hospital master plan

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Republic of Moldova

Ministry of Health

National

Hospital Master Plan

2009 - 2018

Final Report


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Index Page

1 Initial Situation and Assignment 4

2 Executive Summary 8

3 As-Is-Analysis 17

3.1 Environmental and Market Analysis 173.1.1 Geography and Sociodemography ................................................................173.1.2 Economics and Infrastructure .......................................................................193.1.3 Healthcare System Organisation ...................................................................213.1.4 Healthcare Financing ....................................................................................233.2 As-Is Analysis of Hospitals in Moldova 263.2.1 Rural Hospitals in Moldova ..........................................................................263.2.2 Hospitals in Chisinau ....................................................................................363.3 Results and recommendations 40

4 Prognosis of needs for healthcare services 43

4.1 Recommendations for structural changes 444.1.1 Premises for hospital structures ....................................................................444.1.2 Reorganisation of hospital systems...............................................................454.1.3 Options for inpatient care..............................................................................504.1.4. Comparison of the scenarios .........................................................................604.1.5. Recommended Organisational Structures in the Healthcare Zones ..............664.1.6 Legal consequences.......................................................................................714.1.7 Hospital Financing 754.2 Estimating the Demand for Healthcare Services 794.2.1 Description of the Approach .........................................................................79

4.2.2 Summary of Results ......................................................................................854.3. Recommendations for Hospitals 874.3.1. Description of the approach ..........................................................................884.3.1.1Hospital structure .........................................................................................884.3.1.2 Allocation of beds ...................................................................................934.3.1.3. Allocation of Staff..................................................................................954.3.2 Summary of the results..................................................................................96

5 Resulting Investment Needs 99

5.1 Investment in Staff 1025.1.1 Estimations for salaries of hospital staff .....................................................1025.1.2 Educational and further needs.....................................................................1035.2 Investment in Building Structures 1055.2.1 Investment in Building Construction ..........................................................1055.2.2 Investment in building Structures Technical Systems .............................107

Medical gas supply............................................................................................5.2.3 Investment in building structures electric systems...................................1235.3 Investments in Medical Technology 1325.3.1 General........................................................................................................1345.3.2 Transit Hospitals .........................................................................................1355.3.3 Local Hospitals ...........................................................................................1365.3.4 Specialized Care Hospitals..........................................................................1415.3.5 High Specialized Care Hospitals.................................................................149

5.3.6 Centres of Excellence..................................................................................1585.3.7 University Hospitals....................................................................................167


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5.4 Further investment needs 1725.4.1 Data Management .......................................................................................1725.4.2 Other investments.........................................................................................172

6 Effects on other Providers 174

6.1 Ambulant Primary care 1746.2 Emergency Care 1756.3 Rescue Services 1766.3.1 Existing Systems .........................................................................................1786.3.2 Regulations and Operation..........................................................................1796.3.3 Recommendations .......................................................................................1806.4 Rehabilitation 1806.5 Alternative use of Infrastructure 183

7. Timeframe for implementation 187

7.1 Short-Term Changes (1. phase) 1877.2. Mid-term changes (2. + 3. phase) 187

7.2.1 Second phase (2010 2011) .......................................................................1877.2.2 Third phase (2012 2013) ..........................................................................1887.3 Long-term changes (4. + 5. phase) 1887.3.1 Fourth phase (2014 2016) .......................................................................1897.3.2 Fifth phase (2017 2018) ..........................................................................189

Appendices


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1 Initial Situation and Assignment

According to an International World Bank competitive bidding process arranged by the

Ministry of Health of the Republic of Moldova, it was agreed that the German health con-

sultant company top consult kln GmbH should be given the contract to develop a Hos-

pital Master Plan for Moldova.

top consult kln GmbH is an architectural and technical consulting company specialised

in Hospital Planning including mechanical and electrical engineering division. The com-

pany consists of experienced planners, medical experts, specialists in investment and cost-

ing, health care and hospital management, organisation and training.

The National Hospital Master Plan (NHMP) is a part of the reorganisation of the health

care system in Moldova, which started in the 1990s.

A Master Plan has the task of setting general conditions for the future development of the

hospital system, where quality has to defeat habit.

This means getting away from accepted customs and making the necessary settings for a

future-oriented structure in the whole country.

A master plan cannot and should not anticipate or replace detailed studies for each loca-

tion regarding its individual circumstances and possibilities of development.

The restructured hospital sector as recommended in the NHMP, and as according to the

contract will guarantee the improved access of the population to quality hospital care

services to an equal extent for all citizens, as well as a hospital functional and cost-

efficient endowment.

The NHMP was carried out between April 2008 and June 2009 in cooperation with a

Steering Committee from the Ministry of Health. Additional many local consultations be-

tween hospitals, Ministry and the consultant took place as well as local visits of all rural

hospitals by the consultant (see Appendix 8.11 in 10 separate folders). Chisinau hospitals

were not visited because of the existing studies.

According to the phases defined in the terms of references, the study has been presented

in the following sub-reports:


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Inception Report: August, 7, 2008 (see appendix 8.12)

First Interim Report: November, 12, 2008 (see appendix 8.12)

Second Interim Report: December, 4, 2008 (see appendix 8.12)

Final Report: February, 18, 2009 (see appendix 8.12)

The following description reflects some of the basic essentials of the report

INTERNATIONAL TRENDS IN HEALTH CARE

There are some characteristic trends in the organisation of modern healthcare in Western

Countries such as:

- Decentralisation of the simple (simple treatments can be executed at local hospitals, re-

duce of costs)

- Centralisation of the difficult (difficult treatments should be executed at specialized hos-

pitals, only there it is reasonable to keep equipment and specially trained personnel in re-

serve)

- Separation of different forms of emergency care (emergency care has to be executed as

necessary for the individual case, this means raise of quality and reduce of costs)

- More out-patient care and emphasis on primary care (out-patient care for rehabilitation

etc. and better primary care reduce expensive hospital services)

- Less in-patient care and a significant reduction in the average length of stay in hospital

(in-patient care and long stay at the hospital means highest costs per day)

- Day-care (reduce of hotel-services in hospitals means reduce of costs and appropriate

individual supply for the patient by the family)

- Day-surgery (costs result only for surgery, not for hotel-services)

- New less invasive treatment modalities (reduce of necessary wound healing time after

surgical interventions means reduce of costs at the hospital and earlier return to work of

the patient)


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- Emphasis on reconstructive surgery increasing quality of life (especially after defacing

injuries reconstructive surgery can cause considerable bettering of quality of life and by

that reduce necessary medical and psychological treatment)

- New potent drugs (pharmaceutical progress can accelerate recovery and reduce adverse

effects of therapy and by that raise quality of life for the patients)

Medical technology is advancing at an increasing speed. Many laboratory tests can now

be analysed in a decentralised fashion in the doctors office, while other more complicated

analyses are centralised. The new imaging techniques, such as MRI, have greatly im-

proved the diagnostic capabilities. Progress in micro-biology and gene technology will

make further improvement in patient treatment possible over the next few years.

The duration of life is rapidly increasing in many Western countries. More and more peo-

ple are becoming increasingly older. This will create new demand upon the care of the

elderly and the many various forms of care will have to be differentiated.

The progress in medical care will also influence the organisation of medicine. This or-

ganisation needs to become more and more flexible.

There will be more severely ill patients in the secondary hospitals. That will have an im-

pact on the number of staff and on the need for better wardrooms.

Clarifying the reason and alignment of the study the Moldovan situation today has to be

analysed:

There is a difference in life expectancy between Moldova and the Western countries.

Neonatal mortality rate in Moldova has an encouraging decreasing trend.

Socio-demographic details are to be seen in chapter 3.1.1

NEED FOR CHANGES

The old Soviet healthcare system is a comprehensive system based mainly on three types

of hospitals: local, district and republican. Meanwhile the local and district hospitals were

general hospitals with four or five basic departments and some additional specialities; the

republican hospitals were mostly mono-profile institutes specialised on certain illnesses.

The efficiency of this system is in great need of improvement. The basic concept of hospi-


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tal care was the idea of ensuring a bed for every patient, indifferent of hospital services.

Therefore huge hospitals have been created countrywide with a large bed capacity. The

medical services and the related costs didnt play a primer role. Costs have been covered

by the state budget, such as subvention. Because of a lack of competition, the healthcare

systems in the former communist countries have lost the affiliation to the development

registered in the West-European countries.

The modern Western systems are well structured population- and services-based systems.

The efficiency of the services is gaining more and more in importance, so that hospitals

are forced to supply high quality services for a payable price.

It is obvious, both from a medical point of view as from an economical, that the present

situation needs to be changed.


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2 Executive Summary

Chap. 1 Initial situation

1. According to an International World Bank competitive bidding process, arranged by the

Ministry of Health of the Republic of Moldova, a model for the National Hospital Mas-

ter Plan (NHMP) was created. Transnistria was not to be included, but the population of

Bender had to be taken into account. In the following executive summary, the results

have been briefly analysed. The purpose of the development of the NHMP is to close

the gap between the Moldavian situation today and international standards of stationary

healthcare.

2. The plan was carried out between April 2008 and June 2009 in cooperation with the

Moldovan Ministry of health. Additional local visits of all rural hospitals as well as lo-

cal consultations between hospitals, Ministry and the consultant took place. Chisinau

hospitals were not visited because of the existing studies.

3. A study was presented in sub-reports in August 2008, November 2008, December 2008,

and February 2009.

4. The task of a master plan is the setting of general conditions to support the future devel-

opment of hospital services, where quality has to defeat habit. Trends in medical de-

velopment are more minimal invasive techniques in surgical procedures, more option

for treating elderly, as well as the development in pharmacological active substance for

different diseases like Parkinsons diseases. Trend in treatment is ambulant treatment as

many as possible and as outpatients procedure and less hospital treatment. Consequently

customs have to be allowed, but required new adjustments have to be developed and

spread over the whole country. For that purpose, mechanisms have to be established, so

that these new adjustments can be put into practice by everybody. Incentives can be set

and reprehensions can be given in order to put these adjustments into effect. Examples

for these are European hospitals. In most of the European countries the length of stay

dropped by optimising organisational processes. Incentives were set by budget- regula-

tions and controlling activities. In consequence the demand of inpatients-beds de-

creased, less hospitals were necessary, economic inefficient hospitals changed to other

functions like day-hospitals or day-surgery centres or nursing homes.

5. There are some characteristic trends in the organisation of modern healthcare in Western

countries, such as the decentralisation of simple cases and the centralisation of difficult


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cases, more out-patient care and an emphasis on primary care, less in-patient care, a sig-

nificant reduction in the average length of stay in hospital, daycare, day-surgery, new

less invasive treatment modalities, medical technology advancing at a rapid speed, ris-

ing age expectancy. (see chapter 1)

6. The old Soviet Healthcare System is a comprehensive system based on general hospitals

on local and district level (the latter could have some specialities) and mono-profile

hospitals on republican level. On an economical aspect these are mostly insufficient.

The basic principle was to create hospitals ensuring a bed for every patient, indifferent

of hospital services. The outpatient care did not play a significant role. Based on this

countywide colossal hospitals have been created with a great amount of beds, but with-

out defined functionality. Medical services and the related costs were not the main fo-

cus. Costs have been covered from the state budget, such as subvention. Because of a

lack of competition, the Healthcare Systems in the former Communist countries lost al-

legiance to the development registered in the West-European countries. In contrast, the

modern Western systems are well structured, population and service-based systems. The

efficiency of the services gets more and more important, so that hospitals are forced to

supply high quality services for a payable price.

7. It is obvious from both a medical as from an economical point of view that the present

situation needs to be changed.

Chap. 3 As-Is-Analysis

8. The first step for the National Healthcare Master Plan is the As-Is-Analysis based on

geographical, socio-demographical, economical and infrastructural conditions and on

knowledge of the Healthcare System and Healthcare Financing System. Additionally, all

existing public hospitals in rural Moldova and in Chisinau were analysed. Private and

ministerial hospitals were not to be included. This analysis contains information about

the total bed figures, as well as about the departments, the medical activities by diagno-

ses, diagnostic activities and surgical treatment for each hospital. Besides this, the build-

ing and technical situation as well as the medical-technical situation were viewed. The

summary is gathered in a portfolio-analysis with market attractiveness - containing as-

pects of demographic, competition, morbidity rate and location - and competitive advan-

tages - containing aspects of construction, technical infrastructure, medical-technical

supply, further supply, and medical spectrum- as criteria. The As-Is-Analysis showed a


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difference between the hospitals in Chisinau and in rural Moldova. Medical standards

don't comply with Western European standards in the majority of hospitals. In order to

improve the medical situation for the rural population improvements in rural Moldova

should be introduced first. To do so a projection of the requirement of inpatient health-

care services is needed.

Conclusion of that only can be that hospitals in Moldova are at the moment economi-

cally inefficient and concerning building quality and medical infrastructure in bad cir-

cumstances.

Chap. 4 Prognosis of needs for hospital healthcare services -general comments

9. Planning means setting standards. This means fixing normal procedures that have to

be regarded. The basis for these standards in the NHMP is in creating different adequate

healthcare levels all over the country. On the other hand, the system has to be economi-

cal and affordable.

10. In the first step, total Moldova was restructured into 9 district healthcare-zones of nearly

the same population and area. This provides shorter distances to hospitals and better ac-

cessibility of care for the population. Chisinau, Balti and Cahul are special because there

equally high specialised care is provided for the whole country.

11. As verified in chapter 4.1.3. resp. 4.1.5 by the Consultant, a healthcare model with three

to four different healthcare-levels is highly efficient due to economics and resources

utilisation and offers a high qualified level of healthcare services to the population (see

Appendix 8.9).

12. The reorganisation of the hospital system consists of two fundamental aspects: a hori-

zontal reorganisation to arrange an alliance between similarly qualitative hospitals in 9

rural healthcare zones integrating all concerned partners with joint administration and

organization. Besides that, a vertical reorganisation should also be carried out to estab-

lish the approved hospital models and standard levels of therapy. There are four differ-

ent healthcare service levels - basichospital healthcare, offered by local hospitals, spe-

cialised hospital healthcare services, offered by larger hospitals with different medical

equipment, high specialisedmedical centres with an expanded medical spectrum, and

university-hospitals, treating also very rare but complicated diseases.

13. Four different scenarios for hospital care services have been developed and discussed

with the client. Scenario 1shows two levels of care (Local Level Hospitals and Centres


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of Excellence), that means all difficult therapies have to be executed only in the centres

Chisinau, Balti and Cahul. Unexpectedly, this scenario needs higher investments and

running costs than the others. Scenario 2 additionally establishes hospitals for special-

ised medical care. That reduces the distances for the population to reach specialised

therapies and therefore reduces the rush on the centres. Investments would be kept at a

medium level. Scenario 3is similar to scenario 2 but provides higher specialised care at

a reduced number of hospitals, therefore distances are longer than in scenario 2, but

slightly fewer investments would have to be made. Scenario 4additionally provides

Transit Hospitals where basic medical care is provided. On the long run, these hospi-

tals would (after the necessary reduction of patient stay and the upgrade of the other

hospitals are finished) be used alternatively for other healthcare purposes such as nurs-

ing homes or palliative treatment. At Chisinau besides the local hospitals, Excellence

Centres are established partly with functions of an university. This scenario provides the

best conditions for patients and the economy. The scenarios 2 and 4 were detailed elabo-

rated by the consultant for the intermediate (2013) and respective final (2018) situation

as they were favoured by the Ministry of Health under aspects of realisation..

14. To implement the new system the Ministry of Health has to prepare legislation, make

fundamental decisions and offer governance regarding the structures, establishment of

the insurance fund and the way of financing. In addition it has to support establishing a

monitoring system to control the medical and economical results, as well as to fix a re-

quirement plan for the zones. Establishing a hospital committee in the Ministry of

Health is recommended to discuss complex and fundamental issues.

15. A healthcare-counsel has to be established in each healthcare zone to coordinate in-

vestments and decisions in the zone - all hospitals in each zone are assembled under one

administration, managed by an administrative director (Chief executive officer - CEO)

and a chief physician. As long as the hospitals are not yet able to earn their running

costs it would be necessary for the government to make decisions regarding investments

and cost management.

16. The main current problem of hospital financing is the investment backlog that has built

up in the last decades. The gap between structural necessities and economical possibili-

ties makes financial support by the World Bank or other promoters necessary. After

that, the existing system of dual financing provides good opportunities for the future

hospital structure, if bigger investments such as CT or MRT (covered by countrywide


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plans) were promoted by the government, but running costs were refinanced by the

Health Insurance and private patients.

17. Estimations for the demand for a NHMP are dealt within the data 2007 provided by the

client. In order to identify the future size of each hospital, the bed capacity and the

medical spectrum of all Moldavian hospitals were analysed. Each hospital is classified

according to the points of view of four different healthcare-service levels, in all of

which economical and high-quality medical services are required. In addition, the medi-

cal trends and consequences of changes within the financing system have been consid-

ered for the final conclusion.

18. Following the basic idea of building administrative healthcare-zones and based on the

estimation of a per-zone-view, the focus on single hospitals was eliminated. Exceptions

were made for Balti and Cahul which were estimated as single hospitals and Chisinau

which was valued as one healthcare-zone.

19. The line of approach which estimates the demand for inpatient healthcare services in

2013 as well as in 2018 has integrated various different assumptions including specific

medical data, such as demographic and technical effects, e.g. access to technical pro-

gress, infrastructural effects, and general medical effects - including ambulatory treat-

ment. An estimated tendency implies that many patients, who seek care in Chisinau to-

day, would in the future stay in their home district, as quality of care would improve in

rural Moldova. Cases would be distributed differently, according to the level of care for

each medical department. Since maximum care is only provided in Chisinau, Balti and

Cahul, the respective cases would have to be distributed to one of these hospitals. In or-

der to calculate the amount of beds required, the average length of stay and utilisation

per bed has been assumed per medical department. Detailed information and findings

are described in the final report.

20. In order to make recommendations, each public hospital has been allocated as one of the

hospital-types based on the assumptions explained above. In a second step, departments

are defined to be required for basic care resp. to specialised care and are distributed to

the different hospitals. The chain for team-working treatment is represented.

21. Subsequently, the allocations of beds have been defined according to internationally

accepted rates for beds per 10.000 inhabitants. Based on this determination and on the

estimations for cases described above, beds have been distributed per healthcare-zone

and per hospital. Overall 37.4 beds per 10.000 inhabitants (this means a medium quan-


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tity between the international extremes of 64 in Germany and 21 in Turkey (Source:

WHO Regional Office for Europe health for all database) would be required to provide

a high-qualified, affordable healthcare service.

22. Staff allocations have been made according to their different professional groups. These

cover physicians, nurses, medical assistants, administrative and others (laundry, kitchen,

etc.). The staff requirement per bed has been calculated upon approved data from Ger-

many, assessment from the consultant as well as the hospital structure, in which beds are

classified by the average length of stay and utilisation per bed. The focus on the German

system was taken many times because it is shaping up well economically and takes so-

cial aspects into account.

Chap. 5 Resulting investment needs

23. The resulting investments are based upon staff, building-structure, as well as upon

medical technical structure.

24. Investment in staff training and qualification has to be made, some of which could be

financed by large technical firms, establishing new medical-technical infrastructures.

Also the teaching system for physicians, nurses and students has to be adjusted to meet

international standards.

25. Estimations for salaries of hospital staff are based on information relied from the client

and are shown for the different professional groups like physicians, nurses and others.

Other personnel staff includes staff from functional diagnostics, operation-room, medi-

cal-technical as well as administration department staff and staff from kitchen, laundry,

transportation, etc.). For the actual imponderables all costs are measured in today`s

prices.

26. The status and structure of existing hospitals is generally not adequate in terms of tech-

nical standards (lack of thermal insulation, low efficiency of technical equipment, etc.).

Nowadays, the hospitals need for a great improvement in air-conditioned rooms, eleva-

tors, and standards for technical equipment has increased, although during the last dec-

ades, the necessary investments have not been made. Besides that, medical technology

has to be improved at most hospitals, because their equipment is of an even less suffi-

cient standard.

27. The necessary investments until 2013 sum up to 636.987.308 . Until 2018 a total in-

vestment of 1.112.873.779 has to be made. All costs are up to date, but a prognosis for


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the duration of the NHMP cant be made dependably, because the development of costs

(especially in the building sector) is not reliable.

28. Further investment is required. One being a monitoring system for cases of all hospitals.

The Ministry of Health would have to steer the development and investments. This

could begin with a regular collection of basic data and develop to a monitoring system

that made continuous detailed analysis possible. This should be introduced as the first

step of the NHMP.

Chap. 6 Effects concerning other providers

29. The intention of ambulant primary care is to provide basic medical services avoiding a

hospital stay. In accordance with this, ambulant primary care should be offered at day-

clinics, family medical centres, as well as home care. The main focus should be patients

with chronic diseases. Additionally some ambulant primary care institutions should be

equipped in order to carry out basic surgical procedures (see chapter 4.3.2) which

wouldnt have to be followed by a hospital stay. Hospitals and ambulant primary care

institutions should cooperate closely. It would be necessary to apply general definitions

for the classification of patient treatment within institutions of ambulant primary care or

confinement to hospital.

30. On behalf of medical structure emergency care services would be provided by special-

ized hospitals, the Centres of Excellence in Balti, Cahul and Chisinau. These hospitals

should at least offer departments of traumatology, cardiology and neurology. Sufficient

emergency services would need to be supported by a well working system of rescue ser-

vices which would have to be established. Close cooperation between all emergency de-

partments would deliver a better quality of services.

31. The precondition for an ambulant rescue service is an availability of 24 hours per day

and 365 days a year, as well as the accessibility within 30 minutes. Some special condi-

tions would have to be established in general. Each hospital would be able to provide

first aid and therefore serve as a location for rescue services. At least for the first years,

additional bases should be in larger villages e.g. combined with the fire brigades. Emer-

gency doctors or family doctors should provide first qualified medical aid. Therefore the

ambulance cars would not only be used for transportation, but should also be fitted with

medical emergency equipment such as First Aid Kits with respirator, pharmaceuticals

and bandages, heart defibrillator, and suction etc.


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32. Rehabilitation is done currently within Moldovas acute care hospitals followed by an

increase in the average length of stay. Effective rehabilitation is based upon general

standards and requires special medical infrastructure, as well as special building re-

quirements. It should therefore be offered in specialised departments, by means of day

care rehabilitation units or through a home rehabilitation service. This would lead to a

shorter length of stay and therefore the same number of patients could be treated using

less acute care beds. Rehabilitation not utilizing acute care beds would improve the

quality of the services applied and would allow theses services to be carried through

more efficiently. In order to guarantee more efficient services, rehabilitation should be

centralized depending on the patients medical problems.

33. After reconstruction, in 2018 areas and Transit Hospitals would be free for alternative

use. These areas could be used for other medical or non-medical purposes. Therefore

day-surgery for ambulatory operations could be established, especially in hospitals

which had operation theatres. Also long-term care for patients with chronic diseases

could be implemented. Another spectrum could be healthcare service provided for pa-

tients with cancer. This could be in the form of palliative medicine or hospices. Still not

yet taken into account is care for the elderly or homes for social reasons. Staff can be re-

cruited from nurses of the former hospitals; alternatively a new profession based on

nursing can be created.

Chap. 7 Timeframe

34. The implementation of the NHMP needs consensus, because once beginning to intro-

duce the new hospital system structure, it would be fundamental to modernize hospital

(and healthcare) legislation. To avoid frequent changes in the system, it is recommended

that a consensus be negotiated between all participants.

35. Besides that, the infrastructural development of the country and the education of the

personnel are preconditions that have to take place simultaneously, in order to make the

NHMP successful.

36. The new common administration of hospitals in the healthcare zones would have to be

built up first as well as the central administration of the university in Chisinau.

37. By 2013 it would be necessary to increase capacities in basic care and specialised care

at some points all over the country, so that the patient demand on the centres could be

reduced. Especially future Transit Hospitals would have to be taken into account, be-


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cause a minimum quality would have to be provided there, otherwise these mostly small

houses would no longer be accepted at a time when the healthcare system would not yet

be able to cope without their capacity (e.g. before a sufficient reduction of an average

length of stay).

38. Following these steps till 2013, the quality of rural hospital care should be a lot better

than today. Moldova is an agricultural country with larger distances between different

locations. These have to be reduced, especially by the development of infrastructure.

Besides that, quality of care must be upgraded at the rest of the hospitals, especially for

specialised care and future Centres of Excellence, to make the system work as planned.

This could be reached by about 2018, if promotion can be provided as necessary and as

described in the different following chapters.

39. Finally it has to be taken into account that the reliability of all prognosis depends on the

actual development of the situation in Moldova. The evaluation and assumptions are

based on preconditions. If these differ from the real future figures an update of the

NHMP would be necessary.


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3 As-Is-Analysis

Since the Republic of Moldova claimed independence in 1991 there has been civil and politi-

cal conflict in the breakaway district of Transnistria, a district located east of the river Dni-

ester. In international view this conflict has not yet been resolved and the district of Transnis-

tria remains effectively outside of central governmental control. Within the perspective of

healthcare planning and funding, Transnistria is not supported by central government initia-

tives and thus not subject of this analysis. Only the small district of Bender (Tighina), which

is the only part of Transnistria west to the river, is included within our calculations.

After visiting the hospitals in Moldova one has to notice, that generally buildings and equip-

ment are in bad condition.

3.1 Environmental and Market Analysis

3.1.1 Geography and Sociodemography

Moldova is a landlocked country in Southeast-Europe. It borders on the Ukraine in the east

and north and on Romania in the west. Moldova covers more than 33,800 km and is the most

densely populated country of the former Soviet Union. At the time of independence the popu-lation of the Republic of Moldova was 4.4 million people. In 1989 Transnistria had 700 000

inhabitants (population census). By 2008, it has - without Transnistria - decreased to 3.6 mil-

lion people. A combination of decreasing birth rates and increased mortality has been con-

tributing to this trend of negative population growth. Additionally continuing emigration of

the working age population has been one of the Republic's challenges in recent years. In con-

trast different other sources predict an increase in population for the next years. Approxi-

mately 46% of the population live in urban areas. The largest city is the capital city of Chisi-nau (approx. 750,000 people), located in the republic's centre. The second largest city west of

the river Dniester is Balti (152,000 people), all other cities are smaller with a population of

well below 100,000 each.

Life expectancy has stayed on a constant level of about 68 years (male: 64 years; females: 72

years). The total fertility rate has been declining from 2.6 (1970) to 1.2 (2006). To ensure a

stable population size, it would have to be above 2.1 children.


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Figure 1: Basic Population Data.

Source: Moldova in figures 2008, Statistical pocket-book / ed. board: Vladimir Golovatiuc, 2008 (F.E.-

P.Tipografia Central)

Infant mortality shows a constant decline (minus 33 % from 1995 to 2003) reaching 11.8 per

1,000 live births in 2006, a figure still almost two times that of the EU average of 6.07. For

the same period neonatal mortality fell from about 12 deaths per 1,000 live births in 1995 to

about 7 deaths per 1,000 live births in 2006. Between 1992 and 2002, maternal mortality rates

fell by almost 36 %, reaching 16.0 per 100,000 live births in 2006.

While the part of the population aged 0 to 14 is constantly declining over the last decades

reaching 18.2 % in 2006 (EU average: 17%), the rate of the population older than 65 is rising

reaching 10.1 % in 2006 (EU: 14-17%). Thus the age dependency ratio has been constantly

decreasing from 0.52 in 1981 to 0.39 in 2006 showing a decreasing strength of the part of the

population aged 14 to 65 which typically represents a nation's workforce.


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The main causes of death in the Republic of Moldova are diseases of the circulatory system

followed by cancer, diseases of the digestive system as well as injury and poisoning. Increas-

ing tuberculosis (TB) and human immunodeficiency virus (HIV) infection rates are also cause

for concern.

3.1.2 Economics and Infrastructure

Since independence, the Republic of Moldova faces a period of transition to a market econ-

omy, which included the establishment of the Moldavian currency, privatisation of many en-

terprises, removing export controls and freeing interest rates. Internal and neighboring eco-

nomic difficulties have produced a serious drop in prosperity.

From 1993 to 1999 GDP has decreases by about 60 %. Economy activity turned around in

2000, with GDP growing at an average of over 5 % per year. In 2007 the registered GDP per

capita was US $ 3,266 PPP (world average: US $ 10,200). Despite the positive economic de-

velopment since the beginning of the 2000s, Moldova remains the poorest country in Europe,

with an estimated yearly per capita gross national income of US $ 1,100 in 2006. Today, more

than a quarter of the population lives below the poverty line (CIA World Fact book, January

2008). Income inequality between rural an urban population is high. The rural population

compromises over two-thirds of the poor. An estimated one quarter of Moldovas economi-

cally active population has emigrated and remittances amount to 20 - 25 % of GDP (2005).

Figure 2: Economical Figures Republic Moldova

Source: Moldova in figures 2008, Statistical pocket-book / ed. board: Vladimir Golovatiuc, 2008 (F.E.-

P.Tipografia Central)

In 2007 unemployment is estimated to be around 7.3 %, although different sources predict

that this is likely to be a considerable underestimate. The data of the Center for Strategic


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Studies and Reforms indicate that the informal economy amounts to 65 % of the entire econ-

omy. Even though the Gini coefficient (measuring the level of income inequality with 1 indi-

cating a 100 % inequality) changed from 0.38 in 2000 to 0.36 in 2005, inequality is still a big

problem especially between rural and urban areas. Data from the European Commission indi-

cates that by 2000, 90 % of the population was living on less than US $ 1 per day.

Moldova is highly dependent on trade activities especially with the Russian Federation which

is also the supplier of Moldova's energy needs. The Current Account Balance has increased

from US $ -135 Mio. in 2004 to US $ -561 Mio. by 2007 (source: WHO Healthcare Systems

in Transition, Moldova 2008). After the external debt burden grew to 108 % of GDP, a struc-

tural adjustment package with the International Monetary Fund was agreed upon. Still, mar-

ket-oriented reform and privatisation of large-scale enterprises has been slow in Moldova.

This could be one reason for low official unemployment rates. The International Monetary

Fund expects unofficial unemployment to be around 15 times higher than those unemployed

who actually receive benefits. For example, workers who are on unpaid leave are not in-

cluded. On the other hand "hidden" employment without taxes or social contribution exists on

a comparatively large scale. Similar procedures can be expected when interpreting the income

statistics which do not show any salary which is paid informally in cash. This leads to the

suspicion that the amount of money available to the population might be higher than official

statistics show.

The consumption of energy exceeds Moldova's production by far. There is no own production

of oil and natural gas in Moldova at all. The complete amount of 14,000 barrels of oil per day

(2007) and 2.2 billion cubic meters of natural gas are imported from the Russian Federation.

Additionally the consumption of electricity (4.203 billion kwh in 2007) exceeds Moldova's

production of electricity (1.229 billion kwh). Especially in rural areas energy and fresh water

supply tends to be unsteady, leading to divers problems, especially within the greatly depend-

ent healthcare delivery system.

Today, most major roads in Moldova are paved, but their condition varies greatly and driving

can be difficult especially during winter time or after heavy rain falls. There are no major

multiple-lane highways in the country. Train track network exists. There is a nationwide

"public" bus system and taxis operate within the major cities.


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3.1.3 Healthcare System Organisation

At independence in 1991, the Republic of Moldova inherited the extensive Semashko health-

care system structure of the former Soviet Union which was highly centralized with key deci-

sion-making and planning in Moscow. After conquering one's independence Moldova wasfaced with a health system with extensive infrastructure and staff but few resources to sustain

them. This resulted in formal and informal payment requirements which made access to

healthcare services more and more difficult for the poor part of the population.

In 1991 decision-making and fund-raising powers were moved from Moscow to Chisinau and

have since been decentralized further into the countrys 35 districts right of the Dnjester river.

Each district has a hospital (exception: Dubasari) and state institutes concentrated in Chisinau

provide specialised care at the national level. In 1997 Moldova had one of the most extensive

networks of health facilities and staff in either Western Europe or the countries of the former

Soviet Union (source: WHO Healthcare Systems in Transition, Moldova 2008). This high

level of healthcare provision was supposed to be kept through the financial crisis in the 1990s

but the severe fiscal crisis in 1998 finally led to reductions in the number of hospital beds,

activity levels and personnel.

Mandatory social health insurance has been operating since 2004. Financing the healthcaresystem has been contracted with the National Health Insurance Company (established in 2001

as the single purchaser of healthcare services in Moldova) while the organisation of primary

and secondary care was devolved to the Ministry of Health. Hospitals were given the status of

non-profit-making autonomous institutions, enabling them to design and manage their own

activities. They have also been the major contact point for all primary care activities within

their catchment areas until the family medicine centers were officially given independence

from hospital services in January 2008 (source: WHO Healthcare Systems in Transition,Moldova 2008). The district hospitals provide a wide range of secondary care but specialised

and high-technology care is only provided at the republican hospitals and national institutes

mainly situated in Chisinau. These providers are directly subordinated to the Ministry of

Health.


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Figure 2: Health system organisation of Moldova

Source: WHO: Healthcare Systems in Transition - Republic of Moldova (2008)

Overall responsibility of the population's health has been centralized to the Ministry of

Health. Funding of most service providers was centralized to the National Health Insurance

Company. At the same time organisational responsibility of most service provision has been

decentralized to the districts. High specialised healthcare services, rescue- and emergency

services as well as public health institutes are subject to the Ministry of Health's responsibility

but only public health institutes (providing mainly preventive medical care such as immuniza-

tion) and the blood service are funded directly by the Ministry of Health.

Further institutions with major influence on the healthcare system and its financing are

shortly described as follows:

The Parliament approves the budget of the Republic of Moldova on a yearly base. The budget

of the Ministry of Health and the insurance fund's budget are included. The Parliament also

monitors the Ministry of Health and regulates the healthcare system's strategic direction. The


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policy framework is developed in cooperation with the Ministry of Health before it is imple-

mented by this ministry.

The Ministry of Health is responsible for the provision of undergraduate medical education,

also the educational content is overseen by the Ministry of Health.

The Ministry of Transport, the Ministry of Internal Affairs, the Border Guard Department, the

Department of Penitentiary Institutions, the Ministry of Defense, the Security Committee, the

Trade Union Association and the State Chancellery (source: WHO Healthcare Systems in

Transition, Moldova 2008) operate their own systems of healthcare provision within the

health policy framework developed by the Ministry of Health but using their own finance and

management arrangements. By those who use them the parallel services are often viewed asproviding the better quality of care.

The local governments and municipalities are responsible for healthcare facilities located in

their respective areas. They are responsible for the implementation of nationally decided

standards and guidelines.

The EU, the World Bank Group, the Global Fund to fight AIDS, Tuberculosis and Malaria as

well as the Global Drug Facility are only a few of those international organisations which areactive in Moldova's healthcare sector with a variety of activities and in different fields.

Professional associations, patient groups and non-governmental organisations can also be

found in Moldova's healthcare system.

3.1.4 Healthcare Financing

In 2004 the Republic of Moldova spent 7.4 % of GDP on health (US $ 138 PPP per capita).

This figure does not include informal payments which are estimated at 1.2 % of GDP. Since

GDP does not include the informal economic activities, the real amount of financial resources

within the healthcare system is hard to estimate. About 56.8 % were public health expendi-

tures, 43.2 % were private and mostly out-of-pocket payments. Per capita expenditure on

health varies widely across the country. In 2000 while spending was about US $ 109 per cap-

ita in Chisinau, it was only US $ 56 in the wider Chisinau district.


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Figure 3: Trends in health expenditure in Moldova 1998-2004

Source: Healthcare Systems in Transition - Republic of Moldova (2008)

The Health Sector Strategy project (decision of the government of the Republic of Moldova

no. 668, dated on 17 July 1997 Regarding the approval of the concept reffering to the

reformation of the healthcare system of the Republic of Moldova under the financial

condition for the period between 1997-2003), run from 1997 to 2003, aimed at re-orientating

the provision of healthcare services away from inpatient to outpatient oriented services. This

was mainly done through re-allocating healthcare budgets, so that 35 % of local budgets

should be allocated to primary care, 45 % to hospitals, 15 % to emergency services and 5 %

to specialist hospital services.

Moldova's healthcare system is generally financed by four different sources: General reve-

nues allocated to the health sector through central budgets, employer and employee contribu-

tions to the National Health Insurance Company and private out of pocket payments. Addi-

tionally international donations and loan aids have been substantial while contributions of

voluntary health insurances remain very small. While the main source of funding remains to

be budgetary transfers from general taxation, out-of-pocket payments play an important role.

A large part of these private payments are estimated to be informal payments directly tohealthcare providers for services that should be fully funded by official payments. These high

costs of out-of-pocket payments act as a barrier to enter proper healthcare services for poor

households.


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Figure 4: Healthcare Financing Flow Chart

Source: Healthcare Systems in Transition - Republic of Moldova (2008)

Today, Moldova provides healthcare coverage through mandatory healthcare insurance and

some healthcare services provided by a number of internationally funded and government-

funded programs. Health insurance coverage was 75.7 % in 2004 in total and varied greatly

by gender, employment status and by district. The benefit package for the insured is set by the

National Health Insurance Company and the Ministry of Health depending on affordability.

The package's volume may vary from year to year. Additionally, the constitution guarantees a

minimum provision of healthcare services (mainly basic primary healthcare services, emer-

gency care and hospital treatment of Tuberculosis, HIV, cancers, asthma and mental disor-

ders) to the population which is free of charge. Procedures which are not included in this

minimum package or which are not insured by the mandatory coverage have to be paid for out

of pocket.


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3.2 As-Is Analysis of Hospitals in Moldova

3.2.1 Rural Hospitals in Moldova

3.2.1.1 Description of the ApproachThe classic method of portfolio analysis (Sources:

http://en.wikipedia.org/wiki/G._E._multi:factoral_analysis) was adopted in order to score

each rural hospital on multiple variables. In Strategic Management Theory portfolio analyses

are used in many different varieties, in general to compare and display different selection pos-

sibilities on a two-dimensional scale. The two dimensions used are market attractiveness (dis-

playing the external factors which influence each hospital but can not or only rudimentarily

be influenced by the hospital directly) and competitive advantage (representing a set of vari-

ables which are internal from a hospital perspective and thus might be influenced easier).

Thus a good comparison of all rural hospitals as well as hospitals located in Chisinau is pos-

sible (see chapter 3.2.2).

The variables used to measure Market Attractiveness are demography, competition, morbid-

ity, and location. Competitive advantage was measured using the variables construction, tech-

nical infrastructure, medical technical supply, further supply, and medical spectrum.

Each of these variables was divided into sub-criteria which were the actual base of analysis

and which were averaged to each criterion's score. The variables score was then weighted on

a scale from one to ten. Within the criteria used to measure Competitive Advantage the vari-

able "Medical Spectrum" was given the highest weight (4.0) because the base of hospital ser-

vice provision greatly depends on the possible medical spectrum a hospital is able to provide

compared to its competitors. Closely related and also very important for the ability to provide

quality healthcare services is the hospital's "Medical-technical Supply". This variable was

weighted 2.0 just as the variable "Construction", also because changes which would need to

be made lead to relatively high investment needs. Thus a hospital has a relatively large com-

petitive disadvantage if scored low. Due to the same arguments "Technical Infrastructure" and

"Further Supply" was weighted relatively low. The variables defining Market Attractiveness

are weighted more equally. The variables "Demography" and "Morbidity" were given higher

weights (3.0) because these variables cannot be changed by the hospital nor by the healthcare

system. On the other hand "Competition" and "Location" are also interpreted as external vari-


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ables but they might be influenced at least by the healthcare system. Thus these two variables

were weighted a little less (2.0).

The sub-criteria and scoring model of classic portfolio analysis for healthcare are described in

more detail within the following paragraphs.

The analysis of each sub-criteria awarded points of one to six where one is the worst and six

is the best. The average of these sub-criterias points was then multiplied by the criterias

weight. The sum of all weighted variables was divided by 10 and resulted in the final points

for market attractiveness or competitive advantage. These values were transferred into a two-

way-grid, where the hospitals' number of beds defines the size of the circles.

All information was derived from questionnaires distributed to the hospitals, data provided by

the Ministry of Health, publicly available information, and from our on-site-visits to each

hospital.

Criteria Weights

Points

(1 = bad 6 = good) Results

A Demography 3,0 3,0 9,0

B Competition 2,0 2,5 5,0

C Morbidity 3,0 4,0 12,0

D Location 2,0 5,0 10,010 36

Score 3,60

Criteria Weights

Points

(1 = bad; 6 = good) Results

A Const ruct ion 2,0 4,3 8,7

B Technical Infrastructure 1,5 3,7 5,5

C Medical-technical Supply 2,0 3,0 6,0

D Further Supply 0,5 3,5 1,8

E Medical Spectrum 4,0 1,8 7,2

10,0 29,1

Score 2,91

Market Attractiveness

Competitive Advantage

Figure 5: Criteria used for portfolio analysis

(figures are examples)

Each criterion was evaluated for each hospital separately using the same set of decision vari-

ables as described below. Some of the criteria were evaluated differently depending whether

the hospital is located inside or outside Chisinau (see chapter 3.2.2).



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"Demography" was measured using the size of the population of the district where the hospi-

tal is located. Points were awarded as shown in the table below. Generally it was assumed that

the more people have to be served by a hospital the better, since the number of cases increases

as does the population. Demography was weighted 30 % for market attractiveness making it

the most important criterion within this group. Points were given following the grid shown in

table 7. No further distinctions above 150,000 people was made because only very few hospi-

tals serve a population which is larger than 150,000.

Population:

Up to 50,000 1 point

50,001 75,000 2 points

75,001 100,000 3 points

100,001 125,000 4 points

125,001 150,000

5 points150,001 and more 6 points

Figure 6: Points awarded for the criterion "population"

The criterion of "Competition" was measured using two criteria: number of medical depart-

ments and medical technology.

A two step approach was used evaluating "Medical Departments". As task of the As-Is-

Analysis is reporting the existing situation, the number of departments was evaluated from

the answers in the questionnaires, therefore differences to the legal situation are possible.

Starting point was the average number of main medical departments within all rural hospitals

in Moldova. In case a hospital had eight medical departments it started with three points

within the point system. In case it had more than eight it started with four points, in case it

had fewer departments it started with two points. For each competitor (hospitals located in

bordering districts) with more medical departments the given starting points were reduced by

0.5 points in the second step. For each competitor with less medical departments 0.5 points

were added to the given starting points. If a bordering hospital had the same number of medi-

cal departments, the number of points was not changed. Through an iterative process the total

points for each hospital were determined. Whenever Chisinau was the bordering district

points were reduced by 1 point due to the strong competitive position of the hospitals located

in Chisinau (Details for Chisinau see in Chapter 3.2.2).


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A similar two step approach was used measuring "Medical Technology" as a part of the crite-

rion "Competition". Starting point was the average points given within the part "Competitive

Advantage - Medical Technology". In case a hospital was assigned with 2.7 score for Medical

Technology it started with 3 points within the point system. In case it was awarded more than

2.7 it started with 4 points, in case it had a lower score it started with 2 points. For each com-

petitor (hospitals located in bordering districts) with a higher score for "Medical Technology"

the given starting points were reduced by 0.5 points. For each competitor with fewer score

awarded, 0.5 points were added to the given starting points. If a bordering hospital had the

same score, the number of points was not changed. Through an iterative process the total

points for each hospital were determined. Whenever Chisinau was the bordering district

points were reduced by 1 point due to the special position of the hospitals located in Chisinau.

Both variables, "Medical Departments" and "Medical Technology", were averaged to get the

final value for this criterion.

Morbidity was measured using calculated values for the population's incidence and preva-

lence of the district. Points were given using the scales below and averaged in order to get the

criterion's final point value.

Incidence:

Up to 1,500 cases per 10,000 population 1 point

1,501 2,250 cases per 10,000 population 2 points




4,501 and more cases per 10,000 population 6 points

Figure 7: Points awarded measuring the district's incidence.

Prevalence::

Up to 5,000 cases per 10,000 population 1 point





9,001 and more cases per 10,000 population 6 points

Figure 8: Points awarded measuring the district's prevalence.


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The fourth criteria measuring "Market Attractiveness" was the hospital's location. The aspects

used were reachability, road condition, and sign posting. In case the reachability was poor,

road condition was bad and there were no signs directing the patients to the hospital, one to

two points were given. If the reachability was good, roads were bad and signs aware posted

three to four points were awarded. Good reachability and road conditions but bad signs ac-

counted for five points and if reachability, roads and signs were good six points were

awarded.

While "Market Attractiveness" was measured using criteria which cannot be affected by the

hospital directly, all criteria used to measure "Competitive Advantage" were internal criteria.

Competitive Advantage

The first criterion used for "Competitive Advantage" was "Construction" measuring the build-

ings' condition concerning the general structure and the need for repairs and renovation. If the

construction and structure was severely damaged the hospital was given one point. In case the

overall structure was generally acceptable but no repairs and renovations were done recently

two points were awarded. Three points were awarded in case a few renovations and repairshad been done recently. In case these renovations included the roof or the building's cladding

four points were awarded. If structural improvements had recently been done and thus im-

proved the whole hospital's structure five points were given. Only in case the hospital was

technically and optically up to date six points were awarded.

The second criterion measuring "Competitive Advantage" is "Technical Infrastructure". This

criterion represents the condition of the heating system, the sanitary system, the fresh air sup-

ply, electricity, medical gases and fresh water supply. If the infrastructure was at least partly

not working properly only one point was awarded. In case existing infrastructure was working

properly but no repairs and renovation had been done recently two points were awarded. In

case some renovations had been done three to four points were awarded depending on the

extent of these renovations. If substantial renovations and / or repairs had been done recently

five points were given and only in case the technical infrastructure was technically and opti-

cally up to date six points were awarded.


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The criterion "Medical-technical Supply" measures the condition of the hospital's medical

equipment. This includes everything from small consumables to large equipment. We used

the following grouping system to distribute the values on a 6-point scale.

Medical-technical supply:

Defective/non-functional + not up to standard 1 pointTechnically functional but not up to standard 2 points

Technically functional, not up to standard but updateable 3 pointsDefective or non-functional but up to standard 4 points

Technically/optically up to date but functionally not useful 5 pointsTechnically/optically up to date and functionally useful 6 points

Figure 9: Points awarded measuring the hospital's Medical-technical Supply.

The criterion "Further Supply" was used to measure the condition of the hospital's non-

medical supply, such as kitchens or dry-cleaning. It was only weighted 5 % for "Competitive

Advantage" showing that this supply is not very important for the provision of healthcare to

the people. In order to provide sufficient services the non-medical supply of a hospital should

be taken into account and late developments show that these aspects become more and more

important as competition between hospitals increases. One to two points have been awarded

in case the further supply was found to be without recent repair or renovation. In case there

were few repairs and renovations three to four points were given depending on their intensity.If substantial repairs and / or renovations had been done recently five points were awarded

and only in case all further supply has been found to be technically and optically up to date.

The last criterion to measure "Competitive Advantage" was the hospital's "Medical Spec-

trum". This includes the "Degree of Specialisation", the "Spectrum of Medical Care" provided

as well as the possible existence of any unique medical service ("Medical Unique Selling

Proposition") which is rarely provided in any other hospital. The "Medical Spectrum" was

weighted 40 % for "Competitive Advantage" making it the most important aspect within our

portfolio analysis.

The "Degree of Specialisation" and the "Spectrum of Medical Care" was measured using a

multiple step approach using data provided by the hospitals concerning the diagnoses treated

and the interventions done in 2007. Starting point were the 2007 data concerning diagnoses

and interventions of each hospitals. Within the point system the aspect of minimum case load

was recognized.


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Thus in a first step points were given concerning the amount of diagnoses treated and the

number of interventions done. Three points were awarded in case the calculated average of

treated diagnoses (8,048) or interventions (1,618) was reached. Points were awarded to each

hospital depending on the percentage below or above this average on a scale between 0.5 and

6.

In order to measure the amount of treated "Diagnostic Groups" a total of 20 activity groups

based on diagnosis (due to ICD-codex) were developed. Only one hospital has treated all of

these groups. An average of 18.5 activity groups was calculated and three points were

awarded if this average was met. Points were awarded depending on the percentage the num-

ber of diagnostic groups was calculated below or above the average. Every time a hospital

only had 50 cases or below within one of these groups total points were decreased due to the

minimum case load aspect.

Further 16 groups of interventions were formed. The average per hospital was calculated to be

11 groups and three points were awarded if this average was met. Points were awarded de-

pending on the percentage the number of groups of interventions was calculated below or

above the average. Whenever a hospital only had 10 interventions or below within one of

these groups total points were decreased due to the minimum case load aspect.

In order to measure the "Medical Unique Selling Proposition" each hospital was compared to

those hospitals in the neighbouring districts concerning the medical spectrum provided. More

points were awarded to those hospitals which had relatively more treatments in diagnostic

groups than their neighbouring hospitals. Following this scheme one point was awarded in

case some treatments were done more often than in neighbouring hospitals. Two points were

awarded in case no other bordering hospital treated cases within this group. Four points were

awarded if only three or less providers in Moldova treated patients within this group and six

points were awarded in case no other provider treated cases within this group. This procedure

was done with all groups; the points were added and then standardized on a one-to-six-scale.

In order to calculate the total points given for "Medical Spectrum" all points given to these

sub-criteria were averaged.


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3.2.1.2 Summary of Results

The Republic of Moldova is divided into 35 districts including the capital city Chisinau. In

this report hospitals in Chisinau are discussed separately (see chapter 3.2.2). Each rural dis-

trict has one hospital usually located within the districts capital. Hospitals located in Trans-

nistria are not regarded within this report.

The map illustrates that the hospitals' locations are spread all over the country, showing no

inequality of distribution between the areas in the northern and southern part of Moldova. The

map also illustrates people of rural Moldova can reach a hospital within acceptable distance;

there is no larger district whose inhabitants are theoretically not able to reach a hospital

within an acceptable amount of time, not considering inequalities of supply with infrastruc-

ture (roads, public transport etc.) and means of individual transportation.

20 district hospitals are sized 100 to 250 beds, 14 are sized 251 to 500 beds, and the Regional

Hospital in Balti (see Nomenclator Nr. 133, March 27, 2008) has 1,105 beds and is therefore

the largest acute care hospital in the country. Most hospital beds (appr. 7,054) are provided in

Chisinau.


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Number of beds

751 to 1.250

501 to 750

251 500

100 to 150

Number of beds

751 to 1.250

501 to 750

251 500

100 to 150

Figure 10: Hospital Location and Size in Moldova

Source: Ministry of Health - Republic of Moldova

The portfolio analysis as described in chapter 3.2.1 shows that most hospitals were scored

within the mid-range of the one-to-six-scale, only a few are outliers in the positive as well as

the negative direction. On average the scores for "Market Attractiveness" is 3.02 and for"Competitive Advantage" 2.65. The maximum scores of 4.95 and 4.30 respectively are given

to the hospital of Balti which is the largest acute care hospital outside of Chisinau. The hospi-

tal in Balti is given the maximum of all given scores for almost all criteria, only the score for

"Morbidity" is just above average. The minimum score for "Market Attractiveness" is 1.75

and given to the hospital in Taraclia, while the minimum score for "Competitive Advantage"

is given to the hospital in Ocnita. Generally there seems to be a trend that the small hospitals


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(by number of beds) reach fewer points than the larger hospitals even though this can not be

confirmed statistically.

Portfolio Analysis

0

2

4

6

0 2 4 6

Market Att ractiveness

CompetitiveA

dvantage

Anenii NoiBaltiBasarabeascaBriceniCahulCantemirCalarasiCauseniCiadir LungaCimislaComratCriuleniDonduseniDrochiaEdinetFalesti

FlorestiGlodeniHincestiIaloveniLeovaNisporeniOcnitaOrheiRezinaRiscaniSingereiSoldanestiSorocaStefan VodaStraseniTaracliaTelenestiUngheniVulcanesti

Figure 11: Competitive Positions of Hospitals outside Chisinau (The size of the circles are determined by

the number of beds)

Of all criteria measuring "Competitive Advantage" "Construction" is valued best averaging

3.60 on a one-to-six-scale while "Medical Spectrum" only averaged 2.04 which is the lowest

average value of all criteria used in this analysis. Compared to the relatively high value for

"Construction" "Medical-technical Supply" averages 2.74 indicating relatively larger invest-

ment needs.

All hospitals outside Chisinau are located in sites which are valued rather positively averag-

ing 3.64 which make "Location" the criterion with the best average value for "Market Attrac-

tiveness". Competition between the hospitals outside Chisinau varies greatly. This criterion is

valued between six and zero points with an average value of 3.14. The lowest average value


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within Market Attractiveness is "Demography" which is valued at 2.66 on average indicating

that a hospital outside Chisinau serves around 74.000 people. "Morbidity" shows an average

value of 2.90. Values are measured between 1.00 and 5.50 indicating that the incidence and

prevalence varies between the districts.

Some of the input into our analysis was derived from individual visits of all hospitals which

were going to be part of this study and report. These visits were used to get an insight of the

on-site-situation especially concerning building conditions, technical infrastructure, medical-

technical supply and further supply. It can be concluded that no large differences were in-

spected concerning the medical-technical supply. Most hospitals are equipped with similar

anaesthesia machines which are usually donated. In general the standard of medical technical

equipment can be evaluated being low compared to Western European standards (see chapter

5.3 ff). Concerning building locations and conditions some differences could be inspected.

Most hospitals did not undergo any major renovations in the last decades. In many cases

hallways are not wide enough to navigate modern hospital beds and operational theatres do

not comply with modern hygienic and equipment standards. Reanimation departments do not

provide sufficient services in order to be able to provide modern intensive or intermediate

care. Some hospitals are not able to provide sufficient sanitary facilities.

More detailed results for every hospital can be found in the according appendixes Nr 8.5 + 8.6

to this report.

3.2.2 Hospitals in Chisinau

3.2.2.1 Description of Approach

The hospitals in Chisinau were measured using the exact same approach in order to be able to

compare them with the rural hospitals. In particular the municipal hospitals in Chisinau were

found not to be much different from the municipal and district hospitals outside the capital.

Nevertheless a few special aspects have to be taken into account when awarding the measur-

ing points to each hospital for certain criteria:

All hospitals located in Chisinau were awarded with six points for the criterion of "Demogra-

phy", since they all have a catchment area which at the same time is the largest catchment

area by population in Moldova. Above 150 000 inhabitants, differences in the number of

population have no additional influence on the rating (max. = 6 points, see Fig. 7). For the


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criterion of "Morbidity" all hospitals in Chisinau were awarded five points. The incidence and

prevalence is the same for every hospital in the city and it was found to be reported relatively

high. Those hospitals in Chisinau which only provide medical services in one medical profile

and mostly provide highly specialised services had a disadvantage when the points for the

criterion of "Competition" as part of "Market Attractiveness" were awarded. Therefore an

additional point was awarded for theses single-profile hospitals.

3.2.2.2 Summary of Results

A total of 24 hospitals in Chisinau were part of this analysis. Included are the specialised hos-

pitals for Narcology, Psychiatry and Tuberculosis. Besides that some ministerial and private

hospitals are located in Chisinau but not included within this report. Out of the analyzed 24

hospitals 15 were republican hospitals (directly financed by the Ministry of Health) and 9

municipal hospitals (financed just as the hospitals outside Chisinau, see Chapter 3.1.4).

The best recognized hospital in Chisinau is the Republican Clinical Hospital which at the

same time serves as the university hospital of Chisinau although it does not have this particu-

lar status. Most complex cases treated in Moldova are mainly treated here. Also a major part

of practical medical education takes place here. But hardly any medical research is to be

found, which usually is one of the major tasks of university hospitals.

Single-profile hospitals exist for medical fields of Cardiology, Oncology, Gynaecology &

Obstetrics, Dermato-Venerology, Infectious Diseases, Emergency Care, Traumatology & Or-

thopaedics, and Cardio-Surgery. Most of these single-profile hospitals will become part of the

university clinics (in addition to the Republican Hospital) in order to provide best possible

education within these specialised fields of medicine.

Based on the applied criteria chosen by the consultant on international experience described

before, Municipal hospitals in Chisinau are comparable to most rural hospitals in Moldova.

They usually are about the same size and offer about the same variety of medical services.


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Figure 12: Location of hospitals in Chisinau

The portfolio analysis for the hospitals in Chisinau results in higher scores compared to the

results for hospitals outside Chisinau especially for "Market Attractiveness" with an average

score of 4.63. Major drivers are high scores for "Demography" and "Morbidity". The score

for "Location" averages similar to the score for "Location" for the hospitals outside of Chisi-

nau and the score for "Competition" averages slightly lower in Chisinau.

The average score for "Competitive Advantage" for hospitals in Chisinau averages at 2.91

which are only slightly above the average score for the hospitals outside Chisinau. While the

"Medical Spectrum" in Chisinau is scored higher than outside Chisinau, the technical equip-

ment of the hospitals as well as the construction of the buildings is scored similar or slightly

lower in Chisinau.

In total the Republican Clinical Hospital scores best for "Competitive Advantage" (4.24) and

"Market Attractiveness" (5.24). Although the Republican Clinical Hospital has high scores for


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"Medical Spectrum" and "Construction" the scores for "Technical Infrastructure" and "Medi-

cal-technical Supply" are just above average.

Portfolio-Analysis

0

2

4

6

0 2 4 6


CompetitiveAdvantage

IMSP SCR IMSP Centrul de Chirurgie a Inimii

IMSP Institutul de Neurologie ICSOMC

IMSP SCRC "Em.Coaga" Maternitatea Nr.2

IMSP Institutul Oncologic IMSP CNSPMU

SCTO IMSP Institutul de Cardiologie

IMSP SCBI ''Toma Ciorb'' IMSP Spitalul Clinic Municipal nr. 1IMSP SCM "Sfntul Arhanghel Mihail" SCM Sf. Treime

Spitalul Clinic Municipal N4 IMSP SCMC "V.Ignatenco"

IMSP Spi ta lu l c linic municipa l de copi i nr.1 IMSP Spi ta lu l c linic municipa l de bol i contagioase de copii

Figure 13: Competitive Positions of Hospitals in Chisinau (The size of the circles are

determined by the number of beds)

The lowest score for "Competitive Advantage" is reached by the hospital "Maternitatea Nr.2"

(0.88), a hospital specializing in Obstetrics. The lowest score for "Market Attractiveness" isreached by the hospital "IMSP Spitalul clinic municipal de copii nr.1" (4.04). Especially the

score for "Competition" is very low (0.7) for this hospital specialising in Paediatrics.

In general, provision of healthcare services is supposedly better in Chisinau than in rural

Moldova: Many patients travel to Chisinau because they don't trust their local hospitals and

seek for higher quality of care. The difference between the hospitals in Chisinau is generally

larger than the difference between the rural hospitals. While the municipal hospitals in Chisi-

nau are comparable to most rural hospitals in terms of building condition and level of services


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provided, the Republican Clinical Hospital is able to provide a higher level of healthcare ser-

vices to its patients. In comparison to most other hospitals its medical equipment is more ad-

vanced, as well as the building's condition and the technical infrastructure.

More detailed results for every hospital in Chisinau can be found in the according appendix to

this report.

3.3 Results and recommendations

The analysis of the existing hospitals in Moldova and the system overall shows that changes

are necessary. This concerns all aspects such as e.g. organisational structures, buildings and

techniques and financing. Although the whole system has to be transformed in accordancewith western experiences, one has to be aware that

What works in London, Frankfurt, and rural Sweden will not necessarily work in Pal-

estine - will it work in Moldova? (Different historic background and habits could, if

not taken into account, lead to refusal by the population)

Each model must be understood and evaluated in the Moldovan context (Customs

have to be regarded in principle. They can if necessary only be changed if this is well-communicated and people can see a benefit for themselves)

There are however more similarities than differences (e.g. people are accustomed to

receive stationary healthcare on different levels at different places).

The change in hospitals can be summed up in the following points:

Hospitals in Western Europe, North America, Australia etc. now differ in role, func-

tion, and organisation from countries in transition in Central / Eastern Europe (Decen-

tralisation, cooperation and competition have to be implemented)

Day and ambulatory care systems are the major factors of the change in hospitals (re-

duce of stationary care as the most expensive services to the necessary quantity)

A hospital is no longer an institution it is a service organisation ( Task of the hospi-

tal is not creating best benefit for itself, but for welfare of the individual patient)


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Hospitals are organised more corporately not departmentally (regarding the patient

not as a case but as a personality)

Hospitals nowadays manage four distinct patient streams emergency, out-patient,

inpatient and day-patient (providing best kind of service at the adequate level for the

needs of each individual patient)

The purpose of the NHMP is

to provide high-level suggestions to improve inpatient service provision to the Moldo-

van population while considering today's level and distribution of healthcare provision

and while considering economical restrictions

on one hand to provide qualified medical care for the whole population

on the other hand, to be appropriate for a society in transition from the centralised so-

viet system to a modern free market economy

to be fundable for a society that has many other (financial) problems to solve at the

same time.

hospital master plan

Documents