TECHNICAL SERVICES and TECHNICAL ASSISTANCE PHRD Grant

TECHNICAL SERVICES AND TECHNICAL ASSISTANCE PHRD Grant

Moldova

Health Services and Social Assistance Project

Development of a National Master-plan for the Primary Care Workforce and Infrastructure.

Final Report

Prepared by Dr. Daniel Ciurea

September, 2007

Abbreviations

AMT – Territorial Medical Association (Asociatie Medicala Teritoriala) CMF – Center for Family Doctors (Centrul Medicilor de Familie) CS – Health Center (Centru de Sanatate) EMS – Emergency Medicine System HIF – World Bank’s Health Investment Fund project LPA – Local Public Authorities MoH – Ministry of Health OMF – Family Doctor Office (Oficiul Medicului de Familie) PHC – Primary Health Care PM – Health Post (Punct Medical - filiala a CS/OMF) WP – Work Package WG – Working Group

Currency conversion rate

For all the simulations that have been done in this report, the currency conversion rate was:

1 USD = 11 MDL

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Content

1. Executive summary ...... 6 2. Objectives and Tasks ...... 8 3. Project Implementation Organization ...... 8 4. Methodology, Work Packages, Activities and Products of the project...... 9 WP 1 – PHC system assessment ...... 9 WP 2. – Inventory of the PHC facilities, equipment and HR (baseline study) ...... 18 WP 3. – Development of the Master Plan ...... 24 WP 4. – Consensus Building ...... 27 5. Master Plan for the Primary Care Workforce and Infrastructure ...... 29 5.1 General overview of the PHC system in Moldova ...... 29 5.2 The role and the organization of the PHC institutions ...... 31 5.3 Human Resources in the PHC system ...... 44 5.4 PHC Institutions Infrastructure ...... 58 5.5 Equipment of the PHC institutions...... 73 5.6 The provision of services in the PHC system ...... 76 5.7 Assessment of the referral system ...... 77 5.8 Analysis of the financial data of the PHC institutions ...... 78 5.9 Estimation of the costs of rehabilitation of the PHC institutions ...... 83 5.10 Selection of the Rural health Centers for the first rehabilitation phase ...... 87 5.11 Summary of the conclusions ...... 89 5.12 Recommendations ...... 90 Annex 1. – Project Team ...... 98 Annex 2. – Terms of References for local experts ...... 99 Annex 3. – PHC system evaluation questionnaire ...... 102 Annex 4. - Preliminary list of Rural Health Centers selected for rehabilitation ...... 116 Annex 5. - References ...... 121

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List of figures

Figure 1– The structure of the PHC database ...... 13 Figure 2 – Moldova PHC GIS (1) ...... 15 Figure 3 - Moldova PHC GIS (2) ...... 15 Figure 4 - Moldova PHC GIS (3) ...... 16 Figure 5 - Moldova PHC GIS (4) ...... 16 Figure 6 – The management information system of the project ...... 17 Figure 7 – Predicted Public Health Authorities Investments in PHC system, 2007-2010, totals by raion ...... 25 Figure 8 - The organizational chart of the Public Raional Health System ...... 30 Figure 9 – Distribution of PHC institutions by type – total Republic of Moldova ...... 32 Figure 10 – Sanitary authorization of the PHC institutions ...... 33 Figure 11 – Accreditation of the PHC institutions ...... 34 Figure 12 – Status of the roads in the villages with PHC institutions ...... 37 Figure 13 - Number of the localities, by raion, with PHC institutions but no pharmacy units ...... 37 Figure 14 - Maximum coverage range of the raional hospital ...... 39 Figure 15 – Number of localities with no public transport to the hospital, by raion ...... 40 Figure 16 – CS with population less than 1500 ...... 42 Figure 17 - OMF with population less than 800 ...... 42 Figure 18 - PM with population less than 500 and less than 3 km away from another PHC institution 43 Figure 19 – No of OMF that cover a larger population than the CS that they belong to ...... 43 Figure 20 – Number of doctors by year, Republic of Moldova ...... 45 Figure 21 - Number of doctors per 100000 inhabitants, by year, Republic of Moldova ...... 46 Figure 22 – Population ratio to 1 Family Doctor, evolution between 1990 and 2007, Republic of Moldova ...... 49 Figure 23 - Population ratio to 1 Family Doctor, Europe, 2005 ...... 50 Figure 24 - The shortage/surplus of Family Doctors and Nurses in rural area, by raion ...... 52 Figure 25 – Distribution of the Family Doctors by year of birth...... 53 Figure 26 – Detailed report on infrastructure, CS Vadul lui Voda ...... 59 Figure 27 – Distribution of PHC institutions by ownership ...... 60 Figure 28 – Total area of the buildings of the PHC institutions, by raion ...... 61 Figure 29 – Percentage of used area from total area of PHC buildings, totals by raion ...... 62 Figure 30 – Plot diagram of covered population and area of each PHC institution ...... 62 Figure 31 – Number of institutions that are located in buildings older than the year of 1980 ...... 63 Figure 32 – PHC buildings by type, country totals ...... 65 Figure 33 – Quake resistance of the buildings, total by country ...... 66 Figure 34 – No of buildings with ferro-concrete carcass, totals by country ...... 66 Figure 35 – No of buildings that have foundation, total by country ...... 67 Figure 36 – General status of the floor of the PHC buildings ...... 67 Figure 37 – General status of the ceiling of the PHC buildings ...... 68 Figure 38 – General status of the frames of the windows of PHC buildings ...... 68 Figure 39 – General status of the doors of the PHC buildings ...... 69 Figure 40 – Presence of electricity system in PHC buildings ...... 69 Figure 41 - Presence of running water system in PHC buildings ...... 70 Figure 42 – Distribution of the admitted patients by the referral source ...... 78 Figure 43 – Coverage of the population with health insurance, totals by raion ...... 80 Figure 44 – Percentage of the health insured people by health center ...... 80 Figure 45 – Raional CS family doctors’ option for autonomy ...... 82 Figure 46 - Rural CS family doctors’ option for autonomy ...... 83

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List of tables

Table 1- The hierarchy of the PHC institutions in Stefan Voda raion ...... 14 Table 2 – The Gantt chart of the project ...... 17 Table 3 – Inventory of the standard equipment, with less than 50% wear in the PHC institutions (august 2007), total for Moldova ...... 22 Table 4 – Types of expenditures that had been collected from each PHC institution ...... 26 Table 5 – Distribution of PHC institutions by type and raion ...... 33 Table 6 – Distribution of the population by raion ...... 35 Table 7 – Distribution of the population of Stefan Voda raion, by PHC institutions ...... 35 Table 8 - Distribution of the public and private pharmacies in the localities with PHC institutions, by raion ...... 38 Table 9 – The remotest PHC institutions from the Raional Hospital and the distance ...... 40 Table 10 – Distributions of PHC institutions by type and number of Family Doctors ...... 41 Table 11 - OMF that cover a larger population than the CS they belong to and have a larger number of Family Doctors ...... 44 Table 12 – Total number of human resources in the PHC system, by type ...... 45 Table 13 – Ratio of all other staff to a Family Doctor ...... 45 Table 14 – Coverage with Family Doctors and Nurses, by urban/rural area, Republic of Moldova ..... 48 Table 15 – The shortage of Family Doctors and Nurses in rural area, by raion...... 51 Table 16 – Incentives for family doctors (self-administered anonymous questionnaire) ...... 55 Table 17 – Incentives for nurse (self-administered anonymous questionnaire) ...... 55 Table 18 – Number of doctors that work in the PHC system, by specialty ...... 57 Table 19 – Number of doctors by type of graduated Primary Care specialty ...... 57 Table 20 – Number of family doctors, by attended CME type ...... 58 Table 21 – Number of family doctors that attended management courses ...... 58 Table 22 – Number of buildings of the PHC institutions ...... 61 Table 23 – Percentage of PHC institutions that are located in buildings built up before 1980, totals by raion ...... 64 Table 24 – Current functional and structural standard of a Rural Health Center ...... 71 Table 25 - Current functional and structural standard of a Family Doctor Office ...... 72 Table 26 – Number of Rural CS by area of the building ...... 72 Table 27 - Number of OMF by area of the building ...... 72 Table 28 - Number of PM by area of the building...... 72 Table 29 – Elements of the functional and structural standard for infrastructure included in the questionnaire ...... 73 Table 30 – The equipment standard for Rural Health Centers (without consumables) ...... 74 Table 31 – The results of the assessment of the equipment needs through the questionnaire, totals by country ...... 76 Table 32 - Indicators for utilization of PHC services and referrals to specialized care ...... 77 Table 33 – Number and distribution of population by health insured status in Stefan Voda Raion, by institution ...... 79 Table 34 – Income and Expenditure of PHC institutions, total by raion ...... 82 Table 35 – The list of the rehabilitation costs that have been assessed through the questionnaire ...... 84 Table 36 – Locally estimated costs for rural infrastructure rehabilitation, totals by type of PHC institution ...... 84 Table 37 - Locally estimated costs for urban and rural infrastructure rehabilitation, totals by raion..... 85 Table 38 - Estimated costs for rural infrastructure rehabilitation using “standard unit cost by m2” and current buildings’ area, totals by type of PHC institution ...... 86 Table 39 - Estimated costs for rural infrastructure rehabilitation using “standard unit cost by m2” and standard buildings’ area, totals by type of PHC institution ...... 86

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1. Executive summary

The general objective of the project, as it is defined by the ToR, is to contribute to strategic information on costs and consequences of potential models of primary health care that can effectively and reliably provides the entire population of Moldova with high quality, yet cost effective medical services that are physically available and affordable.

The project tasks were the followings: - Inventory of PHC network, state of infrastructure, capacity and geographical distribution of PHC facilities and laboratories; - Inventory of PHC work-force size and structure; - A documented methodology to determine PHC human as well as infrastructure needs; - Definition of functional linkages to in-patient care, to laboratory and diagnostic services, to specialty outpatient care, and to public health institutions and administration; - Selection criteria for PHC facilities restructuring and refurbishment and health workforce rationalization, as well as training needs; - Recommendations for optimum methods of locating, refurbishing and staffing facilities; - Recommendations to the National Center for Public Health and Management with respect to further developing the Geographical Information System (GIS) managed by the Center; - A facility and health workforce rationalization plan (e.g. restructuring/building of new facilities for PHC and for diagnostic services and specialty outpatient care that will support PHC facilities based on available and evidence based evaluation of alternatives); - A financial simulation model to support priority making discussions linking investment planning (costing) to realistic financial parameters and scenarios (expenditure and revenue variables, capital and recurrent costs) including specific volume and productivity level recommendations; - Model(s) of the referral system from PHC facility towards other levels and sectors of the health care system.

The evaluation of the current situation has been done by the following activities: - the analysis of the relevant documents - meetings and interviews with key decision makers - the analysis of the data collected by the following questionnaires: the questionnaire for each PHC institution, the questionnaire for each PHC medical worker (only doctors and nurses), the questionnaire for each Raional Public Health Authorities - site evaluation visits in all 361 Rural Health Centers (CS) - development of the PHC institutions database, the Registry of the PHC Human Resources and the PHC GIS - Detailed analysis of each Rural Health Center (CS), especially its role, HR and infrastructure, together with Family Medicine specialists and civil constructions specialists from the MoH PHC WG, by using the data and the pictures taken during the site visits (over 4000 pictures of all CS.

By having all these information put together in a relational database, the project developed a detailed inventory of all 1261 PHC institutions, including facilities, utilities, equipment, human resources and their medical and management education curriculum.

The analyses of the system and the evaluation against the current and newly proposed functional and structural standards have revealed the followings: - There are a number of PHC institutions that do not comply anymore with the current functional and structural standards by type of institution (CS, OMF and PM). The most Page 6 of 121

important discrepancies with the standards are in terms of population coverage, human resources and the area of the buildings in which they are located. - The geographical coverage is considered to be good, but the physical access to the PHC institutions is difficult for many places due to the lack of public transport means and the bad condition of the roads. - According to the centralized HR planning methodology that is currently in use, there is a surplus of 165 doctors in urban area and a shortage of 362 doctors in rural area, which means a general shortage of 197 doctors at national level and there is a shortage of 408 nurses in urban area and a shortage of 349 nurses in rural area, which means a general shortage of 756 nurses at national level. The variation of these figures among raions is very high. - The infrastructure is quite old, do not comply with resistance norms and in bad shape for more than 50% of the buildings. The surface area of the buildings is oversized, the total by country being 545,118 m2, which means 259 m2 for each family doctor. The used, occupied, area in only 78% of the total area. - The coverage with utilities of the PHC institutions is low, only 22% having running water systems, 43% having sewage systems and only 7% having running hot water. - Only 57% of the PHC institutions belong to Raional Council and can be rehabilitated without any other legal formalities regarding the ownership transfer. - The Rural PHC System total rehabilitation costs that were estimated locally by the beneficiaries are much lower (total cost = 74,200,879 USD, average by Rural CS = 81.202 USD) than the costs estimated by the “standard unit cost per m2” applied to the current area of the PHC facilities (total cost = 171,754,526 USD, average by Rural CS = 427.717 USD), but higher than the costs estimated by “standard unit cost by standard area” methodology (total cost = 54,765,000 USD, average by Rural CS = 90,000 USD). - There is a huge lack of equipment in the PHC institutions, the difference to the current standards (the needs) varying from 40% to 90% for different types of equipment.

Considering the conclusions presented above, we recommend an integrated and cyclic approach for restructuring of the PHC institutions, in order to conclude the Master Plan based on data and evidence, on cost-efficiency and long term investment sustainability principles, by: - Redefining the functional and structural standards for the PHC institutions at central / national level. A proposed model is presented. - Development of local plans for restructuring the PHC institutions at community and raion level - Refining the national level planning and implementing the restructuring measures - Prioritization of investments and designing the national investment plan - Maintaining and further development of the information system as basis for data driven decision making

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2. Objectives and Tasks

3. Project Implementation Organization

The international consultant acted as a team leader for a group of 7 local experts (PHC/ Public Health experts and Civil Construction Engineers, selected and contracted separately by the local partner company, Center for Health Strategies and Policies, Chisinau, Republic of Moldova – see Annex 1. – The project’s team The main tasks of the local experts were: - To contribute to the data collection and design of the Master Plan - On site evaluation of the PHC centers - Recommendations for the selection of the PHC Centers that will be refurbished under the next WB loan. The team worked in close collaboration with the Primary Health Care Group constituted in the Ministry of Health and on a permanently basis with Ms. Tatiana Zatic, coordinator of the Working Group and Mr. Veaceslav Hametchi, civil constructions engineer. MOH and other Government staff were actively involved with the consultant and experts in the planning, designing, implementation, supervision and analysis of each of the activities specified in the ToR, including final recommendations.

The duration of the project was 3 months and the work was done in the Project Office established in the Scientific and Practical Center for Public Health and Health Management, Chisinau, in the Ministry of Health, as well as in the country on site visits, as necessary. Page 8 of 121

4. Methodology, Work Packages, Activities and Products of the project

In order to fulfill the terms of references’ specifications, the activities in the project were grouped in four work packages: 1. WP 1 – PHC system assessment 2. WP 2 – Inventory of the PHC facilities, equipment and HR 3. WP 3 – Development of the Master Plan 4. WP 4 – Consensus building

WP 1 – PHC system assessment

Work Package 1 consisted of the following activities:

1.1. Assessment of the current PHC model and strategy

1.1.1 Constitution of the library/database with specific and relevant documents and tools

1.1.2 Specific legislation reviews

1.1.3 Assessment of the relevant available models, planning, strategies, pilots, etc. within the PHC system and previous initiatives

The list of relevant legislation documents is presented in Annex. 5 - References

In order to asses the current situation and to pool together the relevant documents, the consultant organized meetings and interviews with: - Decision Makers and the Primary Health Care Group within the Ministry of Health - the relevant staff within the Scientific and Practical Center for Public Health and Health Management, regarding the current data collection and methodology and tools for PHC data collection - staff of the previous WB Health Investment Fund project - site visits to 4 PHC institutions in Orhei district - international and local experts working in Public Health Reform Project, Moldova, running the Primary Care Pilot project currently implemented in Orhei and Chisinau. - site visit to PHC Centru Chisinau - meetings with experts from Civil Construction Engineering Faculty, Chisinau, in order to asses and develop a feasible methodology for PHC infrastructure and rehabilitation costs’ evaluation - meetings with experts of INGEOCAD, the institute that is responsible for cadastral and maps development activities for Republic of Moldova, in order to develop the interactive PHC GIS (Geographical Information System – digital map) - other relevant key experts from central and local authorities

The project’s ToR specifies that there is no need to describe the current PHC system general overview. A very detailed and comprehensive overview of the Moldova PHC system is

Page 9 of 121 presented in the report: Atun R, PHC Development Strategy for Moldova. Final Report, March 2007.

1.2 Finalize methods, tools, logistics, data sources and data collection methodology

1.2.1 Analysis of the existing data and data collection tools and procedures

The consultant analyzed the existing data and data collection tools and flows. In summary, there were identified two main data flows within the PHC system: - the National Center for Public Health and Management runs a periodical (biannual) data collection regarding mainly the PHC staff and the services provided - the Ministry of Health (mainly the Primary Health Care Department) runs an annual data collection with some disparate elements of staff, training, infrastructure and financial resource allocation. A set of some relevant indicators is published annually by the Ministry of Health in “Public Health in Moldova” periodical.

The analysis of the existing data showed that the existing data cannot cover the project needs for developing the PHC Master Plan, because of the followings: - there is a lack of data regarding the current infrastructure, its status and the needs for refurbishing of the PHC facilities - there is a lack of data regarding the current equipment in the PHC institutions - the data regarding the PHC HR structure and training needs, although collected, is incomplete and needs to be reassessed. - there is no PHC HR registry - the service and financial data is reported only by district, not by each PHC institution, which determines the impossibility to analyze performance and financial indicators for the PHC institutions - there is a lack of data regarding running costs and investment needs by institution.

The data collection tools are represented by predefined Excel tables, but there is no proper PHC database to join together and analyze the data.

1.2.2 Defining of the data sets that should be addressed by the data collection

The project team, along with the PHC working group in Ministry of Health decided to collect the following data categories – see Annex 3. – PHC system evaluation questionnaire: - general data about each PHC institution regarding population covered, geographical situation, access to the institution and from the institution to emergency services, specialty services, hospital, pharmacy - very detailed infrastructure data, including buildings (current situation and the estimated cost of the refurbishment), utilities (current situation and estimated cost for refurbishment of electrical system, water system, sewing, heating, hot water system, ventilation system, fire/security system, communication system, information system, medical waste disposal system) and conformity with the structural standards. - existence of the cadastral and construction projects (if they exist, they should be delivered) - inventory of the medical equipment: comparison with the standard and necessary supplemental number Page 10 of 121

- human resources: doctors, nurses and other staff - provision of services (as detailed as they can be collected beyond the number of patients visits) - referral system – number of referred patients to each other types of providers - financial indicators: revenues and expenses by categories and salaries - for each PHC staff: training, work, medical and management qualification and incentives, in order to develop the PHC HR registry - preferences of the local authorities for prioritization of the refurbishment investments - a specific part of the questionnaire will evaluate the plans of the Local Authorities to invest in the PHC sector, in order to tailor the WB future interventions with the local initiatives - another specific part of the questionnaire will address the doctors and nurses opinion regarding their specific needs, in order to evaluate and propose incentive packages for HR development in this sector (anonymous survey) - detailed pictures will be taken for each institution’s building

1.2.3 Analysis of the current premises regarding the development of a Geographic Information System (GIS)

The ToR requirements regarding the development of a PHC GIS system is very ambitious. Development of such a system requires available good digital maps, available software programmers and available data for each PHC institution in the country. The team decided to evaluate the premises and to come up with the best feasible solution within the project lifetime. At least a simple electronic map would be developed and linked to the PHC database that will be developed.

1.2.4 Development of the methodology for data collection, data management and analysis

Taking into consideration that: - the existing data is not adequate for designing the Master Plan - short term of the project - lack of computers and software in the PHC institutions - lack of software programmers in the MoH the team decided to have the following approach and methodology for data collection:

- development of a detailed questionnaire that will be filled up by each PHC institution, consisting in all elements needed for PHC Master Plan development: infrastructure, equipment, HR, provision of services, financial resources, as well as running costs and investment needs see Annex 3. – PHC system evaluation questionnaire - the questionnaire will be validated in one PHC Center, prior to national distribution - the questionnaire will be distributed and filled up on paper first and then, the electronic form of it will be put together in the central raional health centers that have computers - the raional representatives will be trained how to fill up the questionnaire - site visits by the project team in the main PHC Centers, after completion of the questionnaires. The site visits were chosen in order to cover the most probable candidates for refurbishing during the next WB project – all the 361 Rural health Centers. The project experts will evaluate the current situation on site and compare with the answers in the questionnaires, with most emphasis on costs estimation. Also, they will take detailed pictures of the buildings for further analysis and documented decisions Page 11 of 121

- the criteria for selection and prioritization of the health centers for rehabilitation will be developed together with the PHC WG - the consultant will develop a Microsoft Access database for data management and analysis - also, the database will incorporate the functional and structural standards and other criteria developed during the project, in order to run analysis and simulations - the analysis and simulations will be done using the data base tool and institution by institution analysis and brainstorming with PHC WG.

1.2.5 Consensus building and decision making on the data sets and data collection tools and methodology

The consensus for the structure of the questionnaire and the data collection was build by having multiple meetings with key experts from Ministry of Health and PHC specialists. The project planning and the final version of the questionnaire were presented to the Minister of Health and all Head of Departments.

1.2.6. Development of the tools for data collection and analysis

The following tools for data collection and analysis have been developed.

1. The electronic version of the questionnaire

The electronic version of the questionnaire has been developed by the consultant in Microsoft Excel. A more performing tool could not be developed because of the time constraints and uncertainty about the compatibility of such a tool with the software the health centers use. The electronic version of the questionnaire was delivered to MoH with the CD attached to this report.

2. The PHC database

The database application was developed by the consultant on Microsoft Access platform. The database fields and structure are based on the questionnaire data set, plus other data elements, as standards from the PHC system and various criteria developed by the project. A more advanced SQL platform would have been preferred, but there was not enough time and there were no software specialists in MoH for completing this job.

The database application was delivered to MoH with the CD attached to this report. The structure of the database is shown in the next picture.

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Figure 1– The structure of the PHC database

Some comments regarding the database:

- it is the adequate tool for storing, management and analysis of the PHC data, as opposite to the disparate Word and Excel tables that are currently in use in the system. Had we not have this tool, it would have been impossible to manage and analyze the huge quantity of data collected through the questionnaires, from such a big number of PHC institution - it allows a correlative analysis of the PHC data - it stores the inventory of the PHC institutions, with all the elements that we have collected - it stores the current standards in the PHC system and it allows comparative analysis of the current situation with the standards - it constitutes a simulation and planning tool – for example, by adding the estimated costs for refurbishing, simulation of various investments scenarios can be done - it could be accessed online, in Internet or intranet in MoH, thus increasing the transparency and data driven decision making process - it is connected with the digital map of the GIS - by storing the PHC system elements in the database, it forced the coding of these elements, like raions, localities, institution, equipment, HR etc and an adequate data management.

The database is organized in such a way that keeps the hierarchy of the PHC system (CS- OMF-PM), therefore allowing the analysis at levels, from the institution level to the cumulative level of a CS or Raion. For example, CS Stefan Voda has OMF Semionovca in its structure, and, down one level, OMF Semionovca had PM Lazo in its structure. The statistics can be generated at CS level by summing up all the levels below it.

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Raion CS OMF OMF PM PM Code Raion Name Code CS Name Code Name Code Name 31 Stefan-Voda 1086 CS Ştefan-Vodă 138 OMF Marianca de Jos 31 Stefan-Voda 1086 CS Ştefan-Vodă 2289 OMF Stefanesti 31 Stefan-Voda 1086 CS Ştefan-Vodă 2337 OMF Brezoaia 31 Stefan-Voda 1086 CS Ştefan-Vodă 2335 OMF Semionovca 137 PM Lazo 31 Stefan-Voda 1086 CS Ştefan-Vodă 136 OMF Alava 31 Stefan-Voda 1086 CS Ştefan-Vodă 2329 OMF Popeasca 31 Stefan-Voda 1086 CS Ştefan-Vodă 2312 OMF Festelita 31 Stefan-Voda 2311 CS Ermoclia 31 Stefan-Voda 2350 CS Volontiri 2306 OMF Copceac 31 Stefan-Voda 2346 CS Tudora 2318 OMF Palanca 31 Stefan-Voda 2297 CS Caplani 31 Stefan-Voda 2310 CS Crocmaz 31 Stefan-Voda 2295 CS Carahasani 31 Stefan-Voda 2330 CS Purcari 139 PM Viisoara 31 Stefan-Voda 2330 CS Purcari 2332 OMF Rascaieti 31 Stefan-Voda 2301 CS Cioburciu 140 OMF Rascaietii Noi 31 Stefan-Voda 2290 CS Antonesti 31 Stefan-Voda 2339 CS Slobozia 31 Stefan-Voda 2340 CS Talmaza 31 Stefan-Voda 2316 CS Olanesti

Table 1- The hierarchy of the PHC institutions in Stefan Voda raion

One major step ahead that the project induced was to collect ALL data at institution level, not aggregated data at CS or raion level as it was done before – for example the provided medical services or the budget of each institution. The database stores all this data and each and every institution, from CS to PM, can be analyzed separately.

3. The PHC system’s Geographical Information System (GIS)

It was done in partnership with INGEOCAD, the institute that is responsible for cadastral and maps development activities for Republic of Moldova. INGEOCAD provided the electronic maps and the consultant developed the link of the map with the PHC database. The GIS data was consolidated by mapping the codes of the PHC database with the codes in the INGEOCAD GIS system.

Each of the 1261 PHC institution is represented on the map by an icon. The biggest icon is for CSs and the smallest icon is for PMs. Each icon is a hyperlink that opens a standardized report of that institution from the PHC database. The GIS system should be developed more into a management tool, but the time constraints of the project did not allow for such a development.

The next pictures represent some snapshots of the PHC GIS.

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Figure 2 – Moldova PHC GIS (1)

Figure 3 - Moldova PHC GIS (2)

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Figure 4 - Moldova PHC GIS (3)

Figure 5 - Moldova PHC GIS (4)

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The information system was completed with a web based picture viewer, developed by the consultant, which links the pictures database with the database and the GIS. The general diagram of the system is:

PHC GIS PHC Database Picture viewer

Figure 6 – The management information system of the project

The Consult’s aim is that the management information system and the database that was used in the project will set the standard for an ongoing system that will be part of the National Integrated Information System that is part of the Health System Development Strategy. Ministry of Health expressed the interest to continue updating the database on a yearly basis.

1.2.7 Develop ToR for the field work

ToR for the field work was developed for the local experts and they were trained accordingly. See Annex 2. – ToR for local experts

1.2.8 - Preparation of the implementation plan

The implementation plan of the project was based on the following Gantt chart. The timeframe of the project was very short, considering the requirements of the ToR, the lack of the relevant data in the health system, the lack of the necessary data collection and analysis tools and the small number of the staff of the project.

14 weeks (June 07 – September 15, 2007) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 WP1: PHC SYSTEM ASSESSMENT WP2: INVENTORY OF THE PHC FACILITIES, EQUIPMENT AND HR WP3: DEVELOPMENT OF THE MASTER PLAN WP4: CONSENSUS BUILDING

Table 2 – The Gantt chart of the project

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WP 2. – Inventory of the PHC facilities, equipment and HR (baseline study)

The Work Package 2 represented the work for completing the baseline, the inventory of the PHC infrastructure, equipment and human resources. The activities in the WP2 represented mainly the data collection, data management and consolidation of the inventories.

2.1 Data collection

2.1.1 – Provision of the relevant training to local experts

Local experts were trained how to conduct the field works, especially regarding how to: - check the questionnaire against the findings - re-evaluate the estimated cost for refurbishment, based of costs per unit - take pictures of the of outside and inside of the buildings - organize the data

2.1.2 – Field data collection

The preliminary testing of the questionnaire was done at CS Peresecina, before distributing it to the raions.

At the beginning of the data collection process, the project, together with the Ministry of Health, organized a meeting with the Vice-Chiefs-Doctors of all Raions, in order to inform them about the project and the data collection and to provide training on how to fill up the questionnaires. They were given the paper and electronic versions of the questionnaires. The Vice-Chiefs-Doctors passed the instructions to the managers of the PHC institutions in their Raions and coordinated the local data collection activities.

The questionnaires were filled up by the management of each institution. They had to consider help from local civil construction experts (generally provided by the local authorities), especially for estimation of the current status of the building and the costs for refurbishment. First, the questionnaires were filled up on paper and then each Raion organized the data input from paper into the Excel forms of the questionnaires that were distributed in advance. Finally, both paper and electronic versions of the questionnaires were sent to the project office in 2-3 weeks.

Then, the project team experts, organized in three teams, went to each rural CS (one team in Northern Raions, on team in Central Raions and one team in Southern Raions) for checking, reevaluating and correcting the reported data together with the local staff. They also took the pictures with each building, outside and inside. Around 361 rural CS had been visited in one month.

Also, the team experts distributed and then collected the anonymous questionnaire from the PHC staff and took around 4000 pictures.

Generally, the field work was done in time, although the time frame for this activity was very short. It is to be mentioned here that both the questionnaires completion and the site visits

Page 18 of 121 required an extraordinary amount of condensed work from the local staff and the project experts.

2.2 Data import, storage and quality assurance

The import of the data from the electronic questionnaires into the database had been done by using software that was developed by the consultant. The database location was selected for the Centrul Stiintifico-Practic de Sanatate Publica si Management Sanitar (Center for Public Health and Health Management) in Chisinau.

One of the most a difficult and time consuming activity in the project was validation and quality assurance of the data, because of the followings: - inconsistency of the reported data (missing data, data errors, methodology errors etc) - lack of coding or inconsistent coding of the main PHC elements – for example, the current coding of the PHC institution had errors which led to a very time consuming data cleaning and recoding) - lack of knowledge or experience in database management among the project staff - lack of comparable data in other studies for some of the indicators, that made the cross- checking and validation of this data to be impossible - very limited time frame of the project

Up to end, the project team succeeded in cleaning and validating the majority of the data, mainly the most important data for our purposes, the Master Plan. Data that lack consistency or that could not be corrected during the life of the project was not considered for analysis and conclusions.

2.3 Consolidation of the inventory of PHC facilities, equipment and human resources

Data that had been collected through the questionnaire (cleaned and validated) was analyzed together with other PHC data in other reporting systems, with the reports of the site evaluators and with the pictures of each Rural Health Center for consolidation of the inventory of all 1261 PHC institutions that were identified.

All these data is stored in the database in the hierarchical PHC system. Statistics and reports can be generated for each institution, as well as for groups of institutions or at raion or country level.

2.3.1 The inventory of PHC institutions

In total, the database contains the year 2006 information about 1261 PHC institutions (demographical data, geographical data, infrastructure data, equipment data, HR data, data regarding the provision of services and financial data), as follows

- 5 AMT (Asociatie Medicala Teritoriala) – Territorial Medical Association - 13 CMF (Centrul Medicilor de Familie) – Center for Family Doctors - 396 CS (Centru de Sanatate) – Health Center - 559 OMF (Oficiul Medicului de Familie) – Family Doctor Office - 288 PM (Punct Medical - filiala a CS/OMF) – Health Post

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In the database, the Raional CMFs were assimilated as CS for data management reasons. For the organization of PHC institutions see Chapter 5.1 General overview of PHC system in Moldova.

2.3.2 Inventory of the PHC facilities

One of the hardest task of our mission was to build up the inventory of the infrastructure of the PHC institutions, in order to set up a clear and comprehensive baseline for developing the Master Plan and for selection and prioritization of the institutions for refurbishment.

The infrastructure was evaluated very thoroughly through the questionnaire and site visits. The evaluation covered every detail of the infrastructure, like: the main building with all its components, utilities infrastructure (electricity system, water supply system, sewage system, heating system, ventilation and AC system etc), the communications, the IT system etc and their conformity with existing structural standards. See Annex 3. – PHC system evaluation questionnaire

For all of these elements the repairing/rehabilitation costs had been estimated. Local estimates had been done by the managers of the respective institutions with help from civil constructions specialists of the Local Public Authorities, if case.

All data had been collected into the database and reports can be extracted at institution, raion or national level.

For a detailed analysis of the current situation and inventory of the PHC facilities, see Chapter 5.4.1. – Inventory of the infrastructure of the PHC institutions.

2.3.3 Inventory of the equipment of the PHC institutions

The inventory of the equipment of the PHC institutions was done by incorporating in the questionnaire the standard list of equipment for rural health institutions, as stated by a common Order of Ministry of Health and of Health Insurance Company, Ordinul Ministerului Sanatatii si Companiei Nationale de Asigurari in Medicina Nr. 144/65-A din 12.04.2007. See Annex 3. – PHC system evaluation questionnaire

Every PHC institution filled up the questionnaire with the following number of units of equipment: standard number of units, existing number of units with less than 50% wear and needed number of units (the wear of the equipment was estimated according with the current norms and regulations.

The following table presents the inventory of the existing equipment with less than 50% wear, as totals for the whole PHC system in the country.

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EQUIPMENT EXISTING, WEAR < 50%

Medical devices 1 Blood pressure meter 3987 2 Stethoscope 4036 3 Ocular tonometer 794 4 Obstetrical stethoscope 1180 5 Children weighting scale 1159 6 Children anthropometer 1079 7 New born examination table 1146 8 Automatic 6 channel electrocardiograph 95 9 Portable 3 channel electrocardiograph 501 10 Adult peakflowmeter 1029 11 Children peakflowmeter 1009 12 Glucosemeter 314 13 Clinical laboratory set 233 14 Biochemistry laboratory set 129 15 Sterilizer 988 16 UV lamp for air disinfection 1155 17 Big stainless steel boxes 1662 18 Small stainless steel boxes 1687 19 stainless steel table for medical devices 1470 20 Gynecology table 1025 21 Pelvimeter 990 22 Neurology examination set 837 23 Othoscope 1461 24 Ophthalmoscope 1528 25 Portable examination lamp 486 26 Guzon ear syringe 379 27 Set of Kramer splints 442 28 Vision chart 1098 29 Computer 415 30 Printer 168 Medical devices set 31 Specule ginecologice 14609 32 Cornţanguri 2237 33 Scalpel 1540 34 Anatomical pincers 1786 35 Surgical scissors (straight) 673 36 Surgical scissors (curved) 661 37 Medical catheters 744 Special objects 38 GP’s medical kit 1747 39 Tourniquet 1612 40 i.v. infusions holder 1582 41 Medical thermometers 4762 42 Length meter 2105 43 Chronometer 1764 44 Goniometer 55 45 Adult rectal tubes 228 46 New born rectal adult 148 Medical equipment and furniture 47 Folding screen 204 48 Medical bed 2646 Page 21 of 121

49 Physician’s table 1263 50 Nurse’s table 1880 51 Drugs cabinet in the medical procedures room 693 52 Drugs cabinet for emergency drugs 590 53 Furniture set for clothes, books 716

Table 3 – Inventory of the standard equipment, with less than 50% wear in the PHC institutions (august 2007), total for Moldova

All data had been collected into the database and reports can be extracted at institution, raion or national level.

2.3.4 Inventory of the Human Resources of the PHC institutions

The inventory of the HR of the PHC institutions had been done by two sections of the questionnaire: - Institution Level HR chapter, where the number and types of the staff had been collected by institution - HR Registry chapter – each PHC staff member filled up personal and professional information, in order to develop the PHC HR Registry See Annex 3. – PHC system evaluation questionnaire

In the Institution Level HR chapter the structure of the PHC workforce had been reported as follows: 2135 Family Doctors, 5380 Nurses, 2242 auxiliary medical staff, 85 pharmacists and 149 accountants.

All data had been collected into the database and reports can be extracted at institution, raion or national level.

For a detailed analysis of the current situation and inventory of the PHC HR, see Chapter 5.3.1 Inventory of the Human Resources in the PHC system

2.3.5 Current situation of the medical and management education of the PHC staff

The current situation of the medical and management education of the PHC staff was evaluated through the HR Registry chapter of the questionnaire. Each PHC doctor and nurse filled up data about their university degree, specialization degree, CME courses attended, management courses, as well as their professional degree/level. See Annex 3. – PHC system evaluation questionnaire

All data had been collected into the PHC HR Registry and reports can be extracted at individual, institution, raion or national level.

IMPORTANT NOTE! The current situation of the medical and management education of the PHC staff was evaluated through the HR Registry chapter of the questionnaire. Because the timeframe of the project was so short, the data reported in this section of the questionnaire was of poor quality and there was no other source data to do cross validation, the data cleaning and validation process was very difficult. It is very important that the data cleaning work should be finalized before running the final statistics on this matter and plan for the future CME courses.

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For a detailed analysis of the current situation of the PHC HR education, see Chapter 5.3.4 Medical and Management Education of the PHC staff.

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WP 3. – Development of the Master Plan

Generally, the development of the Master Plan had three steps: 1. Assessment of the baseline, i.e. the inventory of the PHC HR, infrastructure and equipment 2. Defining of the target model and needs assessment 3. Planning of the restructuring process, on each component, in order to migrate from the current situation (baseline) to the target model

The development of the inventories on each component was shown in the Chapter 2.3 Consolidation of the inventory of PHC facilities, equipment and human resources.

3.1 Methodology for HR needs assessment See Chapter 5.3.2 - Human Resources needs assessment

3.2 Methodology for infrastructure rehabilitation needs assessment See Chapter 5.4.2 – Infrastructure standards and estimating the infrastructure needs

3.3 Methodology for equipment needs assessment See Chapter 5.5 – The Medical Equipment in PHC institutions

3.4 Consensus building on the methodology

The methodology was discussed and elaborated with the MoH PHC WG in multiple brainstorming sessions and then approved by the Ministry of Health.

3.5 Design of the selection and prioritization criteria for infrastructure refurbishment or reconstruction

3.5.1 Assessment of the standards and the results of the previous WB Health Investment Fund project

The project team evaluated the process, the standards and the results of the previous WB HIF project. The 95 Centers that were refurbished then, as well as the equipment and training that was provided, have been evaluated with the same procedure as the for the other PHC institutions. All data is stored and accessible from the database.

3.5.2 Assessment of the complementary investments in PHC system

Although attempts have been made by the consultant that participated in the last Donors’ Meeting within Ministry of Health, links were not identified, except the upcoming EU PHC project.

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Complementary funding has been identified on local Raional level. The Public Health Authorities will invest in water and gas supply system in the next 4 years. The next diagram shows the level of investments, by raion. The kind of investment and the exact value can be extracted from the database for each institution.

Ialoveni Ceadir-Lunga Ocnita Briceni Floresti Telenesti mun. Balti Straseni Dubasari Nisporeni Glodeni Causeni Soldanesti Cantemir Donduseni Orhei Cahul Vulcanesti Ungheni Singerei Rezina Taraclia Stefan-Voda Soroca Riscani mun. Chisinau Leova Falesti Edinet Drochia Criuleni Comrat Cimislia Calarasi Basarabeasca Anenii-Noi Hincesti 0 200 400 600 800 1000 1200 1400 Mii Lei

Figure 7 – Predicted Public Health Authorities Investments in PHC system, 2007-2010, totals by raion

3.5.3 Criteria for the selection and prioritization for infrastructure refurbishment or reconstruction See Chapter 5.10 Selection of the Rural Health Centers for the first rehabilitation phase

3.5.4 Consensus building on selection and prioritization criteria

The Ministry of Health PHC WG participated in the criteria development process and accepted the final version of it.

3.6 Assessment of the infrastructure rehabilitation costs and development of an investment simulation tool

3.6.1 Assessment of the infrastructure rehabilitation costs See Chapter 5.9 – Estimation of the costs for rehabilitation of the PHC institutions

3.6.2 Assessment of the costs of equipment

The assessment of the total cost of the equipment that needs to be procured for the PHC system can be done by having the estimated unit costs in the simulation tool of the database and considering the needs assessment that was done by the project with the adjustments after the local PHC restructuring plan – see the final recommendations of the project.

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3.6.3 Assessment of the running costs of the PHC institutions

In order to assess the running costs of the PHC institutions, the questionnaire had a distinct part that collected the total values for the year of 2006 of the following expenditure types:

Expenditures Salaries Taxes Electricity Gas Heating Drugs total Reimbursed Drugs Drugs for Emergency Fuel Transport Water and Sewage Major rehabilitation Equipment Other expenditures

Table 4 – Types of expenditures that had been collected from each PHC institution

Unfortunately, the current methodology of reporting the expenditures is by aggregating them at raion level, not reporting them at institution level. In order to analyze the running costs of each institution separately, the project need to track down the actual expenditures of them. Therefore, the project initiated a reporting system in the questionnaire that would enable each institution to report its own expenditures.

The analysis of the reported data showed that there is huge variability in the unit running costs among institution and among raions. It was impossible to calculate adequate averages of the unit running costs and to use them in further sustainability simulations. The reasons of this huge variation of the unit running costs are the big differences in the running costs of the utilities among raions, the variation of the presence of utilities among institutions and, probably, the reporting errors due to the fact that these institutions do not keep their own income/expenditure balance.

For some results of the running costs analysis, see Chapter 5.8 – Analysis of the financial data of PHC institutions.

3.6.4 Development of the investment simulation tool

The database application that was developed in the project serves also as a simulation tool. It contains all the PHC institutions with all their characteristics, including the current standards and the estimative costs of refurbishing and the running costs for each institution. In order to provide the simulations for equipment procurement, the estimative costs per unit of the equipment should be filled up. All the simulations that had been done in this project used this tool.

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WP 4. – Consensus Building

The Work Package 4 represented the ongoing effort of consensus building. It was expected to be a difficult process because of the organizational, professional and financial consequences on the whole health system if a major restructuring of the PHC system, PHC role and PHC financial allocation will be adopted as part of the Health System Development Strategy.

The Consultant approached the overall project with two key principles in mind, which we believe have a tremendous impact on the success and long-term sustainability of any project: communication with all key stakeholders and consensus building.

4.1 Consensus building with the MoH PHC WG and other key decision makers within the MoH

The team worked in close collaboration with the Primary Health Care Group constituted in the Ministry of Health and on a permanently basis with Ms. Tatiana Zatic, coordinator of the Working Group and Mr. Veaceslav Hametchi, civil constructions engineer. MOH and other Government staff were actively involved with the consultant and experts in the planning, designing, implementation, supervision and analysis of each of the activities specified in the ToR, including final recommendations.

4.2 Consultations with other institutions with a key role in the PHC system

- the relevant staff within the Scientific and Practical Center for Public Health and Health Management, regarding the current data collection and methodology and tools for PHC data collection - staff of the previous WB Health Investment Fund project - international and local experts working in Public Health Reform Project, Moldova, running the Primary Care Pilot project currently implemented in Orhei and Chisinau. - meetings with experts from Civil Construction Engineering Faculty, Chisinau, in order to asses and develop a feasible methodology for PHC infrastructure and rehabilitation costs’ evaluation - meetings with experts of INGEOCAD, the institute that is responsible for cadastral and maps development activities for Republic of Moldova, in order to develop the interactive PHC GIS (Geographical Information System – digital map)

4.3 Consensus building with the Raional Health Authorities

There were several times when the project team worked for building the consensus with the Raional Health Authorities:

- meeting with Vice-Chiefs-Doctors of all Raions on the occasion of launching the project and training for data collection by the questionnaire - distributing the distinct section of the questionnaire for collecting the opinion of the local authorities regarding the selection and prioritization of the health centers for rehabilitation - distributing the distinct section of the questionnaire for collecting the data regarding their investment planning in the PHC area in the next 4 years - during the site evaluation visits, the local experts usually met the local authorities, too - final conference of the project

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4.4 Final conference of the project It will be held on September 28, 2007. Location: Ministry of Health

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5. Master Plan for the Primary Care Workforce and Infrastructure

5.1 General overview of the PHC system in Moldova

The project’s ToR specifies that there is no need to describe the current PHC system general overview. A very detailed and comprehensive overview of the Moldova PHC system is presented in the report: Atun R, PHC Development Strategy for Moldova. Final Report, March 2007.

The organization of the Primary Health Care system in Moldova is primarily regulated by the Ministry of Health’s Order 190/2003 – Structure of the Municipal and Raional Health System. The figure below presents the Organizational Chart of the Raional PHC System as it is stated in the Order.

In summary, in each raion, the PHC activity is done by the following institutions: - CMF (Centrul Medicilor de Familie) – Center for Family Doctors - CS (Centru de Sanatate) – Health Center - OMF (Oficiul Medicului de Familie) – Family Doctor Office - PM (Punct Medical - filiala a CS/OMF) – Health Post

In each raion, there is one institution, the Center for Family Doctors (CMF) that is responsible for coordinating the whole PHC activity in that raion. CMF is subordinated to the Head Doctor of the Raion and it is run by the PHC Vice-Head Doctor of the raion. CMF consists of all Health Centers (CS) in that raion.

Health centers (CS) are institutions that actually provide PHC services. There is one CS in each capital of the raion and a number of other CS in rural areas. Each CS is run by a Head of CS. CSs usually cover for a number of population greater than 2500 people and have 2 up to 7 family doctors. CSs also include Family Doctor Offices (OMF) and Health Posts (PM).

The Family Doctor Office (OMF) is a smaller institution than CS that provides PHC services. It usually covers for a number of population ranging from 1000 to 2500 people and has 1 doctor.

The Health Posts (PM) is even a smaller institution that provides PHC services, covering for a population fewer than 1000 people. They usually do not have doctors, but nurses.

The organization of the PHC system in Balti city is the quite the same as in raions, with one Municipal Center for Family doctors, some CSs and one OMF, but it is slightly different in Chisinau city, where there are multiple CMFs organized under Territorial Medical Associations (Asociatie Medicala Teritoriala - AMT) that include also hospitals, outpatient services, emergency services and others.

The payment system for PHC services consists mainly of a per capita system.

The detailed description of each element of the PHC system is done under the correspondent chapter of this report.

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Figure 8 - The organizational chart of the Public Raional Health System

PUBLIC RAIONAL HEALTH SYSTEM

Raional Council Ministry of Health

Head Doctor of the Raional System Center for Preventive Medicine Vice Head Doctor for Vice Head Doctor for Vice Head for HR and Juridical Primary Health Care Hospital and Economics Department Specialised Care Medical Informatics Department

Mother and Chield Center for Family Hospitals Accounting Department Doctors (CMF) Department

Outpatients clinics Pharmaceutical Health Center (CS) Department

EMS Technical and Medical Equipment Administrative Family Doctor Department Office (OMF) Department

Stomatology clinics Health Post (PM)

5.2 The role and the organization of the PHC institutions

The evaluation of the current situation has been done by the following activities: - the analysis of the relevant documents - meetings and interviews with key decision makers - the analysis of the data collected by the following questionnaires: the questionnaire for each PHC institution, the questionnaire for each PHC medical worker (only doctors and nurses), the questionnaire for each Raional Public Health Authorities - site evaluation visits in all 361 Rural Health Centers (CS) - development of the PHC institutions database, the Registry of the PHC Human Resources and the PHC GIS - detailed analysis of each Rural Health Center (CS), especially its role, HR and infrastructure, together with Family Medici specialists and civil constructions specialists from the MoH PHC WG, by using the data and the pictures taken during the site visits (over 4000 pictures of all CS.

5.2.1 General situation of the PHC institutions

The database contains detailed information for 2006 for each of the 1261 PHC institutions (geographic and demographic data, infrastructure and equipment data, human resources, provision of services and financial data.

5.2.1.1 Distribution of PHC institutions by type

The following type and number of PHC institutions has been assessed: - 5 AMT (Asociatie Medicala Teritoriala) – Territorial Medical Association - 13 CMF (Centrul Medicilor de Familie) – Center for Family Doctors - 396 CS (Centru de Sanatate) – Health Center - 559 OMF (Oficiul Medicului de Familie) – Family Doctor Office - 288 PM (Punct Medical - filiala a CS/OMF) – Health Post

In the database, the Raional CMFs were assimilated as CS for data management reasons.

AMT; 5; 0% CMF; 13; 1%

PM; 288; 23%

CS; 396; 31%

OMF; 559; 45%

Figure 9 – Distribution of PHC institutions by type – total Republic of Moldova

The following table presents the distribution of the PHC institutions by raion.

Raion AMT CMF CS OMF PM Total mun. Chisinau 5 13 15 9 2 44 mun. Balti 6 1 7 Anenii-Noi 13 14 8 35 Basarabeasca 4 3 7 Briceni 11 16 8 35 Cahul 14 27 2 43 Cantemir 6 31 4 41 Calarasi 11 24 35 Causeni 15 10 3 28 Cimislia 7 15 14 36 Criuleni 12 17 7 36 Donduseni 10 10 6 26 Drochia 14 18 1 33 Dubasari 8 2 1 11 Edinet 14 21 2 37 Falesti 8 26 34 Floresti 14 26 23 63 Glodeni 10 12 4 26 Hincesti 15 23 11 49 Ialoveni 16 6 11 33 Leova 7 16 9 32 Nisporeni 10 13 8 31 Ocnita 9 19 1 29 Orhei 18 30 17 65 Riscani 10 18 19 47 Page 32 of 121

Rezina 7 15 10 32 Singerei 10 16 31 57 Soroca 15 25 18 58 Straseni 13 15 9 37 Soldanesti 9 11 7 27 Stefan-Voda 13 11 2 26 Taraclia 6 9 8 23 Telenesti 10 21 11 42 Ungheni 16 24 31 71 Ceadir-Lunga 9 9 Vulcanesti 3 3 Comrat 8 5 13 Total 5 13 396 559 288 1261 Table 5 – Distribution of PHC institutions by type and raion

5.2.1.2 Sanitary authorization and accreditation of the PHC institutions

As the next figures show, 19% of the PHC institution does not have the sanitary authorization and 20% are not accredited.

NA; 53; 4% no; 244; 19%

yes; 964; 77%

Figure 10 – Sanitary authorization of the PHC institutions

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Neraportat; 65; 5% nu; 251; 20%

da; 945; 75%

Figure 11 – Accreditation of the PHC institutions

5.2.2 Demographic data

Regarding the population demographic data, the database contains breakdown data of population by age and gender for each PHC institutions, including the coverage with health insurance of that population. The following table shows the population by raion as a sum up of the population of each PHC institution in the database.

Raion Population mun. Chisinau 719696 mun. Balti 135157 Anenii-Noi 80445 Basarabeasca 28886 Briceni 79188 Cahul 117272 Cantemir 64708 Calarasi 80020 Causeni 94059 Cimislia 72145 Criuleni 76212 Donduseni 48919 Drochia 89324 Dubasari 31115 Edinet 85106 Falesti 91496 Floresti 89343 Glodeni 65325 Hincesti 119159 Ialoveni 100942 Leova 53131 Nisporeni 64326 Ocnita 56164 Page 34 of 121

Orhei 127589 Riscani 87519 Rezina 49956 Singerei 101058 Soroca 100175 Straseni 87783 Soldanesti 43807 Stefan-Voda 69016 Taraclia 44579 Telenesti 70402 Ungheni 117062 Ceadir-Lunga 62397 Vulcanesti 24506 Comrat 69738 TOTAL MOLDOVA 3497725

Table 6 – Distribution of the population by raion

The following example shows a break down of the population of Stefan Voda raion, by CS, OMF and PM.

Raion PHC Institution Population Stefan-Voda CS Ştefan-Vodă 7801 Stefan-Voda OMF Marianca de Jos 534 Stefan-Voda OMF Stefanesti 1218 Stefan-Voda OMF Brezoaia 1033 Stefan-Voda OMF Semionovca 832 Stefan-Voda PM Lazo 129 Stefan-Voda OMF Alava 366 Stefan-Voda OMF Popeasca 2327 Stefan-Voda OMF Festelita 2843 Stefan-Voda CS Ermoclia 4158 Stefan-Voda CS Volontiri 3833 Stefan-Voda OMF Copceac 2416 Stefan-Voda CS Tudora 1881 Stefan-Voda OMF Palanca 1980 Stefan-Voda CS Caplani 3239 Stefan-Voda CS Crocmaz 2905 Stefan-Voda CS Carahasani 3071 Stefan-Voda CS Purcari 1962 Stefan-Voda PM Viisoara 486 Stefan-Voda OMF Rascaieti 2881 Stefan-Voda CS Cioburciu 2713 Stefan-Voda OMF Rascaietii Noi 654 Stefan-Voda CS Antonesti 2709 Stefan-Voda CS Slobozia 4230 Stefan-Voda CS Talmaza 7324 Stefan-Voda CS Olanesti 5491 Stefan-Voda 69016

Table 7 – Distribution of the population of Stefan Voda raion, by PHC institutions

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5.2.3 Access of the population to medical institutions

Physical (geographical) access to medical institutions is one of the elements of the population access to health services, along with the financial affordability of the health services. Physical access include geographical coverage with medical institutions, availability of specialized staff in the area, availability of specialized services, equipment etc. Some of these elements of the physical access of the populations to primary health care are presented in detail in the report.

A distinct section of the questionnaire has addressed this issue, as it is presented in the following table.

Physical access of population to health care: Average coverage range of the PHC institution (km) Existence of public transport services in the PHC institutions’ localities Average time to PHC institution (min) Status of the roads Physical access of population to pharmaceutical services Existence of a public pharmacy Existence of a private pharmacy Physical access of population to emergency services Existence of an emergency unit Distance of the emergency unit to the PHC institution Access to specialized outpatient services / hospital Distance PHC institution - Hospital Existence of the public transport services to hospital Average time to hospital

Table 8 – Questionnaire data elements of access of the population to medical institutions

Detailed reports can be generated for each institution or raion for each indicator. Some of the national indicators will be presented in the followings.

5.2.3.1 Physical access of the population to PHC institutions

The geographical coverage is considered to be a good one, 87% of the households (93% in urban area and 82% rural area) being within a range of 5 km of a medical institution - see “Accesul Populaţiei Republicii Moldova la Serviciile Medicale”, Berdaga V, Ştefaneţ S, Bivolo. Unicef. Chisinau, Moldova. 2000)

The status of the roads within the localities with PHC institutions

The status of the roads within the localities with PHC institutions is very poor, only 4% of them being reported as concrete made. This situation shows a hard access to PHC institutions, especially in the winter time.

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NA concrete stone 2% 4% 4% concrete and stone 1%

earthen, stone and concrete earthen 40% 22%

earthen and concrete 7% earthen and stone 20%

Figure 12 – Status of the roads in the villages with PHC institutions

The database contains all the other relevant data presented above that can be used for community analysis of the PHC system – see the final recommendations of the project.

5.2.3.2 Physical access of the population to pharmacy services

The number of the localities with PHC institutions that has no pharmacy units is shown in the next figure by raion.

Cahul Ungheni Hincesti Floresti Riscani Singerei Ialoveni Criuleni Straseni Ocnita Cantemir Taraclia Orhei Donduseni Briceni Nisporeni Edinet Comrat Telenesti Soldanesti Leova Soroca Rezina Glodeni Drochia Cimislia Causeni Anenii-Noi Vulcanesti Ceadir-Lunga Stefan-Voda Falesti Dubasari Calarasi Basarabeasca 0 5 10 15 20 25 30 Numar localitati pe raion

Figure 13 - Number of the localities, by raion, with PHC institutions but no pharmacy units

The next table presents the situation of the public and private pharmacies by raion. A number of 179 rural localities have no pharmacy units. Cahul and Ungheni raions have more than 29 localities with no pharmacy unit, but Basarabeasca, Calarasi, Dubasari, Falesti, Stefan Voda, Ceadir-Lunga and Vulcanesti have a full coverage with pharmacies.

No of State Private Raion localities pharmacy pharmacy No pharmacy Page 37 of 121

mun. Chisinau 44 mun. Balti 7 Anenii-Noi 35 34 4 1 Basarabeasca 7 7 2 Briceni 35 26 13 5 Cahul 43 7 9 24 Cantemir 41 30 4 8 Calarasi 35 34 9 Causeni 28 23 5 1 Cimislia 36 33 3 1 Criuleni 36 24 8 9 Donduseni 26 21 5 5 Drochia 33 29 12 1 Dubasari 11 11 3 Edinet 37 30 14 3 Falesti 34 33 6 Floresti 63 40 13 13 Glodeni 26 24 4 1 Hincesti 49 33 10 15 Ialoveni 33 20 8 9 Leova 32 26 4 2 Nisporeni 31 27 2 3 Ocnita 29 15 7 8 Orhei 65 56 9 5 Riscani 47 29 7 12 Rezina 32 27 6 1 Singerei 57 44 9 9 Soroca 58 35 9 1 Straseni 37 28 7 8 Soldanesti 27 25 3 2 Stefan-Voda 26 26 13 Taraclia 23 18 4 5 Telenesti 42 31 6 2 Ungheni 71 47 5 23 Ceadir-Lunga 9 7 8 Vulcanesti 3 3 1 Comrat 13 9 4 2 Total 1261 912 236 179

Table 8 - Distribution of the public and private pharmacies in the localities with PHC institutions, by raion

5.2.3.3 Physical access of the population to specialized outpatient facilities and hospital

In the raions, the specialized outpatient facilities are usually located in the raional hospital.

5.2.3.3.1 Maximum coverage range of the raional hospital

As it is presented in the next figure and table, the maximum coverage range of the Cahul Raional Hospital is the longest (75 km) and the one of Basarabeasca Raional Hospital is the shortest (25 km). The distance from the PHC institution to the Raional Hospital was chosen Page 38 of 121 as a criteria for selecting the PHC institution for rehabilitation: the longer the distance, the higher priority in the rehabilitation list – see Chapter 5.10 – Selection of the Rural health Centers for the first rehabilitation phase

Cahul Hincesti Telenesti Taraclia Glodeni Floresti Criuleni Ialoveni Soroca Cantemir Ungheni Causeni Comrat Ceadir-Lunga Straseni Singerei Rezina Briceni Stefan-Voda Soldanesti Riscani Ocnita Drochia Leova Calarasi Orhei Falesti Anenii-Noi Dubasari Vulcanesti Nisporeni Edinet Donduseni Cimislia Basarabeasca mun. Chisinau mun. Balti 0 10 20 30 40 50 60 70 80 km

Figure 14 - Maximum coverage range of the raional hospital

The next table presents the PHC institutions that are the most far away from the Raional Hospital and the distance in km.

Raion CS or OMF Maximal Distance to Hospital (Km) mun. Balti CS Elizaveta 10 mun. Chisinau OMF Dobruja 22 Basarabeasca CS Bascalia 25 Cimislia PM Sagaidacul Nou 35 Donduseni OMF Teleseuca 35 Edinet OMF Corpaci 35 Nisporeni OMF Bratuleni 35 Vulcanesti CS Etulia 35 Dubasari CS Parata 36 Anenii-Noi CS Varnita 37 Falesti OMF Natalievca 38 Orhei PM Sercani 40 Calarasi OMF Bahu 42 Leova OMF Orac 44 Drochia OMF Popestii de Jos 45 Ocnita PM Berezovca 45 Riscani CS Costesti 45 Soldanesti OMF Gauzeni 45 Stefan-Voda CS Crocmaz 45 Briceni CS Pererata 47 Rezina CS Lalova 47 Singerei OMF Balasesti 50 Straseni CS Micauti 50 Ceadir-Lunga CS Copceac 50 Comrat OMF Cotovscoe 50 Causeni OMF Chircaiestii Noi 55

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Ungheni OMF Cornova 56 Cantemir OMF Taracliica 57 Soroca OMF Regina Maria 57 Ialoveni PM Homuteanovca 58 Criuleni OMF Dolinnoe 60 Floresti CS Sanatauca 60 Glodeni OMF Japca 60 Taraclia CS Tvardita 60 Telenesti OMF Tarsitei 60 Hincesti OMF Poganesti 62 Cahul OMF Frumusica 75

Table 9 – The remotest PHC institutions from the Raional Hospital and the distance

5.2.3.3.2 Public transport to the Raional Hospital

The availability of the public transport to the hospital had bed analyzed for each locality with a PHC institution. At one side, there is Singerei raion where there are 38 localities with no direct public transport to the hospital, while at the other side there are raions like Anenii-Noi, Dubasari, and Soroca etc. with almost full coverage with public transport.

All the localities with no public transport to the hospital can be queried in the database.

Singerei Riscani Hincesti Ialoveni Straseni Drochia Ungheni Leova Cimislia Criuleni Donduseni Comrat Ocnita Nisporeni Taraclia Floresti Glodeni Falesti Cantemir Soldanesti Causeni Telenesti Rezina Edinet Calarasi Vulcanesti Orhei Cahul Basarabeasca mun. Chisinau Stefan-Voda Briceni Soroca Dubasari Anenii-Noi Ceadir-Lunga mun. Balti 0 5 10 15 20 25 30 35 40 45 Numar localitati

Figure 15 – Number of localities with no public transport to the hospital, by raion

5.3.3 Discrepancies in the current organization of the PHC institutions

In general, PHC institutions like AMT, CMF and Raional CS are very distinct and peculiar institution, generally located in or nearby the hospitals (for example rural CS are usually located within the raional hospital), with a large variability of conditions like facilities and human resources depending upon the number of population that they cover. Analysis and optimization of such institutions should be done separately, one by one. Our focus in the next analysis was on rural PHC institutions.

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A summary of the current standards for CS, OMF and PM looks like the followings:

Rural CS – Rural Health Center Population – more than 2500 persons Family Doctors – 2-7 Area - 250-300 m2

OMF - Family Doctor Office Population – 1000 - 2500 persons Family Doctors – 0-1 Area - 150 m2

Filiala a CS/OMF (PM) – Health Posts Population – under 1000 persons Family Doctors – 0 Area - 100 m2

The following examples show some of the discrepancies of the current organization of these institutions against the current standards.

Analysis of the PHC institution by number of Family Doctors. In the next table one can see that there is a big variability among these institutions: 17 CS do not have any Family Doctors and 141 CS have only one Family Doctor, while the standard is two doctors, at least.

The same kind of analysis for OMF shows that there are 44 OMF with more than one doctor and (the standard being 1) and that there are 29 PM with at least one doctors, while they should not have any, according to the standards.

Type of PHC institution Number of Family Doctors Number of institutions CS 10 1 CS 8 3 CS 7 2 CS 6 1 CS 5 17 CS 4 21 CS 3 45 CS 2 109 CS 1 141 CS 0 17 OMF 5 1 OMF 3 2 OMF 2 41 OMF 1 271 OMF 0 244 PM 2 1 PM 1 28 PM 0 259 Table 10 – Distributions of PHC institutions by type and number of Family Doctors

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The following two figures show the CS and PHC type of institutions that cover less population than the standard: 44 CS with population under 1500 (while the standard is 2500) and 68 OMF with population under 800 (while the standard is1500).

CS < 1500; 44; 12%

CS > 1500; 311; 88%

Figure 16 – CS with population less than 1500

OMF < 800; 68; 12%

OMF > 800; 492; 88%

Figure 17 - OMF with population less than 800

Another interesting results was when analyzing the PM with population less than 500 (while the standard is 1000) that are located within a range of 3 km from other PHC institution.

Page 42 of 121

PM < 500, < 3km; 56; 20%

other PM; 231; 80%

Figure 18 - PM with population less than 500 and less than 3 km away from another PHC institution

Another type of discrepancy is the OMF that cover a larger population than the CS that is hierarchically above them. The next figure shows the number of such OMF by raion.

Soroca Floresti Falesti Cahul Orhei Leova Edinet Criuleni Calarasi Ungheni Hincesti Telenesti Stefan- Drochia Taraclia Ocnita Nispore Glodeni Dondus Cimislia 0 1 2 3 4 5 6 7 8 9 10 Number of OMF

Figure 19 – No of OMF that cover a larger population than the CS that they belong to

Finally, the analysis showed the number of OMF that not only that they cover a larger population than the CS they belong to, but have a larger number of Family Doctors, an up- side-down situation when comparing to the standards.

CS OMF Diff. in CS CS No of OMF OMF No of Diff. in No of Raion Name PopulationDoctors Name PopulationDoctors PopulationDoctors CS OMF Calarasi Parjolteni 1946 1 Horodiste 2911 2 -965 -1 Calarasi CS 741 1 OMF 957 2 -216 -1

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Harjauca Palanca CS OMF Edinet Zabriceni 1112 1 Terebna 1473 2 -361 -1 CS OMF Edinet Hincauti 1361 1 Cepeleuti 1792 2 -431 -1 CS OMF Falesti Marandeni2917 1 Rautel 4077 2 -1160 -1 CS OMF Falesti Marandeni2917 1 Parlita 3334 2 -417 -1 CS OMF Floresti Marculesti 2326 0 Bahrinesti 2605 1 -279 -1 CS Gura OMF Floresti Cainarului 1508 1 Prajila 2594 2 -1086 -1 CS OMF Soroca Ocolina 1023 1 Zastanca 2154 2 -1131 -1 CS OMF Soroca Curesnita 507 1 Septelici 1122 2 -615 -1 CS Slobozia - OMF Soroca Cremene 1299 0 Varancau 1812 1 -513 -1 Stefan- CS OMF Voda Purcari 1962 1 Rascaieti 2881 2 -919 -1

Table 11 - OMF that cover a larger population than the CS they belong to and have a larger number of Family Doctors

All the above examples, together with the results of the analysis of the huge area of the buildings and huge rehabilitation costs are strong indications that, before making a final investment planning the decision makers should restructure the PHC institutions at least to fit the current standards, if not a set of more adequate standards. The restructure of these institutions would be the first step towards cost-efficiency and sustainability of the investments – see the final recommendations of the project.

5.3 Human Resources in the PHC system

5.3.1 Inventory of the Human Resources in the PHC system

The table below shows the general situation of the Human Resources for the PHC system in the Republic of Moldova, as it has been evaluated through the questionnaire.

Human Resources Total Number Family Doctors 2135 Nurses 5380 Auxiliary stuff 2242 Pharmacists 85 Page 44 of 121

Accountants 149 Total 9991

Table 12 – Total number of human resources in the PHC system, by type

From this data we can extract the ratio of other type of personnel for a medical doctor. In the PHC system in Moldova there are 2.5 nurses for a family doctor, but the ratio of all personnel to a family doctor is 3.7. These ratios are important especially when you want to anticipate the sustainability of the institutions under complete financial autonomy that is an objective of the National Health Sector Reform Strategy - considering that the personnel salaries are the highest expenditure category from the total expenditures.

Indicator Ration of other staff to a Family Doctor No of nurses to 1 Family Doctor 2,5 No of auxiliary stuff to 1 Family Doctor 1,1 No of all other staff to 1 Family Doctor(*) 3,7 Table 13 – Ratio of all other staff to a Family Doctor (*) – total of all other staff, except the Family Doctors

Regarding the evolution of the number of family doctors from 1990 to date – compared with the ’90, the number increased considerably (2135 today compared with 1440-1500 in the ’90). A significant increase happened in 1999, followed by a constant increasing trend, but starting with 2004 the trend is decreasing.

3000

2563 2521 2500 2417 2446 2272 2280 2208 2135

2000

1733

1527 1521 1494 1502 1490 1505 1500 1441 1441

1000 Numar de medicide de Numar medicina primara

500

0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2007

Figure 20 – Number of doctors by year, Republic of Moldova (source: European health for all database; project’s data for 2007)

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A similar trend is noticed for the ratio of family doctors to the general population number (100,000 inhabitants), as presented in the graph below.

71,12 70 67,7

61,42 61,04 59,03 60 57,06 53,02 53,6

40,33 40 35,01 34,88 34,36 34,54 34,45 34,92 33,12 33,21

Numar de medici de medicina primara la 100000 de de locuitori medicide lade 100000 Numar medicina primara 10

0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2007

Figure 21 - Number of doctors per 100000 inhabitants, by year, Republic of Moldova (source: European health for all database; project’s data for 2007)

5.3.2 Human Resources needs assessment

Several needs assessment and planning methods for medical human resources are described in the relevant literature, based on different criteria: - Health services needs assessment - Utilization of health services - Health services demand - Population (medical personnel / population ratio) - Health policy objectives - Community needs

The method based on Health Services Needs Assessment assumes that previous epidemiological studies had been carried out and that prioritization of interventions based on results of these studies had been done – as it is not possible to satisfy at once all health needs of the population. This method is mainly used in the health systems having a major component of public financing.

The method based on Utilization of Health Services correlates the utilization of health services with the demographic characteristics of the population (age groups, sex and geographic distribution) and tries to estimate the medical human resources needs based on these correlations. The utilization ratio of health services represents the current covered demand for health services, but there will always remain an uncovered demand. Page 46 of 121

The method based on Health Services Demand of the population introduces the economical aspect besides the epidemiological one in the estimation of the medical human resources need – by estimating the financial costs in providing the demanded services to the population. This method is preferred in the evaluation of medical human resources needs in the health systems with an important component of private financing.

The method of Medical Personnel / Population Ratio (medical personnel coverage, density) means the selection of a convenient target for the coverage ratio of the population with medical personnel (usually doctors) This target value is usually picked up by comparison with a country or a region with similar conditions and it is validated by local experience.

The method based on Objectives Setting is a method trying to actively establish a balance among population health needs, existing medical technology and actual available resources in the system. In application of this method, a preliminary planning of the services is done; based on this, an estimation of needs and a planning of the medical human resources is deducted.

The method based on Community Needs is a decentralized method aiming at the local estimation of medical human resources need at local level, within the community; this way, the local specificity of the community, including its values are better reflected in the coverage with medical personnel.

Each of the methods presented above has advantages and disadvantages. These are mainly driven by two major elements: definition of the “need” and the technical difficulty of each method.

Regarding the definition of the “need”, it is already known that this is not a fixed, clearly defined concept, but strongly related with characteristics of the person/ population defining the “need” concept. In our case we can identify at least 3 perspectives for the “health services needs” definition: the patient’s perspective, the medical personnel perspective (mostly the doctor’s) and the financing/ planning agency perspective. These are quite different perspectives and if used separately they can lead to very different results. In practice they are combined and the final result is balanced by the “relative weight” and influence of each perspective.

Regarding the technical difficulty in applying any of the methods described above it is important to underline that the first three of them imply the preliminary existence of exhaustive data bases, specific studies and simulation tools. More than this, because of the complexity of the methodology there is a risk that the results are difficult to be totally accepted by the decision makers.

The medical personnel/ population ratio method it is widely used by the health services planning agencies, even though it presents important limitations; this is mainly because it is a very simple method and it doesn’t need extensive data or complicated studies and/ or simulations done (also more difficult to be understood or controlled).

In reality, the practical approach is to use different elements from more than one method.

As far as this project is concerned, the situation at the beginning at the project was as follows: - There were no available health services needs assessments Page 47 of 121

- There were no available population data (differentiated by age groups and/ or sex) at each institution level, but aggregated, at regional level - The benefits packages in primary health care were defined, but not adequately monitored - The utilization of services data it is not collected by type of services but only as number of visits plus some special categories of services which are paid separately under a fee for service scheme (monitoring of the pregnancy, early detection of TB, outpatient TB treatment, early cancer detection and HBP monitoring) - Data about utilization of health services is reported aggregated at raion level, not at institution level - There is no medical personnel registry (data base) for PHC

Under these circumstances, the medical human resources needs analysis and estimation were done using the “Medical personnel/ population ratio” method at system level (national level, raion level) and at community level (for Medical Health Centers or local groups of PHC institutions) it had been used the “Community needs” based method. More than this, in order to facilitate also the use of other methods/ approaches in the future, complete data regarding human resources, population and health service utilization at the level at each PHC individual institution has been collected – see Annex 3, PHC system evaluation questionnaire.

The method of Medical Personnel/ Population Ratio (medical personnel coverage)

At present, in the PHC system in the Republic of Moldova the needs assessment and planning of medical human resources uses the above mentioned method. The agreed standard is regulated by the Order 420/Dec. 1998 of the Minister of Health “Referitor la noile normative de state si reforma planificarii cheltuielilor in sistemul ocrotirii sanatatii” and has the following values: - 1 doctor and 2 nurses for 1500 inhabitants in urban area - 1 doctor and 3 nurses for 1500 inhabitants in rural

Calculating based on this standard, here there are the results:

Family Standard Shorta Standard Shortag Doctors Number ge Number e Area Standard Population (FD) FDs FDs Nurses Nurses Nurses 1 FD / 1500 p Urban 1 N / 750 p 1288916 1024 859 165 1311 1719 -408 2 FD / 1500 p Rural 1 N / 500 p 2208809 1111 1473 -362 4069 4418 -349 Total 3497725 2135 2332 -197 5380 6136 -756

Table 14 – Coverage with Family Doctors and Nurses, by urban/rural area, Republic of Moldova

- There is a surplus of 165 doctors in urban area and a shortage of 362 doctors in rural area, resulting in a general shortage of 197 doctors at national level - There is a shortage of 408 nurses in urban area and a shortage of 349 nurses in rural area, resulting a general shortage of 756 nurses at national level

As reported by the self administered questionnaire, at present there are 2135 family doctors in Republic Moldova, corresponding to a ratio of 1638 population for 1 doctor. Compared with the ratio from the ’90 (of 2850-3000 population for 1 doctor) the general number of doctors increased, with a better coverage of population; the peak for the increase

Page 48 of 121 has been in 1999 – after this date, the coverage is variable, somewhere in between 1400 and 1900 population for 1 doctor, as reflected in the graph below

3500

3019 3011 3000 2910 2856 2867 2895 2903 2864

2480 2500

2000 1886 1866 1753 1694 1628 1638 1477 1500 1406

1000 Populatie Medic la Medicinade 1 Primara

500

0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2007 Anul

Figure 22 – Population ratio to 1 Family Doctor, evolution between 1990 and 2007, Republic of Moldova (source: European health for all database; project’s data for 2007)

It is difficult to evaluate now if the current standard of 1500 population for 1 doctor is the most appropriate one, as there are neither previous studies available or data regarding the health services needs and/or utilization. If we look at the other European countries we notice that the 1500 population ration to one doctor target represents in fact the average coverage for Europe in general and coverage in countries like Bulgaria, Serbia, Croatia, Hungary etc, as reflected in the graph below. Also, it is noticeable that currently Moldova has a lower coverage than most of the developed countries from EU (France, Austria, Germany etc.), but is still has a better coverage than the former Soviet Union countries.

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France 601 Austria 682 Macedonia 988 Germany 1030 Lithuania 1152 Norway 1376 Czech Republic 1403 Bulgaria 1477 Serbia 1489 Croatia 1491 European Region 1514 Hungary 1531 Republic of Moldova 1628 Armenia 1699 Portugal 1773 Latvia 1806 Netherlands 1938 Ireland 1941 Albania 1965 Slovakia 2310 Eur-B+C 2499 Belarus 2854 Ukraine 3147 Kyrgyzstan 3147 Montenegro 3482

Populatie Medic la (2005) Medicinade 1 Primara CIS 3880 Russian Federation 4243 Georgia 4318 Tajikistan 4660 Bosnia and 4897 Azerbaijan 5669 Kazakhstan 6039 Uzbekistan 6285

0 1000 2000 3000 4000 5000 6000 7000

Figure 23 - Population ratio to 1 Family Doctor, Europe, 2005 (source: European health for all database) European Region: 53 countries in WHO European Region Eur-B+C: 26 countries in WHO European Region with high mortality - Albania, Armenia, Azerbaijan, Belarus, Bosnia and Herzegovina, Bulgaria, Estonia, Georgia, Hungary, Kazakhstan, Kyrgyzstan, Latvia, Lithuania, Montenegro, Poland, Republic of Moldova, Romania, Russian Federation, Serbia, Slovakia, Tajikistan, Macedonia, Turkey, Turkmenistan, Ukraine

A calculation for the doctors and nurses shortage in the rural area has been made, with the 1500 population for 1 doctor and 2 nurses as reference figures. The table below presents the results of these calculations.

Shortag %Shorta Stand Shortag %Shortag Populatio Standard e ge No e e Raion R/U n No FDs No FDs FDs FDs Nurses Nurses Nurses Nurses Hincesti R 102452 26 68 -42 -62% 122 205 -83 -40% Cimislia R 56245 8 37 -29 -79% 72 112 -40 -36% Falesti R 75217 21 50 -29 -58% 144 150 -6 -4% Orhei R 94710 34 63 -29 -46% 172 189 -17 -9% Causeni R 74762 27 50 -23 -46% 134 150 -16 -10% Cantemir R 57908 16 39 -23 -59% 106 116 -10 -8% Cahul R 79932 37 53 -16 -31% 165 160 5 3% Floresti R 73154 33 49 -16 -32% 150 146 4 3% Nisporeni R 47391 16 32 -16 -49% 76 95 -19 -20% Ungheni R 86272 42 58 -16 -27% 175 173 2 1% Leova R 42527 13 28 -15 -54% 74 85 -11 -13% Rezina R 35967 9 24 -15 -62% 63 72 -9 -12% Ialoveni R 83897 42 56 -14 -25% 133 168 -35 -21% Criuleni R 68030 33 45 -12 -27% 125 136 -11 -8% Anenii-Noi R 71662 38 48 -10 -20% 116 143 -27 -19% Glodeni R 53175 26 35 -9 -27% 94 106 -12 -12% Comrat R 45172 21 30 -9 -30% 90 90 0 0% Soroca R 64883 36 43 -7 -17% 140 130 10 8% Page 50 of 121

Singerei R 85556 50 57 -7 -12% 160 171 -11 -6% Stefan-Voda R 61215 34 41 -7 -17% 129 122 7 5% Riscani R 62397 35 42 -7 -16% 136 125 11 9% Dubasari R 31115 17 21 -4 -18% 58 62 -4 -7% Soldanesti R 36330 21 24 -3 -13% 78 73 5 7% Drochia R 69143 43 46 -3 -7% 162 138 24 17% Vulcanesti R 8496 3 6 -3 -47% 15 17 -2 -12% Ceadir-Lunga R 42994 26 29 -3 -9% 85 86 -1 -1% mun. Chisinau R 131377 85 88 -3 -3% 119 263 -144 -55% Taraclia R 29479 18 20 -2 -8% 57 59 -2 -3% Straseni R 69447 45 46 -1 -3% 129 139 -10 -7% Ocnita R 46909 30 31 -1 -4% 104 94 10 11% mun. Balti R 4600 2 3 -1 -35% 7 9 -2 -24% Basarabeasca R 17348 11 12 -1 -5% 27 35 -8 -22% Telenesti R 61802 42 41 1 2% 141 124 17 14% Briceni R 69329 48 46 2 4% 145 139 6 5% Edinet R 67013 47 45 2 5% 163 134 29 22% Calarasi R 62516 46 42 4 10% 112 125 -13 -10% Donduseni R 38387 30 26 4 17% 91 77 14 19% Total 2208809 1111 1473 -362 -25% 4069 4418 -349 -8%

Table 15 – The shortage of Family Doctors and Nurses in rural area, by raion

Based on these calculations, the following results were obtained: 1. Total number of doctors in rural area is 1111 for a population of 2208809 2. The total number for the shortage of doctors in rural area is 362, 25% 3. There are 4 raion with a surplus of doctors in the rural area – Donduseni (4), Briceni (2), Edinet (2) and Telenesti (1) 4. The doctors shortage in rural area varies from 1 to 42/ raion, most affected raion being (absolute numbers) Hincesti (42), Cimislia (29), Falesti (29), Orhei (29), Cantemir (23) and Causeni (23), or percentage wise Cimislia (79%), Hincesti (62%), Rezina (62%), Cantemir (59%), Falesti (58%), Leova (54%), all with a shortage of doctors over 50%. 5. Total number of nurses in rural area is 4418, meaning 3,7 nurses/ doctor (compared with the standard of 3 nurses/ doctor) 6. There is a shortage of 349 nurses (8%) in the rural area overall Moldova 7. There are 13 raion where nurses are in surplus for the rural area, better represented in the raion of (29 nurses - 22%), Drochia (24 nurses - 17%) and Donduseni (14 nurses - 19%). 8. A special case is rural Chisinau area, which seems to have a shortage of 144 nurses – but this figure needs to be double checked, in order to eliminate potential errors. 9. Very affected are raion Hincesti and Cimislia, with high shortages both for doctors and nurses: Hincesti –42 doctors and 83 nurses shortage and Cimislia –29 doctors and 42 nurses shortage. 10. Four raion – Telenesti, Briceni, Edinet and Donduseni have both doctors and nurses surplus.

The graph below is very suggestive for doctors and nurses shortage/surplus in rural areas.

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Stefan-Voda Ceadirmun.-Lunga Chisinau Basarabeasca 0 HincestiCimislia FalestiOrhei CauseniCantemirCahulFlorestiNisporeni UngheniLeovaRezinaIaloveniCriuleniAneniiGlodeni-Noi ComratSorocaSingerei RiscaniDubasariSoldanestiDrochiaVulcanesti TaracliaStraseni Ocnita mun. Balti TelenestiBriceni EdinetCalarasiDonduseni

-20

-40

-60

-80

-100

-120

-140

-160

Shortage FD Shortage Nurses

Figure 24 - The shortage/surplus of Family Doctors and Nurses in rural area, by raion

As a conclusion, there is a wide variability among raion in the coverage of the population with doctors and nurses in rural areas.

Another important factor in the planning of human resources task is the “inputs” (HR generation) and “outputs” (HR loss) balance. This represents the number of trained personnel getting hired inside the system and the number of trained personnel leaving the health system by emigration, retirement, reorientation or career change.

Even though the project scope didn’t include a detailed analysis of this input/output balance, by developing and filling in the registry of medical personnel one can easily get useful information regarding let’s say the “outputs” by retirement, as presented in the graph below. If the medical personnel registry will be constantly and correctly updated, all other types of system “outputs” could be monitored.

The graph below presents the distribution of doctors based on birth year; it is clear that in the next 5 years the total number of doctors getting out of the system based on retirement age is not very high, but starting with 2012 the retirement “outputs” will be significant, more than 50- 60 doctors yearly.

With the same logic as above it is easy to extract from the medical personnel registry the similar data for nurses, or information for each individual resource (medical staff) – making it easier to analyze data at lower levels than national – for example at region or raion level.

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120

100

1929 1933 1935 1937 1939 1941 1943 1945 1947 1949 1951 1953 1955 1957 1959 1961 1963 1965 1967 1969 1971 1973 1975 1977 1979 1981 1987

Figure 25 – Distribution of the Family Doctors by year of birth

The method based on Community Needs (community method)

Considering the information presented up to this point in the report, together with all the other conclusions of this study (the need for reorganization and change of standards for the existing institutions within the PHC system) we propose the community method to be used for rationalization of the human resources in the health system.

This method assumes the following activities will be carried out together within the local communities, with the local authorities participation: - Analysis of the local PHC system, in the context of the local socio-economic status and based on local values - Analysis of the demographics characteristics of the local community - Analysis of the health status of the local population - Analysis of the physical access of the population to PHC services and other health services (elements like public transportation, transportation for medical staff, individual coverage area of each medical institution etc) - Analysis of each PHC facility role and function, including infrastructure and medical equipment inventory evaluation - Analysis of the financial sustainability of each PHC facility - Analysis of the population/ medical personnel coverage (doctors and nurses) and comparing these with national average and accepted standards - Analysis of health services utilization at community level - Discussions of all these analysis results with local authorities - Establishing acceptable local standards for medical human resources - Identification of local resources that can be directed to the PHC system, including incentives to attract or retain the medical staff in the respective local institutions - Communicating the results and conclusions to the central authorities in order to facilitate central planning and redirection of needed resources to the respective community, including creation or enforcement of general incentives mechanisms for PHC personnel.

This analysis and needs assessment methodology for human resources (the combination between the medical personnel coverage and the community methods) had been agreed by the Ministry of Health as appropriate.

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More than this, the data collected through this project (population, human resources and services utilization) can be used at any time in the future to serve as a basis in application of any of the other method for estimation of human resources needs described before.

5.3.3 Incentives for Human Resources in the PHC System

In Moldova, attracting and keeping the medical personnel in the rural area is a very complicated matter. As it was pointed out before, there is an important shortage of medical staff in the rural area, even though a surplus is identified in the urban area.

In order to identify the type of incentives that will increase the satisfaction or will influence the decision of the medical personnel to work in the rural areas, the project team designed in the general questionnaire an anonymous section, asking the participants to answer the following questions: 1. What will be a decent salary level for you? 2. What will be the incentives for medical personnel that you would like to benefit at your work place? 3. Do you already benefit of any incentives from the Local Authorities at your current work place?

The questions requested free text answers, without any indication of variants, trying not to influence at all the free choice and opinion of the participants.

641 doctors (approximately 50%) responded to this part of the questionnaire and 1281 nurses (approximately 25%).

After analysis of the answers, the salary considered decent for participants was: • Doctors – 1501 $ (compared with the current one 150 – 200 USD) • Nurses – 911 $ (compared with the current one 50 – 100 USD)

It is easily noticeable the big discrepancy between the salary levels – the ones considered decent by participants and the actual ones in the PHC system. It is then recommended that a general policy for salaries increase should be designed and started to be implemented – both with a general, centralized component and a component based on incentives (through autonomy, direct contracting of PHC services with providers, payment for performance etc).

Answers from doctors regarding incentives, ranked by highest number of preferences:

Incentives for doctors No of people who answered Computer, Internet, Software, Hardware 448 Transport, gas 404 Telephone mobile, fixed 244 High Performance Equipment 210 Furniture 158 AC 136 Rehabilitation of the PHC facility 112 Laboratory equipment 95 General medical equipment 82 Personal Desk 82 Rest room 79 Page 54 of 121

Increase in No of medical HR 79 Medical books 62 Running water, hot water 59 Heating 54 Sewage, bathroom 43 Decrease in the workload 29 Kitchen 28 Decrease in paper work 23 Holidays bonus 19 Accommodation 18 Free transportation 12

Table 16 – Incentives for family doctors (self-administered anonymous questionnaire)

Answers from nurses regarding incentives, ranked by highest number of preferences:

Incentives for nurses No of people who answered Computer, Internet, Software, Hardware 738 Transport, gas 662 General medical equipment 487 High Performance Equipment 484 Furniture 479 Telephone mobile, fixed 427 AC 290 Running water, hot water 261 Heating 260 Rehabilitation of the PHC facility 219 Rest room 158 Sewage, bathroom 153 Medical books 116 Kitchen 96 Increase in number of medical workers 92 Laboratory equipment 83 Personal Desk 83 Decrease in the workload 54 Free transportation 52 Reduce of the paperwork 46 Holidays bonus 31 Accommodation 16

Table 17 – Incentives for nurse (self-administered anonymous questionnaire)

An interesting ranking is reflected in the answers of the doctors: first 4 positions are: ICT equipment (mainly PCs and internet connection), transportation facilities, communication equipment (phone services) and medical equipment. The ranking for the nurses of the first 4 positions is as follows: ICT equipment (mainly PCs and internet connection), transportation facilities, medical equipment and office furniture.

It is somehow surprising to see that the first position for both categories (doctors and nurses) is ranked for ICT equipment; this could be explained maybe by the fact that this equipment will link them to the world outside the restricted and isolated community they work and live in

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– kind of a substitute for information direct access and the mission component of the social life in the urban communities. On the other hand, the set of a PC and a printer is already part of an agreed equipment standard for a Health Centre in the future integrated health information system, so this medical staff request is a good support for the implementation of this standard. It is suggested that the computers acquisition could be done centrally, possible from the WB project funding or other sources, as a separate program for creation of the integrated health information system, as specified in the Health reform Strategy of Republic of Moldova document. The internet connection could be provided either through the cable/ optical fiber infrastructure or through the mobile phone subscriptions planned for the Health Centers.

The second option of all medical personnel in this ranking is the transportation issue. Already the Ministry of Health has designed a project in order to buy needed vehicles for medical staff in areas with difficult access of the population to the PHC services. This initiative should be supported and if it proves financially sustainable it should be linked with the PHC system reform through community approach.

Regarding the communications preference, land phone line should be part of the general standard and mobile phones could be a substitute where land lines don’t exist, especially if this mobile solution could also provide access to internet.

Medical equipment and office furniture are already part of Health Centers general standard specifications and a first set can be bought through the WB loan/project. It is recommended that in parallel with this acquisition, at least a part of the standard medical equipment should be bought by the central health authorities or even by the Local Authorities, in order to increase the number of facilities respecting the general standards.

The questionnaire revealed that only 15 medical personnel already benefited from Local Authorities incentives, even though there is a specific Law issued that allows them to offer accommodation for young doctors after residency if they want to practice in rural areas.

5.3.4 The training of the PHC health workers

The assessment of the current status of the training and training needs of the PHC HR have been done by the a distinct section of the questionnaire, in which each Family Doctor or Nurse filled up personal data and data about university, specialization, CME, management education and the medical and management degrees that he/she graduated over the time. All these data constitutes the Registry of the PHC HR (only medical personnel).

For details about collected data See Annex 3. – PHC system evaluation questionnaire

IMPORTANT NOTE!

The analysis of the HR education and training has been analyzed based on the data collected through the questionnaire that now constitutes the Registry of PHC Human Resources. Due to the short timeframe of the project, the poor quality of the data collected for this Registry and the lack of alternative data sources for cross-comparison the data cleaning and validation process was very difficult. It is of up most importance that the Registry will be completed and validated before starting to plan for the next workforce training. Because there

Page 56 of 121 are some institutions that did not report these data, the following analysis is only informative, not final.

The Registry of PHC HR is not complete. There are 45 PHC institutions that did not send these data, which means around 191 family doctors. Also, there are some inconsistencies in the current data, when compared to the data reported in the “HR section – total by institution” from the questionnaire. The statistics should be required after the completion of the updating, cleaning and validation process.

The following table presents the specialty of the doctors that work in the PHC system. The total number of doctors, 2226 is bigger than the total number of the doctors that act as Family Doctors, because the Registry collected data for all the doctors that work in the PHC system, not only the Family Doctors.

Specialty No of doctors General Medicine 664 Family medicine 98 Pediatrics 731 Other specialties 733 Total 2226 Table 18 – Number of doctors that work in the PHC system, by specialty

The following table presents the number of doctors by type of the three Primary Care specialty types of courses that they graduated: “Internatura” – one year study “Rezidentiat” – three years study “Specializare Primara” – 4 months study.

One should note that 10% (225 doctors) have declared that they did not graduate any of these specialties!

Internatura Rezidentiat SpecializarePrimara (1 year) (3 years) (4 months) No of doctors No no yes 772 Yes no yes 651 yes no no 367 no no no 225 no yes no 170 no yes yes 25 yes yes yes 12 yes yes no 4 Table 19 – Number of doctors by type of graduated Primary Care specialty

The questionnaire contained also some questions about the CME of the PHC HR. There were basically two kinds of courses: “CIMC” – mandatory periodical courses for doctors and nurse and “HIF” – WB Health Investment Fund funded courses. The table below presents the number of family doctors that attended such courses. One can notice that there are 435 doctors that declared that they did not attend any of these courses.

CIMC CME courses HIF CME courses No of family doctors

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yes Yes 712 yes No 674 no yes 173 no no 435 Table 20 – Number of family doctors, by attended CME type

The next table presents the current situation of Management Training among the Family Doctors. One can notice that only 256 doctors declared that they attended such courses. Management training for family doctors is important especially in the context of the MoH vision of giving juridical and financial autonomy to the PHC providers.

Management Courses No of family doctors yes 256 no 1970 Table 21 – Number of family doctors that attended management courses

The Registry of PHC HR contains data about the professional degrees of each doctor.

All the statistics for family doctors presented above can be queried for nurses working in the system.

All data regarding the education and training of the PHC personnel are stored in the database and reports can be extracted for each person or cumulative by health center, raion or country.

5.4 PHC Institutions Infrastructure

5.4.1 Inventory of the PHC institutions infrastructure

The evaluation of the PHC institutions infrastructure constituted an important chapter of this project research and analysis. The needs for this evaluation came primarily from the necessity to document and draw the baseline to support data driven decision making regarding physical rehabilitation of PHC institutions buildings and utilities. The infrastructure evaluation was done both by revising data collected through the questionnaire and by site visits at different locations. As you can see in the picture below (a data base report based on information from the questionnaire answers) the infrastructure evaluation was very detailed and covered the following aspects: the building with all its components, utilities infrastructure (electricity, running water, sewage system, heating, ventilation etc), the communication system and the IT system etc and their conformity with existing structural standards.

For all of these elements the repairing/rehabilitation costs had been estimated. Local estimates had been done by the managers of the respective institutions with help from constructions specialists of the Local Public Authorities, if case.

All data had been inputted into the data base and reports can be extracted at institution, raion or national level.

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Figure 26 – Detailed report on infrastructure, CS Vadul lui Voda

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We selected several representative reports to highlight the actual status of the PHC institutions infrastructure, out of many reports that can be produced by querying the data base.

5.4.1.1 The ownership of the PHC institutions buildings

This was an important aspect investigated during the project. Its importance will be better understood at the time when the buildings will be effectively nominated for renovation/ rehabilitation and funds needs to be allocated, especially if external donors are involved. The owner of the building could be the Raion Council, the City Hall, individual persons as share holders or any combination of the above. Only buildings owned entirely by the Raion Council can be easily included in the rehabilitation process. The buildings owned by the City Hall or having the ownership shared could not be rehabilitated unless they are transferred to the Raion Council or a special regulation is issued clarifying the ownership statute. As shown in the picture below, only 57% of the institutions self reported that they are owned by the Raion Council:

City Hall and Shares NS; 89; 4; 0% 7%

City Hall; 404; 32%

Shares; 47; 4% Raional Council; 715; Raional Council and 57% Shares; 2; 0%

Figure 27 – Distribution of PHC institutions by ownership

5.4.1.2 Total number of existing buildings

The total number of existing buildings for the 1261 PHC institutions is 1352. Most of the PHC institutions (1188) are located within one building, but 51 institutions have functional spaces in 2 buildings, 18 institutions in 3 buildings and 2 institutions in 4 buildings, as presented in the table below. As a general rule, the more buildings an institutions has spaces in, the higher the rehabilitation costs are, including the costs of the utilities (current water, sewage, gas etc).

No of PHC institutions No of Buildings 1188 1

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No of PHC institutions No of Buildings 51 2 18 3 2 4

Table 22 – Number of buildings of the PHC institutions

5.4.1.3 Total area of the PHC institutions buildings

Total area of the buildings of a PHC institution represents the main proxy for rehabilitation and maintenance costs. The bigger the area, the higher the rehabilitation and maintenance costs - see the section about calculating rehabilitation costs in Chapter 5.9. In the data base we have registered total area and area in use for each PHC institution. In the graph below total area for PHC institutions are presented at raion level.

Total area at national level for PHC institutions is 545.118 m2, an average of 259 m2/ doctor!!!

Ungheni Cahul Riscani Floresti Orhei Anenii-Noi Hincesti Falesti Briceni Edinet Calarasi Cantemir Soroca Causeni Singerei Straseni Telenesti Ialoveni Rezina Drochia Stefan-Voda Nisporeni Criuleni Basarabeasca Glodeni mun. Balti Donduseni Soldanesti Cimislia Taraclia Leova Ocnita Vulcanesti Ceadir-Lunga Dubasari Comrat 0 5000 10000 15000 20000 25000 30000 Suprafata totala

Figure 28 – Total area of the buildings of the PHC institutions, by raion

In the next graph we presented the percentage of used area from the total area, by raion. This is the real area declared by the administration of the questionnaire and not the optimal one, which would be much smaller based on our estimates. As general figures, the % of used area is 78% and the rented area to external users is 5%.

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Causeni Cimislia Taraclia Stefan-Voda Comrat Cantemir Dubasari Soroca Telenesti Ceadir-Lunga Ialoveni Anenii-Noi Nisporeni Glodeni Ocnita Rezina Straseni mun. Balti Orhei Ungheni Criuleni Soldanesti mun. Chisinau Vulcanesti Donduseni Singerei Leova Cahul Calarasi Riscani Floresti Falesti Hincesti Drochia Edinet Briceni Basarabeasca 0% 20% 40% 60% 80% 100% 120% Suprafata utilizata

Figure 29 – Percentage of used area from total area of PHC buildings, totals by raion

In the next graph, each institution is represented as a dot located on the plot based on the number of allocated population and the total area of each institution. This visual representation was preferred because the number of population is also a criterion for human resources standardization, driving to a standard for the used area of the building. An important variability can be noticed among the different PHC institutions and a very small percentage of the building are below the 100-300 m2 recommended benchmark.

40000

35000

30000

25000

20000 Populatia

15000

10000

5000

0 0 500 1000 1500 2000 2500 3000 3500 4000 4500 5000 5500 6000 6500 7000 7500 8000 Suprafata (m2)

Figure 30 – Plot diagram of covered population and area of each PHC institution

5.4.1.4 Buildings age and capital repairs

Year the building has been built (building age) is a status indicator of the infrastructure, especially considering the fact that most of the PHC buildings didn’t occur capital repairing in the last decades – as pointed out by the analysis of the questionnaire results. The buildings were grouped based on the year of construction, as 1980 has been a demarcation year for constructing with more reliable materials for the PHC buildings (concrete). This was not

Page 62 of 121 necessary a general rule but it can be seen as an acceptable proxy for a general view on the infrastructure status.

Floresti Ungheni Singerei Riscani Orhei Soroca Cimislia Cahul Glodeni mun. Chisinau Telenesti Hincesti Straseni Edinet Drochia Briceni Nisporeni Ialoveni Ocnita Cantemir Leova Taraclia Stefan-Voda Donduseni Causeni Calarasi Soldanesti Falesti Criuleni Rezina Comrat Dubasari Ceadir-Lunga mun. Balti Basarabeasca Anenii-Noi Vulcanesti 0 5 10 15 20 25 30 35 40 Numar institutii

Figure 31 – Number of institutions that are located in buildings older than the year of 1980

There are 600 buildings out of the 1261 that had been built before 1980, representing 48% of the total. The situation by raion is presented in the graph above; Floresti and Ungheni raion have the highest number of old buildings from the total, but the percentage of old buildings within a raion is the highest in Glodeni, Cimislia, Rascani and Floresti raion, with over 60% old buildings. As a general conclusion, 20 raion have over 50% of their respective buildings older than 1980, as reflected in the table below.

No of institutions that are located in No of PHC buildings built up Raion institutions by raion before 1980 % Glodeni 26 22 85% Cimislia 36 25 69% Riscani 47 29 62% Floresti 63 38 60% mun. Balti 7 4 57% Taraclia 23 13 57% Cahul 43 24 56% Ceadir-Lunga 9 5 56% Ocnita 29 16 55% Nisporeni 31 17 55% Drochia 33 18 55% Dubasari 11 6 55% Singerei 57 31 54% Ialoveni 33 17 52% Briceni 35 18 51% Edinet 37 19 51% Straseni 37 19 51% Ungheni 71 36 51% mun. Chisinau 44 22 50% Page 63 of 121

Donduseni 26 13 50% Stefan-Voda 26 13 50% Telenesti 42 20 48% Leova 32 15 47% Causeni 28 13 46% Comrat 13 6 46% Soroca 58 25 43% Orhei 65 27 42% Hincesti 49 20 41% Cantemir 41 16 39% Soldanesti 27 10 37% Calarasi 35 12 34% Vulcanesti 3 1 33% Falesti 34 10 29% Basarabeasca 7 2 29% Criuleni 36 9 25% Rezina 32 7 22% Anenii-Noi 35 2 6% Total 1261 600 48%

Table 23 – Percentage of PHC institutions that are located in buildings built up before 1980, totals by raion

Capital repairing has been performed as follows:

- 275 institutions after the year of 2000 - 105 institutions between 1990 and 1999 - 140 institutions between 1980 and 1989 - 88 institutions before 1980 - 653 institutions – no repairing, or no reporting/ knowledge of capital repairing.

5.4.1.5 Types of buildings

Two main categories had been identified: - The Classical Type – built based on a standard project for a special destination as family doctors offices. These are generally built during the ‘80s and several dimensions and projects were designed based on the number of population to be addressed in the specific location. For more details, please refer to the archives of the MoH and the archives of the project. 28% of the PHC buildings belong to this classical type. - The Accommodate Type – buildings that had been built with a different initial purpose, being adapted afterwards to accommodate medical doctors’ facilities. Most of the PHC buildings (64%) are in this category, as shown in the graph below.

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NA; Classical Type; 100; 8% 356; 28%

Accomodate Type 805; 64%

Figure 32 – PHC buildings by type, country totals

As a general conclusion, the Classical Type buildings are made out of concrete, are more resistent, are easier and cheaper to rehabilitate and maintain, but they are oversized (in area and volume) based on the number of population addressed and the recurrent costs are higher. On the other hand, the Accommodate Type buildings have more appropriate dimensions (smaller area and volume) and smaller recurrent costs, but they are older, not so resistent and as a consequence, the rehabilitation could involve increased costs and construction problems.

From the graph above one can see that 28% of the building are of a Classical Type, the rest being of the Accommodate Type.

5.4.1.6 Resistance Structure of the Buildings

Other important resistance characteristics considered for each building and with an important influence on the rehabilitation decision had been as follows:

- If the constructions complies with quake proof regulations - only 57% of the buildings being compliant, as presented in the graph below

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NA; 59; 5%

No; 479; 38%

yes; 723; 57%

Figure 33 – Quake resistance of the buildings, total by country

- If the building has a ferro-concrete carcass, that re-enforce the building – only 47% of the buildings have this carcass, as shown below

NA; 73; 6%

No; 600; 47%

Yes; 588; 47%

Figure 34 – No of buildings with ferro-concrete carcass, totals by country

- If the construction has a foundation – 87% of the buildings have a foundation, as shown below

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no; 61; 5% NA; 97; 8%

yes; 1103; 87%

Figure 35 – No of buildings that have foundation, total by country

5.4.1.7 General status of the PHC buildings

For all of the analyzed infrastructure components it had been analyzed the general status, standard available answers being G (good), S (satisfying) or N (non satisfying). Some examples of the results are shown below:

General status of the floor – non satisfying for 36% of the buildings

NA; 64; 5% G; 100; 8%

S; 646; 51%

N; 451; 36%

Figure 36 – General status of the floor of the PHC buildings

General status of the ceiling – non satisfying for 32% of the buildings

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NA; 49; 4% G; 116; 9%

S; 690; 55% N; 406; 32%

Figure 37 – General status of the ceiling of the PHC buildings

General status of the frames of the windows – non satisfying for 60% of the cases

NA; 42; 3% G; 65; 5% S; 398; 32%

N; 756; 60%

Figure 38 – General status of the frames of the windows of PHC buildings

General status of the doors – non satisfying for 50% of the buildings

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NA; 39; 3% G; 64; 5%

S; 525; 42%

N; 633; 50%

Figure 39 – General status of the doors of the PHC buildings

5.4.1.8 Utilities

The questionnaire also contained questions about the presence and the status of the utilities in PHC institutions. In this report, we will present some of the results, but many more can be searched in the database.

- 96% of the institutions have electricity.

no; 18; 1% NA; 44; 3%

yes; 1199; 96%

Figure 40 – Presence of electricity system in PHC buildings

- 22% of the institutions have running water system

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yes; 280; 22%

no; 981; 78%

Figure 41 - Presence of running water system in PHC buildings

The following table presents the current situation of sewage system, heating system and running hot water system.

Availability of the utilities Sewage Heating Hot water NA 6% 9% 8% Yes 43% 81% 7% No 51% 10% 84%

Regarding the communication and IT systems, 1137 (90%) institutions have telephone, but only 207 have computers.

5.4.2 Infrastructure standards and estimating the infrastructure needs

The role and the functions of a PHC institution will determine the personnel and equipment needs; based on these, the estimation for infrastructure needs can then be determined. This way, a complete functional and structural standard can be designed for a PHC institution, including the infrastructure.

At present, the situation regarding infrastructure standards in the PHC system is unclear. The following elements for driving the analysis had been identified: - Existing norms (sanitary and epidemiological) regarding minimal dimensions of the rooms inside medical institutions, related to the functionality of the rooms - Existing norms regarding the number and types of rooms for each PHC institution (Raional Health Center – Raional CS, Rural Health Center – Rural CS, Family Doctor Office – OMF with or without a doctor) - Existing norms elaborated in the former WB Project, Investment Fund for Health - Current trend of decision makers and professionals from the PHC system to redesign (and reduce) functional and structural standards for each type of PHC institution – this trend was identified by the Consultant during the interviews with the above mentioned persons.

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A synthesis of these standards is presented below. Considering that the Health Centers had been identified as a priority in the infrastructure evaluation process, their standards are presented below. In the next table you can identify the type and functions of different rooms as by the standard as well as minimum corresponding areas (square meters) according to the current sanitary and epidemiological norms.

Rural Health Center (CS) 2 – 6 family doctors + 1 dentist Type and Function of the room Minimum Area (m2) Reception room 10 Triaj room 12 Consultation room for the family doctor 18 (one for each doctor – 2-6 doctors) OBG room 20 Dentist room 18 Head Doctor’s office 18 Coordinating nurse’s office 12 Procedures room 12 Immunization room 12 Laboratory room 18 Pharmacy room 10 Staff rest room 12 Patients waiting room 10 Day stay room for female patients 15 Day stay room for male patients 15 Staff toilet room 2 Female patients toilet 2 Male patients toilet 2 Dressing room 10 TOTAL 200-300 m2

Table 24 – Current functional and structural standard of a Rural Health Center

Other rooms can be added to the standard, if needed – prophylaxis rooms, family planning rooms etc.

The total area, after adding hallways, technical areas and an extra room for each physician reaches about 200-300 m2 for a Health Centre with 2-7 doctors.

Similarly, after deducting a number of rooms according to an informal standard in use (not yet regulated or fully accepted by the users), for a family doctor office (OMF), with or without a doctor, the recommended total area is 100 – 150 m2, as follows.

Family Doctor Office (OMF) 0-1 doctor Type and Function of the room Minimum Area (m2) Consultation room for the family doctor 18 Doctor’s office 18 Nurse’s office 12 OBG room 20

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Procedures room 12 Immunization room 12 Pharmacy room 10 Patients waiting room 10 Day stay room (s) 15 Staff toilet room 2 Female patients toilet 2 Male patients toilet 2 TOTAL 100 – 150 m2

Table 25 - Current functional and structural standard of a Family Doctor Office

The current situation is much more different in reality, the Health Centers area being much wider as compared to the standard, situation presented in the tables below.

Only 93 of the 357 rural Health Centers had a smaller area than 300 m2.

Area (m2) No of Rural CS 3000 - 7000 6 2000 - 3000 14 1000 - 2000 52 300 - 1000 168 200 - 300 28 100 - 200 65 NA 24 Total 357 Table 26 – Number of Rural CS by area of the building

Only 191 of the 559 OMF have an area smaller than 100 m2.

Area (m2) No of OMF 300 - 2100 82 200 - 300 84 100 - 200 189 <100 191 NA 13 Total 559 Table 27 - Number of OMF by area of the building

Only 100 of the 288 PM, 100 have an area smaller than 50 m2 and 98 have an area between 50 and 100 m2.

Area (m2) No of PM 100 - 714 79 50 - 100 98 <50 100 NA 11 Total 288 Table 28 - Number of PM by area of the building

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In the research process, each institution filled up a distinct part of the questionnaire, where they were asked to report the conformity with the general agreed standard of the MoH, consisting of the following elements:

Reception room Triaj room Consultation room for the family doctor Procedures room Immunization room Laboratory room Number of laboratory rooms Pharmacy room Staff rest room Patients waiting room Day stay room for female patients Day stay room for male patients Staff toilet room Female patients toilet Male patients toilet Dressing room

Table 29 – Elements of the functional and structural standard for infrastructure included in the questionnaire

The situation of each individual institution can be analyzed using the created data base. The general analysis showed that, generally, the Health Centers respect the functional standard; the real problem is related with the size of the area, the centers being oversized, with outnumbered rooms or with an overall area much too large, mainly because of non utilized areas.

Related with the standards, the following comments apply: - They are very similar with other standards in the coutries in region, especially the ones from the former Soviet - see also final report of the WB project “Drafting of a Technical Norm for the Configuration of Rural Facilities for Primary Health Care, Tajikistan”, Conseil Santé SA / SOFRECO, 2005 - The decision makers should aim to the lower limit of this standard as most of the Centers have less than 2 doctors and half of the OMF have no doctor. - Another important reason to lower the standard down to the inferior limit is driven by the recurrent maintenance cost and rehabilitation or construction costs, as they go higher as the area goes higher – see also Chapter 5.9 on calculation of rehabilitation costs.

5.5 Equipment of the PHC institutions

No STANDARD EQUIPMENT CS OMF PM Page 73 of 121

Medical devices 1 Blood pressure meter + + + 2 Stethoscope + + + 3 Ocular tonometer + + + 4 Obstetrical stethoscope + + + 5 Children weighting scale + + + 6 Weighting scale and anthropometer for adults + + + 7 Children anthropometer + + + 8 New born examination table + + + 9 Automatic 6 channel electrocardiograph + + 10 Portable 3 channel electrocardiograph + + 11 Adult peakflowmeter + + 12 Children peakflowmeter + + 13 Glucosemeter + + + 14 Clinical laboratory set + 15 Sterilizer + + 16 UV lamp for air disinfection + + + 17 Stainless steel boxes + + 18 Stainless steel table for medical devices + + + 19 Gynecology table + + + 20 Pelvimeter + + + 21 Neurology examination set + + 22 Othoscope + + 23 Ophthalmoscope + + 24 Portable examination lamp + + 25 Guzon ear syringe + + + 26 Set of Kramer splints + + + 27 Vision chart + + 28 Computer + + 29 Printer + + Medical devices set 1. Specule ginecologice + + + 2. Anatomic pincers + + + 3. Surgical pincers + + 4. Surgical scissors + + 5. Medical catheters + + Special objects 6. GP’s medical kit + + 7. Hemostazis rubber + + + 8. Test-tubes + + 9. Test-tube holder + + + 10. Scalpel + + 11. Medical thermometers + + + 12. i.v. infusions holder + 13. Thermometer + + + 14. Length meter + + + 15. Chronometer + + + 16. Goniometer 17. New born and adult rectal tubes + + + Medical equipment and furniture 18. Folding screen 19. Medical bed + + + 20. New born examination table + + + 21. Physician’s table + + + 22. Drugs cabinet + + + 23. Furniture set for clothes, books + + +

Table 30 – The equipment standard for Rural Health Centers (without consumables)

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The following table presents the inventory of the existing equipment with less than 50% wear, as totals for the whole PHC system in the country. The general conclusion is that there is huge lack of equipment in the PHC institutions, the difference to the standards (the needs) varying from 40% to 90% for different types of equipment. The detailed needs assessment for each institution and each raion could be queried in the database.

% PRESENT Necessary EQUIPMENT wear < NECESARY STANDARD from 50% Standard Blood pressure meter 3987 3885 7445 52% Stethoscope 4036 3554 7168 50% Ocular tonometer 794 1160 1809 64% Obstetrical stethoscope 1180 1484 2390 62% Children weighting scale 1159 1091 1998 55% Children anthropometer 1079 1129 2050 55% New born examination table 1146 1169 2094 56% Automatic 6 channel electrocardiograph 95 569 745 76% Portable 3 channel electrocardiograph 501 677 1160 58% Adult peakflowmeter 1029 754 1708 44% Children peakflowmeter 1009 759 1697 45% Glucosemeter 314 1477 1618 91% Clinical laboratory set 233 459 657 70% Biochemistry laboratory set 129 386 495 78% Sterilizer 988 1068 1886 57% UV lamp for air disinfection 1155 2130 2658 80% Big stainless steel boxes 1662 1775 3109 57% Small stainless steel boxes 1687 1944 3301 59% stainless steel table for medical devices 1470 1597 2847 56% Gynecology table 1025 774 1701 46% Pelvimeter 990 977 1865 52% Neurology examination set 837 1036 1714 60% Othoscope 1461 778 2083 37% Ophthalmoscope 1528 758 2124 36% Portable examination lamp 486 1549 1926 80% Guzon ear syringe 379 1481 1805 82% Set of Kramer splints 442 1604 2011 80% Vision chart 1098 1133 2018 56% Computer 415 1696 1993 85% Printer 168 1305 1448 90% Specule ginecologice 14609 28850 43543 66% Cornţanguri 2237 4583 5835 79% Scalpel 1540 10609 10213 104% Anatomical pincers 1786 3554 4333 82% Surgical scissors (straight) 673 1960 2488 79% Surgical scissors (curved) 661 2019 2542 79% Medical catheters 744 4990 5559 90% GP’s medical kit 1747 811 2361 34% Tourniquet 1612 2828 3700 76% Page 75 of 121

i.v. infusions holder 1582 1769 3149 56% Medical thermometers 4762 5574 9385 59% Length meter 2105 3678 5168 71% Chronometer 1764 1767 3458 51% Goniometer 55 778 859 91% Adult rectal tubes 228 3502 3611 97% New born rectal adult 148 3214 3265 98% Folding screen 204 1591 1657 96% Medical bed 2646 2653 5077 52% Physician’s table 1263 1854 2807 66% Nurse’s table 1880 3008 4497 67% Drugs cabinet in the medical procedures room 693 1255 1808 69% Drugs cabinet for emergency drugs 590 1301 1767 74% Furniture set for clothes, books 716 2808 3225 87%

Table 31 – The results of the assessment of the equipment needs through the questionnaire, totals by country

5.6 The provision of services in the PHC system

The evaluation of the provision of the PHC services had bed done by evaluating the following indicators. The results, by raion, are showed in the following table.

Number of visits per inhabitant (utilization of services) has a great variability among raions, between 1.0 in Hincesti and 3.9 in Comrat.

Number of visits per health insured inhabitant is 4 times greater than the number of visits per not insured inhabitant in each raion, which confirms the well known problem of a very low utilization of services and access to the services of not insured people.

Ratio of referrals to specialized outpatient services from the Number of Number of Number of total visits per visits per referrals to number of Number of health not specialized visits to Visits visits per insured insured outpatient PHC Raion Population Total inhabitant inhabitant inhabitant services institution

mun. Chisinau 719 696 2 709 265 3,8 4,2 0,9 1 103 348 41%

mun. Balti 135 157 405 141 3,0 4,3 0,4 60 049 15%

Anenii-Noi 80 445 209 235 2,6 3,1 1,1 90 157 43%

Basarabeasca 28 886 59 159 2,0 2,7 0,8 12 195 21% Briceni 79 188 188 596 2,4 3,7 1,2 22 397 12% Cahul 117 272 244 979 2,1 2,7 0,8 77 647 32%

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Cantemir 64 708 113 837 1,8 2,5 0,3 52 471 46% Calarasi 80 020 243 127 3,0 4,6 1,0 37 072 15% Causeni 94 059 252 918 2,7 3,0 1,5 14 378 6% Cimislia 72 145 157 058 2,2 2,7 1,4 36 179 23% Criuleni 76 212 171 175 2,2 4,1 0,6 14 670 9%

Donduseni 48 919 97 222 2,0 2,4 0,9 17 776 18% Drochia 89 324 200 283 2,2 3,2 0,5 25 950 13% Dubasari 31 115 88 202 2,8 3,9 0,8 2 377 3% Edinet 85 106 217 672 2,6 3,6 0,9 61 874 28% Falesti 91 496 197 447 2,2 3,3 0,6 107 080 54% Floresti 89 343 231 537 2,6 3,8 0,7 23 352 10% Glodeni 65 325 234 193 3,6 3,8 1,2 33 514 14% Hincesti 119 159 119 419 1,0 1,4 0,3 32 696 27% Ialoveni 100 942 299 084 3,0 3,9 0,5 85 037 28% Leova 53 131 97 605 1,8 2,7 0,7 55 569 57% Nisporeni 64 326 167 632 2,6 4,2 0,5 36 659 22% Ocnita 56 164 119 893 2,1 2,3 1,4 4 489 4% Orhei 127 589 280 094 2,2 3,1 0,8 45 021 16% Riscani 87 519 234 907 2,7 3,3 1,1 35 390 15% Rezina 49 956 132 451 2,7 3,5 0,7 26 999 20% Singerei 101 058 237 206 2,3 3,7 0,8 43 377 18% Soroca 100 175 275 068 2,7 3,9 0,7 156 951 57% Straseni 87 783 261 590 3,0 4,1 0,7 24 046 9%

Soldanesti 43 807 122 088 2,8 5,2 1,3 58 475 48%

Stefan-Voda 69 016 188 372 2,7 3,1 1,4 49 199 26% Taraclia 44 579 133 298 3,0 5,1 0,4 49 771 37% Telenesti 70 402 171 769 2,4 3,5 1,2 13 488 8% Ungheni 117 062 384 911 3,3 4,2 1,2 63 764 17%

Ceadir-Lunga 62 397 96 551 1,5 2,0 0,2 22 041 23%

Vulcanesti 24 506 46 000 1,9 2,4 0,4 5 228 11% Comrat 69 738 271 487 3,9 3,3 3,3 44 383 16% Total 3 497 725 9 660 472 2,8 3,6 0,9 2 645 069 27% Table 32 - Indicators for utilization of PHC services and referrals to specialized care

The database contains breakdown information on other types of services provided by the PHC institution, although the main indicator that the system uses for assessment of the provision of services is “number of visits”. More than that, the provision of services is not reported by institution, but aggregated by CS and then it is again aggregated at raion level. It is recommended to change the reporting system in such a way that each institution would report the services, in order to be able to run performance indicators by institution.

5.7 Assessment of the referral system

Regarding the referral system, the quantitative analysis was done by assessing the following indicators:

Ratio of referrals to specialized outpatient services from the total number of visits to PHC institution is very variable among the raions, from 6% in Causeni to 57% in Leova. The Page 77 of 121 overall ratio is 27% - see Table 32 – Indicators for utilization of PHC services and referrals to specialized care

Ratio of admitted patients by PHC referral source from the total admitted patients is 51%, as it is shown in the next figure.

16%

Reffered by family doctors Reffered by EMS 51% Reffered by specialists Self-reffered

26%

Figure 42 – Distribution of the admitted patients by the referral source

The linkage of the PHC providers with other providers in the health system and the referral system should be more assessed in more details, along with assessment of the provision of services, in the context of restructuring the PHC system as it is presented in the final recommendations of the project.

5.8 Analysis of the financial data of the PHC institutions

Financial data of the PHC institutions was collected through a distinct part of the questionnaire – see Annex 3. – PHC system evaluation questionnaire. Income and expenses by type and salaries were collected for each and every institution, although, usually, this data is aggregated at raion level and reported like this.

The current payment system of the PHC providers consists mainly of a per capita system with different tariffs for health insured people and non insured people, as follows. In 2006 the tariff for health insured people was 84 MDL and the tariff for non insured people was 6.5 MDL (13 times less). In 2007 the tariff for health insured people was 154.8 MDL and the tariff for non insured people was 14.8 MDL (10 times less).

Therefore, we have studied the number of population, the number of health insured population and the number of not-insured population for each PHC institution, and the cumulative by raion. The following table presents these data for Stefan Voda Raion. There is a large variation from institution to institution regarding the number and percentage of health insured people.

Population Health Raion Institution Total Insured % Insured Stefan-Voda CS Ştefan-Vodă 7801 7450 96% Page 78 of 121

Stefan-Voda OMF Marianca de Jos 534 469 88% Stefan-Voda OMF Stefanesti 1218 968 79% Stefan-Voda OMF Brezoaia 1033 995 96% Stefan-Voda OMF Semionovca 832 667 80% Stefan-Voda PM Lazo 129 103 80% Stefan-Voda OMF Alava 366 224 61% Stefan-Voda OMF Popeasca 2327 1797 77% Stefan-Voda OMF Festelita 2843 1802 63% Stefan-Voda CS Ermoclia 4158 2648 64% Stefan-Voda CS Volontiri 3833 3090 81% Stefan-Voda OMF Copceac 2416 2049 85% Stefan-Voda CS Tudora 1881 1457 77% Stefan-Voda OMF Palanca 1980 1368 69% Stefan-Voda CS Caplani 3239 2350 73% Stefan-Voda CS Crocmaz 2905 2370 82% Stefan-Voda CS Carahasani 3071 2303 75% Stefan-Voda CS Purcari 1962 1461 74% Stefan-Voda PM Viisoara 486 367 76% Stefan-Voda OMF Rascaieti 2881 1943 67% Stefan-Voda CS Cioburciu 2713 2237 82% Stefan-Voda OMF Rascaietii Noi 654 353 54% Stefan-Voda CS Antonesti 2709 1952 72% Stefan-Voda CS Slobozia 4230 3004 71% Stefan-Voda CS Talmaza 7324 5477 75% Stefan-Voda CS Olanesti 5491 3691 67% Stefan-Voda 69016 52595 76%

Table 33 – Number and distribution of population by health insured status in Stefan Voda Raion, by institution

Regarding the total number and percentage of the health insured people, for the whole country, the database shows a coverage of only 68%, as opposite with the official statistics that is 75% overall. This difference could come from reporting errors, but could also reflect a real situation that should be carefully analyzed. In fact, the payment methodology takes this percentage (75%) into income calculation for each and every institution, since there was no statistics of health insurance coverage at locality level. The data in the database should be verified and updated in order to reflect the reality and to be able to make data-driven decisions.

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mun. Glodeni Stefan- Ocnita Anenii-Noi Donduseni Ceadir- Vulcanesti Ialoveni Causeni Riscani Rezina TOTAL Ungheni Basarabe mun. Balti Straseni Dubasari Cahul Hincesti Cantemir Soroca Falesti Cimislia Comrat Floresti Singerei Edinet Leova Orhei Drochia Calarasi Taraclia Nisporeni Briceni Telenesti Criuleni Soldanesti 0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

Figure 43 – Coverage of the population with health insurance, totals by raion

The figure above presents the coverage of the population with health insurance, by raion. One can notice o lower rate in Soldanesti, Criuleni, and Telenesti etc.

Similarly, the next figure presents the percentages of insured people by CS (Health Center), with a huge variability among CS, ranging from under 20% to more than 95%. This statistics or similar ones are important in the decision making process regarding the change of juridical and financial status of the health centers towards autonomy.

120%

100%

80%

60%

40%

20%

0% 396 Centre de Sanatate (inclusiv OMF si Filiale)

Figure 44 – Percentage of the health insured people by health center

In order to analyze the financial sustainability of the PHC institution, the project team calculated the following indicators for each institution for 2006, based ob the data reported in the questionnaire: - 1 - “Routine income” = Per capita for health insured income + Per capita for not insured income + Performance Bonuses income. This income represents, in a way, Page 80 of 121

a “guaranteed and fixed income”, because it comes from the structure of the population by the health insurance status plus performance indicators. - 2 - “Real income” = Per capita for health insured income + Per capita for not insured income + Performance Bonuses income + Fee for service income + Other income”, which means the Total Income minus Income for Drugs and Income for Investments - 3 - “Recurrent Expenditure” = “Salaries” + “Taxes” + “Electricity” + “Gas” + “Heating” + “Fuel” + “Transport” + “Water and Sewage” + “Other Expenditures”, which means the running costs (recurrent expenditure), or, in other words, Total Expenditure minus expenditures for “Drugs” and “Investments”.

The sum up of these data by raion can is presented in the following table.

Diff. Routine Diff. Income - Real income - Routine Real Recurrent Recurrent Recurrent Income income Expenditure Expenditure Expenditure Raion 1 2 3 4 = 1 - 2 5 = 1 - 3 Anenii-Noi 5684 11124 5837 -153 5287 Basarabeasca 1823 3011 2155 -331 857 Briceni 4304 7964 6805 -2501 1158 Cahul 7160 9043 11005 -3845 -1963 Cantemir 3880 6221 5419 -1539 801 Calarasi 4488 8183 7909 -3420 275 Causeni 6461 9537 7429 -968 2108 Cimislia 4203 6311 6102 -1899 208 Criuleni 3685 5874 6199 -2514 -325 Donduseni 3414 4760 3818 -403 942 Drochia 5070 7483 9124 -4054 -1640 Dubasari 1911 2692 3097 -1186 -405 Falesti 5368 8256 7407 -2039 849 Floresti 5154 1842 7001 -1847 -5159 Glodeni 4810 6462 5972 -1162 490 Ialoveni 6923 9617 7602 -679 2015 Leova 3029 4702 4510 -1481 192 Nisporeni 3499 6603 5526 -2027 1077 Ocnita 3976 4604 2823 1153 1781 Orhei 7355 9582 9044 -1689 537 Riscani 5814 7021 6597 -783 424 Rezina 3301 5069 4209 -908 860 Singerei 5838 11896 13644 -7806 -1748 Soroca 6017 9719 9185 -3168 535 Straseni 5417 9484 9026 -3610 457 Soldanesti 1694 7738 5557 -3863 2181 Stefan-Voda 4884 7103 6501 -1616 602 Taraclia 2388 4406 4249 -1861 157 Telenesti 3713 3888 5241 -1528 -1353 Ungheni 7421 11634 9763 -2341 1871 Ceadir-Lunga 4352 4209 6801 -2449 -2592 Page 81 of 121

Vulcanesti 1689 2843 2822 -1133 21

Table 34 – Income and Expenditure of PHC institutions, total by raion

One may notice that the “Routine Income” did not exceed the “Recurrent Expenditure” for 2006, for any raion. The same situation can be noticed for every institution when doing this analysis on the database. That means that, without additional payment that were usually registered under the category “Other income”, the PHC institutions were not financially sustainable. More than that, the running costs of many institutions are quite low right now, because they do not have the standard utilities. After rehabilitation and setting up of all utilities, it is expected that the running cost would go a lot higher. This is a very important issue that should be taken into consideration in the analysis of the feasibility of autonomous PHC institutions.

With regard to the juridical and financial autonomy of the PHC institutions, the project took the opportunity of delivering the questionnaire to all family doctors to ask them what kind of autonomy would they prefer: not to become autonomous but to remain within the Raional Hospital, within an autonomous CMF (Center for Family Doctors), autonomous public institution or autonomous private institution. The result can be seen in the next two diagrams, 59% of the doctors from Raional Health Centers and 66% of the doctors in the Rural Health Centers said they would prefer to be within an autonomous Center for Family Doctors.

6% 6%

29% Within the Raional hospital

Within an authonomous Center for Family Doctors

Authonomous state institution

Authonomous pricate institution

59%

Figure 45 – Raional CS family doctors’ option for autonomy

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6% 8%

20%

Within the Raional hospital

Within the Center for Family Doctors

Authonomous state institution

Authonomous private institution

66%

Figure 46 - Rural CS family doctors’ option for autonomy

5.9 Estimation of the costs of rehabilitation of the PHC institutions

The estimation of the costs of rehabilitation of the PHC institutions had been a very complex work that the project team did together with the MoH PHC WG. The team tried to estimate, as accurately as possible, the volume of the investments that the Health System in Moldova has to for PHC institutions rehabilitation and to come up with some criteria for selection and prioritization of these investments.

Five methods have been planned to perform the estimation of these costs, but only three of them during the life time of the project, for reasons that will be explained later in these paper.

1. Collection of the cost data from local sources – estimation of costs by the direct beneficiaries, using the questionnaire

The questionnaire that was distributed to the PHC institutions had some distinct fields for cost data collection on various infrastructure elements. The estimations were done by the management of the PHC institutions, some of them with help from civil construction specialists from the Public Health Authorities. Many of the managers had already calculated these costs, prior to the project, in the attempt to raise funds for rehabilitation. The reported cost data was then checked and re-estimated by the civil constructions specialists that had been selected as local experts in the project, during the evaluation site visits to all 361 rural Health Centers.

The following table lists the rehabilitation cost items that have been collected through the questionnaire:

Cost Foundation & Walls Cost Inner Roof Page 83 of 121

Cost Floor Cost Outer Roof Cost Windows Cost Doors Cost Electrical Network Cost Water System Cost Sewage System Cost heating System Cost Hot Water System Cost ventilation & Conditioning Cost Security and Fire Alarm System Cost Telecommunication Cost Fence Cost Total Table 35 – The list of the rehabilitation costs that have been assessed through the questionnaire

The cost data reported by the RURAL beneficiaries was sum up in the table below:

RURAL AREA RURAL PHC Number of Locally Estimated Locally Estimated Average by institution PHC Total area Costs Total Costs Total Institution type institutions (m2) (thousands MDL) (USD) (USD) RURAL CS 257 244 274 229 558 20 868 940 81 202 OMF 559 111 605 528 997 48 090 635 86 030 PM 288 25 798 57 654 5 241 304 18 199 Total 1 104 381 677 816 210 74 200 879 67 211 Table 36 – Locally estimated costs for rural infrastructure rehabilitation, totals by type of PHC institution

Therefore, the beneficiaries reported a total sum of 74,200,879 USD for all RURAL (!!!) institutions, i.e. 67,211 USD per institution – 81,202 for CS, 86,030 for OMF and 18,199 for PM.

The following table presents the total locally estimated cost by raion, including urban and rural area.

URBAN + RURAL AREA Locally Estimated Costs Total Total number of PHC institutions by Raion (thousands MDL) raion Cahul 295508 43 Straseni 78739 37 mun. Chisinau 74085 44 Floresti 60214 63 Orhei 45906 65 Riscani 35337 47 Calarasi 24196 35 Hincesti 24021 49 Stefan-Voda 20822 26 Edinet 18589 37 Ialoveni 17104 33 Ungheni 16981 71 Page 84 of 121

Criuleni 16332 36 Telenesti 15056 42 Glodeni 14882 26 Drochia 14005 33 Donduseni 13007 26 Singerei 12846 57 Soroca 12786 58 Anenii-Noi 12677 35 Ocnita 11730 29 Cantemir 11402 41 Briceni 11055 35 Falesti 10899 34 Nisporeni 10197 31 Soldanesti 9604 27 Taraclia 8990 23 Rezina 8264 32 Leova 7124 32 Comrat 5537 13 Causeni 5226 28 Ceadir-Lunga 4269 9 Cimislia 3189 36 Dubasari 2758 11 Basarabeasca 2598 7 mun. Balti 2411 7 Vulcanesti 1917 3 Total 940263 1261

Table 37 - Locally estimated costs for urban and rural infrastructure rehabilitation, totals by raion

Data for each distinct institution and breakdown by types of costs can be queried in the database.

2. Checking and re-estimation of the locally estimated costs during the site visits of all rural health centers

3. Global estimation of costs using “standard unit cost” methodology

The project team has studied a lot of sources for establishing the “standard unit cost” for rehabilitation of a PHC infrastructure, including detailed invoices of real work for rehabilitation of similar institutions, like a rural kindergarten and a rural public institution (“casa de cultura”). Also, the team has asked the opinion of various civil construction specialists.

The results of this research work were:

- standard unit cost by m2 for capital rehabilitation, including the provision with all necessary utilities (water, sewage, gas systems etc) = 350 – 550 USD / m2 - standard unit cost by m2 for a new construction = 750 USD / m2

When we apply these rehabilitation costs to the existing infrastructure, using the average of 450 USD by m2, the sum up by type of rural institution of the costs looks like in the table below, with a total of 171,754,526 USD for the whole rural PHC system:

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RURAL AREA Total cost using Number of Standard unit “standard unit Average by RURAL PHC PHC Total area cost by m2 cost by m2” Institution institution type institutions (m2) (USD) (USD) (USD) Rural CS 257 244 274 450 109 923 296 427 717 OMF 559 111 605 450 50 222 079 89 843 PM 288 25 798 450 11 609 152 40 310 1 104 381 677 171 754 526 155 575 Table 38 - Estimated costs for rural infrastructure rehabilitation using “standard unit cost by m2” and current buildings’ area, totals by type of PHC institution

On the other hand, when we calculate the rehabilitation costs using “Standard unit cost by m2” methodology with 450 USD by m2, but restricting the area of each institution at the proposed standard area (see the final recommendations of the project), the total cost would be 54,765,000 USD, as it is shown in the table below:

RURAL AREA Total cost using Number of Standard area Standard “standard unit Average by RURAL PHC PHC by type of unit cost by cost by m2” Institution institution type institutions institution (m2) m2 (USD) (USD) (USD) Rural CS 257 200 450 23 130 000 90 000 OMF 559 100 450 25 155 000 45 000 PM 288 50 450 6 480 000 22 500 1 104 54 765 000 49 606 Table 39 - Estimated costs for rural infrastructure rehabilitation using “standard unit cost by m2” and standard buildings’ area, totals by type of PHC institution

4. Evaluation of the health centers, after selection and prioritization, by specialists from Construction Engineering Faculty, Chisinau

5. Final estimation of the costs by technical expertise and development of the rehabilitation project for each selected institution

The last two methods of cost estimation could be applied only after the selection and prioritization of the health centers for rehabilitation.

As a general conclusion, the costs that were estimated locally by the beneficiaries are much lower (74,200,879 USD) than the costs estimated by the “standard unit cost per m2” applied to the current real area of the PHC facilities (171,754,526 USD). The reasons for such a difference could be: - local estimation uses lower construction prices because they take into consideration cheaper local solutions (cheaper workforce or even own workforce, limited repairs or cheaper technical solutions with cheaper construction materials or donations from local organizations etc). On the other hand, the costs of large scale projects is higher because of the higher standards and advanced technical solutions, more expensive labor that often commutes to the rural sites, last generation construction materials etc - local estimation took into calculation only the elements that had to be rehabilitated or constructed as new (for example they did not include the water system if it was already in place and working properly), but the standard unit cost include “everything” that would be needed. Page 86 of 121

The fact that the costs estimated by “standard unit cost by standard area” are considerably lower than the other costs (54,765,000 USD) is a powerful argument, along with a number of other arguments in this paper, for an initial restructuring of the PHC institutions, prior to investment planning and actual rehabilitation – see the final recommendations of the project.

Also, the average cost by CS institution estimated by “standard unit cost by standard area” is slightly above the predicted range of 70-80.000 USD investment per institution in the last MoH-WB agreement.

5.10 Selection of the Rural health Centers for the first rehabilitation phase

The project team, together with the MoH PHC WG has defined the following selection and prioritization criteria for rehabilitation of the Rural health Centers. The list of criteria consists of exclusion criteria (the first four criteria) and selection criteria (the last 11 of them). The order of the criteria in the list is not a ranking, but these criteria should have an equal weight when applied.

In the selection process we used these criteria in the context of each raion. For example when using the “population” criterion, we compared the number of population of each CS with the number of population of the other CSs within that raion.

1. To be a Health Center (CS), not an OMF or PM This criterion was agreed with the WB prior to this project. In reality, the results of this study showed that the PHC institution should be restructured, prior to investment. This way, it is possible that a number of current CS will no longer be a CS after the restructuring process, but some OMF will become CS. On the other hand, the CSs usually have oversized facilities, but OMF have smaller facilities, therefore, rehabilitation of some OMF could be more efficient and sustainable than rehabilitation of the CS in the same area.

2. To be in the rural area This criterion was agreed with the WB prior to this project.

3. It should has not been rehabilitated in the last WB Health Investment Fund project Some 95 rural health centers have been already rehabilitated in the last WB Health Investment Fund project.

4. To be owned by the Raion Council or transferable to it The owner of the building could be the Raion Council, the City Hall, individual persons as share holders or any combination of the above. Only buildings owned entirely by the Raion Council can be easily included in the rehabilitation process. The buildings owned by the City Hall or having a shared ownership could not be rehabilitated unless they are transferred to the Raion Council or a special other regulation is issued.

5. To be nominated in consensus with the Public Health Authority The Public Health Authority filled up a distinct section of the questionnaire, expressing their opinion with regard to which institution is a priority for rehabilitation and the reasons why. Taking into consideration the vision of the MoH towards decentralization and consensus building, together with the project recommendations for a community based PHC institutions restructuring this criterion becomes a very important one.

6. To cover the largest number of population in the area

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If two CS are equal with regard to other criteria, the one that covers a larger number of population will be chosen, in order to have a larger population benefiting from the investment.

7. To be the farthest from the hospital If two CS are equal with regard to other criteria, the one that is located remotest from the hospital will be chosen, in order to enlarge the access to PHC services for the remotest population.

8. The building should be “rehabilitateable” (not too old, not improper construction materials) As the infrastructure evaluation shows, a large number of PHC buildings are very old or the resistance structure is deteriorated or the construction materials are improper (lut, lampaci). For some of these buildings, the analysis showed that it is no longer safe to run public services in, therefore the project has considered that finding or constructing a new building is more appropriate.

9. The area of the building should be small enough (no more than 200 m2 for two family doctors) The larger the building is the bigger the rehabilitation and the running costs would be. See also the Chapter 5.9 Estimation of the costs of rehabilitation of the PHC institutions and the final recommendations of the project.

10. Cost containment (< 100.000 $) The last agreement with the WB foresee that a number of 60-70 CS will be rehabilitated in the rural area that means an average investment value of 70-80,000 USD per institution.

11. To be in conformity with the functional and structural standards Before, but mostly after the rehabilitation, the PHC institution should be(come) in accordance with the function and structure standards in place.

12. To have the largest number of doctors 13. To act as an incentive to attract the doctors to work in the institution The last two criteria, although seems contrary one to another would be consider in different circumstances.

14. To be a selection or priority option of the local experts and evaluators This criterion is a qualitative one, based on the opinion of the evaluators that could give important clues about each CS that could not be extracted from data analysis. For example, some of the doctors made huge personal investments in the PHC institutions, although they do not own it, while others did not care. It seems reasonable to compensate for such efforts, if everything else is equal.

15. Twinning with Local Public Authorities investments Twinning with Local Public Authorities investments in the PHC area (usually in water or gas supply systems) could be an inclusion criterion because it will save funds that can be used in other places. On the other hand, some CS that will not benefit for sure from Local investments could benefit from the WB project to get all the rehabilitation elements they need.

Basically, the project team and the MoH PHC WG have analyzed each and every rural health center, one by one, using the database, the reports of the evaluators and the picture of all these centers against the above criteria. As a result, 116 CS have been preliminary selected for a secondary analysis that will decide for final list of 60-70 of them – see Annex 4. Preliminary list of Rural Health Centers selected for rehabilitation. For each CS in the Page 88 of 121 list there are notes about the criteria used for selection and, also, about the potential problems. One of the major problems during the analysis was the inability to accurately determine the status of the resistance structure of some of the buildings and consequently, the inability to determine if the building can be rehabilitated and at what cost. For this situation, the civil constructions specialists recommended no decision prior to a technical expertise. These cases have been noted down in the list.

IMPORTANT!

This preliminary list of Rural Health Centers that were selected for rehabilitation is not at all a final one. In fact, giving the results and recommendations of the project, a major PHC institutions restructuring process should be done prior to investment, in order to ensure cost-efficiency and long term sustainability of the investments – see the final recommendations of the project. After this restructuring process, it is reasonable to assume that a new list will be put together.

5.11 Summary of the conclusions

The comprehensive PHC system analysis done by the project led to the following conclusions:

Organization of the PHC institutions There are a number of PHC institutions that do not comply anymore with the current functional and structural standards by type of institution (CS, OMF and PM). The most important discrepancies with the standards are in terms of population coverage, human resources and the area of the buildings in which they are located.

Access of the population to PHC institutions The geographical coverage is considered to be good, but the physical access to the PHC institutions is difficult for many places due to the lack of public transport means and the bad condition of the roads.

Human Resources According to the centralized HR planning methodology that is currently in use, - there is a surplus of 165 doctors in urban areas and a shortage of 362 doctors in rural areas, which means a general shortage of 197 doctors at the national level - there is a shortage of 408 nurses in urban areas and a shortage of 349 nurses in rural areas, which means a general shortage of 756 nurses at the national level The variation of these figures among raions is very high. The absolute shortage varies among raions between 1 to 42 family doctors and 1 to 144 nurses, while the shortage in percentages varies between 3% to 79% for doctors and 1% to 40% for nurses, which means an equivalent lack of coverage of the population with PHC services.

Infrastructure Generally, the infrastructure is quite old and does not comply with resistance norms and is in bad shape for more than 50% of the buildings. The area of the buildings is oversized, the total by country being 545,118 m2, which means 259 m2 for each family doctor. The used area is only 78% of the total area.

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The availability of utilities of the PHC institutions is low; only 22% have running water systems of which only 7% have hot water and 43% have sewage systems.

Only 57% of the PHC institutions belong to a Raional Council and can be rehabilitated without any other legal formalities regarding the ownership transfer.

The Rural PHC System total rehabilitation costs that were estimated locally by the beneficiaries are much lower (total cost = 74,200,879 USD, average by CS = 81.202 USD) than the costs estimated by the “standard unit cost per m2” applied to the current area of the PHC facilities (total cost = 171,754,526 USD, average by CS = 427.717 USD), but higher than the costs estimated by “standard unit cost by standard area” methodology (total cost = 54,765,000 USD, average by CS = 90,000 USD).

Medical and non-medical equipment in the PHC institutions There is a huge lack of equipment in the PHC institutions with the difference varying from 40% to 90% between current standards (the needs) and the existing infrastructure for different types of equipment.

5.12 Recommendations

1. Redefining the structural and functional standards for the PHC institutions at central / national level 2. Development of local plans for restructuring the PHC institutions at community and raion level 3. Refining the national level planning process and implementing restructuring measures 4. Prioritization of investments and designing the national investment plan 5. Maintaining and further developing the information system as basis for data driven decision making

National level

Raional Level

Community Level

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1. Redefining the structural and functional standards for the PHC institutions at central/ national level

As a first step, there is a need for redefining in a flexible manner the functional and structural standards for the PHC institutions, as follows:

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Covered Function and Structure Family Doctors Nurses Medical Area of the Population1) Equipment building Rural Standard Minimum Agreed Standard 1 FD for 1500 3 N for 1 FD or Minimum 50 - 300 m2 population 1500 population Agreed (flexible) Standard Centru de Sanatate Over 2500 1. Medical offices and Minimum 2 2 – 3 for a FD or Minimum 200 - 300 m2, Rural (CS) population auxiliary rooms 1 for 1500 standard, correlated 2. Pharmacy office population including with the 3. Laboratory Laboratory number of 4. Dentist office FDs Oficiu al Medicului 1000 - 2500 Minimum 12) 2 – 3 for a FD or Minimum 100 – 150 m2 de Familie (OMF) population 1. Medical office and 1 for 1500 standard auxiliary rooms population 2. Pharmacy office Filiala CS sau OMF below 1000 Minimum 03) 1 – 2 Minimum 50 – 100 m2 (PM) population 1. Medical office and standard auxiliary rooms 1) The covered population is to be calculated including the population not covered by FDs of subordinated institutions, for a general standard of 1500 population for 1 FD. 2)The population surplus compared with the minimum standard for a FD, if any, would be covered by FDs from the corresponding Health Center 3)Population will be covered by the FDs from the corresponding CS or OMF

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2. Development of local plans for restructuring the PHC institutions at community and raion level

The Community Planning Method. This method presumes an integrated approach for the analysis and restructuring of the PHC system within the community, based on general socio- economic conditions and community values, using national standards as a reference.

The following activities need to be performed together with the Local Authorities:

1. Analysis of the PHC system at the community level, identifying the role and situation of each CS, OMF and PM, based on the criteria listed below: - socio-economic characteristics of the community/population - demographic characteristics and the dynamic of the population for that community - general health status of the community - geographical situation and physical access of the population to the PHC services and other health services (coverage area for different health institutions, public transportation, average time to reach the health facilities, transportation for medical staff) - PHC services utilization rates, comparisons with national standard indicators - PHC medical personnel (doctors and nurses) coverage, comparisons with national average and the proposed rural standard presented in the table above - Infrastructure (correspondence with the standard, area, status, rehabilitation potential, utilities existence and status, renovation costs, costs to install new utilities) - Medical equipment, conformity with minimum agreed standard - Health insurance coverage of the population - Individual financial sustainability of each PHC institution - Extra running costs after installing the utilities - The relationship among the CS – OMF – PM, especially by analyzing the possibility to take over the non-covered population by the higher hierarchy institution

All data presented here can be extracted from the database developed in the project, except for the socio-economic status and population health status, which, can be found by looking in different data sources.

2. Discussing the current situation with the local authorities 3. Establishing the local targets and proposing a local reorganization model of the PHC institutions, taking into consideration the following: a. Establish a realistic target for human resources needs at community level; this can be lower than the national standard level (if population needs are covered at least at the national average level of the indicators) or higher (if the population health status, the geographical situation or the utilization of the health services are lower than the national average level of the indicators). At national level, in the rural area, there is a general human resources shortage, that can be addressed by the following actions: i. Internal redistribution of staff from institutions having a surplus, if physically possible (based on doctors’ actual living area, transportation means for staff or patients for areas that are not covered etc) ii. Provision of the transportation means to medical personnel to cover remote areas iii. Incentives to attract medical personnel – incentives from LPA (accommodation, covering of some expenses etc), higher salaries for rural Page 93 of 121

areas, provision of medical equipment, communication related incentives (phone, Internet) iv. Lowering the burden on family doctors, by creating/stimulating alternative service providers – home care, social community services etc. and supporting the development of these services at local level b. Reconfirm or reorganize the existing CS, OMF and PM, based on the following criteria: i. Compliance with the (flexible) general standard for institutions, presented above ii. Compliance with the “most accessible spot” principle in locating the CS that have extended functions (laboratory, dentistry etc). With respect to this, institutions that will be reconfirmed or reorganized as CS should be located on main roads or have direct public transport from the covered areas. iii. Upgrading of the institutions (PM in OMF, OMF in CS). For example, transforming existing OMF in CS for those OMF that either cover a larger population than the standard or that are located in more accessible areas than the CS they belong to. iv. Downgrading of institutions if they don’t comply with the population coverage standard v. Closing of PHC institutions, if the population can be taken over by a different existing one, eventually by reorganization and changing the role/function (social services, home care etc) c. Establish the medical and non medical equipment needs i. After applying the reorganization model for the PHC institutions, the general inventory for equipment need can be finalized, based on the existing standards in place d. Reorganization of the PHC institutions infrastructure, based on the following criteria: i. Conformity with the functional and structural standard, including building areas ii. For buildings that cannot be renovated/rehabilitated or if they require extensive rehabilitation costs (too old, poor general resistance system or inadequate construction materials) it is recommended that another building would be identified to relocate the respective PHC institution or the proposal for constructing a new building will be made iii. For buildings with too large areas, it is recommended that another building would be identified to relocate the respective PHC institution or the area dedicated to the PHC institution in that building should be restricted and available spaces would be used for other purposes – doctors’ housing, transfer to another institution (with a good contract), provision of other alternative community services e. Selection and prioritization of the PHC institutions infrastructure rehabilitation, based on the following criteria: i. To be a Rural Health Center (CS), not an OMF or PM ii. It should not have been rehabilitated in the last WB Health Investment Fund project iii. To be owned by the Raion Council or transferable to it iv. To be in conformity with the functional and structural standards v. To cover the largest population in the selected area vi. To be the farthest from the hospital vii. To act as an incentive to attract doctors to work in the institution viii. To be nominated in consensus with the Public Health Authority 4. Identification of the local resources that can be directed to the PHC system

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a. Incentives to attract or maintain medical personnel in the respective PHC institutions (housing, covering of some expenses, transportation facilities etc) b. Capital investments in the PHC institutions infrastructure (renovation, utilities etc) c. Creating and funding complementary health services, in order to take over some of the PHC system overload d. Improving public transportation and transportation infrastructure for easier population access to medical services 5. Communication of the conclusion to central authorities, to serve for the general planning process and redirection of resources towards the respective community.

3. Refining the national level planning and implementing the restructuring measures

The resulting restructuring plans from the local planning process (community, raion level) will be sent to the central authorities, empowering them to adopt the following measures:

1. Actualization of the national standards based on the analysis of the local plans 2. Refining and regulating the national level planning and restructuring process 3. Creating/enforcing and gradually implementing the general incentives system for PHC medical personnel: a. Designing and implementing a new policy to increase salaries, with 2 main components: a central one, with a gradual general increase of salaries and a decentralized component, with an increase resulting from the autonomy and direct contracting statute of the medical personnel (based on agreed performance criteria) b. Medical equipment and furniture acquisition (based on previous estimated needs) c. Transportation vehicles acquisition for medical staff, to be located in remote areas, with difficult access of the population (based on previous estimated needs) d. Computer acquisition and internet connection facilities (being the first preference of staff when looking at the analysis of the self reported questionnaire); this will also facilitate operation of the data collection system for evaluating and monitoring the PHC system or the distance learning approach for continuous medical education programs, including telemedicine e. Enabling phone communications (land line should be minimal standard and mobile phones could be an option where there is no land line available) 4. Planning for the human resources training, according to the actualized database of the HR Registry done in this project and to the local developed plans 5. Supporting alternative methods to increase population access to services – for example home care services, long term care etc.

4. Prioritization of investments and designing the national investment plan In designing this plan there long term sustainability and cost efficiency principles for capital investments should be considered, respecting the following steps: 1. Analysis and decision should be made based on specific data and evidence for each institution as provided in this project and based on proposed local restructuring plans 2. Twinning with LPA investments 3. Availability of internal and external funding sources 4. Designing the investment plan, with phases, according to the predictable available funds

For infrastructure rehabilitation planning we recommend the following:

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- Only PHC institutions respecting structural and functional standards should be considered to be rehabilitated. Based on project estimations and calculations, if standards are being respected and met, the maximum value for the investment in one CS (max area 200-300 m2) is 90,000-135,000 USD; if utilities are already available (entirely or partially) this value will decrease accordingly - Twinning with LPA investments - The list of institutions to be rehabilitated in the next WB project will be finalized based on the principles nominated here and considering the priorities in the local plans - The financial simulation of the investments will/can be carried out using the database tool

For equipment acquisition planning we recommend the following: - evaluate the needs based on existing data and local restructuring plans - evaluate the acquisition prices for each type of equipment and update the data base with these values - design a standard set of equipment possible to buy from internal sources, specifying exactly the total values and the funding sources - design a standard set of equipment possible to buy from next WB project funds, respecting project budget limits - run financial simulations for different sets of equipment using the simulation tool in the data base - acquisition of the equipment - redistribution to other institutions of the remaining used equipment, if the case

5 Maintaining and further development of the information system as basis for data driven decision making

1. Maintaining and updating the PHC system data base and the Human Resources Registry

a. Establishing the project data collections standards as the national data collection standard for the PHC system and including this standard in the National Integrated Information System of the health System (currently being designed) b. Localizing the data based in a central institution (MoH or subordinated to it); the institution will have the responsibility to maintain and update the database c. Checking for accuracy and integrity the data already collected d. Establishing a protocol to initially and dynamically check data integrity e. Establishing a yearly process for updating the data (yearly data collection) f. Establishing a protocol for regular updates to the HR Registry g. Adding necessary information to the initial questionnaire developed in this project h. Refining (detailing and granularity) the data collected for planning – mainly population data, health insurance data, services provided and financial data (income and expenditures) at the institutional level i. Development of specific software to replace the questionnaire j. Migration of the data base application from Access to SQL (or equivalent) k. Publishing relevant data on the Internet l. Training the MoH staff and professionals to use available data m. Enabling access to data for all decision makers in the system!!! n. Designing and publishing specific reports and statistics for each decision making level (e.g. HR, financial department, services provision department, infrastructure etc.) o. Designing special modules (e.g. planning of HR, planning of services, planning of investments etc.)

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2. Maintain and expand the GIS

a. Signing a protocol with INGEOCAD for dynamic maintenance of the GIS b. Expanding the information stored and published by the GIS c. Improving the GIS interface – data base, for conditional displaying of several data, reports, statistics etc. d. Expanding the GIS to other health subsystems: hospitals, outpatient, pharmacies etc.

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Annex 1. – Project Team

The project team consisted of:

. Daniel Ciurea, Health and Social Services Management specialist, international consultant, team leader . Mihai Ciocanu, Public Health specialist, local coordinator . Capcelea Ludmila, Public Health specialist, local expert . Adomniţei Vitalie, architect, civil constructions specialist, local expert . Gavriliţa Georgeta, Public Health specialist, local expert . Naval Teodor, architect, civil constructions specialist, local expert . Popov Irina, Public Health specialist, local expert . Spinu Alexandru, civil constructions specialist, local expert

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Annex 2. – Terms of References for local experts

The local experts were either public health or primary health care specialist or civil constructions specialists.

The main tasks of the local experts were: - To contribute to the data collection and design of the Master Plan - On site evaluation of the PHC centers - Recommendations for the selection of the PHC Centers that will be refurbished under the next WB loan.

1. Expert in sanătăte publica si echipament medical pentru medicină de familie

Cerinţe: Aptitudini si calificare:  Licenţiere in sănătate publică, management sanitar sau medicina de familie.  Abilitatea de a comunica si întocmi rapoarte in limbile engleza si româna  Studii post-universitare in sănătate publica, management sanitar vor fi un avantaj Experienţa profesionala:  Cel puţin 5 ani de experienţă in sănătate publică / medicină primara  Experienţă in furnizarea serviciilor de medicină primara, selectarea echipamentului şi utilajelor medicale, managementul resurselor umane, tainingul stafului centrului de sănătate.  Experienţă in expertiza oportunităţii echipamentului si a utilajului medical, in expertiza financiara.  Experienţă de lucru in proiecte finanţate de către donatorii internaţionali.  Cunoştinţe in domeniul sistemului de sănătate si în recentele reforme in medicina primara, asigurări medicale, finanţare.

Cerinţe specifice:  Cunoaşterea limbii de stat  Abilitatea de a lucra in condiţii dificile si in termeni de timp limitaţi.  Experienţă de lucru cu echipe multinaţionale.  Un avantaj va constitui cunoaşterea procedurilor din proiectele BM

Sarcini A evalua o serie de centre de sănătate din medicina primara pentru a fi selectate pentru implementarea ulterioara a activităţilor proiectului, in termeni de: Page 99 of 121

 Oportunitatea echipamentului si a celorlalte facilităţi din centrele de sănătate.  Evaluarea capacităţilor personalului si trainingul personalului  Atitudini ale personalului  Atitudinile pacienţilor A revedea programul, investiţiile si condiţiile pentru dezvoltarea ulterioara a medicinii de familie. Durata 30 zile, începînd cu 26 iulie 2007 Activităţi  A evalua investiţiile / echipamentul existen/ personalul angajat  Pregătirea chestionarelor pentru colectarea structurata a datelor in timpul inspecţiilor ( vizitelor la centrele de sănătate ale medicinii primare)  A face un studiu de comparare a acestor centre pentru a fi posibila selectarea centrelor pentru implementarea in continuare a activităţilor proiectului.  Vizita in teren pentru evaluarea centrelor de sănătate selectate  A facilita interesul focus grupului pentru activităţile proiectului  Scrierea rapoartelor Efecte  Scrierea unui raport asupra celor evaluate si concluzii  Master plan pentru dezvoltarea medicinii primare

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2. Expert in lucrări civile, inginer civil

Cerinţe: Aptitudini si calificări:  Licenţiere in domeniul evaluării construcţiilor civile  Abilitatea de a comunica si a întocmi rapoarte in limba engleza si româna Experienţa profesionala:  Cel puţin 5 ani de experienţă in domeniul dat ( inginerie, lucrări civile)  Experienţă in expertiza oportunităţii construcţiilor si in expertiza financiara.  Experienţă de lucru in proiecte finanţate de către donatori străini Cerinţe specifice:  Cunoaşterea limbii de stat  Abilitatea de a lucra in situaţii dificile si in termeni de timp limitat  Experienţă de lucru cu echipe multinaţionale  Un avantaj va constitui cunoaşterea procedurilor din proiecte BM

Sarcini A cerceta o serie de construcţii (clădiri) unde sunt amplasate centre de sănătate pentru selectarea si reabilitarea ulterioara a acestora, in termen de:  Oportunitatea construcţiilor (clădirilor) existente  Calitatea clădirilor  Aprecierea in bani a lucrărilor civile necesare pentru reabilitarea centrelor de sănătate Durata 30 yile începînd cu 26 iulie 2007 Activitati  Evaluarea oportunităţii construcţiilor (clădirilor) existente, fotografierea faţadei şi încăperilor CS  Pregătirea chestionarelor pentru colectarea structurata a datelor in timpul vizitelor la centrele de sănătate  Vizite în teren la centrele de sănătate  Scrierea rapoartelor Efecte Raport asupra celor evaluate si concluzii, Master plan pentru dezvoltarea medicinii primare

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Annex 3. – PHC system evaluation questionnaire

Questionnaire for each PHC system institution

(It has been filed in separately / individually for each CS, OMF and PM)

Question Code Question Answer Format I Name of the PHC institution text P Name of the person filling the questionnaire text ID Institution code (to be filled in afterwards by CSPSPMS) text 1 ADMINISTRATIVE ----- 1.1 AMP Institution ----- 1.2 Type of PHC institution (evaluated institution): ----- 1.3 CS - Centru de Sanatate yes/ no 1.4 OMF - Oficiu al Medicilor de Familie yes/ no 1.5 PM - Punct medical yes/ no 1.6 Raion text 1.7 Locality text 1.8 Facility ownership: ----- 1.9 Raion Council / Municipality yes/ no 1.10 City Hall yes/ no 1.11 Shares yes/ no 1.12 Contact data ----- 1.13 Institution manager – name and surname text 1.14 Phone number (including area code) text 1.15 Number fax text 1.16 e-mail address text 1.17 Population covered ----- 1.18 Total number number 1.19 Women number 1.20 Men number 1.21 Persons age 0-1 years number 1.22 Persons age 0 - 4 years 11months 29 days number 1.23 Persons age 0 - 18 years number 1.24 Adults total (19 years and more) number 1.25 Number of aged persons able to work: number 1.26 women number 1.27 men number 1.28 Number of retired persons number 1.29 Number of insured persons number 1.30 Number of non insured persons number 1.31 Population access to the primary health institution (CS, OMF) ----- 1.32 Area covered km 1.33 Availability of public transportation in the locations of the CS or OMF yes/ no Average time to reach the facility with public transportation/ walking to CS or 1.34 OMF min 1.35 Roads status: ----- 1.36 Country roads yes/ no 1.37 Stoned yes/ no 1.38 Asphalt yes/ no

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1.39 Population access to pharmacy services ----- 1.40 There is a state owned pharmacy yes/ no 1.41 There is a private pharmacy yes/ no 1.42 Access of the population to emergency care ----- 1.43 Are there Emergency Services nearby yes/ no 1.44 Distance to the Centrul de Sanatate / OMF km 1.45 Access to specialized services / Hospital ----- 1.46 Distance from CS / OMF to the Raion / Municipal Hospital km 1.47 There is public transportation available to the Hospital yes/ no 1.48 Average transportation time with public transportation min 1.49 Closest PHC institution ----- 1.50 Name text 1.51 Distance km

Question Answer Code Question Format I Name of the PHC institution ----- P Name of the person filling the questionnaire ----- ID Institution code (to be filled in afterwards by CSPSPMS) ----- 2 INFRASTRUCTURE ----- 2.1 General data about the building ----- 2.2 Sanitary authorization yes/ no 2.3 Accreditation certification (including through CMF) yes/ no 2.4 Year of the construction of the building where CS / OMF is located year 2.5 Number of buildings for the location of the CS / OMF number 2.6 Building type: ----- 2.7 Typical project yes/ no 2.8 Accommodated type yes/ no 2.9 Number of levels, including basement number 2.10 There is a basement yes/ no 2.11 Levels height m 2.12 Total area m2 2.13 Utilized area m2 2.14 Non utilized area m2 2.15 Rented area to other institutions m2 2.16 Date (year) of last capital repair/ consolidation year 2.17 Availability of the documentation for the building construction project yes/ no Availability of the technical expertise for the building (conclusions of the 2.18 expertise to be annexed here) yes/ no 2.19 Funding source for the last capital repairing/ consolidation: ----- 2.20 FIS yes/ no 2.21 Local budget yes/ no 2.22 Others yes/ no 2.23 Year of last maintenance repair year 2.24 Current status of the building and area needing repairing/ consolidation ----- 2.25 General resistance structure ----- 2.26 According to seismic requirements yes/ no 2.27 Availability of the reinforced concrete carcass yes/ no 2.28 Foundation ----- 2.29 Availability of the foundation yes/ no 2.30 Material for the foundation: ----- 2.31 Ferro-concrete yes/ no 2.32 BUT - piatra bruta yes/ no 2.33 Others yes/ no 2.34 Cracks in the foundation yes/ no Page 103 of 121

2.35 Walls ----- 2.36 Material for the walls: ----- 2.37 Cotilet yes/ no 2.38 But - piatra bruta yes/ no 2.39 Clay yes/ no 2.40 Bricks yes/ no 2.41 Lampaci yes/ no 2.42 Pre assembled panels yes/ no 2.43 Others yes/ no 2.44 Walls dimensions cm 2.45 Cracks present yes/ no 2.46 Status of the interior plaster (good B, satisfactory S, non satisfactory N) B / S / N 2.47 Interior plaster area needing repairs % 2.48 Status of the exterior plaster B / S / N 2.49 Façade area needing repair % thousand 2.50 Estimated costs to rehabilitate (repair) the foundation and walls MDL 2.51 Ceiling (attic) ----- 2.52 Materials used: ----- 2.53 Sindrila yes/ no 2.54 Monolit yes/ no 2.55 Barne yes/ no 2.56 Concrete preassembled panels yes/ no 2.57 Status of the ceiling B / S / N 2.58 Availability of thermo isolation (in the attic) yes/ no thousand 2.59 Estimated cost for ceiling rehabilitation/ construction MDL 2.60 Floors ----- 2.61 Material of the support layer for the floors: ----- 2.62 Concrete yes/ no 2.63 Pietris - piatra sparta yes/ no 2.64 Others yes/ no 2.65 Status of the support layer for the floors B / S / N thousand 2.66 Estimated cost for rehabilitation/ installing support layer for floors MDL 2.67 Roof ----- 2.68 Type of roof: ----- 2.69 Flat yes/ no 2.70 Sarpanta (wooden) yes/ no 2.71 For flat roof: ----- 2.72 Material of the flat roof: ----- 2.73 Linocrom yes/ no 2.74 Ruberoid - membrane bituminoase yes/ no 2.75 Others yes/ no 2.76 Number of layers number 2.77 Status B / S / N 2.78 For … roof type sarpanta: ----- 2.79 Material roof type sarpanta: ----- 2.80 Tigla metalica yes/ no 2.81 Foi de ardezie yes/ no 2.82 Tabla zincata yes/ no 2.83 Others yes/ no 2.84 Status of the roof B / S / N 2.85 Status of the wooden structure of the roof B / S / N 2.86 Availability of down comers/ down pipes yes/ no Page 104 of 121

2.87 Status of the of down comers/ down pipes B / S / N 2.88 Year of the last roof renovation year thousand 2.89 Estimated cost for roof rehabilitation/ installing MDL 2.90 Windows ----- 2.91 Material for the windows: ----- 2.92 Wood yes/ no 2.93 PCV/ Aluminum yes/ no 2.94 Status B / S / N thousand 2.95 Estimated cost to install windows MDL 2.96 Doors ----- 2.97 Material: ----- 2.98 Wood yes/ no 2.99 PCV/ Aluminum yes/ no 2.100 Status B / S / N thousand 2.101 Estimated cost to install doors MDL 2.102 Availability and status of the utilities ----- 2.103 Electricity ----- 2.104 Present yes/ no 2.105 Status B / S / N thousand 2.106 Estimated cost to rehabilitate/ install electricity MDL 2.107 Running water system ----- 2.108 Present yes/ no 2.109 Type: ----- 2.110 Central system yes/ no 2.111 Autonomous: yes/ no 2.112 Fountain yes/ no 2.113 Sonda arteziana yes/ no 2.114 Mina yes/ no 2.115 Others yes/ no 2.116 Status of the exterior running water system B / S / N 2.117 Status of the interior running water system B / S / N Estimated cost to rehabilitate/ install exterior and interior running water thousand 2.118 systems MDL 2.119 Sewage system ----- 2.120 Present yes/ no 2.121 Type: ----- 2.122 Central yes/ no 2.123 Autonomous: yes/ no 2.124 Cesspool yes/ no 2.125 Others yes/ no 2.126 Status of the exterior sewage system B / S / N 2.127 Status of the interior sewage systems B / S / N thousand 2.128 Estimated cost to rehabilitate/ install exterior and interior sewage systems MDL 2.129 Heating system ----- 2.130 Present yes/ no 2.131 Type: ----- 2.132 Central system yes/ no 2.133 Autonomous: yes/ no 2.134 Natural gas yes/ no 2.135 Charcoal yes/ no 2.136 Stove ??? yes/ no Page 105 of 121

2.137 Heaters yes/ no 2.138 Others yes/ no 2.139 Status of the exterior heating system B / S / N 2.140 Status of the interior heating systems B / S / N 2.141 Year of the construction of the building where the heating system is located year 2.142 Year of the last renovation of this building year thousand 2.143 Estimated cost to rehabilitate/ install exterior and interior heating systems MDL 2.144 Hot water system ----- 2.145 Present yes/ no 2.146 Status of the exterior shot water system B / S / N 2.147 Status of the interior hot water system B / S / N thousand 2.148 Estimated cost to rehabilitate/ install exterior and interior hot water systems MDL 2.149 Ventilation/ conditioning systems ----- 2.150 Presence of: ----- 2.151 Ventilation yes/ no 2.152 Conditioning yes/ no 2.153 Status of the ventilation/ conditioning systems B / S / N thousand 2.154 Estimated cost to rehabilitate/ install ventilation/ conditioning systems MDL 2.155 Security and fire proof systems ----- 2.156 Present yes/ no 2.157 Status of the security and fire proof systems B / S / N thousand 2.158 Estimated cost to rehabilitate/ install security and fire proof systems MDL 2.159 Telecommunication system ----- 2.160 Present yes/ no 2.161 Type: ----- 2.162 Phone yes/ no 2.163 Fax yes/ no 2.164 Email yes/ no 2.165 Status of the telecommunication system B / S / N thousand 2.166 Estimated cost to rehabilitate/ install telecommunication system MDL 2.167 IT network ----- 2.168 Number of computers number 2.169 Average age of the computers years 2.170 Basic software present (Word, Excel) yes/ no 2.171 Internal network present yes/ no 2.172 Status of the internal network B / S / N 2.173 Internet connection present yes/ no 2.174 Medical waste system ----- 2.175 Burning yes/ no 2.176 Burial yes/ no 2.177 Disinfection and disposal yes/ no 2.178 Special community services collection yes/ no 2.179 Others yes/ no 2.180 Surrounding areas of the building ----- 2.181 Status B / S / N 2.182 Availability of appropriate access paths to the institution yes/ no 2.183 Availability of the fence yes/ no 2.184 Material for the fence: ----- 2.185 Wood yes/ no 2.186 Metal yes/ no 2.187 Stone yes/ no Page 106 of 121

2.188 Status of the fence/ hedge B / S / N thousand 2.189 Estimated cost to rehabilitate/ install the fence/hedge MDL 2.190 Availability of standardized rooms for the PHC system ----- 2.191 Reception yes/ no 2.192 Triage yes/ no 2.193 Number of examination/ consultation rooms number 2.194 Medical procedures room yes/ no 2.195 Immunizations room yes/ no 2.196 Laboratory yes/ no 2.197 Number of laboratory rooms number 2.198 Pharmacy yes/ no 2.199 Staff room (day) yes/ no 2.200 Waiting room/ hallway yes/ no 2.201 Day stay rooms for women yes/ no 2.202 Day stay rooms for men yes/ no 2.203 Staff toilet yes/ no 2.204 Patients women toilet yes/ no 2.205 Patients men toilet yes/ no 2.206 Wardrobe room yes/ no 2.207 Estimated costs ----- Total estimated costs for complete renovation of the building (sum all of the thousand 2.208 above costs) MDL Availability of project plans for the buildings (IF YES, PLEASE ATTACH A 2.209 COPY) ----- 2.210 Availability of the cadastral plan of the building yes/ no 2.211 Availability of the building construction project yes/ no 2.212 Availability of the technical expertise of the building yes/ no

Question Code Question Answer Format I Name of the PHC institution text P Name of the person filling the questionnaire text ID Institution code (to be filled in afterwards by CSPSPMS) text 3 FUNCTIONAL EQUIPMENT LESS THAN 50% WEAR ----- 3.1 Medical devices ----- 3.2 Blood pressure meter number 3.3 Stethoscope number 3.4 Ocular tonometer number 3.5 Obstetrical stethoscope number 3.6 Children weighting scale number 3.7 Children anthropometer number 3.8 New born examination table number 3.9 Automatic 6 channel electrocardiograph number 3.10 Portable 3 channel electrocardiograph number 3.11 Adult peakflowmeter number 3.12 Children peakflowmeter number 3.13 Glucosemeter number 3.14 Clinical laboratory set number 3.15 Biochemistry laboratory set number 3.16 Sterilizer number 3.17 UV lamp for air disinfection number 3.18 Large stainless steel boxes number 3.19 Small stainless steel boxes number 3.20 Stainless stell table for medical devices number

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3.21 Gynecology table number 3.22 Pelvimeter number 3.23 Neurology examination set number 3.24 Othoscope number 3.25 Ophthalmoscope number 3.26 Portable examination lamp number 3.27 Guzon ear syringe number 3.28 Set of Kramer splints number 3.29 Vision chart number 3.30 Computer number 3.31 Printer number 3.32 Medical devices set ----- 3.33 Specule ginecologice number 3.34 Cornţanguri number 3.35 Scalpel number 3.36 Anatomical pincers number 3.37 Surgical scissors (straight) number 3.38 Surgical scissors (curved) number 3.39 Medical catheters number 3.40 Special objects ----- 3.41 GP’s medical kit number 3.42 Tourniquet number 3.43 i.v. infusions holder number 3.44 Medical thermometers number 3.45 Length meter number 3.46 Chronometer number 3.47 Goniometer number 3.48 Adult rectal tubes number 3.49 New born rectal adult number 3.50 Medical equipment and furniture ----- 3.51 Folding screen number 3.52 Medical bed number 3.53 Physician’s table number 3.54 Nurse’s table number 3.55 Drugs cabinet in the medical procedures room number 3.56 Drugs cabinet for emergency drugs number 3.57 Furniture set for clothes, books number

Question Code Question Answer Format I Name of the PHC institution ----- P Name of the person filling the questionnaire ----- ID Institution code (to be filled in afterwards by CSPSPMS) ----- 4 INSTITUTION LEVEL HUMAN RESOURCES ----- 4.1 Total number of doctors (any specialty) ----- 4.2 Total number of doctors in CS or OMF number 4.3 Family doctors ----- 4.4 Available positions number 4.5 Occupied positions number 4.6 Number of doctors number 4.7 Nurses (for family doctors) ----- 4.8 Available positions number 4.9 Occupied positions number 4.10 Number of nurses number

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4.11 Other staff (number of persons) ----- 4.12 Other staff number 4.13 Pharmacists number 4.14 Accountants number 4.15 Other staff number

Question Code Question Answer Format I Name of the PHC institution ----- P Name of the person filling the questionnaire ----- ID Institution code (to be filled in afterwards by CSPSPMS) ----- 5 MEDICAL SERVICES OF AND REFERRALS BY CS/OMF IN 2006 ----- 5.1 Visits to CS or OMF ----- 5.2 Family doctors’ visits TOTAL number 5.3 Prophylaxis visits to the FD number 5.4 Insured persons number 5.5 Non insured persons number 5.6 Other services provided by CS or OMF ----- 5.7 TOTAL number of registered pregnancies number 5.8 Total number of directly detected TB cases number 5.9 Total number of directly detected cancer cases number 5.10 Total number of HBP monitored persons number 5.11 Number of EKGs performed number 5.12 Number of clinical analysis number 5.13 Number of laboratory tests provided number 5.14 Referral system for patients in the covered area ----- 5.15 Number of referrals to the outpatient specialist services number 5.16 Number of referrals admitted into the Hospitals TOTAL number 5.17 Number of admitted patients on family doctors’ referral number 5.18 Number of admitted patients from the emergency medical services number 5.19 Number of admitted patients on specialists’ referral number 5.20 Number of admitted patients with no referral (self-referred) number

Question Code Question Answer Format I Name of the PHC institution ----- P Name of the person filling the questionnaire ----- ID Institution code (to be filled in afterwards by CSPSPMS) ----- 6 Financial activity of the institution in 2007 (6 months) ----- 6.1 6 months 2007 income ----- 6.2 TOTAL income thousand MDL 6.3 Per capita for insured persons thousand MDL 6.4 Per case (treated) thousand MDL 6.5 Premiums thousand MDL 6.6 Per capita for non insured persons thousand MDL 6.7 Direct payments for services - fee for service thousand MDL 6.8 Direct allocations from the founder thousand MDL 6.9 Drugs through national/ municipal/ raion health programs thousand MDL 6.10 Other income thousand MDL 6.11 6 months 2007 expenditures ----- 6.12 Expenditures TOTAL thousand MDL 6.13 Salaries thousand MDL 6.14 Contributions to the state budget thousand MDL 6.15 Electricity thousand MDL 6.16 Gas thousand MDL Page 109 of 121

6.17 Thermal energy thousand MDL 6.18 Drugs total thousand MDL 6.19 Fully reimbursed drugs thousand MDL 6.20 Emergency drugs thousand MDL 6.21 Heating fuel (charcoal) thousand MDL 6.22 Transportation expenses thousand MDL 6.23 Running water and sewage thousand MDL 6.24 Capital repairing thousand MDL 6.25 Equipment acquisition thousand MDL 6.26 Other expenses thousand MDL 6.27 Average salaries 6 months 2007 ----- 6.28 Average institution salary MDL 6.29 Average family doctor position salary MDL 6.30 Average family doctor salary MDL 6.31 Average nurse position salary MDL 6.32 Average nurse salary MDL

Question Code Question Answer Format I Name of the PHC institution ----- P Name of the person filling the questionnaire ----- ID Institution code (to be filled in afterwards by CSPSPMS) ----- INFORMATION ABOUT EACH DOCTOR IN THE RESPECTIVE MEDICAL 7 INSTITUTION ----- 7.1 Doctor ----- 7.2 Name and surname text 7.3 Birth date year 7.4 Medical University graduation year year 7.5 Specialty as by the graduation diploma text 7.6 Year of finalizing the specialty training year 7.7 Time in the PHC systems years 7.8 Time in the current/ present institution years 7.9 Basic Family Medicine training ----- 7.10 Internship yes/ no 7.11 Residency yes/ no 7.12 Basic specialization in family medicine (4 - 6 months) yes/ no 7.13 Continuous education for family medicine or other specialties: ----- 7.14 Special training in family medicine ----- 7.15 CIMC Training yes/ no 7.16 HIF Training yes/ no 7.17 Other courses yes/ no 7.18 Qualification/degree level in family medicine ----- 7.19 Superior yes/ no 7.20 Grade I yes/ no 7.21 Grade II yes/ no 7.22 No grade/ category/ level yes/ no 7.23 Management training ----- 7.24 Management training yes/ no 7.25 Qualification level in management: ----- 7.26 Superior yes/ no 7.27 Grade I yes/ no 7.28 Grade II yes/ no 7.29 No grade/ category/ level yes/ no 7.30 Housing ----- 7.31 Housing situation: ----- Page 110 of 121

7.32 Individual yes/ no 7.33 State owned yes/ no 7.34 Rented yes/ no 7.35 Compensations from Local Public Authorities for housing yes/ no

Question Code Question Answer Format I Name of the PHC institution ----- P Name of the person filling the questionnaire ----- ID Institution code (to be filled in afterwards by CSPSPMS) ----- INFORMATION ON EACH MEDICAL NURSES FROM RESPECTIVE PHC 8 INSTITUTIONS ----- 8.1 Medical nurses ----- 8.2 Name and surname text 8.3 Birth date year 8.4 Graduation year text 8.5 Year finishing specialty training year 8.6 Time in the PHC systems years 8.7 Time in the current/ present institution years 8.8 Basic FAMILY MEDICINE training ----- 8.9 Basic family medicine training yes/ no 8.10 Continuous education for family medicine or other specialties: ----- 8.11 Special training in family medicine ----- 8.12 CIMC Training yes/ no 8.13 HIF Training yes/ no 8.14 Other courses 8.15 Qualification / degree in family medicine: ----- 8.16 Superior yes/ no 8.17 Grade I yes/ no 8.18 Grade II yes/ no 8.19 No grade/ category/ level 8.22 Housing ----- 8.23 Housing situation: ----- 8.24 Individual yes/ no 8.25 State owned yes/ no 8.26 Rented yes/ no 8.27 Compensations from Local Public Authorities for housing yes/ no

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Questionnaire for decision makers in Local Public Administration of each raion

(To be filled up together with Local Health Authorities)

Which would be the first 3-5 Rural Health Centers that you consider as priorities to be rehabilitated in the next World Bank project (fill up in order of priorities):

a) CS 1. …………………………………..

Selection criteria and reasons for CS 1: ……………………………

……………………………………………………………………………………………

b) CS 2. …………………………………..

Selection criteria and reasons for CS : ……………………………

……………………………………………………………………………………………

…………………………………………………………………………………………… c) CS 3. …………………………………..

Selection criteria and reasons for CS 3: ……………………………

……………………………………………………………………………………………

…………………………………………………………………………………………… d) CS 4. …………………………………..

Selection criteria and reasons for CS 4: ……………………………

……………………………………………………………………………………………

…………………………………………………………………………………………… e) CS 5. …………………………………..

Selection criteria and reasons for CS 5: ……………………………

……………………………………………………………………………………………

Verte!

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Planned investments in PHC institution over the next 4 years, from the Local Public Administration funds:

a) CS / OMF / PM 1 ……………………………………… Amount (thousand MDL) ………………………………………...... Technical work: …………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………… b) CS / OMF / PM 2 ……………………………………… Amount (thousand MDL) ………………………………………...... Technical work:: …………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………… c) CS / OMF / PM 3 ……………………………………… Amount (thousand MDL) ………………………………………...... Technical work:: …………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………… d) CS / OMF / PM 4 ……………………………………… Amount (thousand MDL) ………………………………………...... Technical work:: …………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………… e) CS / OMF / PM 5 ……………………………………… Amount (thousand MDL) ………………………………………...... Technical work:: …………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… ……………………………………………………………

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Anonymous questionnaire for each doctor working in the PHC system:

9.1 Work Place ------9.2 Rural OMF yes/no 9.3 Rural CS yes/no 9.4 Raional CS yes/no 9.5 CS Municipal Balti yes/no 9.6 CS Municipal Chisinau yes/no 9.7 Independent CS Municipal Chisinau yes/no What would you prefer regarding the juridical statute and 9.8 contracting? ------9.9 Juridical statute: ------9.10 Within Raional Hospital yes/no 9.11 Within the Center for Family Doctors yes/no 9.12 Autonomous state institution yes/no 9.13 Autonomous private institution yes/no 9.14 Salary ------9.15 What would be the level of a decent salary (USD) $ What would be the supplementary incentives that you consider 9.16 yourself entitled for at work place? ------9.17 Incentive 1. text 9.18 Incentive 2. text 9.19 Incentive 3. text 9.20 Incentive 4. text 9.21 Incentive 5. text

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Anonymous questionnaire for each nurse working in the PHC system:

9.1 Work Place ------9.2 Rural OMF yes/no 9.3 Rural CS yes/no 9.4 Raional CS yes/no 9.5 CS Municipal Balti yes/no 9.6 CS Municipal Chisinau yes/no 9.7 Independent CS Municipal Chisinau yes/no 9.8 Salary ------9.9 What would be the level of a decent salary (USD) $ What would be the supplementary incentives that you consider 9.10 yourself entitled for at work place? ------9.11 Incentive 1. text 9.12 Incentive 2. text 9.13 Incentive 3. text 9.14 Incentive 4. text 9.15 Incentive 5. text

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Annex 4. - Preliminary list of Rural Health Centers selected for rehabilitation

The project team and the MoH PHC WG have analyzed each and every rural health center, one by one, using the database, the reports of the evaluators and the picture of all these centers against the above criteria. As a result, 116 CS have been preliminary selected for a secondary analysis that will decide for final list of 60-70 of them.

In the following table, the column “Criteria and notes” contains a short summary of the selection criteria that have been used and some comments, for each institution - see Chapter 5.10 for the details of the selection criteria. The following abbreviations have been used: 1. P – Population criterion 2. D – Distance from hospital criterion 3. A – Area of the building criterion 4. FD – Number of physicians criterion

Local Distance Public from No of Auth. Popu- Hospital Area family Invest- lation (km) (m2) doctors ments Nr. Raion CS Selection Criteria and notes P D A FD LPAI 1 mun. Chisinau CS Bubuieci da1 P, A, FD 6913 10 230 5 yes 2 mun. Chisinau CS Ciorescu da2 P, A 7071 15 474 4 yes 3 mun. Chisinau CS Ghidighici nu? bad condition, need replacement 5164 8 190,5 3 no 4 Anenii-Noi CS Mereni nu? Rehabilitated in HIF project, but the roof is leaking 6497 19 1000 3 yes 5 Anenii-Noi CS Geamana da?4 P, D, A, bad condition 3599 14 400 2 no 6 Anenii-Noi CS Harbovat da3 P 5856 13 700 4 yes 7 Anenii-Noi CS Speia da2 D 2993 24 1200 2 yes 8 Basarabeasca CS Sadaclia da1 P, D, the only one in the area 4342 17 2584,82 2 yes

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Local Distance Public from No of Auth. Popu- Hospital Area family Invest- lation (km) (m2) doctors ments Nr. Raion CS Selection Criteria and notes P D A FD LPAI 9 Briceni CS Corjeuti da2 P, FD 7347 21 2840 5 yes 10 Briceni CS Tetcani da?3 P, bad roof 2775 27 1051 2 yes 11 Briceni CS Pererata da?4 D, maybe new location 1941 47 370 2 yes 12 Briceni CS Beleavinet da1 A, D 2225 15 245 2 no 13 Briceni CS Grimancauti nu? P, but A seems to be miscalculated 4198 113,12 2 no 14 Cahul CS Borceag da?2 D, bad condition, may new location 1408 65 170 1 yes 15 Cahul CS Giurgiulesti da?3 P, A, D, bad condition 3019 55 288 2 no 16 Cahul CS Larga Noua da?4 D, bad condition 1518 25 732 1 no 17 Cahul CS Zarnesti nu? A 1922 16 420 1 yes 18 Cahul CS Moscovei da?1 P, D 3404 18 1500 2 yes 19 Cantemir CS Larguta da1 P, D, A, the only one in the area, maybe incentive for a doctor 2873 14 448 0 yes 20 Calarasi CS Valcinet da1 very bad condition, technical expertise, maybe relocation 4621 18 615 4 yes 21 Calarasi CS Pitusca da?2 P 3477 12 1200 2 yes 22 Calarasi CS Sadova da?3 P 3000 18 1613 2 yes 23 Causeni CS Chircaiesti da4 P, A, technical expertise 3690 18 444 2 no 24 Causeni CS Tocuz da?2 P, D, maybe relocation 4547 25 195 1 yes 25 Causeni CS Salcuta da3 P, A, D, technical expertise 4860 18 432 1 yes 26 Causeni CS Copanca da1 P, A, D, FD, very bad access, technical expertise 5584 40 336 4 no 27 Causeni CS Taraclia da? P, D, FD 4422 40 960 3 yes 28 Cimislia CS Gura Galbenei da?3 technical expertise 5675 27 417 1 yes 29 Cimislia CS Mihailovca da?2 technical expertise 3685 15 396 2 yes 30 Cimislia CS Satul Nou da?1 technical expertise 2041 20 2047 1 yes 31 Criuleni CS Ratus da?4 D 1431 50 660 1 no 32 Criuleni CS Magdacesti da1 P, A, D, FD 4557 45 400 3 no 33 Criuleni CS Cimiseni da?3 P, A, D, technical expertise 2530 40 300 1 yes 34 Criuleni CS Mascauti da?2 P, A, D, may relocation 4116 25 450 2 yes 35 Donduseni CS Frasin da2 Rented location, very expensive, relocation 1461 25 720 1 yes 36 Donduseni CS Plop da1 technical expertise 1572 8 229 1 yes 37 Drochia CS Drochia da? P, A 2807 12 384 2 yes 38 Drochia CS Maramonovca da? D, relocation 2672 34 1146 2 yes 39 Drochia CS Gribova da technical expertise 1934 18 308 1 yes Page 117 of 121

Local Distance Public from No of Auth. Popu- Hospital Area family Invest- lation (km) (m2) doctors ments Nr. Raion CS Selection Criteria and notes P D A FD LPAI 40 Dubasari CS Holercani da?2 Bad condition 2576 20 232 3 yes 41 Dubasari CS Molovata da1 P, D 3342 35 342 3 yes 42 Dubasari CS Cocieri nu? not clear, should be analyzed 4098 17 136 2 yes 43 Edinet CS Trinca da1 P, technical expertise, rehabilitation of only one building 3675 20 0 2 yes 44 Edinet CS Viisoara nu? D, relocation 1426 30 1250 1 yes 45 Edinet CS Zabriceni da?2 Bad condition, but small population 1112 18 439 1 yes 46 Falesti CS Linguini da?1 P, D, technical expertise, area limiting 3869 22 1582,3 2 yes 47 Floresti CS Profanes da2 Bad condition, relocation 1831 30 200 1 no 48 Floresti CS Trifanesti nu? Bad condition, but small population 1022 23 490 1 yes 49 Floresti CS Ciutulesti da1 Multiple buildings, only one should be rehabilitated and kept 2489 20 385 1 yes 50 Floresti CS Sanatauca da technical expertise 2966 60 347 1 no CS Targul - 51 Floresti Vertiujeni da3 A lot of villages around it, merge the OMF 1120 40 716,1 1 no 52 Glodeni CS Cobani da P, A, bad condition 2674 20 250 2 no 53 Glodeni CS Ciuciulea da3 Multiple buildings, only one should be rehabilitated and kept 3438 15 520 1 no 54 Glodeni CS Fundurii Vechi nu? P, D, but very bad condition building 3540 20 763,6 1 no 55 Glodeni CS Danu da?1 P, but very bad condition building, relocation 3949 8 499 2 yes 56 Glodeni CS Iabloana da2 Milk distribution inside the building that should be taken out 3057 12 285 2 yes 57 Hincesti CS Loganesti da?4 P, A 4016 10 125 1 no 58 Hincesti CS Ciuciuleni da?3 P, D 5231 30 500 3 no 59 Hincesti CS Bujor nu? P, A, bad condition, relocation 3330 36 270 1 no P, D, relocation or new building, maybe incentive for attracting 60 Hincesti CS Mingir da?2 doctors 5583 50 2292,1 1 yes 61 Hincesti CS Cioara nu? D, bad condition, maybe relocation 2101 60 120 1 yes CS 62 Hincesti Crasnoarmeiscoie da?1 P, D, relocation or limiting the area 4715 50 108 1 yes 63 Ialoveni CS Danceni nu? Bad condition, but too close to hospital 2523 7 686,5 2 yes 64 Ialoveni CS Molesti da?4 P (keep as reserve) 2854 19 676,8 1 no 65 Ialoveni CS Razeni da?1 P, D, relocation 6302 27 602 4 yes 66 Ialoveni CS Rusestii Noi da?3 P, A 5186 14 183 3 no 67 Ialoveni CS Tipala nu? P, D, relocation 3640 48 227 2 no

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Local Distance Public from No of Auth. Popu- Hospital Area family Invest- lation (km) (m2) doctors ments Nr. Raion CS Selection Criteria and notes P D A FD LPAI 68 Ialoveni CS Ulmu da?2 New building found, but needs technical expertise 2962 26 182 2 yes 69 Ialoveni CS Vasieni da? P, D, complementary to local investments (74,000 ML) 5224 20 555 2 no 70 Leova CS Borogani da?2 P, building too large 4520 35 355 2 yes 71 Leova CS Tomai da?3 P, building too large 3206 25 26 0 yes 72 Leova CS Sarateni da1 D, but too few population 1100 32 225 1 no 73 Nisporeni CS Marinici da3 Limit the area 2243 16 589 2 yes 74 Nisporeni CS Seliste da1 P, technical expertise 4396 15 300 3 yes 75 Ocnita CS Otaci da3 P, small building ?), move the dentists in other location 8376 26 0 5 yes 76 Ocnita CS Clocusna da1 P, D, A 2454 17 324 2 yes 77 Ocnita CS Hadarauti da2 technical expertise, incentive for attracting a doctor 2039 17 412 0 yes 78 Orhei CS Pelivan da? P, A 2476 10 336,64 2 yes 79 Orhei CS Chiperceni da1 technical expertise 2806 20 328 1 yes 80 Orhei CS Ivancea nu? P (keep as reserve) 2176 17 78 1 no 81 Orhei CS Teleseu da2 P, D 4378 25 1120 1 yes 82 Orhei CS Peresecina da3 P, A, FD 8199 20 370 5 no 83 Riscani CS Mihaileni da Unfinished new construction, technical expertise 4481 28 140 2 yes 84 Riscani CS Recea da?3 FD, bad condition 2150 12 763 3 yes 85 Riscani CS Varatic da?2 technical expertise and demolition 1/3 2257 33 651 1 yes 86 Rezina CS Cuizauca da1 D, A 1381 28 300 1 yes 87 Rezina CS Mateuti da2 P, A, D 2560 15 240 1 yes 88 Singerei CS Copaceni da3 P, A 4736 8 168,75 3 yes 89 Singerei CS Chiscareni da4 technical expertise 4275 25 503,3 3 yes 90 Singerei CS Coscodeni da1 technical expertise 3030 32 762,7 2 yes 91 Singerei CS Radoaia da2 P, D 5364 15 870,6 2 yes 92 Soroca CS Vasilcau da?4 P, but too big area 2254 18 355 1 yes 93 Soroca CS Cainarii Vechi da2 P, D, A 3084 25 320 2 yes 94 Soroca CS Rublenita da4 P, A 3540 12 150 2 no 95 Soroca CS Cosauti nu? Not clear status, to be re-analyzed 2652 14 508 2 no CS Slobozia - 96 Soroca Cremene da1 D, incentive for attracting a doctor 1299 21 1967 0 yes 97 Soroca CS Visoca da?3 D, Found a new place for relocation 2166 40 130 2 yes

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Local Distance Public from No of Auth. Popu- Hospital Area family Invest- lation (km) (m2) doctors ments Nr. Raion CS Selection Criteria and notes P D A FD LPAI 98 Straseni CS Panasesti da P, FD 2691 10 400 2 yes 99 Soldanesti CS Raspopeni da? P, D, but too big, relocation or area limitation 2898 25 1132 2 no 100 Soldanesti CS Oliscani da? P, too large area 2822 7 1500 2 no 101 Stefan-Voda CS Crocmaz da2 P, D, A 2905 45 348 2 yes 102 Stefan-Voda CS Slobozia da? P, Not clear status, to be re-analyzed 4230 12 336 2 yes 103 Stefan-Voda CS Talmaza da1 technical expertise 7324 18 640 4 yes 104 Taraclia CS Albota de Sus da? D, technical expertise 1349 30 400 1 yes 105 Taraclia CS Valea Perjei da? P, FD, bad conditions, relocation 5088 55 684 4 yes 106 Taraclia CS Tvardita da? P, FD, bad conditions, relocation 6135 60 480 5 no 107 Telenesti CS Cazanesti da? very bad conditions, technical expertise 3120 45 528 2 yes 108 Telenesti CS Mîndresti da1 P, FD, new building found 4156 10 425 3 yes 109 Telenesti CS Leuseni da2 Bad conditions, but too big area 1896 16 480 1 yes 110 Ungheni CS Sculeni nu? P, FD, bad conditions, but too big area 2774 25 5700 3 yes 111 Ungheni CS Parlita da? P, New building found 4315 15 484 2 yes 112 Ceadir-Lunga CS Besghioz da?2 P, relocation 3390 12 482 2 yes 113 Ceadir-Lunga CS Baurci da1 P, A, FD 8782 0 4 yes 114 Comrat CS Dezghingea da?2 P, technical expertise or relocation 5242 17 790 2 yes 115 Comrat CS Cioc - Maidan da?3 P, area unclear 3621 20 0 4 no 116 Comrat CS Avdarma da?1 P, incentive for attracting doctors, new building found 3414 20 360 0 yes

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Annex 5. - References (selection)

1. Human resources for health in the WHO European Region, World Health Organization, 2006 2. Sanatate Publica in Moldova, Ministerul Sanatatii, 2006 3. O’Brien-Pallas L et al. Integrating workforce planning, human resources and service planning. Human Resources for Health Development Journal, 2001, 5(1 3):2 16. 4. Dragomiristeanu A et al. Politici de alocare a resurselor si de planificare a personalului medical in sistemele de sanatate, 2001 5. Atun R, PHC Development Strategy for Moldova. Final Report, 2007 6. Salman B et al. Primary care in the driver’s seat. European Observatory on Health Systems and Polices Series, 2006 7. “Drafting of a Technical Norm for the Configuration of Rural Facilities for Primary Health Care, Tajikistan”, Conseil Santé SA / SOFRECO, 2005, Banca Mondiala, Raport final 8. Accesul Populaţiei Republicii Moldova la Serviciile Berdaga V, Ştefaneţ S, Bivolo. medicale.Unicef. Chisinau, Moldova. 2000. 9. LRM nr. 339-XVI din 16.12.2005 „Legea fondurilor asigurării obligatorii de asistenţă medicală pe anul 2006”. 10. Darea de Seama privind Activitatea Sistemului de Sănătate în anul 2006, Ministerul Sanatatii 11. Criteriile de contractare a prestatorilor de servicii medicale în cadrul asigurării obligatorii de asistenţă medicală pentru anul 2007, Anexă la Ordinul MSPS şi CNAM Nr. 477/258-A din 14.11.2006 12. Nota cu privire la Politica de Sănătate, Guvernul Republicii Moldova, Banca Mondială, 2006 13. Ordinul Ministerului Sanatatii si Companiei Nationale de Asigurari in Medicina Nr. 144/65-A din 12.04.2007 privind dotarea standard cu echipamente a institutiilor de medicina primara 14. Primary Care and Social Assistance Project, Health Management and primary health care training component, Final Report, PHRD grant, 2007 15. Strategiei de dezvoltare a sistemului de sănătate în perioada 2007-2016, Guvernul Republicii Moldova, 2007 (supusa spre aprobare) 16. Politica Nationala de Sanatate, Hotarirea Guvernului nr.886 din 6 august 2007 17. Ordinul MS Nr.420 din 29.12.98 “Referitor la noile normative de state si reforma planificarii cheltuielilor in sistemul ocrotirii sanatatii”.

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