Round table “Transparency and economic efficiency in the use of the funds of the National Health Insurance Company”

The study shows that, compared with other countries in Central and Eastern Europe, the Republic of Moldova ranks unfavourably on most indicators measuring the population’s health status. Besides causes related to lifestyle, diet and the environment, this also reflects certain deficiencies in the health care system of the Republic of Moldova. On the other hand, the population’s poor health also implies relatively large financing needs for the system. Thus, the share of health expenditure in GDP is the highest in Moldova compared with the countries of the region, with public expenditure covering only half of total expenditure.

The introduction of compulsory health insurance in 2004 allowed a certain revitalisation of the health protection system. However, health insurance is only one of the important elements that determine the effective functioning of a health protection system. Making the insurance system more efficient must be accompanied by reform of the health care system itself. The analysis of the institutional framework in which the National Health Insurance Company (CNAM) operates highlights an excessive structural and functional complexity of the health care sector. This is reflected in high maintenance costs for surplus infrastructure; an insufficient delimitation of the responsibilities for policy making and financing of the health system in the relationship between CNAM and the Ministry of Health; a package of medical services insufficiently adjusted to needs; unsatisfactory quality of the contracted medical services; inadequately regulated professional performance of medical workers; and imperfect accreditation policies on the part of the National Council for Health Evaluation and Accreditation.

At the same time, a number of improvements can be achieved by strengthening the institutional governance and executive management of CNAM, the problematic aspects being internal institutional governance and the relationship with service providers. Both aspects have a significant impact on the efficiency of, and control over, the use of compulsory health insurance funds.

Another major problem of the system in its current state is the low coverage of the population by compulsory health insurance and the low share of persons who contribute directly to this system. About 30% of Moldova’s population remains uninsured. Of those insured, only 34% contribute directly, the rest being insured by the Government. However, budget transfers are much lower than the cost of an insurance policy or the average percentage contribution paid by employees and employers. This creates an excessive burden and an inequitable fiscal ratio in the financing of the system. The study states that, besides economic factors – low incomes that do not allow the purchase of insurance policies – there are other causes that discourage citizens from getting insured. These include the quality of services not meeting the expectations and needs of the population, the existence of the minimum package of medical services guaranteed by the state, and the possibility of purchasing and activating a health insurance policy at any time of the year. The study finds that at present not all instruments are used to discipline the population in health insurance (in particular those who are not employees), with the exception of a few categories (lawyers, notaries, patent holders).

The authors consider that increasing the percentage contribution and the fixed-amount health insurance contribution, as planned for the next four years, will not solve the system’s fundamental problems unless essential improvements are made in parallel to the quality of services provided by medical providers and an equitable financing system is ensured, in which the financial burden is distributed more evenly across society. In addition, CNAM should impose stricter requirements on medical service providers, without being influenced by its relations with the Ministry of Health, and should not finance activities unsuited to an insurance company.

For the proper functioning of the health insurance system and for successful reforms, human, financial and technical resources are needed, as well as a clear delimitation of responsibilities between the different actors and a full understanding of the context in which the current health insurance system operates. At present, some functions performed by CNAM are not directly within its remit, and responsibilities are dispersed between different institutions, which leads to inefficiency. After these responsibilities have been clearly delimited, the capacities of all institutions involved in the process must also be strengthened in order to ensure the efficiency and correctness of future decisions.

The study recommends strengthening the role of the CNAM Administrative Council, which has often played a purely formal role, increasing the representation of the beneficiaries of the compulsory health insurance system on the CNAM Board of Administration, and strengthening the internal control mechanism over the performance of CNAM staff. It is also necessary to increase CNAM’s autonomy in managing the compulsory health insurance funds (FAOAM), as well as to increase the capacities for monitoring performance and penalising medical service providers for deficiencies in their provision of services.