Center For Health Policies and Studies

Ce modele de dezvoltare asistenței medicale primare în Moldova pot fi aplicate la sate și cum pot fi atrase resurse financiare în acest sens

Models of primary healthcare development in the rural area of the Republic of Moldova. Financial mechanisms

11/9/2020 11:01 AM
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The Lithuanian Embassy of Moldova hosted a closing event of the project "Support for the reform of primary health care (PHC) in the Republic of Moldova", carried out in collaboration with the Center for Health Policy and Analysis (PAS Center). The project ran from October 1st till November 1st and was aimed at 'providing the necessary support to the authorities for the development of primary care, based on international practices which have proven their effectiveness'.

Juozas Galdikas, former Minister of Health of Lithuania (1996-1998) and High Level Adviser of the European Union for Health Reform in Moldova of the EU Delegation in Chisinau (2016-2018), presented a report based on one of the existing primary care models in Lithuania - the individual office of the family doctor.

Such a model of primary care is implemented in various European countries, said Juozas Galdikas. According to the expert, this model involves the reorganization of the existing Offices of Family Doctors (CMF) or Health Centers (CS) or building new ones, which would allow doctors to manage their activity individually. Such a model, said Galdikas, could help Moldova attract family doctors. In the last 10 years, the Republic of Moldova has been affected by a constant shortage of family doctors (general practitioners, GP), especially in rural areas.

In practical terms, the expert proposes the creation/restoration/renovation of 100 Primary Care Centers (up to 4 Family Physicians/nurses/medical staff) with independent legal status - small-medium private enterprise (SME) - on both sides of the Dniester River.

"Creating 80 AMP Centers on the right bank of the Dniester River and possibly 20 on the left bank of the Dniester River would be a sustainable solution for improving primary health care in the Republic of Moldova", believes Juozas Galdikas. Lithuania managed to implement a similar reform in 1999, through the PHARE program. "This experience is followed even 20 years after its implementation", said the Lithuanian expert.

”I worked for this report for 30 days. It was not enough to analyze the situation throughout the country, but it is a first step. These recommendations are made, taking the Lithuanian medical system as an example. As foreign experts, we can only say that this model helped us to succeed. Others might say that it will prove to be ineffective. Further, we need to understand whether it can be implemented in different health systems. Health Authorities from the Republic of Moldova can use this model as a guide when they will be ready to start the PHC reform", said Juozas Galdikas.

Financial support for the building or renovation of the 100 Primary Health Care Centers on both sides of the Dniester River can be identified under the Eastern Partnership Programme, i.e. the Financing Instrument for Small and Medium-sized Enterprises (SMEs), for the 2021-2027 period. The total financial costs can reach EUR 20 million between 2021 and 2025. „Your experience and skills will help you convince the European Union to support and provide financial resources to switch permanently to the new model", he pointed out. The reform may take a year, in the most optimistic scenario, but it can take up to three years.

Thus, at the end of 2025, family doctors from rural areas of the Republic of Moldova could be able to work under appropriate conditions, providing high quality PHC services available 24 hours a day.

"Collaborating with Mr. Galdikas, I became more convinced that we admitted a big mistake, when we tried to reform the entire PHC reform in just half a year, alike in cities and in rural areas. We should not stop on a single form, structure or idea of what the organizational structure of PHC institutions at national level should look like. The project envisages that the reform should start in those rural areas, where we have today a severe lack of medical services. Any reform is projected to improve the quality of services and to make this work we should change not just the structure of PHC, but to adapt to the new changes of the organization, financing, service and resource generation. The PHC reform has failed because all these directions were not taken into account”, said the programme coordinator at the Center for Health Policy and Analysis (PAS Center), Ghenadie Turcanu.

Mr. Oleg Lozan, Director of the School of Public Health Management, mentioned that academia will always support reforms and contribute to the multilateral development of professionals. "This is a very good model of reform, but we need to see if it has perspective in our system. We will help specialists evolve", said Mr. Lozan.

Mrs. Inga Pasecinic, the Chair of the Center for Health Strategies and Policies, mentioned that the managerial capacities of family doctors play a crucial role, but in her opinion few doctors can be good managers too.

"Throughout my work I have met many family doctors. One of the reasons why they do not move to free practice is the lack of managerial capacity and this is a very important issue. Money can be attracted from external sources, but you have to know how to organize yourself", said Inga Pasecinic.

According to the international expert Juozas Galdikas, in order to succeed with the new model of PHC, the Health Authorities should look very closely to the elaboration of the appropriate legal framework, to support private investments in the PHC system, but also to negotiate with the local public administrations to provide the places for the new Primary Care Centers. As we have witnessed, central authorities did not manage so far to establish a proactiv collaboration with local public administrations.

In the last 10 years, the Republic of Moldova has been affected by a constant shortage of family doctors (general practitioners, GP), especially in rural areas. The existing financial mechanisms that national health authorities put in place to stimulate employment of young specialists have not delivered the desired results. High rates of emigration immediately after graduation generates significant losses of public resources allocated for their training, but also a gap of specialists that can no longer be covered at the moment. According to the official data of ANSP (National Agency for Public Health), in the period from 2002 to 2019 the system lost over 450 family doctors. In 2002 there were 2,136 specialists reported and only 1,687 remained in 2019, reaching a coverage of 4.8 per 10,000 population. And the number has been steadily declining over the last decade. Financial and technical assistance of foreign partners during the last 5 years had limited impact on systemic improvement in PHC. The Government of the Republic of Moldova started in early 2019 the liberalization of GP practice, which had shown so far limited results.

The Project „Support for primary health care reform in the Republic of Moldova” is implemented by the Center for Health Policies and Studies (PAS Center) within the framework of the Development Cooperation and Democracy Promotion Programme in Moldova in 2020 with the financial support of the Embassy of Lithuania in the Republic of Moldova.

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