CONSULTING SERVICES FOR THE DEVELOPTMENT OF THE REGIONALIZATION PLAN
Inception Report
This document is presented to the Ministry of Health of the Republic of Moldova October, 2012 Consulting Services for the development of the Regionalization Plan
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The Inception Report is the second deliverable under the Regionalization Plan consultancy carried by Sanigest Internacional under an engagement with the Ministry of Health of the Republic of Moldova in order to analysis, review of Regionalization Framework Plan to optimize the number of health areas and develop in details its organizational structure and as well, the plan for regionalization of health services for Briceni, Ocniţa, Rîşcyear, Edineţ Drochia, Donduşeni districts (rayons).
Sanigest InternacionalÓ 2012 This document is a formal publication by Sanigest Internacional and the Copyright and ownership of the materials and documents prepared by The Firm and approved by the Ministry of Health will be submitted to the Ministry of Health...
Comments and questions regarding this report: We welcome all communications regarding this Report and the Project in general. They may be addressed to the Team Leader (James A. Cercone, [email protected]).
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Acknowledgements
The consultants would like to thank Andrei Usatii for his leadership. Rodica Scutelnic for her collaboration and key insight within the project. Svetlana Cotelea and Oleg Hincu for their initial ideas and comments which shaped the structure and content of this document. The authors would also like to thank participants from PAS, including Andrei Mosneaga and Ghenadie Turcan for their insights. The following hospital directors provided essential inputs for the analytical phase of this assignment; Spitalul raional Briceni, Director Veltman Claudia, Spitalul raional Donduşeni, Director Casian Veaceslav, Spitalul raional Drochia, Director Cojocaru Tudor, Spitalul raional Edineţ, Director Guţu Anatolie, Spitalul raional Ocniţa, Director Iurcu Feodor and Spitalul raional Rîşcani, Direcor Roşu Gheorghe.
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Acronyms and Abbreviations
CIS Commonwealth of Independent States CNAM Compania Nationala de Asigurari in Medicina (national health insurance company) CVD Cardiovascular Disease DALY Disability Adjusted Life Year DRG Diagnosis Related Groups EU European Union ENT Ear Nose and Throat FSU Former Soviet Union FTE Full Time Equivalent Employees GIS Geographical Information System GOM Government Of Moldova HIF Health Insurance Fund HNA Health Needs Assessment ICD International Classification of Diseases IMR Infant Mortality Rate MHSP Moldova Health Service Plan MMR Maternal Mortality Rate MOH Ministry of Health NCD Non-communicable Disease NHIC National Health Insurance Company OHI Obligatory Health Insurance PCU Project Coordination Unit PHC Primary Health Care RHA Regional Health Authority SWOT Strengths, Weaknesses, Opportunities and Threats WHO World Health Organization
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Table of Contents
ACKNOWLEDGEMENTS...... II ACRONYMS AND ABBREVIATIONS ...... III 1. INTRODUCTION...... 10 2. METHODOLOGY AND DATA APPROACH ...... 14 3. SITUATION ANALYSIS...... 16 3.1. Territory Demographics and Dynamic Populations ...... 16 3.2. Current Population and projections...... 16 3.3. Population projections ...... 22 3.4. Aging Population ...... 23 3.5. Rural vs. Urban distribution ...... 26 3.6. Vital Statistics and Overall Health Status...... 28 3.7. Communicable disease...... 34 3.8. Changing disease patterns...... 36 3.9. Cardiovascular Disease ...... 41 4. HOSPITALS ...... 55 4.1. Service delivery ...... 55 4.2. Access to care...... 58 4.3. Utilization rates ...... 59 4.4. Bed turnover rate ...... 60 4.5. Admission Rate...... 61 4.6. Optimal Hospital Size...... 63 4.7. Hospital Beds...... 65 4.8. Trends in the number of beds...... 66 4.9. Number of Beds per Speciality...... 67 4.10. Average Length of Stay (ALOS)...... 68 4.11. Unnecessary hospitalization ...... 71 5. WORKFORCE ...... 74 5.1. Stock (and density) of the healthcare workforce...... 75 5.2. Physician to bed ratios...... 83 5.3. Skills mix: Distribution of HRH by occupation, specialization, or other skill-related characteristic...... 85 5.4. Importance of family medicine in Moldova...... 89 6. PROCEDURES ...... 90 7. OUTPATIENT SERVICES...... 98
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7.1. Equipment assessment...... 99 7.2. Emergency care ...... 101 7.3. Pharmacy ...... 103 7.4. Laboratory...... 104 8. PLANNING AND RESTRUCTURING GUIDELINES AND STANDARDS...... 112 8.1. Process...... 112 8.2. Summary of Key Principles...... 113 8.3. A review of international experiences...... 114 8.4. Planning of hospital capacity ...... 126 9. REDEFINING LEVELS OF CARE...... 133 9.1. Proposed Hospital Levels...... 133 9.2. Differentiating between acute and non-acute care...... 146 9.3. Acute Inpatient Services ...... 146 9.4. Ambulatory surgery...... 147 9.5. Community Hospitals...... 153 10. PREVIOUS MASTER PLAN AND EVALUATION...... 127 10.1. Building upon the existing Master plan...... 128 10.2. Areas for improvement...... 129 10.3. Management issues...... 130 10.4. Planning ahead...... 131 10.5. Grassroots planning...... 131 10.6. Global direction...... 132 11. SUGGESTED OPTIONS FOR NETWORK CONFIGURATION ...... 155 11.1. General Principals...... 156 12. OPTIONS FOR RECONFIGURATION OF NETWORK OF BRICENI, DONDUSENI, DROCHIA, EDINETS, OCNITA AND RISCANI...... 161 12.1. Key Assumptions ...... 162 12.2. Edinets as an inter-district hospital...... 163 12.3. Option 1: Re-profile Edinets, Briceni, Ocnita, Donduseni, Drochia and Riscani...... 166 12.4. Option 2: Re-Profile Edinets, Drochia, Briceni, Ocnita, Donduseni, Riscani...... 167 12.5. Option 3: Reprofile Edinets, Briceni, Ocnita, Donduseni, Drochia and Riscani...... 169 12.6. Option 4: Reprofile Edinets, Briceni, Ocnita and Donduseni...... 171 12.7. Advantages and disadvantages of Regionalization Options 1-4...... 172 12.8. Key Supporting Actions...... 178 13. BRIEF ANALYSIS OF LEGISLATION RELEVANT TO REGIONALIZATION ...... ERROR! BOOKMARK NOT DEFINED.
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ANNEX ...... 181 Annex 1 Total Population by Sex per rayon ...... 181 Annex 2 Number of beds per specialty for northern region...... 185 Annex 3 Availability of equipment...... 190 Annex 3 Availability of equipment...... 192 Annex 4 Availability of services ...... 194 REFERENCES ...... 180
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List of Tables
TABLE 1. POPULATION PROJECTIONS PER RAYON FOR 2020...... 23 TABLE 2. LOW BIRTH WEIGHT FOR THE NORTHERN REGION. SOURCE: SANIGEST 2012...... 29 TABLE 3. LEADING DISABILITY GROUPS IN MOLDOVA (% OF TOTAL DALYS) 2004 SOURCE: WHO...... 34 TABLE 4. RECOMENDED NUMBRE OF PROCEEDURES PER 100,000 ...... 47 TABLE 5. CARDIAC PROCEDURES PER 100,000...... 52 TABLE 6. EXISTING SPECIALIST PER RAYON ...... 56 TABLE 7. TURNOVER/BEDS PER SELECTED RAYON’S SOURCE: SANIGEST 2012 ...... 61 TABLE 8. NUMBER OF TOTAL HOSPITALIZATION AND PERCENTAGE AS TOTAL NUMBER FROM 12 RAYONS. DROCHIA AND EDINEŢ CURRENTLY HOLD THE HIGHEST NUMBER OF HOSPITALIZATIONS WITHIN THE PILOT REGION RAYONS...... 62 TABLE 9. ALOS (IN DAYS) BY SPECIALTY IN SELECTED RAYON’S 2011 ...... 70 TABLE 10. THE NUMBER OF SPECIALIST PER 100,000 IN EUROPE. SOURCE EUROSTAT 2010 ...... 87 TABLE 11. AVAILABILITY OF EQUIPMENT WITHIN PILOT REGION. GREEN INDICATES AVAILABILITY WHILE RED INDICATES NON-EXISTENT...... 99 TABLE 12. MAIN FEATURES OF HOSPITAL RESTRUCTURING IN SELECTED COUNTRIES ...... 114 TABLE 13. LEAD RESPONSIBILITY FOR CAPACITY PLANNING ...... 125 TABLE 14. WE PROVIDE A LIST OF SPECIALTIES THAT SHOULD BE INCLUDED AT EACH PROPOSED LEVEL OF CARE...... 134 TABLE 15. PERCENTAGE OF CASES TO BE MANAGED AT EACH LEVEL WE ARE PROPOSING...... 145 TABLE 16. DAY SURGERY PROCEDURES LISTED BY THE IAAS. 2009...... 148 TABLE 17. AMBULATORY SURGERY MAIN ADVANTAGES ...... 150
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List of Figures
FIGURE 1. POPULATION PROJECTIONS FOR PILOT REGION 2015...... 18 FIGURE 2. POPULATION PROJECTIONS FOR PILOT REGION 2020...... 19 FIGURE 3. POPULATION PROJECTIONS FOR PILOT REGION 2025...... 20 FIGURE 4. POPULATION DENSITIES ACROSS EUROPE 2010 SOURCE THE WORLD BANK ...... 21 FIGURE 5. PROJECTED EVOLUTION OF THE NUMBER OF POPULATION IN MOLDOVA, 2008-2050...... 22 FIGURE 6. PROJECTED VALUES OF THE BIRTH RATE ARE DECREASING FOR MOLDOVA, 2008-2050 (IN %) ...... 22 FIGURE 7. DISEASES SUCH AS CARDIOVASCULAR DISEASE WILL ACCOUNT FOR MORE THAN 60% OF TOTAL MORTALITY BY 2025...... 25 FIGURE 8. POPULATION OVER 65 IN PERCENTAGE PER SELECTED RAYON 2012 ...... 25 FIGURE 9. WITH THE A DECREASE IN BIRTH RATE AND A SHIFT TOWARDS AND AGING POPULATION DRGS FOR THE +65 AGE GROUP WILL BECOME CRITICAL AREAS TO ADDRESS WHEN DECIDING ON PRIORITY...... 26 FIGURE 10. THE CLEAR DOMINANT NUMBER OF CASES FOR THE AGE GROUPS FROM 50-64 AND >65 SEEN FOR EACH OF THE HOSPITALS IN THE CAPITAL. SIMILAR TRENDS EXISTING FOR THE NORTHERN REGION. SOURCE: SANIGEST 2012...... ERROR! BOOKMARK NOT DEFINED. FIGURE 11. THE REGIONALIZATION STRATEGY WILL BENEFIT THE POPULATION CURRENTLY LIVING IN RURAL AREAS BUT ALSO THOSE IN MAJOR URBAN CITIES. TOTAL URBAN VERSUS RURAL DISTRIBUTION BY AGE 2012 SOURCE:SANIGEST ...... 27 FIGURE 12. DYNAMICS OF THE MATERNAL DEATH RATE (IN 100,000 NEW-BORNS) SOURCE: NATIONAL STATISTICS BUREAU. AS WITH PAEDIATRIC AND NEONATAL CARE MATERNAL HEALTH IS INCLUDED WITHIN THE PROPOSED REGIONALIZATION STRATEGY...... 31 FIGURE 13. CAUSE OF DEATH AS % OF TOTAL DEATHS. CVD CAUSES OVERLAPPING GIVING A TOTAL OF 55% AS OF TOTAL DEATHS PER YEAR. ALL FORMS OF CANCER COMBINED TOTAL 12% AS OF TOTAL DEATHS PER YEAR ...... 32 FIGURE 14. ALL POPULATION MORTALITY SHOW CHRONIC DISEASES FOLLOWED BY TRAUMA ACCOUNT FOR MAJORITY OF CASES FOR THE NORTHERN REGION SOURCE: SANIGEST 2012...... 32 FIGURE 15. ALL CANCERS MORTALITY RATES, MALES AND FEMALES, 2009 (OR NEAREST YEAR). CANCER IS THE SECOND LEADING CAUSE OF NCD DEATH IN MOLDOVA. PALLIATIVE CARE IS A CRUCIAL FOR THE NORTHERN REGION ...... 33 FIGURE 16. TB IS OF MAJOR CONCERN IN MOLDOVA WITH AN ALARMING NUMBER OF RESISTANT STRAIN CASES. INFECTIOUS DISEASES SURVEILLANCE AND CONTROL CONTINUES TO BE ON THE AGENDA WITHIN THE REGIONALIZATION STRATEGY...... 35 FIGURE 17. LOOKING SPECIFICALLY AT CVD AND DIABETES, THE RATES ARE INCOMPARABLE TO THAT OF WESTERN EUROPEAN COUNTRIES YET. SOURCE: WHO HEALTH FOR ALL DATA BASE LAST ACCESSED 2012 ...... 36 FIGURE 18. NCD DEATH RATES ARE SIGNIFICANTLY HIGHER THAT WESTERN EUROPEAN COUNTRIES PLAYING A HEAVY FINANCIAL BURDEN ON THE HEALTH SYSTEM. SOURCE: WHO HEALTH FOR ALL DATA BASE LAST ACCESSED 2012 ...... 37 FIGURE 19. PROJECTED VALUES OF THE WEIGHT OF ELDERLY POPULATION APPLIES FOR THE NORTHERN REGION AS WELL, 2008-2050 (IN %) SOURCE: NATIONAL COMMISSION FOR POPULATION AND DEVELOPMENT (NCPD) OF THE REPUBLIC OF MOLDOVA 2009...... 37 FIGURE 20. COMPARISON OF 2001 AND 2010 SMOKING PREVALENCE RATES BY COUNTRY IN 8 FORMER SOVIET UNION COUNTRIES. PREVENTATIVE MEASURES TARGETING RISK FACTORS ARE A PRIORITY AREA WITHIN COMMUNITY CENTRES OFFERING LIFESTYLE CHANGES WITHIN THE REGIONALIZATION STRATEGY...... 39 FIGURE 21. CONSUMPTION OF ALCOHOL PER YEAR IN LITTERS AMONG 10 FORMER SOVIET UNION NATIONS CAPACITATING HEALTH WORKERS TO HELP ADDRESS HIGH ALCOHOL CONSUMPTION IN THE NORTH WILL BE CARRIED OUT AT THE COMMUNITY LEVEL DURING REGIONALIZATION. SOURCE: WHO 2011 ...... 40 FIGURE 22. CAUSE OF DEATH BY CVD...... 41 FIGURE 23. STROKE MORTALITY RATES INTERNATIONAL. MOLDOVA AS MOST FSU COUNTRIES CARRIES A HIGH BURDEN OF CEREBROVASCULAR MORTALITY THEREFORE IMMEDIATE CARE IS ESSENTIAL FOR THE NORTHERN REGION. TRAVEL TO CHISINAU FOR ACUTE CARE IS NO LONGER FEASIBLE...... 42 FIGURE 24. THE CASELOAD FOR CVD DISEASE VARIES AMONG THE NORTHERN RAYONS WITH THE MAJORITY OF CASES OCCURRING IN FLOREŞTI AND SÎNGEREI, SOURCE: SANIGEST 2012 ...... 43 FIGURE 25. PRIMARY PCIS PER YEAR PER MILLION INHABITANTS IN EUROPEAN COUNTRIES. MOLDOVA HAS ONE OF THE LOWEST CARDIOVASCULAR INTERVENTION RATES WITHIN EUROPE. SOURCE: WIDIMSKY P ET ALEURO HEART J 2010 APR 31 (8) 943- 57 ...... 44
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FIGURE 26. CHRONIC DISEASE CARE...... 51 FIGURE 27. BED UTILIZATION CAN DROP AS LOW AS 60% WITHIN RAYONS WITHIN THE PILOT REGION EVIDENCING THE AMOUNT OF EMPTY BEDS. SOURCE: SANIGEST 2012...... 60 FIGURE 28. EDINEŢ HAS THE SECOND HIGHEST ADMISSION RATE FOR THE REGION AT 14% ONLY SECOND TO FLOREŞTI. THIS MALE IT A STRATEGIC ASSESS POINT FOR THE REGIONALIZATION PROPOSAL TO PLACE IT AS THE INTER-DISTRICT HOSPITAL. SOURCE: SANIGEST 2012 ...... 62 FIGURE 29. MOST RAYONS SURPASS THE 200 BED THRESHOLD FOR THE POPULATIONS. SOURCE: SANIGEST 2012 ...... 65 FIGURE 30. NUMBER OF BEDS PER 10,000 POPULATION THIS TREND IN EXCESS IS SEEN THROUGHOUT THE NORTHERN REGION. REGIONALIZATION PAIRING THE NUMBER OF BEDS NEEDED TO THE NEEDS OF THE POPULATION. SOURCE: SANIGEST 2012....67 FIGURE 31. AVERAGE LENGTH OF STAY PER SELECTED RAYON’S. ALOS EXCEEDS THE INTERNATIONAL TRENDS IN ALL RAYONS. SOURCE: SANIGEST...... 68 FIGURE 32. AVERAGE LENGTH OF STAY FOR SELECTED COUNTRIES FROM 1998-2009 SOURCE OECD 2012 ...... 69 FIGURE 33. AVERAGE LENGTH OF STAY REPUBLICAN VS. RAYON . EXCESSIVE ALOS CONSUME RESOURCES THAT COULD BE BETTER LOCATED WITHIN THE HEALTH SECTOR. SOURCE: MOH 2010...... 70 FIGURE 34. TRAUMA AND ORTHOPAEDICS, ONE OF THE TOP CAUSE CAUSES OF DEATH IN MOLDOVA HAS THE LONGEST LENGTH OF STAY COMPARED TO ALL CAUSE SURGICAL CASES. SOURCE: SANIGEST 2012...... 71 FIGURE 35. AS YOUNG DOCTORS FLEE TO THE CAPITOL OR TO OTHER COUNTRIES THE AVERAGE AGE IN THE NORTH FOR MOST RAYON IS CLOSE TO RETIREMENT AGE. SOURCE: SANIGEST 2012 ...... 74 FIGURE 36. AGGREGATED DATA PHYSICIANS PER 1,000 THERE IS A CLEAR LACK OF PHYSICIANS WITHIN THE ENTIRE COUNTRY. SOURCE: WHO 2007 ...... 76 FIGURE 37. DOCTORS PER 100,000 PEOPLE, COMPARATIVE. PHYSICIAN MIGRATION CONTINUES TO BE A MAJOR ISSUE IN TERMS OF THE HEALTH CARE WORKFORCE. SOURCE: OECD LIBRARY LAST ACCESSED 2012 ...... 77 FIGURE 38. DOCTORS PER 1,000 IN SELECTED RAYON’S 2011 STRATEGIES TO RETAIN DOCTORS WITHIN THE NORTHERN REGION WILL NEED TO BE DEVELOPED AS TENDENCIES OF PHYSICIAN SCARCENESS ARE SEEN ACROSS RAYONS. SOURCE: SANIGEST 2012 ....82 FIGURE 39. A CLEAR SHORTAGE OF DOCTORS IN THE NORTHERN REGION COMPARED TO THAT OF OECD COUNTRIES. SOURCE: OECD LIBRARY LAST ACCESSED 2012...... 83 FIGURE 40. TOTAL NUMBER OF DOCTORS PER OCCUPIED BED PER SELECTED RAYON SOURCE: SANIGEST 2012...... 84 FIGURE 41. TOTAL NUMBER OF NURSES PER RAYON...... 86 FIGURE 42. NUMBER OF NURSES PER HOSPITAL BED ...... 87 FIGURE 43. SHARE OF SURGERIES IS VERY LOW REFLECTING LOW-ACUITY OF PATIENTS ...... 90 FIGURE 44. FACTORS SUCH AS LOW NUMBER OF ANAESTHESIOLOGIST AND QUALIFIED SURGEONS LEAVE THE PILOT REGION WITH LOW NUMBER OF SURGICAL OUTPUT...... 92 FIGURE 45. BIRTH STANDARD: 300 MIN BIRTHS PER. ALL RAYONS BELOW THE RED LINE REPRESENT HOSPITALS THAT ARE NOT MEETING THE REQUIRED OUTPUT PER FACILITY. YEAR SOURCE: SANIGEST 2012 ...... 94 FIGURE 46. CAESAREAN SECTION, A COMMON SURGICAL PROCEDURE FOR BENCHMARKING SURGICAL PERFORMANCE SHOWS THE NORTHERN REGION AS HAVING A LOW CASE DENSITY...... 94 FIGURE 47. NUMBER OF SURGERIES VARIES AMONG SPECIALTIES AND REGION WITH GENERAL SURGEONS IN BRICENI PREFORMING AS LITTLE AS 32 ON AVERAGE (COMBINED SPECIALTIES) ...... 97 FIGURE 48. TOTAL NUMBER OF OUTPATIENT-DISCHARGE RATIOS (PER PERSON, PER YEAR), BY RAYON HIGH HOSPITALIZATION RATES RESULT IN LOW OUTPATIENT NUMBERS FAR BELOW INTERNATIONAL BENCHMARKS. SOURCE: SANIGEST 2012...... 98 FIGURE 49. CURRENT LEVEL OF INFRASTRUCTURE AND RECOMMENDED LEVEL FOR NORTHERN REGION. RED REPRESENT THE SANIGEST RECOMMENDATION BASED ON INTERNATIONAL STANDARDS FOR EACH UNIT ...... 101 FIGURE 50. EDINEŢ HAS AN EMERGENCY LABORATORY SETTING AS WELL AS SEPARATE INPATIENT/OUTPATIENT LABORATORY FACILITY ...... 105 FIGURE 51. NUMBER OF LAB TEST ORDERED PER DOCTOR. THANKS TO INTERNATIONAL COOPERATION EFFORTS AND SUPPORT FROM MOH EDINEŢ AND DROCHIA HAVE SOME OF THE STRONGEST LABORATORY INFRASTRUCTURE FOR THE REGION. UNLIKE THE NATIONAL MEDICINES POLICY A CURRENT NATIONAL CLINICAL LABORATORY POLICY DOES NOT EXIST IN MOLDOVA ...... 106 FIGURE 52. PERCENTAGE OF DAY SURGERY PROCEDURES OF TOTAL SURGERIES ...... 150 FIGURE 53. ANNUAL GROWTH RATE LTC HOSPITALS ...... 152 FIGURE 54. GLOBAL TENDENCY TO REDUCE NUMBER OF ACUTE HOSPITALS OVER THE YEARS. SOURCE:OECD LIBRARY LAST ACCESSED 2012...... 157
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. Executive Summary 1. Introduction
This paper is the compilation of research carried out by Sanigest Internacional as part of the analysis and review of the northern region under the second deliverable for the consulting services for the development of the regionalization plan. It analyzes the current situation and organizational structure and as well, the current Plan for regionalization of health services for the northern region. Within a close collaboration with the the Ministry of Health a Plan for regionalization of Ocnita, Briceni, Donduseni, Edinet, Drochia and Riscani rayons has been drafted. It includes concrete recommendations comprising the governing bodies in the context of decentralization of health services. It contains a detailed description of the criteria Sanigest has utilized for staging health services within the each region and the development of integrated health care networks.
Through a systematic benchmarking process the report presents an accurate estimation of the allocation of services needed based on the health needs assessment carried out within the pilot region. This allocation of resources includes structural changes such as the number of the beds with different profiles that are needed, including the long term care and rehabilitation beds; flow of patients in the referral system within the area of health and cooperation mechanisms with emergency and primary health care.
The patient referral mechanism has been elaborated for each level as well as a novel model that proposes new levels of care (primary health care, hospital care, emergency health care, public health services, etc.), and a comprehensive patient referral mechanism has been provided in order to ensure and efficient transit of patients to the next level of provided health care. Included is a determination of the spectrum of provided health services and standards for equipment endowment of health facilities according to the level of the health facility as well as the implementation of population screening programs at the primary health care level for non-communicable disease control.
The situational analysis evaluates and discusses in detail the current system for providing hospital services in the northern region including geographical location and capacity and quality of health care provided in health facilities and interaction with other health facilities (hospitals, Family Doctor Centers, Health Centers, etc.). Sanigest has benchmarked the current health delivery system according to European and international standards, including the capacity of pharmacies located within hospitals to respond to real needs and requirements. From the governance perspective the report takes into consideration up to dated legal norms and standards governing the institutions and services within the region.
As a result of the mentioned above activities, Sanigest has provided four (4) detailed and well reasoned scenarios, which include implications for their implementation and regionalization. These scenarios have come out of the results of the mentioned above analysis and are targeted to a cost-effective use of existing facilities with further development solutions and possible alternative options for future hospital infrastructure and location.
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Vignette 1 Alexandru Cojocaru
Alexandru Cojocaruis a 50-year-old native of Ocniţa, Moldova who works as a construction foreman. He lives with his wife Cristina and his two sons who are 12 and 16. Alexandru was diagnosed with type 2diabetes about 12 years ago, after an ophthalmologist told him it would be a good idea to get his blood sugar checked. He was put on Glucophage and added Actos to his regimen a couple of years ago. “When they told me about the pills, they mentioned to me that I was going to go on insulin eventually-when, they didn't know. It was up to me. So I knew it was going to happen."
Before insulin, Alexandru was constantly felt tired. He would refer the sensation of having a void in his chest and I could hardly breathe. After consulting with his family doctor and the risk of renal failure a likely possibility Alexandru was put on insulin treatment Alexandru is 1’71m and weighs 120 kg. He has been struggling with obesity the majority of his life and in 2010 was sent to the National Institute of Cardiology after having suffered a mild heart attack while on the job. These last couple of years, with the current economic situation and family problems, everything seemed to pile up and Alexandru did not follow his regular treatment for a year or so. That's when he decided he needed lifestyle counselling. His cousin Dorian whom had been working in Austria and had been suffering with similar health problems for a number of years had been receiving lifestyle advise from his family doctor as well as educational groups sessions at the local community clinic.
Before regionalization
Unfortunatly Alexandru would not be able to receive the same quality of treatment as his cousin. When he asked his local family doctor about lifestyle support he was told that this was not something that was available in Ocniţa and that he would be better suited traveling to Balti or Chisinau to consult a private nutritionist. After sitting down and planning his next trip to Chisinau he decided he would visit the entire necessary specialist at once in order to save time. Unfortunately, the cost of visiting a nutritionist, endocrinologist, and cardiologist would surpass the amount of money at his disposal, so he decided to postpone the visit.
Years past and Alexandru has not made that scheduled trip to Chisinau. Regrettabley, insulin is not always available at his local hospotal in Ocnita and sometimes has to be checking in just to be monitored to avoid complication from the lack of medication. Alexandru must now visit the hemodialusos unit twice a week and has recently been diagnosed with left side ventricular hypertrophy and suffers from frecuent arrythmias. He must travel twice a week to the capital to be treated for his multiple contitions and ofter spends up to 12 days visiting specialists. Alexandrus condition has worstened over th last couple of years and has
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. left him unable to work or even perform small tasks arround the house. The financial impact on his family has made things dificult and taking care of his health has become a full time job for him and his wife
After Regionalization, Alexandru can visit the local community hospital were he frecuently visits the chronic care specialist. The specialist is able to perscribe and dispense his insuline treatment and follow up for both his metabolic and cardiovascular issues as well. That same day he can visit the clinical nutritionist at the centre that gives him a tailored dietary regimen that is drawn up according to the lifestyle changes his chronica care doctor had provided.
On Mondays Alexandru visits the group nutritional seminars were he is meets with other friends from his town in Ocnita to receive counceling and advise on topics such blood glucose monitoring, food labels and recipe modification, exercise strategies, associated health care concerns, strategies for change. “The organisation of the various sessions was good; presenters were to the point, frank, helpful and sympathetic” Alexandru mentioned. He remarks that he was surprised at how up to date the community centre doctors were. They even showed him how to use and application on his mobile phone that lets him track his glucose levels and amount of kilometres he walks per week. Lucky for Alexandru, he was able to maintain his glucose levels steady and avoided any further complications. He has not had any heart trouble in years and takes his children to school twice a week.
Alexandru’s case displays the advantages that the regionalization process has brought with it in the northern region. We understand that as with health systems, patients are also complex and dynamic processes that must be address in a holistic and comprehensive manner. Based on our initial assessments of the current situation in the northern region we have identified key areas that have been addressed within the reconfiguration of the network. Areas such as long term care instead of the historical, acute care for all model, community centres that integrate multiple comorbidities and a regional facility close by (Edineţ) that provides patients with timely specialized attention are all aspects we have targeted within this paper.
Since the mid-90s of the last century the Republic of Moldova has started implementing a series of key reforms, intended to improve accessibility and quality of services to increase the efficiency and performance of the healthcare system. These changes were first of all aimed at prioritization of the primary health care (PHC) improvement by means of establishing of the family medicine institution (family doctors), disease control programs (immunizations, MCH, TB, HIV), supplemented by funding system reform through implementation of the obligatory health insurance (OHI). The efficiency of the above mentioned measures has been demonstrated by manifold results achieved and was highly appreciated by international partners. At the same time, the Government of the Republic of Moldova and the Ministry of Health recognize the need for further actions aimed to reform the health sector with the view to improve the quality of services and the population’s satisfaction with them. This goal refers primarily to in-patient medical institutions (hospitals) of different levels, which take a special
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. place within the existing healthcare system due to the considerable amount of human, financial and infrastructure resources they use, and also due to their involvement in supporting of good health condition and social values. In the Republic of Moldova there are 84 public and private hospitals with the capacity of 22,021 beds, the major part being 73 public hospitals with the capacity of 21,817 beds. In 2010 50.7 present of the obligatory health insurance fund was allocated for payment of the current medical services (basic fund), with a total of 553,482 treated cases. The state of hospital buildings is also not satisfactory and most medical equipment in these facilities is obsolete. However, not all the people benefit by quality hospital care, due to the fact that the limited range of profiles and outdated technologies do not reflect the needs of the population. There is overcapacity and duplication of hospital services in Chisinau municipality (about 53% of hospitals beds and over 42 out of a total number of 84 are located on the territory of Chisinau municipality). Republican specialized institutions are concentrated in the capital, including monoprofile institutions (e.g. infectious diseases, trauma and orthopaedics, oncology, cardiology, neurology and neurosurgery, tuberculosis, dermatology-venereology, etc.), resulting in a situation that does not allow the provision of health services based on a multidisciplinary approach, leading to duplication in the use of resources and a high concentration of specialized services in the capital. At the same time, 34 district hospitals (apparently general hospitals by type of health services provided) render health services to different districts, according to the number of population and hospital service needs. Despite the fact that the hospitalization rate in Republic of Moldova is approximately equal to the EU average rate, there is increasing evidence that a significant number of hospital admissions are for cases that are not considered as justified in EU. Another concern is low quality of surgical services, childbirth delivery and specialist medical services within district hospitals, due to a small number of performed surgeries, deliveries and complicated medical conditions assisted by them. The Government has established as a priority within the framework of the Programme of activities for 2011-2014 – “Restructuring of the public hospitals network based on the principles of economic efficiency and provision of secure and qualitative healthcare services, in conformity with the General National Hospital Plan”. This activity corresponds to the best practices in organization of hospital medical assistance, and in conformity with it, the hospitals reform shall ensure the following objectives: i) Adequate access (geographic, financial) to services; ii) High quality of provided services; iii) Effective collaboration and coordination between all levels of hospital medical assistance, as well as with other medical services (primary medical assistance and emergency medical assistance); iv) Enhancement of the efficient use of resources (financial, institutional, human); and v) Satisfaction of patients and community participation.
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2. Methodology and Data Approach
The approach for this project follows the terms of reference and outlines three key work streams which will guide the proposed project implementation. The three works teams, or components, will allow us to separate the main activities under the project and to measure implementation success.
Sanigest Internacional has been asked to pilot the regionalization strategy for the following rayon’s:
Ocniţa Floreşti
Briceni Glodeni
Donduşeni Făleşti
Edineţ Riscani
Soroca Sîngerei
Drochia Floreşti mun.Balti
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After initial consultations with the MoH and key stakeholders it was agreed up that the initial assessment would include Ocniţa, Briceni, Donduşeni, Edineţ Drochia, and Riscani, although we have included initial assessments in some areas for the 12 initial rayons. The first area of focus as mentioned in the initial report is based on estimating health needs: The development of any health master plan should be closely linked to the population’s health needs and the context in which the changes are to be implemented. In this context, as the first sub-component, Sanigest carried out a rapid health needs assessment (HNA) to have a clear picture of the principal health problems facing the nation. The HNA is “a systematic method for reviewing the health issues facing a population, leading to agreed priorities and resource allocation” (Cavanagh and Chadwick, 2005).
This approach was utilized to analyse the current health needs of the Moldovan population and to obtain evidence that that supports several components of the current project. The situation analysis provided us with key information for the pilot region on: (a) the population’s health needs and (b) the performance of the existing provider network. This will also be the basis of our initial discussions with authorities in each rayon and the key stakeholders, including National Health Insurance Fund (CNAM). Using the situation analysis, we will jointly develop a SWOT (strength, weakness, opportunities and threats) analysis for each of the six rayons.
In this phase, the performance of the network was assessed. The situational analysis gauged how well the network performed in each rayon and the major cities and obtained an overview of the current situation in terms of supply and demand for services.
A comparison among the hospitals in each rayon to other countries where Sanigest has carried out master planning is presented. The general framework developed for this part of the assessment was based on the evaluation of resources (inputs such as people, infrastructure, equipment, information, materials, drugs and technology), activities (processes such as “What is done” and “How is it done”), structure and results (outputs and outcomes such as services delivered, health status, etc.) of the health sector in order to assess performance and provide recommendations.
The developing of planning parameters and guidelines is based both on the best practice in hospital networks in Europe as well as the evaluation of what is required for the Moldovan population based on the situation analysis and health needs assessment in the previous sub- component.
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. 3. Situation Analysis
Our population based planning approach started with a thorough assessment of the situation in terms of demographic and epidemiological conditions for the selected pilot regions in Moldova—the health need. This was then complemented with a benchmarking analysis of key indicators in terms of input, processes, output and outcome to better understand how the network should change in the future.
To plan for the modernization of its health facility network, policymakers need to have a clear understanding of the population health conditions and other factors affecting demand for healthcare. Situation analysis is a systematic examination of the health issues facing a population to determine policy development, priorities, and resource allocation. Using international standards, population-based hospital planning can effectively identify excesses and gaps in healthcare on the national and regional levels. This detailed review provides the basis for the development for the health sector regionalization process.
3.1. Territory Demographics and Dynamic Populations
3.1.1 Territory
The Republic of Moldova is a small, land-locked country situated between Ukraine and Romania. Today, agricultural activities cover 75% of the landscape and farmers produce world-famous wines along with cereal grains, corn, fruits, vegetables, nuts and other products.
3.2. Current Population and projections The current population in Moldova is estimated at 3,656,843 (July 2012 est.). In terms of age structure the population from 0-14 years is around 15.5% (male 344,101/female 325,995) and for 15-64 years: 74% (male 1,550,386/female 1,643,108). The population 65 years and over is estimated to be 10.4% (male 164,512/female 286,275) (2011 est. WHO). The median age for the total population is 35.2 years; male 33.3 years and female: 37.2 years (2012 est.). The Republic of Moldova falls, with some exceptions, within the average European limits of the birth rate (12.5‰) and of the mortality rate (12.62‰). The calculated migration rate is currently at -10.02 migrant(s)/1,000 population. In this context the Republic of Moldova makes no exception from the evolution of the demographic phenomena recorded throughout Europe. Thus, the demographic transition in the European states takes place during centuries, while in the Republic of Moldova it takes a few decades only. The Republic of Moldova is just beginning to face demographic issues.
The extent in which the Republic of Moldova is prepared to respond to the challenges of the demographic transition, will determine to a great extent the solutions that will be found for the demographic, as well as the social, economic, and political problems. The evolution of the demographic problems in the space of the Republic of Moldova, as European territory and state unit, can be studied after the Second World War, when the state frontiers were
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. definitely set and the central and territorial statistical authorities were created. There can be distinguished two periods in the evolution of the demographic phenomena:
1. The period 1950-1990, when the population increased significantly as a result of the high birth rate growth, the great reduction of the mortality rate, and the massive immigration of population from the Former Soviet Union (FSU) space. Thus, the number of population increased from 2,290 thousand (1950) to 4,366 thousand (1990), namely by 90.4%.
2. The period after 1990, characterized as a period of demographic decline, as a result of the significant decrease of the birth rate and of the increase of the mortality of the population, followed by the dramatic emigration of the population towards West and East. The first period of demographic evolution was characterized by the increase in number of the population, both on the basis of the high natural growth of population, and on the basis of the fairly high migratory growth, especially during the first post-war decades (1945-965).
As a result, the unbalance in the structure of the population on sexes and ages, the territorial distribution of the population underwent essential changes due to the urbanization process (increased number of urban localities and of urban population). The high birth rate (up to 40‰) determined the high weight of the young population (41-42% with ages of 18-19 years) and of the fit for work population, and a very low weight of the population over the age of 60 (up to 7-8%).
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.
Figure 1. Population projections for pilot region 2015
Source: Sanigest 2012
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. Figure 2. Population projections for pilot region 2020
Source: Sanigest 2012
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. Figure 3. Population projections for pilot region 2025
Source: Sanigest 2012
By 2025 the population over 65 years is estimated to consume more than 60% of the health system resource, long term care will be essential for the future years to come. Source: UNFPA 2011
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. Figure 4. Population Densities across Europe 2010
Source: The World Bank 2010 Although the territory of the Republic of Moldova is compact enough, the evolution of the demographic phenomena (nativity/birth rate, mortality/death rate, natural growth etc.) have a different regional characteristics, but they generally keep the same trends as the national ones, with some differentiations only. There is an essential gap in the evolution of the demographic phenomena in various zones and administrative units and in the demographic units and age groups, respectively. The transformations in the demographic evolution usually start in the northern administrative units, and later on they extend toward the central and then to the southern ones, they start and evolve more intensely in the urban communities than in the rural ones, and the rhythms of demographic transformations are higher than the ones in the rural administrative units.
The decrease of birth rate and the increase of death rate in the Northern Zone started in the 60’s of the 20th century, in the 70’s in the Central Zone, and in the 80’s in the Southern Zone. It is difficult to follow the evolution of the population number due to the numerous territorial changes occurred in the past decade. But one can certainly assert that the number of population has decreased in all administrative units. A partial increase during the
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. years 2004-2008 was recorded in the municipality of Chisinau, in the districts Ialoveni, Dubăsari, Criuleni and UTA Găgăuzia, while the population of the other administrative units diminished.
3.3. Population projections
Projected evolution of the number of population in Moldova, 2008-2050 is shown below. Although total population is projected to increase, disease burden for chronic disease will continue to rise. (Source: National Commission for Population and Development (NCPD) of the Republic of Moldova 2009)
Figure 5. Projected evolution of the number of population in Moldova, 2008-2050.
Source: National Commission for Population and Development (NCPD) of the Republic of Moldova 2009
Figure 6. Projected values of the birth rate are decreasing for Moldova, 2008-2050 (in %)
Source: National Commission for Population and Development (NCPD) of the Republic of Moldova 2009 Below represent population projections for the selected rayon’s included within the initial pilot. Projections are estimated under three separate scenarios with three separate
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. percentages in decreasing population. As mentioned earlier, factoring into account birth rate, mortality rate and migration as pivotal indicators it can then be estimate for a pessimistic, moderate-pessimist and optimistic scenario calculated at 2.33%, 1.59% and 0.57% respectively.
Table 1. Population projections per rayon for 2020 Proectii de evolutie a populatiei pina in anul descrestere de descrestere de descrestere de 2020 2.33% 1.59% 0.57%
scenariul pesimist, scenariul moderat- scenariul optimist, anul 2020 pesimist, anul 2020 anul 2020 2012
Total Republica Moldova 3412.6 3412.5767 3412.5841 3412.5943
Municipiul Balti 128.1 128.0767 128.0841 128.0943
Briceni 74.6 74.5767 74.5841 74.5943
Donduşeni 43.6 43.5767 43.5841 43.5943
Drochia 84.7 84.6767 84.6841 84.6943
Edineţ 80.8 80.7767 80.7841 80.7943
Făleşti 88.7 88.6767 88.6841 88.6943
Floreşti 85.9 85.8767 85.8841 85.8943
Glodeni 58.8 58.7767 58.7841 58.7943
Ocniţa 54.4 54.3767 54.3841 54.3943
Rîşcyears 66.6 66.5767 66.5841 66.5943
Sîngerei 86.6 86.5767 86.5841 86.5943
Soroca 98.6 98.5767 98.5841 98.5943
Source: Sanigest 2012
3.4. Aging Population Moldova like most European
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. n countries are confronted with an aging population. As the proportion of elderly people steadily increases, more healthcare resources will be used and the provider network will be challenged. Several key aspects will need to be taken into account within the health sector.
• Over time, there will need to be a shift towards specialized geriatric care and chronic disease management.
• Rapid urbanization without adequate infrastructure increases socioeconomic disparities and has effects on mental health, obesity, and chronic disease, among others.
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. Figure 7. Diseases such as cardiovascular disease will account for more than 60% of total mortality by 2025
Source: Sanigest 2012
Figure 8. Population over 65 in percentage per selected rayon 2012
Source: Sanigest 2012
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Figure 9. With the a decrease in birth rate and a shift towards and aging population DRGs for the +65 age group will become critical areas to address when deciding on priority.
Source: Sanigest 2012 See Non-Communicable disease for more on health implications
3.5. Rural vs. Urban distribution Urbanization urban population: 47% of total population (2010) Rate of urbanization: 0.9% annual rate of change (2010-15 est.) (source WHO)
The territorial peculiarities of the demographic situation can be analysed under several aspects, such as:
· urban area – rural area;
· Northern, Central, and Southern zones;
· urban communities –rural administrative districts.
In general, the demographic situation in Moldova within the urban area is more favourable than in the rural area, and it is characterized by:
· The birth rate of the urban population (9.3‰) is lower than in the rural area (11.6‰), but due to the lower death rate (9.4‰) than the one in the rural area
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. (13.9‰), the natural growth is within the limit of 0, while in the rural area this indicator is negative (-2.6‰), with slightly increasing trends. · The structure based on gender is more balanced in the rural area (48.9% men and 51.1% women), while in the urban area, the proportion is of 46.9% men against 53.1% women. This fact can be the result of the migration of the older population from rural communities toward urban communities (migration to their children), determined by the higher level of health care and other community services. · The structure on ages of the urban population is more favourable, since the population able to work constitutes 70.7%, the population under the age able to work represents 16.2%, and the population of retiring age represents 13.1%), which totals together 29.3%. The demographic dependence ratio is of 1:2,4, thus, to 2.4 persons with ages able to work corresponds 1 person with age unable to work. In the rural area, the population with ages able to work represents 62.6%, while 21.3%) are under the age able to work, and the population of retiring age represents 16.1%, which total together 37.4%. Thus, the ratio is of 1:1.7. · The life expectancy at birth of the population is of 71.2 years in the urban area and of 68.2 years in the rural area.
Figure 10. The regionalization strategy will benefit the population currently living in rural areas but also those in major urban cities. Total Urban versus Rural distribution by age 2012 Source: Sanigest
Source: Sanigest 2012
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. 3.6. Vital Statistics and Overall Health Status Life expectancy at birth:68.9 total population: 69.51 years country comparison to the world: 149 male: 65.64 years female: 73.63 years (2012)
The life expectancy at birth is 65.3 and 73.4 years for men and women Respectively (WHO). Life expectancy is significantly lower in Moldova compared to the EU average (67 versus 79), particularly for men. This finding is consistent with high overall mortality in Moldova which is more than double that of EU averages (1,341/100,000 versus 636/100,000). Low life expectancy and high overall mortality are due to high rates of disease and disability.
Since the overall morbidity and mortality burden is high, the country can expect to see an increasing demand for healthcare - ´particularly for chronic disease management, to address high levels of heart disease, and geriatric care, to accommodate the needs of the aging population. Since morbidity and mortality patterns heavily impact demand for healthcare, these factors much be considered in the Regionalization plan.
3.6.1 Infant mortality
Children under the age of 5 years underweight: 3.2% (2005) country comparison to the world: 104
Infant mortality rate: total: 13.65 deaths/1,000 live births country comparison to the world: 126 male: 15.59 deaths/1,000 live births
The difficulties of transition and multiple crises have had a negative impact on children. The issue of child health is a primary concern of the Government and has been incorporated into the MDG. Due to sustained efforts, infant mortality has decreased over the past few years. It is one of the major achievements and Moldova is committed to maintain progress.
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. Table 2. Low birth weight for the northern region. Localitatile Numarul nou- Numarul nou- Numarul nou- Decesul perinatal nascutilor cu nascutilor cu nascutilor cu greutatea extrem de greutatea extrem de greutatea extrem de mica (<1000g) mica (1000-1499g) mica (1500-2499g) 2009 2010 2011 2009 2010 2011 2009 2010 2011 2009 2010 2011 Mun. Balti 14 12 10 19 20 9 207 179 193 27,2 10,7 6,6 Briceni 0 0 0 0 1 1 22 15 8 7,3 12,4 11,2 Donduşeni 1 0 0 1 2 0 5 15 5 2,5 14,2 21,5 Drochia 0 0 1 0 1 1 15 14 18 2,4 13,1 20,6 Edineţ 0 0 2 1 2 0 14 56 29 3,8 13,5 8,3 Făleşti 1 1 1 1 0 2 13 11 7 2,0 9,1 14,2 Floreşti 1 2 0 2 5 1 24 25 19 9,6 20,8 9,1 Glodeni 2 1 3 2 0 2 11 12 10 13,3 10,0 13,7 Ocniţa 0 0 0 0 0 0 8 25 13 6,0 13,7 16,6 Riscani 0 1 1 1 2 0 12 8 10 6,1 11,7 18,5 Sîngerei 1 1 1 1 0 0 17 12 6 3,0 17,5 14,3 Soroca 1 0 0 6 1 1 54 36 45 4,2 6,6 9,8
Source: Sanigest 2012
International targets:
· Reduce by two thirds, between 1990 and 2015, the under-five mortality rate.
Initial national targets:
· Reduce the infant mortality rate from 14.7 (per 1,000 live births) in 2002 down to 12.1 in 2006, 9.6 in 2010, and 6.3 in 2015. · Reduce the under-5 mortality rate from 18.3 (per 1,000 live births) in 2002 down to 15.0 in 2006, 11.9 in 2010, and 8.4 in 2015. · Increase the proportion of under-2 children vaccinated against measles from 99.2% in 2002 up to 100%, starting 2006.
(Source: draft National Report „Millennium Development Goals Report: New Challenges – New Objectives”)
Revised national targets:
· Reduce infant mortality from 18.5 per 1,000 live births) in 2006 down to 16.3 in 2010 and 13.2 in 2015 · Reduce the under-5 mortality rate from 20.7 per 1,000 live births in 2002 down to 18.6 in 2010, and 15.3 in 2015 · Maintain the same level of vaccination against measles for children under 2 years, to be no lower than 96% in 2010 and 2015.
Moldova has achieved important progress in reducing infant and child mortality. In 2008 Moldova began to apply the international live birth definition and, as expected, this
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. methodology led to infant mortality indicators rising in that year. In 2009, the situation for infant mortality (12.1 cases per 1,000 live births), as well as the under-five mortality rate (14.3 cases per 1,000 live births) was significantly better than in 2000 (18.3 and, accordingly, 23.2 case per 1,000 live births. The targets for 2010 and 2015 for both indicators have been already achieved and it is important to maintain progress.
Moldova currently has a much higher level of infant mortality than most other European countries. Children from poor families, children from families with many children and Roma children are less likely to have access to health care and face a higher risk of mortality. The second relevant target is increasing the proportion of children immunized against measles. Paediatrics will continue to play a crucial role within the regionalization of the health system for the northern region.
3.6.2 Maternal Mortality
Maternal mortality rate:41 deaths/100,000 live births (2010) country comparison to the world: 114
Maternal mortality is one of the most sensitive and crucial indicators of reproductive health and the Government pay great attention to it and are making serious efforts to decrease it.
International targets
· Initial national targets · In-line with the Millennium Development goals, to reduce by three quarters, by 2015, the maternal mortality rate. Reduce the maternal mortality rate from 28 (per 1,000 live births) in 2002 down to 23 in 2006, 21.0 in 2010, and 13.3 in 2015. · To be achieved by covering all maternity wards with qualified medical staff, starting in 2006 (currently – 99%) as well as providing timely access to prenatal and postnatal care.
Initial national targets
Reduce the maternal mortality rate from 16 (per 1,000 live births) in 2006 down to 15.5 in 2010 and 13.3 in 2015. Maintain the number of births assisted by qualified medical staff during 2010 and 2015 at 99%.In 2008, for the first time in the five years, maternal mortality increased from 15.8 to 38.4 cases per 100.000 births, but in 2009 it declined again (17.2 cases per 100,000 births). Deaths are predominantly caused by bleeding, septic states, thromboembolism, hepatic cirrhosis and, rarely, cases of anaesthesia-related complications. Social determinants, particularly poverty and migration play a decisive role in half of the cases of maternal mortality.
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. Figure 11. Dynamics of the maternal death rate (in 100,000 new-borns) Source: National Statistics Bureau. As with paediatric and neonatal care maternal health is included within the proposed regionalization strategy.
Source: Sanigest 2012 Accomplishing the 2015 target largely depends on ensuring constant financing for this area of health-care, in order to strengthen the measures for early identification of at-risk cases. Regarding the second target of maintaining the high number of births assisted by qualified medical staff, Moldova has made good progress. In 2007-2008 the proportion of births attended by skilled health personnel was 99.5 per cent, while in 2009 it grew to 99.8 per cent. The fact that this percentage has been maintained at such a high level with a growing trend shows that the targets for 2015 will be successfully met if the necessary financial resources are regularly allocated for the healthcare of mothers and children.
3.6.3 All-cause mortality
The Republic of Moldova has a double epidemiological burden as rates of both communicable and non-communicable diseases have steadily increased since independence. The main causes of death in the Republic of Moldova are diseases of the circulatory system followed by cancer and diseases of the digestive system. Many of these deaths can be attributed to very heavy alcohol and tobacco consumption – 57.6% of total male mortality and 62.3% of female mortality in 2010 could be attributed to smoking- related causes while 18.8% of male mortality and 13.7% of female mortality were related to alcohol consumption. Though incidence of chronic liver disease and cirrhosis has decreased over the last five years, this remains a very significant overall cause of mortality in the Republic of Moldova (118.95 per population of 100 000 men and 89.82 per population of 100 000 women in 2010) (WHO).
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. Figure 12. Cause of death as % of total deaths. CVD causes overlapping giving a total of 55% as of total deaths per year. All forms of cancer combined total 12% as of total deaths per year
Source: Sanigest 2012
Figure 13. All population mortality show chronic diseases followed by trauma account for majority of cases for the northern region Source: Sanigest 2012
Source: Sanigest 2012
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Figure 14. All cancers mortality rates, males and females, 2009 (or nearest year). Cancer is the second leading cause of NCD death in Moldova. Palliative care is a crucial for the northern region
Source: OECD 2010
3.6.4 DALYs The burden of disease in a population is the gap between current health status and an ideal situation in which everyone lives into old age, free of disease and disability. Disability adjusted life years (DALY) are a summary measure combining the impact of morbidity, disability and mortality on population health.
The burden of non-communicable disease is not surprising considering the prevalence of overweight and obesity discussed below in this report. Beyond obesity, body composition has an effect on risk of developing a chronic disease. Body composition can vary by ethnic group regardless of weight category. Indo-Asian populations have a propensity to store fat
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. in the abdominal area; increased hip-to-waist ratio is a significant predictor of stroke and ischemic heart disease (Hossain et al. 2007).
Table 3. Leading disability groups in Moldova (% of total DALYs) 2004 Source: WHO Disability Group Country Rate
Cardiovascular disease 9.2
Other unintentional injuries 7.1
Other Cancer 2.7
Neuropsychiatric disorders 2.7
Respiratory infections 2
Road traffic injuries 1.9
Intentional Injuries 1.3
Musculoskeletal diseases 1.2
COPD 1.1
Lung cancer 0.8
Asthma 0.4
Source: Sanigest 2012
3.7. Communicable disease
3.7.1 Tuberculosis The Republic of Moldova is an Eastern European country in transition with a population of approximately 4.0 million. Tuberculosis (TB) re-emerged as an important public health problem after Moldova’s independence in 1991 and its burden remains high. The case notification rate is 141 per 100,000 population (Global Tuberculosis Control: Epidemiology, Strategy, Financing: WHO Report 2009 WHO/HTM/TB/2009.411) and is the second-highest among the 53 countries of the WHO European Region.
As in the other former Soviet Union republics, resistance to anti-TB drugs represents a serious obstacle to effective control of the TB epidemic. The national drug resistance surveillance data in 2010 revealed extremely high prevalence of multidrug-resistant TB (MDR-TB) of 25.8% among new smear positive cases and 65.4% among previously treated cases.
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. Figure 15. TB is of major concern in Moldova with an alarming number of resistant strain cases. Infectious diseases surveillance and control continues to be on the agenda within the regionalization strategy.
Source: WHO 2010
In 2011, a slight increase in TB notifications was documented compared to the year before: a total of 4,208 new and recurrent TB cases were registered in the country, which is equivalent to the rate of 103.1 per 100,000 population.
The MDR-TB levels in Moldova are among the highest in the world, as reported by the most recent WHO report on drug resistance surveillance (Zignol et al., WHO Bulletin, and February 2012). In addition to routine DST testing, in 2011 the second Drug Resistance Survey was conducted with the Global Fund project support, and its results actually proved those obtained within routine surveillance: MDR-TB was found in 26.5% of new cases and 63.8% of retreatment cases (preliminary data, May 2012).
MDR-TB prevalence among new and retreatment culture positive TB cases in the Republic of Moldova, 2006-2010 (%) (source: NTP/NRL)
Within the northern region, Ocniţa is currently in the process of developing new infrastructure in the form of TB services including a TB ward on the west end of the premise.
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3.8. Changing disease patterns.
Although diverse chronic Non-communicable Diseases (NCDs) all deserve proper attention, a group of four diseases (cardiovascular diseases, cancer, diabetes, and chronic respiratory diseases) and their shared risk factors (tobacco use, harmful use of alcohol, physical inactivity and unhealthy diet) account for the majority of preventable disease and death in the WHO European Region.
Figure 16. Looking specifically at CVD and diabetes, the rates are incomparable to that of Western European countries yet.
Source: WHO Health for all data base, last accessed 2012
These four NCDs also share common determinants that are influenced by policies in a range of sectors, from agriculture and the food industry to education, the environment and urban planning. They share common pathways for interventions through public policy. Additionally, obesity merits specific attention, in that it is both a result of many of the same basic risk factors and a cause of other NCDs.
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. Figure 17. NCD death rates are significantly higher that Western European countries playing a heavy financial burden on the health system. Source: WHO Health for all data base last accessed 2012
Source: WHO 2011
With the ageing of the population, health services will need to be restructured from focusing on episodic care for single conditions to encompass the needs of older people, many of whom will have multipathologies.
Figure 18. Projected values of the weight of elderly population applies for the northern region as well, 2008- 2050 (in %)
Source: National Commission for Population and Development (NCPD) of the Republic of Moldova 2009
This will require multidisciplinary stroke units, and packages of care that involve orthopaedic surgery, geriatric medicine and rehabilitation for patients with fractured hips (Saltman & Figueras 1997). According to WHO projections of the burden of disease for 2030, the proportion of people dying from non-communicable diseases will increase, while HIV/AIDS
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. deaths will continue to increase in middle- and lower-income countries (Mathers & Loncar 2006). Changing lifestyles will also result in changing patterns of ill health. The spread of unhealthy diets and fast food in many European countries is likely to increase levels of heart disease and other diet-related diseases. Progression of the tobacco and alcohol consumption epidemic in many countries in CEE can be expected to lead to an increase in tobacco and alcohol-related morbidity and mortality.
The population ageing process raises extremely complex issues for the social insurance and health care system, as it has important implications on the evolution of the economic dependence rate. The increase of the economic charge will be firmly established after the year 2015, the “drive” being the continuous growth of the elderly population, originated from the numerous generations born during the period 1960-1990.The number of persons with retiring ages (57+ for women and 62+ for men) will reach impressive proportions. If in the year 2010 (according to scenario I – pessimistic) 548.5 thousand persons will reach the retiring age, then by the year 2020– 680.6 thousand, by 2030 – 712.9 thousand, by 2040 – 727.2 thousand, and by 2050 – 819.4 thousand will do so. The annual growth rhythm will oscillate within the limits 1.5-2.5%.
Further on in this report during our assessment of the epidemiological burden of NCDs and its role in prioritizing health needs it is discussed together with the risk factors and its impact on the population.
3.8.1 Leading Risk Factors for non-communicable disease The Republic of Moldova has a double epidemiological burden as rates of both communicable and non-communicable diseases have steadily increased since independence. The main causes of death in the Republic of Moldova are diseases of the circulatory system followed by cancer and diseases of the digestive system. Many of these deaths can be attributed to very heavy alcohol and tobacco consumption – 57.6% of total male mortality and 62.3% of female mortality in 2010 could be attributed to smoking- related causes while 18.8% of male mortality and 13.7% of female mortality were related to alcohol consumption.
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. Figure 19. Comparison of 2001 and 2010 Smoking Prevalence Rates by Country in 8 Former Soviet Union Countries. Preventative measures targeting risk factors are a priority area within community centres offering lifestyle changes within the regionalization strategy.
Source: WHO 2010 Though incidence of chronic liver disease and cirrhosis has decreased over the last five years, this remains a very significant overall cause of mortality in the Republic of Moldova (118.95 per population of 100 000 men and 89.82 per population of 100 000 women in 2010).
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. Figure 20. Consumption of alcohol per year in litters among 10 former Soviet union nations Capacitating health workers to help address high alcohol consumption in the north will be carried out at the community level during regionalization.
Source: WHO 2011
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. 3.9. Cardiovascular Disease
Figure 21. Cause of death by CVD While cause of death by CVD remains high at the rayon level, most cases are referred to Chisinau for treatment
Source 2011
According to data from the National Centre for Public Health and Management (2006), the incidence of cardiovascular disease increased by almost 80% between 2000 and 2004, reaching 170/100 000 population, while the standardized mortality rate from cardiovascular disease rose by over 30%. In the same period, the incidence of malignant neoplasms also increased by 20% (National Centre for Public Health and Management 2006). However, the levels are estimated to be much higher as the quality of the data captured in the health system is poor.
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. Figure 22. Stroke Mortality rates International. Moldova as most FSU countries carries a high burden of cerebrovascular mortality therefore immediate care is essential for the northern region. Travel to Chisinau for acute care is no longer feasible.
Source OECD 2010
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. Figure 23. The caseload for CVD disease varies among the northern rayons with the majority of cases occurring in Floreşti and Sîngerei, Source: Sanigest 2012
Source: Sanigest 2012
3.9.1 Implications for the northern region
Variation in the use of invasive cardiac procedures is strongly associated with the population-based availability of catheterization facilities and multi-provider markets and unrelated to cardiologist supply or need (as reflected in the hospitalization rates for myocardial infarction). In a study conducted by West et all 2010 using a multivariate model, an increase of 1 catheterization laboratory per 100,000 population was associated with an increase in the angiography rate of 1.62 per 1000 population. Those service areas with multi-provider markets were associated with an additional increase in the angiography rate of 1.27 per 1000 population.
There was a moderately strong relationship between the catheterization laboratories per capita and the revascularization rates (R2 = 0.43, P = 0.029). Angiography rates were highly associated with cardiac revascularization rates: an increase in the angiography rate of 1 per 1000 population was associated with a 0.46 per 1000 increase in the cardiac revascularization rate. According to international standards the caseload per one FTE interventional cardiologist would be at least 250 thus the northern region would require around 2 full time interventionist for the population.
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. Figure 24. Primary PCIs per year per million inhabitants in European countries. Moldova has one of the lowest cardiovascular intervention rates within Europe.
Source: Widimsky P et alEuro Heart J 2010 Apr 31 (8) 943-57
3.9.2 Proposed Cardiovascular Services for Northern Pilot Region
When planning for any tertiary services, there is a need to balance quality, access and affordability. Tertiary cardiac services include diagnostic catheterizations (angiography), interventional cardiology or percutaneous transluminal coronary angioplasty (PTCA), stenting, and cardiac surgery (including bypass grafting and valve surgery). There is currently one full-service cardiac centre in the capital that provides these services.
Conditions should include: § Primary prevention § Stable angina § Heart Failure § Acute coronary Syndrome § Revascularization
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. § Cardiac rehabilitation § Secondary prevention
Services should include: § coronary intervention § heart surgery § arrhythmia treatment § state-of-the-art imaging § basic science research into understanding heart disease and genetics research into causes and cures § a '24/7' heart attack centre § innovative treatments such as transcutaneous aortic valves and drug eluting stents § teaching (medical and non-medical)
Rapid access chest pain clinic (RACPC)
This service should be offered to all patients with recent or new symptoms of chest pain suggestive of a heart problem such as angina (where the blood flow to a part of the heart muscle is limited causing intermittent pain). The rapid access chest pain clinic (RACPC) will see patients already diagnosed with angina whose symptoms indicate their condition is worsening. Expert nurses run the RACPC and offer patients assessment of symptoms, an ECG and an exercise tolerance test.
Heart failure and valvular heart disease clinics
Staffed by a cardiologist and specialist nurses, these clinics provide a step-by-step approach to diagnosis and treatment. Patients receive multi-disciplinary assessment and typically will have same day echocardiography, (ultrasound of the heart) assessment.
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. Non-invasive cardiology service this department carries out various tests which do not require putting anything into the body and the tests themselves are painless. The department provides a broad range of tests. The tests provided include:
· ECG and exercise ECG · 24 hour ECG monitoring and loop monitoring · 24 hour blood pressure monitoring · Echocardiography
The team should be made up of cardiac physiologists and nurses.
Stress echocardiogram involves ultrasound of the heart under exercise conditions; dobutamine is usually used to induce the effects of exercise on the heart while the patient is at rest.
Invasive and interventional cardiology
The facility should offer a full service in invasive and interventional cardiology through its specialist cardiac catheter laboratory. Procedures should be provided 24/7, including coronary angioplasty services. The catheter laboratory also provides day care services for diagnosing blood flow problems associated with the heart.
Cardiovascular risk management service
This part of the cardiology service is concerned with the prevention of heart disease. It aims to treat patients at risk of heart problems before they begin. The service also helps patients with existing heart disease to prevent worsening of their heart problems. The work of this department is mainly concerned with helping patients to manage their cholesterol levels. Having high or abnormal proportions of cholesterol in the blood is a significant factor in the development of heart disease, and this service aims to help patients control these levels with a combination of lifestyle factors and/or medication. The service can also assist patients with weight management where this contributes to the risk of heart disease.
The service should be in close relation with the rest of the continuing care centres; long term care as well as community hospitals. A close communication and adequate referral system with each rayon is expected.
Cardiac rehabilitation
Cardiac rehabilitation is a programme run by a team of specialist nurses and a physiotherapist. This service is offered to patients who have had a heart attack or heart surgery. This should also function in close relation with community hospitals and long term centres where existent.
Arrhythmia/syncope clinic
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. This is a dedicated clinic which assesses patients with a history of palpitations, dizzy spells or unexplained faints to exclude cardiacarrhythmia. The clinic is supported by a visiting electrophysiologist and would be expected to have strong links to tertiary electrophysiology services at the National institute of cardiology in Chisinau.
Using current referral patterns for all hospital services, a cardiac centre located in Balti or Edineţ would have an annual caseload of approximately 482 surgeries, 500 PCI and 2460 catheterizations per year by 2020. The assumptions related to referrals and the resulting volumes of surgical procedures are identified in Table 4.
Sanigest Internacional reviewed cardiac procedure rates based on international standards taking into account the comparative disease burden in each country. Not only are these recommendations based on international standards but on the current situation within the northern pilot region taking into account morbidity, mortality, current workforce and available infrastructure.
Table 4. Recommended number of procedures per 100,000
Procedures Needed Angiography 2460 PCI 500
Coronary Artery Bypass (CABG) 390
Pacemaker 287
Resynchronisation Therapy 41 Catheter ablations 51
Source: Sanigest 2012 Under this scenario the number of procedures projected for the northern pilot region would be slightly below the minimum targets recommended for quality for PCI and cardiac surgery. The use of current referral patterns as a proxy for future demand may under-estimate the projection of the actual cardiac activity that would be experienced if a centre were located in Balti or Edineţ.
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. Early thrombolysis; Thrombolysis, or treatment with thrombolytic drugs, describes the use of clot dissolving drugs in people suffering from heart attacks. These drugs help reverse the effects of a heart attack by opening the blocked coronary artery and returning the blood supply to the affected part of the heart again. Thrombolytic treatment can be given up to twelve hours after the onset of the symptoms of a heart attack but it is most effective when given within the first two hours.
The value of swift treatment is confirmed by extensive research and so it is recommended that a target be set to administer thrombolysis to all eligible patients within one hour of calling for help (the ‘90-symptom or call-to balloon goal’). A milestone of treating patients within 60 minutes of arrival at hospital (‘door-to-balloon time’) should also be considered were appropriate.
Waiting Times
Many people live with ‘stable angina’ and manage their conditions with drugs and changes to their lifestyles. For others, a cardiologist or heart surgeon may advise angioplasty, or heart bypass surgery - coronary revascularization. This can relieve the angina symptoms more effectively and, for some people, can prolong life. Currently, the overall rate of coronary revascularisation in Moldova is low. By re-designing services, and investing in staff, buildings and equipment revascularization can improve drastically. Currently data on patients waiting for cardiac catheterization procedures are not collected in a consistent and reliable manner to allow Sanigest Internacional to carry out further analysis. Recommendations have been made based on international best practice. – A maximum wait for a scheduled angiography should not surpass 3 months. The same period of time, 3 months should be set for programmed revascularization times as well. As for acute cases PCI should not surpass 90 minutes door-to-balloon time and no more than 60 minutes should pass for thrombolysis therapy to be administered by a specialist.
Infrastructure
Facilities in should include the following.
§ Catheter lab, for diagnosing and treating heart problems, and for monitoring patients undergoing cardiology treatment. § A recovery unit with five beds, including a paediatric recovery area for child heart patients. § 30 single rooms for patients over two wards. § 13 intensive care and high dependency beds for cardiac patients § 12 day patient beds § 9 CCU beds total § Facilities for staff
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. § Dedicated space for medical teaching, and for research into new treatments for heart disease.64
Workforce
Sanigest Internacional does not accept the argument that a cardiac centre should be located in all regions that can provide the minimum volumes consistent with quality. Planning for tertiary services requires balancing all three issues of quality, accessibility and affordability. The expansion in cardiac tertiary services should be done in a gradual manner with time to evaluate the effects on referral patterns, waiting times and capacity in existing centres that occur after the new cardiac centre in the northern region is decided to be placed. Consideration must also be given to the question of human resources, including the national availability of the specialists required.
Staff, is not limited to but should include the following:
§ Clinical lead & interventional cardiology (1) § Clinical lead cardiac catheter laboratory and chest pain service(1) § Interventional cardiology & pulmonary hypertension (1) § Consultant cardiologist (10) § Clinical lead non-invasive diagnostics, heart failure and valvular heart disease (1)
§ Interventional cardiology & devices expert (1) § Non-invasive cardiology and community clinic lead (1) § Consultant chemical pathologist (1) § Clinic lead lipidology & cardiovascular risk factor prevention (1)
Cardiology nursing team § Nurse specialist heart attack service (2) § Nurse specialist, rapid access chest pain service (3) § Nurse specialists, cardiac rehabilitation (3) § Nurse specialist, cardiovascular risk management (4) § Lead nurse, cardiac catheter laboratory (1)
Other key team members § Senior chief cardiac physiologist (1) § Lead pharmacist (1) § Cardiology department co-ordinator (1) § Cardiology admission and community clinic administrator (2) § Assistant operational manager, urgent care (2) § Operational manager cardiothoracic (1)
Competencies
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. Together with planning of cardiovascular within the regionalization strategy the planning of the workforce will mean that competencies must be established for cardiovascular care. The recommend is that these competencies of the current and future workforce address the following areas: ■ prevention (primary and secondary) ■ acute cardiac syndromes ■ angina ■ heart failure ■ revascularisation ■ rehabilitation
It is beyond the scope of this consultancy to determine the exact competencies that each healthcare provider must develop. However, an example is provided regarding what minimum competencies a family doctor must possess in order promote and protect cardiac health: - the factors which determine the risk of CVD and the relative impact - how factors in individuals’ lifestyles (i.e. physical activity, smoking, diet, alcohol consumption) can affect their risk of developing CVD - the nature of CVD, its different forms and its physical, psychological and social effects on individuals and their families - -research-based evidence of the impact of environmental, social, lifestyle and behavioural factors on the incidence of CVD - the possible effects that modification of lifestyle and risk factors may have on individuals
Impact on Existing Cardiac Centre in Chisinau
A cardiac centre located in Edineţ or Balti would draw activity from existing cardiac centres in the capital. One of the principles in planning for new programs is that any new program should not antagonize but synergize efforts and work together in order to benefit both regions by reliving the caseload for the capital and freeing resources.
Recommendations
The major recommendations from these reports are as follows: o sufficient cardiac services be planned in each rayon to meet the o projected needs of residents in each region provided the minimum volumes to ensure o quality and efficiency can be maintained; o a minimum of 500 diagnostic catheterizations and 400 PTCA procedures be o completed at each cath lab site per year to ensure quality of outcomes; o a minimum of 500 cardiac surgical cases (requiring the use of pump or pump standby) be completed at each cardiac surgical centre to ensure quality of outcomes
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. o new cardiac centres provide both diagnostic and interventional cardiac services, including cardiac surgery; o that capacity at current centres is maximized in order to be able to have a strong referral system, prior to establishing any new cardiac centres.
Prevent Modifiable Modifiable Risk Acute Care Preventing Recurrent events risk variables
Figure 25. Chronic disease care
General population At-risk individuals CVD patients End-stage and groups
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Table 5. Cardiac procedures per 100,000
Insertion, revision, replacement, Diagnostic cardiac removal of cardiac catheterization, coronary Percutaneous coronary pacemaker or arteriography angioplasty (PTCA) cardioverter/defibrillator
Recommended number of procedures per 100,000 250 250 150 SR Floreşti 187 187 112 SR Riscani 84 112 50 SR Sîngerei 75 224 45 SR Edineţ 62 206 37 SR Drochia 57 231 34 SR Soroca 51 224 31 SR Făleşti 31 154 19 SR Ocniţa 17 139 10 SR Glodeni 12 174 7 SR Donduşeni 11 233 7 SR Briceni 11 250 7 Total 598 2134 359
Source: Sanigest 2012 Given the population demographics and burden of disease the northern region would require around 500 catheterizations a year. Source: Sanigest 2012
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. Around two full time vascular surgeons would suffice for the northern region based on current demographics and burden of disease.
Creation, revision andEmbolectomy removal of arteriovenousand Varicose vein stripping,fistula or vessel-to-vessel endarterectomy lower limb cannula for dialysis of lower limbs Recommended number of procedures per 100,000 13 50 25 SR Floreşti 10 37 19 SR Riscani 4 17 8 SR Sîngerei 4 15 7 SR Edineţ 3 12 6 SR Drochia 3 11 6 SR Soroca 3 10 5 SR Făleşti 2 6 3 SR Ocniţa 1 3 2 SR Glodeni 1 2 1 SR Donduşeni 1 2 1 SR Briceni 1 2 1 Total 25 117 59
Source: Sanigest 2012
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4. Hospitals
4.1. Service delivery Our initial situational analysis revealed that health care facilities in the north differ little between urban and rural settings. Services included at the rayon level included with the strongest emphasis were general and paediatric consultations and referrals, paediatric development checks and immunization, gynaecoloy-obtetrics, orthopaedics-traumatology, urology, internal medicine, physiotherapy, hepatitis and TB care, acute respiratory illness care, other infectious disease care, ambulance services, and to some extent health promotion.
In theory patients are free to choose the family doctor of their preference, but their choice is restricted by geography as they can only choose a doctor working in their catchment area, and at the rayon level many times there is only one health centre within their catchment area. In the current scenario, family doctors act as gate-keepers to secondary care, providing referrals for access to specialist and inpatient care. They refer patients to the capital when it comes to complex cases and advanced diagnostic investigations not readily available at the local level. , Although significant gaps were encountered within this gate-keeping strategy. Upon interviews with relevant stakeholders it was noted that patients usually prefer to skip local consultation and travel directly to the capital for care. They mentioned that this is often the case, as many patients are of the idea that better technology, better doctors and more modern forms of care. This is done by patients whom have the financial means to seek care in Chisinau.
Those that do visit the local health centre and receive a “referral for specialist consultation” from their family doctor can then choose a specialist, but only one working at the specific institution to which they were referred in most cases.
Referrals for non-urgent inpatient treatment from either family doctors or specialists are reviewed by a Consultative Commission of Physicians and if the referral is considered appropriate by the commission, it then proceeds to select the most appropriate hospital for the procedure. The patient then receives their referral but is not allowed to change the hospital. They are then forced to visit the one to which they have been assigned. However, there is a predefined list of around 90 diagnoses with which patients can have direct access to specialist care without the need of a referral from their first point of care such as diabetes, asthma, TB, most cancers, some cardiovascular diseases and dermatovenereal conditions (Shishkin et al. 2006).
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Table 6. Existing specialist per rayon
Mun. Balti Briceni Donduşeni Drochia Edineţ Făleşti Floreşti Glodeni Ocniţa Riscani Sîngerei Soroca inclusiv: в том числе: Profil terapeutic Терапевтический профиль Terapeutice Терапевтические Geriartrice Гериартрические
Cardiologice pentru adulţi Кардиологические для взрослых Reumatologice pentru adulţi Ревматологические для взрослых inclusiv: в том числе: Artrologice Артрологические Cardioreumatologice pentru copii (сardiologice pentru copii + reumatologice pentru copii) Кардиоревматологические для детей (кардиологические для детей + ревматологические для детей) For a complete list of available services for each rayon see annex 3
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. Rayon hospitals in the northern region provide a relatively broad profile of services to the populations which they serve. Highly specialized services are provided through tertiary level republican hospitals, which are concentrated in the capital and generally have are monoprofile hospitals such as cardiology care or oncology. There are also a number of general hospitals outside the statutory system, which are under the control of other government ministries. There are few private hospitals in Moldova, although it is possible to purchase some additional services in some public hospitals, such as highly specialized diagnostic test. In terms of infrastructure regulation rayon hospitals must first receive authorization from the MOH before modifying infrastructure or human resources. Hospitals serving a population of less than 90 000 such as in the area we have assess provide services in only five basic specialties, while hospitals in larger rayons provide more extensive services to their own population and for patients from smaller rayons that are adjacent.
Private sector care represents only a small percentage of total health care use in Moldova. Use of private care for specialty services such as eye and dental care demonstrate that private care represents a parallel rather than a competing health system.
Traditionally, the healthcare system in Moldova has been bed-centric rather than patient- centric. Not surprisingly, Moldova has significantly more beds, hospitals, and ALOS (per 100,000) than other developed countries. Despite efforts to retain staff in rural facilities, there is an urban bias for physicians and nurses.
This section analyses the performance of Moldova’s hospital sector comparing it, at a national level, to international standards, and, at a regional level, to national benchmarks in the following fields:
· Health systems and health status · Expenditure, personnel, capacity and activity · Patient and hospital service · Use of resources and quality of care
The indicators reflect specific areas of hospital management, namely resources, process, outputs and outcomes, as explained by the diagram below.
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. Where relevant, comparisons are also made between selected indicators and EU and CIS averages. CIS states have been selected as relevant benchmarks because of their geographic proximity and similar standard of living conditions compared to Moldova. EU benchmarks are used because the Government of Moldova, as part of the project objectives, aim to move their national standards to EU benchmarks.
An understanding of how Moldova’s hospital sector is currently performing against international benchmarks can (1) guide government health sector planning to improve standards of health care; and (2) help to identify and communicate to stakeholders key areas for improvement, helping to ensure full backing for future health planning.
A key goal of this section is encouraging health sector performance to be linked to efficiency and outcomes rather than to inputs. For example, past hospital performance assessments have used indicators such as doctor-patient ratios and bed levels to determine performance. This section, while measuring staff and bed levels, will also look closely at measures of efficiency, including average length of stay in hospitals and the use of outpatient and ambulatory services.
4.2. Access to care
When it comes to the utilization of health care services within Moldova insurance is an area that must be carefully looked at. Access is hindered in groups, uninsured and insured. Studies have shown that factors associated with being uninsured include being self-employed (particularly in agriculture), unemployed, younger age and low income. Research has demonstrated that respondents who were self-employed in agriculture were over 27 times more likely to be uninsured than those who were employed. Agricultural workers in Moldova are responsible for purchasing their own cover as most respondents cited cost as the main reason for not doing so (Richardson E. 2012).
Both insured and uninsured face high additional costs of obtaining care, in particular due to payments for pharmaceuticals. The self-employed are expected to purchase their own cover and, since the privatization of collective farms, this group includes most of the agricultural workforce (Gorton and White 2003). However, it is down to the individuals who are self- employed or working informally to ensure they have health insurance as it is not enforced (Atun et al. 2008). The economy in Moldova relies heavily on agriculture, which employs a third of the labour force (Oprunenco and Prohnit¸chi 2009) making such a demographical representation highly relevant.
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. 4.3. Utilization rates
Utilization rates represent the percentage of beds that are occupied on a given night or on an average night over a period of time. The following formula is used to calculate bed and unit utilization rates:
Utilization Rate Formula Total bed days/total bed days available*360 = bed utilization rate
Common Utilization Rate reporting issues
• Underutilization: Usually underutilization is regarded as a bed utilization rate below 65%. If a hospital has a bed utilization rate below 65%, it is often an indicator that there is and excess in available infrastructure and less frequently, that staff are not entering data for each patient.
• Over utilization: is usually taken into account with rates above 105%. If an agency has a bed utilization rate above 105%, it is often an indicator that there is an overburden in regards to occupancy and work overload or that there is insufficient tracking of discharges. The latter case would result in an over-count of the number of patients seen.
Based on international standards a 85% benchmark is used to compare utilization rates across rayons. By observing occupancy rates across rayons we can see that the majority of rayons do not meet the above mentioned benchmark used for occupancy. A underutilization of services is seen across the northern region contributing to a misuse of resources in the health sector. It is important to mention that the regionalization of health services focuses on utilization rates among other essential indicators to determine where services could be placed in order to ensure maximum as well as efficient utilization.
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. Figure 26. Bed utilization can drop as low as 60% within rayons within the pilot region evidencing the amount of empty beds.
Source: Sanigest 2012
4.4. Bed turnover rate
Another measure of hospital utilization is the bed turnover rate. It is the number of times there is change of occupant for a bed during a given time period. This rate indicates the number of times each of the hospital beds changed occupants. Several formulae are in use for determining this rate and there is no universal agreement on the most accurate representation of formula. However, bed turnover rates are considered a measure of bed utilization, especially in conjunction with length of stay.
The formula used in this report is as follows:
§ Hospital Bed turnover rate = Number of discharges (including deaths) in a given time period / Number of beds in the hospital during that time period
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. Table 7. Turnover/beds per selected rayon’s
Hospital District Index of turnover / bed of patients
SR Briceni 37.22
SR Donduşeni 44.88
SR Drochia 34.5
SR Edineţ 27.45
SR Făleşti 34.22
SR Floreşti 38.32
SR Glodeni 37.89
SR Ocniţa 34.18
SR Rîşcyears Source:40.7 Sanigest 2012 SR Sîngerei 40.48 Previous work carried SR Soroca 32 out by Politici şi Analize în Sănătate (PAS) found that several aspects of inpatient care quality is below the desired level, proceeding from the analysis of various aspects of inpatient services. This includes prolonged waiting times in hospital wards, overcrowding in hospital wards for patients, limited access of medical records to patients, providing poor of medical treatment in hospital, self procurment of medicines by patients, unsatifactory turnover rates and patient dissatisfaction with hospital treatment in general.
4.5. Admission Rate Hospital admissions include all admissions for inpatient stays of one (1) night or more. Stays for new-born infants are included in the mother’s stay unless the new-born was discharged at least 24 hours after the mother’s discharge.
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. Figure 27. Edineţ has the second highest admission rate for the region at 14% only second to Floreşti. This male it a strategic assess point for the regionalization proposal to place it as the inter-district hospital.
Source: Sanigest 2012
Table 8. Number of total hospitalization and percentage as total number from 12 Rayons. Drochia and Edineţ currently hold the highest number of hospitalizations within the pilot region rayons. Hospital Name # of hospitalizations % of all Cumulative % hospitalizations (from 12 rayons)
SR Donduşeni 6255 5.99 5.99
SR Ocniţa 6955 6.66 12.66
SR Glodeni 7152 6.85 19.51
SR Briceni 7658 7.34 26.85
SR Riscani 8885 8.51 35.36
SR Sîngerei 9436 9.04 44.40
SR Făleşti 9465 9.07 53.47
SR Soroca 11390 10.91 64.38
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. SR Edineţ 11826 11.33 75.71
SR Drochia 11964 11.46 87.18
SR Floreşti 13383 12.82 100.00
Source: Sanigest 2012
4.6. Optimal Hospital Size
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. A hospital requires a minimum level of patients, staff, infrastructure and resources to be efficient and effective. These levels depend on hospital activity and demand for care. For
example, hospitals with a high burden of cancer in its catchment area should have a larger oncology department than hospitals with relatively low cancer burden in its catchment area.
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. According to international standards, the minimum number of beds necessary to achieve an efficient use of resources is 200-600 with and optimum efficiency level reached at 200-400 (Dorfman S. 2012).
4.7. Hospital Beds
In the selected pilot rayon’s for Moldova , the average size of acute hospitals is 271 beds ranging from 141 beds in SR Donduşeni to 435 beds in SR Edineţ. In general, most of the rayon’s have average hospital sizes above 200 beds.
Figure 28. Most rayons surpass the 200 bed threshold for the populations.
Source: Sanigest 2012
A review of the evidence on the ideal size of a hospital found there was extensive literature with the following results:
• Economies of scale are fully realized when hospital reaches a size of 100 –200 beds • The optimal size for acute hospitals ranges from 200 to 400 beds • Above 400-600 beds, average costs increase. Other authors (World Bank, 2006), however, refer to 400- 600 beds as the optimal size of acute hospitals.
In general, there is an agreement that hospitals below 200 beds or above 600 beds are inefficient. Below 200 beds there are substantial opportunities to improve efficiency by adding more beds to the facility. Between 200 and 600 beds, the evidence shows that efficiency is at its
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. highest and beyond 600 beds efficiency and productivity declines. The wide plateau between 200 and 600 beds is mainly due to the existence of different hospital profiles and the corresponding case mix variations.
4.8. Trends in the number of beds
The reduction in beds in Moldova has followed a similar downward trend as seen with other countries within the region. Total beds per 10,000 people has decreased especially in FSU countries visible throughout the 1985 to 2010 period, declining from just under 120 to 41 beds per 10,000 on average. In comparison to the EU average of roughly 36 beds. In general, a planning standard of 40 beds per 10,000 is widely accepted as the target for acute beds.
Figure 29 Decline in number of hospital beds across countries
Source: Sanigest 2012
Source: OECD 2010
In comparison to the total beds shown our first table, the total number of beds within the Moldova pilot region is still considerably higher than Canada and Australia. Countries around the world such as Finland, Israel and Italy trends point to a decline in the total number of beds as shown in figure 30.
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Figure 30. Number of beds per 10,000 population This trend in excess is seen throughout the northern region. Regionalization pairing the number of beds needed to the needs of the population.
Source: Sanigest 2012
4.9. Number of Beds per Speciality Moldova has a high number of hospital capacity and bed (per 10,000 population) comparable to international standards comparable to that of Denmark for example. In the selected Rayons most hospitals lie within the range of 200-600 total number of beds with some exceptions. In terms of capacity, it is therefore possible to say that Moldova’s health challenges are not due to an undersupply of hospital beds or hospital facilities. In fact, the opposite is probably true. One must then examine the operational levels focusing on efficiency and effectiveness.
One must also take into consideration the healthcare structure implemented under the Soviet Union which emphasized hospital and bed levels as indicators of healthcare quality. With an excess of hospitals and hospital beds, resources are stretched too thinly across the population to be efficient or effective. Hospital and bed levels alone do not ensure positive health outcomes, adequate levels of staff, equipment, drugs, and other factors influence outcomes. Hospital reform needs to focus on providing effective, efficient, and accessible health service throughout Moldova.
Currently, hospitals and hospital resources are not equitably distributed or being efficiently used. By adjusting service delivery methods, such as community care for mental illness instead of long term psychiatric hospitalization and outpatient day surgery rather than inpatient surgery can also help to modernize the health service and reduce costs.
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4.10. Average Length of Stay (ALOS) High ALOS is linked to hospital inefficiencies including long delays before receiving treatment, waiting lists for operations, shortage of certain types of equipment, drugs and disposables, disease burden, among others. However, changes in patient expectations, practices of hospital personnel, the introduction of more effective technology, and increased coordination with primary health care facilities, could improve hospital capacity.
Figure 31. Average length of stay per selected rayon’s. ALOS exceeds the international trends in all rayons.
Source: Sanigest 2012
3.10.1 Trends in the Average Length of Stay (ALOS)
The trend in reducing average length of stay has been significant, falling from around 11 days to 8 days. The EU average is just above six days highlighting the potential to reduce the ALOS for the selected Rayon hospitals in Moldova.
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. Figure 32. Average length of stay for selected countries from 1998-2009 source OECD 2012
Source: OECD 2009 The average length of stay for the selected Rayons is 8 days, compared to around 6 for Netherlands and Canada and under 4 for Australia.
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. Figure 33. Average Length of Stay Republican vs. Rayon . Excessive ALOS consume resources that could be better located within the health sector.
Source: MOH Moldova 2010
3.10.2 ALOS per Specialty
It is difficult to draw conclusions from rayon level averages, however, as there may well be a different mix of clinical services provided in each rayon. Specialty specific ALOS can provide more insight. Hospital discharges have been categorized into 7 different services including surgical specialties, urology, obstetrics and gynaecology, ophthalmology, trauma and orthopaedics, and ENT (ear, nose and throat).
Table 9. ALOS (in days) by specialty in selected rayon’s 2011 Obstetrics Urology ENT Ophthalmology Trauma and Orthopaedics Gynaecology Surgery
Minimum 3 6 3 7 7 4 5
Average 4.5 7.3 5.8 8 9 5 7.25
Maximum 6 9 8 9 11 7 9
The high levels of bed days are a considerable burden on the resources of the hospital network, and the health system as a whole. Longer stays in hospital inevitably mean that resources must be turned away from alternative uses such as drugs and equipment in order to pay for the infrastructure, support and administration needed to provide care within a hospital. Finding
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. way to reduce this burden without reducing the quality of healthcare represents an important opportunity to improve the health outcomes of the population.
Key to solving this problem is understanding which factors contribute most to excess bed days. Conceptually, bed days are simply the multiplication of the average length of stay of a patient, and the number of patients.
Figure 34. Trauma and Orthopaedics, one of the top cause causes of death in Moldova has the longest length of stay compared to all cause surgical cases.
Source: Sanigest 2012
4.11. Unnecessary hospitalization With pressure from government and consumers on health care providers to reduce costs, there is a sharp focus on reducing unnecessary hospitalizations and skilled nursing facilities are at the centre of this critical effort.
Ambulatory care sensitive conditions (ACSCs) are conditions for which timely and effective outpatient care may help to reduce the risk of hospitalization. Inappropriate hospitalizations increase as the number of chronic conditions increase. People with multiple chronic conditions use medical goods and services at higher rates than others and they often receive duplicate testing, conflicting treatment advice and prescriptions that are contra-indicated. These factors may play a role in the correlation between increasing numbers of chronic conditions and increasing numbers of inappropriate hospitalizations. The number of patients that will require chronic care as NCD increase together with the aging population is of urgent concern. With these trends occurring not only in Moldova but also in the rest of the world changes in health care delivery have emerged .
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. Over the past twenty years, changes in the demand for hospital care have led to a rapid decline in the use of hospital services and a concomitant increase in ambulatory care. This trend has been driven by a number of external factors.
The onset of technologies such as laparoscopic and endoscopic procedures, although not readily available at all rayons, lead to the possibility of shorter hospitalization periods.
The introduction of new pharmaceutical regimes which replace the need for extended hospitalization. Examples of this include the use of modern drugs to treat peptic ulcers, chemotherapy and radiotherapy for oncology patients, the introduction of the DOTs regime for TB patients.
The increasing capacity of primary care and the onset of preventive medicine, such as beta blockers, to treat chronic diseases, reduces the need for hospitalization.
Changes in the demographic and epidemiological profile shift the demand for care and highlight the need to improve case management, shifting from episodic care to a more holistic approach and to a non-acute form of care in order to improve health status.
The increasing capacity of diagnostic tools, such as MRI, to diagnose disease without exploratory surgery and without hospitalization reduces the need for unnecessary discharges.
The possibility of using telemedicine to monitor chronic disease and care for elderly significantly reduces the need for hospitalization.
The increasing expectation of the population to receive care in a patient centred system which explicitly considers the patient’s rights and has explicit targets for waiting times and access to care. The implication is that in areas with high admission rates, many hospitalized patients could be treated outside of the hospital without sacrificing quality of care, because admissions are occurring for which hospital-level care is not medically justified.
The term inappropriate is used to refer to those admissions that could be treated adequately on an outpatient basis. Whether inappropriateness explains much of the variation in admission rates is an important issue for public policy and for the cost containment programs of third- party payers. If it does, population-based area utilization rates, which can be identified from routinely collected sources such as claims data, could be used to help identify areas with high rates of inappropriate admissions without the need for expensive reviews.
In addition, to the extent that inappropriateness explains variations, there is evidence that helps to answer the question, “Which rate is right?” Thus, a rationale is created for interventions to reduce admissions in high-rate areas. As stated in Sherman Rolland and Myron Steno’s review of small-area variation studies, “For some it would be a small step from the small area claims to proposals that would establish norms, whether regulatory or voluntary. Others may argue for even more wide sweeping changes in health care delivery as a result of the inefficiencies and inequities implicit in the small area claims.” For example, Elliot Fisher and
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. colleagues propose “a prioritization based on the local hospital resources invested in discretionary medical admissions,” identified by small-area analysis and “setting limits based on units of health care supply.”
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5. Workforce
Health professionals play a central and critical role in improving access and quality health care for the population. They provide essential services that promote health, prevent diseases and deliver health care services to individuals, families and communities based on the primary health care approach. Mechanisms for optimizing the strengths and skills of health professionals will be essential to achieving the Millennium Development Goals. . To make the most of the service delivery contribution provided by existing health workers and to achieve progress on the MDGs, strong systems need to be developed to ensure quality health services through high levels of productivity and performance.
Median age of working physicians per rayon
Figure 35. As young doctors flee to the capitol or to other countries the average age in the north for most rayon is close to retirement age.
Source: Sanigest 2012 Taking a comprehensive approach to assessing the current workforce situation in Moldova requires careful planning. While it is critical to keep the primary goal of a sustainable workforce as the centre of the workforce strategy, it is useful to develop both short-term emergency priority actions that can be taken along with long-term actions. Using the key findings from the situational analysis , discussions and developing a recommended strategy and operational plan with the leadership team that includes both long- and short-term actions is our one of our main task within the Regionalization strategy for Moldova.
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In a study conducted by Shi at colleagues, when state-level economic and demographic characteristics were controlled for, an increase of one primary care physician per 10,000 population (about a 20 percentage increase) was associated with a 6 percentage decrease in all- cause mortality and about a 3 percentage decrease in infant, low-birth weight, and stroke mortality. For total mortality, an increase of one primary care physician per 10,000 population was associated with a reduction of 34.6 deaths per 100,000 population at the state level (L. Shi et al 1999).
5.1. Stock (and density) of the healthcare workforce While there is no universally agreed-upon ideal physician to population ratio, Moldova appears to have higher levels of doctors (per 1,000 population) than the EU average and lower levels of nurses. Sheffler et al 2012 have set a benchmark of .55 physicians per 1,00 population as the minimal standard needed within a country to decrease maternal mortality rates by ensuring that the population has excess to a skilled birth attendant. However, this .55 per 1,000 threshold estimates a minimum health services, not sufficient enough for more developed countries. As doctors are more expensive to train and employ than nurses, this could be seen as system inefficiency. Physician levels vary significantly across Rayons and therefore density should always be interpreted with caution as they do not ensure equal distribution among geographical regions
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. (rural vs. urban).
Figure 36. Aggregated Data Physicians per 1,000 There is a clear lack of physicians within the entire country.
Source: WHO 2007 Healthcare Workforce Sector Problems in Moldova:
· Nonuniform territorial deployment, rural versus urban area
· Nonuniform distribution by specialties, more visible in the hospital area
· Low placement of post-graduate medical students
· Gaps in the professional training of health. Low performance of health professionals
· Low motivation of staff
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· Low focus on performance
· Lack of a planning methodology for Human Resources for Health
· Insufficient monitoring
As a result: Workforce migration from the health care system professionals, especially of nurses
Figure 37. Doctors per 100,000 people, comparative. Physician migration continues to be a major issue in terms of the health care workforce.
Data source: OECD library last accessed 2012
The density of family physicians in a given region is assumed to serve as proxy for the access to and availability of desirable primary care services. study suggest that an additional family physician per 10,000 population has a statistically significant impact in the order of 2% to 4% on self-reported general health status, as well as, other quality of care outcomes (Sarma et al 2008). There are two broad lines of research explaining spatial differences in physician densities. The first strand of literature primarily focuses on the individual location decision. The ‘prior contact theory’, for instance, stresses that physicians are more likely to practice near and in locations where they received their medical education or hold an affiliation to a hospital.
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. Table 9 Proposed number of specialist needed and benchmarked to international standards for the northern pilot region. Sanigest proposed EUROSTAT U.S. Supply benchmark (2009) (2009) per 100,000
Medical Specialities 74.6 79.3 - General Medicine 25.0 69.2 30.2 Accident and Emergency 10.0 3.1 6.9 Anaesthetics (including Intensive Care) 15.3 16.0 11.6 Cardiology 4.4 7.4 6.6 Child and Adolescent Psychiatry 2.0 - - Dermatology 1.9 4.9 3.1111 Endocrinology and Diabetes Mellitus 1.5 1.9 1.2 Gastroenterology 2.6 3.1 3.4 Geriatric Medicine 1.5 - Infectious Diseases 3.0 - 1.2 Medical Oncology 2.0 1.9 1.1 Neumo - 4.3 - Neurology 2.5 6.0 1.8 Nuclear Medicine 1.0 - - Occupational Medicine - 4.1 - Renal Medicine 1.1 - 0.7 Rheumatology 0.8 - 1.3 Paediatric 19.5 13.5 19.0 Paediatrics 15.0 13.5 19.0 Neonatology 3.0 - - Paediatric Surgery 1.5 - - Obstetrics and Gynaecology 20.0 14.8 13.1 Surgical Specialties 30.3 59.0 - General Surgery 11.0 14.8 - Trauma and Orthopaedic Surgery 6.0 8.3 6.9 Cardiothoracic Surgery 0.8 1.1 107.0 Neurosurgery 1.2 1.4 1.5 Ophthalmology 4.7 8.3 6.2 Oral and Maxilo-Facial Surgery 0.8 - - ENT 2.0 6.2 3.0
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. Sanigest proposed EUROSTAT U.S. Supply benchmark (2009) (2009) per 100,000
Plastic Surgery 1.3 1.3 2.1 Urology 2.5 4.8 3.4 Long-term care 6.0 - - TB 2.5 - - Narcology 1 - - Others 3 - - Mental Illness and Disabilities 10.8 - - General Psychiatry 10.0 14.1 - Forensic Psychiatry - - - Psychotherapy 0.8 - - Old Age Psychiatry - - - Learning Disabilities - - - Pathology and Radiology 15.6 - - Chemical Pathology 3.1 3.2 - Clinical Genetics 0.4 - - Clinical Neurophysiology 0.2 - - Clinical Pharmacology and Therapeutics 0.4 - - Clinical Radiology 7.8 11.0 - Haematology 1.2 1.8 1.1 Histopathology 1.5 - - Immunology 0.6 - - Medical Microbiology & Virology 0.4 1.2 2.9 Overall 176.8
The second line of research addresses directly the spatial distribution of physician densities and tries to identify factors explaining differences in the physician workforce over urban and rural areas. Obviously, physician densities reflect not only entry decisions but also migration and market exits of physicians.
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. Table 10 Current number and proposed specialist for pilot region Current Number number of required physicians for pilot pilot region region 400,000 (6 rayon)
Medical Specialties General Medicine 100.0 Accident and Emergency 40.0 Anaesthetics (including Intensive 24.0 61.2 Care) Cardiology 13.0 17.6 Child and Adolescent Psychiatry 1.0 8.0 Dermatology 12.0 7.6 Endocrinology and Diabetes 2.0 6.0 Mellitus Gastroenterology 10.0 10.4 Geriatric Medicine 4.0 6.0 Infectious Diseases 8.0 12.0 Medical Oncology 3.0 8.0 Neurology 17.0 10.0 Nuclear Medicine 0.0 4.0 Occupational Medicine na na Renal Medicine 2.0 4.4 Rheumatology 4.0 3.2 Pediatric 77.0 78.0 Paediatrics 77.0 60.0 Neonatology 4.0 12.0 Paediatric Surgery 17.0 6.0 Obstetrics and Gynaecology 38.0 80.0 Surgical Specialties 121.2 General Surgery 24.0 44.0 Trauma and Orthopaedic Surgery 13.0 24.0 Cardiothoracic Surgery 1.0 3.2 Neurosurgery 5.0 4.8 Ophthalmology 10.0 18.8 Oral and Maxillo Facial Surgery 0.0 3.2 ENT 10.0 8.0
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. Plastic Surgery 0.0 5.2 Urology 6.0 10.0 Long-term care na 24.0 TB na 10.0 Narcology 2 4.0 Others na 10.0 Mental Illness and Disabilities 9.0 43.2 General Psychiatry 9.0 40.0 Forensic Psychiatry 0.0 0.0 Psychotherapy 0.0 3.2 Old Age Psychiatry 0.0 0.0 Learning Disabilities 0.0 0.0 Pathology and Radiology 62.4 Chemical Pathology 0.0 12.4 Clinical Genetics 0.0 1.6 Clinical Neurophysiology 0.0 0.8 Clinical Pharmacology and 28.0 1.6 Therapeutics Clinical Radiology 14.0 31.2 Haematology 1.0 4.8 Histopathology 2.0 6.0 Immunology 1.0 2.4 Medical Microbiology & Virology 1.0 1.6 Overall 707.2 The resulting disparities are typically explained by demand-driven factors, like a region's demographic, socioeconomic and technological background, as well as the specific characteristics of a region's health care system (i.e., the availability of health care facilities acting as substitutes or complements to the outpatient physician workforce), including the corresponding legal environment which is important for a patient's access to health care (e.g., differences in cost sharing schedules between regions).
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. Figure 38. Doctors per 1,000 in selected rayon’s 2011 Strategies to retain doctors within the northern region will need to be developed as tendencies of physician scarceness are seen across rayons.
Source: Sanigest 2012 On average, higher physician density is inconsistently related to better health outcomes. However, there is consistent evidence that what really matters in improving population health is not the number of physicians but, rather, what those physicians do. The availability of an adequate supply of primary care physicians has been consistently identified with better health; simply put, person- rather than disease-cantered care matters.
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. Figure 39. A clear shortage of doctors in the northern region compared to that of OECD countries.
Source: OECD library last accessed 2012
5.2. Physician to bed ratios
To ensure maximized efficiency of resources, bed levels should correspond with disease burden. Areas with low disease burden should have low demand for beds. Excess beds represent poor allocation of bed resources. Areas with high disease burden should see higher demand for beds and should have higher bed levels to meet increased demand. The following section analyses bed supply versus morbidity to assess resource use.
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. Figure 40. Total number of doctors per occupied bed per selected rayon
Figure 41 Source: Sanigest 2012
Physician to occupied bed ratios vary widely across rayon’s. Donduşeni had the highest number for the selected pilot rayon’s with a physician per bed ratio of 1.74 while Edineţ had the lowest with a ratio of 0.50 which translates to 2 beds per physician.
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. Figure 42 Total number of Physician to bed ratio
Source: Sanigest 2012
5.3. Skills mix: Distribution of HRH by occupation, specialization, or other skill-related characteristic.
5.3.1 Nurses Currently, there are 25 848 nurses (63.6 per 10,000 inhabitants) working mainly in the public health system. Each year, around 2000 nurses leave the country in search of better working conditions and a better quality of life.
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. Figure 43. Total number of nurses per rayon
Source: Sanigest 2012
Around 2000 nurses leave the Moldova each year in search of better work conditions and a better quality of life (Buliga & de Rosca 2007). To slow this haemorrhage of nursing staff, in 2006, the government increased nurses’ monthly salary from 45–50 euros to 70 euros, supported their professional development by continuing, free, educational strategies and introduced better working conditions to protect their safety (Buliga & de Rosca 2007).
The problem of health personnel migration is a topical issue for the Republic of Moldova. However, there are no specific statistics on migration. Only a few nurses return home after a migration experience. The majority return because of sickness, and then go back abroad because the socio-economic situation in their own country is difficult. (Palese et al 2010)
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. Figure 44. Number of nurses per hospital bed
Source: OECD library last accessed 2012
The above figure compares number of nurses per hospital bed with international standards. If one takes into account the total number of nursing staff per rayon hospital and compares against the total number of beds the conclusion might be that there is an equal nursing to be radio although the reality of the situation is that as nurses handle a wide range of activities at the rayon level including in some instances administrative support there seems to be an even nurse to bed ratio. However it must be noted that an excess number of beds and multifunctioning nurses can be seen in all rayons.
Table 10. The number of specialist per 100,000 in Europe. Source Eurostat 2010 Average of Per 100K PERCENTILE PERCENTILE Median 25 75 SPECIALTY Accident and emergency medicine 0.2 7.0 1.7 Anaesthesiology and intensive care 12.5 17.2 15.7 Cardiology 3.8 9.3 6.6 Dermatology 3.0 5.5 4.3 Endocrinology 1.0 2.6 1.8 Gastroenterology 1.4 4.4 2.7 General paediatricians 9.6 15.1 13.1 General practitioners 57.1 78.8 67.8
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. Average of Per 100K PERCENTILE PERCENTILE Median 25 75 General surgery 8.9 15.8 13.5 Gynaecologists and obstetricians 10.5 18.3 13.8 Haematology 1.1 2.8 1.7 Immunology 1.3 4.3 2.4 Internal medicine 14.6 35.7 21.5 Medical group of specialists 58.4 97.0 75.5 Microbiology-bacteriology 1.0 2.6 1.4 Neurological surgery 1.0 1.8 1.2 Neurology 4.2 7.5 5.4 Occupational medicine 2.5 10.7 4.0 Oncology 1.2 3.0 2.0 Ophthalmology 6.3 9.5 7.9 Orthopaedics 4.8 9.8 8.1 Other categories not elsewhere classified 6.4 70.8 19.4 Other specialists not elsewhere classified 12.9 80.5 35.4 Otorhinolaryngology 4.3 7.0 5.6 Pathology 2.3 3.9 3.0 Plastic surgery 0.9 1.6 1.4 Psychiatrists 9.7 17.7 13.2 Radiology 8.3 13.4 10.1 Respiratory medicine 2.6 5.2 3.9 Surgical group of specialists 44.1 65.9 54.9 Thoracic surgery 0.8 1.6 1.0 Urology 3.2 5.8 4.7 Grand Total 16.1 22.9 19.2
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5.4. Importance of family medicine in Moldova The specialty of family medicine did not exist in the Republic of Moldova before the fall of the Soviet Union. Following the lead of more developed nations, the establishment of family medicine as a discipline in Moldova was viewed as a major necessary step aimed at modernizing the health care system to meet the needs of its citizens. Therefore, 2 initiatives were used to develop family medicine as a specialty. The first step involved retraining a subset of practicing specialists to become family physicians. In addition, a family medicine residency program was established in 1997 at the sole medical school in Moldova, thereby allowing newly graduated physicians the opportunity to pursue a 3-year training program to become family physicians. As a result of these initiatives, by 2008 there were nearly 2000 family physicians practicing throughout the Republic of Moldova.
Although the scope of family medicine has changed in the Republic of Moldova during the past decade, to our knowledge no studies have examined the role of family medicine from a practicing physician's perspective. Almost three quarters of family physicians in the Republic of Moldova are women.
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6. Procedures
The complexity of health care processes makes identification and measurement of the critical components of high-quality care especially challenging within any health care system. For many years hospital procedure volume has been used as a key indicator as it is relatively easy to measure and it assumed to be a proxy for experience. The amount of procedures carried out within a facility or specific surgical department has long been examined as a predictor of clinical outcomes, and a volume-outcome relationship has been observed for a wide variety of surgeries in different countries. Concentration of surgeries in high-volume centers has been considered a strategy to improve the quality of care, and in select instances, policies to achieve this goal have been implemented as has been the case for many of many soviet countries attempting to centralize specialized care. Although this model has proven successful for specific cases such as complex surgeries the unintended effects brought by the centralization process such as assess issues are now making the regionalization of special procedures and services in Moldova an obvious necessity.
Not only in Moldova but in general health policy measures advocating volume based regionalisation are, for the most part,
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. predicated on the overwhelming empirical evidence of hospital volume-outcome associations. High volume hospitals are assumed to have structural characteristics associated with better quality of care, and providers in these hospitals are thought to improve their processes of care through experience in providing complex care. Central to this framework is an implied linkage between the volume of a specific surgical procedure done in a hospital and the outcome of the same surgical procedure. There has also been evidence that shows best practices in strengthening local level area of care with this framework in the contexts of decentralization such as the proposed case for Moldova (Urbach DR 2004).
The consistent finding of associations between the volume of a procedure and surgical outcome has been interpreted as empirical evidence that the outcomes of surgical procedures are better in hospitals with higher volumes of similar procedures. It is therefore essential within the regionalization process to increase capacity at the decentralized level to increase volumes were needed. Under this interpretation, regionalisation of patients needing complex surgical procedures to a hospital in the northern region that would do a high volume of those procedures would be expected to improve patient outcomes regardless of the underlying causal mechanism of the volume-outcome association.
To ensure favourable health outcomes, with a special focus to patient safety, Moldova most move away from the isolation of patients from the quality of care they deserve within each region. The initial assessment evidenced that low complexity and low volume of surgical procedures are carried out within the northern rayons for a number of surgical specialties.
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. Figure 45. Share of surgeries is very low reflecting low-acuity of patients
Source: Sanigest 2012
In light of wide variation in surgical performance with many procedures, by means of the regionalization strategy efforts will be taken to direct patients toward the highest-quality hospitals in Edineţ or the Balti for care. The Leapfrog Group, a large coalition of healthcare purchasers, has implemented standards for “evidence-based hospital referral” for 5 high-risk procedures. By shifting obstetric, surgical and sub-specialty care the northern region will be able increase not only patient safety standards by optimizing procedure volume but will also maximize resource use in all regions.
Given Moldova’s growing interest in assessing surgical quality in all regions during the past couple of years, there remained controversy about how best to identify high-quality hospitals for individual procedures within rayons. As hospital procedure volume is currently among the most widely used quality indicators we have taken into account not only these indicators but also geographical assess and current infrastructure to best allocate referral for the northern region. There remains little doubt that volume is inversely related to operative mortality with many procedures carried out outside of Chisinau. Nonetheless, stakeholder we interviewed signaled volume as a crude surrogate for quality and a poor predictor of individual hospital performance. Instead, many remarked surgical quality is best judged by direct outcome measures, including operative mortality. For many procedures, however, hospital mortality
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. rates may in the pilot region are hampered by sample size problems given the low volume of cases seen at the rayon level and thus may be too imprecise to meaningfully reflect quality of care
Figure 46. Factors such as low number of anaesthesiologist and qualified surgeons leave the pilot region with low number of surgical output.
Data source: OECD 2010
Given the elevated oncological burden of disease for Moldova, the situation for cancer patients should further be discussed. On the one hand, large population based studies have demonstrated that hospital procedure volume can have a profound effect on outcomes following operations associated with high mortality, such as pancreatectomy. Some prior studies have suggested that a volume-outcome effect may also exist for colon cancer surgery, which is performed more frequently but with less substantial morbidity and mortality. Albeit, locating such specialized procedures and levels of care in the northern region would not be justifiable from a caseload or financial standpoint.
On the other hand, long distance travel times and difficult access to periodical treatment and long term medical care needed for certain oncological patients, build the case for and evident regionalization of services for the northernmost population of Moldova. Therefore a compromise of services and procedures must be agreed upon taking into account the current and future health needs of the population.
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. Figure 47. Birth Standard: 300 min Births per. All rayons below the red line represent hospitals that are not meeting the required output per facility.
Source: Sanigest 2012
Figure 48. Caesarean section, a common surgical procedure for benchmarking surgical performance shows the northern region as having a low case density.
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Data Source: OECD 2010 Building on existing evidence, the regionalization strategy includes a strong referral system founded on evidence based globally accepted standards and policies for specific case referrals. Such is the case for cardiac surgeries including angioplasties. Studies have shown that by setting minimum volume thresholds for specific hospital procedures, one can improve hospital outcomes for a particular setting. Details regarding specific referrals will be discussed further in this report.
Although no one has attempted to standardize a minimum threshold for each surgical procedure that exists for all specialties, key thresholds for surgeries have been discussed in the past. Such is the case of complicated deliveries and low and premature deliveries were groups such as the Leapfrog group have set a minimum of 15 for regional neonatal intensive care units average daily census. Cataract surgeries volumes associated with higher safeties have yet to be internationally standardized but can serve as a useful benchmark for surgical volumes as they are a relatively common procedure in many countries. Compared to other OECD countries, the pilot region in Moldova performance a significantly lesser amount of cataract surgeries per year, almost inexistent in some rayon hospitals.
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. Figure 49 Cataract surgeries for OECD countries and Moldova pilot region
Volume-outcome associations for hospital procedures are not specific to the volume and the outcome of the same procedure. Our data do not support health policy measures predicated on referring patients having a certain surgical procedure to hospitals that do a high volume of the same procedure. A more rational strategy might be simply to regionalise all complex operations at large hospitals. Alternatively, increased allocation of resources to smaller hospitals and targeted quality improvement programmes might reduce some of the variation in short term surgical outcomes across hospitals.
VER the past three decades, numerous studies have described higher rates of operative mortality with selected surgical procedures at hospitals where few such procedures are performed (low-volume hospitals). Several recent reviews suggest that thousands of preventable surgical deaths occur each year in the United States because elective but high-risk surgery is performed in hospitals that have inadequate experience with the surgical procedures involved.
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. Figure 50. Number of surgeries varies among specialties and region with general surgeons in Briceni preforming as little as 32 on averages (combined specialties)
Source: Sanigest 2012
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7. Outpatient services
Outpatient service is care that can be completed in a medical facility without an overnight stay, including counselling, testing, and rehabilitation. Because no overnight stay is required, outpatient services are more economical than inpatient services. Due to high population density, urban dwellers have to travel much smaller distances to reach a health facility compared to their rural counterparts. For this reason, 95% of ambulatory services and 99% of small health centres are located in rural areas.
Figure 51. Total number of outpatient-discharge ratios (per person, per year), by rayon High hospitalization rates result in low outpatient numbers far below international benchmarks.
Source: Sanigest 2012 Outpatient consultations should be a part of a strong referral system. These encounters should be patients’ first stop in the line of health care. If a condition is serious enough to require tertiary level care, then a physician will refer the patient to the appropriate hospital for further treatment. Based on this system of referral, rayon’s should expect to have far more outpatient visits than hospitalizations.
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7.1. Equipment assessment The medical equipment examined in the sample of 6 rayon public hospitals was well maintained, although a high proportion was beyond its life expectancy. A large proportion of equipment was in poor condition, in that it was unreliable, had excessive downtime and/or had doubtful availability of spare parts. For the 6 hospitals examined, sever pieces of equipment in poor condition such as radiology machines needs to be replaced immediately.
Effective equipment management and decision-making will require a comprehensive assessment of the relative costs of continued maintenance versus replacement. None of the 6 hospitals seemed to have established a proper asset management planning processes to identify their equipment needs, including funding requirements, nor had they developed strategies to address funding gaps.
Capacity building for equipment use is critical. During our assessment it was observed cases where state of the art donated ventilator machines were not used because of the staff and physicians were never capacitated to use such equipment. Below represents the finding encountered after an assessment of the current situation regarding equipment for six hospitals in the northern region. One must be cautious when interpreting these results for two reasons. First of all the total numbers presented do not account for outdates equipment; a section of the analysis accounted for but will present later on. The second point to consider is the fact that several pieces of equipment donated from external partners were observed and are usually not reported by hospitals.
In terms of infrastructure, one of the desired outcomes would be that critical patients should not have to travel long distances for simple test or procedures.
Table 11. Availability of equipment within pilot region. Green indicates availability while red indicates non- existent.
Briceni DonduşeniDrochiaEdineţ Ocniţa Riscani
Anaesthesia Unit
Refrigerator, Blood Bank
Ventilator, Adult
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Ventilator, Neonatal
Electrocardiograph
Electroencephalograph
Electromyography
Defibrillator/Monitor
Arthroscopy Unit
Endoscope, flexible
For complete list see annex 3
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. Figure 52. Current level of infrastructure and recommended level for northern region. Red represents the Sanigest recommendation based on international standards for each unit
Source: Sanigest 2012
The current situational analysis for equipment in the northern shows an urgent need to scale up equipment infrastructure as shown in Figure 52. Colum in blue represents the current number of equipment per 100,000. The red column shows the amount of equipment needed based on international standards per 100,000 populations.
7.2. Emergency care
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. The Moldovan emergency care system is a consolidated network. Emergency teams in the north employ doctors and paramedic staff. The whole emergency care system was upgraded in 2003, with new investments in ambulances and emergency equipment, which included the northern region.
Before 2004, there were substantial problems with the accessibility of emergency ambulance services, particularly in rural areas. Consequently, in order to create direct incentives for increasing provider productivity and to ensure sufficient access, the service payment method was changed to a per visit basis. Once this goal was achieved, the payment method was changed to a capitation payment method, but access is said to be unaffected.
Ocniţa Ambulance Ocniţa (main station): 2 ambulance vehicles Otaci (substation): 1 ambulance vehicle Serving range 35-40 km
Briceni Ambulance Briceni (main station): 2 or 3 ambulance vehicles Lipcani (substation): 2 ambulance vehicles Corjeuti (substation): 1 ambulance Vehicle Larga (substation): 1 ambulance vehicle Serving range: 60 minutes Hospital has a contract with private taxi company that can take the patient to the hospital in no ambulance is available
Edineţ Ambulance Edineţ (main station): 2 or 3 ambulance vehicles Brinzeni (substation): 1 ambulance vehicle Bratuseni (substation): 1 ambulance vehicle Cupcini (substation): 1 ambulance vehicle Serving range -40 km
Donduşeni Ambulance Donduşeni (main station): 3 ambulance vehicles Sudarca (substation): 1 ambulance vehicle Serving range 25-30 km
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. Drochia Ambulance Drochia (main station): 4 ambulance vehicles Ochiul alb (substation): 1 ambulance vehicle Pelenia (substation): 1 ambulance vehicle Serving range 35-40 km
Riscani Ambulance Riscani (main station): 2 ambulance vehicles Costesti (substation): 1 ambulance vehicle Sapte bani (substation): 1 ambulance vehicle Zaicani (substation): 1 ambulance vehicle Serving range 40 km
7.3. Pharmacy
Rayon hospital operates under the National Medicines Policy. The implementation of the policy id regularly monitored by the sector of the Ministry of Health entitles the Medicines Agency. The aspects covered within the National Medicines Policy includes the selection of essential medicines, medicines, medicines pricing, medicines procurement, medicines distribution, medicines regulation, pharmacovigilance, rational use of medicines, human resource development, research, and traditional Medicine.
Within this legislation population groups provided with medicines free of charge include children under the age of five and pregnant women. Medication provided free of charge include tuberculosis treatment, treatment for HIV/AIDS, immunizations and certain medication for non-communicable diseases.
Procurement and distribution at the rayon of essential medicines is ultimately decided by a formal committee that has established the National Essential Medicines List. Although rayon hospitals follow the use of medication for treatment based on the National standard Treatment Guidelines, Moldova has yet to set into place national guidelines on distribution practices.
It was observed that at the rayon level, antibiotics as well as injectable medication is often sold over the counter without a prescription. Nurses and pharmacist also seem to prescribe prescription only medications both at the primary care level and in the public sector.
Ocniţa has a pharmacy on site that cover 90 % of the population needs and works with CMAN. There are currently two private pharmacies within a 200m range. The Briceni pharmacy located within the hospital covers 70% of the general population needs. There are two private
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. pharmacies on hospital ground site. Edineţ hospital pharmacy covers around 90% of the population needs. There is one private pharmacy on campus and one private pharmacy 15 minutes away.
The pharmacy hospital in Donduşeni covers 90% of population needs. There is one private hospital on campus and three private pharmacies within a 100m range. The Drochia pharmacy within the pharmacy also covers 90% of the populations needs. There are other two private pharmacies on site. The Riscani hospital also has reported population needs coverage of 90%. There are two private pharmacies within a 200m range.
7.4. Laboratory
The clinical laboratory is a crucial component of the health care sector. The dependence of patient management on laboratory data highlights the need for ensuring the quality of these services for the northern region. In recent year a focus on quality indicators in the laboratory setting has begun to emerge. Indicators in laboratory processes and procedures are many time parts of hospital guidelines at the national level. Unfortunately there is little or no evidence in term of the quantity of services to be provided as this function depends on particular each particular setting and level of care. Nonetheless, the use of point-of-care testing in primary care is important for the purpose of reducing the time taken to make decisions on patient management. Thus, the availability of a limited number of laboratory tests is especially of concern for the region... Infections and inflammatory conditions are prevalent among patients using services at the rayon level, but with the low volume of patients, the central government has in some instances limited the amount of resources dedicated to laboratory usage. One particular case was observed during the initial situational analysis were stakeholders commented that PCR quantification, useful for infectious and inflammatory conditions, donated by an external agency was taken to the capitol due to the lack of usage.
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. Figure 53. Edineţ has an emergency laboratory setting as well as separate inpatient/outpatient laboratory facility
Source: Sanigest 2012
The data shown reveals the frequency of laboratory test ordered per discharge at the rayon level. In an effort to compare to limited international standards, the analysis reveals the low volume of laboratory procedures carried out per discharge, 3.9, compared to that of a typical regional clinic in USA. For future data collection it is important that rayons document quality indicators that are emerging in the area of laboratory quality assurance such as rejections due to sample inadequacy, inappropriateness, and incorrect patient information due to incorrect phlebotomy practices and/or ignorance and non-compliance by the phlebotomists. Haemolysis is the most common anomaly observed during the assessment of preanalytical indicators followed by improper samples for coagulation profiles (incorrect proportion of anticoagulant to plasma and clotted samples) seen in many western countries and thus should be documented in Moldova as well.
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. Figure 54. Number of lab test ordered per doctor. Thanks to international cooperation efforts and support from MoH Edineţ and Drochia have some of the strongest laboratory infrastructure for the region. Unlike the National Medicines Policy a current National clinical laboratory policy does not exist in Moldova
Source: Sanigest 2012. The modernization of healthcare process in recent decades and the need to obtain objective data for decision-making in the health care management process at any level has led to a steady increase in the imp
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. Ordnance of the laboratory service as an essential tool in primary care. The expansion of the laboratory in health care results in increased economic importance, which some authors come to represent more than 10% of total health expenditure in any system health. Nevertheless, research on the use of the laboratory from is scarce. Nonetheless it is important that basic services not only exist at the primary level but be kept up to date and utilize international best practices.
8. Brief analysis of legislation relevant to regionalization
Actual normative Reglementările Implicaţii juridice pentru reformă
1) Legea ocrotirii sănătăţii Despre structura sistemului nu se vorbeşte nimic. Astfel noua structură a nr.411 din 28.03.1995 cu Articolul 2. Structura şi principiile fundamentale ale spitalelor va fi necesar de aprobat prin lege (a se vedea mai jos). modificările şi sistemului de ocrotire a sănătăţii completările ulterioare Totodată o clasificare a spitalelor (mai mult confuză este stabil http://lex.justice.md/ind Hotărîrii Guvernului nr. 379 din 07.05.2010 „Cu privire la Programul de ex.php?action=view&vie dezvoltare a asistenţei medicale spitaliceşti pe anii 2010 w=doc&lang=1&id=31282 http://lex.justice.md/index.php?action=view&view=doc&lang=1&id=334577 Sistemul de ocrotire a sănătăţii este constituit din 3 unităţi curativ-profilactice, sanitaro-profilactice, Având în vedere că actul normativ susmenţionat este până la finele anului 2012, sanitaro-antiepidemice, farmaceutice şi de altă clasificarea respectivă este vremelnică natură,
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Articolul 4. Instituţiile medico-sanitare Întrebarea fundamentală care trebuie clarificată atunci când vorbim de o (1) Instituţiile medico-sanitare pot fi publice sau instituţie ce acordă servicii medicale este ce statut are aceasta: este comerciant, private, cu excepţia celor care, în conformitate cu sau instituţie publică, or Codul civil nu oferă alte opţiuni. Legislaţia în vigoare este legislaţia în vigoare, nu pot fi decît publice. totalmente confuză în acest sens – instituţiile me instituţii publice, pe când acele private sunt comercianţi. (2) Instituţia medico-sanitară publică se instituie prin este nici o deosebire de natură funcţională. decizie a Ministerului Sănătăţii sau a autorităţii administraţiei publice locale.Instituţia medico- sanitară publică departamentală se instituie prin decizie a autorităţii centrale de specialitate. Nu avem o definiţie a conceptului şi o descriere a regimului juridic al instituţiei medico-sanitare, doar o listă a tipurilor instituţiilor medicale, care nici nu este (6) Parlamentul reorganizează, prin acte legislative, exhaustivă, respectiv, nu rezolvă nici măcar cerinţa de categorisire a instituţiilor sistemul naţional de sănătate, domeniul medicale. Cel mai deranjant este că norma nu explică în ce mod aceste instituţii medicamentului şi al activităţii farmaceutice. se îmbină într-o schemă şi cum funcţionează relaţiile dintre elementele schemei şi stat. (7) Fondatorul aprobă organigrama şi statele de personal ale instituţiei medico-sanitare.
Articolul 21. Tipurile de asistenţă medicală, modul În acest context prevederile alin (6) prin care Parlamentul reorganizează, prin lor de acordare acte legislative, sistemul naţional de sănătate…pot fi utilizate de oponenţii reformei spitalelor ca bariere în calea stabilirii structurii regionalizate a asistenţei (1) Tipurile de asistenţă medicală sînt: asistenţa medicale spitaliceşti. Prin Ordinul MS nr.404 din 30.10.2007 „Cu privire la medicală urgentă prespitalicească; asistenţa delimitarea juridică a asistenţei medicale primare la nivel raional” medicală primară; asistenţa medicală specializată de http://lex.justice.md/index.php?action=view&view=doc&lang=1&id=327667 ambulator, inclusiv stomatologică; asistenţa medicală spitalicească; servicii medicale de înaltă a fost aprobată Organigrama model a sistemului de sănătate rational. performanţă; îngrijiri medicale la domiciliu. urmare, noua structură de sănătate la nivel naţional ar necesita să fie apr prin lege. Cu toatea acestea cea mai corectă normă legală privind structura sistemului de sănătate este stabilită în Constituţie. Conform alin. (3) art.36 din Constituţie structura sistemului naţional mijloacele de protecţie a sănătăţii fizice şi mentale a potrivit legii organice. Astfel structura sismemului naţional spitalicesc în variant regionalizată ve fi necesar de aprobat prin legea organic (Legea ocrotirii sănătăţii nr.411 din 28.03.1995)
(21) Conducătorii instituţiilor medico-sanitare publice republicane, municipale, raionale sînt selectaţi prin Prevederile alin.(21) sunt reglementate prin Hotărârea Guvernului nr.1079 din concurs organizat de Ministerul Sănătăţii şi sînt 02.10.2007 “Pentru aprobarea Regulamentului privind numirea în funcţie pe bază numiţi în funcţie de către fondator. Eliberarea din de consurs a conducătorilor instituţiilor medico funcţie a conducătorilor instituţiilor medico-sanitare http://lex.justice.md/index.php?action=view&view=doc&lang=1&id=325382 publice republicane, municipale, raionale se efectuează de către fondator. Regulamentul privind
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numirea în funcţie a conducătorilor instituţiilor medico-sanitare publice în bază de concurs se aprobă de Guvern. Dacă MS ar încerca să creeze spitale regionale în baza unor spitale rationale şi sau municipal şi ar dori ca conducătorii acestora să fie numiţi de MS, atunci a lucru va fi imposibil.
(3) Persoanele fizice şi persoanele juridice au dreptul să fondeze instituţii medico-sanitare (curative, Aliniatul 3 este redundant, reproduce un principiu general stabilit în legislaţia cu profilactice, epidemiologice, farmaceutice şi de altă privire la activitatea de întreprinzător – fiecare pe natură) şi poartă răspundere pentru asigurarea lor întemeieze o afacere atât timp cât aceasta nu este interzis de legislaţie. A se financiară şi tehnico-materială, pentru organizarea vedea art. 10 „Reglementarea activităţii de antreprenoriat”, din Legea cu privire de asistenţă medicală şi pentru calitatea ei, conform la întreprinderi şi antreprenoriat, care stipulează că întreprinderea legislaţiei în vigoare. să practice oricare activităţi cu excepţia celor interzise prin lege.
(5) Regulamentele şi nomenclatorul instituţiilor medico-sanitare, indiferent de tipul de proprietate şi Acest alineat nu influenţează nici într-un fel reforma spitalelor pentru că forma juridică de organizare, precum şi lista nomenclatorul instituţiilor medico-sanitare spitalice serviciilor prestate de acestea, sînt aprobate de Nomenclator al spitalelor este aprobat prin Ordinul MS nr. 41 din 20.01.2011 „Cu Ministerul Sănătăţii, cu excepţia celor ale organelor privire la Nomenclatorul instituţiilor medico de drept şi ale organelor militare. http://www.ms.gov.md/public/legal/ordinele/
Articolul 5. Subordonarea unităţilor din sistemul de ocrotire a sănătăţii Prevederile acestui articol sunt în divergenţă cu prevederile alin (2) art 4. Astfel instituţia medico-sanitară publică al căror fondator este autoritatea publică (1) Instituţiile de învăţămînt de stat, instituţiile de locală, este în subordinea acesteia şi nu în subordinea Ministerului Sănătăţii. cercetări ştiinţifice din sistemul de ocrotire a sănătăţii, precum şi spitalele, dispensarele republicane şi alte instituţii republicane de asigurare Numai în trei autorităţi administrative (mun.Chişinău (capitala ţării), mun. Bălţi şi a sănătăţii se află în subordinea Ministerului Unitatea Tteritorială Autonomă Găgăuzia (Gagauz Sănătăţii şi Protecţiei Sociale. Celelalte unităţi unităţi administrativ-teritoriale, există subdiviziuni cu atribuţii de administrare a medico-sanitare se subordonează Ministerului serviciilor de sănătate din subordine. În raioane (32 la număr), responsabilitatea Sănătăţii şi Protecţiei Sociale şi autorităţilor pentru administrarea serviciilor de sănătate din subordine revine aparatului administraţiei publice locale. central al Ministerului Sănătăţii, care este dislocat în mun. Chişinău. Ca rezultat, administraţia raională nu are capacităţi de gestionare a serviciilor de sănătate, iar (2) Instituţiile departamentale curativ-profilactice, pentru că cadrul legal ce ţine de competenţele autorităţilor administraţiei publice sanitaro-antiepidemice şi de altă natură se locale în sănătate este confuz şi contradictoriu, eficacitatea autorităţilor subordonează departamentelor respective. În plan responsabile de sănătate din cele trei teritorii menţionate mai sus este sub nivel. metodic, de control al calităţii asistenţei medicale şi de atestare a cadrelor instituţiile respective sînt subordonate Ministerului Sănătăţii şi Protecţiei Sociale. În circumstanţe extraordinare de izbucnire a unor maladii de masă, unităţile medico-sanitare
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Actual normative Reglementările Implicaţii juridice pentru reformă
nominalizate vor acorda, conform deciziei Guvernului, asistenţă medicală sinistraţilor. În perioada de răspîndire a maladiilor transmisibile toate centrele de igienă şi antiepidemice sînt obligate să-şi coordoneze activitatea cu Ministerul Sănătăţii.
(3) Unităţile medico-sanitare private şi persoanele care exercită independent profesiune medico- sanitară se supun autorităţilor administaţiei publice locale, Ministerului Sănătăţii şi Protecţiei Sociale, altor organe şi organizaţii, în condiţia legii.
2) Legea nr.436 din Articolul 43. Competenţele consiliului raional Această legea stabileşte competenţa consiliului rational în baza domeniilor proprii 28.12.2006 privind de activitate stabilite prin Legea privind descentralizarea administraţia public (1) Pornind de la domeniile de activitate ale Sănătatea nu este domeniu propriue de activitate. Aceasta a fost delegată locală autorităţilor administraţiei publice locale de nivelul autorităţilor publice locale prin legislaţia care guverna anterior administraţia al doilea stabilite la art.4 alin.(2) din Legea privind public locală. Prin urmare de facto APL de nivelul II gestionează serviciile de descentralizarea administrativă (a se vedea mai jos), sănătate ca competenţă delegată anterior, iar actual lege nu prevede aceasta. consiliul raional realizează în teritoriul administrat consecinţă, serviciile de sănătate, in special spitalele pot fi centralizate de către următoarele competenţe de bază: MS.
a) aprobă organigrama şi statele de personal ale aparatului preşedintelui raionului, ale direcţiilor şi ale altor subdiviziuni subordonate consiliului raional, precum şi suma totală a cheltuielilor necesare pentru asigurarea activităţii lor;
3) Legea nr.435 din (2) Pentru autorităţile publice locale de nivelul al Sănătate nu se află printre competenţele proprii ale APL de nivelul II. 28.12.2006 privind doilea se stabilesc următoarele domenii proprii de descentralizarea activitate: Totodată Strategia naţională de descentralizare şi Planului de acţiuni privind administrativă implementarea Strategiei naţionale de descentralizare pentru anii 2012 a) administrarea bunurilor din domeniile public şi aprobată prin Legea nr.68 din 04.05.2012 prevede: privat ale raionului; 5.1. Examinarea oportunităţilor de raţionalizare a structurilor administrativ b) planificarea şi administrarea lucrărilor de teritoriale, în baza studiilor privind consolidarea capacităţilor UAT, în construcţie, întreţinere şi gestionare a unor obiective conformitate cu criteriile şi principiile cuprinse în prezenta Strategie. publice de interes raional; 5.2. Consultarea membrilor comunităţilor locale, inclusiv a grupurilor vulnerabile, c) construcţia, administrarea şi repararea drumurilor asupra opţiunilor de consolidare a capacităţilor UAT şi de cooperare de interes raional, precum şi a infrastructurii rutiere; intermunicipală.
d) organizarea transportului auto de călători, 5.3. Crearea de condiţii pentru implementarea opţiunilor de consolidare a administrarea autogărilor şi staţiilor auto de interes capacităţilor UAT şi de cooperare intermunicipală. raional;
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Activităţile 5.1–5.3 se referă la fragmentarea administrativă excesivă care e) stabilirea unui cadru general pentru amenajarea generează lipsa de eficienţă (în furnizare) şi propune realizarea teritoriului la nivel de raion şi protecţia pădurilor de vor conduce la explorarea unor soluţii bazate pe două modele de acţiune: interes raional; a) modelul normativ – amalgamarea unităţilor administrativ f) sus ţinerea şi stimularea ini ţiativelor privind consolidarea administrativă, astfel încît să fie respectate principiile şi criteriile de dezvoltarea economică a unităţii administrativ- eficienţă, să crească accesul beneficiarilor la serviciile publice şi, implicit, calitatea teritoriale; acestor servicii;
g) elaborarea şi implementarea proiectelor de b) modelul cooperant – dezvoltarea instrumentelor specifice cooperării construcţie a gazoductelor interurbane (inclusiv a intermunicipale şi de stimulare a acesteia (în special financiare), astfel gazoductelor de presiune medie), a altor obiective serviciile publice să fie furnizate în comun de mai multe UAT, sporind accesul la termoenergetice cu destinaţie locală; serviciile publice prestate şi calitatea acestora.
g1) întreţinerea şcolilor primare şi şcolilor primare- Astfel există posibilitatea ca mai multe unităţi administrative grădiniţe, gimnaziilor şi liceelor, instituţiilor de coopereze şi să organizarea prestării în comun a unor servicii publice pentru toate învăţămînt secundar profesional, şcolilor-internat şi UAT. gimnaziilor-internat cu regim special, altor instituţii din domeniul învăţămîntului care deservesc Cu toate că modelul cooperant este mai „prietenos” şi nu provoacă atît de multă populaţia raionului respectiv, precum şi activitatea opunere din partea celor interesaţi, acesta este mai puţin efficient, în viziunea metodică, alte activităţi din domeniu; autorilor Strategiei. Sistemul de stimulente trebuie elaborat cu foarte mare atenţie, astfel încît să stimuleze în mod real furnizarea în comun a serviciilor [Art.4 al.(2), lit.g1) introdusă prin LP91 din 26.04.12, publice de către UAT. Modelul are şi un defect: ca să fie eficace, acesta presupune MO113-118/08.06.12 art.375; în vigoare 01.01.13] existenţa unei anumite culturi a cooperării, a i compromisului/consensului între diverse autorităţi publice de diferite dimensiuni h) administrarea instituţiilor de cultură, turism şi şi culori politice. Acest lucru este destul de dificil în multe ţări aflate în tranziţie. sport de interes raional, alte activităţi cu caracter educaţional, cultural şi sportiv de interes raional; Activităţile 5.2 şi 5.3 sînt necesare pentru organizarea unor consultări publice pe această problemă sensibilă cu toţi factorii interesaţi h) administrarea instituţiilor de cultură, turism şi societatea civilă şi populaţia, inclusiv grupurile vulnerabile sport de interes raional, alte activităţi cu caracter unei decizii politice clare. De asemenea, vor fi întrepr cultural şi sportiv de interes raional; pentru perfecţionarea unui cadru normativ adecvat.
[Art.4 al.(2), lit.h) modificată prin LP91 din 26.04.12, MO113-118/08.06.12 art.375; în vigoare 01.01.13]
i) administrarea întreprinderilor municipale de interes raional;
j) administrarea unităţilor de asistenţă socială de interes raional;
k) dezvoltarea şi gestionarea serviciilor sociale comunitare pentru categoriile social-vulnerabile, monitorizarea calităţii serviciilor sociale.
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9. Planning and Restructuring guidelines and standards
9.1. Process
The application of standards for beds, staff and technology to the population of each selected rayon constitutes a first step in estimating the need for the supply of services in each region. At the same time, a thorough analysis of the Needs Assessment and Benchmarking contributes to an understanding of the demand for care and opportunities to improve the overall performance of the health system in each selected pilot region.
This paper describes in detail the various steps involved within the process concluding with our recommendations based on international standards and the current situation within the pilot region.
After presenting the situation analysis we compare number and figures to international standards through a systematic benchmarking process. Benchmarking includes a wide range of examples including OECD and European Union averages. International best practices are presented in the different areas of the regionalization strategy including health workforce, infrastructure and health system processes. Based on our findings and best practices four different options have been proposed on how to reconfigure the network. Explained in detail are the advantages and disadvantages of each scenario and how they fit in the existing health system.
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Then next steps will be to establish consultations with relevant stakeholders in order to identify the option most suitable for Moldova.
Planning issues
Hospital planning guidelines are essential for the successful transformation of the hospital sector of Moldova. In the process of regionalization, hospital guidelines are important to define how the network of providers would look like in the long run, contributing in this way to the conformation of an integrated vision of the health sector.
The systematic use of proper guidelines may be useful for several reasons:
· To increase MOH and subordinated institutions capacity in investment planning based on adopted international standards to address population needs
· To develop health care restructuring in order to address country and regional needs and specifics
· To improve hospital efficiency
After the initial situational analysis the Sanigest approach moves to the phase of developing the standards and planning parameters as inputs for the regionalization process. There are number of contextual, or policy factors, which also drive the need for change. The shift to regionalization creates a number of opportunities, and risks, for the implementation of healthcare network reconfiguration.
9.2. Summary of Key Principles
A number of underlying issues frame the basic methodology that is under development. These include: 1. Timely access to hospital services for all 2. Safe, quality hospital services delivered according to international standards of care; 3. Development of a sustainable financing framework that adjusts the services delivered to the resources available; and 4. Creation of hospital centres of excellence delivering the highest level of care to the entire population The approach outlined, also advocates for three additional aspects of hospital planning: Services should be built around the needs of people not institutions Services offered should be sustainable within the existing financial framework Minimum volumes should be based on evidence based studies of outcomes
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9.3. A review of international experiences This section presents some key trends observed at the international level in terms of hospital network restructuring. Initially, a summary table is provided to highlight the main lessons learned from a review of restructuring projects in other countries. The chapter then moves to discuss, in greater detail, the experiences of Ireland and the Tuscany region (Italy) in Europe, basically because they represent two examples that share similarities with the situation in Moldova and because they also introduced some of the principles and measures proposed for the Regionalization.
To understand the complex process of restructuring hospitals, the consultancy reviewed the experiences of numerous countries that have developed hospital restructuring plans, or master plans, over the past decade. This included:
• Canada • Estonia • Georgia • Ireland • Latvia • Mongolia • Romania • Serbia • Slovakia • Spain (Valencia Region) • Tuscany Region, Italy
The main features of each reform are outlined in the following table. This review attempts to highlight the aspects which are most relevant for the Regionalization plans in Moldova.
Table 12. Main features of Hospital Restructuring in Selected Countries Country Years Case Examples
Reviewed
Canada 1996-2000 1996-2000 Amalgamation of several hospitals to form new, fewer but larger health care organizations, including:
Closure of 31 public hospitals, six private and six provincial psychiatric hospital (PPH) sites Takeover of four hospitals by other hospital corporations
Creation of several joint committees to provide shared governance to multiple organizations
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Creation of 18 rural/northern hospital networks
Establishment of a variety of regional and provincial networks (including child health networks in Ottawa, Toronto and London, rehabilitation networks and a French language services network in Ottawa)
Motivation for the reforms was established to provide: Removal of excess hospital bed capacity & Better use of capital resources
Rationalized hospital programs and services considered:
Multi-institutional organizations with a single governance structure
A more appropriate balance of institutional and community-based care
Increased hospital capacity with greater efficiencies, resources, and increased emergency room and ambulatory capacities
Expanded home care and long-term care, enabling hospitals to focus on the accommodation of acutely ill patients
Incorporation of a population needs approach in developing planning guidelines for reinvestment
New resources and funds
Pinpointing data needs and limitations
New networks focused on building a better continuum of care
Determining the need for new funding tools and mechanisms to support future health system development
Estonia 2001-2015 2001-2015 Estonia, which inherited a large hospital network with an excess number of beds inherited from the Soviet
Semashko Model has successfully rationalized the number of hospitals and beds in line with the Hospital Network Development Plan (HNDP). Structural reforms, which created new organizational forms and enabled incorporation of hospitals as foundations (trusts) or joint stock companies under private law, created incentives for efficient resource use
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and encouraged orderly rationalization through hospital mergers.
Between 1993 and 2001, the number of hospitals declined from 115 to 67, while the number of hospital beds was reduced from 14,400 to 9,200. In the same period, the average length of hospital stay per admission declined from 15.4 to 8.7 days—still greater than the EU average.
The HNDP aims to create an optimal hospital network that provides uniform quality of care, has set the objectives to reduce the number of acute care beds by over 50% (from 6,500 to 3200
Estonia 2001-2015 Estonia, which inherited a large hospital network with an excess number of beds inherited from the Soviet Semashko Model, has successfully rationalized the number of hospitals and
beds in line with the Hospital Network Development Plan (HNDP). Structural reforms, which created new organizational forms and enabled incorporation of hospitals as foundations (trusts) or joint stock companies under private law, created incentives for efficient resource use and encouraged orderly rationalization through hospital mergers.
Between 1993 and 2001, the number of hospitals declined from 115 to 67, while the number of hospital beds was reduced from 14,400 to 9,200. In the same period, the average length of Georgia 1998-2009 The initial rationalization plan proposed a sharp decrease in the number of hospitals based on the application of population based standards and target occupancy rates of 85% versus the levels of below 50% in many hospitals. The initial master plan also targeted extreme changes in the level of hospitalization with decreases in ALOS. The plan was based on a staged approach:
--- Stage 1 criteria were based on bed capacity, age of the building, and seismic safety.
--- Stage 2 screened for low utilization, whether standards were met (e.g. laboratory and radiology), and whether the physical upgrade would be too expensive.
--- Stage 3 evaluated the level of investment needed to bring each facility up to an appropriate standard.
--- Stage 4 selected facilities to remain in the public domain, based on location, scope and level of services, and necessary capital investment.
In a second phase of restructuring, after the initial consolidation had only minor effects and no public money was available for infrastructure, the government initiated a privatization process whereby winning
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consortiums were to build a replacement hospital, consolidating several of the hospitals targeted for closure and allowing the private companies to then sell off the land of the closed hospitals to compensate for the investment costs.
Some of the key principles of the 2007-2009 reforms were:
--- Hospitals will be located in all districts of Georgia;
--- 90% of population will have access to hospital care within 30 minutes of reach;
--- Currently occupied beds - 5600; Inefficiency rate- 68,2% (11,130 beds);
--- Targeted bed occupancy - 85%;
--- Targeted average length of stay – 5 for acute care, 20 days for medium care;
--- Increase of hospital service utilization - 35%;
--- Strictly defining the rate of high tech beds - 14,7% of total; - 1150 countrywide; out of it
- 744 in Tbilisi;
--- Defining the space requirements per bed: 50 sq. m in 15 and 25 bed hospitals; 75 sq. m. in 50 and more bed hospitals;
Latvia 2001-2006 Restructuring was based on:
--- application of European standards for population based beds, equipment and staffing by region, adapted with Latvian experts in consensus process;
--- Consolidation of mono-profile hospitals into multi-profile hospitals
--- Use of GIS to determine accessibility and catchment areas for each hospital
--- Significantly larger department sizes, which generally range from 25 to 50, with average around 30.
--- Creation of multi—hospital governance structures.
Georgia 1998-2009 The initial rationalization plan proposed a sharp decrease in the number of hospitals based on the application of population based standards and target occupancy rates of 85% versus the levels of below 50% in many
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hospitals. The initial master plan also targeted extreme changes in the level of hospitalization with decreases in ALOS. The plan was based on a staged approach:
--- Stage 1 criteria were based on bed capacity, age of the building, and seismic safety.
--- Stage 2 screened for low utilization, whether standards were met (e.g. laboratory and radiology), and whether the physical upgrade would be too expensive.
--- Stage 3 evaluated the level of investment needed to bring each facility up to an appropriate standard.
--- Stage 4 selected facilities to remain in the public domain, based on location, scope and level of services, and necessary capital investment.
In a second phase of restructuring, after the initial consolidation had only minor effects and no public money was available for infrastructure, the government initiated a privatization process whereby winning consortiums were to build a replacement hospital, consolidating several of the hospitals targeted for closure and allowing the private companies to then sell off the land of the closed hospitals to compensate for the investment costs.
Some of the key principles of the 2007-2009 reforms were:
--- Hospitals will be located in all districts of Georgia;
--- 90% of population will have access to hospital care within 30 minutes of reach;
--- Currently occupied beds - 5600; Inefficiency rate- 68,2% (11,130 beds);
--- Targeted bed occupancy - 85%;
--- Targeted average length of stay – 5 for acute care, 20 days for medium care;
--- Increase of hospital service utilization - 35%;
--- Strictly defining the rate of high tech beds - 14,7% of total; - 1150 countrywide; out of it
- 744 in Tbilisi;
--- Defining the space requirements per bed: 50 sq. m in 15 and 25 bed
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. Country Years Case Examples
Reviewed
hospitals; 75 sq. m. in 50 and more bed hospitals;
Latvia 2001-2006 Restructuring was based on:
--- application of European standards for population based beds, equipment and staffing by region, adapted with Latvian experts in consensus process;
--- Consolidation of mono-profile hospitals into multi-profile hospitals
--- Use of GIS to determine accessibility and catchment areas for each hospital
--- Significantly larger department sizes, which generally range from 25 to 50, with average around 30.
The restructuring was based on combination of German and European norms for beds and staff, using macro-specialties to establish required levels of care. Given small size of the country, several centres of excellence were proposed to consolidate the more complex care in intra-district hospitals. Most rural hospitals were closed or converted to community centres offering non-acute care.
Mongolia The need to make hospital services more efficient in using existing expenditures was well documented and has been reported on for a number of years. Relative to its population of 2.5 million, Mongolia has too many hospitals, which possess an excess of beds and are overstaffed.
The number of hospitals per 100,000 people in Mongolia is over double that of the European Union (EU) and the Commonwealth of Independent States (CIS) averages. The hospital structure differs between Ulaanbaatar and rural areas, so the approach taken to optimize the sector should be different. In Ulaanbaatar, an emphasis on rationalization (merging and closing smaller hospitals) is necessary, while in rural areas increased efficiency and a structural shift from inpatient to outpatient care would aid in producing a more cost- effective system. The specific steps proposed were:
--- Bring all hospitals in Ulaanbaatar under a unified regulatory framework with improved information and payment systems that would provide strong incentives to increase efficiency and quality of care.
--- Quickly re-organize the hospital network in Ulaanbaatar by merging small, specialist hospitals into larger tertiary clinical hospitals, thus generating savings that can be invested in public health and primary care.
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. Country Years Case Examples
Reviewed
Romania 2002 The Romanian national strategy for the rationalization
Romania 2002 2002 The Romanian national strategy for the rationalization of hospital services started in 2002 with the following objectives: (1) implement programmes of care (acute and chronic, aged care and social care) and focus hospital care on acute and chronic services; (2) reduce dependency on
inpatient hospital services by reducing ALOS and hospital admissions and increasing occupancy rates and hospital throughput; (3) close, convert or restructure surplus or
underutilized hospital facilities and recover the savings for application to new health services; (4) expand PHC and functionally integrate primary and family care, ambulatory services and hospital services; (5) implement more effective and higher performing hospital services (new service modes) to deliver increased hospital output; and (6) guide the operational and financial management activities deemed necessary to sustain the strategy (Blight 2003).
Serbia 2006-2008 2006-2008 Serbia restructuring focused on introducing population based planning parameters for the minimum network of providers. Because Serbia had fewer excess beds than many other CEE/CIS countries, the reconfiguration process focused more on the strengthening of core services, such as cardiovascular care and ambulatory surgery, rather than on reducing the number of hospitals. Nonetheless, opportunities for reducing multiple buildings on hospital campuses were identified to promote inter-hospital consolidation and efficiencies.
Slovakia 2002-2006 2002-2006 The Slovak restructuring process introduced the concept of a Minimum Public network of providers. Given the multi-payer structure of the system, the estimation of the minimum levels of beds to be contracted on a population basis for each region was established as the minimum network. This was based on the application of European averages by specialty. Targets were established for reducing average length of stay to European levels, increasing ambulatory surgery and consolidating acute care into the better performing facilities following a complete national hospital assessment.
The reforms also promoted the development of multiple-hospital management boards with responsibility for multiple hospitals, especially at the local level, and promoted the
privatization of polyclinics who then invested capital as a condition of the privatization and were contracted to the public insurance network.
Spain Spain The experience of Valencia, Spain reflects an innovative approach
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. Country Years Case Examples
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to developing a PP whereby the private provider was given a concession to manage the primary through hospital network.
This included the building of new primary clinics over a ten-year period and the building and management of a regional hospital. The concession was given on a per capita basis, covering all services from PHC to hospital, for a fixed amount
In summary, many of the above mentioned experiences share common traits that govern both the objective and the methods of the restructuring processes reviewed. The following points highlight key factors to consider for the Regionalization process within Moldova.
In short, international trends show the following stylized facts regarding hospital modernization processes.
A. Increased efficiency, access and alignment with international clinical practice represent a standard for Regionalization. These conditions are found in many European nations and in around the Globe.
The conditions present a set of initial conditions, most of them similar to the situation of Moldova. Potential benefits seen by implementing key recommendation made by Sanigest International address the following:
• A significant increment in the number of admissions of any type, from acute admissions to emergency cases, due to the inexistence of a well-organized system of referrals so self-referring was a common practice. As a result, such distortions lead to a large percentage of unnecessary hospitalizations and inefficient allocation of resources to less cost effective activities (for instance, postponement of elective surgeries). In Tuscany Region, for example, the number of hospitalizations in excess was estimated at a target 160 admissions per 1,000 population from a 184 admissions rate. A large number of, sometimes, small hospitals scattered in the territory and located not according to access criteria or population needs but by historical reasons. In Tuscany, prior to the reform, the region had 1 hospital per 37,000 population while the optimal rate was estimated at 1 hospital per 90,000 persons.
• An ageing infrastructure and equipment. In the case of the Tuscany region, 75 per cent of the hospitals were built before 1920.
• Absence of a network vision that, in the case of Ireland, generated “delayed discharges from acute hospitals due to insufficient community places for transfer or rehabilitation” and “a large number of hospital beds occupied by patients with chronic diseases, including (but not limited to) the elderly, who tend to be admitted periodically to stabilize their condition (Cole, 2009)
• Strong difficulties to keep high-quality complex care in small hospitals
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. • A tertiary sector that absorbed a disproportionate share of funds. Significant waiting lists for general practitioner (GP) referrals for hospital outpatient appointments, diagnostics, and elective surgery or other treatments (Cole, 2009)
• Medical and non-medical staff lagging behind best practices in clinical Practice.
B. All cases share similar principles and lines of action that guided the hospital reform process
As in the previous case, there is a list of common principles that guide the reforms of both experiences:
1. New hospital provision of services based on a patient-focused perspective that is, looking first at the needs of the population. Consequently, the number of beds per specialty and region is calculated according to demographic and epidemiological conditions for each rayon.
2. Health services should be located closer to patients, so effective access remains as one of the key principles of the reconfiguration process (solidarity principle). The principle is complemented by the idea that, when possible, more at home care is better and is desirable.
3. Reduce the need for hospitalization, through greater use of prevention programs, primary care and community services. Enhanced role of community services as part of an integrated continuum of facilities that comprise home care, primary care, community, sub-acute and acute providers. Also, health services should be integrated to other social services.
4. Concentration of complex services in fewer facilities
5. As a result of 3 and 4, capital investments are prioritized along the continuum of care, not just in the acute sector. Investments were address to: a. Rationalize and simplify the hospital network b. Renew hospital facilities c. Rearrange facilities for outpatient treatment
The results of the redefinition of the financial allocation were considerable. In 1994, 57 per cent of Tuscany’s health care expenditures were directed to hospital services and by 2006 43 per cent of the health budget was allocated to secondary and tertiary care.
6. Appropriateness of treatments and use of resources; reliability of services (patient safety and security)
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. 7. Division of the territory for planning purposes according to broad segments defined according to predetermined criteria (urban/rural settings, population, access conditions, etc.)
8. Modernization of medical care and ancillary services (innovation principle) through acquiring and using the latest diagnostic, therapeutic and technological solutions.
9. Renewal of region’s health infrastructure
10. Training and research focus by encouraging a culture of professional advancement and by stimulating intellectual, clinical and medical advances;
11. Enhance emphasis on education regarding health care for the population.
C. The average size of acute hospitals is recommended to be between 200 beds and 600 beds
The World Bank (2006) and other authors suggest that, although informally, the optimal size of acute hospitals should be in the range 200-600 beds. Hospitals with a number of beds below 200 or above 800 beds are not recommended due to efficiency and management issues. The case of Tuscany clearly illustrates this trend so by 2000 the average size of its acute hospitals was in the range 400-450 beds.
The average ward size recommended in a multi-profile hospital is today between 25 to 30 beds. This is the size at which appropriate nursing care can be provided and patient distribution and space planning is optimized. In this regard, and in-line with recommendations to ensure adequate staffing for specialties, most studies are recommending that minimum bed sizes increase to the minimum size of the ward. Any level of beds projected for a facility less than the ward size would be incorporated into the general departments of internal medicine, surgery or long-term care.
D. Hospitals are usually conceived as part of network of services (a continuum of care) with an enhanced role of community services within the network.
One of the key elements of the discussed reforms was the implementation of integrated networks of care where less specialized services are moved away from acute facilities to community-based facilities. In this way, less complex providers like primary care and community centres become in charge of earlier diagnosis and preventive therapies so hospitalizations fell. Community health centres (level 2) becomes the cornerstone of the model by delivering health promotion, illness prevention and earlier diagnosis and intervention, on one hand, and by horizontally and vertically integrate the network enhancing in this way cooperation with home care and primary care centres with outpatient and inpatient services.
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.
The introduction of networks of care also implies bringing services closer to patients, by strengthening the capacity of intra-district hospitals to provide services such as oncology, and using specialists from tertiary level facilities in regional hospitals to provide periodic, such as weekly, clinics at smaller hospitals rather than maintaining full time specialists.
E. Hospital modernization also involves the introduction or enhancement of clinical practices in line with international best-practices.
An additional feature of hospital modernization processes is the introduction or reinforcement of clinical practices that are highly cost-effective but have been lagging the regular activity of tertiary care centres. Among others, some of the most common practices that the new model motivated to increase were:
• Increments in the rate of day-case procedures. In Tuscany’s hospitals, for example, the percentage of day- case hospitalizations jumped from 15 per cent in the mid-1990s to more than 50 per cent in 2006. Ambulatory surgeries play a critical role in the achievement of this goal.
• Treatment of Ambulatory Care Sensitive Conditions in primary care and community centres instead of hospital facilities Extensive use of clinical pathways/protocols to guide and standardize clinical practices.
• Hospitals are no longer organized along the lines of clinical specialties or departments just because they have to exist. Now, the organization of the facilities depends on the health needs of the population, and the number of departments is limited so about 95 per cent of hospital admissions can be treated in 10 units or so. This is usually recalled as the designing for flexibility approach in which hospital beds are not labelled (i.e. these are for cardiology, these ones for rheumatology, etc.) but they are now occupied according to the needs of the population. Consequently, hospital buildings are constructed using a more universal standard and not thinking in one particular area.
Conceptually, planning is associated with two different functions: strategic planning and operational planning. Strategic planning involves framework-setting and defining the principles of the health system and its general thrust, and is most frequently undertaken by authorities at the highest level of health-system governance, such as the central ministry of health (England, France, Italy and New Zealand) or the respective regional or local tier in decentralized systems (provincial/ territorial governments and regional health authorities (RHAs) in Canada and federal states in Germany (hospital care only). In contrast, Denmark and Finland have devolved the strategic planning to regional and local authorities. The degree of involvement of lower- level administrations in strategic planning is largely determined by their levels of autonomy and their decision-making powers.
Operational planning refers to the translation of the strategic plan into activities, which might cover the whole range of operations involved in health care provision, including the allocation of budgets and resources, the organization of services and the provision of staff, facilities and equipment. This function is most often carried out by regional authorities but can also involve
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. local authorities, such as the RHAs in Canada, the municipalities in Denmark and Finland and the primary-care trusts in England. In some countries, regional/local planning is directly informed by national health plans, and regional authorities are required to integrate national directives with regional health plans (“vertical integration”). This is generally the case in England, France, Italy and New Zealand, as well as in Canada, where the RHAs have to adopt and implement health plans developed by the provincial or territorial governments.
Table 13. Lead responsibility for capacity planning
Country Lead responsibility for capacity planning
Canada Planning is the responsibility of the provinces/territories, guided in some cases by national frameworks, with participation from local authorities
Denmark Regions and municipalities plan different areas of health care autonomously, with some central supervision
England National and regional planning is directed by the central government with the participation of local authorities
Finland Planning is the responsibility of municipalities and hospital districts (formed by municipalities)
France Regional hospital agencies plan hospital care within a centrally determined framework in consultation with regional stakeholders
Germany Länder (state) governments plan hospital capacity on the basis of national and regional legislation in consultation with regional stakeholders
Italy Regional governments plan health care (mainly hospital care), using a national health plan as a guide
Netherlands Regional provider organizations plan acute hospital care (subject to approval from the central government)
New Zealand Responsibility for planning is shared by the central government and the DHBs
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. 9.4. Planning of hospital capacity
The planning of hospital capacity involves several dimensions: capital investment in existing facilities and new developments; investment in equipment and technology (such as magnetic resonance imaging scanners); service delivery; and allocation of human and financial resources. Given the variety of approaches to health care organization, it is not surprising that the intensity of the planning devoted to each of these aspects varies between countries. Most countries plan the number of hospitals, but the scope and level of detail differ, with some health plans outlining only the number and locations of facilities, generally on the basis of the existing infrastructure. Others take planning much further, determining, in detail, the number and designs of specialty departments and their geographical distribution within a defined area.
Traditionally, bed capacity has been the preferred unit of planning for hospital care, and this remains the case in countries such as Finland, Italy and New Zealand, and in most Canadian provinces/territories and the German Länder. In contrast, England and France have recently departed from this approach, moving towards planning with respect to service volume and activity.
4.6 Developments in health care capacity planning
The experience of health care capacity planning in nine countries illustrates how approaches to planning strongly reflect the institutional, legislative and regulatory framework of a country’s health system, and this, in turn, reflects the wider political, social, economic and cultural context. Consequently, capacity planning is often inadvertently influenced by contextual changes. One example is provided by Denmark, where reform of the administrative system is under way and involves a redistribution of health care responsibilities between the regions and the municipalities. These developments are likely to have a substantial impact on capacity planning in the health care sector, for example with regard to the distribution of specialist services. Capacity planning is also affected by administrative decentralization in the health sector. Thus, regionalization in Italy has transferred major responsibility for planning from the centre to the regions.
Similarly, in France, responsibility for planning and organizing hospital care has been transferred from the central Ministry of Health to the regional authorities. However, the French Government has retained an overall steering role. Conversely, some countries with a strong tradition of decentralization have experienced increased levels of central government involvement in predominantly regional and local matters. Again, Denmark’s example can be seen as representing an attempt to increase the supervisory role of the central government in planning and delivering health care through its subordinate body, the National Board of Health. In Finland, the central government’s influence on local health care decision-making has gradually become more prominent over the past decade via earmarked budgets and the
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. financing of particular projects for implementation by the municipalities. The trend towards increased central involvement in these two countries reflects a heightened awareness of – and a decline in – the (political) acceptability of regional inequalities in health care.
There is also discussion in Finland about whether the role of the existing Social Welfare and Health Care Target and operational Plan should be strengthened with a view to developing a central steering tool. This plan was first introduced in 1999 and is prepared by each newly elected national government for a four-year period. It is developed under the auspices of the Ministry of Health in cooperation with municipalities, nongovernmental organizations and the health care professions. By developing and communicating targets to which all health-system stakeholders contribute, its role has so far been mainly strategic.
Health care reforms as they relate to financing mechanisms and the introduction of new models of health care delivery may also have an impact on planning. Germany, for example, like other countries, introduced diagnosis related groups to fund hospitals; it is expected that this change in financing will have an impact on approaches to hospital planning at the Länder level. In Finland, the introduction of private-provider commissioning in a predominantly public primary-care sector may lead to further developments in planning methodologies.
The health insurance reform that took place in the Netherlands in 2006 is likely to reshape the provider landscape by introducing individual contracts between private health insurers and providers. In this context, an interesting case is represented by New Zealand: following experiments with markets and competition, in 2000 the government introduced health plans and planning frameworks, after having abolished them in the 1990s. These examples illustrate the challenge, for governments, of reconciling the responsibility for providing equitable, affordable and accessible health care with policies such as decentralization, competition and provider pluralism, which are intended to encourage responsiveness and enhance efficiency. The diversity of approaches to planning (or, in some sectors or countries, not planning) reflects the difficulty of balancing local, regional and central decision-making on the one hand with provider competition and regulation on the other.
10. Previous master plan and evaluation
Recently Moldova has established as a priority within the framework of the Programme of activities for 2011-2014 – “Restructuring of the public hospitals network based on the principles of economic efficiency and provision of secure and qualitative healthcare services, in conformity with the General National Hospital Plan”. This activity corresponded to the best practices in organization of hospital medical assistance, and in conformity with it, the hospitals and hoped to ensure the following objectives: i) Adequate access (geographic, financial) to services; ii) High quality of provided services; iii) Effective collaboration and coordination between all levels of hospital medical assistance, as well as with other medical services (primary medical assistance
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. and emergency medical assistance); iv) Enhancement of the efficient use of resources (financial, institutional, human); and v) Satisfaction of patients and community participation. The National Master Plan for hospitals was prepared by TOP Konsult with the World Bank project support and outlines a proposal to organize the hospital network into 9 regional networks. These regional networks were designed to include 1st level and 2nd level facilities with further referral to tertiary facilities / national Centres of Excellence for highly specialized medicine. With this proposal, the Ministry of Health then intended to accelerate the implementation of hospital sector reform for which the decision was made to initiate the process within the northern region of the country. Relevant stakeholders and authorities were engaged in consultation to agree on the selected Rayons for current situational analysis as previously described. The intent has been to provide support to the Ministry of Health to develop the mechanisms to operationalize the health system reforms and to provide a clear implementation strategy for the regionalization of care initially outlined in the Master Plan and build upon this plan to better suit the needs of the selected population.
10.1. Building upon the existing Master plan The existing Master Plan has laid out the path needed in modifying the was hospitals and health care systems currently operating in Moldova but importantly notes that a detailed roadmap is still needed in order to carry out these changes. By utilizing the Hospital Master plan as a starting point, the regionalization strategy will address the complexities that have arisen alongside the task of reconfiguring the health care network.
Securing access in accordance with population needs and opportune access times while at the same time eliminate losses in the hospitals by improve efficiency and quality in operations are key examples of how previous master plans and the current regionalization strategy have synergized visions. The regionalization process hopes to build on key aspects needed to ensure adequate and efficient health care delivery and build on the existing master plan to ensure a continuous transition.
Key point on which the regionalization strategy has built upon utilizing the previous Hospital Master plan are the following:
To centralize or retain central provision in the capital city or, if appropriate, regional centres where it is necessary to ensure a critical mass of services for reasons of quality, safety, workforce constraints or economies of scale. Examples include cancer surgery, vascular surgery, cardiac surgery, the treatment of rare metabolic diseases. In the medium term retaining some services such as complex joint replacement, angioplasty, major paediatric surgery etc. . . . In this aspect it is agreed upon that chronic disease management and high caseload interventions area were urgent configuration in most urgent. As mentioned later in this report, identifying
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. strategic locations to ensure mobilization of resources to better address population needs is essential.
The Master plan and the current regionalization strategy both agree that by increasing the size of the population served by smaller general hospitals to create regional hospitals would ensure high quality and cost-effective care. Decentralizing specific services where this is appropriate and affordable taking into consideration projected populations and disease burdens. Both plans aim to strengthen the supporting infrastructure and services by investing to create modern facilities capable of delivering up to date health care.
The World Bank calculated that in 2000, the 17 tertiary level hospitals and 40 district hospitals consumed over 70% of total health spending (World Bank 2000). Of this, most was estimated to have been spent on the physical infrastructure of the hospital buildings rather than on medical equipment and pharmaceuticals, treatment or staff salaries (World Bank 2000). By reconfiguring the orientation of the health care system towards primary and community care and reducing the overall share of hospitals in the health budget would improve the quality and efficiency of hospital services across rayons. Based on this principal and describing into detail the process of well-defined acute, long term community and day hospitals would have a profound impact on how health care is delivered at each different level.
In order to improve the efficiency of hospital services it is essential to break away from the historical hospitalization models and push to shorten lengths of stay, increased day case work and other more efficient practices. Geographically speaking, region 1 of the existing Master Plan includes grouping of Briceni, Edineţ, Ocniţa and Donduşeni, similar to one of our proposed Regionalization plans will be discussed under regionalization options later on in this report.
10.2. Areas for improvement The current master plan proposed the notion to develop larger centres located in Cahul and Balti of some specialties currently only provided in Chisinau however the size and scope of facilities at each level including regional offices has yet to be concretely defined. The Master plan has yet to lay out the specifics on what specialties would be offered and how the actual patient referral and patient flow will occur in relation to community hospitals and the newly reconfigured rayon health centres. This goes for its relationship with specialist monoprofile hospitals in the capital as well.
It fails to mention how the process of actual resource mobilization will occur. Upon our first phase of the situational analysis carried out in the north hospital directors and other relevant stakeholder agreed upon the fact that the concept of regionalization is one that must move forward but highlighted several implementation issues that might arise during the process. One of these issues was resource mobilization, especially in the area of workforce mobilization. These aspects as well as retention strategies must no longer be left on the backburner and
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. fortunately in light of recent expert consultations will continue to be a key issue in any effort of health system reconfiguration.
As patterns of care, such as non-acute and community centres transition into the new system over the next couple of years, existing health centres will need to loosen constraints on patient care centralization and move towards integrated care at the local level. The importance of efficient referral systems will be key in determining what patients are suitable for primary care management and who actually needs acute treatment. During field assessment of the region numerous cases were conditions easily treated in the ambulatory setting were not only admitted but remained in the hospital for an unnecessary amount of time. This observation is not new but on the contrary exceedingly characteristic of FSU countries seen before. Many have suggested that this form of care is a product of the inherited ex-soviet system characterized by a collection of unnecessary hospitalizations and overwhelming ALOS. Therefore efficient triage as well as discharge mechanisms are of the utmost essence when redesigning and efficient restructuring strategy.
10.3. Management issues The Master plan proposes, (similar to the most successful health care systems in the world), to move away from the classic acute care delivery model towards more recent trends such as rehabilitation, palliative care, long-term and chronic disease management support. To better illustrate the managerial and governing issues this transition will bring about a real case scenario encountered during the situational analysis in one of the northern pilot regions is presented.
When assessing the current levels of infrastructure in the northern region one of many an on- site visits of an existing surgical unit at one of the rayon hospitals was conducted. Similar to what had seen in other units the anaesthesia machines appeared to be somewhat archaic dating back to the 1980’s. But much to our surprise a state of the art, unused anaesthesia machine stood in one of the hall corners with the sole purpose of collecting dust. Upon interrogation, the local personal informed us that the machine had been donated a year ago by the French government. Unfortunately, the local staff had not been capacitated to use the device and were therefore still using the out of date machine.
Let us imagine that a new health care delivery strategies such as shifting to long term care and community hospitals are the new anaesthesia machine. Much like the new piece of equipment, these restructuring ideas come from the west/north where they were developed. If not accompanied by the proper training and capacitation of the personnel and staff that will use them and who ultimately will affect, they will not bring maximum benefit. This applies especially to the managerial staff of the hospital. Without the proper understanding of why and how these strategies must be carried out there is less chance of success.
The same principal applies to the proposed effort to partly decentralize oncological care such as chemotherapy and in the future radiotherapy. These effort are a worthy example of where
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. improved efficiency and reduced costs are also likely to create major benefits for patients. The same education and training issues that will apply to managerial staff as well as other decentralized services will need to be discussed. This capacitation must also ensure that the regional hospitals are able to deal with the emergency management of patients with complications resulting from decentralized care. But it must be emphasise that managing staff must be capable of conveying the changes needed to occur now and in the future. They must be able to effectively address the technical mechanisms needed to be changes in their own arena. When assessing the current healthcare workforce several specialists that are recognized by the MoH as professionals with health care management qualifications exist within the northern region. These individuals could be the needed vessels to ensure high quality leadership within the transition.
10.4. Planning ahead The current master plan also seems to focus heavily on the future of the hospital system on figures such as hospital distance, hospitalization rates and performance indicators yet it lacks adequate population projections with possible migratory trends. Looking at current birth, mortality and migration rates in Moldova we will see that with some exceptions Moldova falls within the average of European limits of population projections. With this data it is possible to estimate the future demographical situation for the northern region of the country. Unfortunately, also similar to European trends are the implications that these demographic shifts will have on the disease profile within the region. Such is the case with chronic conditions such as cardiovascular disease and metabolic and oncological pathologies- something that has yet to be covered into detail by the current Master plan. In the near future there will be much needed support for chronic disease management integration into current health service delivery and the shift to ambulatory care. Countries have begun to realize this in the last decade and champion health systems such as Australia have now begun to prepare for a shift towards an aging population and implicitly, chronic disease management.
As communicable disease push their way to the top as leading causes of death in every single country around the world diagnostic and treatment options evolve as well. The increase for demand implies a change in treatment options as NCD are put on the research agenda and private companies strive to become leaders in the market. As with any other specialty, up to date treatment and technology are ever-changing entities that must evolve with time. The Regionalization Plan will strive to integrate a sufficiently flexible system that will allow for the integration of new technologies and advancements to me introduced together with the change in the way health care is delivered at the regional level.
10.5. Grassroots planning Health system planning many times is directed at high level restructuring within the health care system and the Master Plan is not the exception. A top to bottom situational analysis with recommended interventions was carried out ignoring the practicalities of implementation and the need to put into place a dynamic system that in constantly being updated based on
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. population needs and international standards. There is no doubt that the top to bottom planning approach carried out is pointed into the right direction but without the integration of actual providers at the grass roots level, one is sure to encounter a less than smooth implementation phase. The aim is to achieve integrated and participatory development at the disaggregated level.
Sanigest Internacional has defined three steps for streamlining the process of Regionalization planning at the rayon and regional level which it used to carry out the situational analysis phase of the regionalization process. These steps include decentralized assessments, planning, consolidation and integration. Throughout previous experience it has been found that a high degree of participation and coordination is the best way to carry out the process of developing these decentralized rayon assessments. The first process of ‘decentralized assessment’ involves determining the main priorities and identifying ways to ensure the participatory process involving all stakeholders at the rayon level For this reason hospital staff and directors at the different care centres in the Northern region were consulted. Within the Regionalization planning framework the infrastructure and resources, population needs, and future population projection implications for the regionalization, was assessed for the next 10 years.
10.6. Global direction Special attention should be made regarding the notable lack of integrating social determinants of health into the existing Master Plan. Moldova, as one of the poorest countries in Europe must ensure that a health in all policies approach is taken in order to better address population needs within the health system. The complexities of the shifting global dynamics in demographics, epidemiology, and socioeconomic factors, one persistent trend spans the transitions: inequalities continue to grow through widening gaps in the distribution of key social determinants of health (e.g., food security and working conditions, income levels). Moldova is not the exception and additional concern regarding the distribution of the welfare outcomes of growth and remittances is the inequality of household incomes, which remained unchanged in recent years, roughly at a Gina coefficient of 0.3 as reported by the UN .One key example of the effects on social determinants and health within the country is the relationship between multiple risk factors such as nutrition and cardiovascular disease. The extent to which the quality of food intake is affected by socioeconomic variables is confirmed by evidence coming not only from low /middle income countries similar to Moldova but from across multiple European countries as well.
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.
11.Redefining levels of care
For the reconfiguration of the network for Regionalization, the following levels of healthcare are considered.
Secondary care institutions are split into two packages of services. Please note levels of care do not define types of hospitals, but are rather considered as packages of services, which the Ministry is obliged to contract in a particular region.
> 1 million Population highly specialized (e.g. Transplants, genetics)
150,000 to 600,000 pop, includes TB, Psychiatry, Long Term (rehab)
100,000 to 1,000,000 pop, includes Multi-profile Regional, Children’s and Oncology
50,000 - 100,000 covering all basic specialties + advanced specialties such as cardiology, neurology, endocrinology
20,000 - 50,000 covering basic 4 specialties (internal medicine, surgery, ob-gyn, paediatrics + clinics for specialties
11.1. Proposed Hospital Levels
We propose to define the following categories of hospitals:
§ Level 1: District § Level 2: Inter-District § Level 3: Regional § Level 4: Long-Term § Level 5: National Centres of Excellence/mono-profile
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A different reorganization of the hospital categories would include the following:
1. District hospitals in charge of delivering acute care for 4 core specialties (general medicine, surgery, pediatrics and obstetrics-gynecology) plus clinics, or periodic visits from secondary level hospitals for specialties such as cardiology, endocrinology, dermatology and other as needed for a catchment area of between 20,000 and 50,000 inhabitants. For those rayons with fewer than 20,000 people, only non-acute care would be provided including up to 50 beds with the support of general practitioners, internal medicine specialists and potentially support from obstetricians and paediatricians from a district hospital on a part time basis.
No surgeries or births, except those that can be provided by the GP, would be provided. Roughly half of the beds would be used as day beds for general convalescence of patients in need of non-acute care. Patients requiring long-term observation could be transferred to either an intra-district hospital or to the nearest district hospital.
2. Intra-district hospitals are acute, multi-profile hospitals that provide people with secondary and tertiary health care although the scope of acute and chronic illnesses may be limited. This second level of care would group care for 50,000 to 100,000 persons.
3. Regional Hospitals are facilities at the rayont level specialized in covering tertiary level specialties. In general, there would be 1 tertiary hospital in Edineţ to cover the needs of the 6 northern rayons within the pilot region.
4. Long term care refer to those centres specialized in non-acute care. This includes: TB hospitals, Psychiatric facilities, Long-term Rehabilitation and Substance Abuse Rehab (narcology).
5. National Centres of Excellence The high levels of population required to sustain comprehensive and clinically viable tertiary services requires that they should be planned on a national basis § In general terms, tertiary hospitals providing a wide range of specialised services should be linked to regional hospitals and interdistric centre as well as all forms of care. § Adequate communication and transfer mechanisms should be followed in order to ensure a smooth transition from acute to long term care.
Table 14 A list of specialties that should be included at each proposed level of care. 1. SPECIALTIES
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Rayon Inter-district (Edineţ) Regional (Balti) Republican / CE Level 1 level 2 level 3 level 4 Medical Specialities General Medicine x x Accident and Emergency x Anaesthetics (including Intensive Care) x x x Cardiology x x x Child and Adolescent Psychiatry x x Dermatology x x Endocrinology and Diabetes Mellitus x x x Gastroenterology x x x Geriatric Medicine x Infectious Diseases x x Medical Oncology x Neurology x x x Nuclear Medicine x x Renal Medicine x x x Rheumatology x x Paediatric Paediatrics x x Neonatology x x x Paediatric Surgery x x Obstetrics and Gynaecology Obstetrics (maternity) x x x Gynecology x x x Surgical Specialties General Surgery x x Trauma and Orthopaedic Surgery x x x Cardiothoracic Surgery x x Neurosurgery x x Ophthalmology x x x Oral and Maxillo-Facial Surgery x x ENT x x x Plastic Surgery x x Urology x x x Long-term care TB x Narcology x x Others x x x Mental Illness and Disabilities General Psychiatry x x x Forensic Psychiatry x x x Psychotherapy x x x Old Age Psychiatry x x Learning Disabilities x x x
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. Rayon Inter-district (Edineţ) Regional (Balti) Republican / CE Level 1 level 2 level 3 level 4 Pathology and Radiology Chemical Pathology x x x Clinical Genetics x Clinical Neurophysiology x x Clinical Pharmacology and Therapeutics x x x Clinical Radiology x x x x Haematology x x Histopathology x x x Immunology x x x Medical Microbiology & Virology x x x Overall
9.1.1 Primary care
Similar to the proposed organization of primary care in the current system, primary health care acts as primary gatekeeper to the health care system. It should consist of the following services: § Immunisation § Dentistry § Mental Health Care (basic well-being services e.g. mild depression) § Ante and Post-natal care § Occupational Medicine § Community hospital § Health Promotion § Minor surgical procedures (e.g. wart removals) § Preventative Medicine § Counselling Services § Physiotherapy § Speech Therapy § Gynaecology § Family Planning § Simple Diagnostic Services - Radiology § Pathology § ECG § Ultrasound
If we were to adhere to the current system to the highest possible extent, these services would be provided by the following specialties: § GP pediatrics § GP adults § Family medicine § Stomatology § Psychiatry § Physical Rehabilitation
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. § Gynecology § Basic diagnostic and laboratory services
The trend is to provide the majority of these services by a multispecialty community health care centre providing a range of primary health care services, instead of a single physician provider. Range of services provided should be upgraded.
9.1.2 Community hospitals
Community hospitals can become more effective in delivery population based health care especially when it comes to chronic disease management and complex comorbidities in the aging population. These types of hospitals are put in place to support patient’s transition through the health care system. They provide a collection of community services, preventive care, make most effective use of inpatient and ambulatory services offered local. Services delivered at community hospitals including rehabilitation and specialist mental illness and palliative care service. By effectively providing these services to the northern population, these facilities can help to prevent emergency admissions to acute hospitals and will play a significant role in supporting the reduction of ALOS and unnecessary hospitalizations.
In recent years, community hospitals in several countries have integrated social care practitioners and other staff to facilitate a more holistic approach for patients and service users. Similar to what is being proposed for long term centres, community hospitals must allow for constant updating and adaptation of population needs. It is this flexibility and person centred approach to care that will enable community hospitals to provide the best possible care for the region.
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· Orientation to elderly Multi- disciplic care ary care · Medical efficiency · Social interaction Rehabilit encouraged ation · Help patients improve and health status · Relatives involved in indepen care dence · High standard of care encoura · Lack of stimulation · Homely setting: quite ged · Calm ambience Holistic, patien- centred care
How do community hospitals actually work? These facilities are usually led by local GPs who provide the clinical leadership and the focus of the services that the community hospital offers. Usually service is delivered by medical teams that integrate several aspects of care needed at the facility. The medical teamwork is underpinned by nurses, allied health professionals and social work teams who deliver the majority of the care and support to patients. Ensuring that these professionals are supported in these roles and have time to work together will ensure the continuity of care and support that community hospitals need to deliver.
What services are provided by Community hospitals? At the risk of oversimplifying the role that community hospitals carry out, let us say that these facilities have three main functions:
o first, they support the rehabilitation and recovery of patients whom transition from an acute hospital; o second, they provide the specialist end of community services, whether this be coordinating care around high risk patients, providing services that patients have traditionally had to travel to Chisinau for and beds for clinical specialties (such as palliative care and mental health); o third, they provide a basic level of diagnostic and outpatient services.
The majority of community hospitals and the clinical services they provide will see patients in most of these categories.
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9.1.3 Secondary care Secondary care consists of two levels of services. The regional hospital in Edineţ, which would, would include:
Internal Medicine o range of interventions including the care and treatment of chronic diseases, including serious infections requiring surgical intervention, o care and treatment of acute gastrointestinal disorders and infectious diseases. o isolation wards for highly infectious diseases such as measles o management of sexually transmitted diseases including AIDS o services of medical specialties of general internal medicine, pulmonology, cardiology, gastroenterology, diabetology, dermatology & venereal diseases, endocrinology, oncology, communicable diseases, angiology and phlebology, rheumatology, o Neurology and stroke care Cardiovascular care o Neurology and stroke care coronary intervention o heart surgery o arrhythmia treatment o diagnostic cardio-imaging o basic science research into understanding heart disease and genetics research into causes and cures o a '24/7' heart attack care o invasive treatments such as transcutaneous aortic valves and drug eluting stents Surgery o range of procedures including incision, management of trauma and a variety of abdominal procedures including hernia repair. o surgical interventions requiring specialist aftercare e.g. thyroidectomy o trauma and orthopaedic surgery o surgical and orthopaedics high risk cases that do not need ICU or specialized post-surgical observation or after care o ENT (allergology, audiology, logopedie, and oto-rhinolaryngology) o Ophthalmology o Urology Paediatrics o basic and complex neonatal care o care and treatment of acute diarrhoea and other infectious diseases
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. (cases of specific infectious diseases) Obstetrics o antenatal care o pathology of pregnancy o complicated deliveries o non-high risk pregnancy control and delivery or C-section including foetal or mother life threat Gynaecology o range of interventions including evacuation of uterus for spontaneous, incomplete or medically-indicated abortion, investigative and therapeutic laparoscopy and hysterectomy for various conditions o septic abortions including mother life threat o basic surgical interventions Paramedical care o physiotherapy aftercare o dietetics/nutrition advice o occupational therapy o speech therapy in complex cases o psychology Acute psychiatry beds Inpatient Rehabilitation Beds Accident and emergency services o 24/7 medical cover o facilities for safely receiving and stabilizing emergency cases prior to in-patient admission Basic diagnostic services o Radiology including non-complex X-ray investigations o Ultrasound o Pathology: all routine and complex services in Haematology, Histo-pathology, Biochemistry and Chemical Pathology Pharmacy services including dispensing and preparation of IV fluids Counselling services and social support Stomatology
The range of secondary health care services in a rayon hospital providing services in options that include services: Medicine - range of interventions including the care and treatment of complex diseases, including serious infections not requiring surgical intervention, - care and treatment of acute gastrointestinal disorders and infectious diseases.
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. - isolation wards for highly infectious diseases such as TB and measles - management of sexually transmitted diseases excluding AIDS Surgery - range of basic procedures including incision, management of trauma and a variety of abdominal procedures including hernia repair. Paediatrics - basic neonatal care - care and treatment of acute diarrhoea and other infectious diseases - low complexity for diagnosis and treatment Obstetrics - antenatal care - pathology of pregnancy - routine deliveries - low, medium and high risk pregnancy control and delivery or C-section without foetal or mother threat Gynaecology - range of interventions including evacuation of uterus for spontaneous, incomplete or medically-indicated abortion, investigative and therapeutic laparoscopy and hysterectomy for various conditions Accident and emergency services -24/7 medical cover in some cases depending on geographic conditions. facilities for safely receiving and stabilizing emergency cases prior to inpatient admission
Basic diagnostic services Radiology including non-complex X-ray investigations Ultrasound Pathology: all routine services in Haematology, Histo-pathology, Biochemistry and Chemical Pathology Pharmacy services including dispensing and preparation of IV fluids Counselling services and social support Other services can be provided on the outpatient basis
9.1.4 Tertiary care
Tertiary includes all secondary services plus expanded specialist care: Internal Medicine § Allergology § Endocrinology § Neurology § Nephrology § Oncology § Dermatology
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. § Sexually Transmitted Diseases § Physical Medicine and Rehabilitation § Rheumatology § Cardiology § Gastroenterology § Gerontology § Infectious Diseases § Accident and Emergency § Long Term Care § Social Care § Intensive Care § Coronary Care § High Dependency Care § General Surgery § Thoracic/Cardio Vascular Surgery § Urology § Orthopaedic Surgery and Trauma (incl. hand surgery) § Plastic Surgery and Burns § Neurosurgery § Ophthalmology § ENT/Otorhinolaryngology § Gynaecology as a separate surgical specialty § Neonatology § Paediatric Oncology § Pathology § Radiology § Nuclear Medicine § Radiotherapy § Anaesthetics § Admissions § Psychiatry § Addiction treatment
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. Tertiary care includes central / teaching hospitals and specialized monoprofile national institutes.
The following is a suggested list of services which are considered to be of such a specialized nature that they should be provided at Tertiary level, together with some advice on Indicative Planning Populations (IPP).
Suggested list of Tertiary Services
1. Specialized Cancer services (adult) - IPP 2 million -stereotactic radiosurgery -brachytherapy -thoracic surgery for treatment of cancer -radionuclide therapy -photodynamic therapy -radiotherapy -familial genetics -specialized palliative services - rare cancers such as central nervous system, endocrine, mesothelioma, head and neck, pituitary tumors and teenage and young adult cancers -IPP 4 million
2. Specialized services for blood and marrow transplantation – IPP 7 million
3. Specialized services for hemophilia and other related bleeding disorders – IPP 4 million
4. Specialized services for Women’s’ Health IPP 1-2 million -specialized fetal medicine, including prenatal diagnosis and fetal therapy -specialized maternal medicine, -complex minimal access Gynecological surgery -tertiary infertility services 5. The assessment and provision of equipment for people with complex physical disability – IPP 2 million
6. Specialized spinal services – IPP 4 million
7. Complex specialized rehabilitation for brain injury – IPP 4 million
8. Specialized neurosciences (adult), including neurosurgery, neurology (excluding stroke), neurorehabilitation and neuropathology –IPP 3-4 million
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9. Specialized burns services – IPP 3 million
10. Renal services – IPP 1-2 million
11. Specialized cardiology and cardiac surgery, including transplantation –IPP 1-2 million
12. HIV/AIDS treatment and care – IPP 1 million
13. Cleft lip and palate services – IPP 4 million
14. Specialized immunology – IPP 7 million
15. Specialized allergy – IPP 2 million
16. Specialized services for infectious diseases – IPP 1 million
17. Specialized services for hepatology, hepatobiliary and pancreatic surgery – IPP 4-6 million
18. Medical genetics – IPP 4 million
19. Specialized learning disability services – IPP 2 million
20. Specialized mental health, including forensic services, specialist addiction services and neuropsychiatry – IPP 2 million
21. Specialized services for children including neonatal and pediatric intensive care, specialized child and adolescent mental health services, cardiology and cardiothoracic surgery, nephrology and oncology – IPP 4 million
22. Specialized Dermatology – IPP 2 million
23. Specialized Pathology – IPP 7 million
24. Specialized rheumatology, endocrinology, respiratory, vascular, colorectal and orthopedic services – IPP 2 million
Below, included the percentage of cases to be managed at each level being proposed.
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. Table 15. Percentage of cases to be managed at each level being proposing.
CASES TO BE MANAGED (%)
Rayon Inter-district (Edineţ) Regional (Balti) Republican / CE Level 1 level 2 level 3 level 4 Medical Specialities General Medicine 80.00 20.00 Accident and Emergency 100.00 Anaesthetics (including Intensive Care) Cardiology 60.00 20.00 20 Child and Adolescent Psychiatry 70.00 30 Dermatology 50.00 50 Endocrinology and Diabetes Mellitus 50.00 30.00 20 Gastroenterology 60.00 20.00 20 Geriatric Medicine 100.00 Infectious Diseases 50.00 50.00 Medical Oncology 100.00 Neurology 60.00 20.00 20 Nuclear Medicine 20.00 80 Renal Medicine 60.00 30.00 10 Rheumatology 50.00 50 Paediatric Paediatrics 80.00 20.00 Neonatology 60.00 30.00 10.00 Paediatric Surgery 40.00 60.00 Obstetrics and Gynaecology Obstetrics (maternity) 60.00 30.00 10.00 Gynecology 60.00 30.00 10.00 Surgical Specialties General Surgery 80.00 20.00 Trauma and Orthopaedic Surgery 80.00 10.00 10.00 Cardiothoracic Surgery 70.00 30.00 Neurosurgery 50.00 50.00 Ophthalmology 70.00 30.00 10.00 Oral and Maxillo Facial Surgery 50.00 50.00 ENT 70.00 30.00 10.00 Plastic Surgery 50.00 50.00 Urology 60.00 20.00 20.00 Long-term care TB 100 Narcology 60.00 40.00 Others 80.00 20.00 Mental Illness and Disabilities General Psychiatry 60.00 30.00 10 Forensic Psychiatry 40.00 30.00 30
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. Rayon Inter-district (Edineţ) Regional (Balti) Republican / CE Level 1 level 2 level 3 level 4 Psychotherapy 60.00 30.00 10 Old Age Psychiatry 90 10.00 Learning Disabilities 40.00 30.00 30 Pathology and Radiology Chemical Pathology x x x Clinical Genetics x Clinical Neurophysiology x x Clinical Pharmacology and Therapeutics x x x Clinical Radiology x x x x Haematology x x Histopathology x x x Immunology x x x Medical Microbiology & Virology x x x
11.2. Differentiating between acute and non-acute care
Long-term care will be designated for patient whose chronic illness, physical disability or mental disorder makes it difficult for them to take care of their own basic needs. Treatment is specific to the patient's underling condition and may include rehabilitation. Long-term care can be provided by a nurse or other health-care practitioner, and it might take place in the patient's residence or in a facility or institution. Unlike long-term care for chronic conditions, acute care is required when a patient needs treatment for a brief but severe, medical condition. Such is the case for emergency surgery or accidents and other types of trauma or heart attack or stroke for example. Acute care is typically administered by specialized medical practitioners in a hospital, and it can involve areas such as intensive care and/or emergency medicine. The ultimate goal of acute care is to stabilize the patient's condition to allow for discharge from the hospital, with recovery finishing at home.
By utilizing a well-established system to distinguish both types of care, resources can be used in a more optimal manner instead of the historical model where many patients in need of chronic care were seen at acute care facilities.
11.3. Acute Inpatient Services
For the purposes of this paper, acute inpatient services refers to an acute care facility with a range of services including basic emergency services, general medicine, low risk obstetrics, observational paediatrics, convalescence, palliative, and respite care. This includes diagnostic services (lab/X ray). Generally, northern rayon hospitals provide minimal acute inpatient care.
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. Judged by lengths of stay, diagnoses, level of care and utilization rates, most bed days are for patients of low acuity. In most rayons, utilization rates are variable, and can range from 60 to 90%.
11.4. Ambulatory surgery
The term “ambulatory surgery”, refers to the practice of admitting carefully-selected and prepared patients into the hospital for a planned, non-emergency surgical procedure on the day of surgery and discharging them within hours of that surgery. Some commonly used synonyms to this term are: same-day surgery, day-only surgery or day-surgery (Castoro, 2007). The particularity of these services compared to other outpatient services is that day-surgery patients are those who require full operating theatre facilities. Procedures which were previously performed as inpatient cases are now considered appropriate for ambulatory surgery, while minor outpatient procedures and most day-case endoscopic procedures, which would never have involved admission, are excluded (Castoro, 2007). A day-surgery case is a patient who is admitted for an operation on a planned non-resident basis but nonetheless requires facilities for recovery. The whole procedure should not require an overnight stay in a hospital bed. An impressive growth in ambulatory surgery has been recorded during the last two decades, following the development of short-acting anaesthetics and new surgical techniques. It is now a high-quality, safe and cost-effective approaches to surgical health care, enjoying a high rate of patient satisfaction. In countries such as the United States and Canada, it accounts for nearly 90% of all surgeries performed (Toftgaard and Parmentier 2006). Although it is fast becoming the norm for nearly all elective surgery it remains much less common in many other countries. An understanding of the scope of ambulatory surgery is of critical importance for health policy makers. Expansion can have profound implications for the design of health facilities and the composition of the health care workforce. The expansion also entails a change in mind-set. Often, changes in national policies and regulations will be necessary, such as the removal of incentives that promote unnecessary hospital stays. As previously mentioned in this report unnecessary hospital stays as well as unnecessary hospitalization are two critical areas that need to be corrected within the Moldovan health system. Moving to ambulatory surgery is a critical steps towards addressing these issues. In most developed countries ambulatory surgery is an important factor maximizing the utilisation of limited economic resources whilst still providing the highest level of quality treatment. In developing countries this may be the only possibility for treatment for many patients due to a lack of resources.
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. Major advances in surgical and anaesthetic techniques can enable the vast majority of surgery, perhaps 80% or more, to be carried out on an ambulatory surgery basis (British Association of Day Surgery, 2008). Many organisations still underperform in terms of ambulatory surgery, resulting in an adverse effect on the health economy and a poorer experience for the patient. Continued advancements in minimally invasive surgery enable further progress. The ambulatory surgery route should be the default pathway for surgery with inpatient stay chosen only by exclusion. Best Practices for ambulatory surgery include a planned pathway. It begins in the General Practitioner’s surgery with knowledge of the procedures that can be feasibly carried out on an ambulatory basis, referral to a care provider with an intention of day surgery management, expectation that the provider will accommodate a quality assured care process with booking, the period of admission, and provision of follow up support in the immediate period after home discharge. In order to try to document some of the developments, the International Association for Ambulatory Surgery (IAAS) conducts an international survey of day surgery activities every two years. This project began in the mid 90’s with 20 surgical procedures and has now expanded to 37 procedures (Toftgaard, 2009). The current listed procedures can be seen in Table 1.
Table 16. Day Surgery Procedures listed by the IAAS. 2009 Medical Speciality Procedures ENT Myringotomy with tube insertion Tonsillectomy Rhinoplasty Broncho-mediastinoscopy Eye surgery Cataract Squint Orthopaedics Knee arthroscopy Arthroscopic meniscus operation Removal of bone implants Repair of deformities of the foot Carpal tunnel release Baker cyst Dupuytrens contracture Crusiate ligaments repair Disc operations
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. Medical Speciality Procedures Vascular surgery Varicose veins Jaw surgery Surgical removal of teeth Plastic surgery Bilateral breast reduction Abdominoplasty Gynaecology Endoscopic sterilisation Legal abortion Dilatation and curettage of uterus Hysterectomy by LAVH Repair of cysto- and rectocele General surgery Local excision of breast/Lumpectomy Mastectomy Laparoscopic cholecystectomy Laparoscopic antireflux surgery Haemorrhoidectomy Inguinal hernia repair Colonoscopy with or without biopsy Removal of colon polyps Pilonoidal cyst Urology Circumcision Orchidectomy or orchidopexy Male sterilisation TURP
The latest results regarding percentage of day surgery procedures in the basket in the surveys from the countries included on the 2009 survey of the IAAS can be seen on the following chart:
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. Figure 55. Percentage of day surgery procedures of total surgeries
Data source: OECD 2010 The overall result of the surveys to this point are that US and Canada have the highest percentage of ambulatory surgery, the Scandinavian countries are close to the US, France and Germany are in the middle, and Poland and Portugal are comparably low. There are large differences between countries for the number of surgeries in the same procedures and in total numbers. There are even large differences within the same country (between regions, counties, and hospitals). An example of the discrepancy is the data for inguinal hernia repair, which shows clear differences in surgery numbers although countries are at the same level of development. In general the main advantages that ambulatory surgery provides to health systems can be summarized in the following table. As shown, the advantages may occur at different levels of the health system affecting and benefiting several stakeholders.
Table 17. Ambulatory Surgery Main Advantages Subject Advantage For the patient · High level of satisfaction · Less hospital infections · Convenience · Quality service is as least the same For the hospital · Function is well planned with lesser cancellations · There is a decreasing need for
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. Subject Advantage beds · Very cost effective For the · Cheaper treatment community · Better utilisation of closed emergency/inpatient facilities For the staff · Promotes teamwork, · Daytime work · Higher satisfaction
Another important aspect to take into consideration when analysing possible recommendations for adopting national policies on ambulatory surgery programs are the main problems that delay progress in implementing those programs. The most important or common problems are the following: · Tradition: Health care workers, especially surgeons, can be rather conservative but also hospital managers and even patients can be difficult to convince on the advantages of day surgery. · Culture: People differ in open-mindedness and some procedures can have a religious or traditional “overlay” that makes it unacceptable to do in a short stay procedure. · Incentives system: Reimbursement can be better for inpatient procedures than for ambulatory, the key question is: What are the incentives and disincentives to make the change? · Organisation of the health system: There can be a difference if the system is primarily public or private. There is often more focus on efficiency in the private sector than the public sector. · Geography: Difficulty in getting to and from the facility for treatment can be a major barrier for ambulatory treatment. Long-term care facilities
Long-term care is an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness. The key to effective long-term care is to provide a safe way for the individual to address their physical and psychological distress. In Moldova this form of care is at an incipient stage and there is no systematic approach on this segment as well as much information available. This form of care is a variety of services that includes medical and non-medical care to people who have a chronic illness or disability. Long- term care would help meet health or personal needs of the population for the northern region. Services provided by long term care facilities generally consist of professional nursing care, medical services, social work services and personal care services. The also provide nutritional services designed to provide safe, nutritious quality meals to meet the nutritional, therapeutic
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. and social needs of residents. In terms of pharmacy services activities would include documentation on medication procurement, storage, administration and record keeping. Therapeutic rehabilitative and restorative services would be designed to integrate multiple comorbidity commonly seen within the northern region population such as cardiovascular disease, metabolic disorders and mental illness.
Figure 56. Annual growth rate LTC hospitals
Data Source: WHO Health for All data base
Healthcare systems worldwide are moving from acute hospital towards long term hospital LTC As evidenced here by the average growth rate of LTC in OECD countries, Source: OECD library last accessed 2012
It is recommended that operational standards be set in parallel to the establishment of long- term facilities. These operational standards should acknowledge the unique and complex needs of the population and the additional specific knowledge, skills and facilities needed to deliver a quality service. They should include a mechanism for internal and external reviews and must be
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. implemented in a manner that reflects the requirements and expectations of the Northern region. They should plan to be monitored by the regional health authorities to ensure that facilities operate within established criteria and are committed to continuous quality improvement. It is recognized that as the population ages in Moldova, program and service requirements will change as well. The development of new and revised standards will be necessary to respond to changes in resident needs. The standards should be reviewed and revised if necessary to incorporate new ideas that will support a standard that best meets the care, program and service needs of the population. This process will also be discussed and developed in conjunction with all long-term care stakeholders and it is recommend to occur every two (2) years.
Based on the results of our situational analysis, we recommend that certain specialist services that have been traditionally offered at large acute care facilities be offered at the community level. This includes specialist services such as cardiovascular disease management, mental health, and palliative care for cancer patients. This does not necessarily require a senior cardiologist but could involve specialist nurses or family doctors with training in any of the relevant fields. Basic diagnostic tests and procedures, minor injury services or general clinical services would also be readily available. This ensures that services are delivered as close to patients as possible and in remote and rural areas of the northern region. Undoubtedly this will result in patient’s savings hours of costly transport to and from Chisinau and the stress and other opportunity costs associated with travel.
11.5. Community Hospitals
Scientific evidence has shown that community hospitals provide clinically effective services that improve the outcomes for patients and support the delivery of services closer to home. Research looking at the NHS delivery of care model for community hospitals using a survey conducted regarding the inpatient experience at these facilities showed that the scores for the majority of questions were either on a par with the national average or significantly higher. As with other levels of care within the system, it is vital that community hospitals are as effective as possible at delivering pathways of care and have clear links with the broad range of services provided by the current MoH in Moldova. They must work to synergize efforts with existing players withinth the system in particular, acute hospitals, monoprofile institutions and social care services. Results from international studies indicate that on going care after hospital treatment is of concern to a number of patients that have attended community hospitals and as such, the links with ongoing care such as social services and care homes should be strengthened.
Centralized leaderships in Moldova needs to ensure that strong relationships are built up with other areas in the system, whether this be with secondary care services and clinicians or
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. community based teams and facilities such as rayon hospitals. Community hospitals that work in isolation lessen the impact that they have on the end goal of improving patient outcomes.
Patients that have received treatment at a major acute facility, but have reached a certain level of stability and no longer need to receive specialist acute care, can make the transition to a community hospital to continue their rehabilitation before being discharged. This ensures that patients are treated in the most appropriate setting, with the right level of care, are often closer to home for friends and families to visit and is often a more relaxed atmosphere than a major acute site. Transfer to a community hospital frees up specialist beds in acute hospitals ensuring their more efficient use.
It is critical that community hospital providers comprehend their contribution to the ‘complete health system’ in terms of patient flow. It is important that they strive to identify patients who are ready for and will gain from the services which they provide without delay. This would benefit the patient as it would prevent any delay in providing treatment at the community level while ensuring that resources are freed up and available in a timely manner for those patients requiring the use of an acute setting.
The transition to a community hospital will place the patient back under the care of the local GP and his team and discharge for patients can then be better integrated with local community and social care services, including life style orientation and chronic disease prevention strategies.
Scientific evidence has compared the clinical outcomes for patients who have a period of rehabilitation within a community hospital as opposed to a general hospital. The evidence suggest that patients have improved independence once they return home in cases where their rehabilitation has been conducted within a community hospital as opposed to a general hospital. The use of an intermediate care team like the one previously mentioned aids in strengthening this process.
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12. Suggested options for Network Configuration Vignette 2-Grigore Ciocirla
Grigore Ciocirla, 54, from Briceni, was teaching an electronics course in February, when he felt a sudden tiredness come over him. “In ten years I had never had to stop teaching in the middle of a class,” Grigore says. “I went home and went to bed. When I woke up, I had a stroke.”
Grigore's wife, Larisa, recalls, “I was downstairs watching television, and I heard a noise from upstairs. I found Grigore on the floor. He couldn't move the left side of his body and his speech was barely intelligible.”
Given the severity of his case, Grigore was rushed to Balti hospital were his vital signs were stabilized so he could be referred to Chisinau for further treatment at the national Institute of Neurology. Although doctors were able to stop the progression of damaged tissue, delayed treatment due to the prolonged travel time, resulted in complete hemiplegia of the left side of his body. It would be unlikely that he would ever recover full function but specialized care could potentially restore some movement. Now the only option for Grigore would be full time rehabilitation therapy at a specialized institution in the capital. He would be forced to relocate to Chisinau for the time being in order to receive specialized care and rehabilitation therapy as long term specialized care was not readily available in Briceni. Larisa was extremely supportive and the first two week was at Grigore side constantly but as Grigore’s job was their only source of income, she was forced to travel back to Briceni to find work. Being far from home and away from Laris, Grigore felt unmotivated and apathetic. Doctors saw little improvement in the weeks to come and eventually told him the grim reality that his quality of life would never again be the same. He decided to travel back to his hometown and spend the remainder of his days at home. After regionalization Grifore visits the acute care stroke unit in the Edineţ hospital. From there Grigore's doctor recommended that he go to Briceni for his rehabilitation at the new long term community hospital. Both Grigore and Larisa arrived at the Briceni Rehabilitation Hospital on a Friday and treatment began right away. Grigore's wheelchair was waiting for him in his room, so he immediately had mobility and could get outside for fresh air. They also met with Grigore's doctor on Saturday and began to plan his treatment. When he was first admitted to the Briceni rehab centre, Grigore was confined to lying flat on his bed. He had no control over the left side of his body and could hardly speak. He also lacked
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. any sense of centre or balance and couldn't maintain a sitting position. One of the first goals was to have Grigore sit up straight in a chair. In addition to participating in sessions of a variety of therapies including cognitive, physical, and occupational and speech, Grigore went to a Stroke support group in the afternoons following therapy. “Grigore was always tired after a full day of therapy, as were all the other stroke patients, but the group was a great place for support and education,” Larisa recalls. After discharge from them Briceni Rehabilitation Hospital, Grigore went to outpatient therapy for six months at the outpatient clinic adjacent to the rehab centre. Through the work he did in inpatient and outpatient therapy, as well as the independent exercise program, Grigore progressed from being completely immobile on his bed to being able to get up out of his bed and walk independently. “The rehab centre gave me my life back,” Grigore says. He is now back at home with his wife and continues to teach at the local high school. By having facilities located closer to the population, immediate and opportune treatment will be available for urgent cases such as stroke and acute cardiovascular. By receiving early treatment patients such as Grigore will be able to avoid complications resulting from long treatment times. Rehabilitation and palliative care is also a key component to any health system. Our regionalization proposal aims at incorporating rehabilitation and long term care into the existing network to address population needs. Four suggested options for regionalization in the northern region are provided based on the analysis of the current situation. These recommendations build on the existing Master Plan and provide detailed aspects of the regionalization strategy for the northern region. The general principals and changes that all four suggested options share are described and subsequently each option is discussed into further detail.
12.1. General Principals The regionalization strategy is established on a basic principle that the services need to be built around the needs of the people, not institutions, and that the services e proposed should be sustainable within the existing financial framework. Along these lines, the proposed regionalization strategy proposes to structure the network around the population’s needs and access to services, rather than placing Hospital Network Restructuring in the North according to political or administrative suitability. This will make the network more consistent with the principles of the regionalization which aims to allow the patient greater access to care and suitable facilities where they are most needed.
A core component of the Regionalization strategy is to apply population-based planning parameters to estimate the network coverage required by specialty including setting standards per 100,000 population, to determine the level of infrastructure required to ensure that the hospital network is patient-centred and that the network is built around the patient's needs.
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. The regionalization methodology accounts for demographic change by using population projections by age and sex through 2025. This accounts for the corresponding changes in hospital demand that will occur as a result of the population aging and the epidemiological changes.
The proposed Master Plan builds on the need to strengthen chronic disease care while ensuring adequate long term care through the reconfiguration on the existing network. The proposed planning guidelines for beds by specialty are emphasis on the distribution by macro-specialty, to allow for more rationalization of beds within individual specialties. High priority must be given to existing deficits in the current system such as stroke care and cardiovascular disease in general. It is important that this increase access to cardiovascular care should be in line with the MOH strategy for Cardiovascular Care. The future pattern of some specialist services that are currently centralized but which could be devolved or developed in Edineţ or Balti are also addressed. Being prepared to deal with how these may change over time is also important.
A key component of the restructuring process rests in the changes in chronic disease care and long-term facilities. In this regard, several shifts are emphasized in the development of the regionalization strategy:
Figure 57. Global tendency to reduce number of acute hospitals over the years.
Data Source: OECD library last accessed 2012 Changes in the approach taken to areas of medicine where there are opportunities to modernize the approach. For example, the integration a multiple disease management approach where treatment and prevention strategies are synergized among specialties.
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. The re-design of the hospital network should ensure, were appropriate, the renewal of the aging hospital infrastructure, aiming to achieve global standards in care. Through our situational analysis it has been observed that the physical state of current infrastructure is unacceptable and much of the equipment is out of date. In some cases this can increase the operational cost of hospitals as well as providing suboptimal care for patients and poor working environments for staff.
A core component of the restructuring should be the amalgamation of laboratory and ancillary services to allow for greater economy of scale and quality control in laboratory and support services. These services include the modernizing and restructuring diagnostic imaging. This includes: introducing digital machines or digitization of film to allow for electronic transmission of data and the centralized reading of imaging results and outsourcing of imaging interpretation. Continuing the use of out of date imaging techniques have been observed in the northern region not only proves inefficient quality of care but also poses significant health risks to operators and patients.
The introduction of modern hospital practices to reduce unnecessary hospitalizations including:
Increase ambulatory surgery to at least 40 percentages of total surgeries.
· Development of new modalities of long-term care to assist with the shift from maintaining non-acute patients in acute hospitals.
· Improved case management of chronic diseases in a continuum of care to reduce unnecessary hospitalization.
· Development of the long-term care network including assisted and no assisted living components.
The purchasing strategy should be closely influenced by the development of the regionalization strategy to ensure that the contracting and payment mechanisms are consistent with the goal of reducing hospitalization.
Efforts in accreditation and licensing should consider the implementation of rationalization efforts and support the trend to reduced hospitalization, modern facilities and European planning standards.
The existence of a modern information system is critical for the adequate functioning of the system as a whole. Changing the structure of the IT system goes beyond the modernization of the hardware and software but includes the use of an appropriate monitoring and evaluation system, a trained staff in such practices and changes in certain management and hospital practices like disease coding.
A strong involvement of the key clinical and political stakeholders is required in order to ensure a smooth and efficient transition. In order to increase effectiveness, regional hospitals will need
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. to be establish a highly capable triage system in order to efficiently mobilize patients to either inpatient or outpatient services in order to avoid unnecessary hospitalization. Well established discharge criteria should also be sent in place in order to mobilize patients to either home care with appropriate support or to the proposed community care and long term centres that will be able to provide follow up care rehabilitation/palliative treatment. Rethinking the role of primary care and ambulatory care and how this can reduce the demand for hospital admission and improve the health status of the population. Solid legislative reforms that support this type of network management will be crucial.
Specialty services
For the purposes of this paper, core specialty services in tertiary care include general surgery, anaesthesia, psychiatry, internal medicine, obstetrics & gynaecology, and paediatrics. Depending on the catchment population and location, specialty services outside major referral centres may include other specialties such as orthopaedics, urology, ophthalmology, and otolaryngology. In determining the sustainability of specialty services, the critical mass factor is important. The need for 24-hour coverage in each specialty is considered. The capacity of communities to support specialist physician services can be calculated based on the physician standards, by specialty. For a hospital to provide specialty services at a sustainable level, it must support a group of specialists that can maintain a reasonable on-call schedule and a degree of sub-specialization. Some modification may be needed where specialties mutually support one another, such as trauma services, and where, in smaller communities, general and specialty practices co-exist. For specialties where the requirement is for 24/7 coverage, this will usually mean a range of three to five physicians, depending on the frequency of call-out and other factors.
For specialties where 24/7 coverage is not required, a smaller group size is reasonable. For a primary specialty such as surgery, it is desirable to have a range of three to five surgeons in the community so that emergency surgical coverage is available at all times. For some specialties like obstetrics, 1 or 2 obstetricians could be sufficient, as the primary call for maternity rests with general practitioners.
For reconfiguration a main focus is suggested for internal medicine, surgery and obstetrics. Each scenario has provided different options regarding the availability of each specialty. Sub- specialty services at the rayon level are not desirable in most circumstances both due to the episodic nature of the service provided and the lack of peer consultation. Moving sub- specialties to Edineţ and when relevant to Balti or Chisinau.
In the proposed scenario were rayon hospitals maintain capacity and have practitioners with enhanced training in surgery, anaesthesia, obstetrics (caesarean sections), etc., a level of service may be available that could not be sustainable provided solely by specialists. In these
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. instances, at the rayon level, low risk obstetrics would continue to be performed by obstetrician and GP obstetricians.
In option 1 and Drochia in option 2 will provide, in addition to general practice, 24 hour coverage in the following specialties - internal medicine, general surgery, anaesthesia, paediatrics and two to three obstetricians. These acute inpatient facilities offering specialist services but not subspecialist services will need to give the same priority to patient transfers from rural and remote areas as their local population. Option 4 shifts from acute and inpatient surgical cases to ambulatory surgery.
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13. Options for Reconfiguration of Network of Briceni, Donduşeni, Drochia, Edineţ, Ocniţa and Riscani Vignette -Elena Melniciuk
Elena works at a local bakery in Briceni were she is know arround town as the local queen of pastries, famous for her calorie overflow of an apple pie. She lives there with her husban Tudor and her only daugher Liudmila who is six who just started school. One evening before going to bed, Elena did a self-examinationand and found a lump in her right breast. She got out of bed and went to the bathroom to have a look. She quickly decided it looked a bit odd and this was a Sunday night, so she thought on Monday she would pay the doctor a visit.
Elena drove from her hometown Tabani to the rayon hospital in Briceni were she met with the general practitioner. He then refered her to the National Oncology institute in the capital. After asking for time off from work, her husban Tudor drove her to the capitol were she was sheduled for testing. The following day after arriving in Chisinau Elena had a mammogram and returned to the hospital three days after for her results. The test came back as likley for fibrous tissue. The oncology specialist recommended further testing as he explained, imagery is not always 100 percent acurate . After discussing all possible options with the specialist she was admitted for a scheduled biopsy. A day after the biopsy she was told she had breast cancer. Unfortunately the cancer has spread to her lymph nodes and a radical mastectomy was in order. She then spent 20 days in the hospital and was scheduled to return the following week to Chisinau for a 6 dose regimen of chemotherapy to better increase her chances for survival.
The first three weeks of chemotherapy at the Institute were very difficult on Elena. Elena felt many things when she was told she had breast cancer, but more than anything, she felt alone. Radical mastectomy is psychologically one of the most difficult surgical procedures a woman can endure and far away from friends and family, including her daughter; this was proving to be the most challenging trial Elena had ever been faced with. As if this were not enough to bare, she was informed later on that week that the bakery had found someone to replace her and was now out of a job.
After regionalization Elena drives from he hometown Tabani to the rayon hospital in Briceni were she meets with the general practitioner. He referes her to Balti were she meets with a specialist who oversees her chemotherapy regimen. The first three weeks of chemotherapy were very difficult for Elena but thanks to the loving support of her older sisters and friends who were close by, she was able to successfully complete her treatment. She remarks that
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. having her daughter by her side really motivated her to push through and fight to see another day.
13.1. Key Assumptions Based on the current findings from the situational analysis the following key assumptions have been made. Discharge levels will increase for surgery by about 50% and ambulatory surgery increases will increase to 20% of total. This translates to a total of 1.5 days ALOS. A proposed day care facility would mean that day beds would increase to treat 20% of medical specialty discharges. Founded on the current scenario in the northern region and on international standards it is assumed that ALOS is six days for surgical specialties and eight days for medical. It has also assumed that one day for day care and 15 days for rehab/non-acute cases. Using data from the six rayons it is assumed that occupancy rate is estimated at 85%.
Population growth models used for the projected number of resources needed in our model are based on migration, growth and mortality rates on a national level given the lack of migration data for each rayon. Occupancy rates assumed that demand for services will continue to follow current trends for the next decade. In terms of physician and health workforce production we have assumed that there will continue to be a steady production of specialist taking into account the high attrition rate Moldova is currently facing. This area may need to be addressed in the future for further scale up of regional specialist in Moldova.
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13.2. Edineţ as an inter-district hospital It is the administrative centre of the rayon. The town is located 201 km north of the capital, Chișinău. The town administers also two suburban villages, Alexăndreni and Gordineştii Noi.
The population is 20,200 with a density of 3,543,8/km2. Situated in the hearth of the northern region bordering all rayons within the pilot area except for Drochia makes Edineţ the optimal choice for an inter-district hospital. With the on-going renovation of roads in the northern region, travel time and distances to Edineţ are ideal for acute as well as non-acute cases for neighbouring rayons.
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. Travel Distance to Edineţ Absolute Distance KM Time min. Ocniţa 42 40 Briceni 30 25 Donduşeni 34 33 Drochia 56 50 Riscani 36 35
In terms of infrastructure, the Edineţ rayon hospital has been awarded numerous development contracts to scale up infrastructure and technology from key international organizations. In 2010 the European Union, spearheaded by the French government invested in up scaling the surgical facilities at the institution. Edineţ now has some of the most up-to date equipment such as state of the art surgical lamps comparable to many developing countries. The Japanese government has also shown special interest in Edineţ supplying it with top of the line diagnostic equipment for the laboratory such as centrifuges.
Services to be offered at the interdistrict hospital in Edineţ would include:
Internal Medicine Would include a range of interventions targeting chronic diseases, including serious infections requiring surgical intervention . There would be isolation wards for highly infectious diseases such as measles and the management of sexually transmitted diseases including HIV/AIDS. All services of medical specialties of general internal medicine including pulmonology, cardiology, gastroenterology, diabetology, dermatology & venereal diseases, endocrinology, oncology, communicable diseases, angiology and phlebology, rheumatology, and neurology and stroke care. Cardiovascular care Interventional support t would include stroke care and coronary intervention but also heart surgery. Electrophysiology care would consist of arrhythmia treatment as well as diagnostic cardio-imaging. A '24/7' heart attack care would be available and invasive treatments such as transcutaneous aortic valves and drug eluting stents would be provided. Surgery Procedures including incision, management of trauma and a variety of abdominal procedures including hernia repair as well as surgical interventions requiring specialist aftercare . Complex trauma and orthopaedic surgery for high risk cases that might need ICU or specialized post- surgical observation or after care. Specialties such as ENT (allergology, audiology, logopedie, and oto-rhinolaryngology), Ophthalmology and Urology would also be available. Paediatrics Basic and complex neonatal care and care and treatment of acute diarrhoea and other infectious diseases will be provided.
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. Obstetrics Antenatal care and complicated deliveries would be managed in Edineţ. As well as all other high risk pregnancy control and delivery or C-section including foetal or mother life threating cases.
Gynaecology A range of interventions including evacuation of uterus for spontaneous, incomplete or medically-indicated abortion, investigative and therapeutic laparoscopy and hysterectomy for various conditions. Septic abortions including mother life threating cases and basic surgical interventions
Accident and emergency services These services would operate under 24/7 medical coverage with facilities for safely receiving and stabilizing emergency cases prior to in-patient admission.
Basic diagnostic services Services would include up to date radiology including complex X-ray investigations, ultrasound And pathology: all routine and complex services in Haematology, histo-pathology, biochemistry and Chemical Pathology.
Other areas to be offered Pharmacy services would continue to be offered in Edineţ and adjacent to these departments would include counselling services and social support. Stomatology would continue as currently operated. Physiotherapy aftercare, dietetics/nutrition advice, occupational therapy, speech therapy in complex cases and psychology would be offered including acute psychiatry beds.
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. 13.3. Option 1: Re-profile Edineţ, Briceni, Ocniţa, Donduşeni, Drochia and Riscani. Population Rayons Covered Service Profile Acute Beds Non-Acute Beds Coverage
404,700 Briceni, Edineţ 5 other rayons 24 hour 805 605 Drochia, multi- service for general Donduşeni, profile surgery and internal Edineţ, medicine Ocniţa and Riscani
With option 1, all sub-specialties would be closed to the rayon level and shifted to Edineţ. Concentrating resources from the five rayon hospitals to Edineţ would allow for capacity build up at the interdistrict level better suited to deal with complex cases.
Edineţ would serve as a second level hospital providing care for the specialties previously mentioned. As for Briceni, Ocniţa, Donduşeni, Drochia and Riscani, these hospitals would remain as 24 hour facilities where general surgery and internal medicine cases would be dealt with. All other complex surgeries as well as elective surgeries would be referred to Edineţ. Subspecialties would now be dealt with in Edineţ as well. Although day beds would remain for these facilities a notable reduction in bed numbers would be seen. A total number of 805 acute beds and 605 non-acute beds would be required for the northern pilot region.
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. Services provided at the rayon level would include:
Internal Medicine A range of interventions including the care and treatment of non-complicated diseases, and cases not requiring complex surgical intervention. The care and treatment of acute gastrointestinal disorders and infectious diseases would be included. Management of non- complicated sexually transmitted diseases excluding HIV/AIDS.
Surgery Activities would include a range of basic procedures including incision, management of trauma and a variety of abdominal procedures including hernia repair.
Paediatrics Services would provide basic neonatal care, care and treatment of acute diarrhoea and other infectious diseases and low complexity for diagnosis and treatment.
Basic diagnostic services Include radiology, such as non-complex X-ray investigations and ultrasound.
Pathology Services would include basic services in Haematology, Histo-pathology, and Biochemistry .
Pharmacy Services would continue dispensing and preparing IV fluids.
A long-term care facility would be established for rehabilitation cases and social care. Day beds would also be developed within this option.
13.4. Option 2: Re-Profile Edineţ, Drochia, Briceni, Ocniţa, Donduşeni, Riscani. Population Rayons Covered Service Profile Acute Non- Coverage Beds Acute Beds 404,700 Briceni, Drochia, Edineţ Drochia 24 4 other rayons 749 645 Donduşeni, multi- hour general day hospitals Edineţ, Ocniţa profile surgery + for internal and Riscani general medicine medicine
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. In this scenario Briceni , Ocniţa, Donduşeni and Riscani would have neither obstetrics nor surgery. Drochia and Edineţ would absorb all cases for these two specialties. Drochia as a 1 level hospital and Edineţ as a second level hospital.
The rayon hospitals in Briceni , Ocniţa, Donduşeni and Riscani would be re-profiled and converted to Day hospitals, closing facilities during the evening and resuming activities the next morning.
All rayons within the region would transfer all sub-specialties to Edineţ keeping only general internal medicine beds. Drochia would retain its capacity to treat surgical as well as obstetric cases. As in option 1, long-term care and day beds would be developed.
Long term care and day beds would provide professional nursing care, medical services, social work services and personal care services. The would also provide nutritional services designed to provide safe, nutritious quality meals to meet the nutritional, therapeutic and social needs of residents. This would be a crucial element as nutrition place a vital role in chronic disease which are seen every more present in the northern region of the country. In terms of pharmacy services activities would include documentation on medication procurement, storage, administration and record keeping. Therapeutic rehabilitative and restorative services would be designed to integrate multiple comorbidity commonly seen within the northern region population such as cardiovascular disease, metabolic disorders and mental illness.
The advantage to this model would be its ability to re-distribute resources from Briceni, Ocniţa, Donduşeni and Riscani to both Drochia and Edineţ, leaving these centres to deal with more acute and complex cases.
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13.5. Option 3: Reprofile Edineţ, Briceni, Ocniţa, Donduşeni, Drochia and Riscani.
Population Rayons Covered Service Profile Acute Non- Coverage Beds Acute Beds 404,700 Briceni, Drochia, Edineţ 5 other rayons Day 665 466 Donduşeni, Edineţ, multi- Hospitals (<24 hour Ocniţa and Riscani profile service) with only general internal medicine
For option three all surgery and obstetrics cases would be closed for Briceni, Ocniţa, Donduşeni, Drochia and Riscani. These cases together with sub-specialties would be transferred to Edineţ which would operate as the single 24 hour multi-purpose hospital in the northern zone. The five (5) rayon hospitals would be converted to day hospitals and would maintain their capacity to treat internal medicine cases. These day hospitals would not operate 24 hours but would close during evenings. Cases treated at the five rayons would include internal medicine cases that would not require urgent, surgical or complex care.
The number of acute beds projected for the region would be 665, while the amount of non-acute beds has been projected at 466.
Long term care would be developed for rehabilitation and social cases. This would include.
Rehabilitation care would include patients with the following conditions:
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. § Amputations § Brain Injury § Cardiac and Pulmonary Conditions o Inpatient Program for Cardiopulmonary Rehabilitation o Community Reintegration o Outpatient Program for Cardiopulmonary Rehabilitation o Outpatient Maintenance o Preparing for Rehabilitation § Multiple Sclerosis § Orthopaedic/Musculoskeletal Conditions § Parkinson's Disease § Paediatric Injuries and Conditions § Spinal Cord Injury § Sports Injuries § Stroke § Vestibular Conditions
Given the overwhelming burden of cardiovascular disease a special focus would be given to cardiac conditions. Special competencies and staffing would be designated to cardiopulmonary rehabilitation program has been the delivery of a “full circle of care” for cardiopulmonary health. A model of transit cardiac and lung conditions based on the health needs of the pilot population.
Within this model of care patients would transit through numerous phases. These phases would include:
· Phase Ia: Acute Care · Phase Ib: Inpatient Rehabilitation · Phase Ic: Community Re-integration · Phase II: Outpatient Cardiac Rehabilitation and Outpatient Pulmonary Rehabilitation · Phase III: Outpatient Maintenance Program
To enhance their -integration into the community, patients would be encouraged to participate in a cardiovascular disease support group. These support groups would be available for various chronic diseases.
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13.6. Option 4: Reprofile Edineţ, Briceni, Ocniţa and Donduşeni Population Rayons Service Profile Acute Non- Coverage Covered Beds Acute Beds 253,400 Briceni, Edineţ Drochia and 3 other rayons 385 371 Donduşeni, multi- Riscani day hospital Edineţ and profile transferred to limit to Ocniţa . another region. internal medicine
In the fourth option Briceni, Ocniţa and Donduşeni are reprofiled to include only general internal medicine. Internal medicine attention would include the management of all exiting cases currently seen at these hospitals with the exception of subspecialty cases which would be referred to Edineţ.
Instead of the traditional 24 hour hospital service they normally would provide they now would be converted to Community Hospitals . These facilities would provide support for rehabilitation and recovery of patients whom transition from an acute hospital; second, they would provide the specialist end of community services, whether this be coordinating care around high risk patients, providing services that patients have traditionally had to travel to Chisinau for and beds for clinical specialties (such as palliative care and mental health); third, they provide a basic level of diagnostic and outpatient services. These hospitals would offer patients chronic disease management and lifestyle support for a wide range of conditions including non-communicable diseases and ageing care. A gradual transition would be recommended and initially facilities would move not to day care centres but towards community hospitals. These facilities would be led by local GPs equipped with a community
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. hospital medical team. This team would integrate several aspects of care needed at the facility. The medical teams work would be underpinned by nurses, allied health professionals and social work teams who deliver the majority of the care and support to patients. It would be important to ensure that these professionals are supported in these roles and have time to work together to ensure the continuity of care and support that community hospitals need to deliver.
All obstetrics, surgery and sub-specialties would be transferred to Edineţ. Drochia and Riscani would be shifted to another zone corresponding to the Balti Region.
Ambulatory surgery would be introduced in Briceni Ocniţa and Donduşeni. Ambulatory surgery cases would involve carefully-selected and prepared patients sent the hospital for a planned, non-emergency surgical procedure on the day of surgery and discharging them within hours of that surgery. Specialties dealing with minor surgeries would include ophthalmological surgery, ENT, orthopaedics, stomatology, plastic surgery, gynaecology, general surgery and urology.
Operating theatres used by the ambulatory surgery facility must have the same standards as those applying to inpatient services with regard to their physical condition. The same applies to equipment provisions, especially regarding the equipment needed to protect patient integrity and health.
Ambulatory surgery will maximize the utilisation of limited economic resources whilst still providing the highest level of quality treatment for the northern population.
13.7. Advantages and disadvantages of Regionalization Options 1-4 Option Advantages Disadvantages
Option 1 · Political feasibility: compared to the other · The transformation, which implies rather options, the least resistance to changes is minor changes to the system of provision of expected from the central and local level health services, is not in line with the overall politicians and decision makers, as well as national policies such as Government’s from the communities regionalization strategy and MOH strategy for hospitals’ optimization and quality of care · Technical feasibility: compared to the improvement other options, no major problems are expected vis-à-vis ownership issues · The structure and scope of services do not contracting issues, specialty re-profiling, correspond to the current and future medical etc. needs of the population deriving from epidemiological and demographic trends such · There are no substantial threats for as ageing population, etc. medical staff in terms of staff reductions, need to change specialty, need to relocate, · The transformation does not solve problems in etc. terms of geographical access and addressing social needs of the population in the zone (e.g. · Additional investments required are not chronic care)
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. Option Advantages Disadvantages large, which makes feasible identification of funding sources · The changes will have insufficient effect on improving the referral system within the larger · Overall, this option may well serve as the Northern region and beyond initial stage for the forthcoming more substantial transformations proposed · Expected impact on improving quality of acute under the other options medical care is minimal
· The options does not create good opportunities for diversification of medical care according to the population needs (such expanding ambulatory care, day care including day surgery, rehabilitation, long-term / chronic care)
· There is little potential for generation of new jobs in the zone
· Potential efficiency gains (on short- and longer-term) are minimal
· Excess hospital capacity is likely to persist, leading to high and unnecessary costs of maintaining infrastructure and inefficient services
Option 2 · The option offers a good opportunity and · The transformation (i.e. three different types potential for substantially improving of hospitals in one zone) is not fully in line quality of acute medical care services with the overall national policies such as Government’s regionalization strategy, MOH · There is good opportunity and potential strategy for hospitals’ optimization and quality for diversification of medical care of care improvement according to the population needs (balancing ambulatory care, 24-h acute · Political feasibility: resistance to changes is care, day care including day surgery, likely from the central and local level rehabilitation, long-term / chronic care) politicians and decision makers, as well as from the communities in three rayons where downsizing is planned
· Technical feasibility: the need to solve ownership issues (for the new facility), contracting issues, specialty re-profiling, etc.
· Substantial investment funds for the new facility are required which may be difficult to obtain (medical infrastructure, other infrastructure, human capital)
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. Option Advantages Disadvantages
Option 3 · The changes correspondence to current · At the initial stages, problems in terms of and future medical needs of the geographical access and addressing social population, taking into account needs of the population in the zone (e.g. epidemiological and demographic trends chronic care) may be expected such as ageing population, etc. · Political feasibility: resistance to changes is · There is good opportunity and potential likely from the central and local level for diversification of medical care politicians and decision makers, as well as according to the population needs from the communities in three rayons where (balancing ambulatory care, 24-h acute downsizing is planned care, day care including day surgery, rehabilitation, long-term / chronic care) · Technical feasibility: the need to solve ownership issues (for the new facility), · The transformation will support workforce contracting issues, specialty re-profiling, etc. development in the zone as it creates opportunities for generation of jobs (in · The size of the zone may distort successful health care and beyond) health care regionalization beyond this area (i.e. the other zones within the larger Northern region will be difficult to define and optimize)
· There are potential threats for medical staff in terms of staff reductions, need to change specialty and need to relocate
· Substantial investment funds for the new facility are required which may be difficult to obtain (medical infrastructure, other infrastructure, human capital)
· There is a risk of creating new excess capacity and additional unnecessary costs at the new facility, which will be under-utilized by the population in the zone, which is traditionally oriented towards other poles (Riscani, Drochia)
Option 4 · The changes are in line with the overall · Political feasibility: resistance to changes may national policies such as Government’s be expected, at least in short-term span, from regionalization strategy, promotion of the central and local level politicians and cooperation between administrative decision makers, as well as from the territories for better provision of public communities in three rayons where services, MOH strategy for hospitals’ downsizing is planned optimization and quality of care improvement, etc. · Technical feasibility: the need to solve ownership issues (for the new facility),
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. Option Advantages Disadvantages · The transformation corresponds to current contracting issues, specialty re-profiling, etc. and future medical needs of the population taking into account · Although less in size when compared to epidemiological and demographic trends Options 2 and 3 above, difficulties may be such as ageing population, etc. expected to obtain investment funds in the new facility (medical infrastructure, other · The option provides for ensuring good infrastructure, human capital) geographical access and addressing the social needs of the population in the zone (e.g. chronic care)
· The model will contribute to successful health care regionalization beyond this health zone (referral within the larger region, regional hospital, and tertiary level / centers of excellence)
· The option offers a good opportunity and potential for substantially improving quality of acute medical care services
· There is good opportunity and potential for diversification of medical care according to the population needs (balancing ambulatory care, 24-h acute care, day care including day surgery, rehabilitation, long-term / chronic care)
· There are no major potential threats for medical staff in terms of staff reductions, specialty changes, need to relocate, etc.
· The transformation will support workforce development in the zone as it creates opportunities for generation of jobs (in health care and beyond)
· Visible and rapid increase in patient / client satisfaction is expected
· Substantial efficiency gains are expected on short- and longer-term
· Risks of excess capacity and unnecessary costs for infrastructure and services are minimal
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No. Criteria Legend Option Option Option Option Average 1 2 3 4 score 1 Compliance with the overall national policies Very low 2 2 3 4 2.75 (such as Government’s regionalization (1) ----> policies, promotion of cooperation between Very high administrative territories for better (5) provision of public services, MOH policy for hospitals’ optimization and quality of care improvement, etc.) 2 Correspondence to current and future Very low 1 3 4 4 3.00 medical needs of the population (e.g. taking (1) ----> into account epidemiological needs, Very high demographic trends such as ageing (5) population, etc.) 3 Addressing the social needs of the Very low 1 3 2 4 2.50 population (e.g. chronic care, access to poor, (1) ----> geographical access to needed services) Very high (5) 4 Political feasibility (short- and longer-term Very low 4 2 1 3 2.50 support to change by central level and local (1) ----> level politicians, decision makers, Very high communities) (5) 5 Technical feasibility (ownership issues, Very low 5 2 2 3 3.00 contracting issues, specialty profiling, etc.) (1) ----> Very high (5) 6 Contribution to successful health care Very low 1 3 2 5 2.75 regionalization beyond this health zone (1) ----> (referral within the larger region, regional Very high hospital, and tertiary level / centers of (5) excellence 7 Improving quality of acute care Very low 2 4 3 5 3.50 (1) ----> Very high (5) 8 Potential for diversification of medical care Very low 2 4 5 5 4.00 according to population needs (24-h acute (1) ----> care, day care including day surgery, Very high ambulatory care, rehabilitation, long-term / (5) chronic care) 9 Potential threats for medical staff (staff Very high 5 3 2 4 3.50 reductions, need to change specialty, need (1) ----> to relocate, etc.) Very low (5)
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. 10 Potential for generation of jobs (workforce Very low 2 3 4 5 3.50 development in the zone, in health care and (1) ----> beyond) Very high (5) 11 Improvement of patient / client satisfaction Very low 1 3 3 4 2.75 (1) ----> Very high (5) 12 Size of investment required (in medical Very high 5 2 1 3 2.75 infrastructure, other infrastructure, human (1) ----> capital) Very low (5) 13 Potential efficiency gains (on short- and Very low 2 3 3 5 3.25 longer-term) (1) ----> Very high (5) 14 Risk of excess capacity and costs (i.e. Very high 2 3 1 4 2.50 creating infrastructure and services that will (1) ----> not be solicited and/or difficult to maintain) Very low (5) TOTAL POINTS 35 40 36 58 42.25
AVERAGE SCORE 2.50 2.86 2.57 4.14 3.02
Stakeholder results Recommended-Option 4
After stakeholder consultation and agreement, the client has decided that Option 4 would best fit the regionalization strategy objectives and contributes the overall national policies within the Government’s regionalization strategy. It presents a clear promotion of cooperation between administrative territories and the MOH which will ensure a high degree of quality within the health services. Given its special attention to current and future medical needs of the population, option 4 takes into account epidemiological and demographic trends for the northern region such as ageing population and chronic disease management.
By strategically locating each level of care the option ensures good geographical but at the same time contributes to successful health care regionalization beyond this six rayon zone by establishing a strong referral system within the larger region, regional hospital, and tertiary level / centers of excellence. By allocating cases to Edineţ, the option offers a good opportunity and potential for substantially improving quality of acute medical care services by freeing useful resources. By selectively locating specialty services in Edineţ there will be a potential chance for diversification of medical care according to the population needs of each rayon. This will includes balancing ambulatory care with continues around the clock acute care, and day care
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. including day surgery. Non acute care such as rehabilitation and long-term or chronic care will provide the type of medical care needed.
In terms of human resources, this option was considered the most valuable as there are no major potential threats for medical staff in terms of staff reductions, specialty changes or urgent needs to relocate staff. By scaling up chronic care at the rayon level and investing in specialized care at Edineţ, the transformation will support workforce development in the zone as it creates opportunities for generation of jobs. Further down the line mechanism will be needed to document the increase in patient and client satisfaction as expected.
13.8. Key Supporting Actions To ensure a successful reconfiguration process certain key supporting actions must be taken into account. The efficient mobilization of financial resources will need to be addressed. There will be a need to include changes in payment mechanism from CNAM to support the changes in network. An example could be the partial payment for ambulatory care sensitive conditions. In the scenario where rayon hospitals are reconfigured to act as day hospitals, these would essentially have different payment prices. As for hospitals that are in rayons, even for those operating 24 hours, would receive a reduced price for internal medicine DRGs, e.g. 50% of average rate (new base rate). A carefully planned strategy must be set in place in order to guarantee a proficient price setting process.
The reconfiguration process for Regionalization will bring with it the need for equipment purchases, maintenance and much needed renovations for certain facilities. Decisions will have to be made regarding the use of public private partnerships (PPPs) taking into account mechanism that will allow capital cost to be repaid in the future. By establishing a clear method of capital payments as well as a proficient s price setting system Moldova can then readily attract investors for PPPs.
Consideration of new versus refurbishment points to greater advantages in building a new facility. Existing facilities are difficult, if not impossible to fit out to international standards: low floor-ceiling heights, lack of adequate load for modern equipment, no use of natural light, no basic patient safety standards, electrical and lack of gas installation complicates use of modern equipment. The repeated need for refurbishment on on-going basis (e.g. every 3 years) actually increases the on-going costs beyond the single capital costs of a new facility The design of a single, regional facility in Balti, built to international standards, would require investment estimated at over $100 million and would not resolve capacity constraints at lower level.
As for capacity strengthening the low capacity of rayon hospitals will point to the need to strengthen the capacity of inter-rayon facilities. There are important volume limitations in having care fragmented into six (6) small hospitals of which only two (Drochia and Edineţ) reach minimum rates for births and surgery. Design of a new inter-rayon hospital in Edineţ would
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. relieve some of the burden on Balti and Chisinau, reduce fragmentation in care and consolidate volumes to improve quality and efficiency.
14.Next steps
The next phase will identify opportunities (minimum 3) for Public-Private Partnership (PPP). For each opportunity, in accordance with Law on PPP No. 179 of 2008 a feasibility study with the identification of the PPP object and its objective shall be developed. Sanigest will identify a country in Europe, where such a scenario has already been successfully implemented and will facilitate the organization of a study visit of the Working Group of the Ministry of Health and representatives of the hospitals concerned. Sanigest will work with authorities in the Ministry Of Health and the Ministry of Finance to develop potential transactions for implementing PPPs In the Moldovan Health system. This approach will be look at some of the different models that have been used in PPPs and will review the options which are outlined for investment in each district. Based on This framework, Sanigest will work with Moldovan officials to define the most appropriate PPP model for the country. The definition of the model for PPPs in Moldova will draw heavily on the review of cases From around The world, including Developed countries Such as Austria, Spain and the UK but also look at experiences in emerging Countries such as Slovenia and the Czech Republic. The following key Policy issues will be highlighted in our Approach to Defining the Appropriate model. Based on the client selected option for reconfiguration, cost-effectiveness and future costs (capital and maintenance costs) for the proposed development alternative shall be developed, estimating economic benefits, the reimbursement rate and duration of the investment.
During the following months Sanigest shal develope indicators for impact evaluation and identify sources of information for monitoring and evaluation and prepare a monitoring and evaluation system for future impact of the consultancy. The final phase of the Project refers to the cost estimation of the Regionalization Plans, that is, the financial Impact of implementing and running the new level of services proposed through the integrated network. The costing Report implies the estimation Of 4 categories of cost: investment costs, operational costs, civil works and maintenance costs (i.e. recurrent and Capital costs). In addition, savings from The downsizing process will be a counterbalance to the costs of new staff, equipment and infrastructure. At the moment of preparing the expenditure plan, the previous information should be clear and at hand.
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15.References
Ettelt, Stefanie et al (2008). Capacity Planning in Health Care. A Review of the International Experience. Denmark: European Observatory on Health Systems and Policies, Policy Brief, World Health Organization
Rechel, Bernd et al (2009) Investing in Hospitals of the Future. WHO: European Observatory on Health Systems and Policies Studies Series 16. London. A Palese , E Cristea, M Mesaglio ,et al Italian-Moldovan international nurse migration: rendering visible the loss of human capital. Int Nurs Rev. 2010 Mar;57(1):64-9. Nigel Edwards. Improving the hospital system in the Republic of Moldova. WHO Regional Office for Europe. 2011. Republic of Moldova OECDHealthData2012. OECD Health Data 2012 - Frequently Requested Data http://www.oecd.org/els/healthpoliciesanddata/oecdhealthdata2012- frequentlyrequesteddata.htm. Last accessed Sept 7th 2012
Dorfman S., Scale optimization is important in hospital initiatives in South Africa. SAMJ 2011.101, (7) Richardson E. Health insurance coverage and health care Access in Moldova. Health Policy Plan. Epub 2012 27 (3) 204-212.
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Annex
Annex 1 Total Population by Sex per rayon Total Population for selected pilot rayon’s
2011 Total
Both Sexes Male Female
Total Age - total 3559985 1711915 1848070
from 0 to 4 years 193288 99775 93513
from 5 to 14 years 388131 199390 188822
from 15 to 64 years 2624094 1280063 1344032
above 65 354471 132768 221703
Mun. Balti Age - total 149044 68446 80598
from 0 to 4 years 7398 3838 3560.5
from 5 to 14 years 13301 6807 6493
from 15 to 64 years 113974 52590 61384
above o 65 14371 5210 9161
Briceni Age - total 74957 35713 39244
from 0 to 4 years 3761 1947 1814
from 5 to 14 years 8060 4180 3880
from 15 to 64 years 50741 24986 25755
above 65 12395 4600 7795
Donduşeni Age - total 44945 21006 23938
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. Total Population for selected pilot rayon’s
from 0 to 4 years 2026 1032 995
from 5 to 14 years 4570 2364 2207
from 15 to 64 years 30147 14658 15490
above 65 8200 2953 5247
Drochia Age - total 89811 42678 47133
from 0 to 4 years 4423 2220 2204
from 5 to 14 years 9420 4837 4583
from 15 to 64 years 61217 30155 31062
above 65 14750 5467 9283
Edineţ Age - total 82730.5 39132 43598.5
from 0 to 4 years 4242 2206 2036
from 5 to 14 years 8653 4426 4227
from 15 to 64 years 56575 27657 28918
above 65 13260 4842 8418
Făleşti Age - total 92476.5 44810 47666.5
from 0 to 4 years 5407 2797 2609
from 5 to 14 years 11118 5605 5513
from 15 to 64 years 64938 32212 32725
above 65 11013 4194 6819
Floreşti Age - total 89776.5 43041 46735.5
from 0 to 4 years 4880 2470 2410
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. Total Population for selected pilot rayon’s
from 5 to 14 years 9628 4908 4720
from 15 to 64 years 63730 31509 32221
above 65 11538 4153 7385
Glodeni Age - total 61654.5 29577 32077.5
from 0 to 4 years 3284 1711 1572
from 5 to 14 years 7120 3639 3481
from 15 to 64 years 43218 21274 21945
above 65 8032 2953 5080
Ocniţa Age - total 55919 26466.5 29452.5
from 0 to 4 years 2505 1292 1214
from 5 to 14 years 5254 2729 2524
from 15 to 64 years 39850 19428 20421
above 65 8310 3017 5293
Rîşcyears Age - total 69733.5 33396 36337.5
from 0 to 4 years 3550 1856 1693
from 5 to 14 years 7652 3966 3686
from 15 to 64 years 47650 23540 24109
above 65 10881 4032 6849
Sîngerei Age - total 93308.5 45598.5 47710
from 0 to 4 years 5539 2944 2595
from 5 to 14 years 12120 6129 5990
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. Total Population for selected pilot rayon’s
from 15 to 64 years 65952 32972 32980
above 65 9697 3553 6144
Soroca Age - total 100231.5 48664.5 51567
from 0 to 4 years 4817 2438 2379
from 5 to 14 years 11161 5767 5393
from 15 to 64 years 71706 35988 35718
above 65 12546 4470 8076
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Annex 2 Number of beds per specialty for northern region Obstetrics
Rayon Hospital Number of beds profile
SCM Bălţi 70
SR Briceni 10
SR Donduşeni 9
SR Drochia 20
SR Edineţ 20
SR Făleşti 20
SR Floreşti 15
SR Glodeni 12
SR Ocniţa 10
SR Rîşcyears 8
SR Sîngerei 20
SR Soroca 30
Urology
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. Rayon Hospital Number of beds in the field
SCM Bălţi 35
SR Briceni 5
SR Donduşeni 4
SR Drochia 10
SR Floreşti 10
SR Rîşcyears 8
SR Sîngerei 7
SR Soroca 5
ENT
Rayon Hospital Number of beds in the field, including children SCM Bălţi 45
SR Drochia 10 SR Edineţ 20 SR Făleşti 10 SR Floreşti 15 SR Glodeni 4 SR Rîşcyears 8 SR Sîngerei 10 SR Soroca 5
Ophthalmology
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. Rayon Hospital Number of beds in the field, including children SCM Bălţi 30 SR Drochia 10 SR Edineţ 20 SR Făleşti 10 SR Floreşti 10 SR Glodeni 3 SR Rîşcyears 6 SR Sîngerei 8 SR Soroca 10
Traumatology and Orthopaedics
Rayon Hospital Number of beds in the field, including children SCM Bălţi 55 SR Briceni 20 SR Donduşeni 8 SR Drochia 30 SR Edineţ 35 SR Făleşti 25 SR Floreşti 35 SR Glodeni 18 SR Ocniţa 10 SR Rîşcyears 20 SR Sîngerei 20 SR Soroca 25
Gynaecology
Rayon hospital Number of beds in the field, including children SCM Bălţi 25
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. SR Briceni 5 SR Donduşeni 10 SR Drochia 25 SR Edineţ 15 SR Făleşti 15 SR Floreşti 10 SR Glodeni 5 SR Ocniţa 15 SR Rîşcyears 14 SR Sîngerei 20 SR Soroca 10
Surgery
Rayon Hospital Number of beds in the field, including children SCM Bălţi 120 SR Briceni 35 SR Donduşeni 23 SR Drochia 30 SR Edineţ 50 SR Făleşti 25 SR Floreşti 40 SR Glodeni 25 SR Ocniţa 35 SR Rîşcyears 33 SR Sîngerei 25 SR Soroca 40
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. Annex 3 Availability of equipment
Briceni Donduşeni Drochia Edineţ Ocniţa Riscani
Blood Gas Analyser
Clinical Chemistry Analyser
Haematology Analyser
Microscope, Electronic
Patient Monitor
Morgue Refrigerators
Incubators, Infant, Intensive Care
Phototherapy Unit Briceni Donduşeni Drochia Edineţ Ocniţa Riscani
Laparoscopy Unit
ENT Chair
Haemodialysis Unit
Water Purification System (RO)
Angiography, digital unit
CT Scanner
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Briceni Donduşeni Drochia Edineţ Ocniţa Riscani
Ecograph, general purpose
Mammography Unit
X-Ray Unit
X-Ray Unit, Mobile
Briceni Donduşeni Drochia Edineţ Ocniţa Riscani
Slit Lamp
Tonometer, Electronic
Sterilizer, Low Temperature
Sterilizer, Plasma
Sterilizer, Steam
Electrosurgical Unit
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. Annex 3 Availability of equipment IMSP SPITALUL IMSP IMSP IMSP RAIONAL Instituţia Medico- "Spitalul Spitalul Spitalul DROCHIA Sanitară Publică raional Raional Raional ,,NICOLAE Spitalul raional Total Edineţ" Briceni Donduşeni TESTEMITANU" Ocniţa Riscani general Anaesthesi 1 3 1 1 1 2 9 a Unit Refrigerato r, Blood NA NA 1 NA NA 1 2 Bank Ventilator, 6 1 2 5 1 5 20 Adult Ventilator, NA NA NA NA 1 NA 1 Neonatal Ventilator, NA 2 1 NA 1 NA 4 Paediatric Dental Unit 10 5 2 10 1 11 39 Electrocardi 5 NA 1 10 1 4 21 ograph Defibrillato 2 NA 1 NA 1 2 6 r/Monitor Endoscope, NA NA 1 NA NA 1 2 flexible Laparoscop NA NA NA NA 1 NA 1 y Unit ENT Chair NA NA NA NA NA 1 1 Hospital NA NA NA NA 1 NA 1 Bed ICU Beds 5 NA 1 NA NA NA 6 Ecograph, general NA NA 1 NA NA 1 2 purpose Mammogra 1 NA NA NA NA NA 1 phy Unit X-Ray Unit NA 1 NA 2 1 1 5 X-Ray Unit, NA NA NA NA NA 1 1 Mobile Infusion 4 1 1 3 1 NA 10 Pump Clinical Chemistry 1 NA 2 NA 1 1 5 Analyser Haematolo 2 NA 1 NA 1 1 5 gy Analyser Microscope 6 NA NA 6 1 NA 13 , Electronic Patient 10 NA 2 10 1 2 25
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. IMSP SPITALUL IMSP IMSP IMSP RAIONAL Instituţia Medico- "Spitalul Spitalul Spitalul DROCHIA Sanitară Publică raional Raional Raional ,,NICOLAE Spitalul raional Total Edineţ" Briceni Donduşeni TESTEMITANU" Ocniţa Riscani general Monitor Incubators, Infant, 2 NA 1 NA 1 1 5 Intensive Care Photothera 1 NA NA NA NA 1 2 py Unit Slit Lamp 1 NA 1 2 NA NA 4 Tonometer, NA NA NA 1 NA NA 1 Electronic Sterilizer, Low 1 NA NA 3 1 4 9 Temperatur e Sterilizer, NA NA NA NA 1 NA 1 Plasma Sterilizer, 9 NA 1 4 1 NA 15 Steam Electrosurgi NA 2 NA NA 1 NA 3 cal Unit Operating 6 3 1 5 1 1 17 Table Surgical Lamp, 3 NA 1 3 1 1 9 ceiling 76 18 23 65 22 42 246
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Annex 4 Availability of services
Profilurile Spitalelor
Mun. Balti Briceni Donduşeni Drochia Edineţ Făleşti Floreşti Glodeni Ocniţa inclusiv: в том числе: Profil terapeutic Терапевтический профиль Terapeutice Терапевтические Geriartrice Гериартрические
Cardiologice pentru adulţi Кардиологические для взрослых Reumatologice pentru adulţi Ревматологические для взрослых inclusiv: в том числе: Artrologice Артрологические Cardioreumatologice pentru copii (сardiologice pentru copii + reumatologice pentru copii) Кардиоревматологические для детей (кардиологические для детей + ревматологические для детей) Gastroenterologice pentru adulţi Гастроэнтерологические для взрослых Hepatologice Гепатологические Gastroenterologice pentru copii Гастроэнтерологические для детей Endocrinologice pentru adulţi Эндокринологические для взрослых Endocrinologice pentru copii Эндокринологические для детей
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. Mun. Balti Briceni Donduşeni Drochia Edineţ Făleşti Floreşti Glodeni Ocniţa Alergologice pentru adulţi Аллергологические для взрослых Alergologice pentru copii Аллергологические для детей Pulmonologice pentru adulţi Пульмонологические для взрослых Pulmonologice pentru copii Пульмонологические для детей Hematologice pentru adulţi Гематологические для взрослых Hematologice pentru copii Гематологические для детей Nefrologice pentru adulţi Нефрологические для взрослых Nefrologice pentru copii Нефрологические для детей Hemodializa Гемодиализ Infecţioase pentru adulţi Инфекционные для взрослых Infecţioase pentru copii Инфекционные для детей Recuperarea sănătăţii pentru adulţi Восстановительного лечения для взрослых Recuperarea sănătăţii pentru copii Восстановительного лечения для детей Îngrijirea medicală paliativă Медицинский паллиативный уход Profil chirurgical Хирургический профиль Chirurgicale pentru adulţi Хирургические для взрослых Chirurgicale pentru copii Хирургические для детей Traumatologice pentru adulţi Травматологические для взрослых
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. Mun. Balti Briceni Donduşeni Drochia Edineţ Făleşti Floreşti Glodeni Ocniţa Traumatologice pentru copii Травматологические для детей Urologice pentru adulţi Урологические для взрослых Urologice pentru copii Урологические для детей Neurochirurgicale pentru adulţi Нейрохирургические для взрослых Neurochirurgicale pentru copii Нейрохирургические для детей Chirurgie toracală pentru adulţi Торакальная хирургия для взрослых Chirurgie toracală pentru copii Торакальная хирургия для детей Cardiochirurgicale pentru adulţi Кардиохирургические для взрослых Cardiochirurgicale pentru copii Кардиохирургические для детей Chirurgie septică pentru adulţi Гнойная хирургия для взрослых Chirurgie septică pentru copii Гнойная хирургия для детей Chirurgie vasculară Сосудистая хирургия Microchirurgie Микрохирургия inclusiv: в том числе: - microchirurgie pentru copii - микрохирургия для детей Proctologice Проктологические Pentru arsuri pentru adulţi Ожоговые для взрослых
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. Mun. Balti Briceni Donduşeni Drochia Edineţ Făleşti Floreşti Glodeni Ocniţa Pentru arsuri pentru copii Ожоговые для детей Ortopedice pentru adulţi Ортопедические для взрослых Ortopedice pentru copii Ортопедические для детей Stomatologice pentru adulţi Стоматологические для взрослых Stomatologice pentru copii Стоматологические для детей Oncologice pentru adulţi Онкологические для взрослых Oncologice pentru copii Онкологические для детей Radiologice şi roentghenologice Радиологические и рентгенологические Pentru gravide şi lăuze (în afară de patologia gravidităţii) Для беременных и рожениц (кроме патологии беременных) Patologia gravidităţii Патологии беременности Ginecologice Гинекологические Pentru întreruperea sarcinii Для прерывания беременности Ftiziopneumologice pentru adulţi Фтизиопульмонологические для взрослых Ftiziopneumologice pentru copii Фтизиопульмонологические для детей Neurologice pentru adulţi Неврологические для взрослых Neurologice pentru copii Неврологические для детей Psihiatrice (psihoneurologice) pentru adulţi Психиатрические для
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. Mun. Balti Briceni Donduşeni Drochia Edineţ Făleşti Floreşti Glodeni Ocniţa взрослых
Psihiatrice (psihoneurologice) pentru copii Психиатрические для детей Narcologice Наркологические Oftalmologice pentru adulţi Офтальмологические для взрослых Oftalmologice pentru copii Офтальмологические для детей Otorinolaringologice pentru adulţi Отоларингологические для взрослых Otorinolaringologice pentru copii Отоларингологические для детей Dermatovenerologice pentru adulţi Дерматовенерологические для взрослых Dermatovenerologice pentru copii Дерматовенерологические для детей Pediatrice Педиатрические inclusiv: в том числе: - pentru prematuri - для недоношенных - pentru sugaci - для грудных детей De reanimare pentru adulţi Реанимационные для взрослых De reanimare pentru copii Реанимационные для детей
Annex
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. List of Participants
Ministry of Health:
· Andrei Usatii, Ministrul Sanatatii · Rodica Scutelnic, Sef directive asistenta medicala spitaliceasca si urgenta · Ludmila Topchin, Sef directie medicamente si dispositive medicale · Silvia Volosatii, Sef directie investiti capitae si administrarea proprietatii publice · Svetlana Cotelea, Sef directie sanatate publica · Oleg Hincu, Coordonator proiectul SSAS
Centrul pentru Politici ai Analiza in Sanatate (PAS):
· Viorel Soltan, Director · Andrei Mosneaga, Director, Programs Management · Ghenadie Turcanu, Coordonator de programe
Centrul National de Management in Sanatate:
· Director, Oleg Barba
Compania Nationala de Asigurari in Medicina (CNAM):
· Director, Mircea Buga
Hospitals:
· Spitalul raional Briceni, Director Veltman Claudia · Spitalul raional Donduşeni, Director Casian Veaceslav · Spitalul raional Drochia, Director Cojocaru Tudor · Spitalul raional Edineţ, Director Guţu Anatolie · Spitalul raional Ocniţa, Director Iurcu Feodor · Spitalul raional Rîşcani, Direcor Roşu Gheorghe
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