Joint efforts to curb out-of-pocket payments for health care in the Republic of Moldova


A recent study conducted in the Republic of Moldova with support from WHO and the Ministry of Health showed that access to health services has improved in recent years, but financial protection of the poor remains a problem. Preliminary findings of the study on drivers of out-of-pocket (OOP) payments in health care were presented at a national policy dialogue organized for key stakeholders in the Republic of Moldova on 31 January 2014 in Chisinau.

The study was conducted during the second half of 2013 as a follow-up of previous reviews on health financing in the Republic of Moldova, and paid particular attention to causes of health system inefficiencies and informal payments. The event provided stakeholders the opportunity to discuss the findings and provide feedback to the authors on potential actions to be taken. 

Study findings

The preliminary findings of the study were presented by lead author Taryn Vian, Associate professor of International Health at the School of Public Health, Boston University. The study revealed that OOP payments occur most often in hospitals (with an increasing trend over past years) while the largest OOP payments are made for medicines procured in pharmacies, caused in large part by irrational use of medicines. Informal payments are made mainly on a voluntary basis. However conditioned informal payments also persist. 

A positive trend over the past few years has been a decrease in the share of hospitalized persons with health insurance coverage paying directly to providers. 

The most important areas to tackle identified by the study are:

  • reform on medicines 
  • improving accountability of providers
  • performance monitoring of providers
  • transparent governance of the health system. 

Commitment to curb OOP payments

Participants in the policy dialogue addressed the following topics:

  • the definition of out-of-pocket payments (formal and informal) in the Republic of Moldova context; 
  • the breakdown between formal and informal payments;
  • the underlying factors of these payments in Republic of Moldova;
  • possible and preferred policy options to reduce OOP payments in the country.

In the opening session, Minister of Health Dr Andrei Usatii expressed the Government's commitment to ensuring access to affordable high-quality care for all citizens, improved universal coverage, improved equity and expanded financial protection. Informal payments are hindering the achievement of these objectives. The fact that OOP payments were found to persist in hospitals and outpatient settings calls for increased accountability in the hospitals and among other service providers to decrease the financial burden to patients. Dr Usatii also gave examples of how these payments discredit the health insurance system in the country.

The WHO Representative to the Republic of Moldova Dr Jarno Habicht mentioned in his opening words the important milestones achieved by the Government in the last few years on its path towards universal health coverage (UHC), particularly in the area of health financing reform. He welcomed these successes but also pointed to the urgent need to address out-of-pocket payments to ensure access to quality health services.

Next steps

The financial hardship of seeking care acts as a deterrent for many people and reinforces the need for governments to advance universal health coverage (UHC). Factors such as weak and inefficient health systems and financing arrangements without proper incentives can influence progress towards UHC. 

The additional financial resources needed to achieve UHC can be drawn from efficiency and quality gains. UHC is therefore not only about health financing, but entails broader health system reforms. The Deputy Minister of Health, Mihai Ciocanu, spoke about the necessity to address OOP payments as a prerequisite to foster the implementation of existing reforms in the health system and reflected on the further steps to be taken in partnership with national and international organizations.

The stakeholder discussion revealed many ways to improve health system efficiency and financial protection that would call for action by all stakeholders. 

The event gathered representatives from the ministries of health and finance, the National Health Insurance Company, National Anticorruption Center and other national bodies. The directors of republican and municipal hospitals together with the directors of the primary health care centres were also present as were representatives of international organizations, including the Swiss Agency for Development and Cooperation and World Bank.

Final report

The study's final report will integrate the results of the discussions and reflections on policy options and will be presented to a larger audience in the Republic of Moldova later in the year.

The policy dialogue on health financing was organized as part of the biennial collaborative agreement (BCA) 2014–2015 between the Ministry of Health of the Republic of Moldova and WHO/Europe. It was also linked to the European Union/WHO joint initiative to support policy dialogue and universal health coverage.