The Government of the Republic of Moldova is committed to ensuring access to
affordable high-quality health care for all citizens through health reforms which
promote universal coverage, reduce inequities, improve efficiency and expand
financial protection. There is concern that high out-of-pocket (OOP) payments and the
presence of informal payments may be hindering achievement of these goals. This
report presents a discussion of how OOP and informal payments in the Republic of
Moldova are affecting health sector objectives; a framework for understanding the
drivers; and suggestions for policy options to reduce these payments.
Previous analyses have provided background on formal OOP payments and proposed
a range of policy options, some of which are already under implementation. Reforms
targeting informal payments are high on the agenda of the Government and civil
society, yet this sensitive issue has not yet been addressed comprehensively. While
this study touches on all types of OOP payments, the aim is to provide more detail on
informal payments and to focus recommendations in this area.
Methods
Data were collected between August and October 2013 through review of documents,
health laws and regulations; key informant interviews; focus groups with providers
and patients; and analysis of quantitative data on salaries and household care seeking
behaviour and expenditures. A policy workshop for 45 participants was held at the
Ministry of Health of the Republic of Moldova on 31 January 2014 to present the draft
framework and discuss policy options. The final report incorporates input from this
workshop.
Definitions
OOP payments are defined as “any direct outlay by households, including gratuities
and in-kind payments, to health practitioners and suppliers of pharmaceuticals,
therapeutic appliances, and other goods and services whose primary intent” is to
enhance or restore health status. OOP payments include both formal and
informal payments. Formal payments are user fees paid to private health-care
providers; officially approved user fees charged in public facilities; and purchases of
medicines. Informal payments are defined as “a direct contribution, which is made
in addition to any contribution determined by the terms of entitlement, in cash or
in-kind, by patients or others acting on their behalf, to health care providers for
services that the patients are entitled to.” In the Republic of Moldova, people refer to
three types of informal payments: (i) conditioned payments – payments demanded by
providers or which patients feel obliged to pay in order to access good-quality care;
(ii) facilitation payments – payments which patients pay voluntarily (e.g. to obtain
specialist care without a referral or to skip a queue); and (iii) gifts – in-kind or cash
amounts given freely to express gratitude.
Findings
Over the past 10 years, the Government of the Republic of Moldova has engaged
in reforms to improve the quality and use of medical services and to provide
financial protection and equitable access to care. These include national pooling
of funds managed by the National Health Insurance Company (CNAM) to reduce fragmented and inequitable health financing allocations; universal coverage for
primary health care (PHC) services; and incentives to increase insurance
coverage among self-employed people. Insured people are entitled to free
inpatient medical care services listed in the benefit package without coinsurance,
deductibles or co-payments. For outpatient care, insurance covers the cost
of consultations and some ancillary testing, also without co-insurance, deductibles
or co-payments. Certain outpatient medicines listed on CNAM’s compensated or
reimbursed medicines list are covered in full or in part. Outpatients have to
purchase any medicines that are not on the compensated medicines list, and pay
any portion of the price not covered by insurance. These medicines are sold at
private pharmacies. Facilities are allowed to charge user fees for services to uninsured
patients and for services which are not part of the insurance benefit package,
following a nationally approved price list.
Implementation of these reforms has expanded health insurance coverage to almost
80% of the population and increased use of services. In 2010, Moldovans had 6.5
outpatient contacts per person per year; exceeding the European Union (EU) average
of 6.3 contacts per person per year. In addition, reforms have reduced financial barriers
to accessing care. Over the past four years, the proportion of people who said they did
not seek care when they needed it due to financial reasons fell by half: from 29.2% in
2008 to 14.8% in 2012. Still, data show that people who are in the lowest consumption
quintile, lack health insurance and live in rural areas are more likely to have financial
problems in accessing care.