title: Expansion of health insurance in Moldova and associated improvements in access and reductions in direct payments.
abstract: BACKGROUND
  Moldova is the poorest country in Europe. Economic constraints mean that Moldova faces challenges in protecting individuals from excessive costs, improving population health and securing health system sustainability. The Moldovan government has introduced a state benefit package and expanded health insurance coverage to reduce the burden of health care costs for citizens. This study examines the effects of expanded health insurance by examining factors associated with health insurance coverage, likelihood of incurring out-of-pocket (OOP) payments for medicines or services, and the likelihood of forgoing health care when unwell.
  
  
  METHODS
  Using publically available databases and the annual Moldova Household Budgetary Survey, we examine trends in health system financing, health care utilization, health insurance coverage, and costs incurred by individuals for the years 2006-2012. We perform logistic regression to assess the likelihood of having health insurance, incurring a cost for health care, and forgoing health care when ill, controlling for socio-economic and demographic covariates.
  
  
  RESULTS
  Private expenditure accounted for 55.5% of total health expenditures in 2012. 83.2% of private health expenditures is OOP payments-especially for medicines. Healthcare utilization is in line with EU averages of 6.93 outpatient visits per person. Being uninsured is associated with groups of those aged 25-49 years, the self-employed, unpaid family workers, and the unemployed, although we find lower likelihood of being uninsured for some of these groups over time. Over time, the likelihood of OOP for medicines increased (odds ratio OR = 1.422 in 2012 compared to 2006), but fell for health care services (OR = 0.873 in 2012 compared to 2006). No insurance and being older and male, was associated with increased likelihood of forgoing health care when sick, but we found the likelihood of forgoing health care to be increasing over time (OR = 1.295 in 2012 compared to 2009).
  
  
  CONCLUSIONS
  Moldova has achieved improvements in health insurance coverage with reductions in OOP for services, which are modest but are eroded by increasing likelihood of OOP for medicines. Insurance coverage was an important determinant for health care costs incurred by patients and patients forgoing health care. Improvements notwithstanding, there is an unfinished agenda of attaining universal health coverage in Moldova to protect individuals from health care costs.
authors.affiliation: Department of Primary Care and Public Health, Imperial College, London, UK.
authors.forename: Thomas
authors.initials: T
authors.lastname: Hone
authors.affiliation: WHO Country Office in Kyrgyzstan, World Health Organization.
authors.forename: Jarno
authors.initials: J
authors.lastname: Habicht
authors.affiliation: WHO Project Office in Greece, World Health Organization.
authors.forename: Silviu
authors.initials: S
authors.lastname: Domente
authors.affiliation: Harvard T. H. Chan School of Public Health, Boston, MA, USA.
authors.forename: Rifat
authors.initials: R
authors.lastname: Atun
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D002675:Child, Preschool; D005260:Female; D005380:Financing, Government; D005382:Financing, Personal; D005102:Health Expenditures; D006297:Health Services Accessibility / Q000191:economics*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D019458:Insurance Coverage; D007348:Insurance, Health; D008297:Male; D017057:Medically Uninsured; D008875:Middle Aged; D008966:Moldova; D010342:Patient Acceptance of Health Care; D012737:Sex Factors; D055815:Young Adult