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 Page 2 of 121 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 Page 3 of 121 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