Health Systems in Transition Vol. 10 No. 5 2008 Moldova Health system review Rifat Atun • Erica Richardson Sergey Shishkin • Gintaras Kacevicius Mihai Ciocanu • Valeriu Sava Editors: Erica Richardson • Svetlana Ancker Editorial Board Editor in chief Elias Mossialos, London School of Economics and Political Science, United Kingdom and European Observatory on Health Systems and Policies Editors Reinhard Busse, Berlin Technical University, Germany Josep Figueras, European Observatory on Health Systems and Policies Martin McKee, London School of Hygiene and Tropical Medicine, United Kingdom and European Observatory on Health Systems and Policies Richard Saltman, Emory University, United States Editorial team Sara Allin, European Observatory on Health Systems and Policies Cristina Hernandez Quevedo, European Observatory on Health Systems and Policies Anna Maresso, European Observatory on Health Systems and Policies David McDaid, European Observatory on Health Systems and Policies Sherry Merkur, European Observatory on Health Systems and Policies Philipa Mladovsky, European Observatory on Health Systems and Policies Bernd Rechel, European Observatory on Health Systems and Policies Erica Richardson, European Observatory on Health Systems and Policies Sarah Thomson, European Observatory on Health Systems and Policies International advisory board Tit Albreht, Institute of Public Health, Slovenia Carlos Alvarez-Dardet Díaz, University of Alicante, Spain Rifat Atun, Imperial College London, United Kingdom Johan Calltorp, Swedish Association of Local Authorities and Regions, Sweden Armin Fidler, The World Bank Colleen Flood, University of Toronto, Canada Péter Gaál, Semmelweis University, Hungary Unto Häkkinen, Centre for Health Economics at Stakes, Finland William Hsiao, Harvard University, United States Alan Krasnik, University of Copenhagen, Denmark Joseph Kutzin, World Health Organization Regional Office for Europe Soonman Kwon, Seoul National University, Korea John Lavis, McMaster University, Canada Vivien Lin, La Trobe University, Australia Greg Marchildon, University of Regina, Canada Alan Maynard, University of York, United Kingdom Nata Menabde, World Health Organization Regional Office for Europe Ellen Nolte, London School of Hygiene and Tropical Medicine, United Kingdom Charles Normand, University of Dublin, Ireland Robin Osborn, The Commonwealth Fund, United States Dominique Polton, National Health Insurance Fund for Salaried Staff (CNAMTS), France Sophia Schlette, Health Policy Monitor, Germany Igor Sheiman, Higher School of Economics, Russia Peter C. Smith, University of York, United Kingdom Wynand P.M.M. van de Ven, Erasmus University, The Netherlands Witold Zatonski, Marie Sklodowska-Curie Memorial Cancer Centre, Poland Health Systems in Transition Written by Rifat Atun, Centre for Health Management, Imperial College, London Erica Richardson, European Observatory on Health Systems and Policies Sergey Shishkin, Independent Institute for Social Policy, Moscow, Russian Federation Gintaras Kacevicius, independent consultant specializing in health systems financing Mihai Ciocanu, National Centre of Health Management and School of Public Health, Moldova Valeriu Sava, Health Insurance Department, Ministry of Health, Moldova Edited by Erica Richardson, European Observatory on Health Systems and Policies Svetlana Ancker, European Observatory on Health Systems and Policies Moldova: Health System Review 2008 The European Observatory on Health Systems and Policies is a partnership between the World Health Organization Regional Office for Europe, the Governments of Belgium, Finland, Greece, Norway, Slovenia, Spain and Sweden, the Veneto Region of Italy, the European Investment Bank, the Open Society Institute, the World Bank, the London School of Economics and Political Science, and the London School of Hygiene & Tropical Medicine. Keywords: DELIVERY OF HEALTH CARE EVALUATION STUDIES FINANCING, HEALTH HEALTH CARE REFORM HEALTH SYSTEM PLANS – organization and administration MOLDOVA © World Health Organization 2008, on behalf of the European Observatory on Health Systems and Policies All rights reserved The European Observatory on Health Systems and Policies welcomes requests for permission to reproduce or translate its publications, in part or in full Please address requests about this to: Publications WHO Regional Office for Europe Scherfigsvej 8 DK-2100 Copenhagen Ø, Denmark Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the WHO/Europe web site at http://www euro who int/PubRequest The views expressed by authors or editors do not necessarily represent the decisions or the stated policies of the European Observatory on Health Systems and Policies or any of its partners The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the European Observatory on Health Systems and Policies or any of its partners concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries Where the designation “country or area” appears in the headings of tables, it covers countries, territories, cities, or areas Dotted lines on maps represent approximate border lines for which there may not yet be full agreement The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the European Observatory on Health Systems and Policies in preference to others of a similar nature that are not mentioned Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters The European Observatory on Health Systems and Policies does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use Printed and bound in the United Kingdom Suggested citation: Atun R, Richardson E, Shishkin S, Kacevicius G, Ciocanu M, Sava V and Ancker S. Moldova: Health system review. Health Systems in Transition. 2008; 10(5): 1–138. ISSN 1817-6127 Vol. 10 No. 5 Contents Preface ............................................................................................................v Acknowledgements ..................................................................................... vii List of abbreviations .....................................................................................ix List of tables and figures ...............................................................................xi Abstract ...................................................................................................... xiii Executive summary ......................................................................................xv 1. Introduction ..........................................................................................1 1.1 Geography and sociodemography .................................................1 1.2 Economic context ..........................................................................4 1.3 Political context .............................................................................7 1.4 Health status .................................................................................10 2. Organizational structure .....................................................................17 2.1 Overview of the health system ....................................................17 2.2 Historical background ..................................................................19 2.3 Organizational overview ..............................................................21 2.4 Decentralization and centralization .............................................26 2.5 Patient empowerment ..................................................................27 3. Financing ...........................................................................................35 3.1 Health expenditure .......................................................................35 3.2 Population coverage and basis for entitlement ............................41 3.3 Revenue collection/sources of funding ........................................46 3.4 Pooling of funds ...........................................................................52 3.5 Purchasing and purchaser–provider relations ..............................54 3.6 Payment mechanisms ...................................................................55 4. Planning and regulation .....................................................................65 4.1 Regulation ....................................................................................65 4.2 Planning and health information management ............................68 iii Health systems in transition Moldova 5. Physical and human resources ...........................................................75 5.1 Physical resources ........................................................................75 5.2 Human resources .........................................................................80 6. Provision of services ..........................................................................91 6.1 Public health ................................................................................91 6.2 Primary/ambulatory care .............................................................92 6.3 Specialized ambulatory/inpatient care .........................................97