451,550 USD or 19,593,181 Euro)

Table 15 Emergency care budget in Moldova

Budget perinhabitant in Euro

Total budget, Euro

Moldova5.60 19,593,181

Austria47.62 400,000,000

Bulgaria5.20 38,350,000

UK - -

Estonia20.14 27,000,000

Finland15.68 85,000,000

Lithuania10.09 33,300,000


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As one can observe from the table above, when comparing Moldova to the rest of thecountries at 2008 budget levels, Moldova is at the bottom of the per capita budget. The mailcategories where the budget is allocated are:

Salaries staff Procurement of medicines and para-pharmaceuticals Providing employees with professional clothing Procurement of medical equipment Ensure phone connections Provision of fuel

5.2. Legislation

In Accordance with the Government decision nr. 891 from 17.07.2003, “regarding theestablishment of the emergency health assistance in Moldova” the emergency medicalservice was created in Moldova. Normative acts that regulate the organizational structure,obligations, and responsibilities of each subdivision in part, how emergency medical serviceis delivered and collaboration of the emergency service with other sectors of the healthcaresystem were created. Ministry of Health order Nr. 85 from 30.03.2009 regarding theorganization and operation of emergency medical services.

5.3. Availability and spreading of ambulance care

National Scientific and Practical Centre of Emergency Medicine (CNSPMU) includes: a clinicwith 600 beds, four outpatient orthopaedics and traumatology sections, pre-hospitalemergency medical service with 903 beds, 5 substations and 5 points AMU(emergencyassistance). CNSPMU ensures the organization and provision of emergency medical carethroughout the country. It is engaged in providing emergency medical assistance scheduledat both the pre-hospital stage as well as clinic.

Table 16 Emergency teams to 10 thousand population 01.04.2013

Team profile MunChişinău

ZSCentre

ZSNorth

ZSSouth

ZSGăgăuzia

TOTALSAMUrepublican

General profile teams 31 46 35,5 11 3 126,5

Includingpaediatric profile teams

5 1 1 1 - 8

Specialized teams total,Including:

15 1 6 1 - 23

Cardiology 7 1 3 1 - 12

reanimation adults 1 - 1 - 2

child reanimation 2 - 1 - 3

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The Service of Emergency care involves 233 teams that is 0.65, the norm being 0.8 per10,000 population teams, including general profile teams 126.5 and 83.5 feldshers teams.The Emergency Service is organized into 23 specialized teams of which 15 or 65.2% are inthe Emergency service in Chisinau. Share of teams of doctors are 64.2% and 35.8% of thefeldshers teams. As of 2011, there were 367 emergency vehicles. Out of them, 102 vehicleshave a wear of over 100%, 60 vehicles over 50%, 61 vehicles 50-30% and 114 vehicles have awear of 30-10%.

Table 17 Regional Ambulance Services and dispatch centre

Nr of patientstransported

Nr of patientstransported to100,000 pop

Nr of calls Nr of calls to100,000 pop

Edineţ 4,4145,681 18,520 23,835

Briceni 2,9164,005 16,357 22,468

Ocniţa 2,9585,881 9,901 19,684

Donduşeni 3,8329,392 9,602 23,534


1. Zonal station AMU Centre includes 17 substations in the following rayonal centres:Anenii Noi, Basarabeasca, Calarasi, Criuleni, Cimislia, Dubasari, Causeni, Ialoveni,Nisporeni, Orhei, Hincesti, Ungheni, Rezina, Telenesti, Soldanesti, Stefan Voda,Straseni, and 37 AMU points in the rural areas.

2. Zonal station AMU North includes 12 substations in the municipality of Balti and inthe following rayonal centres: Glodeni, Falesti, Singerei, Riscani, Drochia, Soroca,Floresti, Edineţ, Ocnita, Briceni, Donduseni and 26 AMU points in the rural area

Neurology 2 - - - - 2

Psychiatry 2 - 1 - 3

Obstetrical-gynaecological

1 - - - - 1

Teams of feldshers 6 28 29,5 9 11 83,5

de facto in the reportingperiod

52 75 71,0 21 14 233

To 10 thousandpopulation AMU team

0,66 0,63 0,69 0,72 0,77 0,65

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3. Zonal station AMU South includes 4 substations in the following rayonal centres:Cahul, Cantemir, Leova, Taraclia and 13 AMU points in the rural areas.

4. Zonal station AMU UTA Gagauzia includes 3 substations in the municipality ofComrat, rayonal center Ceadir-Lunga, the town Vulcanesti and 7 AMU points in therural areas.

Each AMU station has general teams and specialized teams. Current norm is 0.8 teams/shiftto 10,000 people, which is comparable to other countries like Estonia. At this point in time,the ambulance teams are mixed in Moldova. In some cases, it may consist only of feldshers,and in others of feldshers and physicians. There are no paramedics on ambulance teams.Each AMU structure covers a range of up to 25 km. By the current norms, one emergencyvehicle covers 10,000 residents.

5.4. Response time

Alarm time (after taking the request to start) is less than 90 seconds, The time to reach in case of major surgical emergencies (from request to arrival at

the event) in 10 minutes in municipal centres, cities, communes and villages, place ofresidence subdivisions AMU station, and under 15 minutes for other request fromother territories,

The time from the ambulance stopping until first contact with the emergencyphysician in the emergency department / admission department is under 90 seconds

Transferring the patient to healthcare institutions is under 5 minutes.

In general these times of response are very comparable to most EU countries, and in somecases are even shorter. But it should also be considered that Moldova does not have biggeographical impediments to transport, like mountains and water basins.

5.5. Process flow

In the call center, the call is received by the dispatcher and recorded. Dispatcher confirmsthat the call is officially received, and informs the patient to expect the ambulance. The callis registered with a unique numeric code. Within one minute, the call is forwarded to theclosest serving station, which depending on priority and triage, is forwarded to theemergency team that will be dispatched.

The coordinating doctor on guard, along with the dispatcher are responsible for receiving,forwarding the call and dispatching the vehicle as well as monitoring them. Most of theambulances in Chisinau are equipped with GPS transmitters and by the end of year it isplanned to equip all ambulances.

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Figure 8 Emergency care process flow algorithm


5.6. Technology

In general the emergency system in Moldova is developing well and on the right track. Mostmunicipal ambulance vehicles are equipped with GPS transmitters, and are planning toinstall them on all vehicles during the next year.

Ambulance vehicles that have ECGs on board also have the telemedicine concept in place.The feldsher can send the ECG results to a central office where it is read and results withdiagnostics and recommendations are sent back to the vehicle while the team is still withthe patient. Most ambulances are equipped with the following:

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Table 18 Ambulance equipment

- ECG devices - mimics - tonometers

- defibrillators - hydrometer -birth assistance kit

- Pulse oximetry - Sources of oxygen: O2inhalation and artificialrespiration

-splints, including cervicaladults, children, new-born

- glucometers -pneumatic splints - manual vacuum

-laryngoscopes - Long and short boards - AMU medical kits

- cardiostimulator - Pants shockproof -ATLS equipment


5.7. Requests by profile

Cardiologic profile requests can be assessed by the major share averaging 23.7% comparedto 24.2% in 2011. Requests for neurological profile is 12.4% compared with 10.9%,Traumatology profile requests 9.0% (8.2%), surgical applications - 4.7% (4.6%), infection is 56% compared with 6.4%., tox-0.8%.Requests for therapeutic profile is 37.4% compared to32.1% in 2011. Share of calls on the basis of respiratory profile constitute 44.4% of alltherapeutic profile requests. Table 19 illustrates the percentage of requested services byprofile and hospital facility.

Table 19 Emergency servicer request by specialty profile

Requests by profile

Nr. Indicator mun.Chişinău

SZ AMU SZ AMUNorth

SZ AMUSouth

SZ AMU Total RM

Centre Găgăuzia

1 requests therapeuticprofile 102,181 127,823 77,156 30,484 19,181 356,825% Of total requestsserviced

41,2 38,4 31,6 37,3 40,1 37,4

1.1 including respiratory /% 48,836 48,615 38,567 12,457 9,798 158,273

47,8 38,0 50,1 40,7 51,1% 44,4

2 requests surgicalprofile 16,171 13,301 10,142 3,764 1,277 44,655

% Of total requestsserviced

6,5 4,0 4,2 4,6% 2,7% 4,7

3 requests psychiatricprofile 9,127 9,991 4,705 2,324 1,969 28,116% Of total requestsserviced

3,73

1,93

4,1 2,9

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Requests by profile4 Requests obstetrical-

gynaecological profile 15,178 14,477 9,521 3,274 1,593 44,043


6,1 4,3 3,9 4,0 3,3 4,6

5 Requests infectiousprofile 36,968 4,846 9,487 1,073 866 53,240


14,9 1,5 3,9 1,3 1,8 5,6

6 Requests neurologicprofile 27,941 38,670 36,004 8,777 7,074 118,466


11,3 11,6 14,8 10,7 14,8 12,4

7 Requeststraumatology profile

27991`28,371 20,497 6,262 3,101 86,222


11,3 8,5 8,4 7,77

9,0

8 Requests cardiologicprofile 56,494 81,004 57,649 20,820 10,444 226,411


22,8 24,3 23,4 25,5 21,824

9 Requests toxicologicalprofile 2,328 1,821 2,235 576 330 7,290


0,9 0,5 0,9 0,7 0,7 0,8

10 Other unclearemergency 2,308 12,670 10,143 4,525 2,026 31,672% Of total requestsserviced

0,9 3,8 4,26

4,2 3,3


5.8. Cooperation with other partners

Emergency Medical Assistance Service cooperates with the Ministry of Interior, Departmentof Exceptional Circumstances, municipal and district departments of exceptionalcircumstances, municipal and regional police departments, units of the Ministry of NationalDefence in the agreements concluded by the Ministry of Health.

5.9. Situation in the Northern region

The table below indicates that the number of calls is much higher than the number ofpatients transported. This is due the fact that not all the patients have to be hospitalized.The team who arrives to the call decides whether the patient should be hospitalized, or canbe stabilized and left at home care.

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Table 20 Emergency response for northern region

Nr ofpatientstransported

Nr of kmdriven

km driveon avg/call

Nr of calls Populationserved

Nr ofvehicles

Emergencydoctors

Edineţ4,414 314,328 17.00 18,520 77,700 9 16

Briceni2,916 266,017 16.30 16,357 72,800 8 16

Ocnita2,958 240,804 24.30 9,901 50,300 4 13

Donduseni3,832 207,450 21.60 9,602 40,800 4 10


The 2012 budget of the Zonal Station AMU North was 88,630,664 lei. (AMU North includesthe following rayons: Glodeni, Falesti, Singerei, Riscani, Drochia, Soroca, Floresti, Edineţ,Ocnita, Briceni, Donduseni and the mun. Balti). Time from call to hospital: Rayonal center –6.05 min and in Rural area – 14.19 min.

5.10. Ambulance response time

In general, the norms and standards in Moldova are similar to other countries and in somecases even stricter. For example in Moldovan legislation, the norm is to have one ambulancefor 10,000 inhabitants, while other countries like Estonia and Lithuania, the norm is oneambulance for a population from 10 to 15 thousand.

Table 21 Ambulance response time


A similar situation is with the time from call to patient. Current legislation in Moldova statesthat an ambulance has to reach the patient by 15 minutes. Most countries in ourcomparison have the same standard, but some do not even stipulate any time brackets.

Nr ofambulances

Call to sitetime

Ambulancesper 10,000

Moldova333

< 15 min 0.95

Austria 2,500 < 15 min 2.98

Bulgaria675

10 - 20 min 0.91

UK 2,021 9 - 19 min 0.32

Estonia90

0.67

Finland800

15> 1.48

Lithuania256

10 - 25 min 0.78

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5.11. Personnel:

As of 2012, a total of 3216 individuals are working in the Emergency care service inMoldova. Out of them 542 are doctors, 1263 are middle medical personnel, 362 inferiormedical personnel, and 1071 are drivers and others.

Table 22 Ambulance personnel

Workers Workers per100,000 pop

Moldova 3,21691.89

Austria 5,00059.52

Bulgaria 7,11396.38

UK 17,02826.95

Estonia 1,33699.66

Finland 2,00036.89

Lithuania 2,35071.21


Table 23 Number of Calls

# of calls # Calls per100,000 pop

Moldova954,000 27,257.14

Austria867,000 10,321.43

Bulgaria620,000 8,401.08

UK7,200,000 11,395.83

Estonia250,000 18,648.37

Finland550,000 10,143.86

Lithuania730,000 22,121.21


For a complete list se Annex 1

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5.12. Recommendations

Access to emergency care is a fundamental system issue that should be considered in everyfunding and planning decision, whether at the government level, the local rayon level or atthe facility/organization level. Emergency department accessibility is the responsibility of allof the players in the healthcare system, and ensuring success will require the concertedcommitment of all involved within the northern region.

Drawing upon the initial findings highlighted in this chapter, Sanigest recommendsestablishing a central point of coordination as part of a two phase approach to theemergency care restructuring within the northern region. During the first phase, theambulance network will be coordinated from Balti for the entire northern area. This willhelp ensure a smooth transition given the current level of complex cases and maturenetwork of emergency care within Balti. The second phase would then establish Edineţ asthe coordinating entity for emergency services for the northern region. As specializedadvanced care, such as interventional cardiology, stroke units and state of the arttechnology will be available within the newly established inter-rayon hospital in Edineţ, byphase 2 the hospital facility will be ready to act as the local coordinating entity. Theproposed changes should also be considered in close relation to the current legislationinvolving public private partnerships; În temeiul art. 11 lit. a), b) si e) din Legea nr. 179-XVIdin 10 iulie 2008 cu privire la parteneriatul public-privat (Monitorul Oficial al RepubliciiMoldova, 2008, nr.165-166, art. 605).

There is also a need to improve the critical pathway for patients with urgent acute care. Theaim of a care pathway is to enhance the quality of care across the continuum by improvingrisk-adjusted patient outcomes, promoting patient safety, increasing patient satisfaction,and optimizing the use of resources. Clinical Pathways were introduced in the early 1990s inthe UK and the USA, and are being increasingly used throughout the developed world. Theyare structured, multidisplinary plans of care designed to support the implementation ofclinical guidelines and protocols.

Critical pathways are designed to support clinical management, clinical and non-clinicalresource management, clinical audit and also financial management. They provide detailedguidance for each stage in the management of a patient (treatments, interventions etc. )with a specific condition over a given time period, and include progress and outcomesdetails. Clinical Pathways aim to improve, in particular, the continuity and co-ordination ofcare across different disciplines and sectors. They can be viewed as algorithms in as much asthey offer a flow chart format of the decisions to be made and the care to be provided for agiven patient or patient group for a given condition in a step-wise sequence.

Currently practice guideline have been established for several areas of care such as neonatalcare and stroke care. Clinical Pathways differ from practice guidelines, protocols andalgorithms as they are utilised by a multidisciplinary team and have a focus on the qualityand co-ordination of care. Introducing a critical pathway for emergency care in the northernregion will help to:

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Support the introduction of evidence-based medicine and use of clinical guidelines Support clinical effectiveness, risk management and clinical audit Improve multidisciplinary communication, teamwork and care planning Can support continuity and co-ordination of care across different clinical disciplines

and sectors; Provide explicit and well-defined standards for care; Help reduce variations in patient care (by promoting standardisation); Help improve clinical outcomes; Help improve and even reduce patient documentation Support training; Optimise the management of resources; Can help ensure quality of care and provide a means of continuous quality

improvement; Support the implementation of continuous clinical audit in clinical practice Support the use of guidelines in clinical practice; Help empower patients; Help manage clinical risk; Help improve communications between different care sectors; Disseminate accepted standards of care; Provide a baseline for future initiatives; Not prescriptive: don't override clinical judgement; Expected to help reduce risk; Expected to help reduce costs by shortening hospital stays

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6. Palliative care and other chronic care services

Previous reports developed by Sanigest to the Ministry of Health of Moldova havehighlighted the importance of separating chronic and acute care within the northern regionand the description of services at each level Figure 9. Palliative care is an important elementof chronic care that aims to improve the quality of life for patients approaching the finalyears of life. Palliative care will be an important element included within the three chroniccare centres in Briceni, Donduseni and Ocnita.

This chapter focuses on the description of palliative care projected to be available within theCCCs and a description of the dynamic working relation that has been envisioned, betweenCCCs and the inter-rayon hospital in Edineţ. Finally, the chapter describes the differentmodalities of chronic care services related to long term treatment that will be madeavailable at the CCC level.

The Moldovan society like the majority of countries around the globe is ageing. Thisproduces a need not only to improve health by preventing disease and disability but also toimprove the quality of life that remains, enabling people to live well and, when the timecomes, to die well. Chronic care is an important public health issue due to populationageing, the increasing number of older people in most societies and insufficient attention totheir complex needs.

Figure 9 Separating acute and chronic care services in Moldova

Source: Sanigest Internacional 2013

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Palliative care, a subtype of chronic care, focuses on improving the symptoms, dignity andquality of life of people approaching the end of their lives and on the care of and support fortheir families and friends. This topic is often neglected, although it is relevant to everybody.In the past, palliative care was mostly offered to people with cancer in hospice settings. Itmust now be offered more widely and integrated more broadly across health care services.

6.1. Changing disease patterns

Palliative care has traditionally been offered to people with cancer, but people aged 85years and older are more likely to die from cardiovascular disease than cancer. Bettermeeting the needs of older people in Moldova requires improving and widening the accessto palliative care to include people dying from diseases other than cancer and who havemultiple illnesses. Designating infrastructure within health care facilities is one of the initialsteps in improving palliative care within the country. Other countries such as Germany haveestablished national benchmarks for the number of beds to be included within their longterm care facilities dedicated to palliative care-Table 24.

Table 24 Palliative Care in Germany 2011

Beds within PalliativeCare Unit(Department)

Germany 2.43Source: Sanigest Internacional

6.2. Complex needs in chronic care

Older people reaching the end of life frequently have multiple debilitating diseases (such asdementia, osteoporosis and arthritis), and they often do so over longer periods of time. Forexample, studies have shown that one quarter of the people aged 85 years and older havedementia. They may therefore have palliative care needs at any point in the illnesstrajectory and not just the terminal phase. As such, palliative care should be integrated intochronic disease management. With non-malignant disease, the point in later life at which“really sick becomes dying” can be much more difficult to determine. In many Europeancountries such as France-Table 25, care homes (nursing or residential homes, aged or long-term care facilities and continuing care units) play an increasing role in caring for frail olderpeople at the end of life. For example, in England, 17% of the people older than 65 yearswho die each year do so in a care home . The number of older people dying in care homes isalmost certain to increase with the ageing population of Moldova.

Table 25 Palliative care in France 2007

Number ofMobile Teams

Number ofPalliative Care

Units

Beds within Palliative Care Unit(Department)

0.45 0.12 0.99Source: Sanigest Internacional

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Many older people who move to care homes acknowledge these as a last resting placebefore death. Many develop palliative care needs. Specialist palliative care services may berequired for a small number of residents, whereas general palliative care is appropriate forall residents regardless of their diagnosis. When they die, they are likely to have lived withmultiple, often-disabling chronic conditions over a long period of time. Common diagnosesinclude: stroke, cardiac failure, chronic obstructive pulmonary disease, Parkinson’s diseaseand dementia. There are also high levels of impaired cognition, sight and hearing.

Many residents experience pain, which is often not well treated and sometimes not treatedat all. However, the assessment of pain can be complicated by cognitive and sensoryimpairment. The losses experienced by some residents (such as the loss of their homes andindependence) can result in a loss of their sense of dignity. Initiatives to improve palliativecare in care homes include: the work of clinical nurse specialists, the use of hospice beds incare homes, education and training, the use of link nurses and quality initiatives such asdeveloping guidelines and standards for providing palliative care in care homes6.3. Integrated care pathways

Chronic care centres will have to work in coordination with acute care centres for a numberof reasons. Patients whom encounter severe complications seen at CC will be translated atthe inter-rayon level for immediate care. At the same time, patients discharged from theacute setting will in some instances transition to CCCs for long term care as seen in thefigure below. A clear and integrated care pathway will ensure that this transition issuccessful.

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Figure 10 Patients are seen at the level of care they need


Care pathways are structured upon multidisciplinary care plans that detail essential steps inthe care of people with a specific clinical problem and describe their expected clinicalcourse. They can provide a link between the establishment of clinical guidelines and theiruse, can help in communicating with the people who need care by giving them access to aclearly written summary of their expected care plan and progress over time, and will helpset a clear treatment path for health care providers at both the CCC and acute setting. Carepathways will help promote teamwork and patient-centred care.

Such care pathways for palliative and end-of life care have been developed in severalcountries, including for inpatients and oncology units in the United States of America and inother settings .6.4. Long term care

Long term care is for the whole person, aiming to meet all needs – physical, emotional,social and spiritual. At home, in day care and in the CCCs, they care for the person who isfacing the end-of0life and for those who love them. Staff and volunteers work inmultiprofessional teams to provide care based on individual need and personal choice,striving to offer freedom from pain, dignity, peace and calm.

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6.5. End-of-life care

End-of-life care may be used synonymously with palliative care or long-term care, with end-of-life understood as an extended period of one to two years during which thepatient/family and health professionals become aware of the life-limiting nature of theirillness. The term ‘end-of-life care’ is widely used in North America and it has been picked upby regulatory bodies in European countries, sometimes with the understanding thatpalliative care is associated predominantly with cancer, whereas end-of-life care would beapplicable to all patients. For example, in England, the NHS End of Life Care Strategy waspublished in 2008 to improve dying for all patients wherever they receive care.

End-of-life care may also be understood more specifically as comprehensive carefor dying patients in the last few hours or days of life. End-of-life care in the restricted timeframe of the last 48 or 72 hours of life is the goal of the Liverpool Care Pathway for theDying Patient. This approach has been promoted to transfer the hospice model of care topatients dying in non-specialised settings. Used with this connotation, end-of-life care mayalso be implemented as a standard of care for dying patients not requiring palliative care.Considering the ambiguity of the term and the degree of overlap between end-of-life careand palliative care, no specific reference will be made to end-of-life care in this paper.

6.6. Terminal care

Terminal care is an older term that has been used for comprehensive care of patients withadvanced cancer and restricted life expectancy. More recent definitions of palliative careare not restricted to patients with restricted life

6.7. Supportive care

Supportive care is the prevention and management of the adverse effects of cancerand its treatment. This includes physical and psychosocial symptoms and side-effects acrossthe entire continuum of the cancer experience, including the enhancement of rehabilitationand survivorship. There is considerable overlap and no clear differentiation between the useof the terms ‘palliative care’ and ‘supportive care’.

However, most experts agree that supportive care is more appropriate for patients stillreceiving antineoplastic therapies and also extends to survivors, whereas palliative care hasits major focus on patients with far advanced disease where antineoplastic therapies havebeen withdrawn. However, a national survey in Germany has shown that 9% of the patientsin palliative care units received chemotherapy.

Cancer survivors would not be included in the target groups of palliative care. On the otherhand, palliative care covers not only cancer patients, but also other patient groups with life-

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threatening diseases. Supportive care should not be used as a synonym of palliative care.Supportive care is part of oncological care, whereas palliative care is a field of its ownextending to all patients with life-threatening disease.

6.8. Disease stage

There is no predefined time point in the course of the disease marking the transition fromcurative to palliative care. Palliative care is appropriate for all patients from the time ofdiagnosis with a life-threatening or debilitating illness. The term ‘life-threatening ordebilitating illness’ here is assumed to encompass the population of patients of all ages witha broad range of diagnostic categories, who are living with a persistent or recurringcondition that adversely affects daily functioning or will predictably reduce life expectancy.

Most patients in Moldova will need palliative care only with far advanced disease, but somepatients may require palliative care interventions for crisis management earlier in theirdisease trajectory. This can be a period of several years, months, weeks or days. Thetransition from the acute setting in Edineţ to CCCs will often be gradual rather than a cleartime point, as the treatment goal shifts more and more from life prolongation at all costs topreservation of quality-of-life, with a need to balance between treatment benefit andburden.

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7. Governance issues

The regionalization strategy will bring with it a significant change within the northern regionwhich will involve shifting not only services but also patients, doctors, nurses, and all cadresof healthcare professionals. Sanigest recognises that this requires a shift of mindset, and apotentially difficult process of accepting that diverse and innovative approaches mustreplace traditional “blueprints”. However, Sanigest is equally clear that only local innovationcan provide sustainable solutions to the provision of local hospital services for the northernregion. It will therefore be crucial that a strong governing mechanism be set in place to helplead the way through this transition. A solid governance structure will ensure that all partiesinvolved in the transition are provided with a clear and visible path toward a bettertomorrow for healthcare services in the northern region.

Over the past few decades, health authorities not only in Moldova by in many Europeancountries have shown little evidence of their ability to anticipate such changes, prepare forthem or even adapt to them when they have become an everyday reality. This is worryingbecause the rate of change is accelerating. Globalization, urbanization and ageing will becompounded by the health effects of other global phenomena, such as climate change, theimpact of which is expected to be greatest among the most vulnerable communities living inthe poorest countries. Precisely how these will affect health in the coming years is moredifficult to predict, but rapid changes in disease burden, growing health inequalities anddisruption of social cohesion and health sector resilience are to be expected. Public-healthinterventions to remove the major risk factors of disease are often neglected, even whenthey are particularly cost-effective: they have the potential to reduce premature deaths by47% and increase global healthy life expectancy by 9.3 years 64,66.

For example, premature tobacco-attributable deaths from ischaemic heart disease,cerebrovascular disease, chronic obstructive pulmonary disease and other diseases areprojected to rise from 5.4 million in 2004 to 8.3 million in 2030. Community governance hasbeen shifting away from direct democracy of locally elected community boards towardengagement through various other mechanisms such as information sharing andconsultation, and by the establishment of community advisory committees, councils orgroups. From the perspective of governments, devolved authority to regional structures andthe encouragement of citizen participation in planning and priority setting through thesevarious means is seen as moving healthcare closer to communities.

The concept of ‘governance’ refers to a shift from a hierarchical mode of organisation,usually associated with the term government, to forms that are based on networks andcollective action. States with a more regionalised framework co-ordination can beaccomplished through the use of national-regional agreements with varying levels offormality and legal status. Formal contracts detail projects to be jointly financed betweenthe centre and the region and involve a thorough process of consultation.

However, an important challenge for this system is to ensure that the limited strength of theregions in comparison to the centre (for instance in terms of financial competence) does notconstrain their input into negotiations. Voluntary agreements, where legal rights and

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obligations are absent, can provide flexibility where a system is moving from old to newmodels of governance.

Table 26 Advantages and disadvantages of different governance structures

Advantages Disadvantages

Separate hospitalgovernance

better servicecoordination

cleareraccountability

localresponsiveness

delivery of servicesby professionalswith decision-making

somewhatremoved frompolitical influence

services can beprovided usingmore professional

expertise than maybe available to themunicipalgovernment

increases the risk ofconstituencies emergingto defend sector interests

although special rayonsmay work to coordinateindividual services acrossboundaries, they are notsuitable for achievingoverall regionalcoordination

New regional healthauthority

more streamlineddecision-making

they could also facilitateinter-municipalagreements to improvethe coordination ofservices such as water,waste management, andtransit


The governance of health is among the core public policy instruments for institutionalizedprotection and redistribution. In modern states, governments are expected to protecthealth, to guarantee access to healthcare and to safeguard people from the

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impoverishment that illness can bring. It will therefore be crucial to set a strong governingmechanism at the regional level within the north led by either the MoH, a regional board, ahospital board, or a strong collaborative hybrid of these options.

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8. Strengthening services

The response of the health sector and societies to the challenges such as transitioningburden of disease and shifting levels of care has been slow and inadequate. This reflectsboth an inability to mobilize the requisite resources and institutions to transform healtharound the values of primary health care, as well as a failure to either counter orsubstantially modify forces that resist change, namely: a disproportionate focus on specialisthospital care; fragmentation of health systems; and the proliferation of unregulatedcommercial care.

Primary Care Networks (PCNs) are considered a basic building block for the primary caresystem of the future for Moldova. The majority of PCNs are functioning well in terms ofproviding accessible, good quality, team-based healthcare. They are seen as innovative andas having played a major role in getting the northern region ahead of the primary care curveacross Moldova.

Quality improvement needs to be an integral part of “the fabric of primary health carepractice”, consistent with the Triple Aim objectives of: better health, care, and value. Thisrequires the development, tracking and reporting of meaningful metrics. There is aconsensus among stakeholders in Moldova on the need to focus on results. The “nextgeneration” of primary healthcare clinics and practitioners, for example, need to provide:enhanced linkages and partnerships with other community services, fully interoperableelectronic patient records, formal attachment of patients, enhanced illness prevention andhealth promotion, a broader team mix of health and social service providers working to fullscope of practice.

The service delivery reforms advocated by the PHC movement aim to put people at thecentre of healthcare, so as to make services more effective, efficient and equitable. Healthservices that do this start from a close and direct relationship between individuals andcommunities and their caregivers. This, then, provides the basis for person-centeredness,continuity, comprehensiveness and integration, which constitute the distinctive features ofprimary care. Table 27 summarizes the differences between primary care and care providedin conventional settings, such as in clinics or hospital outpatient departments, or throughthe disease control programmes that shape many health services.

Table 27 Aspects of care that distinguish conventional health care from people-centred primary care

Conventional ambulatorymedical care in clinics oroutpatient departments

Disease control programmes People-centred primary care

Focus on illness and cure Focus on priority diseasesFocus on health needs

Relationship limited to themoment of

Relationship limited toprogramme

Enduring personal relationship

Consultation ImplementationEpisodic curative care Programme-defined disease

controlComprehensive, continuous andperson-

Interventions centred care

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Conventional ambulatorymedical care in clinics oroutpatient departments

Disease control programmes People-centred primary care

Responsibility limited toeffective and safe advice to thepatient at the moment ofconsultation

Responsibility for disease-control targets among thetarget population

Responsibility for the health of allin the community along the lifecycle; responsibility for tacklingdeterminants of ill-health

Users are consumers of thecare they purchase

Population groups are targetsof disease-controlinterventions

People are partners in managingtheir own health and that of theircommunity


8.1. Improving transportation to improve access

Transportation within the northern region has seen significant improvements within the lastdecade both for health services and civilians but there is still room for improvement. Themost common problems include poor public transport, inaccessible services, parking issues,limited access to specialist transport services for those with social needs, and underresourced rural transport services. People who are socially excluded may be experiencing anumber of factors that in themselves have a negative impact on gaining access to healthservices. These may include low income, disability and age coupled with poor transportprovision or services sited in inaccessible locations. For example, 14% of adults have aphysical disability or long-standing health problem that makes it difficult for them to go outon foot or use public transport. This rises to over 70% among people who are over 85 yearsold. The main reasons why people cannot access health services are:

Availability and physical accessibility of transport

Cost of transport

Inaccessible location of health services

Services delivered at times which reduce the opportunities for patients to attend

Safety and security

Travel horizons – people on low incomes travel shorter distances from home

Historically in Moldova there has not been a cross-government approach between allministries to tackling patient access to health and other services. Consequently, publicservices have not been encouraged sufficiently to work together to increase accessibility byimproving the location, design and delivery of services. Public funding for patient access tohealth services has been disjointed and often lacked any coordination. It has included avariety of funding streams for provision of mainstream local transport services, funding forambulance services as well as separate funding for social services and education transportservices.

The regionalization strategy in future years should commit to better patient access tohospital services by reviewing and improving all ambulance, medical retrieval and patientand staff transport services – as well as financial assistance schemes relevant to healthrelated travel such as:

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Developing transport plans for new inter-rayon site

Introducing transport plans to existing CCC sites

Developing integrated public sector transport services– including health, education,social services and ambulance services

Bus service developments

Tram and rail services

Improved park-and-ride facilities

Improved walking routes

Improved cycle routes

Taxi schemes

Parking schemes

Improving community transport provision (including voluntary driver/car schemes)

Linking timing and booking of Edinets services with public transport provision

Roadside improvements, bus shelters and lower pavements at transportinterchanges at Edineţ sites

Information provision about, and promotion of, northern region-related transport

Reduced fare schemes.

Experience of improving patient access to health services at the rayon level has highlightedthe need for:

Coordinated local research to understand access needs

A focus on reducing the need to travel to Balti and Chisinau sites as well as improvingtransport access

Effective transport and health partnerships with identified inter-rayon contacts towork with local authorities and other partners

Joint commissioning and provision of resources of transport services to the MoH,linked to the broader integration of public and specialist transport services in thearea

Development of local indicators and targets to track improvements in access toservices.

Electronic tracking systems and other technologies can be used in other processes as well. Inthe United Kingdom, St. Vincent hospital installed a patient transportation softwareprogram which allows nurses to make patient transport requests electronically. Before

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making the request, nurses can see how many requests are already in the system, and theymay choose to discharge the patient themselves to avoid bottlenecks. Such strategies couldbe adopted within the newly devised health care network in the northern region.

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9. Nomenclature transition

Changing the existing nomenclature to one that better reflects the new proposed serviceswithin the acute as well as the chronic centres will be crucial. In order to maximize usage ofexisting infrastructure, the current hospital in Edinets would form part of the newlyestablished CCC network functioning as a CCC as those in Briceni, Donduseni and Ocnita.Current practice of operating with satellite hospitals will be reorganized. Through the initialassessment highlighted in the previous report it was found that satellite hospitals do needto meet the need-demand criteria established by international standards at the operationallevel. The closing of these facilities will result in clear saving of financial as well as humanresources due to the consolidation of health services. The satellite facilities (organizationallypart of Rayon Hospitals) are to be closed in the northern region, such as the branch ofBriceni Rayon Hospital in Lipcani.

The following tables represent the current and proposed Nomenclature for both the inter-rayon hospital in Edineţ as well as the hospitals in Briceni, Donduşeni and Ocniţa. It shouldbe emphasized that proposals need to be reinforced by CNAM in the contracting process.

Table 28 Nomenclator for Rayon Hospitals in the four rayons northern region

Current Nomenclature

CodulIMSP

Unitateaadministrativteritorială

DenumireaIMSP Profil pat

1575 BriceniIMSP Spitalul

raionalBriceni

General medicine

SurgeryObstetrics andGynaecology

PaediatricInfectious diseases

1579 DonduşeniIMSP Spitalul

raionalDonduşeni

General medicine



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Current Nomenclature

1586 OcniţaIMSP Spitalul

raionalOcniţa

General medicine



1572 EdineţIMSP Spitalul

raionalEdineţ

General medicine




Proposed Nomenclature

CodulIMSP

Unitateaadministrativteritorială

DenumireaIMSP Profil pat

1575 BriceniIMSP Spitalul

raionalBriceni

Long term care

Rehabilitation

1579 DonduşeniIMSP Spitalul

raionalDonduşeni

Long term care

Rehabilitation

1586 OcniţaIMSP Spitalul

raionalOcniţa

Long term care

Rehabilitation

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Proposed Nomenclature

1572 EdineţIMSP Spitalul

raionalEdineţ

General medicine



Neurology

Neurology Cerebrovasculardisease

Haemodialysis

Cardiology/Interventional cardiology

Traumatology/Orthopaedics

UrologyOphthalmology

RadiologyEndocrinology

ENTGastroenterology

RheumatologyLong term careRehabilitation


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10.Change management

Change is a fundamental component of continuous quality improvement. Any improvementmethodology involves introducing change and measuring its impact. In the northern region,there has been a recognized need for system change to support the delivery of safe andhigh-quality care. Awareness of the range of reactions to change will help the healthcaremanager responsible for the change process to respond appropriately to the expressedconcerns. Understanding the reasoning behind these reactions may assist the manager tointroduce change in a manner that anticipates, acknowledges and responds to concerns. Asdepicted in figure 11, the change management process involves a continuous flow ofinformation through the entire process.


Staff may:

• not be aware of the reasons why change is necessary

• feel that there are other more important issues to be dealt with

• not agree with the proposed change, or feel that there is a better way toachieve the outcome

• disagree about how the change should be implemented

• feel there is a criticism about the way they do things implied in the changeprocess

• feel that they have done this before and nothing changed

• feel that there will be extra work for them as a result of the changes

Figure 11 Change management components

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Effectively managing the transition from the status quo to the desired regionalization ofhealthcare services for the northern region will involve the integration of several activitiesthat should be carried out in parallel to change management. At the heart of the process ispaying special attention to the existing relationships within the healthcare service structureas seen in figure 12. These relationships include not only patient-physician relationship butalso institutional relationships at the various levels.

Figure 12 The change process and its layers


Change will be more successful in Moldova, and more people will be committed to thechange, if they believe it will improve things. The “What’s in it for me?” test helps to identifyuseful motivators. The best scenario is to have a ‘win-win’ situation, where the changemanagement will have a positive outcome for all. The following list provides helpfulelements that can be used to relay this message:

• Have a defined communication strategy

• Be consistent about sharing information

• Consider using a variety of media to reach people

• Involve stakeholders in the planning process

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• Support staff with training and opportunities to practice

• Listen and act on questions, feedback and concerns

• Celebrate ideas, achievements and successes

• Have a clear reason for implementing change

• Have a shared vision about what the change will achieve

• When developing strategies, consider the barriers to implementing changeand cater for them within the strategy development

• Remember that resistance is a natural response to change that is introducedby somebody else

• Identify the change champions, the innovators; these are the people who willbe prepared to introduce change

• Be aware of the different rate of uptake of change

One of the key elements for enabling “system reform” will be the creation of incentives thatenable hospitals to work collaboratively to develop new approaches and solutions inresponse to inter-hospital system reform. Increasingly, northern rayon leaders will needsupport in developing solutions which may involve significant reconfiguration andnetworking of services across organisational boundaries, the latter of which may currentlybe perceived as a “loss” to a particular organisation.

Basic amenities like residential quarters, family services like day care and safety are pre-requisites for the incentive scheme to be of any value. These needs have to be ensured.There should be timely disbursal of the funds for the scheme and payments made regularlyevery three months. Lack of this leads to amotivation which is difficult to get back.

Non-financial incentives have been found to be important to encourage smooth transitions.These include professional support, possibility of a promotion, subsidy for further educationand some preferential treatment by the government in the form of loans and post-graduateeducation. It was also found that some community services supporting family membersliving with the personnel would also motivate them to stay at the rural level rather thanmere financial incentives alone.

There is a need for good governance oversight to ensure that medical personnel do notclaim the incentive without staying at the rayon area. Frequent visits to address theirconcerns as well as to ensure that they stay would make sure that the incentive scheme isnot misused.

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Staff who are posted to the rayon level and function well, should be recognized andawarded by the system as a form of positive re-enforcement. Although these incentiveschemes have been introduced with the good intention of increasing health personnel inremote areas, implementation will only happen if solid infrastructure is in place. Thesefacilities should be reviewed regularly and feedback from the staff obtained to ensure thattheir basic needs are met.

Incentive programs should be developed in order to encourage the relocation of existingphysicians and attract new ones as well. A number of incentive programs have beenintroduced at the international level including subsidies for locum travel costreimbursement and the specialist locum subsidy in Canada. Other countries have seen theimplementation of locum programs for rural doctors to give them adequate time for rest,established housing, and professional development as well. Other incentives such assubsidized transport and rural placement for training physicians are discussed elsewhere inthis report.

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11. Public Private Partnerships Discourse and Strategy

11.1. Project Description

The proposal is to commission, develop, procure and deliver a new, inter-district hospital inEdinets, Moldova. In the following chapter, Sanigest presents an Illustrative modelhighlighting how a real Public Private Partnership (PPP) could work for proposed inter-rayonEdinets hospital. A further full modeling would be required at a further stage as a feasibiltiystudy to verify assumptions presented within the model.

The service model for this new hospital covers four major service groups; clinical services,clinical support services, non-clinical support services, and administrative services. Theproposed services under each major service group are thus:

Clinical Services; Outpatients Department Day Surgery Haemodialysis Accident & Emergency Inpatients – General Medicine, Paediatrics, Surgery & Trauma, Maternity Obstetric & Gynaecological Unit Surgical Suite Stroke Unit Rehabilitation

Clinical Support Services; Imaging Laboratory Pharmacy Central Sterile Supply Department Physiotherapy & Rehabilitation

Non-Clinical Support Services; Dietary Materials Management Environmental Services; Laundry, Linen and Housekeeping Waste Management Engineering & Maintenance Transport Mortuary

Administrative Services; Management: Human Resources, Finance, Nurse Administration, Admissions, Quality

Assurance and Safety

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Procurement Medical Records Training & Education Security

It is anticipated that the hospital would be developed in two phases; Phase I would see 124beds delivered, with an additional 120 beds in Phase II.

11.2. Current Scope

The proposed service model for this hospital appears to be well aligned to modern,established and developing international models of care, which are seeing a migration awayfrom secondary care to primary care, with the consequent provision of non-urgent medicalservices in the heart of the community. This is recognised as international best practice andhas been referred to as care to the patient, rather than patient to the care. It puts thepatient at the heart of health service delivery, using integrated care teams and ultimatelyaims to provide every single patient with his / her personal healthcare plan.As models of care develop rapidly, it can often be the case that a facility that is modern andfit-for-purpose on opening can be out-of-date and unsuitable within a number of years,certainly before the building has outlived its physical value. In order to protect the facilityagainst this service redundancy, it is essential that the proposed development is futureproofed. This is achieved by introducing flexibility into the design and also importantly intoany longer term service contracts or agreements. The PPP model, in addition to providingthe finance for the project and managing the risks of delivery, can also satisfy both of theserequirements.

11.3. A PPP Rationale

PPP is often thought of simply as a means of financing a project when the capital costs arenot affordable by the public authority within current budgetary limits. Whilst this may thecase in Edinets, it should not be the only deciding factor.PPP cannot make a bad project into a good one and it is not free money. The costs need tobe repaid over a long period with interest at a rate that is always more expensive thangovernment bonds. Investors will expect a return on their investment and lenders willrequire certain collateral assurances that they will get their money back. Therefore thereneed to be other reasons to justify the additional costs of finance.

PPP was developed in order to address a number of significant problems encountered usingtraditional procurement. These were, inter alia: little or no risk transfer from the publicsector commissioner to the private sector provider, serious cost and time overruns whichsaw assets delivered years late and many times their original budget, interface issuesbetween all the contracted parties required to develop a major piece of infrastructure and

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construction companies that would build to bare minimum standards and walk away,leaving all of the lifetime risks with the public authority.Public authorities too also tended to avoid or ignore crucial maintenance issues related tothe physical assets due to them either not having the money or simply that such matterswere not a priority. To overcome these problems, an integrated, risk sharing, Whole of Lifeapproach was adopted through PPP.It is difficult to raise private finance for a project, however the high level of discipline andproject management skills required to conclude such a project, tend to ensure the quality ofthe end product. Therefore although the preparation phase of the project may take longer,it is usually for good reason and usually pays off with on-time implementation and overallbetter efficiency during the lifetime of the operation.

Post construction and for consideration at the operational stage, one of the fundamentalquestions facing health project commissioners is, do they want to own and maintainbuildings, or instead concentrate all of their efforts in the provision and management ofmodern healthcare services?For example, in the case of medical equipment such as a scanner; does a commissionerwant to have to buy, maintain, repair and replace highly sophisticated and technicalmachinery, or would the commissioner rather pay a supplier to do all of the difficult workand simply only pay for the availability of the scanner? When the scanner breaks down,does a commissioner want to have to try and find a specialist to replace it, or simply havethe contracted provider replace the faulty scanner with a new one?

A further key consideration in healthcare project is to decide which elements of serviceshould be delivered by public sector employees and which should be outsourced to privatecontractors. These decisions vary from country to country and even within countries theyvary from project to project but importantly decisions need to be taken at a relatively earlystage of the project development in order for an appropriate business case to be developed.

11.4. Strategic and Project Specific Risks

In considering the approach taken to the further development of this project proposal, thecommissioners and procuring authority should consider the points discussed below, beforefinalising the project’s implementation plan.

The following section describes the risks that might be ascribed to PPP procurement that arenot related to specific projects but should be of generic concern to governments and publicauthorities considering adopting a PPP form of procurement.

11.5. Political Support

A successful project generally requires a project sponsor at a senior political level, at asenior public sector official level, and at a senior clinician level. These individuals help theproject delivery team to overcome obstacles during the different phases of development,

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procurement and delivery. The political sponsor often helps to communicate the benefits ofthe project and to allay any concerns within the local community. The senior public officialcan help to overcome the inevitable bureaucratic barriers that present themselves in such aproject. The sponsor clinician helps to ensure that all of the professionals and practitionersbuy into and continue to support the project.

High level support is essential in order to realize a PPP project in any sector. Without it theproject will struggle and probably fail. Private sector parties from funders to operators willwant to see evidence of this support before they commit to the substantial costs and humanresources involved in a bid.

This support needs to exist within the national government, within the Ministry of Healthand the Ministry of Finance and within their local equivalents. Stakeholders need to beconsulted about the rationale for a project and their broad agreement should be sought.Again private entities will need to see evidence of such stakeholder engagement. This is amatter of credibility. In the case of a healthcare project, stakeholders as an entity wouldinclude clinicians and other healthcare workers as well as citizens groups and civil societyorganisations with an interest in public health. Public perception towards PPP is similar inmany countries with economies in transition, where its adoption is at an early stage. It canwrongly be perceived by those new to it, as privatisation, which can lead to resistance to itsimplementation within communities. A public awareness campaign, simply setting out theneed and the available options would help to overcome this matter and ensure basic publicacceptability and sufficient political support.

11.6. Funding Sustainability

Availability of funding into the medium and long term is vital i.e. central and sub-nationalgovernment budgets. This is especially important in the case of a PPP solution, which wouldrequire the Ministries of Finance and Health to recognise and commit to long term on-goingpayments to a private sector partner. Funders will require substantial comfort in thismatter. In the case of the first healthcare project in the UK, the government had to changethe law allowing financial commitments made in a longterm contract to take fundingprecedence, in order to give lenders sufficient comfort.

Lenders will want to know not ‘if’ they will get their money back, but ‘when’ and ‘how’ theywill get their money back. They will state the terms on which they are prepared to lend andwhat securities they require in addition. First and foremost they need to be fully convincedthat the flow of revenues can cover the debt service and the principal repayment, even at a‘worst case scenario basis’. This is one of the main reasons why lenders prefer the reliabilityof payments made on the basis of availability rather than the much more unpredictable‘user pays’ model that is susceptible to demand fluctuations.

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Additionally lenders will seek security over the project cash flows and indeed will require acontractual commitment for ‘Step-in Rights’ in the event that the private company starts toget in to difficulties or is unable to meet its own obligations to the public authority.In many cases, lenders will also seek a sovereign guarantee to cover the debt. It can havethe effect of reducing the cost of the loan and therefore reduce the overall costs of theproject. However this is a choice for the government to make as it would almost certainlyhave to be recognised as part of the national debt. See the section below on Fiscal Risk.

11.7. Fiscal Risk

It is perhaps clear with healthcare PPP projects that on-going liabilities will be incurredthrough an obligation to pay the Unitary Charge as long as the project is ‘Available’.When the subject of risk is raised with private bidders in the context of PPP, the discussionturns immediately and often entirely to the subject of project risk: the risks contained withinthe project itself and usually only from the perspective of the private sector. Commonlythese are issues such as construction risk, operational risk and future regulatory risks. Theseare all important issues as they have a profound bearing on the pricing of the debt andequity in the project and therefore the ultimate likely cost of the project to the governmentand to the user of the services. Importantly these project risks are risks of principle concernto the investors and lenders.However; often overlooked are the risks that should naturally concern governments andsub-national entities. They are perhaps overlooked because not surprisingly they are rarelyraised as issues by the investors.

Quite often when PPP projects are being negotiated, experienced and sophisticated privatesector investors can persuade the commissioners to reduce the risks in the project for theprivate company by, for example providing a guarantee against the senior debt of theproject in exchange for more favourable pricing on services or other fees to be charged foruse of the asset. Whilst this is true (as the level of perceived risk in the project diminishes,so too should the cost of raising and servicing that debt) it is not a true reflection of thereality. In effect, the private company is seeking to either transfer the risk to thegovernment wholly or in part. Therefore in the event that the project company finds itself infinancial difficulties and defaults on its loan used to finance the project, the lenders mayseek recourse from the government.

Whilst it is not wrong for governments to consider and even accept such risk transfer, if itcan be shown to be good value to do so, it is wrong to ignore the potential consequences ofthese risks and pretend that contingent liabilities do not exist as a result. The value of theunderwritten loan may even appear on the government’s accounts as ‘national debt’. Fulldisclosure and transparency is therefore necessary. Not only is this good practice, it will alsoassist budget officials to prepare future budgets with greater knowledge of the non-discretionary commitments contained in PPP contracts that it may be called upon to make.The real risk therefore lies within un-managed fiscal risk.

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Additionally there are a number of contractual clauses that may lead to the realisation offiscal risk.Shown below are the main types of instruments that can create fiscal risks:

State Guarantees on the debt raised against the project Minimum Revenue Guarantee System Clauses that require the State to buy back the assets in the event of termination

at either ‘market value’ or write down value. These values can be verysubstantial. All PPP contracts have clauses that provide agreement on theconditions and means by which the contract may be terminated. All Terminationclauses in PPP contracts have the potential to incur fiscal risk, some substantially.

Other asset ‘Buy Back’ clauses

11.8. Lack of Implementing Capacity in the Public Sector

Public authorities in most countries have a deficit in the capacity that would allow them todevelop, procure, and deliver large scale infrastructure projects.Since PPP projects are entirely governed by the ‘Project Agreement’ and the associated(many) financing documents, the way in which risks are apportioned is a matter for highlyskilled and experienced negotiators.That is why countries which have little experience of the subject put themselves at riskwhen faced with highly experienced and motivated private sector counterparts. It is rarely anegotiation conducted between equals. Employing the skills of a professional projectmanagement company to act for the commissioning authority could resolve this issue,although it would add 2-3% to the capital costs of the project.

11.9. Legal Framework

Given the existence of the PPP Law , there would appear to be few legal impediments to theadoption of a PPP solution. This appears to allow for step in rights and for independentdispute resolution. Crucially the law is not restrictive in defining the types of PPP that maybe allowed. This therefore allows the flexibility for any hybrid model of PPP to be developedand any of the options discussed in Section 5.2 appear to be possible. The 2011 EBRDassessment of the quality of the PPP legislation and of the effectiveness of itsimplementation gave Moldova a credible score of 97/135 (or 71.9%) for the quality of thelegislation but only 15/51 (or 32.7%) for its implementing effectiveness. This issue ismentioned at other points in this paper. However a full review of other related legalinstruments would be necessary to be certain.

One issue that needs to be considered is the rather prescriptive time limits for bidders torespond to RFPs (60 days) and for concluding the contract beyond that (30 days). Whilst thisis onerous, it is not impossible if the correct procurement strategy is chosen. This situationmay lend itself to a form of Competitive Dialogue as practiced throughout the EU. Careful

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conduct of this procedure is required in order to avoid legal challenge and is betterconducted through the guidance of an objective outside consulting firm. See Section 7.

11.10. Domestic Market Capacity

A further strategic risk could be the capacity of the necessary service providers in Moldova,especially in the case of a PPP solution. Capacity relates to both size and technical capabilityand relates not only to construction companies and facilty management service providersbut also to the domestic investor and lender markets. A market capacity study should beundertaken to determine whether or not sufficient capacity exists within the current localmarket. One solution could be for local companies to partner with capable foreigncompanies.

11.11. Economy and Finance

Donor finance may be possible for a project of this nature since the availability and high costof debt in Moldova is a major strategic risk in the country's infrastructure development. Theinterest charges are very high, typically 18% and the tenor is short, typically no more thanseven years. This could make the implementation of a wholly local PPP solution difficultwithout loan guarantees.The existing scoping paper proposes that 50% of the required capex will come fromgovernment sources, leaving a shortfall of 50%, or approximately €16m. Although oneoption could be to attract the additional required capital from the international donorcommunity, such as USAID, SIDA or DfID, another would be to try to attract private capitalto supplement the public sector finance.It should be noted that private investors would only participate in a PPP project if they wereto have control of the project company. Therefore a government contribution of 50% wouldnot necessarily acquire 50% of control over the project company. It might be better for thegovernment to contribute 45% and invest the remaining finance into project managementand assurance measures that could improve overall impact and value for money in theproject. The government must exercise its influence over the project company through thecontract as a ‘smart customer’ and through effective monitoring and contract managementprocedures.The basic premise of attracting private capital to Moldova for infrastructure developmentcould prove difficult given Moldova’s current high corruption index, which would act as adisincentive to conventional investors. However the political situation in Moldova appearsstable in recent times and this stability would be vital in any future attempts to attractprivate capital.

If a private capital / project finance solution is chosen from the options assessment and costbenefit analysis, the government’s willingness to guarantee or underwrite financing,including the agreed payment mechanism between the procuring authority and the privatesector partner, could reduce the cost of finance by lowering the risk profile and ultimatelymake the project bankable and affordable.

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Funders, like investors will offer loan terms based on the perceived risks of the project. Forthem the key risks are ‘not getting paid on time or in full’ or worse still ‘not getting paid atall’. Therefore they will look at the creditworthiness of the commissioning authority. Thismeans that sub-national bodies such as municipalities and health authorities may appear tolack the substance of national entities such as line ministries.

Funders will also look critically at the parent companies of the project consortium and willdemand ‘Parent Company Guarantees’ so that in the event of a failing in the projectsubsidiary, the payment to the funders is guaranteed by the main company(s).Therefore it is similar with the government side where funders will typically seek the furtherre-assurance of a Sovereign Guarantee – the government equivalent of a Parent CompanyGuarantee. Funders essentially want to move the loan repayment risk to the entity (publicor private sector) with the deepest pockets. Other international parties may also beprepared to play a similar loan guarantee role.

11.12. Project Risks

A clearly defined project budget must be set out in the project business case and agreed tobefore procurement commences. The project scope is also aligned to this budget. The scopemust also be fixed before procurement, to eliminate any extension of the scope bypoliticians, user groups or architects, which can undermine a successful procurement as thescope expands but the budget does not. This is a very real risk to successful project delivery.

One of the key project risks is demand risk. This is where the need or future demand for theplanned services is calculated and forecasted. It is essential that these calculations areaccurate. Otherwise, the facility will be too small, or too large, or in the wrong location, orgenerally not fit for purpose. The needs identification and scoping of demand for a hospitalis a public sector risk and dependent upon the services being commissioned. The servicedesign must be thoroughly developed before any facility is designed. The development mustbe commissioner-led, rather than architect- or design-led.

Risk management in PPP projects involves the following principles: Each identified risk must be accepted by the party best able to manage the risk

or to withstand the burden of the risk materialising For those risks that neither party can manage effectively, insurance is commonly

used to cover the risk (on conventionally procured projects often governmentsself-insure)

Transferring unrealistic risks to the private sector creates a risk in itself Transferring risks to the private sector that it cannot manage will cost more –

they will charge a premium for managing the risk

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‘The risk should be borne by the party best able to manage it or to manage the financialconsequences of it being realised’These words are often quoted in texts on PPP. They are true words but not often fullyunderstood or considered. For example it is often assumed without thought, that all therisks of operational activity should be transferred to the private sector. This implies forexample that private companies can buy energy cheaper than the government. This isusually not the case and it is possible that through this kind of risk transfer, the governmentmight end up paying more through a PPP arrangement. For the same reason ‘demand risk’should not be transferred to the private sector unless there is a substantial element ofdirect user charges / fees / tolls.

Some risks in a PPP project can be readily identified as generic risks whilst some may bespecific to the nature of the project itself.

Similarly some risks in a PPP project can be easily and logically allocated, for example therisk of the construction is quite clearly borne by the construction company as it is theireveryday business – governments do not generally engage directly in construction activities.Another example might be the risk of a change of law that has an adverse effect on thespecific project. This is an area where the government would logically accept the risk sincegovernments make the laws and can therefore influence the risk materialising. Investorsand construction companies do not make laws and cannot manage that risk effectively. Theycould of course manage it by adding a risk premium to the price of the project but since thegovernment is likely to be paying that price, it would be self-defeating for the governmentto transfer that risk.

11.13. Risk evaluation

In the case of all PPP projects, all project related risks must be identified and evaluated, tobe able to make a decision on the best possible risk allocation. Assuming that the risks areallocated to the partner that is in the best position to manage and impact them, the privatepartner will put a price tag (usually known as ‘risk premium') on the risks allocated to himand take them into account for his offer.

The quantitative risk evaluation usually consists of the calculation of the so-called risk value.The identified risks are then prioritized according to the probability of their occurrence andthe expected level of related damages. (Risk value = probability of occurrence (in %) x levelof damages (in %). When the risks can be covered by commercial insurance, the insurancepremium to be paid should be used as a basis for comparison.

The following table gives an overview of the most common risks in PPP Projects and theirdistribution between the Responsible Public Authority and the private contractor. When an‘x’ is shown in both boxes, the risk is shared.

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Table 29 Distribution between the Responsible Risks in PPP Projects

PUBLICRISK

PRIVATERISK

Planning and Building Risks

Site riskGround specifications, i.e. legacies, structure etc.,

and construction quality/existing building don’tcorrespond to the expectations.

X X

Design Risk

The design of the facilities causes implementationproblems.

The design of the facilities cause operationalproblem. s

X

Planning risk

Risk that planning mistakes or new considerationslead to planning changes or new planning.

Mistakes or differences between the originalmaster plan and the work executed.

X

Permittingrisk

The necessary permits are not granted or delayedand granted with additional requirements7. X X

Constructionrisks

During construction qualitative or timerequirements are not fulfilled (Reasons: technicalshortcomings, interface problems, wrong roll out

planning etc.).

X

Risk ofchanges inthe law

Changes in the legal requirements (i.e. fireprotection) during the construction phase. X X

Risk ofAuthoritychanging thescope of theproject

Planning changes on the side of the ResponsiblePublic Authority. X

Insolvencyrisk

Insolvency of the planners or the constructioncompanies. X X

Risk of ForceMajeure

Events like social upheaval or bad weatherdamage which might seriously delay or destroy

the project.X X

Operational and Maintenance RisksRisk of The calculated frequency of maintenance cycles is X

7 Permitting risk is often perceived by bidders as substantial. They will examine what they consider ‘the ease ofdoing business in a country’ and are likely to be heavily influenced in their judgement by publications such asthe World Bank / IFC ‘Doing Business Report’. The way that permitting risk is allocated generally is establishedon which party might be considered at fault. For example, if the private company is slow to deliver technicalinformation it is likely to be at fault. If the delay is purely a result of bureaucratic inefficiency, the privatecompany will seek redress from the government.

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PUBLICRISK

PRIVATERISK

miscalculation, scope andquality ofmaintenance

insufficient to keep up with the standardsrequired by the contract.

The calculated life cycle of the premises does notmaterialise.

The quality does not match the requirements ofthe call for tenders.

Equipmentwear andtear

The equipment’s quality is not up to the requiredstandard and becomes unserviceable before its

planned replacement.X

Costs ofgeneralmaintenance

The costs of maintaining the buildings and otherassets are higher than expected. X

Risk of priceincrease Price increases develop differently than expected. X

Risk ofvandalism Extra work and cost due to damage to the asset. X X

Implementation RisksMiscalculation by theprivatepartner

Uncertainties in terms of costs (material andpersonnel) as well as energy.

The performances quality does match therequirements of the call for tenders.

X

Miscalculation of theResponsiblePublicAuthority’scosts

Miscalculation of the material and personnelcosts covered by the Responsible Public Authority

(i.e. hospital or prison personnel).X

Miscellaneous RisksChange oflaw risk(general)

General or specific changes in legal dispositions.For example changes in taxes or social

contributions.X

Discriminatory change oflaw

General or specific requirements that arespecifically targeted at the project (or maybe

against PPP).X X

Funding risk Risk that the interest rate changes differentlythan anticipated. X

Risk ofsubsequentuse

Risk of subsequent use of the site at the end ofthe contract period.8 X X

Income risk The level of income anticipated does not match X

8 One or the other – rarely shared

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PUBLICRISK

PRIVATERISK

the reality of income received.Source: Sanigest Internacional

A key risk to any construction project is land title (a significant risk in former Eastern BlocCountries) and also the planning consent, including any required licences for theconstruction and operation of the facility. Land ownership and registration must betransparently demonstrated before procurement, especially where a PPP solution may beused. All property matters should be resolved prior to the procurement phase otherwisefunders will not lend. In this case, it is assumed that the land would be provided by the localauthority. The rayon government would have to transfer ownership of the land to theMinistry of Health as founder of the hospital.

Generally, obtainment of outline planning consent, showing the mass and form of thebuilding and access / egress, is sufficient to allow procurement to begin. To do otherwisesimply puts the entire project at risk. It will not be able to insure the hospital or satisfypotential lenders unless all of this information can be clearly provided.

As well as the required skills within the Commissioning Authority, another crucial successfactor is the skills of the Authority’s Project Director and his / her team’s skills. This teamneeds to be able to work with both the public and private sectors and to bridge the gap inbetween. They will need to understand heath service delivery, be able to prepare theproject business case, understand design principles, negotiate with bidders, graspcommercial principles and ultimately be resolute, as this entire process is not without itsdifficulties. The Project Director and the Authority’s team should be supported by aprofessional team of financial, legal, technical, design, ICT and insurance advisors. A majorproject risk is generally where the Authority does not provide sufficient budget for theemployment of these professional advisors and the project is almost certain to fail as aresult.

Another key risk is to defer the appointment of a Contract Manager until after the contracthas been signed. The Project Agreement will contain many nuances and for the public sectorto actually realise its contractual benefits over the duration of the contract, it will need acontract manager who was involved in the development of the hospital and especially oneinvolved in the commercial negotiations.

One of the key risks in a hospital project is Design Risk. Ultimately the CommissioningAuthority should always transfer this risk to the private sector, otherwise any potentiallatent Defects will be attributed by the builder to the Authority and the Authority will beunable to pursue the builder for compensation through dispute resolution. Transfer ofDesign Risk can be achieved in traditional procurement through Novation of the Authority’sarchitect across to the builder. In a PPP, it is automatic with no novation required, as it is thePPP provider that develops the detailed design with user groups.

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Within the design process, in either scenario, it is essential that so-called ‘user groups’ areestablished and commit themselves fully to working with healthcare planners and architectsto develop a solution that works for all. A user group typically consists of clinicians, nurses,allied health professionals, patients, hospital staff, commissioner, medical equipmentprovider and a Facilities Management provider. The clinical and nurse participants need tobe leaders within their own groups, in order to maintain project support and credibility withbidders. Numbers within the user groups should be kept to a manageable level.

11.14. Affordability

Investment cost of proposed Edineţ hospital-The capital investment necessary for a newinter-rayon, or zonal, hospital in Edineţ is based on the cost of construction and equipping a120-bed hospital. The hospital is anticipated to be built over the span of two years with acontracted operation of 25 years .

In order to estimate the total capital investment for the construction and equipment of theproposed new hospital facility, the hospital is assumed to have 120 beds with 145 squaremeters per bed (The Facility Guidelines Institute, 2010; AHIA, 2010). At an average cost ofbuilding of €1,800 per square meter (Turner & Townsend, 2012; 2013), the constructioncost would add up to €31.32 million for the zone hospital.

Table 30 Spatial characteristics of zone hospital

Hospital Number of beds m2 per bed Total construction cost(€ millions)

1. Spitalul raional Edineţ 2. 120 3. 145 4. 31.32In addition to the chosen total amount of investment, the equipment for the Edineţ inter-rayon hospital described above will represent almost 23% of additional capital expenditures,which makes the total investment equal to €38.5 million. The equipment investment of€7.18 million is divided into two disbursements. All estimates can be summarized in Table 2.Annex 5 gives details the equipment required by functional area for the new hospital. Thelist included outlines 80 percent of the equipment, all major categories, estimated for thenew hospital.

Table 31 Total investment estimates for Edineţ

CAPEX (€ mil ) CAPEX (MDL mil)9

5. Building 6. 31.32 7. 512.608. Equipment 9. 7.20 10.117.90

9 All estimates in Moldovan Lei use an exchange rate of 16.3666 MDL/€.

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CAPEX (€ mil ) CAPEX (MDL mil)9

11.Working Capital 12.0.04 13.0.6114.Total Project Cost 15.38.56 16.631.11


Ultimately the preferred option must be affordable. Within a hospital development of thistype, there is almost always a natural tension between long term economic benefit (valuefor money) and short term budgetary pressure. This often leads to disagreement between aMinistry of Health and a Ministry of Finance. In the end it all comes down to what theCommissioning Authority can afford, taking into account potential central governmentbudgetary support.

The key question in the case of the Edineţ hospital project is: Does the Procuring Authorityhave €31.32 million to deliver the facility and € 7.2 million for the equipment? If not, then itwill either have to find the viability gap capital funding from another party, or else spreadthe development cost over a longer period by paying smaller amounts on an annual basis,while at the same time benefitting from the availability of the facility – a form of PPP.

Options for procuring and delivering the hospital under different funding scenarios areconsidered in section 5.

16.1. Project Income / Demand Assumptions

PPP funding would have to come primarily from the Health Insurance Fund. This would needto be guaranteed throughout the life of the loan to a level that funders find satisfactory.The 120-bed hospital is intended to accommodate the demand of over 11,000hospitalization cases a year in the zone. In order to estimate the resulting operatingrevenues and costs, 60% of the cases are assumed be surgical, where 30% are ambulatorysurgery, and 40% of the rest of surgical procedures are expected to be complex.Additionally, 30% of internal medicine cases are day cases. The average length of stay(ALOS) of a surgery is estimated at 5 days for complex procedures, 3 for simpler surgeries,and 5 days for internal medicine, 2 days for normal births, 3 days for C-Sections, which addsup to a total of 22,477 bed days for surgery, 12,967 bed days for internal medicine and3,977 bed days for births. All of these parameters have been programmed separately aspart of the model to allow for different estimates under alternative inputs.

The following table lists the average cost / revenue per type of health service used in themodel, where both out-of-pocket and insurer fees are expected to be the same. Theseprices were based on the current CNAM reimbursements with minor adjustments for futureprice increases and levels of complexity for the new hospital. The prices are still well below

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market prices, and probably well below the actual cost of the services. The prices areestimated to check that the future operating costs are not higher than the current budget ofthe Edineţ hospital, considering additional volumes from the Ocnita, Briceni and Dondusenihospitals that would be moved to Edineţ.

Table 32 Average cost per case (MDL)

Service Cost per case

17.Surgery (highly complex) 18.4,000

19.Surgery (low complexity) 20.2,000

21.Ambulatory surgery 22.2,000

23.Hospitalization 24.840

25.One-day inpatient care 26.252

27.Normal Birth 28.890

29.C-Section 30.1860


It is understood that up to 10% of the potential healthcare customers could be private‘paying’ customers. This could significantly improve the funding viability of the project.However in order for this to count in the eyes of potential funders, a significant amount ofevidence would need to be brought forward. Evidence would need to include the ‘proven’existence of this private patient market, the type of services that they use and how muchthey currently pay for them. Projections that estimate increased usage and/or increasedlevels of payment for these services need to be credible and fully justified otherwise funderswill not allow them to be considered in the credit approval process.

When developing a health facility such as the Edineţ hospital, the project commissionersand authority may wish to consider broadening the scope of the project beyond simplypublic healthcare services. They could, for example, co-locate community, social and familyservices with health services. Also, mental health services should be considered forinclusion. This would help generate additional income from other parts of the budget. Thereis a trend to bundle PHC clinics with the hospitals as well to increase the attractiveness ofthe model. Not only does this offer the potential to integrate public health services on to asingle ‘health campus’ and therefore making the service more efficient for the patients andcitizens, but it can attract the funds reserved for these purposes in to the project andtherefore gain economies of scale.

Appropriate commercial real estate opportunities could generate additional revenue for thefacility. This form of third party income is a successful form of revenue enhancement used

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internationally, whereby the private partner develops additional and appropriatecommercial facilities such as retail, private health services, gymnasium, Well Being spa, etc.The income generated from the commercial development offsets the development costsand / or reduces the Unitary Payment.

Additionally, on many hospital developments some residential accommodation is providedfor key workers such as clinicians and nurses, who may be working long hours or on shiftsand for whom it is not efficient to travel home for short periods of time before returning towork. These are generally apartments and can be rented at commercially viable rates.

Therefore besides operating revenues, the commissioning authorities should consider thepossibility of non-operating income, such as the rental income for retail space, cafeteriaoutsourcing or sale of apartments designated for future staff or health care personnel.Initial estimates consider the rental of 100 units of 60 square meters each, at a cost of 5euro per square meter, which amounts to MDL 5.89 million the first year. Approximately1,000 square meters of retail space, at the same price per square meter, adds MDL 982thousand. These parameters would need to be verified on the basis of a ‘soft market test’(See section 6).

30.1. Procurement Strategy

Appropriate risk allocation will lead to a high degree of market appetite amongst bidders forthe project, leading to competitive tension. It is this competitive tension in the marketwhich drives value for money.PPP solutions generally achieve much higher levels of risk transfer than traditionalprocurement and therefore can offer significantly greater value for money for thegovernment or procuring authority if the job of risk allocation is done correctly.

A PPP solution offers the procuring authority price certainty. The Project Agreement signedat Financial Close is a fixed price contract and cannot be increased other than through pre-agreed indexed inflation rises, usually every year. This price / cost certainty avoids costoverruns and gives the procuring authority the ability to manage and forecast its publicbudget with confidence and accuracy in the delivery of its major projects. This is usuallyimpossible using traditional procurement.

An important aspect of a PPP solution is that it incentivises the contractor to deliver thehospital on time. The contractor does not receive any payment until the hospital has beenfully delivered to the satisfaction of the procuring authority. This point is known as PracticalCompletion (PC). The PC date is agreed by the contractor, the commissioning authority andthe lender (normally the bank or bond holder) at contract award. If the contractor is lateand does not meet the agreed PC date, then it still must begin paying back the lender at thatdate, from its own funds, which is extremely onerous for any contractor, and so thecontractor performs well, ensuring that the hospital is delivered on time and starts to

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receive payment from the commissioning authority in order to avoid the prospect of havingto make payments from its own funds.

Another important difference between a traditionally procured contract and a PPP contractis that the former is based upon the public sector having to manage all of the inputs (‘how’),while the PPP is based upon an output specification (‘what’). In simple terms this meansthat within a PPP, the procuring authority simply has to specify ‘what’ it wants and thentransfers all of the risks about ‘how’ the specification is met, i.e. the delivery risks, over tothe private provider, by way of the contract. Where the provider’s performance fails tomeet the agreed standards, or where the hospital or part of the hospital is not available, asper the contract, then deductions are made to the payment that the private service providerreceives. In this way, the commissioning authority passes the majority of project risks to theprivate sector and incentivises higher performance and greater service compliance of thehospital than is possible through a traditional procurement.

30.2. Procurement Options

The full range of procurement options open to the procuring authority in its procurement ofEdineţ hospital is presented below. They range from traditional methods to a PPP and somehybrid options in between.

The method of procurement is often determined by the level of public capital available. Inthe first options 100% public capital is available.

(i) BuildThis is the simplest traditional procurement model, i.e. a construction contract, whereby theprocuring authority holds a separate design competition, for the detailed design of thehospital, prior to the construction procurement and then novates transfers by guaranteethe agreed design across to the contractor. This does not achieve design risk transfer orconstruction risk transfer and leaves all of the project delivery risks with the public sector.

In this type of procurement, the contractor receives staged payments at agreed“milestones” but often leaves the building at 90% complete because it is too costly to finishthe work and it has already received 90% of the money. The procuring authority then has tohold a second procurement for a replacement contractor, which will cost much more sinceany contractor will add a premium for the risk involved in taking on a part built project.

In traditional procurement, the costs of any latent defects in the building are often neverrecoverable because the contractor is able to blame the design for any defects and will beable to avoid any compensation to the authority. This is called an ‘interface risk’.

The procuring authority then must let separate contracts for the hospital’s operationalphase; facilities maintenance, energy, ICT and all other non-clinical services. This multi

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procurement / multi contract arrangement leaves the public sector trying and often failingto manage a host of interface risks and ultimately sees it holding the vast majority of allproject risks without the ability to manage them. This can be very costly.

(ii) Design & Build (D&B)In this traditional procurement model a contract is let with a company to design the hospitaland construct it. This is usually a better solution than the simple ‘build’ model, as it canachieve design risk transfer for the detailed design, provided that the public sector hasissued a specification in the tender as opposed to its own detailed design, but it still has allof the problems associated with the traditional Build model, including build and walk away,late delivery, cost overruns and interface risks. Again, it can be very costly and representpoor value for money.

(iii) Design, Build, Finance (DBF)This is a hybrid procurement model which adopts some of the aspects of a PPP while using100% capital funding. It achieves design risk transfer, construction risk transfer, on timedelivery and price certainty. However, it still leaves the authority having to manage someinterface risks, albeit fewer than for option (i) and (ii), and having to let and managecontracts for all of the operational phase services such as; facilities maintenance, energy,ICT and all other non-clinical services.

As for PPP, DBF sees the construction company borrowing the project debt finance from alender. The authority, the contractor and the lender then all agree the PC date for thedelivery of the hospital. As previously explained for the PPP model, should the contractorfail to meet the agreed PC date, it is then forced to begin repaying the bank from its ownfunds. This incentivises on-time hospital delivery. Once PC has been achieved, the authoritypays the contractor the full amount of the contract. The contractor then repays the lenderin full and retains the profit. It is the participation of third party finance that makes this100% capital solution so effective regarding asset delivery.

The cost of this model is theoretically slightly higher than the traditional procurementmodel, given the higher cost of private capital compared to public capital, (circa 3%).However, in practice, when the cost over-runs traditionally procured projects can be 40%and higher, the 3% premium that DBF requires appears cheap by comparison and candeliver much greater value for money than options (i) or (ii).

We will now consider procurement options where 100% public capital is not available to theprocuring authority and where it needs to employ private capital and pay for the hospitalover a longer time frame.

(iv) Design, Build, Finance, Maintain (DBFM)DBFM is a full PPP model that sees the authority entering into a long term (25-30 years)single contract with a consortium, called a Special Purpose Company (SPC), for the deliveryand maintenance of the hospital. The SPC again borrows the project debt from a lender but

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this time for a much longer period (years), as the SPC is responsible for service delivery andasset availability during the operational phase. DBFM achieves maximum risk transfer andvalue for money and also reduces interface risks for the public sector to a minimum. Aspreviously explained, under a DBFM, the authority makes regular (quarterly, six monthly oryearly) payments (Unitary Charge) for the availability and performance of the hospitalbuilding. Where the agreed performance and availability standards are not met by the SPC,payment deductions are made. DBFM sees the maintenance and lifecycle budgets for thehospital agreed upfront, so that the hospital will remain in good condition in 15 or 20 years.No other procurement model protects the building as well as a PPP solution.

In a DBFM model, the patients, staff and society can enjoy the benefits of the hospital whilstthey are paying for it, as the full costs are spread out over the contract period of 25-30years. However, the authority must satisfy itself, from the outset and before beginning theprocurement process, that it can afford to meet its Unitary Charge obligations over thatperiod of time.

(v) Third Party Development (3PD)A suitable DBFM model for a project such as the Edineţ hospital is Third Party Development.This is essentially a lease taken out by the authority for up to 25 years. 3PD is a full PPPmodel, whereby there is no upfront capital payment and the authority pays for the hospitalfacilities over the long term.

In 3PD, the authority specifies its facility requirements through a Schedule ofAccommodation. The private sector development company then provides a DBFM serviceaccording to the public sector’s specification. This is a model that is often used in thecommercial property business. Additionally, the developer is permitted to innovate and toadd any other appropriate commercial development to the healthcare facility. As thecommercial customer base, or footfall, is being generated as a result of the public sectorinvestment, the authority shares in the commercial benefit by receiving an on-goingpayment from the developer to offset the public sector’s costs. This is a profit sharingsystem called known as ‘gain share’.

(vi) DBFM with Bullet PaymentDBFM with Bullet is a hybrid procurement model. In this case, where the public authorityhas some but not all of the capital available to it, it can make a once off capital payment tothe SPC at Practical Completion. This serves to reduce the unitary charge payments over thelifetime of the contract, whilst achieving maximum risk transfer. This is a popular andeffective PPP variant. This could work well in the case of Edineţ, where it could make apayment of €16 million at PC and then make smaller Unitary Charge payments over thecontract period.

(vii) Design, Build, Finance, Maintain, Operate (DBFMO)DBFMO is a full PPP model. This is used where the clinical services are included in thecontract. As it is proposed that the clinical services in Edineţ hospital will be provided by the

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public sector, this option can be ruled out, but it could be employed if private sector clinicalservice provision is ever considered in the future. This scheme has the advantage of theintegration of all the services under the contract and there may be efficiency savings to begained as a result. The disadvantage is that such arrangements tend to be unpopular amongpractitioners and the general public, and may make it more difficult to implement.

N.B. In all long term PPP models, the service provision should be market tested andbenchmarked every 5-7 years, to ensure that the authority is not paying too much, or toolittle, compared with rates as at the outset of the operational phase. This is known as gain /pain share and it a feature of risk transfer. In this way it should also be possible to changethe nature of the outsourced services.

The financing for the new hospital can be designed under different scenarios, with acombination of public, private and donor financing. Three options are considered:

Option 1: Mixed PPP. In this scenario, a private operator would build and operate the facilityunder a 25-year concession. Because of the higher cost of private financing, this scenariowould combine a public financing contribution of 10 million euro, availability payments toensure sufficient cash flow, and private financing. Reimbursement would come from CNAM.

Option 2: Donor-PPP financing. Under this scenario, private finance would be combinedwith grant financing from different sources. The estimated grant financing would cover 50%of the capital costs and the remaining financing would be provided by private finance –combination of equity and debt, and availability payments.

Option 3: Pure Public. Under this option, the hospital would be extensively financed bypublic funds. The facility would be done under a traditional procurement and therefore allcosts and risks would be borne by the public sector.

Option 4: Pure PPP. Under this scenario, the private finance of the total project cost wouldbe combined by the availability payments, without additional grants.

The main sources of financing for the construction of the health facility described aboveinclude debt, common share equity from a private and a grant to cover part of the equity.All options that include private debt finance include a 30/70 debt to equity ratio.

The following table includes the terms of the debt considered in this model.

Table 33 Terms of Long Term Debt Financing (MDL)

Term Detail

Interest Rate 11%Loan term 20 yearsGrace period 1 year


30.2.1. Discounted cash flows

As explained above, a 25-year projection was prepared in order to evaluate the net presentvalue (NPV) of the health facility project, comparing the four different scenarios in which the

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financing structure changes. In order to estimate the NPV, the Free Cash Flow for Equity(FCFE) was estimated. This represents the resources available to shareholders after thepayment of debt.

Given that the project is an on-going operation, the perpetuity growth model was used,which includes a terminal value10 in year 25. All cash flows consider a 7% discount rate (DR)and 4% average local inflation rate, except for the prices which are expected to increase at a5% rate and availability payments, which will increase at the same rate as GDP (an averageof 1% per year).

30.2.2. Results

The following table summarizes the cash flows for the project that are available to financiersby subtracting from net income capital expenditures and debt payments, and adding non-cash expenditures to estimate the NPV of the above-described scenarios. In order for theNPV of the project to be positive for private investors, an availability payment is included toensure sufficient return on investment and positive cash flow. Without availabilitypayments, a purely public project, without any debt, would not yield a significant internalrate of return (IRR) (0.2%) and a negative NPV (negative MDL 436 million).

By establishing a minimum IRR of 10%, we can compare Option 1, 2 and 4 which include aprivate investor to design, build and operate the hospital. Over the prescribed period, givena fixed 10% internal rate of return (IRR), the project yields a NPV ranging from MDL 139million to MDL 252 million. A more detailed description of average revenue and costsestimates over a 10-year and 25-year period for each option is included in Table 35.

The following figure illustrates the increase in availability payment amounts depending onthe project's financing. Option 4, with a Pure PPP model in which the government’sinvestment consists of the availability payments and CNAM reimbursements, requires thehighest availability payments given that the private party finances all capital expendituresthrough private debt and equity and therefore faces higher long term loan payments. Thereis a trade-off between the amount financed by the private party and the amount ofavailability payments that the government must pay.

10 Discount rate of 7% and a conservative compound annual growth rate of 2%

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Figure 13 Availability Payments by Option (MDL mil)


Pure Public,0.00

Donor-PPP,26.19

Mixed PPP,42.98

Pure PPP, 61.41

0

10

20

30

40

50

60

70

Pure Public Donor-PPP Mixed PPP Pure PPP

Firs

t Yea

r Ava

ilabi

lity

Paym

ents

(MDL

)

Mill

ions

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Table 34 Equity Cash Flow from project by Option (MDL million)

Year 0 1 2 3 4 5 6 7 8 9 10 … 23 24 25

Option 1Net Income 81.8 82.2 (3.5) 0.8 4.7 8.6 11.3 13.9 16.6 19.2 21.8 … 60.2 62.7 65.3Depreciation - 32.4 29.9 27.7 25.8 24.0 22.4 20.9 19.6 18.4 17.3 9.0 8.7 8.3WKR (1.6) 0.3 (0.4) (0.2) (0.2) (0.2) (0.1) (0.1) (0.1) (0.1) (0.2) (0.3) (0.3) (0.3)CAPEX (352.0) (289.6) - - - - - - - - - - - -NetBorrowing 81.5 43.9 (18.3) (18.3) (18.3) (18.3) (18.3) (18.3) (18.3) (18.3) (18.3) - - -

FCF (190.3) (130.8) 7.7 10.0 11.9 14.0 15.2 16.4 17.7 19.1 20.6 … 68.9 71.0 73.3Terminalvalue … 1332.8

ECF (190.3) (130.8) 7.7 10.0 11.9 14.0 15.2 16.4 17.7 19.1 20.6 … 68.9 71.0 1406.1IRR 10%NPV 193.17DR 7%

Option 2Net Income 176.8 133.1 (15.7) (11.6) (7.5) (3.5) (0.8) 1.6 3.9 6.2 8.5 … 41.0 43.3 45.8Depreciation - 32.4 29.9 27.7 25.8 24.0 22.4 20.9 19.6 18.4 17.3 9.0 8.7 8.3WKR (1.6) 0.3 (0.4) (0.2) (0.2) (0.2) (0.1) (0.1) (0.1) (0.1) (0.2) (0.3) (0.3) (0.3)CAPEX (352.0) (289.6) - - - - - - - - - - - -NetBorrowing 53.0 31.1 (12.3) (12.3) (12.3) (12.3) (12.3) (12.3) (12.3) (12.3) (12.3) - - -

FCF (123.8) (92.7) 1.6 3.6 5.7 7.9 9.1 10.1 11.1 12.2 13.4 … 49.7 51.7 53.8Terminalvalue … 977.4

ECF (123.8) (92.7) 1.6 3.6 5.7 7.9 9.1 10.1 11.1 12.2 13.4 … 49.7 51.7 1031.1

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Year 0 1 2 3 4 5 6 7 8 9 10 … 23 24 25IRR 10%NPV 138.87DR 7%

Option 3Net Income - (27.1) (31.7) (28.1) (24.6) (21.0) (18.9) (16.9) (14.9) (13.1) (11.2) … 11.7 13.7 15.8Depreciation - 32.4 29.9 27.7 25.8 24.0 22.4 20.9 19.6 18.4 17.3 9.0 8.7 8.3WKR (1.6) 0.3 (0.4) (0.2) (0.2) (0.2) (0.1) (0.1) (0.1) (0.1) (0.2) (0.3) (0.3) (0.3)CAPEX (352.0) (289.6) - - - - - - - - - - - -NetBorrowing - - - - - - - - - - - - - -

FCF (353.7) (284.0) (2.2) (0.6) 1.0 2.7 3.3 3.9 4.5 5.2 5.9 … 20.4 22.1 23.8Terminalvalue … 433.1

ECF (353.7) (284.0) (2.2) (0.6) 1.0 2.7 3.3 3.9 4.5 5.2 5.9 … 20.4 22.1 457.0IRR 0.2%NPV (436.16)DR 7%

Option 4Net Income - 11.8 8.5 12.7 16.9 21.1 24.1 27.1 30.0 33.0 36.0 … 80.5 83.2 86.1Depreciation - 32.4 29.9 27.7 25.8 24.0 22.4 20.9 19.6 18.4 17.3 9.0 8.7 8.3WKR (1.6) 0.3 (0.4) (0.2) (0.2) (0.2) (0.1) (0.1) (0.1) (0.1) (0.2) (0.3) (0.3) (0.3)CAPEX (352.0) (289.6) - - - - - - - - - - - -NetBorrowing 106.1 62.2 (24.6) (24.6) (24.6) (24.6) (24.6) (24.6) (24.6) (24.6) (24.6) - - -

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Year 0 1 2 3 4 5 6 7 8 9 10 … 23 24 25FCF (247.6) (182.9) 13.5 15.7 17.8 20.2 21.7 23.3 24.9 26.7 28.6 … 89.2 91.6 94.0Terminalvalue … 1709.7

ECF (247.6) (182.9) 13.5 15.7 17.8 20.2 21.7 23.3 24.9 26.7 28.6 … 89.2 91.6 1803.7IRR 10%NPV 252.32DR 7%


Table 35 Average project revenue and cost per Option (MDL million)

Option 1- Mixed PPP Option 2- Donor-PPP Option 3- Pure Public Option 4-Pure PPP

10-year AVG 25-year AVG 10-year AVG 25-year AVG 10-year AVG 25-year AVG 10-year AVG 25-year AVGCNAM Revenues 38.24 60.00 38.24 60.00 38.24 60.00 38.24 60.00OOP Revenues 6.25 9.82 6.25 9.82 6.25 9.82 6.25 9.82Rental Revenues 8.25 11.45 8.25 11.45 8.25 11.45 8.25 11.45Total Revenues 52.74 81.27 52.74 81.27 52.74 81.27 52.74 81.27Total Availability Payments 45.30 48.92 27.40 29.59 - - 64.28 69.41Total OPEX 49.65 71.02 49.65 71.02 49.65 71.02 49.65 71.02Total Depreciation 23.84 16.55 23.84 16.55 23.84 16.55 23.84 16.55Total Financial Costs (interestpayment) 14.12 8.19 9.47 5.49 - - 18.94 10.98Total Net Income 17.54 34.24 11.42 21.60 (20.75) (6.63) 22.13 46.91EBITDA margin 88% 75% 55% 50% 5% 11% 123% 102%Profit Margin 17% 34% -6% 15% -39% -14% 40% 54%Source: Sanigest Internacional

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30.2.3. Sensitivity analysis

In order to evaluate the sensitivity of the model with reference to the amount of grant andcost, two options are considered that only consider the grant and one general optimisticPPP scenario. In the case of the optimistic scenario, infrastructure cost decreases by half,the increase of the operating cost is only 28% and rental income increases by 30%. In thiscase, a 10% IRR would yield a project NPV of almost MDL 90 million, and would require anavailability payment of MDL 2.1 million the first year.

If the grant amounts to €15 million (MDL 245.5 million), which represent approximately38% of the project cost, the NPV of the project is MDL 161 million, with an IRR of 9.9%. Inthis case, availability payments would have to be over MDL 34 million. With a grantamount of €20 million (MDL 327.3 million), 51% of project cost, NPV is approximately MDL137 million and availability payments decrease to MDL 25.6 million the first year.

30.3. Soft Market Testing

Once the preferred option has been identified and selected, including the preferredprocurement option through standard project appraisal and Cost Benefit Analysis, andbefore procurement commences, it is good practice to carry out a soft market testingexercise.

Soft market testing is where the procuring authority produces a summary document of theprocurement and delivery approach that it is proposing to adopt and then shares it withthe key players in each area of the market, such as contractors / equity, lenders, FMcompanies, legal and financial advisors. The document sets out the salient points aroundrisk, funding / financing and headline contract terms. It then poses a series of questions forthe respondent in each of these areas asking whether or not, in the respondent’s view, theproposed approach is the correct / optimal one. The feedback from the market is thenused to inform the authority the suitability or otherwise of its procurement proposition.

The soft market test is typically carried out by the authority’s advisers and is conducted bythem in order to promote objectivity in the nature of the information exchanged and toprotect the authority from any future accusations of impropriety.

It essentially comprises an interview with potential bidders or service providers based on aset of questions agreed upon with the authority. Questions must be identical for each typeof possible service provider to avoid bias. The interviews can be carried out by telephoneor face-to-face depending on practicalities but it must aim to be as complete as possible.Those service providers that are not interviewed may feel they have been treated unfairly.

The benefits of soft market testing to the authority, if done properly are:• The market feedback represents ‘free consultancy’ and is used to improve theauthority’s proposition

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• Ensures that the final proposition is aligned to available market conditions• Ensures that the final proposition reflects best practice, up-to-date andinternational procurement models• Demonstrates to the market that the procuring authority is a ‘listening’ authorityand liable to make a good long term partner• Warms up the market ahead of procurement• Increases bidder appetite• Increases competitive tension in the market• Should improve value for money

30.4. Procurement Plan

There are a number of different types of procurement procedure that can be used for aproject such as Edineţ hospital. The ones that are compliant with EU rules (and thereforeacceptable to most credible bidders) are:

• Open Procedure: a single stage bid - does not include a qualification stage (RFQ)• Restricted Procedure: a two stage bid that includes RFQ, has a very detailed designand specification and does not allow for innovation or scope changes. This is basically apricing competition for a firmly fixed project scope.• Negotiated Procedure: includes RFQ and selects a Preferred Bidder (PB) at theoutline proposal stage. It permits renegotiation after PB and therefore increasinglydiscouraged by the EU.• Competitive Dialogue: includes RFQ and selects Preferred Bidder at detailed designstage. It only permits ‘clarifications’ after PB and does not permit renegotiation.

If the Edineţ project is selected for a PPP delivery route, it is certain that some dialogue willbe required post-PB stage and therefore Competitive Dialogue might be the recommendedprocedure. Competitive Dialogue (CD) is mandated throughout the EU and adopted bysome countries that have applied for EU membership. In the event that there are no legalimpediments to using this procurement technique, this would be the recommendedapproach for a hospital PPP project as it allows the flexibility in designing the scheme thatwill be essential. The legal requirement for bidders to return tenders after only 60 days andfor the contract to be agreed in a further 30 days means that most of the issues need to beresolved in the time leading up the RFP. It is likely that only Competitive Dialogue wouldallow these timescales to be achieved.

The figure below shows a typical CD process for a hospital procurement.

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Figure 14 Competitive Dialogue Process for Hospital Procurement

Source: Sanigest 2013

In cases where private capital is to be employed, i.e. PPP or Hybrid PPP, the fundingcompetition to obtain the necessary debt finance is held just following PB. This is done sothat the terms offered by lenders can be held until Financial Close / contract award.

Following soft market testing, the finalised procurement option is approved by theauthority and also normally by the Ministries of Health and Finance, according to standardgovernment business case approval for major projects, an example of which is shown inthe diagram below.

OJEU Notice

Pre -Qualification

Select Participants

Stage 2AStrategic Approach

Stage 2BPreliminary Design Concept

Stage 2CFirm Design Proposals

Stage 2DPreliminary Total Package Offer

Final Tenders

Evaluate TendersSeek Clarification

Select Preferred BidderNotify Unsuccessful Bidder

Appoint Preferred Bidder

Final Contract Development /Submit Planning Application

Approval to FBC

Financial CloseContract Signature

Stage 1

Stage 4

Stage 3

Stage 2

Pre - Qualification

CompetitiveDialogue

Final Tender &Bid Evaluation

Finalisation

4 Bidders

3 Bidders

Advertisement / Notice

Pre -Qualification

Select Participants

Stage 2AStrategic Approach

Stage 2BPreliminary Design Concept

Stage 2CFirm Design Proposals

Stage 2DPreliminary Total Package Offer

Final Tenders

Evaluate TendersSeek Clarification

Select Preferred BidderNotify Unsuccessful Bidder

Appoint Preferred Bidder

Final Contract Development /Submit Planning Application

Approval to Final Business Case

Financial CloseContract Signature

Stage 1

Stage 4

Stage 3

Stage 2

Qualification

CompetitiveDialogue

Final Tender &Bid Evaluation

Finalisation

4 Bidders

3 Bidders

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Figure 15 Procurement option process

Table 36 Indicative Timescales (From Decision to Use PPP)

Initial Business Case Preparation 2 monthsSoft Market Test 1 monthRevised Business Case 1 monthStart Formal Procurement Process with RFQ:RFQ to RFP including 2 rounds of ‘Dialogue’ 6-9 monthsRFP 2 months (60 DAYS in accordance with the law)PB to Contract Award 1 month (30 Days in accordance with the law)Assumptions:1. Competent Advisers are engaged by the commissioning authority2. All relevant authorities make rapid decisions when they are required3. That Competitive Dialogue is the chosen procurement route

Stage 1

Stage 2

Stage 3

Stage 3a

Stage 4

Establish Need for the Service

Appraise the options

Business Case and Reference Project

Market sounding

Creating the project team

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Important Note: The above Timescales represent Best Practice. Allowances will need to bemade for the relative inexperience of the public authorities.

30.5. Delivery Arrangements

These arrangements consist of three elements:• Resources• Timetable• MilestonesTo assure quality in delivery, and in order to manage and monitor risks to successfulprocurement, it is essential that the project is subject to peer-review at appropriate stages.In the UK, this process has been formally developed and adopted for all hospital projects. Itis called Gateway Review (shown below). It is recommended that a similar approach beadopted for Edineţ hospital project.

Table 37 Governing th Process-Gateway Review

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Next Steps to Take - Edineţ Inter Rayon Hospital Proposal

Strategic Decision about best Procurement Option: PPP or not – publicauthority

Strategic Decision about which Services should be out-sourced under a PPPimplementation – public authority

Develop an outline Business Case and Feasibility Study – consultants / publicauthority

Soft market-test the preferred option (In particular check the viability ofprivate sector finance) – consultants / public authority

Refine the Business Case based on information gathered from the soft markettest - consultants

Decide on viability of proposed option: affordability / availability of fundingand service providers / technical viability – public authority

Procurement – public authority with consultant assistance

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31. Improving laboratory services

Previous reports have described in detail the newly envisioned network strategy for thenorthern region including expected profile of services, financing issues, potential PPPmodels, and staff and training issues.

The new restructured laboratory services will be able to ensure adequate time to resultsand an improved validity and reliability of laboratory processes. A proper digitalinformation flow will facilitate shorter time to results and provide more efficiency andtransparency. It will also help to ensure that proper data collection is established for futureimprovement of the laboratory network and will provide epidemiological data whenneeded. The modernization of equipment and processes will also improve safety forpersonnel and reduce the contamination of samples. In terms of infrastructure, the Edineţrayon hospital has been awarded numerous development contracts to scale upinfrastructure and technology from key international organizations. In 2010 the EuropeanUnion, spearheaded by the French government invested in upscaling the surgical facilitiesat the institution. Edineţ now has some of the most up-to date equipment such as state-of-the-art surgical lamps comparable to many developing countries. The Japanesegovernment has also shown special interest in Edineţ supplying it with top-of-the-linediagnostic equipment for the laboratory, such as centrifuges and other laboratoryequipment.

Improved testing areas within standard laboratories will also lead to a much neededexpansion of the current range of analysis. This will permit facilities to include essentialmicrobiological testing and improve resistance testing. Currently the lab network hasbecome overburdened with a unnecessary amount of test per person calculated bySanigest at around 14.5 test per individual. The following table highlights laboratorybenchmarks based on European standards.

Table 38 Laboratory assessment based on European standard 2010

Countries Population 10 GDP GDP /

capitaTHE /capita

THEas %GDP

IVDmkt.10

IVDmkt.growthrate 09-10

IVDmkt./THE

IVDmkt./capita

000 Mio. € € € % Mio. € % % €Source EDMA/OECD

Germany 82.834 2.397.100 29.268 3.399 11,6 2.157,

91 -0,1 0,8 26,1

France 62.451 1.907.145 30.448 3.587 11,8 1.773,

00 4,2 0,8 28,4

UK* 61.349 1.626.62 26.696 2.611 9,8 773,85 6,2 0,5 12,6

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Countries Population 10 GDP GDP /

capitaTHE /capita

THEas %GDP

IVDmkt.10

IVDmkt.growthrate 09-10

IVDmkt./THE

IVDmkt./capita

7

Italy 59.018 1.519.702 25.781 2.443 9,5 1.702,

50 1,1 1,2 28,8

Spain 46.073 1.503.974 32.746 2.182 6,7 1.093,

70 0,5 1,1 23,7

Netherlands 16.448 571.979 34.839 4.167 12,0 315,80 2,2 0,5 19,2Portugal 10.665 168.610 15.862 1.626 10,3 258,00 -0,8 1,5 24,2Belgium 10.556 339.162 31.416 3.417 10,9 340,00 1,8 0,9 32,2Sweden 9.385 320.685 34.479 3.490 10,1 177,28 4,0 0,5 18,9Austria 8.388 274.320 32.802 3.624 11,0 249,00 2,0 0,8 29,7Denmark 5.544 222.634 40.339 4.647 11,5 134,29 2,6 0,5 24,2Ireland 4.470 159.645 35.803 3.414 9,5 80,00 -3,6 0,5 17,9

EU-15 394.330

11.455.865 2.985 10,2 9.345,

29 1,5 0,8 23,7

Source: Press release of the European Diagnostic Manufacturers Association from 15th November 2011:„The European In Vitro Diagnostic Market in 2010“

When comparing current figures on laboratory testing in Moldova we can observeexceptionally high number of test per inhabitant for the northern region. Between 1993–94 and 1997–98 the number of pathology services provided in Australia increased byalmost 10 million, or 22%. If laboratory testing were to be brought down to internationalstandards, a significant amount of savings, totalling to 100,000 Euro a year would be seenin the northern region alone. This could potentially return investment in 3 years asobserved in table 37.

Table 39 Cutting back on unneeded testing

Simulation of potential savingscost per test 0.09 EuroPopulation 253,000Tests 3,668,500Test per person 14.5test per person prime 10Potential saving 2,530,000Cost baseline 330,165 EuroCost rationalisation 227,700 EuroSavings 102,465 Euro

Estimated cost of new lab 302,000

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Simulation of potential savingsstructurePayback time in years 2.95


PricewaterhouseCoopers estimates that the minimum number of tests per day for a viablecomprehensive laboratory would be around 5,000. That is, the set up costs for a laboratoryto provide a smaller number of tests per day would be too high to be covered by therevenue it could generate and therefore the laboratory is unlikely to be financially viable.Alternatively, a laboratory that reaches financial viability at 5,000 tests per day may be ableto accommodate an additional number of tests, which incur direct costs, such as collectionand reagent costs, but do not need to contribute to the fixed costs, which remain thesame.

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32.Renovate vs. rebuild

Faced with outdated wards, equipment and heating and ventilation systems along withinefficient department designs, growing patient volume and a limited budget to boot, thehospitals system across the northern region has the clear task of upgrading or building anew facility to improve health services. There is no question that renovating existingfacilities in most circumstances is more cost effective as a short term solution to moreexpensive new construction. However, building new facilities offers a wide range ofopportunities and preparedness that many renovations cannot. The following figureillustrates the degradation curve seen with infrastructure conditions in relation to cost.

Figure 16 Condition cost relationship


In financial terms, the cost to renovate far outweighs that of building a replacement facilityin the long run, given that the renovation would include significant new modifications ininfrastructure. Furthermore, operational efficiency can be created by designing a facility inEdineţ which streamlines clinical processes, installing updated heating, cooling andplumbing systems that are energy efficient, planning for growth and expansion of services,adapting to changing technology with the space design, and having little to no disruption inday-to-day operations. With a new facility in Edineţ, healthcare services and personnel can

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.

move from a dark, cold, institution-like facility with shared hospital rooms, showers andbathrooms to a healing environment with warm colours and natural lighting, privaterooms, showers and bathrooms.

Technology has radically changed how we use buildings. As technology continues toadvance, the existing hospital buildings in the northern region will not be able toaccommodate changes such as computers, AV equipment, internet, medical head walls,and new diagnostic and surgical equipment and in some cases can lead to unsafe practicesresulting in hospital acquired infection and an unsafe environment for staff. The cost offacility down-time or of relocating to another space during construction has beenconsidered in the cost/value calculation of renovating versus rebuilding for the inter-rayonhospital. If economical land is available in Edineţ to build the new facility while the oldcontinues to operate, this cost is minimized.

The aging facilities within the northern region restrict the hospitals' ability to reach theirstrategic goals. So with proper planning and stakeholder buy-in, the new inter-rayonhospital can ensure that the decision to replace will be made strategically for the hospital’sfuture growth and sustainability. New construction is often considerably more expensive,but renovation is a short term solution.

32.1. Phased Approach

The planning process of the new inter rayon hospital in Edinets will be carried out as partof a two phased process-Figure 18. Phase one will include 120 beds and a full suite ofdiagnostic services, outpatient, and inpatient specialized services. The second phase willsee an additional 100 bed capacity infrastructure, operating rooms, ICU beds and newequipment (e.g. MRI).

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Figure 17 Two phased approach


32.2. Planned Scope of Services

Obstetrics, surgery and sub-specialties in internal medicine will be provided exclusively bythe inter-rayon level as highlighted in the previous report. It is anticipated that a broadrange of general hospital services be provided:

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-119-


.





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.

Figure 18 Range of services within the new facility

Source Sanigest 2013

The full range of diagnostic (imaging and laboratory) services can be provided by thenorthern rayon network or outsourced as there is a fairly good market of private diagnosticimaging and laboratory service providers. With regard to the treatment of cardiovasculardisease and stroke care, it is noted that the new inter-rayon hospital in Edinets will becomethe benchmark hospital in the northern region for high quality services.

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33. Saving lives

The Republic of Moldova presents a double epidemiological burden as rates of bothcommunicable and non-communicable diseases have steadily increased since itsindependence. The main causes of death in the Republic of Moldova are diseases of thecirculatory system, cardiovascular disease and stroke. As regionalization of health servicesbrings with it new underlying infrastructure and resources, it also brings a uniqueopportunity not only for the northern region but for Moldova in general to reassess anddevelop reorganized strategy for cardiovascular and stroke care.

Improving CVD mortality rate to those similar to current Eastern EU standards wouldpotentially save 4,756 lives, while decreasing CVD mortality to Western European countrieswould have to potential to save 5, 810 lives as depicted in the following figure.

Figure 19 Improving standards of care will help save lives in Moldova

Source: Sanigest International 2012

Optimally reconfiguring patient flows, equipment infrastructure, treatment standards andother existing processes in parallel with preventive strategies targeting identified risk

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.

33. Saving lives






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.

33. Saving lives






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.

factors will serve as an opportunity to archetype for future reconfiguration ofcardiovascular and stroke care for the rest of the nation. By implementing these muchneeded changes, mortality rates would potentially reach similar levels to those of otherWestern European countries. Recent improvements in the monitoring and modelling ofstroke have led to more reliable estimates of stroke mortality and burden worldwide.

Disease-related impairment of household consumption and educational performance hashad a negative effect on gross domestic product (GDP). As expenditure on chronic carerises across Europe, it takes up increasingly greater proportions of public and privatebudgets. Figure 20 illustrates the healthy years of life lost due to stroke compared to otherEuropean countries. Figure 21 represent the number of lives that could be saved byachieving mortality rates similar to Western and Eastern European countries.

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.

Figure 20 Years of life lost to stroke

Source : WHO

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Figure 21. Stroke care within the northern region


33.1. Quick wins

Quick Wins represent good practice. They focus on materials where recovery rates can beincreased over baseline performance (standard practice) without the need for significantinvestment or major changes. Quick win in the health sector refer to relatively cheap andeasy initiatives that can be quickly implemented in an attempt to secure communitysupport for a regeneration scheme. Some Quick Wins could bring vital gains in well-beingto thousands of people and start Moldova on the path to its future goals. With adequateresources, some Quick Wins for the northern region could include:

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33.1. Quick wins


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33.1. Quick wins


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Table 40 Quick wins for the northern region

Proposed 'quick win' Expected benefits Estimated time and costsassociated withimplementation

Mobile catheterization lab The mobile service costshalf of what a comparableprocedure would cost atan urban cath-lab.

Avoids the inconvenienceof patients traveling to bigcities

The procedure can bedone in familiarsurroundings with closefamily and friendsavailable to the patient.

Patient loses less daysform work.

It allows the family doctorto be present during theprocedure to takeimmediate decision andhelp comfort the patient.

Mobile catheterization canbe accomplished with ahigh procedural successrate and fewcomplications(procedure complicationrate was 1.2%*).

Most patients do not needfurther referral to atertiary site for additional

Time- Immediate

Cost-Total investmenttowards establishing theMobile Cath lab is close to€269,000+

Mobile MRI Bring medical diagnosticservices to as manypatients even in farreaching areas.

Save on additionaltransportation expensesfor patients.

Less days away fromfamily and work results in

Time-Immediate

Cost-€130,000-€650,000 (0.5T), €1.2 (1.5 T)

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.


decreased emotional andfinancial toll for patients.

Keeps patients closer totheir communities, localhospitals, and primarycare physicians

Provides access to state-of-the-art technology withno capital expenditure.

Better control of patientdisease management andearly disease detection

Programmed investigationunits using the day model ofcare

Duration of admissions onwards per DRG can fall upto 24%.±

The cost per patient candrop by 25% overall.±

Increased efficiency in useof medical time.

Drop in average length ofstay

Cost-€9,200Time- Set up 6 months

Improve networkcoordination

Improve access to thesystem

Reduce inappropriate care Reduce fragmentation of

health care prevent duplication of

infrastructure and services Reduce production and

transaction costs, Respond better to

community health needs Reductions in unnecessary

hospitalizations,reductions in excessiveutilization of services anddiagnostic testing,

Reductions in the lengthof hospital stays,

Improvements ineconomies of scale and ofscopes

Increased production

Cost-€12,000

Time-Implementation time 3months

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volumes, Increases in system

productivity

Online appointment system Enhanced efficiency Appointments may be

made after hours No waiting to book an

appointment Receptionist conflict is

avoided Appointment reminders

are generatedautomatically

Advantageous for thehearing impaired

Enhanced follow-upcapability≠

Cost-€270 +€77 maintenancecost per month

Time-Set up 3 months

*R. Bersin, C. Elliott, A. E. , J. Fedor . Mobile cardiac catheterization registry: Report of the first 1,001 patientsCatheterization and Cardiovascular Diagnosis. Volume 31, Issue 1, pages 1–7, January 1994

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34. Recommendations

This chapter provides final recommendations highlighting recommendations describedthought out this report.

Over the counter medicines should be de-regulated and made available at

convenient stores and filling stations so that access is facilitated for people in

geographically constrained areas

An additional study is recommended to define how many pharmaceutical

service points are truly necessary in the remainder of underserved areas;

introduce an awareness campaign directed to educate patients to the benefits

of proper use of medicines

Enforce an effective monitoring and pharmacovigilance system should be put

into place to protect the public from counterfeit, ineffective and/or harmful

medicines

Establish a central point of coordination for emergency services within the

region and adopt the strategies that have been implemented in Chisinau

Emergency Network in terms of GPS on ambulances, information systems and

telemedicine for EKG implementation.

Increase the use of thromblytics in heart attack and stroke patients.

Incorporate current PPP legislation for future emergency care services

Introduce a modernized critical pathway for patients with urgent acute care

Establish guidelines for an integrated care pathway to transition patients from

the acute to the chronic setting and vice versa.

Develop a tracking and reporting of metrics for quality improvement in primary

health care services

Enhanced linkages and partnerships on primary health care with other

community services;

Establish fully interoperable electronic patient records for primary health care

linked to all levels of care

Create formal attachment of patients within the primary care setting

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Introduce enhanced illness prevention and health promotion within the primary

care setting

Develop transport plans for new inter-rayon site

Introduce transport plans to existing CCC sites

Developing integrated public sector transport services– including health,

education, social services and ambulance services

Improve tram and rail services

Improve park-and-ride facilities

Improve walking routes

Improved cycle routes

Introduce taxi schemes for patient transport.

Implement parking schemes to increase revenue at hospitals

Improving community transport provision (including voluntary driver/car

schemes)

Link timing and booking of Edinets services with public transport provision

Create roadside improvements, bus shelters and lower pavements at transport

interchanges at Edineţ sites

Create information provision about, and promotion of, northern region-related

transport

Update the existing nomenclature to one that better reflects the new proposed

services within the acute as well as the chronic centres

Closure of existent satellite facilities within the northern regional network

Establish a defined communication strategy for the implementation of the

regionalization strategy

Identify the change champions, the innovators; who will be prepared to

introduce change

Reduce laboratory testing for the northern region to 14.5 laboratory test per

person

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Introduce a mobile catheterization laboratory for the northern region

Implement Mobile MRI in Edinets

Create programmed investigation units using the day model of care

Invest financial resources to improve network coordination by using

international frameworks

The provision of accommodation should be considered as one strategy in

encouraging health workers from the other northern rayons to work in Edinet.

Access to communications should be considered as part of a package of

incentives.

An orientation program which recognizes the importance of social orientation

be developed and implemented for newly recruited health workers to the inter

rayon hospital.

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.

35.References

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Supply Chains and Global Health: An Imperative for Bringing Operations ManagementScholarship into Action; Yadav, P; Kraiselburd, S; Production and Operations ManagementVol. 0, No. 0, xxxx–xxxx 2012, pp. 1–5 ISSN 1059-1478

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Improving Access to Essential Medicines Through Public-Private Partnerships; Kyla Hayford,Lois Privor-Dumm and Orin Levine; International Vaccine Access Centre (IVAC); JohnsHopkins Bloomberg School of Public Health, (2004)

Improving Maternal Health by Scaling Up Contractual Management of Basic Health Unitsin Sindh Province, Pakistan: A Health Systems Approach; Anna Heard, Riaz Memon andImran Chandio; The World Bank; Commissioned Paper for the International Conference onScaling Up, Dhaka, Bangladesh. (Dec 2008);

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Achieving the Twin Objectives of Efficiency and Equity: Contracting Health Services inCambodia. Indu Bhushan, Sheryl Keller, and Brand Schwartz; ERD Policy Brief 6; AsianDevelopment Bank, Manila 2002; ISBN 1655-5260

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The Best Things in Life are (Nearly) Free: Technology, Knowledge and Global Health; UrsulaCasabonne (The World Bank), Charles Kenny (Centre for Global Development); Centre forGlobal Development, Working Paper 252 (May 2011)

Health Information and Health Care: The Role of Technology in Unlocking Data andWellness – A Discussion Paper; Jody Ranck; United Nations Foundation & VodafoneFoundation Technology Partnership, Washington D.C., February 2011.

Consulting Services for the development of the regionalization plan for the Republic ofMoldova; Inception Plan; Sanigest International (2012)

American Academy of Neurology Workforce Task Force Study: Final Report. VectorResearch, Inc., January 15,1999, p. C-5.

American Association of Neurological Surgeons Survey. AANS Winter 2003 Bulletin.

Anderson, G. et. al. (1997). A Comparison of Three Methods for Estimating theRequirements for Medical Specialists: The Case of Otolaryngologists. Health Ser¬vicesResearch, 32:2, p. 147.

Clouse, J. et. al. (1998). Benchmarking U.S. Nuclear Medicine Physician Work¬forceRequirements Based on Managed Care Organization Effects. Journal of Nuclear Medicine,39:7, p. 2.

Colletti, R. et. al. (1997). Paediatric Gastroenterology Workforce Survey and Future Supplyand Demand. Journal of Paediatric Gastroenterology and Nutrition, 26:1, p. 112.

Estimating Workforce and Training Requirements for Nephrologists Through the Year 2010.Abt Associates, September 1996, p. 32.

Estimation of Physician Work Force Requirements in Anaesthesiology. The AmericanSociety of Anesthesiologists, September 16,1994, p. 44.

Family Physicians Workforce Reform: Recommendations of the American Academy ofFamily Physicians. September 1995, p. 3.

Haase, C. et. al. (1995). Do Estimates of Emergency Physician Workforce UnderestimateCurrent Needs. Annals of Emergency Medicine, 28:6, p. 669.

Hogan, P. et. al. (1995). Physical Medicine and Rehabilitation Workforce Study. AmericanAcademy of Physical Medicine and Rehabilitation, p. 29.

Holliman et. al. (1997). Workforce Projections for Emergency Medicine: How ManyEmergency Physicians Does the United States Need? Academy of Emer¬gency Medicine,1997; 4: 725-720, p. 727.

Lee, P. et. al. (1998). Demand-Based Assessment of Workforce Requirements forOrthopaedic Services. The Journal of Bone and Joint. Surgery, 80:3, p. 313.

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Mechanic, R. et. al. (1996). Health Care Market Change and Future Rheuma¬tologyWorkforce Requirements. American College of Rheumatology, p. 18.

Moorehead, J. et. al. (1998). A Study of the Workforce in Emergency Medicine.

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Preparation of Needs-Based Requirements for Allergy and Clinical Immunology for the Year2010. Abt Associates, November 12,1990, p. 19.

The Paediatric Neurology Survey. The American Academy of Paediatrics. 1998.

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.

Annex

1. Emergency service personnel for the northern region

PersonnelNameIMSPAMU

ScripticFunctions

2012/2011

Individualstotal

2012/2011

Doctors Med Personnel.middle

Med Personnel.Inferior

Others andDrivers

%fulfilled

20122011

Scr.

2012/2011

Ind(abs)%ofassurance

201122011

Scr.

2012/2011


201122011

Scr.

2012/2011


201122011

Scr.

2012/2011


20122011

Mun.Chişinău

1228,0

1083,25

726

660

334,25

293,0

267(171)52,7%

14950,9%

421,5

365,0

391(235)55, 8%

22160,1%

158,75

163,25

102 (98)61,7%

10161,9

313,5

546,0

310(222)70,8%

39472,2%

59,1%

60,2%

SZ Centre 1570,5

1570,5

976

1003

407,25

386,0

14635,914846,2%

611.5

611,5

41067,141382,8%

125,5

137,0

9071,710980,3%

426,5

434,0

33078,133376,7%

71,9%

73,2%

SZ North 1305,0

1321,75

1041

1043

269

271,0

16360.6

16561,1%

482

473,0

41285,5

40285,0%

170

186,0

13881,214578,0%

38485,4

392,75

328

33184,3%

79.8

78,9%

SZ South 412,0

412,0

295

298

99,0

99,0

4242,4%4343,0%

161,0

160,0

12778,8%12578,1%

27,0

28,0

2696,3%2796,4%

125,0

125,0

10281,6%10180,8

71,6%

72,3%

SZGagauzia

301,25

324,25

178

190

63,0

63,0

2031,7%2031,7%

113,0

107,0

7969,9%8276,6%

33,0

62,0

1030,3%1829,0%

92,25

92,25

6974,8%7075,9%

59,1%

58,6%

TOTALSAMU

4816,5

4720,75

3216

3191

1172,5

1128

54246,2%53447,3%

1789,0

1712,5

126370,6%123572,1%

514.25

580,25

36270,4%39768,4%

1341,25

1584,0

107179,9%122577,3

66,8

67,6


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.

2. Characteristics of Northern region emergency care services

Nr ofpatientstranspor

ted

Nr ofpatientstranspor

ted to100,000

pop

Nr ofcalls

Nr ofcalls

to100,0

00pop

Populationserve

d

Nr ofvehicl

es

Emergency

doctors

Nr ofkm

driven

kmdrive

onavg/call

Edineţ 4,414 5,681 18,52

023,835

77,700

9 16 314,328

17.00

Briceni 2,916 4,005 16,35

722,468

72,800

8 16 266,017

16.30

Ocnita 2,958 5,881 9,901 19,68

450,300

4 13 240,804

24.30

Donduseni

3,832 9,392 9,602 23,534

40,800

4 10 207,450

21.60

Time from call tohospital in

minutes

6.05

14.19Budget MDL

88,630,664

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.

35.1. Proposed financial configuration model

Case 1- MixedPPP

Case 2- Donor-PPP

Case 3- PurePublic

Case 4-Pure PPP

10-YearAVG

25-YearAVG

10-YearAVG

25-YearAVG

10-YearAVG

25-YearAVG

10-YearAVG

25-YearAVG

CNAM Revenues 38.24 60.00 38.24 60.00 38.24 60.00 38.24 60.00

OOP Revenues 6.25 9.82 6.25 9.82 6.25 9.82 6.25 9.82

Rental Revenues 25 yrAverage

8.25 11.45 8.25 11.45 8.25 11.45 8.25 11.45

Total Revenues 52.74 81.27 52.74 81.27 52.74 81.27 52.74 81.27

Total AvailabilityPayments

15.55 16.79 10.99 11.86 - - 30.29 32.71

Total OPEX 49.65 71.02 49.65 71.02 49.65 71.02 49.65 71.02

Total Depreciation 23.84 16.55 23.84 16.55 23.84 16.55 23.84 16.55

Total Financial Costs(interest payment)

11.71 6.79 9.47 5.49 - - 18.94 10.98

Total Net Income (5.86) 7.06 (4.77) 5.04 (20.75) (6.63) (9.46) 13.48

EBITDA margin 33% 33% 25% 26% 5% 11% 60% 54%

Profit Margin -31% -3% -36% -7% -39% -14% -18% 10%

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3. Characteristics of Northern region emergency care services II

Budget perinhabitant inEuro

Total budget,Euro

Nr ofambulances

Call to sitetime Ambulances

per 10,000Population

Workers Workersper 100,000

pop

# of calls # Calls per100,000 pop

Moldova5.60 19,593,181 367

< 15 min1.05 3,500,000 3,216 91.89 954,000 27,257.14

Austria47.62 400,000,000 2,500

< 15 min2.98 8,400,000 5,000 59.52 867,000 10,321.43

Bulgaria5.20 38,350,000 675

10 - 20min 0.91 7,380,000 7,113 96.38 620,000 8,401.08

UK- - 2,021

9 - 19 min0.32 63,181,000 17,028 26.95 7,200,000 11,395.83

Estonia20.14 27,000,000 90 0.67 1,340,600 1,336 99.66 250,000 18,648.37

Finland15.68 85,000,000 800

15>1.48 5,422,000 2,000 36.89 550,000 10,143.86

Lithuania10.09 33,300,000 256

10 - 25min 0.78 3,300,000 2,350 71.21 730,000 22,121.21


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.

4. Mortality before arrival and in the presence of the team

Mortality before arrival and in the presence of the teamDenumirea

indicatoruluiYears mun. Chişinau SZ AMU SZ AMU

NorthSZ AMUSouth

SZ AMU TotalRMCentre Găgăuzia

No. deceased untilthe arrival of AMUteam / includingchildren

2011 1163 936 933 235 209 347614 39 28 2 3 86

2012 1197 1103 899 244 192 363510 56 32 5 4 107

No. deceased in thepresence of AMUteam,

2011 119 59 55 12 11 2562 3 0 1 0 6

2012 98 68 52 19 15 2520 4 3 1 2 10


5. Details the equipment required by functional area for the new hospital

Service Department SubareaSpaceUniCode Space Name Units Description

Sumade Qty

ESSENTIALCLINICAL

DAYHOSPITAL PATIENT SUPPORT 01.09.03.03 Nurse Station 1

Cardiograph (EKG) 1Medication Cart 1

01.09.03.05

EndoscopesDecontamination Station 1

Washer/disinfector, 1

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.

endoscope

PT CARE AREAS /OPERATING ROOMS(1) 01.09.02.01

OperatingRoom(s),Ambulatory 1

Anaesthesia machine, 2vaporizers, basic (inclcylinders) 1Electrosurgery unit,mono/bipolar cutting, 300W 1General operating table 1Light, operating, double,ceiling mounted 1Monitor, patient, multiparameters 1Video Endoscopy System(w/Light source andInsuflator) 1

RECOVERY 01.09.04.02RecoveryRooms 4

Monitor, patient, multiparameters 4

01.09.04.03 Isolation Rooms 2Monitor, patient, multiparameters 2

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.

Pump, infusion,volumetric 2

RECOVERY SUPPORT 01.09.05.03Crash CartAlcove 1

Cart crash withdefibrillator 1

EMERGENCYAMBULATORYENTRY / WAITING 01.01.01.04

TriageWorkstation(s) 1

Pulse Oxymeter 1

PATIENT SUPPORT 01.01.04.01 Nurse Station 1Cardiograph (EKG) 1Cart crash withdefibrillator 1Medication Cart 1Pump, infusion,volumetric 1Ventilator, intensive care,adult / child 1

01.01.04.04 Satellite Lab 1Analyzer, Blood Gases,POC 1

URGENT CARE 01.01.03.01Exam,Treatment Room 6

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.

Examination Light 6Monitor, patient, multiparameters 6Stretchers, Mobile,Hospital 6

INTENSIVECARE UNIT(ICU) - 12Beds PATIENT AREAS 01.03.02.01

Critical CarePatient Room(s) 10

Bed, ICU, 4 sections,trendelenburg, electricoperated 10Monitor, patient, multiparameters 10Pump, infusion,volumetric 10Pump, Syringe 10Ventilator, intensive care,adult / child 10

01.03.02.03 Isolation Room 2Bed, ICU, 4 sections,trendelenburg, electricoperated 2Monitor, patient, multiparameters 2Pump, infusion, 2

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.

volumetricPump, Syringe 2Ventilator, intensive care,adult / child 2

PATIENT SUPPORT 01.03.03.01

DecentralizedNurse WorkStations 2

Medication Cart 2Monitoring CentralStation, 12 bed 2

01.03.03.04

RespiratoryTherapy BloodGas Lab 1

Analyzer, blood gas 1

01.03.03.08

Soiled UtilityWorkroom /Soiled HoldingRoom 1

Washer/DecontaminationUnits, Bedpan/AncillaryUtensil 1

01.03.03.09EquipmentStorage 1

Doppler Vascular 1

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.

BidirectionalHypo/Hyperthermia Units 1Pacemaker single chamber 1PCA Pump 1Pump, infusion,volumetric 1Ventilator, intensive care,adult / child 1Warmer, infusion andblood 1

01.03.03.12CPR CartStorage Alcove 1


LABOR /DELIVERY /RECOVERY

CAESAREANSECTION / DELIVERYSUITE 01.05.02.05

Control / NurseStation 1

Medication Cart 1

01.05.02.07

Caesarean /DeliveryRoom(s) 1


01.05.02.08 C-Section 2

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.

Recovery(PACU)


LABOR ANDDELIVERY 01.05.02.04 LDR Room(s) 4

Bed, birthing 4Light, operating, double,ceiling mounted 4Monitor, CTG, on trolley 4Pulse Oxymeter 4

PATIENT AREAS 01.05.02.01Non-Stress TestRoom(s)/Exam 1

Monitor, AntepartumFetal Monitor, on trolley 1

PATIENT SUPPORT 01.05.03.01 Nurse Station 1Medication Cart 1

01.05.03.05 Consultation 1Monitor, AntepartumFetal Monitor, on trolley 1

01.05.03.11CPR CartStorage Alcove 1

Cart crash with 1

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.

defibrillator

01.05.03.12

PortableEquipmentStorage Alcove 1

Pulse Oxymeter 1Pump, infusion,volumetric 1

OUTPATIENTDEPARTMENT

CONSULTATIONAND EXAMINATIONROOMS 01.06.02.05 Cardiology 1

Cardiograph (EKG) 1Doppler VascularBidirectional 1

01.06.02.06 ENT 3ENT Unit with Chair, basic 3

01.06.02.07 Ophtalmology 3Lamp, slit 3

SUPPORT AREAS 01.06.03.08

EquipmentAlcove,Emergency 1


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.

01.06.03.09Storage,Equipment 1

Pulse Oxymeter 1

OUTPATIENTHEMODIALYSIS PATIENT AREA 01.07.02.02 Nurses' Station 1

Medication Cart 1

01.07.02.03DialysisTreatment Bay 16

Hemodialysis Units 16

01.07.02.05Treatment /Prep Room 1

Dialyzer ReprocessingUnits 1

PATIENT SUPPORT 01.07.03.08Crash CartAlcove 1


01.07.03.13

WaterTreatmentRoom 1

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.

Water Purification Plantfor Hemodialysis 1

OUTPATIENT PHYSICALTHERAPY HYDROTHERAPY 01.08.02.07

WhirlpoolExtremity Tank 2

Whirlpool Extremity Tank 2

01.08.02.08 Whirlpool Tub 2Whirlpool Tub 2

01.08.02.09Mini WhirlpoolButterfly 1

Mini Whirlpool Butterfly 1

THERAPY/TREATMENT AREAS 01.08.02.01

Gym/ ExerciseStations 1

Bicycle, exercise 1

01.08.02.02TreatmentCubicle(s) 10

Combination therapy unit(multistimulator &ultrasound) 10Magnetotherapy Unit 10Pack heater table modelwith standard hot packs 10Shortwave therapy unit 10

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.

01.08.02.03

TractionTreatmentCubicle(s) 2

Table, traction, completewith accessories 2

SURGERY PACU 01.02.02.02 Patient Bays 6Monitor, patient, multiparameters 6

PATIENT SUPPORT 01.02.03.03 Nurse Station 1Cart crash withdefibrillator 1Hypo/Hyperthermia Units 1Medication Cart 1

01.02.03.09AnesthesiaWorkroom 1

Monitor, patient, multiparameters 1Pump, infusion,volumetric 1

PRE / POST OP 01.02.02.04 Patient Rooms 8Monitor, patient, multiparameters 8Pump, infusion, 8

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.

volumetric

PT CARE AREAS /OPERATING ROOMS(4) 01.02.02.01

OperatingRoom(s),General 4

Anaesthesia machine, 2vaporizers, basic (inclcylinders) 4Electrosurgery unit, withArgon Plasma Coagulator 4General operating table 4Light, operating, double,ceiling mounted 4Monitor, patient, multiparameters 4Video Endoscopy System(w/Light source andInsuflator) 4

ESSENTIALCLINICALSUPPORT

CENTRALSTERILESUPPLY DECONTAMINATION 02.05.01.03

Washer /Disinfector 1

Ultrasonic Washer/DryerSystems 1Washer/Decontaminators 1

STERILIZATION 02.05.02.02 Large Sterilizers 2Steam Sterilizer, double 2

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.

door

02.05.02.03

ETO Sterilizer orPlasmaSterilizer 2

Low TemperatureSterilizer 2

ENDOSCOPYPATIENT CAREAREAS 02.03.02.03

EndoscopyProcedureRoom(s) 4

Electrosurgery unit,mono/bipolar cutting, 300W 4General operating table 4Light, operating, double,ceiling mounted 4Monitor, patient, multiparameters 4Video Endoscopy System(w/Light source andInsuflator) 4

PATIENT SUPPORT 02.03.03.04

ScopeProcessingRoom 1

Cabinet, Endoscope 1Washer/disinfector, 1

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endoscope

FUNCTIONALDIAGNOSTICS

CARDIOPULMONARY/RT/EKG 02.02.02.01

PulmonaryFunctionTesting Room 1

plethysmograph 1

02.02.02.02 EKG 2Cardiograph (EKG) 2

NEURODIAGNOSTICS 02.02.02.03

Exam Room,EEG 1

EEG(electroencephalograph) 1

02.02.02.04Exam Room,ENG 1

Electronystagmography 1

02.02.02.05Exam Room, EPand EMG 1

EMG (electromyograph) 1EP (Evoked potentials) 1

IMAGINGDIAGNOSTICS

CATH LAB/SPECIALPROCEDURES 02.01.2B.04 Cath Lab 1

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AngiographicInterventional System 1Injectors Contrast Mediafor Angiography 1

02.01.2B.09EquipmentRoom 1


COMPUTERIZEDTOMOGRAPHYSUITE 02.01.2C.04

InjectionRoom/PrepArea 1

Injectors Contrast Mediafor CT 1

02.01.2C.05 Scanner Room 1CT Scanner, 16 multislice 1

02.01.2C.08

Record Viewing/ InterpretationRoom 1

Dry Printer 1WORKSTATION, PACS,FLAT, DUAL 1

DIAGNOSTICRADIOLOGY SUITE 02.01.2A.02

Radiography /Fluoroscopy 1

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.

(R&F) Rooms

X-ray, radiology andfluoroscopy, basic 1

02.01.2A.03RadiographyRoom(s) 3

X-Ray, bucky, with verticalwall bucky stand 3

MAMMOGRAPHY 02.01.2D.02MammographyRoom 1

Digital mammographyFFDM 1

MRI SUITE 02.01.2F.04 MRI 1Injectors, Contrast Media,MRI 1Monitor, patient, multiparameters, MRI 1MRI System 1.5T 1

02.01.2F.07

Record Viewing/ InterpretationRoom 1

Dry Printer 1WORKSTATION, PACS,FLAT, DUAL 1

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PATIENT SUPPORT 02.01.03.02CPR CartStorage Alcove 1


02.01.03.03Storage,Equipment 1

Monitor, patient, multiparameters 1Pulse Oxymeter 1Pump, infusion,volumetric 1

02.01.03.04

PortableEquipmentAlcove 1

X-Ray, Mobile Unit, Digital 1

ULTRASOUND 02.01.2E.01UltrasoundRoom 2

Ultrasound GeneralPurpose System 2

LABORATORY BLOOD BANK 02.04.02.07 Cell Washer 2

Centrifuge, cell washer 2

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02.04.02.08CountertopCentrifuge 2

Countertop Centrifuge 2

02.04.02.09 Incubator 2Incubator, 50 l, up to 70 °C 2

02.04.02.10MicroscopeWorkstation 2

Microscope, binocular, 3objectives 2

02.04.02.11 Automation 1Automated Blood BankSystem 1

CENTRAL SPECIMENPROCESSING 02.04.02.06 Freezer Storage 1

Freezer Storage 1

HISTOLOGY/CYTOLOGY/GROSSING 02.04.02.13

Tissue FlotationBath and Leicamicrotome 2

Microtome, rotating,paraffin and CO2 freezing 2Tissue Flotation Bath 2

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ESSENTIALNONCLINICALSUPPORT

ENVIRONMENTALSERVICES LINEN SERVICES 04.02.01.03

Washer / DryerArea 1

Dryer/Tumbler, 33 kg,electrical heated, singledoor 1Roll heated flatworkironer 1Washer/extractor, 50 kg,electrical heated 1

MORGUE WORKING AREA 04.07.01.01Body HoldingCooler 1

Mortuary cooling unit, 6corpses 1Trolley, mortuary, heightadjustable 1

04.07.01.02 Autopsy Room 1Light, operating, double,ceiling mounted 1Tables, Autopsy/Dissecting 1

PHARMACY MIXING 04.04.02.01

Unit DosePickingStation(s) /Workroom 1

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Pill Counter, tablets,manual 1

04.04.02.02IV AdmixtureRoom(s) 1

Hood, laminar flow, 6 ft 1

04.04.02.05 Chemo Clean 1Chemo Hood 1

STORAGE 04.04.03.04RefrigeratedStorage Area 5

Pharmacy Refrigerator 5

INPATIENT

MEDICAL/SURGICALUNIT- 48beds

NURSING SUPPORTAREA 03.02.03.01

Nurses' Station/ Charting /Monitoring 2

Cart crash withdefibrillator 2Medication Cart 2Monitoring CentralStation, 48 bed 2

03.02.03.07EquipmentStorage Room 2


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Pulse Oxymeter 2Pump, infusion,volumetric 2Pump, Syringe 2Ventilator, intensive care,adult / child 2Warmer, infusion andblood 2

03.02.03.13Soiled UtilityRoom 2


PATIENT AREA 03.02.02.01

Double PatientRoom w/ Toilet/ Shower 20

Bed, ICU, 4 sections,trendelenburg, electricoperated 20Monitor, patient, multiparameters 20Pump, infusion,volumetric 20

03.02.02.02PrivateIrradiation 4

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.

Patient Roomw/ Toilet /Shower


03.02.02.04

IsolationPatient Roomw/ Toilet /Shower 4


NURSERY -16 Bassinets PATIENT AREA 03.06.02.01

Full-TermNursery 1

Medication Cart 1Pulse Oxymeter 1

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03.06.02.02IsolationRoom(s) 1

Heater, radiant,newborns, mobile 1Incubator, neonatal 1Monitor, patient, multiparameters 1Phototherapy unit, mobile 1

03.06.02.06

Exam /Treatment /CircumcisionRoom(s) 1

Light, operating, double,ceiling mounted 1

PATIENT SUPPORT 03.06.03.05Soiled UtilityRoom 1


ORTHO/NEURO UNIT- 32beds




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Pulse Oxymeter 2Pump, infusion,volumetric 2Pump, Syringe 2




Private PatientRoom w/ Toilet/ Shower 30

Bed, Hospital, 3 sections,trendelemburg withmattress 30Monitor, patient, multiparameters 30Pump, infusion,volumetric 30

03.03.02.03

IsolationPatient Roomw/ Toilet / 2

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Shower

Bed, Hospital, 3 sections,trendelemburg withmattress 2Monitor, patient, multiparameters 2Pump, infusion,volumetric 2

PEDIATRICUNIT - 16Beds



Medication Cart 1Monitoring CentralStation, 16 bed 1Pulse Oxymeter 1Pump, infusion,volumetric 1



PATIENT AREA 03.07.02.01Double PatientRoom w/ Toilet 6

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/ Shower

Bed, Hospital, infant, withmattress, 1.30 x 0.80 m 6

03.07.02.03


Bed, Hospital, infant, withmattress, 1.30 x 0.80 m 2

POSTPARTUMUNIT - 24Beds





Monitor, patient, multiparameters 1Pulse Oxymeter 1Pump, infusion,volumetric 1Pump, Syringe 1

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.





Bed, Hospital, 3 sections,trendelemburg withmattress 10

03.05.02.02

Private BariatricPatient Roomw/ Toilet/Show. 2


PRE-ADMISSIONTESTING PATIENT AREAS 03.01.02.03

SpecimenProcessing /EKG Workroom 1

Cardiograph (EKG) 1

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REHABUNIT- 24beds









03.04.02.03



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.

ECRICODE

(UMDNS)ECRI CODE Name Description Qty

10134 Anesthesia Units Anaesthesia machine, 2 vaporizers,basic (incl cylinders) 5

10334 Cleaners, Bedpan Washer/Decontamination Units,Bedpan/Ancillary Utensil 9

10347 Beds, Electric Bed, ICU, 4 sections, trendelenburg,electric operated 40

10353 Beds, Hydraulic Bed, Hospital, 3 sections,trendelemburg with mattress 56

10362 Beds, Fixed, Cradle, Pediatrics Bed, Hospital, infant, with mattress,1.30 x 0.80 m 8

10385 Exercisers, Bicycle Bicycle, exercise 1

10429 Detectors, Blood Flow,Ultrasonic Doppler Vascular Bidirectional 2

10447 Warmers, Blood/Solution Warmer, infusion and blood 3

10644 Carts, Medication Medication Cart 16

10647 Carts, Resuscitation Cart crash with defibrillator 10

10780 Centrifuges, Tabletop Countertop Centrifuge 2

11218 Hemodialysis Units Hemodialysis Units 16

11246 Diathermy Units, Shortwave Shortwave therapy unit 10

11467 Electroencephalographs EEG (electroencephalograph) 1

11474 Electromyographs EMG (electromyograph) 1

11479 Electronystagmographs Electronystagmography 1

11585 Ear/Nose/Throat TreatmentUnits ENT Unit with Chair, basic 3

11614 Recorders, Graphic, EvokedPotential EP (Evoked potentials) 1

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.

12025 Hoods, Isolation, Laminar AirFlow Chemo Hood 1

Hood, laminar flow, 6 ft 1

12068 Hypo/Hyperthermia Units Hypo/Hyperthermia Units 2

12112 Incubators Incubator, 50 l, up to 70 °C 2

12113 Incubators, Infant Incubator, neonatal 1

12276 Lights, Examination Examination Light 6

12281 Slit Lamps Lamp, slit 3

12282 Lights, Surgical Light, operating, double, ceilingmounted 15

12415 Stimulators, Electromagnetic Magnetotherapy Unit 10

12536 Microscopes Microscope, binocular, 3 objectives 2

12647 Physiologic MonitoringSystems, Acute Care Monitor, patient, multi parameters 117

Monitor, patient, multi parameters,MRI 1

12853 Oximeters Pulse Oxymeter 15

13056 Plethysmographs plethysmograph 1

13217 Infusion Pumps, Syringe Pump, Syringe 17

13267 Radiographic Units X-Ray, bucky, with vertical wall buckystand 3

13272 Radiographic Units, Mobile X-Ray, Mobile Unit, Digital 1

13315 Refrigerators Pharmacy Refrigerator 5

13316 Refrigerators, Morgue Mortuary cooling unit, 6 corpses 1

13469 Scanning Systems, ComputedTomography CT Scanner, 16 multislice 1

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.

13746 Sterilizing Units, Steam Steam Sterilizer, double door 2

13953 Tables, Autopsy/Dissecting Tables, Autopsy/Dissecting 1

13961 Tables, Operating General operating table 9

13967

Tables,Examination/Treatment,Adjustable, Orthopedic,Traction

Table, traction, complete withaccessories 2

14263 Ultrasonic Cleaning Systems Ultrasonic Washer/Dryer Systems 1

14450 Baths, Whirlpool Mini Whirlpool Butterfly 1

Whirlpool Extremity Tank 2

Whirlpool Tub 2

15114 Washers, Cell Centrifuge, cell washer 2

15146 Analysers, Laboratory,Hematology, Hemoglobine Automated Blood Bank System 1

15157 Microtomes, Cryostat Microtome, rotating, paraffin and CO2freezing 2

15190 Tissue Processors Tissue Processors 2

15284 Injectors, Contrast Media,Angiography

Injectors Contrast Media forAngiography 1

15583 Freezers Freezer Storage 1

15612 Water Purification Systems Water Purification Plant forHemodialysis 1

15916 Laundry Equipment Dryer/Tumbler, 33 kg, electricalheated, single door 1

Roll heated flatwork ironer 1

Washer/extractor, 50 kg, electricalheated 1

15938 X-ray Film Processors,Automatic Dry Printer 2

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.

15952 Radiographic/FluoroscopicUnits X-ray, radiology and fluoroscopy, basic 1

15976 Scanning Systems, Ultrasonic,General Purpose Ultrasound General Purpose System 2

15999 Washers, Flexible Endoscope Washer/disinfector, endoscope 2

16018 Dialyzer Reprocessing Units Dialyzer Reprocessing Units 1

16260 Scanning Systems, MagneticResonance Imaging MRI System 1.5T 1

16484 Television Systems, PatientMonitor Monitoring Central Station, 12 bed 2

Monitoring Central Station, 16 bed 1




16495 Infusion Pumps Pump, infusion, volumetric 93

16509 Heating Units, Hot Pack Pack heater table model with standardhot packs 10

16597Radiographic/FluoroscopicSystems,Angiographic/Interventional

Angiographic Interventional System 1

16786 Stretchers, Mobile, Hospital Stretchers, Mobile, Hospital 6

16924 Infusion Pumps, Patient-Controlled Analgesic PCA Pump 1

17146 Washers, Rigid Endoscope Cabinet, Endoscope 1

17429 Ventilators, Intensive Care Ventilator, intensive care, adult / child 16

17433 Warmers, Radiant, Infant,Mobile Heater, radiant, newborns, mobile 1

17671 Washer/Decontaminators Washer/Decontaminators 1

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.

17739 Electrosurgical Units, Argon-Enhanced Coagulation

Electrosurgery unit, with Argon PlasmaCoagulator 4

17901 Carts, Mortuary Trolley, mortuary, height adjustable 1

17908UltrasonicUnits/NeuromuscularStimulators, Physical Therapy

Combination therapy unit(multistimulator & ultrasound) 10

17969 Injectors, Contrast Media,Computed Tomography Injectors Contrast Media for CT 1

18146 Sterilizing Units, Plasma Low Temperature Sterilizer 2

18158 Injectors, Contrast Media,Magnetic Resonance Imaging Injectors, Contrast Media, MRI 1

18171 Pill Counters, Manual Pill Counter, tablets, manual 1

18231 Electrosurgical Units,Monopolar/Bipolar

Electrosurgery unit, mono/bipolarcutting, 300 W 5

18329 Electrocardiographs,Multichannel Cardiograph (EKG) 6

18339 Cardiotocographs, Antepartum Monitor, Antepartum Fetal Monitor,on trolley 2

18340 Cardiotocographs, Intrapartum Monitor, CTG, on trolley 4

18388 Beds, Mechanical, Birthing Bed, birthing 4

18432 Radiographic Systems, Digital,Mammographic Digital mammography FFDM 1

18497 Pacemakers, Cardiac, External Pacemaker single chamber 1

18510 Analyzers, Point-of-Care,Whole Blood, Gas/pH Analyzer, Blood Gases, POC 1

18511Analyzers, Point-of-Care,Whole Blood,Gas/pH/Electrolyte

Analyzer, blood gas 1

20796 Workstations, DigitalRadiography WORKSTATION, PACS, FLAT, DUAL 2

Video Endoscopy System (w/Lightsource and Insuflator) 9

13037 Phototherapy Units Phototherapy unit, mobile 1

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.

17723 Physiologic Monitoring Systems,Stress Exercise, Cardiac Stress test system 1

17422 Scanning Systems, Ultrasonic,Cardiac Ultrasound, Diagnostic-Cardio 1

ECRICODE

(UMDNS)

ECRI CODEName Description Description / Specs

10134 Anesthesia Units

Anaesthesiamachine, 2vaporizers, basic(incl cylinders)

Anesthesia Machine,. Patients: Pediatric(>8kg) to Adult. Ventilation mode: VCV, PCV, SIMV+VCV+PSV,SIMV+PCV+PSV, Manual, Standby. Tidal volume(VT) 40 to 1500 mL. Frequency (f) 4 to 60 bpm / I:E 3:1 to 1:6(Increment：0.5). Inspiratory pause (Tp) OFF，5%～50%. E-PEEP OFF，4～20 cmH2O. Pressure Limit PEEP+5～PEEP+70 cmH2O. Parameter monitoring

- Inspiratory tidal volume(VTI) 0-2000ml / Expiratorytidal vomume(VTE) 0-2000ml

- Minute volume(MV) 0-60L- Frequency(f) 0-100bpm- Ppeak -12--100 cmH2O / Pmean 0-100 cmH2O /

Pplat， 0-100 cmH2O- FiO2 21%-100%- Compliance 0-200ml/ cmH2O- Resistance 0-200cmH2O(L/S)- Waveform P-T, F-T, V-T,- Alarm setting VT, MV, f, FiO2, Airway pressure,

High continuous airway pressure, Negative pressure,Apnea, O2 supply failure, Mains failure, Battery lowcapacity, Battery exhausted.

- Alarm mute < 100s. Gas supply Pipeline：O2, N2O and Air；Yoke: 1x O2;1x N2O;. Vaporizer 2 stations. Flowmeter Mechanical 5 tubes with back lightfunction. APL valve 2～70 cmH2O. CO2 Canister. By-pass. Automatic; change soda lime during operation.. Bag/vent switch switch for manual ventilation andmechanical ventilation

10334 Cleaners,Bedpan

Washer/Decontamination Units,Bedpan/Ancillary

Bedpan washer made entirely of stainless steel AISI316, strong structure one-piece wash chamber withefficient self-cleaning system for thermal disinfection.

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.

Utensil With multifunctional aid, capable of holding all thereceptacles commonly used in hospitalsAutomatic door. Accessories included.

10347 Beds, ElectricBed, ICU, 4 sections,trendelenburg,electric operated

Bed, ICU, 4 sections, trendelenburg, electric operated

10353 Beds, Hydraulic

Bed, Hospital, 3sections,trendelemburg withmattress

Bed, Hospital, 3 sections, trendelemburg withmattress

10362Beds, Fixed,Cradle,Pediatrics

Bed, Hospital,infant, withmattress, 1.30 x0.80 m

Bed, Hospital, infant, with mattress, 1.30 x 0.80 m

10385 Exercisers,Bicycle Bicycle, exercise

Free standing exercise unit, with integralspeedometer/timing device, tubular steel frame, withfront and rear stabilizer bars, height adjustable seat,adjustable electromagnenic resistance. Approx.dimension 110h x 95w x 50d cm

10429 Detectors, BloodFlow, Ultrasonic

Doppler VascularBidirectional

Doppler Vascular Bidirectional, on cart with printer. 4 MHz & 8 MHz continuous Doppler. Bidirectional Doppler for Angiologist, Phlebologist,Cardiologist, Diabetologist. Arterial & venous Doppler. Real-time colour spectral analysis. Audio output:

- Two loud speakers- Stereo, separated reverse and forward flows

. Six indices displayed in real time (Vs, Vd, Vm, Hr, RI,PI, S/D). Display of the curve or spectrum· Probes: 1 x 4 MHz probe and 1 x 8 MHz probe. 7’’ WVGA touch screen (TFT colour)· 1 Double foot switch pedal· 1 Trolley. 1 External Printer

10447 Warmers,Blood/Solution

Warmer, infusionand blood

User adjustable set point temperature 36C or 39°C,No disposable set required, Temperature Display,Over temperature alarm, for use with standard tubesized 4mm and 5mm, Simple channel setting: 1 to 15ml/min., Dual channel setting: 1 to 20 ml/min

10644 Carts,Medication Medication Cart Trolley, medical records, 20 files

10647 Carts,Resuscitation

Cart crash withdefibrillator

Defibrillator to include non-invasive pacing and two sets of externalpaddles. ulti-function defibrillator pads —adult and pediatric padsfor defibrillation, ecg monitoring, pacing and synchronizedcardioversion.

10780 Centrifuges,Tabletop

CountertopCentrifuge Centrifuge, bacteriological, 7 x 6 ml

11218 HemodialysisUnits Hemodialysis Units

Hemodialysis unit. Back flow prevention;proportional mixing system; heat and chemicaldisinfection; single needle system; heparin pump;

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.




























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.




























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.

blood pressure

11246 Diathermy Units,Shortwave

Shortwave therapyunit

Shortwave Diathermy Unitsoft-rubber electrodes, used either in continuous orpulsed modes.Possibility to use in a shallow penetration withcapacitive electrodes.Include: 2 soft-rubber capacitive applicators, 6 feltspacers, cloth coverselastic straps

11467 Electroencephalographs

EEG(electroencephalograph)

EEG (electroencephalograph) neurodiagnstic system.32 channels

11474 Electromyographs

EMG(electromyograph)

Electromyograph (EMG), diagnostic and multi-modality monitoring. With 2, 4 or 8 channelconfigurations; including cart w/built- intransformer/power supply & emg sp

11479 Electronystagmographs

Electronystagmography Electronystagmography

11585 Ear/Nose/ThroatTreatment Units

ENT Unit with Chair,basic

Endoscopy unit with microscope. Light source, withtwo lamps 250W Halogen. Manual brightnesscontrol.Complete with suitable light cable. CCD camera ofhigh sensitivity (min 3 lux) and high resolutionAutomatic brightness control and white balancecontrol.Complete with camera head and lens. Min 14 inchcolour monitor with high resolution screen.Colour video printer, with multiple frame memory,printing time approx. 60 sec. CD/DVD recorder. Hi-Fistereo sound VHS.Plug-and-play.System picture: Mobile unit tower with space ofstorage of min 5 different units and one drawer fordrugs and accessories. 4 antistatic wheels withbrakes.Telescope for ear 25° - 30°.Telescope laryngo-pharyngoscope 70° (to be usedwith stoboscope generator).Telescope for nose and paranassal sinuses 25°-30°.Flexible, fibre-optic, naso-laryngo-pharyngoendoscope, approx. external diameter 5mm,biopsy channel diameter approx. 2.2mm, distal dipcontrol up 130, down 130, working length approx.330mm.

11614Recorders,Graphic, EvokedPotential

EP (Evokedpotentials)

EP tests:- SEP: Somatosensory Evoked Potentials- VEP: Visual Evoked Potentials - Steady State too- AEP: Acoustic Evoked Potentials (Middle, LongLatency)- BAEP: Brain Acoustic Evoked Potentials- MEP: Motor Evoked Potentials- LEP: Laser Evoked Potentials- MMN: Cognitive Evoked Potentials

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.

12025 Hoods, Isolation,Laminar Air Flow

Hood, laminar flow,6 ft

6ft horizontal laminar flow clean bench with basecabinet. ISO Class 5 (Class 100) environment.

12025 Hoods, Isolation,Laminar Air Flow Chemo Hood

Vertical flow hood (biological safety cabinet). Airblows towards worker; Used for chemotherapypreparations.

12068 Hypo/Hyperthermia Units

Hypo/HyperthermiaUnits

Three sets of fluid inlet/outlets for connecting tocirculating water blankets, to be used with child oradult full body or joint/limb pads (blankets), digitaldisplay of water temperature, set point and patienttemperature, lighted indicators forcooling/heating/at set point, alarms and silence,paddle wheel flow indicator

12112 Incubators Incubator, 50 l, upto 70 °C

Microprocessor equipped incubator, benchtopmodel. 50 l, up to 70 °C. Digital display.

12113 Incubators,Infant Incubator, neonatal

Infant Incubator, Microprocessor based servocontrolled temperature system;Six windows, two side windows can be swiveled andFront drawers – 2 piecesLED display air tempeature and set temperature,Four alarm functions;A second thermal cut-out function for more safety,Temperature deviation adjustable automatically, >37°C temperature setting, Humidity is adjustable intwo gradeInfant bed inclination angle is adjustable andMattress – 1pieceBracket with stand and Rails for accessories – 2piecesPatient skin probe reusable –2 pcs

12276 Lights,Examination Examination Light Light, ceiling mounted or mobile, single exam. Lamp

160,000 lux

12281 Slit Lamps Lamp, slit

Automated system, able to incorporaterefractometer, keratometer, lensmeter,opthalmometer and automatic chart projector.Counter balanced suspension arm with safety lock forswinging.Interfaces for autorefractometer and autolensmeter,

sockets for examination instruments.Electric examination chair, fully reclaimable backrest

180, rotatable 360°, with adjustable backrestIllumination system:Slit width : continuously variable, approx. 0 to 14mmSlit length (Aperture) : 0.2, 1, 2, 5, 10, 14mm (preset)& 1 to 12mm continously variable, 14mm dia. Bluefilter is mounted on apreture length select turretSlit rotation : Up to 90 degree on either side ofvertival positionMirror rotation : 7mm in either direction on targetplate.Slit tilting : 0, 5, 10, 15, 20 degree steps.Filters (UV cut filter is incorporated) : Red-free, hearabsorbing, ND (28% transmission) and blue filtersUnit to include 2 spare bulbs

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.

Applanation Tonometer (Table type)* Measuring force generated : By leverage weight* Measuring range : 0-80mmHg

12282 Lights, SurgicalLight, operating,double, ceilingmounted

Dual head led surgical light. 160,000 lux

12282 Lights, SurgicalLight, operating,double, ceilingmounted

Recessed dual birthing light in ceiling, with lightcontroller

12415 Stimulators,Electromagnetic

MagnetotherapyUnit

2-channel portable thermal magnetic therapymachine

12536 MicroscopesMicroscope,binocular, 3objectives

Suitable for bight field and dark field microscopyapplications.Infinity corrected optics.Binocular eyepiece tube inclined rotatable through360°, of magnification 10x.Interpupillary distance adjustable.Revolving nosepiece 5 place with objectives ofmagnification 4x, 10x, 20x, 40x, 100x (oil), planachromatic type.Rackless mechanical stage with tension adjustment,coarse and fine controls (1im sensitivity).Specimen holder X-Y motion.Type of the illumination system according to theKoehler method.To include a polariser.Abbe condencer NA 1,25 with carrier for blue andgreen filter.

12647

PhysiologicMonitoringSystems, AcuteCare

Monitor, patient,multi parameters

Touch screen integrated patient monitor, 4 wavesegments, drug calculator, anesthesia oleh support, 2lithium-ion batteries, anesthesia software,multimeasurement server w/ecg/resp, sp02, nibp,ivp, thermal array recorder.

12647

PhysiologicMonitoringSystems, AcuteCare

Monitor, patient,multi parameters,MRI

Multi parametric monitor for MRI. Touch screenintegrated patient monitor, 4 wave segments, drugcalculator, anesthesia oleh support, 2 lithium-ionbatteries, anesthesia software, multimeasurementserver w/ecg/resp, sp02, nibp, ivp, thermal arrayrecorder.

12853 Oximeters Pulse Oxymeter Handheld Oximeter, Display: SpO2 value, Pulse rate

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.

value, bar graph, Pulse waveform

13056 Plethysmographs plethysmograph

Plethysmography, body box. Provides truecompression; free flow volume loops; resistancemeasurements in panting or quiet breathing modes,even on the most difficult patients to test.

13217 Infusion Pumps,Syringe Pump, Syringe

Syringe Pump,. Drug library,. For universal syringes of 5-60ml. Max rate: 1800ml/h,. Accuracy: 2%,. KVO/Bolus. Battery for continous operation. Alarm: Audible and visible

13267 RadiographicUnits

X-Ray, bucky, withvertical wall buckystand

Digital radiography unit for excellent image qualitySystem to support connection to a RadiologyInformation System (RIS) and to DICOM-compatiblediagnostic units and archives.Digital Flat Detector with field size approx. 43 x 43 cmOperating station for automatic processing, viewingand reprocessing of Images.Digital multipurpose single detector stand for allgeneral radiographic applications.Single sided height adjustable table50 KW Generator : micro-processor controlled highfrequency controlled X-ray converter generator witharea dose calculator for 1 tube nominal rating 50 KW,with exposure times from 1 ms up to 4 sec.Automatic collimation : Equipment for automaticbeam limitation at digital flat panel detectorBucky : Ceiling suspended column for X-ray tubeassembly.Vertical Bucky Stand: Counter-balanced verticalmovement of the potter bucky with emergencymechanical brake. Potter bucky for cassettes from 13x 18 to 36 x 43 cm with cassette insertion on bothsides. Auto-centering cassette trayCS ceiling rails: For longitudinal carriages of CSmonitor ceiling suspensionHigh resolution 19" TFT color LCD DisplayDICOM package for easy integration ofDigitalDiagnost into DICOM compatibleenvironments.

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.

13272 RadiographicUnits, Mobile

X-Ray, Mobile Unit,Digital

. Stand:- Focus floor distance from 496 to 2022mm (Z axis)- Monobloc rotation around: the arm axis ±180° (X

axis); its axis +103° -50° (Y axis)- Column rotation around its axis (ß axis: ±90°)- Holder pocket for FPD Flat panel detector

. Generator with high frequency working:- Frequency 40kHz- Max. power 30kW (Residual wave <2%)

. Detector for digital acquisition and storage ofradiographs.

- X-ray sensing surface: 35.4 x 42.5 cm (14” x 16.7”)- Usable pixel matrix: 2455 x 3056- Pixel size: 139 x 139 ?m

. Built-in monitor

. DICOM compatible

13315 Refrigerators PharmacyRefrigerator

Pharmacy refrigerator/freezer, 2-door, 140Litresrefrigerator, 20Litres freezer, self-contained unit

13316 Refrigerators,Morgue

Mortuary coolingunit, 6 corpses

2x3 Enamelled steel construction.2 tier x 3 to accommodate 6 cadavers.Self contained unit refrigeration systems.Built-in thermometer.Audible and visual alarms for temperature rise.Removable mortuary trays.To be provided with remote alarm system.

13469

ScanningSystems,ComputedTomography

CT Scanner, 16multislice

CT Scanner, 16 multislice system with tableCT Scanner mode: multisliceSlices rotation: 16 Slice Solid State DetectorsHigh Performance DASOperators ConsoleMagnetic Optical Disk StorageType of positioning lights: LaserX-RAY Generator:X-RAY Generator Power rating (kW): 53.2kV settings available80, 100, 120, 140mA Range and Step size: 10 - 440(5mA steps)Focal spot size(s) (mm), quoted to IEC 336/93standard0.6 x 0.70.9 x 0.9X-RAY Heat capacity: 6.3 MHU TubeGANTRY: 70 CM Gantry ApertureTotal effective length of detector array at isocentre(mm)Scan fields of view (cm): 25 and 50Nominal slice widths for axial scans (mm): 0.625,1.25, 2.5, 3.75, 5, 7.5, 10Tilt range (degrees)± 30Table:Horizontal movement range (cm): 170Horizontal movement speeds (mm/sec): up to 100Vertical movement range out of gantry (cm): 51 - 99Vertical movement range in gantry (cm): 88 - 99Scan projection radiography (SPR):Maximum SPR length (mm)1600

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SPR field dimensions (mm x mm)500 x 1600

13746 Sterilizing Units,Steam

Steam Sterilizer,double door

Sterilizer, steam, double door, 378 lts, w/generator.Transfer carriage and loading car

13953Tables,Autopsy/Dissecting

Tables,Autopsy/Dissecting Complete Tables for Autopsy and Dissection

13961 Tables,Operating

General operatingtable

General Surgical table. Mobile and manuallyoperated. 3 sections, mechanical, with standardaccessories.

13967

Tables,Examination/Treatment,Adjustable,Orthopedic,Traction

Table, traction,complete withaccessories

Table padded to facilitate traction, aprox dimension190cmx70cmVariable height ,Gas assisted head and foot sections,Industrial strength retractable castors,Adjustable foot for uneven floors,Traction machine mount variable height for differenttreatment

14263UltrasonicCleaningSystems

UltrasonicWasher/DryerSystems

Ultrasonic console, washer/dryer system. Includingcleaner and port flushing kit, pure water inlet.Complete with lid and accessories.

14450 Baths, Whirlpool Whirlpool ExtremityTank Whirlpool Extremity Tank

14450 Baths, Whirlpool Whirlpool Tub Whirlpool Tub

14450 Baths, Whirlpool Mini WhirlpoolButterfly Mini Whirlpool Butterfly

15114 Washers, Cell Centrifuge, cellwasher

Centrifuge, cell washer, 3550/700 rpm, 12-placecapacity;

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15146

Analysers,Laboratory,Hematology,Hemoglobine

Automated BloodBank System

Hematology analyzer.. Parameters: WBC, LYM#, MID#, GRAN#, LYM%,MID%, GRAN%, RBC, HGB, HCT, MCV,MCH,MCHC,RDW-CV, RDW-SD, PLT, MPV, PDW, PCT, 3-part differentiation of WBC, 19 parameters and 3histograms. Principles of operation: WBC/RBC/PLT: ElectricalImpedance / HGB: Photoelectric colorimetry. More than 100,000 sample results with histograms. Throughput: 60 samples per hour

15157 Microtomes,Cryostat

Microtome,rotating, paraffinand CO2 freezing

Sectioning all types of tissue. Floor standing unit,chamber made of stainless steel.Capable of cutting sections from 1 to 60 microns,with 1 to 5 microns increment.With rotary microtome fitted with micro adjusting,aligning anti-roll device.Heated window.Microprocessor controlled electronic temperaturecontrol and digital display from ambient to -35°C.Freezing shelf with capacity around 10 specimendiscs.With quick-freezing system -55°C.Programmable automatic defrost system and manualdefrost system.Interchangeable knife holder system to accept bothdisposable blades and standard steel knives.Includes holder for disposable blades and 50disposable blades.motor control for electrically driven specimenadvance.Speed approx. 0.2 MM.sec and 0.7 MM/Sec.It can work with the open window.Includes waste disposal system. Easy to clean.Complete with necessary accessories.

15190 TissueProcessors Tissue Processors Tissue Processor, Floor Model

15284Injectors,Contrast Media,Angiography

Injectors ContrastMedia forAngiography

Contrast media injector for use in angiography. Dualsyringe (contrast and saline).

15583 Freezers Freezer Storage

Ultra low freezer(-70C) to have a minimum of 5" offoamed in place polyurethane with a R factor ratingof 38.5. To have copper evaporator coils on all sidesand base for maximum heat removal and uniformtemperature.

15612Water

PurificationSystems

Water PurificationPlant forHemodialysis

Water Purification Plant for Hemodialysis

15916 LaundryEquipment

Washer/extractor,50 kg, electricalheated

Washer/extractor, 50 kg, electrical heated


Dryer/Tumbler, 33kg, electricalheated, single door

Dryer/Tumbler, 33 kg, electrical heated, single door

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Roll heated flatworkironer

Simple chain drive mechanism with single motorHeating roll made of high quality stainless steelLarge contact area of 300 degree to maximize heatexchangePatented automatic belt tensioning systemeliminates manual adjustmentVariable speed frequency inverter controlGradual speed increment between rolls to improveironing quality by stretching effectHeat isolation panel on feeding sideSimple control with ON/OFF button and speedadjustmentHeating roll and guide shaft drive simultaneouslyFloat type steam trap reduces steam consumption

15938X-ray FilmProcessors,Automatic

Dry Printer

Dry laser imager for centralized imagers, ultra-highspeed. Between 110 and 160 films per hour. Features50-micron high resolution printing and approved foruse with Full Field Digital Mammography (FFDM)devices. Accommodates all common film sizes, 3 ormore film drawers and top-mounted 4 or 6 bin filmsorter.

15952 Radiographic/Fluoroscopic Units

X-ray, radiology andfluoroscopy, basic

Multipurpose radiographic/fluoroscopic system.Flexible configurations, full range of r&f andinterventional procedures, full featured digitalsystem, and compact installation requirements.90/90 tilt table100 kw high frequency generator, 1000ma maxRemote mobile cart for generator and digital control,pulsed fluoro, 1024x1024 12 bit ccd tv system, 18"dual lcd ceiling suspended in-room monitors, 18" lcdcontrol room monitorInterface to PACS system: DICOM 3 standard

15976

ScanningSystems,Ultrasonic,General Purpose

Ultrasound GeneralPurpose System

3D/4D Ultrasound Doppler Color with probes forgeneral abdominal, obstetrics and gynecology andpossibly echocardiography exams. Main unit. 19”LCD monitor. 1pc convex probe. 1pc transvaginal probe. 1pc phased array probe. 4D package including volume probe + software +Extended Cardiac Package. 4pcs probe connector.

15999Washers,FlexibleEndoscope

Washer/disinfector,endoscope

Disinfecting unit, liquid, flexible endoscope, dualcapacity, air compressor

16018DialyzerReprocessingUnits

DialyzerReprocessing Units Automatic Dialyzer Reprocessing Units

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16260

ScanningSystems,MagneticResonanceImaging

MRI System 1.5T

MRI system 1.5 t with 16 channels.High-density, 16-channel, head-neck-spine arrayimage without changing coils or repositioning thepatient. Whole-body, high resolution, high signal-to-noise ratio scanner with short scan times. With a fullsuite of brain and spine imaging applications,insensitive to susceptibility effects, even in areas thatwould otherwise be difficult to image such as boneand air-tissue interfaces.Coils: head and body, abdomen, spine, breast, knee,shoulder, cardiac imagingpower requirements: 480 or 380/415cooling system: closed-loop water-cooled gradientcryogen use: less than 0.03 l/hr liquid heliumspectroscopy: possiblesynchronization: ecg/peripheral, respiratory gating,imaging modes: 2d single slice, multi slice, and 3dvolume images, multi slab, cinefov: 1cm to 48cm continuousslice thickness: 2d 0.7mm to 20mm; 3d 0.1mm to5mmdisplay matrix: 1028 x 1024measuring matrix: 128 x 512 steps 32 phase encodepixel intensity 256 gray levels

16484TelevisionSystems, PatientMonitor

Monitoring CentralStation, 16 bed

Central station database, 16 patient capability, dualdisplay capability, 150 alarms, hl7 export, 48 hourcer, 19" touch display, usb recorder, printer,installation site services, site specific services.

16495 Infusion Pumps Pump, infusion,volumetric

IV Infusion Pump,. For universal IV sets. With drop detector (patented),. Max rate:1200ml/h,. Accuracy:2% to 5%,. KVO/Bolus,. Battery for continous operation. Alarm: Audible and visible

16509 Heating Units,Hot Pack

Pack heater tablemodel withstandard hot packs

Set of 4 different size hot packs used for pain relief,Neck, back, shoulder, and general.

16597

Radiographic/FluoroscopicSystems,Angiographic/Interventional

AngiographicInterventionalSystem

Complete Angiographic configurations, full range ofinterventional procedures, full featured digitalsystem, and compact installation requirements.90/90 tilt table with integrated isocentric c-arm100 kw high frequency generator, 1000ma maxdsa and inteventional applications, remote mobile

cart for generator and digital control, pulsed fluoro,1024x1024 12 bit ccd tv system, 18" dual lcd ceilingsuspended in-room monitors, 18" lcd control roommonitorInterface to PACS system: DICOM 3 standard

16786 Stretchers,Mobile, Hospital

Stretchers, Mobile,Hospital

Stretcher procedural with manual knee gatch,radiolucent top, steering plus, IV pole, push handles,and mattress

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16924

Infusion Pumps,Patient-ControlledAnalgesic

PCA Pump

PCA Pump including locking syringe cover andsecurity codes, large, back-lit display, easilyprogrammed infusion modes, takes 4 "d" sizebatteries or standard ac power kit

17146 Washers, RigidEndoscope Cabinet, Endoscope

Laminated Endoscope Cabinet (6 Scopes). Box withlid specially designed for manual disinfection of rigidscopes. Fully laminated and washable, single door.Vented at the bottom of the door. Scopes hangstraight without touching at the top or bottom.Padded back and drip tray.

17429 Ventilators,Intensive Care

Ventilator, intensivecare, adult / child

Mobile pedestal for ventilator or mounted on castorsModes: assist/control (a/c), synchronizedintermittent mandatory ventilation (simv), orspontaneous (spont), bi-levelMandatory breath types: volume control (vc),pressure control (pc) or volume control plus withvolume ventilation plus optionPatient circuit type: pediatric, adult or neonateSpontaneous breath types: pressure supported (ps),volume supported (vs), proportional assist (pa), nonevent type: invasive or noninvasive pressure support:0 to 70 cm H2ORise time %: 1% to 100%Expiratory sensitivity: 1% to 80%; 1 l/min to 10 l/minwith PAVTidal volume (vt): 25 to 2,500 ml, 2 to 315 mlRespiratory rate (f): 1.0 to 100 /min, 1 to 150 /minPeak inspiratory flow (Vmax): 3 to 150 l/min for IBW> 24 kg; 3 to 60 l/min for IBW ≤ 24 kg, 1 to 30 l/minFlow pattern: square or descending ramp plateautime: 0.0 to 2.0 secondsInspiratory pressure: 5 to 90 cm H2OI:E ratio: 0.2 to 8.0 seconds / ≤ 1:299-4.00:1Pressure sensitivity : 0.1 to 20 cm H2O below peep

17433Warmers,Radiant, Infant,Mobile

Heater, radiant,newborns, mobile

Infant Warmer, Microprocessor servo controlled.Alarm functions for safety includes: Power failure,temperature deviation, Temperature sensor failure,over temperature. The alarms are audible and visual.Transparent protectorA second thermal cut-out function for more safetySkin temperature sensor failure protect functionavoid over temperature. Warmer temp range min 18-30 deg CMounted to four castors with brake for maximummobility

17671 Washer/Decontaminators

Washer/Decontaminators

Washer/disinfector, 8 adjustable cycles, powerdouble doors, baskets and cart for load and unload

17739

ElectrosurgicalUnits, Argon-EnhancedCoagulation

Electrosurgery unit,with Argon PlasmaCoagulator

Electrosurgical unit with argon plasma coagulator,foot pedals, 4 apc applicators, 6 biclamps, 3 bipolarinline coagulators. (OR and GI configuration)

17901 Carts, Mortuary Trolley, mortuary,height adjustable Trolley, mortuary, height adjustable

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17908

UltrasonicUnits/NeuromuscularStimulators,Physical Therapy

Combinationtherapy unit(multistimulator &ultrasound)

Combined ultrasound and electrotherapy unit withtwo frequencies 1 & 3 MHz simultaneously from onetreatment head. Electrotherapy with all treatmentcurrents such as interferential, rectangular andtriangular pulsed, continuous direct, biphasicsymmetrical pulsed, diadynamic, lontophoresis etc.

17969

Injectors,Contrast Media,ComputedTomography

Injectors ContrastMedia for CT

Mri contrast media injector for use with up to 3.0tmagnets. Dual syringe (contrast and saline).Ceiling or Mobile

18146 Sterilizing Units,Plasma

Low TemperatureSterilizer

Low Temperature Sterilizer, 100 lts. Free standinglow temperature sterilizer. Transfer carriage andloading car

18158

Injectors,Contrast Media,MagneticResonanceImaging

Injectors, ContrastMedia, MRI

Contrast media injector for use in RMI. Dual syringe(contrast and saline).

18171 Pill Counters,Manual

Pill Counter, tablets,manual Pill Counter, tablets, manual

18231

ElectrosurgicalUnits,Monopolar/Bipolar

Electrosurgery unit,mono/bipolarcutting, 300 W

Nominal initial power – monopolar max. 300 W,Bipolar 100 W, Nominal frequency 350 kHzWorking regimes: mono-polar scission, mono polarscission with coagulation, possibility to choosedegree of coagulation, mono coagulation – soft,forced and spray, bi-polar coagulation –soft, forcedand section.Automatic regulation of working regime dependingon: type of tissue, scission velocity and parameters ofthe electrode used;Automatic start with bi-polar coagulation withpossibility to choose the start timeNeutral electrode loop control per electric currentand impedancePossibility to operate by pedal and manual buttonsAuto test of the instrument and the accessoriesfunctionalityAlarm in case of errorsPossibility to program the appliance depending onthe individual needs and requirements.Completion of the Electric Coagulator: Neutralelectrode – multiple, Neutral electrode cable, Two-step pedal, Electrode handle with two buttons – 2pieces, Electrode handle cable – 2 pieces, Electrodesfor scission and coagulation – 8 pieces, a set with astand – 2 pieces, bi-polar pincers, straightbi-polar pincers cable, All accessories for operationmust be supplied

18329Electrocardiographs,Multichannel

Cardiograph (EKG)Portable electrocardiograph (ECG), with cart andrechargeable battery;12-lead algorithm, high-resolution display

18339 Cardiotocographs, Antepartum

Monitor,Antepartum Fetal

Maternal fetal monitor, including direct fetal heartrate, toco and intrauterine pressure, as well as

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Monitor, on trolley maternal blood pressure, pulse rate, ecg, and spo2.equipped for twins.

18340 Cardiotocographs, Intrapartum

Monitor, CTG, ontrolley

Intrapartum, foetal monitor measuring 2 HRdisplayed numerically. Measurement of direct ECG,maternal HR, uterine activity.The unit should have three inputs: MECG,Ultrasound transducer, ECSInclude: multi channel thermal printer, mobile cart,electrodes and associated transducers (Ext. Toco,dECG, mECG, Ultrasound, Uterine catheter).Intrauterine pressure with signal range in: 100-130mm Hg.Possible telemetry interface.Self test facility

18388Beds,Mechanical,Birthing

Bed, birthing

Birthing bed to include lumbar and seat air package,"v" cut-out or straight edge, comfortline mattress,fluid basin, batteryback-up, and powered foot section; cable for bed int

18432RadiographicSystems, Digital,Mammographic

DigitalmammographyFFDM

. Mammographic unit complete with 5 kW 100 kHz x-ray generator. a-Se digital flat panel detector 18x24cm (with leadmarkers),. Flat compression paddle 18x24cm, automaticcollimation, lexan screen (for patient faceprotection), fully automatic exposure system. Upgrade to 24x30 a-Se digital flat panel detector(2816x3584 pixels). High Speed Starter. Motorized C-arm rotation and Isocentric "C" Armwith fixed FFD predisposed for accepting biopsy

18497 Pacemakers,Cardiac, External

Pacemaker singlechamber

Pacemaker, single chamber temporary external unit;modes incl: ai, aoo, vvi, voo; sensitivity adjustable0.5-20 mv

18510Analyzers, Point-of-Care, WholeBlood, Gas/pH

Analyzer, BloodGases, POC

Point-of-care testing (POCT) satellite laboratoryBlood glucose, urine human chorionic gonadotropin,urine dipstick, creatine kinase-MB, and troponintests.

18511

Analyzers, Point-of-Care, WholeBlood,Gas/pH/Electrolyte

Analyzer, blood gas

Multi-parameter analyzer for blood gas, electrolytes,co-oximetry and metabolites for critical-care testingthroughput of up to 30 samples per hour for syringeor 27 samples per hour for capillary.

20796Workstations,DigitalRadiography

WORKSTATION,PACS, FLAT, DUAL

Workstation, pacs, flat, dual 3-mega pixel, 20",monochrome, to be used in diagnostic qualityreading (2048 x 1536 matrix), including tilt and swivelstand and budget for client pacs software.

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Video EndoscopySystem (w/Lightsource andInsuflator)

Video Endoscopy System for Surgery w/Light sourceand Insuflator, includes:Video Endoscope unit for surgeryEndoscope flushing pump. Automatically flushesscopes channels with detergent, water and air.Color video printer. HDTV: RGB/YPbPr (commonconnector with SDTV) input connection.Endoscopic video system. HDTV, narrow-bandimaging, two types of structure enhancement,electronic magnification, digital output capability,pictureXenon light source. 300-watt lamp, automatic lightadjustment. Equipped with specially coated filters forNBI (Narrow Band Imaging).High definition LCD monitor. 19 "LCD MonitorEndoscopy procedure cart with scope pole kit. LCDmonitor arm, integrated cable management, gasbottle holder, isolation transformer

13037 PhototherapyUnits

Phototherapy unit,mobile

Phototherapy Unit with mobile Stand, Blue / whitelight fluorescent tube

17723

PhysiologicMonitoringSystems, StressExercise, Cardiac

Stress test system

Cardiac stress test with treadmill system, P.C. basedstress test system with monitor. Treadmill, cardio-exercise , 20x55 walking surface, 400 lb. weight cap.,1-10mph, 0-25% elevation, with short side handrail

17422

ScanningSystems,Ultrasonic,Cardiac

Ultrasound,Diagnostic-Cardio

Ultrasound, cardiovascular, cardiac, adult, pediatric,tee, vascular, carotid, transcranial doppler (tcd),intraoperative.


Site Visit-Lista ajustata (activitati in cadrul Planului de regionalizare a spitalelor din zona denord)

1. Octavian

2. Rodica

3. Andrei Matei

4. Osoianu – CNAM

5. Talmaci Valeriu – medic, SR Briceni

6. Roler Sergiu – medic, SR Ocnita

For further study site visit plans please refer to “Proces verbal nr 250 din 04.06.13 -limitarea instruirilor-CS Gangura solicitarea-Raport 3 DecentralizChimioterapie-IDf Grantactivitati suplim-reselectarea Audit Codif-Audit acceptat raport.”

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