Health Systems: The Players and Payers

Viorel Soltan, MD, MBA, MPH Center for Health Policies and Studies (PAS Center)

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

Key players: Parliament
Every year approves “Annual budget” including health budget A parliamentary Committee on Health and Social Welfare monitors MOH activity and interministerial coordination Together with the MOH develops health policy framework worked then into national strategy and action plan

Key players: Ministry of Health
Policy development, quality control, and overall stewardship of the health care system and health reform The national preventive medicine network is also subordinated to and directly funded by the MOH The MOH directly finances some national programmes such as tuberculosis and HIV/AIDS Specialized medical institutes, hospitals and clinics are also all directly subordinated to the MOH The same is true of the national emergency medicine network

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 Insurance Company

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

Key players: National Health Insurance Company

It is a single purchaser of health care services in Moldova NHIC is a government subordinated agency consisting of an Administrative Council and Executive Board The Administrative Council is the supreme body of the NHIC, consisting of fifteen members, including representatives of parliament, President’s Office, government (MOH, Ministry of Finance, and Ministry for the Economy), National Confederation of Employers, trade unions, physicians and patient organizations

Key players: National Center for Preventive Medicine

Preventive medicine institutions maintain a vertical hierarchical structure and are accountable to the MOH through the National Centre for Preventive Medicine There are 36 branches in each district and municipality which are responsible locally for implementing standards and guidelines for environmental health, communicable diseases and occupational health The NCPM is also in charge of immunization.

Key players: National Center for Emergency Medicine

Emergency services also maintain a hierarchical structure and are accountable to the MOH through the National Center for Emergency Medicine It has four emergency medicine stations covering their specified zones (Central, North, South and Gagauzia) contract with the National Health Insurance Company for funding In addition to the four zonal emergency stations, there are 43 emergency sub-stations in each of the district, municipality and other autonomous units

Key players: Professional Associations

The Nurses Association of Moldova was founded in 1994 as a nongovernmental professional organization It is a dynamic organization, affiliated with the European Nursing Forum There are also a number of professional medical associations such as the Association of Surgeons, the League of Physicians and the Family Medicine Association The Sanatatea Trade Union for medical personnel is also active and plays an important role in negotiating salary scales

Key players: Patient groups
The Republic of Moldova is home to a number of local patient groups and advocacy organizations, including the Patient Rights Group, the Association of Patients on Haemodialysis, the Association of Diabetic Patients and the Association of Handicapped and Paralysed Patients However, the capacity of patient groups to lobby at the national level remains limited

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 ward for them at a paediatric hospital with educational materials, toys, support from volunteer staff, and a child friendly environment

Health System Overview (1)
The primary care sector is based on a general practice model with family doctors Secondary care is provided through general hospitals at the district / municipal level Specialized and high technology care is provided through the republican hospitals and national institutes Emergency care services are subordinated to the MOH through the National Centre for Emergency Health Care

Health System Overview (2)
Financing principle: Service providers for emergency, primary, secondary and tertiary levels contract with the National Health Insurance Company (NHIC) Preventive medicine network which conducts public health monitoring, is subordinated to and directly financed by the MOH A number of parallel health services are financed from the state budget via the relevant ministries but also contract with the NHIC

Central Government Ministry of Health Ministry of Interior, Defense, Justice etc. Regional Emergency Health Stations Municipal hospitals Family medicine centers District health authority District hospitals Family medicine centers National Center for Preventive Medicine Other republican hospitals District preventive medicine offices Mother & child health, oncologic, cardiologic, neurologic, tuberculosis and lung diseases centers, infection diseases, clinical hospital etc.

National Center for Emergency Medicine Chisinau Municipal Health Authority

Parallel health care services

National Health Insurance Company

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 thirdparty payers, or health plan sponsors (employers or unions).
* Mosby's Dental Dictionary, 2nd edition.

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

Health care reform: background
 After the collapse of the Soviet Union, the population faced severe social and economic upheaval; the health system found itself unable to provide adequate, consistent and affordable health care  A number of preventive programmes (i.e. national immunization programme) were on the verge of collapse in the early 1990s  Increasing informal charges deterred many from attending health facilities at all  health reform became a pressing issue, particularly following the collapse of the Russian rouble in 1998 with its negative repercussions for the Moldovan economy

Health care reform: principals (1)
 Organizational and structural changes to develop family medicine centred primary health care, creating incentives for increasing health promotion and preventive activities, improving the management of HR, introducing care guidelines and restructuring the hospital network  Modifications of financing and provider payment system by introducing mandatory health insurance and contracting, changing provider payment systems (from line-item budgeting to per capita or fee-for-service mechanisms), and allocating state funds to the HIC to cover vulnerable groups and priority national programmes

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 policies and by introducing regulations for medicines management

Financial flows
GENERAL POPULATION
General taxation

Employer and employee contributions

Out-of-pocket payment

International loan and aid

Health Insurance Fund

State budget Ministry of Health

Health Investment Fund

Health Insurance Company

Preventive medicine

PUBLIC HEALTH CARE PROVIDERS

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 with 2003 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

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 1991 and 2006 the hospital stock was reduced by 75% – in 2006 there were 84 hospitals

Outcomes for health care system

The transformation of the system of health care financing was smooth, and the provision of medical services was uninterrupted Public funding of health care increased by 19 percent in 2004 in real terms, and by 16 percent in 2005 Reforms have increased the stability of public funding for health care The achievement of a real balance between state guarantees of free health care and their public funding
* Shishkin, Kacevicius et al. 2006

Outcomes for health facilities
Increased income Stability of public funding Acceleration of funding transfer from budgets to facilities Increased autonomy in spending decisions The creation of real incentives to increase efficiency

Outcomes for health professionals

Salary increases The possibility of earning salaries based on the real volume and quality of their work

Outcomes for general population

Improved accessibility of emergency prehospital and inpatient care for the insured (data on out-patient care not reliable enough to draw conclusions) Decrease in the magnitude of informal payments

Future developments
 Over the past five years, the Republic of Moldova has made significant progress in reforming the health sector  The first phase of reforms was driven by financial crisis in the sector which forced local governments to close small district hospitals and reduce the number of health care personnel  The second phase has been largely driven by the introduction of mandatory social health insurance and the commensurate increases in health financing  With health spending at nearly 10% of GDP, it is critical to introduce a new phase of reforms in order to make gains in efficiency and quality