Human Development Assessment for Moldova Background Paper on Health This draft prepared February 15, 2022 Content Acknowledgments ................................................................................................................................... 1 Health outcomes ..................................................................................................................................... 2 Health care organization and provider network ..................................................................................... 5 Health financing ...................................................................................................................................... 8 Mandatory health insurance ................................................................................................................. 13 Provider payment mechanisms ............................................................................................................. 14 Service provision/health care utilization ............................................................................................... 15 Impact of the COVID-19 pandemic........................................................................................................ 17 Recommendations ................................................................................................................................ 18 References ............................................................................................................................................. 20 Acknowledgments This report was prepared by staff and consultants of the World Bank. The authors of the report are Luka Voncina (International Consultant), Adrien Dozol (Senior Health Specialist), Ilie Volovei (Consultant), and Volkan Cetinkaya (Senior Economist). The authors are grateful to the staff of the Ministry of Health, National Health Insurance Company, National Agency for Public Health, and UNICEF Moldova for assistance with access to data and feedback provided during the preparation of this report. It was prepared under the overall guidance of Caryn Bredenkamp (Task Team Leader, Program Leader for Human Development for Eastern Europe), Inguna Dobraja (Country Manager, Moldova), Fadia Saadah (Regional Director for Human Development for Europe and Central Asia), and Arup Banerji (Regional Country Director for Eastern Europe) The analysis in this report was undertaken before the invasion of Ukraine on February 24, 2022, and reflects the human development outcomes and policies in place in the Republic of Moldova at that time. This report was produced with the financial support of the European Union. The findings, interpretations, and conclusions expressed herein are those of the authors and do not necessarily reflect the view of the World Bank Group, its Board of Directors, or the governments they represent. Similarly, the views expressed by authors do not necessarily reflect the views of the European Union. 1 Health outcomes The population of Moldova is ageing and shrinking rapidly due to a combination of low birth rates, emigration, and rising life expectancy. The total fertility rate has halved from 2.6 in the mid-1980s to around 1.3 births per woman in the beginning of the 2000s and has since remained stable (World Bank 2021a). Widespread poverty and lack of job opportunities have caused many Moldovans to look for employment in other countries. This trend is continuing as, according to the International Office for Migration (IOM), the net migration rate in 2019 amounted to −15.6 migrants per 1,000 population (IOM 2021). Life expectancy has increased steadily from 2000 when it was 67 years, reaching 71.9 years in 2019 (World Bank 2021a). From 2015 to 2060, the population is projected to shrink by 31 percent, or 1.2 million inhabitants. The average age will increase from 38 to 47 years. In the same period, the share of the elderly will more than double, to 27 percent (World Bank 2016). More detail is available in Figure 1. Figure 1: Total Fertility Rate, Population Growth, and Share of Population above 65 Source: UNSTAT, latest data. Life expectancy has moderately improved over the last two decades, more so in cities than in rural areas and more so for women than for men, but the gap to the European Union (EU) average has decreased only marginally. Moldovans can expect to live a full 9.1 years shorter than the average EU citizen. In 2000, average life expectancy in Moldova amounted to 67 years compared to the EU average of 77 years, while in 2019 Moldova recorded 71.9 years and the EU 81 years. From 2000 to 2019, total life expectancy in the country grew from 67 to 71.9 years, an increase of 4.9 years. Life expectancy differs significantly when adjusting for gender; female life expectancy increased from 71 to 76.2, an increase of 5.2 years, while the male life expectancy increased from 63 to 67.6, an increase of 4.6 years. Male life expectancy continues to lag and now has a difference of 8.6 years.1 Residents of rural areas have not benefited as much as the urban population. From 2000 to 2014, total life expectancy in the country grew by 3.95 years while in rural areas it increased only by 3 years, also with a notable gender gap, as rural women gained 3.7 and rural men gained only 2.8 years (NBS 2017). Healthy life expectancy records a similar trend when compared to other European countries. The World Health Organization (WHO) estimates for the Republic of Moldova show that healthy life expectancy, that is, the average number of years that a person can expect to live in "full health", increased by 2.4 years to 59 years for men and by 3.6 years to 66 years for women between 2000 and 1 World Development Indicators 2021. https://databank.worldbank.org/source/world-development-indicators. 2 2013. These estimates were 4 to 5 years lower than the estimates for the WHO EURO Region: 64.3 years for men and 69.6 years for women (WHO 2016a). Despite substantial improvements (see Figure 2), child and maternal health indicators still vastly lag EU levels. In 2019, the infant mortality rate (IMR) was 12.4 per 1,000 live births and the under-5 mortality rate (U5MR) was 14.4, both substantially higher than the EU averages of 3.32 IMR and 3.95 U5MR. In 2016, the maternal mortality rate of 17 per 100,000 live births was more than double the EU average of 8 (World Bank 2021a). An estimated 20 percent of child deaths, which are preventable if health care is sought and is timely, still occur at home or within 24 hours of hospitalization. Figure 2: Infant Mortality, Maternal Mortality, and Life Expectancy Source: World Development Indicators database. The prevalence of noncommunicable diseases (NCDs) is rising sharply, while most infectious diseases have, before the COVID-10 pandemic, been on a steady decline. The prevalence of main NCDs has grown substantially between 2008 and 2015: diabetes increased by 75 percent, circulatory diseases increased by 41 percent, diseases of the respiratory system by 40 percent, and prevalence of malignant neoplasms by 23 percent (NBS 2017). On the other hand, infectious diseases have in most part been on a decline. The incidence of tuberculosis has declined from 142 per 100,000 in 2005 to 80 per 100,000 in 2019 while HIV incidence per 1,000 uninfected people almost halved, decreasing from its all-time high of 0.42 in 2008 and 2009 to 0.24 in 2020 (World Bank 2021a). However, the prevalence of chronic hepatitis rose from 2008 to 2015, increasing by 23 percent. Widespread behavioral risk factors are contributing to the rising prevalence of NCDs in Moldova. Among young adults and people of prime working age, nearly half of all men smoke, and close to a half have excessively drunk in the last 30 days (six or more standard drinks on a single occasion at least once in the previous 30 days). Moldova also records one of the highest per capita alcohol consumption rates in Europe amounting to 20.6 liters of pure alcohol per year (de Walque 2014). Few men or women exercise, that is, 92 percent of women of prime working age do not engage in moderate-intensity exercise at all and obesity rates are also very high (up to 80 percent), especially among 60–64-year-old females (Brown 2017). More detail is available in Table 1. Table 1: Risk Factors Affecting Population’s Health Population Group and Risk Factor Young Adult Prime Working Age Ageing Elderly Whole population Smoker (%) 27 28 21 13 Excessive alcohol episode in last 30 days (%) 32 33 33 21 3 Population Group and Risk Factor Young Adult Prime Working Age Ageing Elderly No exercise (%) 78 89 94 96 Women Smoker (%) 7 6 3 2 Excessive alcohol episode in last 30 days (%) 18 15 19 9 No exercise (%) 86 92 94 97 Men Smoker (%) 45 47 39 26 Excessive alcohol episode in last 30 days (%) 42 46 44 32 No exercise (%) 70 86 93 95 Source: Brown 2017. In terms of public health risks, declining immunization rates against key childhood illnesses and environmental challenges such as access to contemporary sanitation could be playing a role in population health. Total immunization coverage in Moldova is relatively high. In 2012, 89 percent of the children 15–26 months of age received all recommended vaccines. However, Moldova is facing an alarming trend of declining vaccine coverage (UNICEF 2012). Furthermore, in 2015, as much as 24 percent of the population did not have access to improved sanitation facilities (WHO 2016a). Unimproved sanitation facilities include public or shared latrines and open and bucket latrines. Improved sanitation facilities usually ensure separation of human excreta from human contact and include connection to a public sewer or to a septic system and pour flush, simple pit or a ventilated improved pit latrine. The total burden of disease (measured in disability-adjusted life years [DALYs]) has reduced slightly over the last 20 years but it is still substantially higher than the EU average and is heavily dominated by NCDs. From 2000 to 2019, the overall disease burden in Moldova measured in DALYs (a measure of healthy life lost, either through premature death or living with disability due to illness or injury) has declined by 7 percent but it is still substantially higher than the EU average. In 2019, the total number of DALYs per 100,000 population reached 37,030, compared to the EU average of 30,671 (IHME 2021). NCDs (including cancer) account for over 80 percent of the disease burden measured in DALYs and WHO estimates the 89 percent of deaths in Moldova are caused by NCDs (WHO 2015b). See Figure 3 and Figure 4 for more detail. Figure 3: Distribution of DALYs in 2019 DALYs in 2019 as % of the total 80.0% 69.7% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 12.3% 10.7% 7.3% 10.0% 0.0% Source: IHME 2021. 4 Figure 4: Share of Deaths Source: Institute of Health Metrics and Evaluation database. The pattern of the disease burden within different age groups in Moldova resembles that of other low-income settings in which NCDs are not confined to the elderly but also affect the working-age population (de Walque 2014). Table 2 presents results from a nationally representative survey (WHO 2014), in which blood pressure and cholesterol levels of respondents were measured. While half the ageing (50+) or elderly (65+) population exhibited high blood pressure and high cholesterol, these indicators were not trivial among the population ages 35–49 either. Nearly half of this group also had high cholesterol, and nearly 30 percent had high blood pressure (Brown 2017). Table 2: Prevalence of Hypertension, High Cholesterol, and Cardiovascular Events, 2013 Young Adult Prime Working Age Ageing Elderly High blood pressure (hypertension) (%) 18 28 49 51 High cholesterol (%) 41 45 54 52 Cardiovascular events (%) 7 12 22 31 Source: Brown 2017. Sexual and reproductive health of adolescents has improved, but it requires additional attention. From 2013 to 2018, the fertility rate of those ages 15–19 decreased by 25 percent, and abortions in this age group decreased by 20 percent. The number of abortions among minors has nearly halved, from 243 in 2016 to 141 in 2018. Another positive development is seen in several studies indicating that the proportion of 15-year-olds who have started having sex decreased from 18 percent in 2014 to 13.3 percent in 2018. Also, the use of the contraceptive pill among sexually active 15-year- olds increased from 6 percent in 2014 to 10 percent in 2018. However, several challenges remain. The incidence of HIV among young people has stayed the same in recent years, and condom use among sexually active young people ages 15–17 is inconsistent (WHO 2020a). Health care organization and provider network Health care in Moldova is provided at primary, secondary, and tertiary levels (depending on the complexity of care required), by public facilities and private providers, supplemented by several vertical programs that ensure comparatively better funding for priority conditions in public settings. Tertiary care is provided only in public facilities. Both public and private providers participate in the 5 provision of primary and secondary care services. Vertical programs that ensure availability of medicines for selected conditions include tuberculosis, HIV/AIDS, diabetes and cancer treatment, vaccination programs, and others (Turcanu et al. 2012). There has been a sharp increase in the number of private establishments, possibly reflecting issues with service provision in the public sector. Provision of care in private hospitals and outpatient establishments is not publicly subsidized and needs to be paid out of pocket in full. Due to growing demand, tentatively caused by dissatisfaction with the level of care provided in the public setting, from 2008 to 2015, the number of private hospitals increased from 10 to 14 (versus a total of 71 public hospitals), while the number of outpatient establishments rose from 496 to 595 (see table 3 for more detail). Table 3: Network of Health Care Establishments in Moldova 2008 2009 2010 2011 2012 2013 2014 2015 2020 Public institutions Municipal hospitals 10 10 10 10 10 10 10 10 10 District hospitals 34 34 34 35 35 35 35 35 35 Republican hospitals 18 18 18 17 16 16 16 15 17 Hospitals subordinated to 10 11 11 11 11 11 11 11 6 other ministries Subtotal Public Hospitals 72 73 73 73 72 72 72 71 68 Independent polyclinics 106 105 106 105 96 80 101 96 97 Primary health care (PHC) 67 67 87 100 134 200 250 259 268 facilities Private establishments Hospitals 10 10 11 13 13 13 15 14 17 Individual outpatient 496 503 516 554 511 590 596 595 603 establishments Source: National Agency for Public Health, Statistical Yearbook of the Health System. Local government owned ‘family medicine centers’ and ‘health centers’ are contracted by National Health Insurance Company (Compania Naţională de Asigurări în Medicină, CNAM) to provide primary care services. In rural areas, services are provided by family doctor offices and health centers while in urban areas, these services are delivered through big family health centers (formerly referred to as ‘polyclinics’). In 2008, primary care facilities were administratively separated from hospitals and allowed to independently enter into contractual relationships with CNAM and manage their affairs on their own. All doctors working at the PHC level practice family medicine and other specialists, who previously worked in the polyclinics, are now attached to hospitals even if they still work in the same building alongside family medicine doctors (Turcanu et al. 2012). Public hospital services are provided by local government (secondary care) and state (tertiary care) owned facilities which in most part focus on delivering acute care and lack long-term and palliative care capacities. Secondary care in Moldova is focused on acute services which are provided in inpatient and specialized ambulatory (outpatient) settings by district and municipal hospitals owned by local governments. The exception is the capital city Chisinau, where specialized outpatient care is provided by ‘territorial medical associations’ that are independent of municipal hospitals. Most hospital beds are dedicated for acute care. Palliative, long-term, and rehabilitation care capacities are not sufficiently developed, which affects the system’s overall efficiency. Most long-term care is provided in the family, and there are few resources available for informal caregivers (Turcanu et al. 2012). Tertiary care 6 facilities that provide skilled and highly specialized medical care are mainly located in the capital city and are subordinated to the Ministry of Health, Labor and Social Protection (MoHLSP). Despite closing down a number of rural hospitals in the early 2000s, the hospital sector still suffers from fragmentation with a high number of small hospitals, while the overall number of hospital beds is in line with the EU average. Moldova managed to close many rural hospitals during the early 2000s, but dealing with the larger ones located in district centers and big cities proved to be a greater challenge. The National Hospital Masterplan 2009–2018, developed in 2009 with World Bank support, is yet to be implemented. It envisions a network of 9 regional hospitals and the development of 2 larger centers (specialized hospitals) in Cahul and Balti to replace existing 35 rayon (district) hospitals (Edwards 2011). In addition, the Ministry of Defense and Ministry of Interior hospitals (some contracted by CNAM) continue to provide services for the military and the police. In 2014, Moldova recorded 5.66 hospital beds per 1,000 people and the EU 5.59. The number of hospital beds in the EU has since decreased to 4.6 in 2019 (World Bank 2021a). The health sector employs fewer physicians and far fewer nurses and midwifes relative to the population compared to the EU average, and the number of both qualified doctors and nurses as well as graduates entering the medical profession has been on a decrease. In per capita terms, Moldova had 3.5 doctors and 6.7 nurses per 1,000 inhabitants in 2018, below the EU averages of 3.6 doctors and 8.6 nurses (World Bank 2020). Furthermore, the annual number of doctors graduating from universities declined by 18 percent from 427 in 2005 to 349 in 2014.2 If this trend continues, Moldova may start to face challenges in ensuring necessary physician resources for the population, in particular if these trends are further aggravated by continued emigration. According to a 2012 study by the WHO, around one-quarter to one-third of the study respondents noted that the political structure, poor working conditions, dissatisfaction with the medical system, and limited professional development opportunities are factors forcing them to seek employment outside the country (WHO 2012b). However, the expected population decline may balance out with the reduced number of health professionals. This is an area to be carefully monitored over the coming years. National averages on the availability of human resources hide significant subnational differences with some regions, with rural areas in particular faring much worse than large city centers. These are a consequence of internal migrations that lead to substantial inequities in the supply of human resources between regions (see Figure 5) and between urban and rural settings. In 2016, the number of physicians per 10,000 population was 37 on average, but only 6 in rural areas, compared to 78 in urban areas (National Agency of Public Health 2019). These differences are driven by push factors that include insufficient remuneration, demotivating working conditions, corruption and nepotism, lack of prospects for professional development, lack of adequate infrastructure for their families in rural areas, and unfriendly attitudes in health institutions (Lozan et al. 2015). In addition, there are several identified pull factors: higher chances of succeeding in other regions, greater possibilities to open own business, professional and career development, attractive remuneration, safety, and less demanding working regimes. 2WHO HFA-DB 2017. European ‘Health for All’ Database (HFA-DB). World Health Organization Regional Office for Europe. http://www.euro.who.int/hfadb. 7 Figure 5: Physician Supply through Regional Equity Lens3 Number of Physicians per 100,000 Inhabitants Number of Family Doctors per 10,000 Inhabitants 40 8 35 7 30 6 25 5 20 4 15 3 10 2 5 1 0 Whole country Ministry of Municipality North Center South 0 Health Chisinau Municipality Chisinau North Center South 2008 2012 2015 2008 2012 2015 Source: NBS 2017. Some progress has been achieved in improving governance; for instance, the transparency and efficiency of procuring hospital medicines has been enhanced through centralization. Hospitals are not allowed to procure medicines on their own as all hospital medicines should be procured by the National Centre for Centralized Procurement in Health. This leads to lower prices and savings due to economies of scale and reduces the risk of corruption. The list of medicines that are procured is primarily determined based on national pharmacotherapeutic protocols for over 300 diseases. However, as the list has not been updated for several years, hospitals are allowed to request procurement of unlisted medicines as well. Some hospitals nevertheless also engage in individual procurement, bypassing the centralized procedure altogether. The exact extent of the issue remains unclear but the greatest part of total procurement remains centralized. There have also been advances in implementing information technology solutions in primary care and hospitals, though with mixed results both in terms of coverage and functionality. By the end of 2019, around 20 percent of primary health centers and hospitals had a functioning IT system. Furthermore, the Government’s mConnect platform became operational, which allowed for safe and efficient data exchange between public institutions, and work had begun on the development of a cancer registry and an electronic registration system for births and deaths. Nevertheless, the lack of an overarching health information system vision underlying these developments resulted in deficiencies in coordination, overlaps in data collection, and a lack of interoperability between the various components of the information systems. As a result, health information is not yet used for policy making, resource planning, and quality control in a systematic and transparent way. Health financing Despite economic growth in the last decade, with Moldovan gross domestic product (GDP) per capita rising 2.4-fold from 2009 to 2019, per capita current health expenditure did not grow. It remains at around one-sixteenth of the EU average and is below that of a number of regional countries such as Georgia, Armenia, and Ukraine that share a more comparable level of economic development.4 From 2009 to 2019, the Moldovan economy has grown steadily with GDP per capita rising from US$1,899 to 3 The ratio for the whole country is higher than the rate reported for the system under control of the MoH because other ministries that also have health care facilities employ medical doctors, which results in a higher ratio. 4 GDP per capita, purchasing power parity (current international $) in 2019 ranged in the group of countries between US$13,350 (Ukraine) and US$15,623 (Georgia). 8 US$4,551 (current US$). Current health expenditure has, on the other hand, increased only marginally in the same period, from US$209 to US$213 per capita (current US$), and is substantially below the EU average of US$3,525. Other regional countries recorded higher total health expenditure as well, that is, Armenia (US$422), Ukraine (US$228), and Georgia (US$312) (World Bank 2021a). See Figure 6 and Figure 7 for more detail and comparison with a larger group of countries. Due to the disproportionate trends between the economic growth and health spending, current health expenditure as percentage of GDP has almost halved from 2009 to 2019. It falls far behind the EU average as well as that of Armenia, but the gap is less pronounced if other regional countries such as Georgia and Ukraine are compared. Current health expenditure as percentage of GDP has been on a sharp decline from 2009 to 2018, falling from 11.4 percent to 6.6 percent. This is substantially less than the 9.9 percent average of EU countries and Armenia (10 percent) in the same year and lower than in Georgia (7.1 percent) and Ukraine (7.7 percent)5 (World Bank 2021a). Figure 6: Per Capita GDP and Current Health Spending over Time Source: Global Health Expenditure Database - WHO. 5Eurosta 2020. https://ec.europa.eu/eurostat/web/products-eurostat-news/-/ddn-20201202- 1#:~:text=On%20average%20in%20the%20EU,followed%20by%20Sweden%20(10.9%25). 9 Figure 7: Health Expenditure as % of GDP in 2018 12 10 8 6 4 2 0 Bosnia and… Turkey Albania Latvia Montenegro Serbia Romania Belarus Kyrgyz Republic Cyprus Georgia Azerbaijan Uzbekistan Russian Federation Poland Moldova Hungary Ukraine Slovak Republic Croatia Bulgaria Slovenia Kosovo Kazakhstan Lithuania Estonia Czech Republic Malta Tajikistan Armenia North Macedonia Turkmenistan Health Expenditure as % of GDP, 2018 European Union Global MICs ECA - MIC Source: World Development Indicators 2021. https://databank.worldbank.org/source/world-development- indicators. Even though Moldovan government (public) health expenditure per capita is far from the EU benchmarks, it is higher than in Armenia and Ukraine, and the public-private split in financing is more favorable in Moldova than it is in most regional comparator countries. Observed in current dollars, during 2009 to 2019, government per capita health expenditure increased by almost a half (from US$88 to US$120) while per capita out-of-pocket expenditure fell by 10 percent (from US$95 to US$85), all amounts in current dollars; improving the public-private split in health care financing. The share of current health expenditure paid by the government was on a rise from 2009 to 2018, growing from 42.6 percent to 56.5 percent of the total (see Figure 8), which was still well below the EU average of 74.4 percent. On the other hand, Moldova’s public-private split in health financing compares favorably with most regional countries (World Bank 2021a). A comparison with a number of countries is available in Figure 9. Figure 8: Public and Private Expenditure on Health Source: Global Health Expenditure Database - WHO. 10 Figure 9: Out-of-Pocket Payments as Percentage of Total Health Spending in 2018 90 80 70 60 50 40 30 20 10 0 Turkey Serbia Latvia Albania Romania Belarus Montenegro Georgia Hungary Moldova Bulgaria Kyrgyz Republic Croatia Cyprus Ukraine Slovenia Slovak Republic Poland Uzbekistan Azerbaijan Czech Republic Estonia Lithuania Malta Kosovo Kazakhstan Russian Federation Tajikistan Armenia Bosnia and Herzegovina North Macedonia Turkmenistan OOP as % of CHE, 2018 European Union Global MICs ECA - MIC Source: World Development Indicators 2021. The modest growth of government health expenditure (compared to the increase in GDP per capita) reflected the growth of overall government revenues as the share of general government expenditure spent on health declined only slightly from 2009 to 2018 and remained higher than in all regional countries. The share of general government expenditure spent on health declined from 12.9 percent to 12 percent, still higher than in countries such as Armenia (5.3 percent), Ukraine (8.9 percent), and Georgia (10.3 percent) (World Bank 2021a). See Figure 10 for a comparison with more countries. Figure 10: Government Health Expenditure as Percentage of Total Government Expenditure 18 16 14 12 10 8 6 4 2 0 Bosnia and… Turkey Albania Serbia Latvia Montenegro Belarus Romania Kyrgyz Republic Hungary Georgia Moldova Cyprus Ukraine Poland Bulgaria Croatia Slovak Republic Slovenia Kosovo Azerbaijan Uzbekistan Estonia Czech Republic Tajikistan Kazakhstan Russian Federation Malta Lithuania Armenia Turkmenistan North Macedonia Government health expenditure as total government expenditure, 2018 European Union Global MICs ECA - MIC Source: World Development Indicators 2021. 11 Reflecting the devaluation of the local currency against the dollar, out-of-pocket payments in Moldovan leu actually increased by 16 percent from 2008 to 2016, with evidence of poorer households foregoing care due to financial hardship as well as experiencing a growing financial burden. Out-of-pocket payments in the period rose from MDL 1,313 to MDL 1,529 per household. All quintiles experienced higher out-of-pocket payments in 2016 than in 2008, but the increase was largest for the poorest and second quintiles and smallest for the third and fourth quintiles. Spending rises with household consumption. In 2008, the richest households were spending around eight times as much as the poorest quintile. By 2016, the differential was smaller, but the richest households were still spending around five times as much as the poorest. This difference is likely to reflect higher levels of unmet need for health care among poor households (WHO 2020b). Outpatient medicines account for the largest share of out-of-pocket spending in Moldova; this is followed by inpatient care, dental care, and outpatient care. The share of outpatient medicines in total out-of-pocket spending increased from 69 percent to 79 percent from 2008 to 2016, while the shares of inpatient, dental, and outpatient care (second, third, and fourth largest expenditure items) declined. Across all years, private expenditure on diagnostic tests and medical products is comparatively limited (WHO 2020b). The incidence of catastrophic health spending6 in the Republic of Moldova is among the highest in Europe and Central Asia and it primarily affects the poorest households. In 2016, 17 percent of households experienced catastrophic levels of spending on health, around half of which were in the poorest quintile, while one-fifth were in the second quintile. The incidence of catastrophic spending on health has increased over time; in 2015 and 2016 it was higher than in all other years from 2008. As with out-of-pocket payments, outpatient medicines are the largest driver in all quintiles, accounting for 74 percent of catastrophic expenditure. Figure 11 provides a comparison of the incidence of catastrophic spending on health with a number of European countries. 6Households with catastrophic levels of out-of-pocket payments are defined as those who spend more than 40 percent of their capacity to pay. 12 Figure 11: Incidence of Catastrophic Spending on Health in Selected European Countries Source: WHO 2020b. Mandatory health insurance Moldova’s mandatory health insurance (MHI) system became operational in 2004 with the health insurance fund (CNAM) in charge of pooling state budget transfers and payroll contributions for health care. The health budget is approved annually at the national level through the Law on the State Budget and the Law on Mandatory Health Insurance Funds. Payroll taxes are deducted monthly from salaries, with both employees and employers contributing (Turcanu et al. 2012). Self-employed individuals need to pay for their health insurance on their own. If they procure insurance in the first three months of each calendar year, they get a 50 percent discount. To achieve universal health coverage, Moldova has taken a ‘whole systems approach’ (Kutzin 2013), seeking not only to create and expand health insurance enrollment but also to adopt health policies which would increase equity in service use and improve efficiency of public spending while expanding financial protection for all citizens (CNAM 2013; Domente et al. 2013; Hone et al. 2016; MoH 2014). CNAM MHI benefits include an essential package of emergency, primary care, and hospital services provided with no user charges as well as access to a modest range of outpatient medicines. CNAM manages five funds: the Fund for Reimbursement of Health Services, the Reserve Fund, the Fund for Prophylactic Measures, the Fund for the Development and Modernization of Public Health Service Providers, and the Administrative Fund for the MHI system. The benefits package includes medicines in inpatient settings and a limited list of reimbursable medicines for outpatient care, some of which are subject to copayments (Richardson et al. 2012; Shishkin and Jowett 2012). 13 Coverage under the MHI system has grown gradually, reaching 87.78 percent in 2020, but it is still lower than levels recorded in the EU that range between 93 and 100 percent (OECD 2013). An amendment to the Law on Mandatory Health Insurance in 2009 was a major turning point in improving coverage as it ensured that families living below the poverty line, even if formally self-employed, would automatically receive fully subsidized health insurance (WHO 2012a) with no contributions required. Despite formal MHI entitlements, in reality many patients still need to pay out-of-pocket charges for services that should be publicly provided for free. The gradual expansion of health insurance benefits has not been followed by adequate increase in funding for CNAM and this limits its ability to adequately fund the covered services. Therefore, insured patients still often pay in the public sector for services that should be provided for free or seek care for these services in the private sector (Richardson et al. 2012). As of 2010, with the government primarily aiming to improve access in rural areas, all citizens, regardless of health insurance status have been entitled to free outpatient emergency care in hospitals and full access to family medicine doctors. Amendments to the Law on Mandatory Health Insurance in 2010 provided all citizens, regardless of income, with access to free PHC services from family medicine doctors (Domente et al. 2013) and pre-hospital emergency care services but not outpatient consultations or inpatient treatment (Shishkin and Jowett 2012). Provider payment mechanisms All health care providers that operate under the MoHLSP are contracted and paid for their services by CNAM, using payment mechanisms that are generally in line with good practice implemented in developed European countries but that require substantial additional refinement. An annual order, issued jointly by CNAM and the MoHLSP, allocates CNAM’s contracting budget between (a) pre- hospital emergency medical assistance, (b) PHC and outpatient medicines, (c) outpatient specialized health care, (d) hospital care, (e) advanced medical services, and (f) community and home-based medical care. The indicated expenditure limits can be adjusted at the moment of contracting according to accumulated savings and actual resources available. While payment reforms are moving in the right direction, payment systems still require substantial additional work to adequately provide financial incentives for the provision of efficient and high-quality care. Primary care (family medicine) is in most part financed through risk-adjusted capitation payments which are further supplemented by performance-based payments. Age adjusted capitation accounts for 85 percent of all expenditure on primary care. It was introduced in 2009 and the rates reflect the age structure of patients registered in care (see Table 4 for more details). Additional payments are disbursed according to performance against 38 indicators (as of 2017) rather than on achievement of targets for early detection and prevention of NCDs (cardiovascular diseases, diabetes, cancers), tuberculosis treatment, reproductive and child health, and so on. However, the extent to which providers achieve the targets has not been optimal, and reporting is not fully digitalized, so it presents an administrative burden to providers. Table 4: Capitation Rates for PHC - October 1–December 31, 2020 Age Category Rate in MDL Rate in US$ From 0 to 4 years 11 months 29 days 164.16 9.5 From 5 to 49 years 11 months 29 days 96.58 5.6 From 50 years and above 144.86 8.4 Source: CNAM. 14 Hospital treatment, including day care surgery, is financed through diagnostic related groups (DRGs, case-based payments that reflect the complexity of care), up to the contracted volume set for each hospital. DRG payments accounted for over 80 percent of the CNAM expenditures for acute inpatient care in 2017, the rest being reimbursed through the following payment methods: per bed-day, depending on the profile, through the global budget or retrospective reimbursement of expenses. Expensive medicines and consumables, dialysis, radiotherapy, and doctors’ salaries are financed in addition to DRG payments through separate budgets, with the contracting of expenses depending on the hospital. Other health care services are financed in a mix of different payment models that reflect the nature of care provided, also under hard budget ceilings. Specialist outpatient consultations are funded through global budgets with limited use of other payment models for specific types of care; per case payments are used in rehabilitation and drug addiction services, fee for service payments in rehabilitation treatment of children, and a combination of per capita payments and global budgets are used in dentistry. Financing of community and home-based (including palliative) care is organized on the basis of per visit payments while emergency care is financed through per capita payments. The allocation of funds for providers of all types of care is organized monthly, with quarterly settlements that account for actual service provision. The monthly amount sent to providers equals 80 percent of one-twelfth of the annual contracted amount. After each quarter, the payment is made in full for the remaining part of the contracted amount based on actual invoices provided by facilities, or, in per capita arrangements, based on the actual number of patients registered with the provider at the end of each quarterly period. If any invoices are not validated by CNAM, the respective claims are rejected and are not paid for. Service provision/health care utilization Utilization of all types of services at the national level has been relatively stable over the years; it varies considerably by region and setting (urban versus rural), with residents of the capital Chisinau enjoying much better access to health care than others. For example, in 2017, the South region recorded 40 percent less outpatient visits and 34 percent less family medicine visits per capita than Chisinau. In the same year, the North region recorded 25 percent less ambulance calls per capita than the capital. These differences in utilization cannot be explained by population health needs but rather by inequities in access to care, which appear to have in most part grown in during 2008 to 2015. People living in rural areas are also less likely to use specialists, pharmacists, and dentists than people living in urban areas (WHO 2020b). The quality and development of transport infrastructure could also be having an impact on the equity of service provision between urban and rural areas. Besides being a consequence of the uneven distribution of health care professionals, barriers to access in rural areas may also be linked to distance to facilities, poor road quality, and lack of public transport; these types of barriers are found to have a greater impact on some groups of people, including pensioners, unemployed people, and people with disabilities (WHO 2020b). Table 5: Health Service Utilization Data 2010 2015 2019 Outpatient visits per capita per year Whole country 6.5 6.2 6.5 Chisinau 6.7 7.0 6.8 North 5.1 5.1 5.2 15 2010 2015 2019 Center 5.0 4.8 4.7 South 4.7 4.2 4.6 Family medicine visits per capita per year Whole country 2.9 2.8 6.5 Chisinau 3.2 3.5 6.8 North 2.7 2.7 5.2 Center 3.0 2.6 4.7 South 2.5 2.3 4.6 Emergency medicine calls per 1,000 inhabitants Whole country 283 278 248.6 Municipality Chisinau 329 335 299.2 North 268 250 256.9 Center 282 254 207.7 South 229 291 222.1 Total inpatient admissions per 100 inhabitants Whole country 18.1 17.8 17.4 Municipality Chisinau — — 11.3 North — — 13.0 Center — — 8.5 South — — 9.6 Source: National Agency for Public Health, Statistical Yearbook of the Health System. There is marked income inequality in the use of health services with the poorest segments of the population accessing substantially less specialist services than those who are better off and frequently foregoing medical care when in need. Household budget surveys conducted in 2008, 2010, 2013 (NBS 2013), and 2016 (NBS 2017) reveal that the richest 20 percent of households used twice as many hospital services compared to the poorest 20 percent (see Figure 12). The 2017 survey further showed that people in the richest quintile were five times as likely to use dentists as people in the lowest quintile. Inequities in utilization of outpatient specialist services have somewhat decreased through the period. A multiple indicator cluster survey conducted by the United Nations Children's Fund (UNICEF) in 2012 (UNICEF 2012) further revealed that the most impoverished 20 percent women were 4 times more likely to forego antenatal care during pregnancy, and, if they sought care, they were 5.5 times more likely to receive inadequate prenatal supervision (that is, less than four antenatal visits). As a consequence, they were 2.7 times more likely to have longer postpartum stay in hospitals, possibly due to delivery complications, and had 0.6 times lower probability of visiting a health provider after birth compared to the richest 20 percent. 16 Figure 12. Service Utilization Ratios during 2008–2013 EQUITY RATIO BETWEEN RICHEST 20% AND POOREST 20% 2.97 2.99 2.93 2.79 2.21 2.31 2.12 2.16 1.77 1.84 1.76 1.88 2008 2009 2010 2011 2012 2013 Outpatient service utilization during 4 weeks prior to survey Inpatient service utilization during 12 month prior to survey Source: NBS 2017. Despite the large degree of income inequality in the use of specialists, the share of the total population foregoing care due to access barriers (self-reported unmet need for health care) has fallen substantially over time. The share of people reporting unmet need due to cost has fallen from over 25 percent in 2008 to just under 15 percent in 2016. Unmet need is slightly higher among the whole population than among people covered by CNAM, but the gap between these two groups has narrowed over time. This major reduction in unmet need over time is encouraging, but the fact that a relatively high share of people covered by CNAM (13 percent) still report unmet need due to cost is striking (WHO 2020b). The overall efficiency of service provision as well as quality of care, particularly in rural settings, could be improved. According to a WHO study that analyzed hospitalizations in Moldovan hospitals in 2013, at least 60 percent of hypertension (about 12,000 admissions) and 40 percent of diabetes hospitalizations (5,000 admissions) could have been avoided by strengthening interventions at the PHC level (WHO 2015a). Another report (Blake et al. 2019) on the quality of care for NCDs in PHC facilities and pharmacies published in 2019 found weaknesses in areas such as health workforce, medical products, financing, and leadership/governance and established that urban facilities generally fare better across all observed quality indicators than the rural ones. Impact of the COVID-19 pandemic Compared to the EU, Moldova has been hard hit by COVID-19 and the share of the population that has been fully vaccinated is very low. As of October 8, 2021, Moldova registered 303,208 COVID-19 cases and 6,954 deaths. As elsewhere, older people have been more vulnerable to the disease. While people ages 60 and older account for 30 percent of cases, they account for 80 percent of all deaths, with the average age among those who died being 67.4 years.7 The cumulative number of deaths attributed to COVID-19 reached 254 per 100,000 population, substantially higher than the EU average of 173 per 100,000 population. Around 30 percent of the population has been fully vaccinated, less than half of the EU average of 63 percent.8 7 MoHLSP 2021. Government COVID-19 website. https://gismoldova.maps.arcgis.com/apps/opsdashboard/index.html#/d274da857ed345efa66e1fbc959b021b. 8 FT (Financial Times). 2021. Coronavirus tracked. https://ig.ft.com/coronavirus- chart/?areas=eur&areas=mda&areasRegional=usny&areasRegional=usla&areasRegional=usnd&areasRegional=usms&areas Regional=usfl&areasRegional=ustn&cumulative=1&logScale=0&per100K=1&startDate=2020-09-01&values=deaths. 17 As in most countries, the pandemic has disrupted service provision for other conditions; the pressure of surging numbers of COVID-19 patients on human resources and bed capacities has forced hospitals to focus care on life-threatening and most essential cases which nevertheless recorded substantial decreases. Pre-pandemic planned interventions were canceled and hospitals focused on medical emergencies such as acute life-threatening conditions, obstetric and neonatological cases, medical dialysis, and so on. Essential care such as cancer treatment was also prioritized within available capacities. A comparison of services provided over the first nine months of 2019 versus 2020 clearly shows the disruption and indicates that even most essential care was hard hit. Table 6: Disruptions in Service Provision in 2020 Services First 9 months of 2019 First 9 months of 2020 Outpatient consultations 6,020,420 3,035,213 Cancer hospitalizations 22,119 18,586 Diabetes hospitalizations 9,062 4,995 Cataract operations 4,367 3,294 Prolonged heart attack hospitalizations 410 224 Prescriptions for outpatient medicines 4,155,027 3,709,422 Source: CNAM data. Throughout the pandemic, Moldova has, with the support of development partners, made important steps in improving its pandemic preparedness and COVID-19 response. A review conducted by the WHO at the MoHLSP’s request (GHS 2019) revealed that the health care system was very vulnerable to public health crises and that it had low preparedness for epidemics; Moldova scored 42.9 points out of possible 100. Since then, much has been improved. Laboratory testing capabilities have been expanded and the surveillance system has been adjusted to comply with WHO recommendations. National clinical protocols for treatment as well as management of complications are regularly reviewed. The implementation of the World Bank’s Program ‘Emergency Response to COVID in the Republic of Moldova’ has allowed for substantial investments in critical medical equipment. Recommendations Short-term actions Given the high and growing burden of NCDs, additional efforts should be invested in tackling widespread behavioral risk factors such as smoking, low physical activity, obesity, and alcohol consumption. These should include a combination of public health and taxation-based efforts to educate and motivate the population to live healthier lives. Appalling child and maternal health indicators mandate prompt action aimed at improving prevention and care provided to mothers and children. Steps should be taken to educate parents of the necessity of using these health services as well as improve their accessibility and quality. Unprecedented work has been undertaken in the Republic of Moldova to ensure that adolescents can access sexual and reproductive health services, following a systematic process outlined by the WHO. Youth-friendly clinics were established in every district and municipality between 2002 and 2017. Nevertheless, further steps should be taken in improving adolescent health, focusing primarily on healthier lifestyles and prevention of sexually transmitted infections and adolescent pregnancies. A part of acute hospital capacities should be reoriented toward the provision of long-term and palliative care services, which are currently underprovided. This does not necessarily require large 18 construction works and will improve the overall quality and continuity of care. It will also positively affect efficiency as some of these services are currently unnecessarily provided in more expensive, acute settings. Given the macroeconomic context, Moldova’s allocations for health care are not likely to grow substantially in the medium term. Nevertheless, the government should seek to increase mandatory health insurance coverage, particularly among the worst-off who are currently foregoing care due to financial hardship and are experiencing the highest levels of catastrophic expenditure. This should reduce their level of out-of-pocket payments. Annual financial plans should make sure that the mandatory health insurance benefit package is adequately funded. If available public funding is not sufficient to cover all desired services, the services in the benefit package should be prioritized. Pricing and reimbursement of medicines needs to be revisited urgently as medicines account for the largest share of out-of-pocket payments and catastrophic expenditures on health. Medium-term actions Primary care needs to be strengthened professionally and reinforced financially to improve its gatekeeping function—preventing unnecessary hospitalizations and providing comprehensive and quality care to the population. The National Hospital Masterplan should be implemented and the health system rationalized in terms of the number of district and municipal hospitals. Reconstruction of hospitals should also be used to improve energy efficiency and resilience to earthquakes. Oversupply of hospital infrastructure absorbs considerable public resources because much of the infrastructure is not used optimally. The uneven distribution of health professionals within the country needs to be taken into account besides ensuring access to citizens who live in rural areas. Further work is required on improving provider payment mechanisms to ensure that they promote efficient, integrated, and high-quality care. Quality of service provision in hospitals should be advanced by implementing quality assurance and improvement programs such as hospital accreditation. Further investments should be directed in the development of the health information system, ensuring that they reduce network fragmentation and promote cooperation among institutions in exchanging health information. 19 References Blake, C., L. F. Bohle, C. Rotaru, et al. 2019. “Quality of Care for Non-communicable Diseases in the Republic of Moldova: A Survey across Primary Health Care Facilities and Pharmacies.� BMC Health Serv Res 19 (353). https://doi.org/10.11 86/s12913-019-4180-4. Brown, B. 2017. A Human Rights-Based Approach To The Economic Security Of Older People. Washington, DC. 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