title: Barriers to universal health coverage in Republic of Moldova: a policy analysis of formal and informal out-of-pocket payments.
abstract: BACKGROUND
  Universal Health Coverage seeks to assure that everyone can obtain the health services they need without financial hardship. Countries which rely heavily on out-of-pocket (OOP) payments, including informal payments (IP), to finance total health expenditures are not likely to achieve universal coverage. The Republic of Moldova is committed to promoting universal coverage, reducing inequities, and expanding financial protection. To achieve these goals, the country must reduce the proportion of total health expenditures paid by households. This study documents the extent of OOP payments and IP in Moldova, analyses trends over time, and identifies factors which may be driving these payments.
  
  
  METHODS
  The study includes analysis of household budget survey data and previous research and policy documents. The team also conducted a review of administrative law intended to control OOP payments and IPs. Focus groups, interviews, and a policy dialogue with key stakeholders were held to validate and discuss findings.
  
  
  RESULTS
  OOP payments account for 45% of total health expenditures. Sixteen percent of outpatients and 30% of inpatients reporting that they made OOP payments when seeking care at a health facility in 2012, more than two-thirds of whom also reported paying for medicines at a pharmacy. Among those who paid anything, 36% of outpatients and 82% of inpatients reported paying informally, with the proportion increasing over time for inpatient care. Although many patients consider these payments to be gifts, around one-third of IPs appear to be forced, posing a threat to health care access. Patients perceive that payments are driven by the limited list of reimbursable medicines, a desire to receive better treatment, and fear or extortion. Providers suggested irrational prescribing and ordering of tests as drivers. Providers may believe that IPs are gifts and do not cause harm for patients and the health system in general.
  
  
  CONCLUSIONS
  Efforts to expand financial protection should focus on reducing household spending on medicines and hospital-based IPs. Reforms should consider ways to reduce medicine prices and promote rational use, strengthen administrative controls, and increase incentives for quality health care provision.
authors.affiliation: Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown Building 3rd floor, Boston, MA, 02118, USA. tvian@bu.edu.
authors.forename: Taryn
authors.initials: T
authors.lastname: Vian
authors.affiliation: Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown Building 3rd floor, Boston, MA, 02118, USA. ffeeley@bu.edu.
authors.forename: Frank G
authors.initials: FG
authors.lastname: Feeley
authors.affiliation: World Health Organization Country Office in Republic of Moldova, Sfatul Tarii Str. 29, MD-2012, Chisinau, Republic of Moldova. DomenteS@euro.who.int.
authors.forename: Silviu
authors.initials: S
authors.lastname: Domente
authors.affiliation: National Bureau of Statistics, 106 Grenoble Str., MD-2019, Chisinau, Republic of Moldova. ala.negruta@statistica.md.
authors.forename: Ala
authors.initials: A
authors.lastname: Negruta
authors.affiliation: World Health Organization Country Office in Republic of Moldova, Sfatul Tarii Str. 29, MD-2012, Chisinau, Republic of Moldova. mat@euro.who.int.
authors.forename: Andrei
authors.initials: A
authors.lastname: Matei
authors.affiliation: World Health Organization Country Office in Republic of Moldova, Sfatul Tarii Str. 29, MD-2012, Chisinau, Republic of Moldova. habichtj@euro.who.int.
authors.forename: Jarno
authors.initials: J
authors.lastname: Habicht
mesh_terms: D005260:Female; D005382:Financing, Personal / Q000379:methods*; D005102:Health Expenditures / Q000706:statistics & numerical data; D006296:Health Services / Q000191:economics; D006297:Health Services Accessibility / Q000191:economics; D006301:Health Services Needs and Demand / Q000191:economics; D006801:Humans; D007297:Inpatients; D008297:Male; D008966:Moldova; D010045:Outpatients; D011050:Policy Making; D011787:Quality of Health Care / Q000191:economics; D019472:Universal Health Insurance / Q000191:economics*