2015年-世界发展银行全球_How_to_Reduce_Out-of-Pocket_Payments_in_the_Health_Sector_in_Moldova__20页_1mb

Summary of Policy Note: How to Reduce Out-of-Pocket Payments (OOPs) in the Health Sector in Moldova

Core Content

This policy note examines the issue of out-of-pocket payments (OOPs) in Moldova's health sector from 2007 to 2013. It highlights the prevalence and trends of OOPs, their impact on economic well-being, and the key drivers behind the current situation. The document also suggests policy options to reduce OOPs and improve financial protection for the population.

Main Points

1. Prevalence and Trends of OOPs

• From 2007 to 2013, households' OOPs more than doubled, increasing from approximately 2.32 billion Moldovan Leu (US$ 191.4 million) to 5.28 billion Leu (US$ 404.7 million).
• OOPs accounted for over 50% of total health expenditure by the end of the period.
• About 160,000 people (4.5% of the population) faced catastrophic health expenditure annually, defined as OOPs exceeding 40% of their total non-food consumption.

2. Distribution of OOPs Across Socio-Economic Groups

• The richest 40% of the population accounted for 65% of total OOPs in 2013, while the poorest 40% accounted for 18%.
• The poorest 20% had the lowest share of catastrophic health expenditure (2.7%) and the lowest utilization of health services.
• The poorest quintile experienced an annual growth rate of OOPs of 11.4%, while the overall average was 21.5%.
• The poorest households were less likely to use health services, leading to worse health outcomes.

3. What is Being Purchased with OOPs

• The majority of OOPs are spent on drugs (49%) and medical consumables (22%), totaling 71% of OOPs.
• Outpatient services (18%) and hospital services (10%) also contribute to OOPs.
• Patients often have to bring their own drugs, consumables, and even food to hospitals due to unavailability or quality concerns.

4. Key Drivers of OOPs

• Inadequate coverage of the Mandatory Health Insurance (MHI), especially for the poor, self-employed, and agricultural workers.
• High out-of-pocket costs for pharmaceuticals due to limited coverage and the lack of generic substitution.
• High drug prices in both public and private pharmacies, five times higher than international reference prices.
• Informal payments (IPs) are widespread, driven by low provider salaries, lack of transparency, and weak sanction systems.
• Excessive health facility capacity relative to available resources, leading to underfunded and under-resourced facilities.
• Unfunded mandates for CNAM (National Health Insurance Company) to expand benefits without corresponding funding.
• Lack of transparency and accountability in procurement and regulatory practices, leading to corruption and inefficiency.

Policy Recommendations

4.1 Reduce Burden Imposed by Drug Expenditure

• Introduce pharmaceutical audits by CNAM to monitor prescribing patterns and reduce corrupt practices.
• Strengthen pharmacy regulation with certification and licensing, and revoke licenses for those engaging in side-payments.
• Implement INN (International Nonproprietary Names) prescribing mandates for outpatient drugs to limit promotion of expensive drugs.
• Promote low-priced, quality-assured generics through appropriate regulations and INN mandates.
• Institutionalize e-prescription to improve monitoring, control prices, and eliminate low-standard drugs.
• Ensure transparency in government tenders for drugs, using public disclosure mechanisms.
• Expand outpatient drug benefits under MHI, especially for the poor and prevalent health conditions, but only after addressing drug pricing and regulation.

4.2 Minimize Informal OOPs Paid to Health Services Providers

• Rationalize the health care delivery system, including strategic purchasing, reducing excess capacity, and consolidating the hospital network.
• Adjust reimbursement levels for essential treatments to ensure adequate provider income and reduce informal payments.
• Use pay-for-performance mechanisms to improve quality of care and counteract informal payments.
• Improve targeting of MHI for the poor, using means testing similar to the "Ajutor Social" program.
• Enhance understanding of the Basic Benefit Package (BBP) among the insured population to increase demand for free or subsidized services.

Conclusion

Despite significant increases in government health spending, financial protection in Moldova has not improved, and OOPs remain a major concern. The current system is trapped in a "vicious cycle" driven by inadequate coverage, high drug prices, informal payments, and inefficient management. Breaking this cycle requires a multi-pronged policy approach, including transparency, regulation, and targeted expansion of health benefits. These measures are essential to reduce financial barriers to care, improve health outcomes, and ensure equitable access to health services.