Expansion of Health Care in Moldova
Moldova officially the Republic of Moldova (Romanian: Republica Moldova, is a landlocked country in Eastern Europe, bordered by Romania to the west and Ukraine to the north, east, and south (by way of the disputed territory of Transnistria.
The capital of Moldova is Chisinau. The local language is Romanian, based on the Latin alphabet, but Russian is widely used. Moldova is a multi-ethnic republic that has suffered from violent ethnic conflict. In 1990 the self-proclaimed Transnistria Republic in eastern Moldova declared independence and a civil war was fought during the first half of 1992. A ceasefire was declared and Transnistria has maintained de facto independence with its own government and currency but is not recognized by any other country. Economic links have been re-established between these two parts of Moldova despite failure in political negotiations. The major religion in Moldova is Orthodox Christian.
Moldova’s population is occupied mainly in food production and processing. Once known as “the garden” of the Soviet Union, Moldova has now lost most of its traditional Russian markets for agricultural products and is exploring new international markets.
Moldova is the poorest country in Europe. Economic constraints mean that Moldova faces challenges in protecting individuals from excessive costs, improving population health and securing health system sustainability. The Moldovan government has introduced a state benefit package and expanded health insurance coverage to reduce the burden of health care costs for citizens. This study examines the effects of expanded health insurance by examining factors associated with health insurance coverage, likelihood of incurring out–of–pocket (OOP) payments for medicines or services, and the likelihood of forgoing health care when unwell.
Using publically available databases and the annual Moldova Household Budgetary Survey, we examine trends in health system financing, health care utilization, health insurance coverage, and costs incurred by individuals for the years 2006–2012. We perform logistic regression to assess the likelihood of having health insurance, incurring a cost for health care, and forgoing health care when ill, controlling for socio–economic and demographic covariates.
Private expenditure accounted for 55.5% of total health expenditures in 2012. 83.2% of private health expenditures is OOP payments–especially for medicines. Healthcare utilization is in line with EU averages of 6.93 outpatient visits per person. Being uninsured is associated with groups of those aged 25–49 years, the self–employed, unpaid family workers, and the unemployed, although we find lower likelihood of being uninsured for some of these groups over time. Over time, the likelihood of OOP for medicines increased (odds ratio OR = 1.422 in 2012 compared to 2006), but fell for health care services (OR = 0.873 in 2012 compared to 2006). No insurance and being older and male, was associated with increased likelihood of forgoing health care when sick, but we found the likelihood of forgoing health care to be increasing over time (OR = 1.295 in 2012 compared to 2009).
The State System
The basic package of free healthcare is limited to emergency assistance and treatment and treatment for acute illness. However, different medical organisations take varied views on what procedures are offered and where.
Financing of Moldovan healthcare is predominantly done through taxation, but there are pilot plans in operation whereby employers pay a flat rate contribution to a healthcare fund for each person they employ. There is no option for opting out of the state scheme. Vulnerable groups like retired citizens, the disabled or those who have lost the income from the breadwinner have their contributions paid by the state, as long as long as there are no other possible means of making the contribution i.e. no other member of the family can afford to pay the contribution for them. When healthcare contributions are paid by the state, the beneficiary only receives a minimal amount of healthcare.
In addition to taxation, one third of healthcare finance comes from out-of-pocket payments from the patient. Citizens have to pay for prescription medicine (children under five are exempt) and medical treatments deemed nonessential, like cosmetic surgery, dental care, massage and some laboratory investigations. Patients also make under-the-table payments to doctors, consultants and nursing staff. Such payments may be in the form of a gift or actual monetary payments.
There is a private health system in Moldova; however, the system is used by a limited number of people like MPs and wealthy entrepreneurs because the treatments are extremely expensive. Patients who use private doctors make out-of-pocket payments directly to the doctors to pay for the cost of their treatment. Private practice is still limited to a small number of consultancies, which offer diagnostic rather than curative services. Fees for private healthcare are fixed centrally, but doctors make up their money through additional out-of-pocket payments.
All communities in Moldova have access to healthcare. In rural areas, there is a network of 1011 health posts. They are staffed by a feldscher, a midwife and general assistants and they offer a basic package of care including general cover, maternal and child health services, comprehensive developmental checks, immunisation, health education and a basic 24-hour emergency cover.
There are 189 health centres in rural areas, each staffed by three doctors. Some health centres have facilities for inpatient care. Many of the services provided by the health centre are similar to those provided by the polyclinics in more densely populated areas.
Towns and districts with a population over 3,000 people are served by polyclinics, which are staffed by doctors of internal medicine, paediatrics, obstetrics, gynaecology and dentistry. Nurses, midwives and medical assistants also operate from the polyclinics. Each doctor is assisted by two medical nurses. Polyclinics in densely populated areas also offer some medical and surgical treatments on an outpatient basis.
Consultants are senior doctors who have completed a higher level of specialised training. In Moldova, there are 15,700 specialist doctors throughout, who are highly trained. Consultants regularly accept under-the-table payments in lieu of services provided. There are numerous specialist fields of medicine in Moldova like gynaecology, oncology, paediatrics and dermatology. There is often a waiting list to see consultant doctors.
Hospitals and clinics exist in all major towns and cities of Moldova; there is usually at least one hospital per district or municipality. In total, there are 100 hospitals across the country (which includes rural hospitals and Central District Hospitals), five Outpatient Clinics, a Dentistry, a Psychiatric and a Dermatology Hospital in the capital city of Chisinau. Additionally, there is a railway, a military and a trade union hospital. Waiting lists are long and facilities and equipment are poor. Some hospitals in the capital cannot even afford running water between the hours of 8pm and 6am. General hospitals provide services to patients referred from district and municipal health institutions. Patients are referred to general hospitals by doctors and consultants.
Rural hospitals offer a limited service, which includes basic specialist treatment and some surgery. Cases that are more complex are referred to the regional hospital. All rural hospitals offer a 24-hour emergency service with doctors operating an emergency rota system from their homes.
Central District Hospitals (CDH)
The CDH cover most surgical eventualities but Moldova’s declining economic conditions have meant that surgical activity in CDH is now limited. In many areas, CDH can now only carry out surgery in emergency cases and much of the need for non-emergency surgery goes unmet.
Emergency care is available free for everyone including those without state health insurance. Emergency departments are open non-stop all year. You may use their services if you need immediate attention, or if your GP refers you to them, or if there is no GP service available.
Whilst there are a small number of private GP practices, there are no private clinics or hospitals.
Dental care is deemed a non-essential service and all treatment must be paid for by the patient directly to the dentist.
Medicines are in short supply; shortages exist for antibiotics, anaesthetics, analgesics, medicine to treat tuberculosis and drugs used in oncology amongst others.
Pharmacies in Moldova are not stocked to western standards, labels are not in English, and there is a chance that the medicines are not approved, and could have been tampered with on the black market.
There are private and state pharmacies, although most of the state pharmacies are in the process of privatisation. Within the private pharmacies, there are security measures in place to make sure all products are not tampered with and are approved. Children under five years old qualify for free prescription medicine.
Moldova has achieved improvements in health insurance coverage with reductions in OOP for services, which are modest but are eroded by increasing likelihood of OOP for medicines. Insurance coverage was an important determinant for health care costs incurred by patients and patients forgoing health care. Improvements notwithstanding, there is an unfinished agenda of attaining universal health coverage in Moldova to protect individuals from health care costs.