Health system Moldova

8/6/2019 Health system Moldova

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Health Systems:The Players and Payers

Viorel Soltan, MD, MBA, MPH

Center for Health Policies and

Studies (PAS Center)


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The Players

players in the healthcare system includ care

insurers, providers, government agencies,

pharmaceutical and biotechnology companies,

diagnostic service providers, medical producers,

drug distributors, professional associations as

well as patient groups and non-governmental

organizations


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Key players: Parliament

Every year approves Annual budget including

health budget

A parliamentary Committee on Health and Social

Welfare monitors MOH activity and inter-

ministerial coordination

Together with the MOH develops health policy

framework worked then into national strategyand action plan


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Key players: Ministry of Health

Policy development, quality control, and overallstewardship of the health care system and healthreform

The national preventive medicine network is alsosubordinated to and directly funded by the MOH

The MOH directly finances some nationalprogrammes such as tuberculosis and HIV/AIDS

Specialized medical institutes, hospitals and

clinics are also all directly subordinated to theMOHThe same is true of the national emergency

medicine network


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Key players: Ministry of Finance

Works with the Ministry of Health to advise

parliament on a suitable level of funding for

health care services and to agree the annual

health budget

Departments within the Ministry of Finance are

also responsible for the auditing and regulation

of contracts with the National Health InsuranceCompany


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Key players: Ministry of Education

Ministry of Education is responsible for the

provision of undergraduate medical education for

health services staff

The Ministry of Health oversees the content of

undergraduate education


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Key players: National Health Insurance

CompanyIt is a single purchaser of health care services in

MoldovaNHIC is a government subordinated agency

consisting of an Administrative Council andExecutive BoardThe Administrative Council is the supreme body

of the NHIC, consisting of fifteen members,including representatives of parliament,

Presidents Office, government (MOH, Ministry ofFinance, and Ministry for the Economy), NationalConfederation of Employers, trade unions,physicians and patient organizations


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Key players: National Center for Preventive

MedicinePreventive medicine institutions maintain a

vertical hierarchical structure and areaccountable to the MOH through the National

Centre for Preventive MedicineThere are 36 branches in each district and

municipality which are responsible locally forimplementing standards and guidelines for

environmental health, communicable diseasesand occupational health

The NCPM is also in charge of immunization.


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Key players: National Center for Emergency

MedicineEmergency services also maintain a hierarchical

structure and are accountable to the MOHthrough the National Center for Emergency

MedicineIt has four emergency medicine stations covering

their specified zones (Central, North, South andGagauzia) contract with the National Health

Insurance Company for fundingIn addition to the four zonal emergency stations,

there are 43 emergency sub-stations in each ofthe district, municipality and other autonomous

units


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Key players: Professional Associations

The Nurses Association of Moldova was foundedin 1994 as a nongovernmental professionalorganization

It is a dynamic organization, affiliated with theEuropean Nursing Forum

There are also a number of professional medicalassociations such as the Association of Surgeons,the League of Physicians and the Family Medicine

AssociationThe Sanatatea Trade Union for medical personnelis also active and plays an important role innegotiating salary scales


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Key players: Patient groups

The Republic of Moldova is home to a number oflocal patient groups and advocacy organizations,including the Patient Rights Group, the

Association of Patients on Haemodialysis, theAssociation of Diabetic Patients and theAssociation of Handicapped and ParalysedPatients

However, the capacity of patient groups to lobbyat the national level remains limited


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Key players: NGOs

A range of both international and local

organizations focusing on health operates in the

Republic of Moldova

Local NGOs are increasingly important actors in

the provision of health services. For example, in

order to meet the needs of children abandoned in

hospitals, one NGO has organized a specific wardfor them at a paediatric hospital with educational

materials, toys, support from volunteer staff, and

a child friendly environment


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Health System Overview (1)

The primary care sector is based on a generalpractice model with family doctors

Secondary care is provided through general

hospitals at the district / municipal levelSpecialized and high technology care is provided

through the republican hospitals and nationalinstitutes

Emergency care services are subordinated to theMOH through the National Centre for EmergencyHealth Care


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Health System Overview (2)

Financing principle: Service providers foremergency, primary, secondary and tertiarylevels contract with the National Health

Insurance Company (NHIC)Preventive medicine network which conducts

public health monitoring, is subordinated to anddirectly financed by the MOH

A number of parallel health services are financedfrom the state budget via the relevant ministriesbut also contract with the NHIC


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Central Government

Parallel health care

services

District health

authority

Chisinau Municipal

Health Authority

National Center for

Emergency Medicine

Ministry of Interior,

Defense, Justice etc.

Ministry of Health

Regional Emergency

Health Stations

Municipal hospitals

Family medicinecenters

District hospitals

Family medicine

centers

National Center for

Preventive Medicine

District preventive

medicine offices

Other republican

hospitals

Mother & child health, oncologic, cardiologic, neurologic, tuberculosis and

lung diseases centers, infection diseases, clinical hospital etc.

National Health

Insurance Company


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The payers

in health care, payers generally refer to entities

other than the patient that finance or reimburse

the cost of health services. In most cases, this

term refers to insurance carriers, other third-

party payers, or health plan sponsors (employers

or unions).

* Mosby's Dental Dictionary, 2nd edition.


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Health care system

The Moldovan health care system aims to provide

the entire population with universal access to a

basic package of health care services, and

to extend the accessibility of health care services

free at the point of use to the population


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Health care reform: background

After the collapse of the Soviet Union, the populationfaced severe social and economic upheaval; thehealth system found itself unable to provide

adequate, consistent and affordable health careA number of preventive programmes (i.e. nationalimmunization programme) were on the verge ofcollapse in the early 1990s

Increasing informal charges deterred many from

attending health facilities at allhealth reform became a pressing issue, particularly

following the collapse of the Russian rouble in 1998with its negative repercussions for the Moldovan

economy


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Health care reform: principals (1)

Organizational and structural changes to developfamily medicine centred primary health care,creating incentives for increasing health promotion

and preventive activities, improving themanagement of HR, introducing care guidelines andrestructuring the hospital network

Modifications of financing and provider paymentsystem by introducing mandatory health insurance

and contracting, changing provider paymentsystems (from line-item budgeting to per capita orfee-for-service mechanisms), and allocating statefunds to the HIC to cover vulnerable groups and

priority national programmes


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Health care reform: principals (2)

Reform of the education and training system for

medical staff (by changing the training curricula

in line with best developed practice,

strengthening continuing medical education,

and reforming medical specialties)

Pharmaceutical reform introducing rational

prescribing, developing pharmaceutical policiesand by introducing regulations for medicines

management


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Financial flows

GENERAL POPULATION

PUBLIC HEALTH CARE PROVIDERS

Out-of-pocketpaym

ent

Health InsuranceFund

Health InsuranceCompany

State budget

Ministry of Health

Preventive medicine

International loanand aid

Health InvestmentFund

Em

ployerand

employee

co

ntributions

Generaltaxation


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Equity in health

It is a key performance measure: payments

should be progressive, with richer households

paying proportionally more than poorer

households

In 2004, average direct household expenditure

on health for the poorest 20 percent of the

population fell 21% in real terms compared with2003

The share of out-of-pocket payment for health

has fallen from 51.5% in 2003 to 42.3% in 2005,

for both official and unofficial payments


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Efficient resource allocation

Efficiency in Moldova has been limited by

excessive and inefficient infrastructure, the

limited use of appropriate clinical protocols, and

a lack of capacity in the primary health care

system

In just one year, 1998-1999, the number of

hospitals fell from 276 to 150 and between 1991and 2006 the hospital stock was reduced by 75%

in 2006 there were 84 hospitals


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Outcomes for health care system

The transformation of the system of health carefinancing was smooth, and the provision ofmedical services was uninterrupted

Public funding of health care increased by 19percent in 2004 in real terms, and by 16 percentin 2005

Reforms have increased the stability of publicfunding for health care

The achievement of a real balance between stateguarantees of free health care and their publicfunding

* Shishkin, Kacevicius et al. 2006


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Outcomes for health facilities

Increased incomeStability of public fundingAcceleration of funding transfer from budgets

to facilitiesIncreased autonomy in spending decisionsThe creation of real incentives to increase

efficiency


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Outcomes for health professionals

Salary increasesThe possibility of earning salaries based on the

real volume and quality of their work


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Outcomes for general population

Improved accessibility of emergency pre-hospital and inpatient care for the insured (dataon out-patient care not reliable enough to draw

conclusions)Decrease in the magnitude of informal

payments


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Future developments

Over the past five years, the Republic of Moldova hasmade significant progress in reforming the healthsector

The first phase of reforms was driven by financialcrisis in the sector which forced local governments toclose small district hospitals and reduce the numberof health care personnel

The second phase has been largely driven by the

introduction of mandatory social health insuranceand the commensurate increases in health financing

With health spending at nearly 10% of GDP, it iscritical to introduce a new phase of reforms in order

to make gains in efficiency and quality

Health system Moldova

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