Tehnical Services and Tehnical Assistance PHRD Grant

Transcription

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
CMF
CS
EMS
HIF
LPA
MoH
OMF
PHC
PM
WP
WG
– Territorial Medical Association (Asociatie Medicala Teritoriala)
– Center for Family Doctors (Centrul Medicilor de Familie)
– Health Center (Centru de Sanatate)
– Emergency Medicine System
– World Bank’s Health Investment Fund project
– Local Public Authorities
– Ministry of Health
– Family Doctor Office (Oficiul Medicului de Familie)
– Primary Health Care
– Health Post (Punct Medical - filiala a CS/OMF)
– Work Package
– 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 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
Page 4 of 121
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
Page 5 of 121
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
Page 7 of 121
2. Objectives and Tasks
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.
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.
Page 12 of 121
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 (CSOMF-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.
Page 13 of 121
Raion
Code
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
31
Raion Name
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
CS
Code
1086
1086
1086
1086
1086
1086
1086
2311
2350
2346
2297
2310
2295
2330
2330
2301
2290
2339
2340
2316
CS Name
CS Ştefan-Vodă
CS Ştefan-Vodă
CS Ştefan-Vodă
CS Ştefan-Vodă
CS Ştefan-Vodă
CS Ştefan-Vodă
CS Ştefan-Vodă
CS Ermoclia
CS Volontiri
CS Tudora
CS Caplani
CS Crocmaz
CS Carahasani
CS Purcari
CS Purcari
CS Cioburciu
CS Antonesti
CS Slobozia
CS Talmaza
CS Olanesti
OMF
Code
138
2289
2337
2335
136
2329
2312
OMF
Name
OMF Marianca de Jos
OMF Stefanesti
OMF Brezoaia
OMF Semionovca
OMF Alava
OMF Popeasca
OMF Festelita
2306
2318
OMF Copceac
OMF Palanca
2332
140
PM
Code
PM
Name
137
PM Lazo
139
PM Viisoara
OMF Rascaieti
OMF Rascaietii Noi
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.
Page 14 of 121
Figure 2 – Moldova PHC GIS (1)
Figure 3 - Moldova PHC GIS (2)
Page 15 of 121
Page 16 of 121
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
Page 17 of 121
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 crosschecking 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
Page 19 of 121
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.
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.
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.
Page 20 of 121
EQUIPMENT
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
Medical devices
Blood pressure meter
Stethoscope
Ocular tonometer
Obstetrical stethoscope
Children weighting scale
Children anthropometer
New born examination table
Automatic 6 channel electrocardiograph
Portable 3 channel electrocardiograph
Adult peakflowmeter
Children peakflowmeter
Glucosemeter
Clinical laboratory set
Biochemistry laboratory set
Sterilizer
UV lamp for air disinfection
Big stainless steel boxes
Small stainless steel boxes
stainless steel table for medical devices
Gynecology table
Pelvimeter
Neurology examination set
Othoscope
Ophthalmoscope
Portable examination lamp
Guzon ear syringe
Set of Kramer splints
Vision chart
Computer
Printer
Medical devices set
Specule ginecologice
Cornţanguri
Scalpel
Anatomical pincers
Surgical scissors (straight)
Surgical scissors (curved)
Medical catheters
Special objects
GP’s medical kit
Tourniquet
i.v. infusions holder
Medical thermometers
Length meter
Chronometer
Goniometer
Adult rectal tubes
New born rectal adult
Medical equipment and furniture
Folding screen
Medical bed
EXISTING, WEAR < 50%
3987
4036
794
1180
1159
1079
1146
95
501
1029
1009
314
233
129
988
1155
1662
1687
1470
1025
990
837
1461
1528
486
379
442
1098
415
168
14609
2237
1540
1786
673
661
744
1747
1612
1582
4762
2105
1764
55
228
148
204
2646
Page 21 of 121
49
50
51
52
53
Physician’s table
Nurse’s table
Drugs cabinet in the medical procedures room
Drugs cabinet for emergency drugs
Furniture set for clothes, books
1263
1880
693
590
716
Table 3 – Inventory of the standard equipment, with less than 50% wear in the PHC institutions (august 2007), total
for Moldova
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.
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.
Page 22 of 121
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.
Page 23 of 121
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.
Page 24 of 121
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.
Page 25 of 121
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.
Page 26 of 121
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
Page 27 of 121
4.4 Final conference of the project
It will be held on September 28, 2007. Location: Ministry of Health
Page 28 of 121
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.
Page 29 of 121
Figure 8 - The organizational chart of the Public Raional Health System
PUBLIC RAIONAL HEALTH SYSTEM
Ministry of Health
Raional Council
Head Doctor of the
Raional System
Vice Head Doctor for
Primary Health Care
Vice Head Doctor for
Hospital and
Specialised Care
Vice Head for
Economics
Center for
Preventive
Medicine
HR and Juridical
Department
Medical Informatics
Department
Center for Family
Doctors (CMF)
Health Center (CS)
Hospitals
Family Doctor
Office (OMF)
Stomatology clinics
Mother and Chield
Department
Pharmaceutical
Department
Outpatients clinics
EMS
Health Post (PM)
Accounting
Department
Technical and
Administrative
Department
Medical Equipment
Department
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.
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.
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
mun. Chisinau
mun. Balti
Anenii-Noi
Basarabeasca
Briceni
Cahul
Cantemir
Calarasi
Causeni
Cimislia
Criuleni
Donduseni
Drochia
Dubasari
Edinet
Falesti
Floresti
Glodeni
Hincesti
Ialoveni
Leova
Nisporeni
Ocnita
Orhei
Riscani
AMT
5
CMF
13
CS
15
6
13
4
11
14
6
11
15
7
12
10
14
8
14
8
14
10
15
16
7
10
9
18
10
OMF
9
1
14
3
16
27
31
24
10
15
17
10
18
2
21
26
26
12
23
6
16
13
19
30
18
PM
2
8
8
2
4
3
14
7
6
1
1
2
23
4
11
11
9
8
1
17
19
Total
44
7
35
7
35
43
41
35
28
36
36
26
33
11
37
34
63
26
49
33
32
31
29
65
47
Page 32 of 121
32
Rezina
7
15
10
57
Singerei
10
16
31
58
Soroca
15
25
18
37
Straseni
13
15
9
27
Soldanesti
9
11
7
26
Stefan-Voda
13
11
2
23
Taraclia
6
9
8
42
Telenesti
10
21
11
71
Ungheni
16
24
31
9
Ceadir-Lunga
9
3
Vulcanesti
3
13
Comrat
8
5
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
Page 33 of 121
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
mun. Chisinau
mun. Balti
Anenii-Noi
Basarabeasca
Briceni
Cahul
Cantemir
Calarasi
Causeni
Cimislia
Criuleni
Donduseni
Drochia
Dubasari
Edinet
Falesti
Floresti
Glodeni
Hincesti
Ialoveni
Leova
Nisporeni
Ocnita
Population
719696
135157
80445
28886
79188
117272
64708
80020
94059
72145
76212
48919
89324
31115
85106
91496
89343
65325
119159
100942
53131
64326
56164
Page 34 of 121
Orhei
Riscani
Rezina
Singerei
Soroca
Straseni
Soldanesti
Stefan-Voda
Taraclia
Telenesti
Ungheni
Ceadir-Lunga
Vulcanesti
Comrat
TOTAL MOLDOVA
127589
87519
49956
101058
100175
87783
43807
69016
44579
70402
117062
62397
24506
69738
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
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
PHC Institution
CS Ştefan-Vodă
OMF Marianca de Jos
OMF Stefanesti
OMF Brezoaia
OMF Semionovca
PM Lazo
OMF Alava
OMF Popeasca
OMF Festelita
CS Ermoclia
CS Volontiri
OMF Copceac
CS Tudora
OMF Palanca
CS Caplani
CS Crocmaz
CS Carahasani
CS Purcari
PM Viisoara
OMF Rascaieti
CS Cioburciu
OMF Rascaietii Noi
CS Antonesti
CS Slobozia
CS Talmaza
CS Olanesti
Population
7801
534
1218
1033
832
129
366
2327
2843
4158
3833
2416
1881
1980
3239
2905
3071
1962
486
2881
2713
654
2709
4230
7324
5491
69016
Table 7 – Distribution of the population of Stefan Voda raion, by PHC institutions
Page 35 of 121
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.
Page 36 of 121
NA
concrete
stone
4%
4%
concrete and stone
1%
2%
earthen, stone and concrete
40%
earthen
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.
Raion
No of
localities
State
pharmacy
Private
pharmacy
No pharmacy
Page 37 of 121
mun. Chisinau
mun. Balti
Anenii-Noi
Basarabeasca
Briceni
Cahul
Cantemir
Calarasi
Causeni
Cimislia
Criuleni
Donduseni
Drochia
Dubasari
Edinet
Falesti
Floresti
Glodeni
Hincesti
Ialoveni
Leova
Nisporeni
Ocnita
Orhei
Riscani
Rezina
Singerei
Soroca
Straseni
Soldanesti
Stefan-Voda
Taraclia
Telenesti
Ungheni
Ceadir-Lunga
Vulcanesti
Comrat
Total
44
7
35
7
35
43
41
35
28
36
36
26
33
11
37
34
63
26
49
33
32
31
29
65
47
32
57
58
37
27
26
23
42
71
9
3
13
1261
34
7
26
7
30
34
23
33
24
21
29
11
30
33
40
24
33
20
26
27
15
56
29
27
44
35
28
25
26
18
31
47
7
3
9
912
4
2
13
9
4
9
5
3
8
5
12
3
14
6
13
4
10
8
4
2
7
9
7
6
9
9
7
3
13
4
6
5
8
1
4
236
1
5
24
8
1
1
9
5
1
3
13
1
15
9
2
3
8
5
12
1
9
1
8
2
5
2
23
2
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
mun. Balti
mun. Chisinau
Basarabeasca
Cimislia
Donduseni
Edinet
Nisporeni
Vulcanesti
Dubasari
Anenii-Noi
Falesti
Orhei
Calarasi
Leova
Drochia
Ocnita
Riscani
Soldanesti
Stefan-Voda
Briceni
Rezina
Singerei
Straseni
Ceadir-Lunga
Comrat
Causeni
CS or OMF
CS Elizaveta
OMF Dobruja
CS Bascalia
PM Sagaidacul Nou
OMF Teleseuca
OMF Corpaci
OMF Bratuleni
CS Etulia
CS Parata
CS Varnita
OMF Natalievca
PM Sercani
OMF Bahu
OMF Orac
OMF Popestii de Jos
PM Berezovca
CS Costesti
OMF Gauzeni
CS Crocmaz
CS Pererata
CS Lalova
OMF Balasesti
CS Micauti
CS Copceac
OMF Cotovscoe
OMF Chircaiestii Noi
Maximal Distance to Hospital (Km)
10
22
25
35
35
35
35
35
36
37
38
40
42
44
45
45
45
45
45
47
47
50
50
50
50
55
Page 39 of 121
Ungheni
Cantemir
Soroca
Ialoveni
Criuleni
Floresti
Glodeni
Taraclia
Telenesti
Hincesti
Cahul
OMF Cornova
OMF Taracliica
OMF Regina Maria
PM Homuteanovca
OMF Dolinnoe
CS Sanatauca
OMF Japca
CS Tvardita
OMF Tarsitei
OMF Poganesti
OMF Frumusica
56
57
57
58
60
60
60
60
60
62
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.
Page 40 of 121
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
Page 41 of 121
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
StefanDrochia
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 upside-down situation when comparing to the standards.
CS
Raion
Name
CS
Calarasi Parjolteni
Calarasi CS
CS
CS
No of OMF
Population Doctors Name
OMF
1946
1
Horodiste
741
1
OMF
OMF
Diff. in
OMF
No of
Diff. in No of
Population Doctors Population Doctors
2911
957
2
2
-965
-216
-1
-1
Page 43 of 121
Harjauca
CS
Edinet Zabriceni 1112
CS
Edinet Hincauti 1361
CS
Falesti Marandeni2917
CS
Falesti Marandeni2917
CS
Floresti Marculesti 2326
CS Gura
Floresti Cainarului 1508
CS
Soroca Ocolina 1023
CS
Soroca Curesnita 507
CS
Slobozia Soroca Cremene 1299
Stefan- CS
Voda
Purcari
1962
Palanca
OMF
Terebna
OMF
Cepeleuti
OMF
Rautel
OMF
Parlita
OMF
Bahrinesti
OMF
Prajila
OMF
Zastanca
OMF
Septelici
1
1
1
1
0
1
1
1
1473
2
-361
-1
1792
2
-431
-1
4077
2
-1160
-1
3334
2
-417
-1
2605
1
-279
-1
2594
2
-1086
-1
2154
2
-1131
-1
1122
2
-615
-1
1
-513
-1
2
-919
-1
OMF
Varancau 1812
OMF
Rascaieti 2881
0
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
No of nurses to 1 Family Doctor
No of auxiliary stuff to 1 Family Doctor
No of all other staff to 1 Family Doctor(*)
Ration of other staff to a Family Doctor
2,5
1,1
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
2280
2272
Numar de medici de medicina primara
2446
2208
2135
2000
1733
1527
1521
1441
1500
1494
1502
1993
1994
1441
1490
1505
1996
1997
1000
500
0
1990
1991
1992
1995
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)
Page 45 of 121
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.
80
Numar de medici de medicina primara la 100000 de locuitori
71,12
70
67,7
61,42
61,04
2005
2007
59,03
60
57,06
53,6
53,02
50
40,33
40
35,01
34,88
1990
1991
33,12
34,36
34,54
1993
1994
33,21
34,45
34,92
1996
1997
30
20
10
0
1992
1995
1998
1999
2000
2001
2002
2003
2004
Figure 21 - Number of doctors per 100000 inhabitants, by year, Republic of Moldova
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:
Area
Standard
Urban
1 FD / 1500 p
1 N / 750 p
Rural
Total
2 FD / 1500 p
1 N / 500 p
Population
Family
Doctors
(FD)
Standard
Number
FDs
Shorta
ge
FDs
Nurses
Standard
Number
Nurses
Shortag
e
Nurses
1288916
1024
859
165
1311
1719
-408
2208809
3497725
1111
2135
1473
2332
-362
-197
4069
5380
4418
6136
-349
-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
Populatie la 1 Medic de Medicina Primara
3000
2856
3011
2910
2867
2903
2895
2864
2480
2500
2000
1886
1866
1753
1694
1477
1500
1628
1638
2005
2007
1406
1000
500
0
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
Anul
Figure 22 – Population ratio to 1 Family Doctor, evolution between 1990 and 2007, Republic of Moldova
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.
Page 49 of 121
Populatie la 1 Medic de Medicina Primara (2005)
France
Austria
Macedonia
Germany
Lithuania
Norway
Czech Republic
Bulgaria
Serbia
Croatia
European Region
Hungary
Republic of Moldova
Armenia
Portugal
Latvia
Netherlands
Ireland
Albania
Slovakia
Eur-B+C
Belarus
Ukraine
Kyrgyzstan
Montenegro
CIS
Russian Federation
Georgia
Tajikistan
Bosnia and
Azerbaijan
Kazakhstan
Uzbekistan
601
682
988
1030
1152
1376
1403
1477
1489
1491
1514
1531
1628
1699
1773
1806
1938
1941
1965
2310
2499
2854
3147
3147
3482
3880
4243
4318
4660
4897
5669
6039
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.
Raion
R/U
Populatio
n
No FDs
Standard
No FDs
Shortag
e
FDs
%Shorta
ge
FDs
Nurses
Stand
No
Nurses
Shortag
e
Nurses
%Shortag
e
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
Total
38387
30
26
4
17%
91
77
14
19%
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.
Page 51 of 121
40
20
0
Basarabeasca
Ceadir-Lunga
mun. Chisinau
Stefan-Voda
Anenii-Noi
Soldanesti
Donduseni
Vulcanesti
Cantemir
Nisporeni
Ialoveni
Singerei
Dubasari
Ungheni
Criuleni
Glodeni
Drochia
Taraclia
Straseni
Cimislia
LeovaRezina
Comrat
Soroca
Hincesti
FalestiOrhei Causeni
Riscani
Briceni
EdinetCalarasi
CahulFloresti
Ocnitamun. Balti Telenesti
-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 5060 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.
Page 52 of 121
120
100
80
60
40
20
0
19
29
19
33
35
19
37
19
39
19
41
19
43
19
45
19
47
19
19
49
19
51
53
19
55
19
57
19
59
19
61
19
63
19
65
19
19
67
69
19
71
19
73
19
75
19
77
19
79
19
81
19
87
19
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.
Page 53 of 121
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
Computer, Internet, Software, Hardware
Transport, gas
Telephone mobile, fixed
High Performance Equipment
Furniture
AC
Rehabilitation of the PHC facility
Laboratory equipment
General medical equipment
Personal Desk
Rest room
No of people who answered
448
404
244
210
158
136
112
95
82
82
79
Page 54 of 121
Increase in No of medical HR
Medical books
Running water, hot water
Heating
Sewage, bathroom
Decrease in the workload
Kitchen
Decrease in paper work
Holidays bonus
Accommodation
Free transportation
79
62
59
54
43
29
28
23
19
18
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
Computer, Internet, Software, Hardware
Transport, gas
General medical equipment
High Performance Equipment
Furniture
Telephone mobile, fixed
AC
Running water, hot water
Heating
Rehabilitation of the PHC facility
Rest room
Sewage, bathroom
Medical books
Kitchen
Increase in number of medical workers
Laboratory equipment
Personal Desk
Decrease in the workload
Free transportation
Reduce of the paperwork
Holidays bonus
Accommodation
No of people who answered
738
662
487
484
479
427
290
261
260
219
158
153
116
96
92
83
83
54
52
46
31
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
Page 55 of 121
– 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
General Medicine
Family medicine
Pediatrics
Other specialties
Total
No of doctors
664
98
731
733
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
(1 year)
No
Yes
yes
no
no
no
yes
yes
Rezidentiat
(3 years)
no
no
no
no
yes
yes
yes
yes
SpecializarePrimara
(4 months)
No of doctors
yes
772
yes
651
no
367
no
225
no
170
yes
25
yes
12
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
Page 57 of 121
yes
yes
no
no
Yes
No
yes
no
712
674
173
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
yes
no
No of family doctors
256
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.
Page 58 of 121
Figure 26 – Detailed report on infrastructure, CS Vadul lui Voda
Page 59 of 121
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
4; 0%
NS; 89;
7%
City Hall; 404;
32%
Shares; 47;
4%
Raional Council and
Shares; 2; 0%
Raional Council; 715;
57%
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
Page 60 of 121
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%.
Page 61 of 121
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
Populatia
25000
20000
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.
Raion
Glodeni
Cimislia
Riscani
Floresti
mun. Balti
Taraclia
Cahul
Ceadir-Lunga
Ocnita
Nisporeni
Drochia
Dubasari
Singerei
Ialoveni
Briceni
Edinet
Straseni
Ungheni
mun. Chisinau
No of PHC
institutions by raion
26
36
47
63
7
23
43
9
29
31
33
11
57
33
35
37
37
71
44
No of institutions that
are located in
buildings built up
before 1980
22
25
29
38
4
13
24
5
16
17
18
6
31
17
18
19
19
36
22
%
85%
69%
62%
60%
57%
57%
56%
56%
55%
55%
55%
55%
54%
52%
51%
51%
51%
51%
50%
Page 63 of 121
Donduseni
Stefan-Voda
Telenesti
Leova
Causeni
Comrat
Soroca
Orhei
Hincesti
Cantemir
Soldanesti
Calarasi
Vulcanesti
Falesti
Basarabeasca
Criuleni
Rezina
Anenii-Noi
Total
26
26
42
32
28
13
58
65
49
41
27
35
3
34
7
36
32
35
1261
13
13
20
15
13
6
25
27
20
16
10
12
1
10
2
9
7
2
600
50%
50%
48%
47%
46%
46%
43%
42%
41%
39%
37%
34%
33%
29%
29%
25%
22%
6%
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.
Page 64 of 121
Classical Type;
356; 28%
NA;
100; 8%
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
Page 65 of 121
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
Page 66 of 121
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
Page 67 of 121
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
Page 68 of 121
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
Page 69 of 121
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
NA
Yes
No
Sewage
6%
43%
51%
Heating
9%
81%
10%
Hot water
8%
7%
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.
Page 70 of 121
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
Reception room
Triaj room
Consultation room for the family doctor
(one for each doctor – 2-6 doctors)
OBG room
Dentist room
Head Doctor’s office
Coordinating nurse’s office
Procedures room
Immunization room
Laboratory room
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
Minimum Area (m2)
10
12
18
TOTAL
20
18
18
12
12
12
18
10
12
10
15
15
2
2
2
10
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
Doctor’s office
Nurse’s office
OBG room
Minimum Area (m2)
18
18
12
20
Page 71 of 121
Procedures room
Immunization room
Pharmacy room
Day stay room (s)
Staff toilet room
TOTAL
12
12
10
10
15
2
2
2
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)
3000 - 7000
2000 - 3000
1000 - 2000
300 - 1000
200 - 300
100 - 200
NA
Total
No of Rural CS
6
14
52
168
28
65
24
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
Page 72 of 121
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
Procedures room
Immunization room
Laboratory room
Number of laboratory rooms
Pharmacy room
Staff rest room
Day stay room for female patients
Day stay room for male patients
Staff toilet room
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
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
No
STANDARD EQUIPMENT
CS
OMF
PM
Page 73 of 121
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
Medical devices
Stethoscope
Ocular tonometer
Weighting scale and anthropometer for adults
Adult peakflowmeter
Glucosemeter
Sterilizer
Stainless steel boxes
Stainless steel table for medical devices
Gynecology table
Pelvimeter
Othoscope
Ophthalmoscope
Guzon ear syringe
Vision chart
Computer
Printer
Medical devices set
Anatomic pincers
Surgical pincers
Surgical scissors
Medical catheters
Special objects
GP’s medical kit
Hemostazis rubber
Test-tubes
Test-tube holder
Scalpel
Thermometer
Length meter
Chronometer
Goniometer
New born and adult rectal tubes
Folding screen
Medical bed
Physician’s table
Drugs cabinet
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
Table 30 – The equipment standard for Rural Health Centers (without consumables)
Page 74 of 121
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. 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.
EQUIPMENT
Stethoscope
Ocular tonometer
Adult peakflowmeter
Glucosemeter
Sterilizer
Big stainless steel boxes
stainless steel table for medical devices
Gynecology table
Pelvimeter
Othoscope
Ophthalmoscope
Guzon ear syringe
Vision chart
Computer
Printer
Cornţanguri
Scalpel
Anatomical pincers
Medical catheters
GP’s medical kit
Tourniquet
PRESENT
wear <
50%
NECESARY
STANDARD
3987
4036
794
1180
1159
1079
1146
95
501
1029
1009
314
233
129
988
1155
1662
1687
1470
1025
990
837
1461
1528
486
379
442
1098
415
168
14609
2237
1540
1786
673
661
744
1747
1612
3885
3554
1160
1484
1091
1129
1169
569
677
754
759
1477
459
386
1068
2130
1775
1944
1597
774
977
1036
778
758
1549
1481
1604
1133
1696
1305
28850
4583
10609
3554
1960
2019
4990
811
2828
7445
7168
1809
2390
1998
2050
2094
745
1160
1708
1697
1618
657
495
1886
2658
3109
3301
2847
1701
1865
1714
2083
2124
1926
1805
2011
2018
1993
1448
43543
5835
10213
4333
2488
2542
5559
2361
3700
%
Necessary
from
Standard
52%
50%
64%
62%
55%
55%
56%
76%
58%
44%
45%
91%
70%
78%
57%
80%
57%
59%
56%
46%
52%
60%
37%
36%
80%
82%
80%
56%
85%
90%
66%
79%
104%
82%
79%
79%
90%
34%
76%
Page 75 of 121
Length meter
Chronometer
Goniometer
Adult rectal tubes
Folding screen
Medical bed
Physician’s table
Nurse’s table
Drugs cabinet in the medical
procedures room
1582
4762
2105
1764
55
228
148
204
2646
1263
1880
1769
5574
3678
1767
778
3502
3214
1591
2653
1854
3008
3149
9385
5168
3458
859
3611
3265
1657
5077
2807
4497
56%
59%
71%
51%
91%
97%
98%
96%
52%
66%
67%
693
590
716
1255
1301
2808
1808
1767
3225
69%
74%
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.
Raion
Population
Visits
Total
Number of
visits per
inhabitant
Number of
visits per
health
insured
inhabitant
Number of
visits per
not
insured
inhabitant
Number of
referrals to
specialized
outpatient
services
Ratio of
referrals to
specialized
outpatient
services
from the
total
number of
visits to
PHC
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%
28 886
79 188
117 272
59 159
188 596
244 979
2,0
2,4
2,1
2,7
3,7
2,7
0,8
1,2
0,8
12 195
22 397
77 647
21%
12%
32%
Basarabeasca
Briceni
Cahul
Page 76 of 121
Cantemir
Calarasi
Causeni
Cimislia
Criuleni
64 708
80 020
94 059
72 145
76 212
113 837
243 127
252 918
157 058
171 175
1,8
3,0
2,7
2,2
2,2
2,5
4,6
3,0
2,7
4,1
0,3
1,0
1,5
1,4
0,6
52 471
37 072
14 378
36 179
14 670
46%
15%
6%
23%
9%
Donduseni
Drochia
Dubasari
Edinet
Falesti
Floresti
Glodeni
Hincesti
Ialoveni
Leova
Nisporeni
Ocnita
Orhei
Riscani
Rezina
Singerei
Soroca
Straseni
48 919
89 324
31 115
85 106
91 496
89 343
65 325
119 159
100 942
53 131
64 326
56 164
127 589
87 519
49 956
101 058
100 175
87 783
97 222
200 283
88 202
217 672
197 447
231 537
234 193
119 419
299 084
97 605
167 632
119 893
280 094
234 907
132 451
237 206
275 068
261 590
2,0
2,2
2,8
2,6
2,2
2,6
3,6
1,0
3,0
1,8
2,6
2,1
2,2
2,7
2,7
2,3
2,7
3,0
2,4
3,2
3,9
3,6
3,3
3,8
3,8
1,4
3,9
2,7
4,2
2,3
3,1
3,3
3,5
3,7
3,9
4,1
0,9
0,5
0,8
0,9
0,6
0,7
1,2
0,3
0,5
0,7
0,5
1,4
0,8
1,1
0,7
0,8
0,7
0,7
17 776
25 950
2 377
61 874
107 080
23 352
33 514
32 696
85 037
55 569
36 659
4 489
45 021
35 390
26 999
43 377
156 951
24 046
18%
13%
3%
28%
54%
10%
14%
27%
28%
57%
22%
4%
16%
15%
20%
18%
57%
9%
Soldanesti
43 807
122 088
2,8
5,2
1,3
58 475
48%
Stefan-Voda
Taraclia
Telenesti
Ungheni
69 016
44 579
70 402
117 062
188 372
133 298
171 769
384 911
2,7
3,0
2,4
3,3
3,1
5,1
3,5
4,2
1,4
0,4
1,2
1,2
49 199
49 771
13 488
63 764
26%
37%
8%
17%
Ceadir-Lunga
62 397
96 551
1,5
2,0
0,2
22 041
23%
0,4
3,3
0,9
5 228
44 383
2 645 069
11%
16%
27%
Vulcanesti
24 506
46 000
1,9
2,4
Comrat
69 738
271 487
3,9
3,3
Total
3 497 725 9 660 472
2,8
3,6
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.
7%
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.
Raion
Stefan-Voda
Institution
CS Ştefan-Vodă
Population
Total
7801
Health
Insured
7450
% Insured
96%
Page 78 of 121
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
Stefan-Voda
OMF Marianca de Jos
OMF Stefanesti
OMF Brezoaia
OMF Semionovca
PM Lazo
OMF Alava
OMF Popeasca
OMF Festelita
CS Ermoclia
CS Volontiri
OMF Copceac
CS Tudora
OMF Palanca
CS Caplani
CS Crocmaz
CS Carahasani
CS Purcari
PM Viisoara
OMF Rascaieti
CS Cioburciu
OMF Rascaietii Noi
CS Antonesti
CS Slobozia
CS Talmaza
CS Olanesti
534
1218
1033
832
129
366
2327
2843
4158
3833
2416
1881
1980
3239
2905
3071
1962
486
2881
2713
654
2709
4230
7324
5491
69016
469
968
995
667
103
224
1797
1802
2648
3090
2049
1457
1368
2350
2370
2303
1461
367
1943
2237
353
1952
3004
5477
3691
52595
88%
79%
96%
80%
80%
61%
77%
63%
64%
81%
85%
77%
69%
73%
82%
75%
74%
76%
67%
82%
54%
72%
71%
75%
67%
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.
Page 79 of 121
mun.
Glodeni
StefanOcnita
Anenii-Noi
Donduseni
CeadirVulcanesti
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.
Raion
Anenii-Noi
Basarabeasca
Briceni
Cahul
Cantemir
Calarasi
Causeni
Cimislia
Criuleni
Donduseni
Drochia
Dubasari
Falesti
Floresti
Glodeni
Ialoveni
Leova
Nisporeni
Ocnita
Orhei
Riscani
Rezina
Singerei
Soroca
Straseni
Soldanesti
Stefan-Voda
Taraclia
Telenesti
Ungheni
Ceadir-Lunga
Routine
Real
Recurrent
Income income Expenditure
1
2
3
5684
11124
5837
1823
3011
2155
4304
7964
6805
7160
9043
11005
3880
6221
5419
4488
8183
7909
6461
9537
7429
4203
6311
6102
3685
5874
6199
3414
4760
3818
5070
7483
9124
1911
2692
3097
5368
8256
7407
5154
1842
7001
4810
6462
5972
6923
9617
7602
3029
4702
4510
3499
6603
5526
3976
4604
2823
7355
9582
9044
5814
7021
6597
3301
5069
4209
5838
11896
13644
6017
9719
9185
5417
9484
9026
1694
7738
5557
4884
7103
6501
2388
4406
4249
3713
3888
5241
7421
11634
9763
4352
4209
6801
Diff.
Routine
Diff.
Income - Real income Recurrent
Recurrent
Expenditure Expenditure
4=1-2
5=1-3
-153
5287
-331
857
-2501
1158
-3845
-1963
-1539
801
-3420
275
-968
2108
-1899
208
-2514
-325
-403
942
-4054
-1640
-1186
-405
-2039
849
-1847
-5159
-1162
490
-679
2015
-1481
192
-2027
1077
1153
1781
-1689
537
-783
424
-908
860
-7806
-1748
-3168
535
-3610
457
-3863
2181
-1616
602
-1861
157
-1528
-1353
-2341
1871
-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
Page 82 of 121
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
Raion
Cahul
Straseni
mun. Chisinau
Floresti
Orhei
Riscani
Calarasi
Hincesti
Stefan-Voda
Edinet
Ialoveni
Ungheni
Locally Estimated
Total number of PHC institutions by
Costs Total
(thousands MDL) raion
295508
78739
74085
60214
45906
35337
24196
24021
20822
18589
17104
16981
43
37
44
63
65
47
35
49
26
37
33
71
Page 84 of 121
Criuleni
Telenesti
Glodeni
Drochia
Donduseni
Singerei
Soroca
Anenii-Noi
Ocnita
Cantemir
Briceni
Falesti
Nisporeni
Soldanesti
Taraclia
Rezina
Leova
Comrat
Causeni
Ceadir-Lunga
Cimislia
Dubasari
Basarabeasca
mun. Balti
Vulcanesti
Total
16332
15056
14882
14005
13007
12846
12786
12677
11730
11402
11055
10899
10197
9604
8990
8264
7124
5537
5226
4269
3189
2758
2598
2411
1917
940263
36
42
26
33
26
57
58
35
29
41
35
34
31
27
23
32
32
13
28
9
36
11
7
7
3
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:
Page 85 of 121
RURAL AREA
Total cost using
Number of
Standard unit
“standard unit
Average by
2
2
RURAL PHC
PHC
Total area
cost by m
cost by m ”
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
Page 87 of 121
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.
Page 89 of 121
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
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.
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
Page 90 of 121
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:
Page 91 of 121
Covered
Population1)
Rural Standard
Function and Structure
Family Doctors
Nurses
Minimum Agreed Standard
1 FD for 1500
population
(flexible)
Minimum 2
3 N for 1 FD or
1500 population
Medical
Equipment
Minimum
Agreed
Standard
Minimum
standard,
including
Laboratory
Area of the
building
50 - 300 m2
1. Medical offices and
2 – 3 for a FD or
200 - 300 m2,
auxiliary rooms
1 for 1500
correlated
2. Pharmacy office
population
with the
3. 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
Centru de Sanatate
Rural (CS)
Over 2500
population
Page 92 of 121
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 socioeconomic 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
Page 94 of 121
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:
Page 95 of 121
-
-
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.)
Page 96 of 121
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.
Page 97 of 121
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
Page 98 of 121
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
Page 100 of 121
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
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
Sarcini
Page 101 of 121
Questionnaire for each PHC system institution
(It has been filed in separately / individually for each CS, OMF and PM)
Question
Code
I
P
ID
1
1.1
1.2
1.3
1.4
1.5
1.6
1.7
1.8
1.9
1.10
1.11
1.12
1.13
1.14
1.15
1.16
1.17
1.18
1.19
1.20
1.21
1.22
1.23
1.24
1.25
1.26
1.27
1.28
1.29
1.30
1.31
1.32
1.33
1.34
1.35
1.36
1.37
1.38
Question
Name of the PHC institution
Name of the person filling the questionnaire
Institution code (to be filled in afterwards by CSPSPMS)
ADMINISTRATIVE
AMP Institution
Type of PHC institution (evaluated institution):
CS - Centru de Sanatate
OMF - Oficiu al Medicilor de Familie
PM - Punct medical
Raion
Locality
Facility ownership:
Raion Council / Municipality
City Hall
Shares
Contact data
Institution manager – name and surname
Phone number (including area code)
Number fax
e-mail address
Population covered
Total number
Women
Men
Persons age 0-1 years
Persons age 0 - 4 years 11months 29 days
Persons age 0 - 18 years
Adults total (19 years and more)
Number of aged persons able to work:
women
men
Number of retired persons
Number of insured persons
Number of non insured persons
Population access to the primary health institution (CS, OMF)
Area covered
Availability of public transportation in the locations of the CS or OMF
Average time to reach the facility with public transportation/ walking to CS or
OMF
Roads status:
Country roads
Stoned
Asphalt
Answer Format
text
text
text
------------yes/ no
yes/ no
yes/ no
text
text
----yes/ no
yes/ no
yes/ no
----text
text
text
text
----number
number
number
number
number
number
number
number
number
number
number
number
number
----km
yes/ no
min
----yes/ no
yes/ no
yes/ no
Page 102 of 121
1.39
1.40
1.41
1.42
1.43
1.44
1.45
1.46
1.47
1.48
1.49
1.50
1.51
Question
Code
I
P
ID
2
2.1
2.2
2.3
2.4
2.5
2.6
2.7
2.8
2.9
2.10
2.11
2.12
2.13
2.14
2.15
2.16
2.17
2.18
2.19
2.20
2.21
2.22
2.23
2.24
2.25
2.26
2.27
2.28
2.29
2.30
2.31
2.32
2.33
2.34
Population access to pharmacy services
There is a state owned pharmacy
There is a private pharmacy
Access of the population to emergency care
Are there Emergency Services nearby
Distance to the Centrul de Sanatate / OMF
Access to specialized services / Hospital
Distance from CS / OMF to the Raion / Municipal Hospital
There is public transportation available to the Hospital
Average transportation time with public transportation
Closest PHC institution
Name
Distance
Question
INFRASTRUCTURE
General data about the building
Sanitary authorization
Accreditation certification (including through CMF)
Year of the construction of the building where CS / OMF is located
Number of buildings for the location of the CS / OMF
Building type:
Typical project
Accommodated type
Number of levels, including basement
There is a basement
Levels height
Total area
Utilized area
Non utilized area
Rented area to other institutions
Date (year) of last capital repair/ consolidation
Availability of the documentation for the building construction project
Availability of the technical expertise for the building (conclusions of the
expertise to be annexed here)
Funding source for the last capital repairing/ consolidation:
FIS
Local budget
Others
Year of last maintenance repair
Current status of the building and area needing repairing/ consolidation
General resistance structure
According to seismic requirements
Availability of the reinforced concrete carcass
Foundation
Availability of the foundation
Material for the foundation:
Ferro-concrete
BUT - piatra bruta
Others
Cracks in the foundation
----yes/ no
yes/ no
----yes/ no
km
----km
yes/ no
min
----text
km
Answer
Format
--------------------yes/ no
yes/ no
year
number
----yes/ no
yes/ no
number
yes/ no
m
m2
m2
m2
m2
year
yes/ no
yes/ no
----yes/ no
yes/ no
yes/ no
year
--------yes/ no
yes/ no
----yes/ no
----yes/ no
yes/ no
yes/ no
yes/ no
Page 103 of 121
2.35
2.36
2.37
2.38
2.39
2.40
2.41
2.42
2.43
2.44
2.45
2.46
2.47
2.48
2.49
Walls
Material for the walls:
Cotilet
But - piatra bruta
Clay
Bricks
Lampaci
Pre assembled panels
Others
Walls dimensions
Cracks present
Status of the interior plaster (good B, satisfactory S, non satisfactory N)
Interior plaster area needing repairs
Status of the exterior plaster
Façade area needing repair
2.50
2.51
2.52
2.53
2.54
2.55
2.56
2.57
2.58
Estimated costs to rehabilitate (repair) the foundation and walls
Ceiling (attic)
Materials used:
Sindrila
Monolit
Barne
Concrete preassembled panels
Status of the ceiling
Availability of thermo isolation (in the attic)
2.59
2.60
2.61
2.62
2.63
2.64
2.65
Estimated cost for ceiling rehabilitation/ construction
Floors
Material of the support layer for the floors:
Concrete
Pietris - piatra sparta
Others
Status of the support layer for the floors
2.66
2.67
2.68
2.69
2.70
2.71
2.72
2.73
2.74
2.75
2.76
2.77
2.78
2.79
2.80
2.81
2.82
2.83
2.84
2.85
2.86
Estimated cost for rehabilitation/ installing support layer for floors
Roof
Type of roof:
Flat
Sarpanta (wooden)
For flat roof:
Material of the flat roof:
Linocrom
Ruberoid - membrane bituminoase
Others
Number of layers
Status
For … roof type sarpanta:
Material roof type sarpanta:
Tigla metalica
Foi de ardezie
Tabla zincata
Others
Status of the roof
Status of the wooden structure of the roof
Availability of down comers/ down pipes
--------yes/ no
yes/ no
yes/ no
yes/ no
yes/ no
yes/ no
yes/ no
cm
yes/ no
B/S/N
%
B/S/N
%
thousand
MDL
--------yes/ no
yes/ no
yes/ no
yes/ no
B/S/N
yes/ no
thousand
MDL
--------yes/ no
yes/ no
yes/ no
B/S/N
thousand
MDL
--------yes/ no
yes/ no
--------yes/ no
yes/ no
yes/ no
number
B/S/N
--------yes/ no
yes/ no
yes/ no
yes/ no
B/S/N
B/S/N
yes/ no
Page 104 of 121
2.87
2.88
Status of the of down comers/ down pipes
Year of the last roof renovation
2.89
2.90
2.91
2.92
2.93
2.94
Estimated cost for roof rehabilitation/ installing
Windows
Material for the windows:
Wood
PCV/ Aluminum
Status
2.95
2.96
2.97
2.98
2.99
2.100
Estimated cost to install windows
Doors
Material:
Wood
PCV/ Aluminum
Status
2.101
2.102
2.103
2.104
2.105
Estimated cost to install doors
Availability and status of the utilities
Electricity
Present
Status
2.106
2.107
2.108
2.109
2.110
2.111
2.112
2.113
2.114
2.115
2.116
2.117
2.118
2.119
2.120
2.121
2.122
2.123
2.124
2.125
2.126
2.127
Estimated cost to rehabilitate/ install electricity
Running water system
Present
Type:
Central system
Autonomous:
Fountain
Sonda arteziana
Mina
Others
Status of the exterior running water system
Status of the interior running water system
Estimated cost to rehabilitate/ install exterior and interior running water
systems
Sewage system
Present
Type:
Central
Autonomous:
Cesspool
Others
Status of the exterior sewage system
Status of the interior sewage systems
2.128
2.129
2.130
2.131
2.132
2.133
2.134
2.135
2.136
Estimated cost to rehabilitate/ install exterior and interior sewage systems
Heating system
Present
Type:
Central system
Autonomous:
Natural gas
Charcoal
Stove ???
B/S/N
year
thousand
MDL
--------yes/ no
yes/ no
B/S/N
thousand
MDL
--------yes/ no
yes/ no
B/S/N
thousand
MDL
--------yes/ no
B/S/N
thousand
MDL
----yes/ no
----yes/ no
yes/ no
yes/ no
yes/ no
yes/ no
yes/ no
B/S/N
B/S/N
thousand
MDL
----yes/ no
----yes/ no
yes/ no
yes/ no
yes/ no
B/S/N
B/S/N
thousand
MDL
----yes/ no
----yes/ no
yes/ no
yes/ no
yes/ no
yes/ no
Page 105 of 121
2.137
2.138
2.139
2.140
2.141
2.142
Heaters
Others
Status of the exterior heating system
Status of the interior heating systems
Year of the construction of the building where the heating system is located
Year of the last renovation of this building
2.143
2.144
2.145
2.146
2.147
Estimated cost to rehabilitate/ install exterior and interior heating systems
Hot water system
Present
Status of the exterior shot water system
Status of the interior hot water system
2.148
2.149
2.150
2.151
2.152
2.153
Estimated cost to rehabilitate/ install exterior and interior hot water systems
Ventilation/ conditioning systems
Presence of:
Ventilation
Conditioning
Status of the ventilation/ conditioning systems
2.154
2.155
2.156
2.157
Estimated cost to rehabilitate/ install ventilation/ conditioning systems
Security and fire proof systems
Present
Status of the security and fire proof systems
2.158
2.159
2.160
2.161
2.162
2.163
2.164
2.165
Estimated cost to rehabilitate/ install security and fire proof systems
Telecommunication system
Present
Type:
Phone
Fax
Email
Status of the telecommunication system
2.166
2.167
2.168
2.169
2.170
2.171
2.172
2.173
2.174
2.175
2.176
2.177
2.178
2.179
2.180
2.181
2.182
2.183
2.184
2.185
2.186
2.187
Estimated cost to rehabilitate/ install telecommunication system
IT network
Number of computers
Average age of the computers
Basic software present (Word, Excel)
Internal network present
Status of the internal network
Internet connection present
Medical waste system
Burning
Burial
Disinfection and disposal
Special community services collection
Others
Surrounding areas of the building
Status
Availability of appropriate access paths to the institution
Availability of the fence
Material for the fence:
Wood
Metal
Stone
yes/ no
yes/ no
B/S/N
B/S/N
year
year
thousand
MDL
----yes/ no
B/S/N
B/S/N
thousand
MDL
--------yes/ no
yes/ no
B/S/N
thousand
MDL
----yes/ no
B/S/N
thousand
MDL
----yes/ no
----yes/ no
yes/ no
yes/ no
B/S/N
thousand
MDL
----number
years
yes/ no
yes/ no
B/S/N
yes/ no
----yes/ no
yes/ no
yes/ no
yes/ no
yes/ no
----B/S/N
yes/ no
yes/ no
----yes/ no
yes/ no
yes/ no
Page 106 of 121
2.188
Status of the fence/ hedge
2.189
2.190
2.191
2.192
2.193
2.194
2.195
2.196
2.197
2.198
2.199
2.200
2.201
2.202
2.203
2.204
2.205
2.206
2.207
Estimated cost to rehabilitate/ install the fence/hedge
Availability of standardized rooms for the PHC system
Reception
Triage
Number of examination/ consultation rooms
Medical procedures room
Immunizations room
Laboratory
Number of laboratory rooms
Pharmacy
Staff room (day)
Waiting room/ hallway
Day stay rooms for women
Day stay rooms for men
Staff toilet
Patients women toilet
Patients men toilet
Wardrobe room
Estimated costs
Total estimated costs for complete renovation of the building (sum all of the
above costs)
Availability of project plans for the buildings (IF YES, PLEASE ATTACH A
COPY)
Availability of the cadastral plan of the building
Availability of the building construction project
Availability of the technical expertise of the building
2.208
2.209
2.210
2.211
2.212
Question
Code
I
P
ID
3
3.1
3.2
3.3
3.4
3.5
3.6
3.7
3.8
3.9
3.10
3.11
3.12
3.13
3.14
3.15
3.16
3.17
3.18
3.19
3.20
Question
FUNCTIONAL EQUIPMENT LESS THAN 50% WEAR
Medical devices
Stethoscope
Ocular tonometer
Adult peakflowmeter
Glucosemeter
Sterilizer
Large stainless steel boxes
Stainless stell table for medical devices
B/S/N
thousand
MDL
----yes/ no
yes/ no
number
yes/ no
yes/ no
yes/ no
number
yes/ no
yes/ no
yes/ no
yes/ no
yes/ no
yes/ no
yes/ no
yes/ no
yes/ no
----thousand
MDL
----yes/ no
yes/ no
yes/ no
Answer Format
text
text
text
--------number
number
number
number
number
number
number
number
number
number
number
number
number
number
number
number
number
number
number
Page 107 of 121
3.21
3.22
3.23
3.24
3.25
3.26
3.27
3.28
3.29
3.30
3.31
3.32
3.33
3.34
3.35
3.36
3.37
3.38
3.39
3.40
3.41
3.42
3.43
3.44
3.45
3.46
3.47
3.48
3.49
3.50
3.51
3.52
3.53
3.54
3.55
3.56
3.57
Question
Code
I
P
ID
4
4.1
4.2
4.3
4.4
4.5
4.6
4.7
4.8
4.9
4.10
Gynecology table
Pelvimeter
Othoscope
Ophthalmoscope
Guzon ear syringe
Vision chart
Computer
Printer
Medical devices set
Cornţanguri
Scalpel
Anatomical pincers
Medical catheters
Special objects
GP’s medical kit
Tourniquet
Length meter
Chronometer
Goniometer
Adult rectal tubes
Folding screen
Medical bed
Physician’s table
Nurse’s table
Drugs cabinet in the medical procedures room
number
number
number
number
number
number
number
number
number
number
number
----number
number
number
number
number
number
number
----number
number
number
number
number
number
number
number
number
----number
number
number
number
number
number
number
Question
INSTITUTION LEVEL HUMAN RESOURCES
Total number of doctors (any specialty)
Total number of doctors in CS or OMF
Family doctors
Available positions
Occupied positions
Number of doctors
Nurses (for family doctors)
Available positions
Occupied positions
Number of nurses
Answer Format
--------------------number
----number
number
number
----number
number
number
Page 108 of 121
4.11
4.12
4.13
4.14
4.15
Question
Code
I
P
ID
5
5.1
5.2
5.3
5.4
5.5
5.6
5.7
5.8
5.9
5.10
5.11
5.12
5.13
5.14
5.15
5.16
5.17
5.18
5.19
5.20
Question
Code
I
P
ID
6
6.1
6.2
6.3
6.4
6.5
6.6
6.7
6.8
6.9
6.10
6.11
6.12
6.13
6.14
6.15
6.16
Other staff (number of persons)
Other staff
Pharmacists
Accountants
Other staff
----number
number
number
number
Question
MEDICAL SERVICES OF AND REFERRALS BY CS/OMF IN 2006
Visits to CS or OMF
Family doctors’ visits TOTAL
Prophylaxis visits to the FD
Insured persons
Non insured persons
Other services provided by CS or OMF
TOTAL number of registered pregnancies
Total number of directly detected TB cases
Total number of directly detected cancer cases
Total number of HBP monitored persons
Number of EKGs performed
Number of clinical analysis
Number of laboratory tests provided
Referral system for patients in the covered area
Number of referrals to the outpatient specialist services
Number of referrals admitted into the Hospitals TOTAL
Number of admitted patients on family doctors’ referral
Number of admitted patients from the emergency medical services
Number of admitted patients on specialists’ referral
Number of admitted patients with no referral (self-referred)
Answer Format
--------------------number
number
number
number
----number
number
number
number
number
number
number
----number
number
number
number
number
number
Question
Financial activity of the institution in 2007 (6 months)
6 months 2007 income
TOTAL income
Per capita for insured persons
Per case (treated)
Premiums
Per capita for non insured persons
Direct payments for services - fee for service
Direct allocations from the founder
Drugs through national/ municipal/ raion health programs
Other income
6 months 2007 expenditures
Expenditures TOTAL
Salaries
Contributions to the state budget
Electricity
Gas
Answer Format
--------------------thousand MDL
thousand MDL
thousand MDL
thousand MDL
thousand MDL
thousand MDL
thousand MDL
thousand MDL
thousand MDL
----thousand MDL
thousand MDL
thousand MDL
thousand MDL
thousand MDL
Page 109 of 121
6.17
6.18
6.19
6.20
6.21
6.22
6.23
6.24
6.25
6.26
6.27
6.28
6.29
6.30
6.31
6.32
Question
Code
I
P
ID
7
7.1
7.2
7.3
7.4
7.5
7.6
7.7
7.8
7.9
7.10
7.11
7.12
7.13
7.14
7.15
7.16
7.17
7.18
7.19
7.20
7.21
7.22
7.23
7.24
7.25
7.26
7.27
7.28
7.29
7.30
7.31
Thermal energy
Drugs total
Fully reimbursed drugs
Emergency drugs
Heating fuel (charcoal)
Transportation expenses
Running water and sewage
Capital repairing
Equipment acquisition
Other expenses
Average salaries 6 months 2007
Average institution salary
Average family doctor position salary
Average family doctor salary
Average nurse position salary
Average nurse salary
thousand MDL
thousand MDL
thousand MDL
thousand MDL
thousand MDL
thousand MDL
thousand MDL
thousand MDL
thousand MDL
thousand MDL
----MDL
MDL
MDL
MDL
MDL
Question
INFORMATION ABOUT EACH DOCTOR IN THE RESPECTIVE MEDICAL
INSTITUTION
Doctor
Name and surname
Birth date
Medical University graduation year
Specialty as by the graduation diploma
Year of finalizing the specialty training
Time in the PHC systems
Time in the current/ present institution
Basic Family Medicine training
Internship
Residency
Basic specialization in family medicine (4 - 6 months)
Continuous education for family medicine or other specialties:
Special training in family medicine
CIMC Training
HIF Training
Other courses
Qualification/degree level in family medicine
Superior
Grade I
Grade II
No grade/ category/ level
Management training
Management training
Qualification level in management:
Superior
Grade I
Grade II
Housing
Housing situation:
Answer Format
--------------------text
year
year
text
year
years
years
----yes/ no
yes/ no
yes/ no
--------yes/ no
yes/ no
yes/ no
----yes/ no
yes/ no
yes/ no
yes/ no
----yes/ no
----yes/ no
yes/ no
yes/ no
yes/ no
---------
Page 110 of 121
7.32
7.33
7.34
7.35
Question
Code
I
P
ID
8
8.1
8.2
8.3
8.4
8.5
8.6
8.7
8.8
8.9
8.10
8.11
8.12
8.13
8.14
8.15
8.16
8.17
8.18
8.19
8.22
8.23
8.24
8.25
8.26
8.27
Individual
State owned
Rented
Compensations from Local Public Authorities for housing
yes/ no
yes/ no
yes/ no
yes/ no
Question
INFORMATION ON EACH MEDICAL NURSES FROM RESPECTIVE PHC
INSTITUTIONS
Medical nurses
Name and surname
Birth date
Graduation year
Year finishing specialty training
Time in the PHC systems
Time in the current/ present institution
Basic FAMILY MEDICINE training
Basic family medicine training
Continuous education for family medicine or other specialties:
Special training in family medicine
CIMC Training
HIF Training
Other courses
Qualification / degree in family medicine:
Superior
Grade I
Grade II
Housing
Housing situation:
Individual
State owned
Rented
Compensations from Local Public Authorities for housing
Answer Format
--------------------text
year
text
year
years
years
----yes/ no
--------yes/ no
yes/ no
----yes/ no
yes/ no
yes/ no
--------yes/ no
yes/ no
yes/ no
yes/ no
Page 111 of 121
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. …………………………………..
……………………………………………………………………………………………
……………………………………………………………………………………………
d) CS 4. …………………………………..
……………………………………………………………………………………………
……………………………………………………………………………………………
e) CS 5. …………………………………..
……………………………………………………………………………………………
……………………………………………………………………………………………
Verte!
Page 112 of 121
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 ………………………………………
Technical work:: ……………………………………………
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
……………………………………………………………
c) CS / OMF / PM 3 ………………………………………
Technical work:: ……………………………………………
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
……………………………………………………………
d) CS / OMF / PM 4 ………………………………………
Technical work:: ……………………………………………
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
……………………………………………………………
e) CS / OMF / PM 5 ………………………………………
Technical work:: ……………………………………………
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
……………………………………………………………
Page 113 of 121
Anonymous questionnaire for each doctor working in the PHC system:
9.1
9.2
9.3
9.4
9.5
9.6
9.7
9.8
9.9
9.10
9.11
9.12
9.13
9.14
9.15
9.16
9.17
9.18
9.19
9.20
9.21
Work Place
Rural OMF
Rural CS
Raional CS
CS Municipal Balti
CS Municipal Chisinau
Independent CS Municipal Chisinau
What would you prefer regarding the juridical statute and
contracting?
Juridical statute:
Within Raional Hospital
Within the Center for Family Doctors
Autonomous state institution
Autonomous private institution
Salary
What would be the level of a decent salary (USD)
What would be the supplementary incentives that you consider
yourself entitled for at work place?
Incentive 1.
Incentive 2.
Incentive 3.
Incentive 4.
Incentive 5.
-----
----yes/no
yes/no
yes/no
yes/no
yes/no
yes/no
---------
--------yes/no
yes/no
yes/no
yes/no
----$
-----
-----
----text
text
text
text
text
Page 114 of 121
Anonymous questionnaire for each nurse working in the PHC system:
9.1
9.2
9.3
9.4
9.5
9.6
9.7
9.8
9.9
9.10
9.11
9.12
9.13
9.14
9.15
Work Place
Rural OMF
Rural CS
Raional CS
CS Municipal Balti
CS Municipal Chisinau
Independent CS Municipal Chisinau
Salary
What would be the level of a decent salary (USD)
What would be the supplementary incentives that you consider
yourself entitled for at work place?
Incentive 1.
Incentive 2.
Incentive 3.
Incentive 4.
Incentive 5.
-----
----yes/no
yes/no
yes/no
yes/no
yes/no
yes/no
-----
----$
-----
----text
text
text
text
text
Page 115 of 121
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.
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.
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
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.
Nr.
1
2
3
4
5
6
7
8
Raion
mun. Chisinau
mun. Chisinau
mun. Chisinau
Anenii-Noi
Anenii-Noi
Anenii-Noi
Anenii-Noi
Basarabeasca
CS
CS Bubuieci
CS Ciorescu
CS Ghidighici
CS Mereni
CS Geamana
CS Harbovat
CS Speia
CS Sadaclia
Selection
da1
da2
nu?
nu?
da?4
da3
da2
da1
Criteria and notes
P, A, FD
P, A
bad condition, need replacement
Rehabilitated in HIF project, but the roof is leaking
P, D, A, bad condition
P
D
P, D, the only one in the area
Population
P
6913
7071
5164
6497
3599
5856
2993
4342
Distance
from
Hospital
(km)
D
10
15
8
19
14
13
24
17
Area
(m2)
A
230
474
190,5
1000
400
700
1200
2584,82
No of
family
doctors
FD
5
4
3
3
2
4
2
2
Local
Public
Auth.
Investments
LPAI
yes
yes
no
yes
no
yes
yes
yes
Page 116 of 121
Nr.
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
Raion
Briceni
Briceni
Briceni
Briceni
Briceni
Cahul
Cahul
Cahul
Cahul
Cahul
Cantemir
Calarasi
Calarasi
Calarasi
Causeni
Causeni
Causeni
Causeni
Causeni
Cimislia
Cimislia
Cimislia
Criuleni
Criuleni
Criuleni
Criuleni
Donduseni
Donduseni
Drochia
Drochia
Drochia
Population
CS
Selection
Criteria and notes
P
CS Corjeuti
da2
P, FD
7347
CS Tetcani
da?3 P, bad roof
2775
CS Pererata
da?4 D, maybe new location
1941
CS Beleavinet
da1
A, D
2225
CS Grimancauti nu?
P, but A seems to be miscalculated
4198
CS Borceag
da?2 D, bad condition, may new location
1408
CS Giurgiulesti da?3 P, A, D, bad condition
3019
CS Larga Noua da?4 D, bad condition
1518
CS Zarnesti
nu?
A
1922
CS Moscovei
da?1 P, D
3404
CS Larguta
da1
P, D, A, the only one in the area, maybe incentive for a doctor 2873
CS Valcinet
da1
very bad condition, technical expertise, maybe relocation
4621
CS Pitusca
da?2 P
3477
CS Sadova
da?3 P
3000
CS Chircaiesti
da4
P, A, technical expertise
3690
CS Tocuz
da?2 P, D, maybe relocation
4547
CS Salcuta
da3
P, A, D, technical expertise
4860
CS Copanca
da1
P, A, D, FD, very bad access, technical expertise
5584
CS Taraclia
da?
P, D, FD
4422
CS Gura Galbenei da?3 technical expertise
5675
CS Mihailovca
da?2 technical expertise
3685
CS Satul Nou
da?1 technical expertise
2041
CS Ratus
da?4 D
1431
CS Magdacesti da1
P, A, D, FD
4557
CS Cimiseni
da?3 P, A, D, technical expertise
2530
CS Mascauti
da?2 P, A, D, may relocation
4116
CS Frasin
da2
Rented location, very expensive, relocation
1461
CS Plop
da1
technical expertise
1572
CS Drochia
da?
P, A
2807
CS Maramonovca da?
D, relocation
2672
CS Gribova
da
technical expertise
1934
Distance
from
Hospital
(km)
D
21
27
47
15
65
55
25
16
18
14
18
12
18
18
25
18
40
40
27
15
20
50
45
40
25
25
8
12
34
18
Area
2
(m )
A
2840
1051
370
245
113,12
170
288
732
420
1500
448
615
1200
1613
444
195
432
336
960
417
396
2047
660
400
300
450
720
229
384
1146
308
No of
family
doctors
FD
5
2
2
2
2
1
2
1
1
2
0
4
2
2
2
1
1
4
3
1
2
1
1
3
1
2
1
1
2
2
1
Local
Public
Auth.
Investments
LPAI
yes
yes
yes
no
no
yes
no
no
yes
yes
yes
yes
yes
yes
no
yes
yes
no
yes
yes
yes
yes
no
no
yes
yes
yes
yes
yes
yes
yes
Page 117 of 121
Nr.
40
41
42
43
44
45
46
47
48
49
50
Raion
Dubasari
Dubasari
Dubasari
Edinet
Edinet
Edinet
Falesti
Floresti
Floresti
Floresti
Floresti
51
52
53
54
55
56
57
58
59
Floresti
Glodeni
Glodeni
Glodeni
Glodeni
Glodeni
Hincesti
Hincesti
Hincesti
60 Hincesti
61 Hincesti
62
63
64
65
66
67
Hincesti
Ialoveni
Ialoveni
Ialoveni
Ialoveni
Ialoveni
CS
CS Holercani
CS Molovata
CS Cocieri
CS Trinca
CS Viisoara
CS Zabriceni
CS Linguini
CS Profanes
CS Trifanesti
CS Ciutulesti
CS Sanatauca
CS Targul Vertiujeni
CS Cobani
CS Ciuciulea
CS Fundurii Vechi
CS Danu
CS Iabloana
CS Loganesti
CS Ciuciuleni
CS Bujor
Selection
da?2
da1
nu?
da1
nu?
da?2
da?1
da2
nu?
da1
da
CS Mingir
CS Cioara
CS
Crasnoarmeiscoie
CS Danceni
CS Molesti
CS Razeni
CS Rusestii Noi
CS Tipala
da?2
nu?
A lot of villages around it, merge the OMF
P, A, bad condition
Multiple buildings, only one should be rehabilitated and kept
P, D, but very bad condition building
P, but very bad condition building, relocation
Milk distribution inside the building that should be taken out
P, A
P, D
P, A, bad condition, relocation
P, D, relocation or new building, maybe incentive for attracting
doctors
D, bad condition, maybe relocation
da?1
nu?
da?4
da?1
da?3
nu?
P, D, relocation or limiting the area
Bad condition, but too close to hospital
P (keep as reserve)
P, D, relocation
P, A
P, D, relocation
da3
da
da3
nu?
da?1
da2
da?4
da?3
nu?
Criteria and notes
Bad condition
P, D
not clear, should be analyzed
P, technical expertise, rehabilitation of only one building
D, relocation
Bad condition, but small population
P, D, technical expertise, area limiting
Bad condition, relocation
Bad condition, but small population
Multiple buildings, only one should be rehabilitated and kept
technical expertise
Area
2
(m )
A
232
342
136
0
1250
439
1582,3
200
490
385
347
No of
family
doctors
FD
3
3
2
2
1
1
2
1
1
1
1
Local
Public
Auth.
Investments
LPAI
yes
yes
yes
yes
yes
yes
yes
no
yes
yes
no
40
20
15
20
8
12
10
30
36
716,1
250
520
763,6
499
285
125
500
270
1
2
1
1
2
2
1
3
1
no
no
no
no
yes
yes
no
no
no
5583
2101
50
60
2292,1
120
1
1
yes
yes
4715
2523
2854
6302
5186
3640
50
7
19
27
14
48
108
686,5
676,8
602
183
227
1
2
1
4
3
2
yes
yes
no
yes
no
no
Population
P
2576
3342
4098
3675
1426
1112
3869
1831
1022
2489
2966
Distance
from
Hospital
(km)
D
20
35
17
20
30
18
22
30
23
20
60
1120
2674
3438
3540
3949
3057
4016
5231
3330
Page 118 of 121
Nr.
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
Raion
Ialoveni
Ialoveni
Leova
Leova
Leova
Nisporeni
Nisporeni
Ocnita
Ocnita
Ocnita
Orhei
Orhei
Orhei
Orhei
Orhei
Riscani
Riscani
Riscani
Rezina
Rezina
Singerei
Singerei
Singerei
Singerei
Soroca
Soroca
Soroca
Soroca
96 Soroca
97 Soroca
CS
CS Ulmu
CS Vasieni
CS Borogani
CS Tomai
CS Sarateni
CS Marinici
CS Seliste
CS Otaci
CS Clocusna
CS Hadarauti
CS Pelivan
CS Chiperceni
CS Ivancea
CS Teleseu
CS Peresecina
CS Mihaileni
CS Recea
CS Varatic
CS Cuizauca
CS Mateuti
CS Copaceni
CS Chiscareni
CS Coscodeni
CS Radoaia
CS Vasilcau
CS Cainarii Vechi
CS Rublenita
CS Cosauti
CS Slobozia Cremene
CS Visoca
Selection
da?2
da?
da?2
da?3
da1
da3
da1
da3
da1
da2
da?
da1
nu?
da2
da3
da
da?3
da?2
da1
da2
da3
da4
da1
da2
da?4
da2
da4
nu?
Criteria and notes
New building found, but needs technical expertise
P, D, complementary to local investments (74,000 ML)
P, building too large
P, building too large
D, but too few population
Limit the area
P, technical expertise
P, small building ?), move the dentists in other location
P, D, A
technical expertise, incentiv e for attracting a doctor
P, A
technical expertise
P (keep as reserve)
P, D
P, A, FD
Unfinished new construction, technical expertise
FD, bad condition
technical expertise and demolition 1/3
D, A
P, A, D
P, A
technical expertise
technical expertise
P, D
P, but too big area
P, D, A
P, A
Not clear status, to be re-analyzed
da1
da?3
D, incentive for attracting a doctor
D, Found a new place for relocation
Population
P
2962
5224
4520
3206
1100
2243
4396
8376
2454
2039
2476
2806
2176
4378
8199
4481
2150
2257
1381
2560
4736
4275
3030
5364
2254
3084
3540
2652
Distance
from
Hospital
(km)
D
26
20
35
25
32
16
15
26
17
17
10
20
17
25
20
28
12
33
28
15
8
25
32
15
18
25
12
14
1299
2166
21
40
Area
2
(m )
A
182
555
355
26
225
589
300
0
324
412
336,64
328
78
1120
370
140
763
651
300
240
168,75
503,3
762,7
870,6
355
320
150
508
No of
family
doctors
FD
2
2
2
0
1
2
3
5
2
0
2
1
1
1
5
2
3
1
1
1
3
3
2
2
1
2
2
2
Local
Public
Auth.
Investments
LPAI
yes
no
yes
yes
no
yes
yes
yes
yes
yes
yes
yes
no
yes
no
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
no
no
1967
130
0
2
yes
yes
Page 119 of 121
Nr.
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
Raion
Straseni
Soldanesti
Soldanesti
Stefan-Voda
Stefan-Voda
Stefan-Voda
Taraclia
Taraclia
Taraclia
Telenesti
Telenesti
Telenesti
Ungheni
Ungheni
Ceadir-Lunga
Ceadir-Lunga
Comrat
Comrat
Comrat
CS
CS Panasesti
CS Raspopeni
CS Oliscani
CS Crocmaz
CS Slobozia
CS Talmaza
CS Albota de Sus
CS Valea Perjei
CS Tvardita
CS Cazanesti
CS Mîndresti
CS Leuseni
CS Sculeni
CS Parlita
CS Besghioz
CS Baurci
CS Dezghingea
CS Cioc - Maidan
CS Avdarma
Selection
da
da?
da?
da2
da?
da1
da?
da?
da?
da?
da1
da2
nu?
da?
da?2
da1
da?2
da?3
da?1
Criteria and notes
P, FD
P, D, but too big, relocation or area limitation
P, too large area
P, D, A
P, Not clear status, to be re-analyzed
technical expertise
D, technical expertise
P, FD, bad conditions, relocation
P, FD, bad conditions, relocation
very bad conditions, technical expertise
P, FD, new building found
Bad conditions, but too big area
P, FD, bad conditions, but too big area
P, New building found
P, relocation
P, A, FD
P, technical expertise or relocation
P, area unclear
P, incentive for attracting doctors, new building found
Population
P
2691
2898
2822
2905
4230
7324
1349
5088
6135
3120
4156
1896
2774
4315
3390
8782
5242
3621
3414
Distance
from
Hospital
(km)
D
10
25
7
45
12
18
30
55
60
45
10
16
25
15
12
17
20
20
Area
2
(m )
A
400
1132
1500
348
336
640
400
684
480
528
425
480
5700
484
482
0
790
0
360
No of
family
doctors
FD
2
2
2
2
2
4
1
4
5
2
3
1
3
2
2
4
2
4
0
Local
Public
Auth.
Investments
LPAI
yes
no
no
yes
yes
yes
yes
yes
no
yes
yes
yes
yes
yes
yes
yes
yes
no
yes
Page 120 of 121
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”.
Page 121 of 121

Tehnical Services and Tehnical Assistance PHRD Grant

Transcription

Similar documents

Flu policy changes and how it affects you!

soloFLEX - Easyfairs

September 2015 - Pueblo Ham Club

Bond Movies Dr. Jonathan M Sackier As an Englishman of a certain

June 2012 - PHC News

table of contents

Enterprising Eastern Perthshire Ltd

Pan-Canadian Primary Health Care Indicators

Vision One Supports Private Optometric Practice Transitions One of

EUROPEAN AGRICULTURE FUND FOR RURAL DEVELOPMENT