Republic of Moldova Ministry of Healthold.ms.gov.md/_files/8201-1-Hospital%20Master%20P… · · 2011-04-01NHMP top consult kşln GmbH page 1 Republic of Moldova Ministry of Health

NHMP

top consult kşln GmbH page 1

Republic of Moldova Ministry of Health

National Hospital Master Plan

2009 - 2018 Final Report

NHMP

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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 17 3.1.1 Geography and Sociodemography ................................................................17 3.1.2 Economics and Infrastructure .......................................................................19 3.1.3 Healthcare System Organisation ...................................................................21 3.1.4 Healthcare Financing ....................................................................................23 3.2 As-Is Analysis of Hospitals in Moldova 26 3.2.1 Rural Hospitals in Moldova ..........................................................................26 3.2.2 Hospitals in Chisinau ....................................................................................36 3.3 Results and recommendations 40

4 Prognosis of needs for healthcare services 43

4.1 Recommendations for structural changes 44 4.1.1 Premises for hospital structures ....................................................................44 4.1.2 Reorganisation of hospital systems...............................................................45 4.1.3 Options for inpatient care..............................................................................50 4.1.4. Comparison of the scenarios .........................................................................60 4.1.5. Recommended Organisational Structures in the Healthcare Zones ..............66 4.1.6 Legal consequences.......................................................................................71 4.1.7 Hospital Financing 75 4.2 Estimating the Demand for Healthcare Services 79 4.2.1 Description of the Approach .........................................................................79 4.2.2 Summary of Results ......................................................................................85 4.3. Recommendations for Hospitals 87 4.3.1. Description of the approach ..........................................................................88 4.3.1.1Hospital structure .........................................................................................88 4.3.1.2 Allocation of beds ...................................................................................93 4.3.1.3. Allocation of Staff..................................................................................95 4.3.2 Summary of the results..................................................................................96

5 Resulting Investment Needs 99

5.1 Investment in Staff 102 5.1.1 Estimations for salaries of hospital staff .....................................................102 5.1.2 Educational and further needs.....................................................................103 5.2 Investment in Building Structures 105 5.2.1 Investment in Building Construction ..........................................................105 5.2.2 Investment in building Structures – Technical Systems .............................107 Medical gas supply............................................................................................ 5.2.3 Investment in building structures – electric systems...................................123 5.3 Investments in Medical Technology 132 5.3.1 General ........................................................................................................134 5.3.2 Transit Hospitals .........................................................................................135 5.3.3 Local Hospitals ...........................................................................................136 5.3.4 Specialized Care Hospitals..........................................................................141 5.3.5 High Specialized Care Hospitals.................................................................149 5.3.6 Centres of Excellence..................................................................................158 5.3.7 University Hospitals....................................................................................167

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5.4 Further investment needs 172 5.4.1 Data Management .......................................................................................172 5.4.2 Other investments.........................................................................................172

6 Effects on other Providers 174

6.1 Ambulant Primary care 174 6.2 Emergency Care 175 6.3 Rescue Services 176 6.3.1 Existing Systems .........................................................................................178 6.3.2 Regulations and Operation..........................................................................179 6.3.3 Recommendations .......................................................................................180 6.4 Rehabilitation 180 6.5 Alternative use of Infrastructure 183

7. Timeframe for implementation 187

7.1 Short-Term Changes (1. phase) 187 7.2. Mid-term changes (2. + 3. phase) 187 7.2.1 Second phase (2010 – 2011) .......................................................................187 7.2.2 Third phase (2012 – 2013) ..........................................................................188 7.3 Long-term changes (4. + 5. phase) 188 7.3.1 Fourth phase (2014 – 2016) .......................................................................189 7.3.2 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 köln GmbH” should be given the contract to develop a Hos-

pital Master Plan for Moldova.

“top consult köln 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 doctor’s 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 didn’t 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 Parkinson’s 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, day–care, 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 - basic hospital healthcare, offered by local hospitals, spe-

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

equipment, high specialised medical 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 1 shows 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 3 is 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 4 additionally 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 can’t 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

wouldn’t 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 Moldova’s 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 km² 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 Moldova’s 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 was

faced 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 country’s 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 healthcare

system 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 as

providing 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 are

active 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 to

healthcare 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 Approach

The 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 variable’s 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-criteria’s points was then multiplied by the criteria’s

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 WeightsPoints

(1 = bad 6 = good) ResultsA Demography 3,0 3,0 9,0B Competition 2,0 2,5 5,0C Morbidity 3,0 4,0 12,0D Location 2,0 5,0 10,0

10 36Score 3,60

Criteria WeightsPoints

(1 = bad; 6 = good) ResultsA Construction 2,0 4,3 8,7B Technical Infrastructure 1,5 3,7 5,5C Medical-technical Supply 2,0 3,0 6,0D Further Supply 0,5 3,5 1,8E Medical Spectrum 4,0 1,8 7,2

10,0 29,1Score 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 point50,001 – 75,000 2 points75,001 – 100,000 3 points100,001 – 125,000 4 points125,001 – 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 point1,501 – 2,250 cases per 10,000 population 2 points2,251 – 3,000 cases per 10,000 population 3 points3,001 – 3,750 cases per 10,000 population 4 points3,751 – 4,500 cases per 10,000 population 5 points4,501 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 point5,001 – 6,000 cases per 10,000 population 2 points6,001 – 7,000 cases per 10,000 population 3 points7,001 – 8,000 cases per 10,000 population 4 points8,001 – 9,000 cases per 10,000 population 5 points9,001 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 repairs

had 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 pointsTechnically functional, not up to standard but updateable 3 pointsDefective or non-functional but up to standard 4 pointsTechnically/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 district‘s 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 1.250501 to 750251 500100 to 150

Number of beds

751 to 1.250501 to 750251 500100 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


Com

petit

ive

Adv

anta

ge

Anenii NoiBaltiBasarabeascaBriceniCahulCantemirCalarasiCauseniCiadir LungaCimislaComratCriuleniDonduseniDrochiaEdinetFalestiFlorestiGlodeniHincestiIaloveniLeovaNisporeniOcnitaOrheiRezinaRiscaniSingereiSoldanestiSorocaStefan 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


Com

petit

ive

Adv

anta

ge

IMSP SCR IMSP Centrul de Chirurgie a Inimii

IMSP Institutul de Neurologie ICSOMCIMSP SCRC "Em.Coţaga" Maternitatea Nr.2

IMSP Institutul Oncologic IMSP CNSPMUSCTO IMSP Institutul de Cardiologie

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

Spitalul Clinic Municipal N4 IMSP SCMC "V.Ignatenco"IMSP Spitalul clinic municipal de copii nr.1 IMSP Spitalul clinic municipal de boli 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" is

reached 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

NHMP


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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 accordance

with 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.

• not to define detailed plans for each hospital and other healthcare service providers in

Moldova, which have to be developed regarding the agenda defined in the NHMP.

Therefore strong and positive effects should also be achieved by

• Savings in management and administration

• Savings by centralized purchasing

• Better utilization of useful areas

• Reduction of energy consumption by up to date building standards

• Economic size of departments

• Better working conditions for personnel

• Savings by the reduction of therapy for nosocomial infects

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For detailed instructions and proposals regard the following chapters.

An efficient hospital organization should be as follows:

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4 Prognosis of needs for healthcare services

Planning means setting standards: hospital planning as well as e.g. finance planning or legis-

lation means just fixing the “normal procedures” that need to be taken into account.

Standards are not abstracts that can be used anywhere at any time - they have to be developed

on the basis of local, district and historical conditions. Besides it is important to review the

standards at regular intervals and to adjust them to changed conditions. In general it is not

possible to take an existing complex foreign system and superimpose it on the existing system

of another country without taking the different conditions into consideration.

The standardisation of fact-finding, approach and methodology is necessary in order to pro-

vide equal or similar conditions of life and healthcare for the population (see: sources, Ap-

pendix 8.14)

These is

• Standard of buildings, as defined in the chapters concerning investment in building

construction, technical and electrical systems

• Standard of medical equipment, as defined in the chapter about investments in medical

technology

• Standard of medical therapy (to be defined by medical experts on WHO specifica-

tions)

• Standard of education and training (to be defined by medical experts on international

specifications in the professional organisations).

• Standard of financing the healthcare needs (to be defined in negotiations between all

partners in the healthcare system).

In order to prepare the implementation of the NHMP, further detailed elaborations at a more

detailed level (which is not part of this study) for the various aspects will need to be made.

The basis for all standards in the NHMP is to create different adequate healthcare levels as

defined in the appendix 8.1 + chapter 4.3.2).

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4.1 Recommendations for structural changes

Based on the appraisal results of the first phase (As-Is-Analysis) of the NHMP, the following

general conditions, findings and specifications for the master plan have been developed in

accordance with Western European, Austrian, Lithuanian and especially German standards.

As explained above, a system cannot simply be copied for Moldova, but by evaluating differ-

ent systems a new standard can be created. The continuation of the unimproved hospital struc-

ture with a simple adaption to modern technology will not be efficient and will therefore

waste public funds. To implement a new hospital system structural changes are mandatory.

4.1.1 Premises for hospital structures

In search of sustainable healthcare services, both the medical care for the population of

Moldova as well as economical and affordable aspects has to be taken into consideration.

There are different models in Western Europe. Main differences result from the number of

beds and the medical technical equipment which determines the options of medical treatment.

As verified in different studies, the German healthcare model with three to four different

healthcare levels offers a highly economical and a highly qualified level of healthcare ser-

vices to the population. The benefit of the Transit hospitals, proposed by the consultant addi-

tionally, is mainly closing the gap of care for people who do not need acute stationary treat-

ment. In Moldova today elderly people, who do not need acute hospital care are generally not

supported at all. Besides that it means a reduction of costs for the next 10 years because run-

ning a Transit hospital is cheaper than a local or specialized hospital. The Transit hospitals

are therefore an adjustment of the necessary investment to medical necessities.

Running costs are essential criteria. These will be influenced by maintenance and personnel

costs. In Germany the capacity of personnel is lower than in several other European countries:

in 2005 the rate of hospital staff / 10,000 inhabitants in Germany was 10.8, in Austria 15.3, in

Ireland 14.9, Italy 12.3, in the USA 16.1, the highest rate.

These facts directly influence other costs such as costs / case: in 2005 the average costs per

case in Germany were 4,565 €, in Sweden 4,728 €, in Italy 5,669 €, in Canada 8,611 €, in the

USA 11,210 €. In 2000, the cost for hospitals in relation to the costs in the total healthcare

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sector amount in Germany to 35 %, in Denmark to 63 %, in Italy to 47 %, in France to 45 %,

in Canada to 44 %, in USA and also in UK to 42 %.

4.1.2 Reorganisation of hospital systems

A reorganisation of the hospital system consists of two fundamental aspects. One is the ade-

quate supply with medical care for the population within an achievable time; the other aspect

is the adaptation of organisational structure, so that horizontal and vertical reorganisation ac-

complishes a balance of similarly qualitative hospitals.

4.1.2.1 Horizontal Reorganisation

The horizontal reorganisation requires a territorial or zonal reorganisation, creating the need

for the cooperation of neighbouring hospitals as well as the set up of a zonal network between

them. It has been shown that this cooperation can theoretically be established without chang-

ing the organisational structure by the creation of well-supported common territorial admini-

stration, organisation and usage of administrative resources. This effect can easily be illus-

trated by example: If the hospitals in each zone are assembled under just one administration

costs for two or three CEOs can be saved. Even if the salary for the remaining CEO is a bit

higher this means a remarkable reduction of costs. At the same time the zonal hospital can

much better and much more successful negotiate prices and conditions for consumable sup-

plies than each hospital of it’s own.

The creation of the healthcare zones will ensure equal health care throughout the country and

with it area-wide accessibility for all citizens. It is also useful to take into consideration the

number of inhabitants living in similar catchment areas, so that they can also be offered a

comparable healthcare quality. The zones should also be socially and economically compara-

ble.

In accordance with the above-mentioned proposals, the total surface area of Moldova is di-

vided into 9 rural zones (plus centres in Balti and Cahul) and Chisinau as a zone by itself.

These zones are based upon population figures, economic situation and development poten-

tial. The economic situation does not differ very much in the rural districts. Moldova is in

most parts an agrarian country, where industry is not of great importance. This means that the

average income is accordingly low. Industries and the private sectors are concentrated in the

main cities, where wages are slightly higher (see chap. 3.1).

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At the moment it cannot be reliably predicted whether or not any rural parts of the country

will develop particularly well in the future. Nevertheless, as mentioned later, it can be as-

sumed that the quality of the road system will be much better in the future. However it is a

probable assumption that the southern district will profit from the geographic situation (access

to the River Danube and therefore an increase of industry).

The statistics regarding the size of the zones and population development were assembled in

the allocation plans

• For an intermediate situation 2013 (Appendix 8.2)

• For the final situation 2018 (Appendix 8.3).

Following are relevant figures for each planned healthcare zone, differentiated by

• surface area (km²)

• existing population

• inhabitants per km²

• estimated population for 2013

• estimated population for 2018

In short, surface area and population development for each zone can be summarized as fol-

lows: by building these zones, the hospital care for the population will be established or ad-

justed according to the necessities (see allocation table, Appendix 8.2 + 8.3)

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Healthcare

Zone

Surface

Area km²

Population

2007

Inhabitants

per km²

Population

2013

Population

2018

Healthcare

Zone 1 3,213 263,700 82.1 254,207 246,296

Healthcare

Zone 2 4,12 321,700 80.2 310,119 300,468

Healthcare

Zone 3 2,424 284,500 117.4 274,258 265,723

Healthcare

Zone 4 2,724 264,200 97.0 254,662 246,763

Healthcare

Zone 5 3,225 298,100 92.4 287,369 278,726

Healthcare

Zone 6 2,799 240,300 85.9 231,650 224,441

Healthcare

Zone 7

(excluding

Bender)

3,101 345,400 111.4 332,963 322,603

Healthcare

Zone 8 1,886 165,400 87.7 159,446 154,484

Healthcare

Zone 9 3,542 285,100 80.5 274,831 266,284

Balti 78 127,600 1,635.9 138,318 147,250

Chisinau 635 717,900 1,130.6 778,204 828,457

Cahul 1,447 123,800 85.6 134,199 142,865

Total 29,086 3,437,700 118.12 3,430,226 3,424,360

The figures show a decrease of population in rural zones and an increase in urban centres.

In all rural Healthcare Zones (excluding Zone 8), the actual number of inhabitants lies be-

tween 240,300 and 345,400. In 2018 this figure will sink to between 224,441 and 322,603.

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The number of inhabitants in all rural zones without zone 8 ranges between 80.2 and 117.4

per km². Regarding this, the difference between the largest and smallest Healthcare Zone is

less than 30 percent.

Zone 8 (Causeni, Stefan-Voda) varies slightly because on the one hand, its geographic situa-

tion does not make expansion possible, on the other hand, if Bender has to be included in

Zone 7 (Criuleni, Straseni, Ialoveni, Anenii Noi) the situation in this part of the country has to

be rechecked at all.

Accessibility of the hospitals and cooperation between the various locations is to be supported

by infrastructural measures. As the World Bank is about to promote an investment of 500

million $ for the road system in Moldova, it should be possible to upgrade the connections

between the future cooperating hospitals. As the consultant has taken a radius of 30 km as a

basis for a first hospital care distance, it should be possible to reach a hospital in about 30

minutes in emergency cases.

The model of “healthcare zones”, integrates all health system partners concerned in order to

combine actions, visions and definite measures. The joint administration and organisation,

sharing of technical and human resources as well as joint purchasing creates the possibility of

synchronising all hospital services. This means that instead of ineffective competition be-

tween the hospitals, co-operation is established between them, in which each hospital in a

district utilises its existing strengths and supports cooperation by ensuring that highly skilled

services are offered to the entire district, therefore minimising such high demands on the ex-

isting centres. Overall efficiency will increase by decreasing costs.

This creates specific advantages, especially higher effectiveness in healthcare as a result of an

improvement in the quality of medical services. District healthcare of the population will be

improved, and access to hospital services is consistently guaranteed for all. Investment and

development decisions would be based on a zonal level rather than a local level, so that as

stated above, unhealthy competition could be avoided and investment efficiency improved.

Management and organisation of each location has to be agreed. In view of these consultation

processes, despite increased efforts in coordination and communication between health ser-

vice partners, decision-making would nevertheless be complicated. However, the quality of

decision-making under the aspect of such social and investment viewpoints would increase

with the necessary consultation.

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4.1.2.2 Vertical Reorganisation

A vertical reorganisation of the hospital system shall also be carried out, particularly when

compared to Western European (especially German) standards (see sources, Appendix 8.14).

This means that approved hospital models and various corresponding standard level ratings

shall be established. For international examples of vertical hospital organisation see: WHO:

Health Systems in Transition, France 2004, Norway 2006, Netherlands 2004).

These performance levels shall be established nationwide as coherent healthcare standards,

and must be supported by appropriate medical and technical equipment, meaning that quali-

fied personnel are to be appropriately provided for.

It must be assumed that for the above-mentioned reasons, cooperation between neighbouring

hospitals is prerequisite to the reorganisation of the hospital healthcare system in the Republic

of Moldova. The intention of cooperations are primarily an economic one by using synergetic

effects in the treatment of patients. Sharing e.g. diagnostics-equipment, in high priced medi-

cal-technical equipment in operation theatre for low number of cases helps to reduce costs

and on the other side make expensive equipment profitable. For being successful in coopera-

tion general regulations between the hospitals have to be arranged - like the use of the equip-

ment, the number of cases or medical competencies. Cooperations may be arranged based on

diagnoses / indications, on medical departments with different services, on aftertreatment-care

and others (see also fig 22). All conceivable future scenarios recommending an improvement

in the hospital healthcare of the population should therefore include this requirement.

There are four different healthcare service levels:

• basic medical assistance, offered by local hospitals,

• Specialised healthcare services, offered by larger hospitals with different medical

equipment,

• Specialized medical centres with an expanded medical spectrum, and

• University hospitals, treating also very rare diseases.

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Patients are sent to the hospitals by their family doctors or by ambulatory care specialists. The

treatment is adapted to the necessary therapy, but at the same time, the location of the treat-

ment is ruled by these criteria.

Overall 10 Centres of Excellence located in Chisinau, as well as 2 Centres for Highly Special-

ised Medical Care in Balti and Cahul will be most useful due to the existing geographic infra-

structure and local-custom situations, and also on the basis of the existing and projected popu-

lation figures.

With regard to Chisinau and the existing studies, the question may also be raised as to how

the future form of medical training at a university centre should be organised. 7 Centres of

Excellence must be qualified and developed accordingly as part of the medical university,

with the aim of providing more effective services under jointly organised administration.

Based on the current local situation, there are in addition 6 Centres of Excellence as Mono-

profile Specialised Hospitals, which are also to be operated under common management, pro-

viding for all needs of highly professional treatment. In addition 8 Municipal Hospital will

exist in the future on the basis of a needs assessment. The Hospital of the Ministry of Health

will retain the actually status as department hospital.

Structures of management and organisation of the hospitals are described in chapter 4.1.5

4.1.3 Options for inpatient care

Taking the existing local structures in Moldova into account, the consultant has developed

several scenarios from which different models to provide healthcare for the population are

deduced (see chapter 4.3.2).

As previously mentioned, it must be assumed that the factors presented for the Chisinau dis-

trict (with Republican, University and Municipal Hospitals) as well as for Balti and Cahul are

to be presented in a similar way in all future scenarios.

It is important to note that changes to the hospital care system are unique, fundamental deci-

sions concerning the future of the healthcare system, and their implementation as a future

system will no doubt result in a highly satisfied population. From this point of view, it is justi-

fied to decide against the current political and district funding systems.

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In the following the different scenarios are described and compared just to the one below. In

chapter 4.1.4 all scenarios are judged following equal criteria and faced at a cost perspective

(see figure 14 + 15) As far as Coordination in the zones is concerned see figure 22.

A reduce of costs by installing additional medical levels is reached by providing services on

adequate but well-priced level and avoiding double services. Having differentiated levels it is

not necessary to cover simple medical requirements at an inflated technical and economic

standard.

Scenario 4

Local level hospitalsand basic medical care

Maximum medicalcare / Centres of

Excellence


Specialised medicalcare


Excellence


High specialisedmedical care


Excellence



Excellence

Specialised medicalcare

High specialisedmedical care

Gateway hospitals

Scenario 1 Scenario 2 Scenario 3

NHMP


Scenario 1: “Go to the centre” / Dual system

NHMP


This development model is essentially based on the existing hospital structure. It involves

slight changes to the system and is characterised as follows:

Only basic hospital care (general medicine, general surgery, Gynaecology/obstetrics, paedia-

try) is offered in the healthcare zones. All specialised medical care is to be provided at the

three central locations: Balti, Cahul and Chisinau. (tasks of the hospitals: see in chapter

4.3.2).

This creates the following effects: Investments in highly qualified medical services, as well as

those involving high costs, would only be required at a few different locations, allowing for

highly efficient utilisation of resources. Structural revaluation and related investments in rural

areas are only necessary on a small scale. Investment in these areas with less technology stan-

dards today keeps the volume of investment in medical technology in each area to a mini-

mum, and the main requirement is structural modification to reach up-to-date standards.

This naturally means that highly specialised care is only offered centrally, and maximum

medical care resources are economically concentrated in the central locations. With this focus

on the central locations, and as a result of citizens visiting the central facilities, permanent

survival of smaller hospitals cannot be guaranteed, as patients become accustomed to visiting

these “Highly Specialised Care Providers” even for minor cases. Centralisation trends in

health care will become even stronger in Scenario 1 due to socio-economic needs and the as-

sociated anticipated improvement of transportation. Emergency care cannot be guaranteed

locally or within the maximum acceptable duration of care by the tending decline in the num-

ber of small hospitals. Naturally the distance to Highly Specialised Care Providers is long, so

that access to these centres would be restricted for a certain part of the population.

In Scenario 1 care is principally provided on 2 levels.

Regarding Point 4.1.2 of the assignment it must be noted that the fixed objectives of the con-

tract: “Delivery of the major necessary health care services at district level” and “the export

of the services … from the Excellence Centres to their filial from the areas…and from the

References Hospitals to the Community Hospitals” can hardly be fulfilled by this scenario.

NHMP


Scenario 2: “Close to the patient”

NHMP


Scenario 2 is characterised by a three-level hospital structure - local, specialised and maxi-

mum medical care. The objective of this alternative is to have the opportunity of treating a

large number of patients with specific needs in “Local Level Hospitals” close to their homes.

Thus, a large number of patients from the northern and southern parts of the country could

possibly save a trip to the Balti and Cahul Centres. To provide this, those hospitals which are

most suitable to manage the zonal network will be upgraded to the level of “Specialized

Medical Care” by means of additional qualifications (1 or 2 additional service profiles, (see

appendices 8.2 + 8.3), purpose is to present all relevant specialisations in each zone, tasks of

the hospitals: (see in chapter 4.3.2).Even with this scenario, the free choice of treatment by

district allocation is to some extent limited

As mentioned earlier, the functionality of the Balti, Chisinau and Cahul centres compared to

the first scenario remains unchanged. Regarding the Chisinau district separately, however, it

is assumed that due to travel distance, the existing concentration of the treatment of specific

diseases in Chisinau will remain the same. It is therefore assumed that the treatment of cases

with “Specialised Medical Care” is to be provided by the “Mono-profile Specialised Hospi-

tals” in Chisinau.

Compared to previous conditions, Scenario 2 demands an increased effort in coordination that

could possibly be minimised by the integration of these “Specialised Medical Care” hospitals

into the administrative network of the individual zones. (The additional effort in coordination

explicates by a raised need for diagnostic differentiation, billing and controlling as well as

internal adjustments). Especially for the rural districts, an improved provision of hospital ser-

vices would be available, technical and human resources of the existing hospitals could be

better utilised, because special treatment for all larger lists of patients would be available at

each place and smaller treatment units could be avoided. In addition, by working together

beyond the borders of the zones, economic networks with trend-setting features can be devel-

oped.

On the other hand, compared with the first scenario, there would be an increased need for

investment punctually, but in the whole country total investment is lower (see Appendix 8.9).

It should also be noted, that difficult decisions concerning the distribution of services by dif-

ferent hospitals have to be anticipated.

NHMP


Scenario 3: “Centre in the zone “

NHMP


Scenario 3 is also a three level system structure - local, highly specialised and maximum

medical care. The specialised functions of the Balti, Chisinau and Cahul centres remain un-

changed. Compared to the second scenario, the fundamental difference is that a greater num-

ber of “Specialised Medical Care” centres, each with one or two additionally created treat-

ment profiles, will not be created, but that a greater concentration will be achieved, a smaller

number of hospitals will be set up to meet the needs of “Highly Specialised Medical Care”,

with three or four additional treatment profiles (see appendix 8.2 + 8.3) in the northern and

southern districts. Even in Scenario 3, a more efficient allocation of resources, though at a

higher level than in Scenario 2, would be achieved.

Especially for the rural districts, the result would be further improvements in the quality of

hospital care, as more treatment would be carried out in relatively near proximity to the pa-

tient’s place of residence, although due to the reduced number of “Highly Specialised Medical

Care” hospitals travel time may be slightly longer.

Compared to Scenario 2, fewer hospitals receive an upgrade in medical technology with

highly qualified and cost-intensive investments (tasks of the hospitals: see in chapter 4.3.2).

Overall, the decentralisation leads to a wider distribution of highly specialised medical health

care throughout the entire country. The remodelling of more “Local Level Hospitals” into

“Highly Specialised Medical Care Hospitals”, unlike Scenarios 1 and 2, would require in-

creased coordination efforts.

NHMP


Scenario 4: “Combined care”

NHMP


Scenario 4 is a four-level system structure - local, specialised, highly specialised and maxi-

mum medical care. In addition, the existing small rural hospitals (so called Transit Hospitals)

are necessary to provide local hospital care to the population up until the complete fulfilment

of the NHMP in 2018. Both “Local Level Hospitals” and “Specialised Medical Care Hospi-

tals” offer local patient healthcare. The specialised functions of the Balti, Chisinau and Cahul

centres remain unchanged.

Because of its variability, this model offers the best opportunities for responding to changes in

circumstances during the course of the NHMP. The decentralisation and relocation of many

services to local centre areas could lead to minimised central demand and therefore a reduc-

tion of cost-intensive areas in the hospital system. This would be a benefit for the economy

and in the interest of the whole society. On the other hand the effective use of existing struc-

tural and medical resources, high cost-effectiveness and efficiency could be provided. By im-

proved specification, higher coordination efforts would naturally be required, as compared to

Scenarios 1 – 3. In addition, better provision of care will be available, especially for rural dis-

tricts.

In the interest of providing optimal treatment units, grading of the local level hospitals would

be conducted. In order to avoid closing down the small uneconomically run hospitals, such

hospitals would be converted into “Transit Hospitals”. This transformation would mean that

patient care would be provided by locally resident visiting doctors and specialists. The Transit

Hospital itself would be managed centrally within the zonal structure of the country and com-

pared to other hospitals they will require minimal doctor and care services, depending on the

qualifications and availability of the local attending doctors. Functionally, the Transit Hospi-

tal would ensure that risk patients receive professional primary care, and would allow for the

transferral of the patient to another hospital for further treatment or treatment as an out-patient

upon diagnosis, as required. By introducing the Transit Hospitals, the long-term survival of

the existing small hospitals under the zonal administration could be guaranteed and can be

developed through general changes in economic, structural and transport conditions.

Compared to all other scenarios scenario 4 with increased differentiation would require higher

investments in comparison to Scenarios 1 and 3, but financial expenses would be lower than

compared to Scenario 2, as investment needs of the “Transit Hospitals” would not be as high

as those of the “Local Level Hospitals” (tasks of the hospitals: see in chapter 4.3.2).

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Based on the previously mentioned decision-making principles, this scenario requires further

vertical differentiation, leading to increased long-term economic efficiency and effectiveness

of the hospital system. As Scenario 4 implies the largest deviations and differentiations, in

comparison to the previous hospital structure in Moldova, it can be assumed that there would

be relatively large resistance in administrative relationships and opposition may also be ex-

pected from other interested parties. Reconciliation and persuasion would be estimated on a

high level; however this scenario also offers, as already indicated, the optimal future sustain-

ability of the entire system.

4.1.4. Comparison of the scenarios

All four scenarios which were developed as alternatives for the new Moldovan system of

acute care provision differ in various goals.

For the purpose of comparing all four scenarios, two blocks of goals were developed. The

first block covers goals concerning healthcare provision and quality of care while the second

block contains economic goals, including investment costs and costs for personnel. Each goal

was evaluated on a seven-step ordinal scale ranging from "+++" to "---". In total 11 goals

concerning healthcare provision and quality of care as well as 6 economic goals were evalu-

ated. Each scenario was valued on the scale for goals of healthcare provision and quality of

care and the scale of economic goals separately.

The goals of healthcare provision and quality of care were defined as:

1. Decentralisation of special care to healthcare zones

2. Bundling healthcare provision within healthcare zones

3. Development of cross-sectoral healthcare provision networks

4. Unrestricted access to care

5. Reducing intensity of service provision in Chisinau

6. Securing provision of emergency care

7. Ensuring good working conditions for medical personnel

8. Generating indirect positive effects for rural Moldova

9. Reducing travel times for patients

10. Provision of medical training

11. Ensuring high quality basic medicine

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The economic goals were defined as:

1. Little need of investments into the system

2. Low costs of coordination

3. Low operating costs

4. Secured long-term financing of the system

5. Generating indirect positive economic effects for rural Moldova

6. Efficient use of medical resources

Overall no single scenario is superior to the other scenarios as far as these goals are con-

cerned. With regard to the goals of healthcare provision and quality, the score for scenario 1

in particular was inferior to all other scenarios. The analysis resulted in low scores for almost

all goals out of this block except for the goal "securing provision of emergency care", where

scenario 1 scored just as well as scenario 3. Scenario 4 scored higher in the goals 1, 3, 4, 5

and 6 (see figure 14) while scenario 3 scored higher in the goals 2, 7, 8, 9 and 10. Thus sce-

nario 4 would be superior in the event that decentralisation of special care to the healthcare

zones, the development of a cross-sectoral healthcare provision network and securing the

provision of emergency services are thought to be the most important goals. Generally scenar-

ios 3 and 4 scored almost equally with regard to the goals of healthcare provision and quality

of care.

Scenario 1

Scenario 2

Scenario 3

Scenario 4

Goals of Healthcare Provision and Quality of CareGoals +++ ++ + 0 - -- ---1. Decentralization of special care to healthcare zones

2. Bundling health care provision within healthcare zones

3. Development of cross-sectoral healthcare provisionnetworks




7. Ensuring good working conditions for medicalpersonnel





Scenario 1

Scenario 2

Scenario 3

Scenario 4

Scenario 1

Scenario 2

Scenario 3

Scenario 4
































Figure 14: Scenarios 1 - 4: Goals of healthcare provision and quality of care

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Scenario 1 also received relatively low scores for the defined economic goals (see figure 15).

Especially the scores for "low operating costs" and "secured long-term financing" are inferior

while scenario 4 scored higher than all other scenarios with regard to these goals. Generally

scenario 4 received the best scores for almost all economic goals. Only the goal "low cost of

coordination" scored relatively low for scenario 4. While scenario 3 received relatively high

scores for the first block of goals it received rather low scores for the chosen set of economic

goals. Thus scenario 4 is superior concerning the set of economic goals.

Figure 15: Scenarios 1 - 4: Economic goals

As described in Part 4.1 the four developed scenarios differ in many aspects. Using an overall

perspective on both sets of goals, scenario 4 scored best out of all scenarios, followed by sce-

narios 3 and 2 while scenario 1 scored lower than all other scenarios.

Investment costs at first seem very high, but they are incurred only once, unlike the personnel

costs which burden the budget (whoever will pay for it) every year. The largest differentiation

between service levels is included in scenario 4, so this has been taken as the basis for the

determination.

It makes most sense to judge investments by calculating average values based on costs per

bed. This means that all costs of the hospital (investment or running costs such as e.g. person-

nel) are converted to the unit of the number of beds. So this amount “costs per bed” does not

only figure out the costs of the bed itself, that is the least part of it, but it includes part of all

investments that are necessary to make a hospital function: new buildings, renovations, eleva-

Scenario Scenario

Scenario 3Scenario 4

Economic Goals Goals +++ ++ + 0 - -- --- 1. Little need of investments into the system

2. Low costs of coordination

3. Low operating costs

4. Secured long-term financing of the system

5. Generating indirect positive economic effects for rural

Moldova 6. Efficient use of medical resources

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tors, technical and medical equipment etc.. All costs are measured in today’s prices, because

especially for the actual imponderables a forecast over 10 or more years seems too unreliable.

Based on the calculations in appendix 8 (determination of costs per bed) investment costs per

bed amount to:

Local Hospitals 65.000 € per bed

Specialised Care Hospitals 86.000 € per bed

Highly Specialised Care Hospitals 99.000 € per bed

Centres of Excellence 104.000 € per bed

This calculation would not be applicable to Transit hospitals because these hospitals are to be

divested from the hospital system and therefore only minimum investments would be needed

to keep care upright. These were estimated at

10.000 € per bed.

Based on this data it is possible to calculate investment costs for the different scenarios by the

number of beds per level, total number of beds are not different. The personnel costs can be

calculated in the same way (see data in the “allocation plan”, appendix 2 and 3).

Scenario 1 consists of only two levels of care. This means on the one hand, that (like today’s

legal situation) local hospitals should have no more than only 4 medical departments, (general

medicine/infectious diseases, surgery, paediatrics, gynaecology/obstetrics); on the other hand,

all cases with more than average requirements would have to be treated in centres of excel-

lence. As explained in appendix 9 “Financial comparison of scenarios” this would require

4,908 beds in centres of excellence plus 10,007 beds in local hospitals. This means the highest

investments in centres of excellence. Also in this scenario, important investments have to be

made, as this is the only way in which Western European standards in buildings, therapy and

equipment can be achieved.

Besides this, as a relatively large number of personnel would be required in centres of excel-

lence, the running costs for personnel related to the other scenarios are considerable.

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As also shown in appendix 9 (“financial comparison of scenarios”) Scenario 1 requires

Investment costs 1,160,880,000 €

Personnel costs p.a. 62,608,000 €

Scenario 2 consists of three levels of care. Hospitals for specialised care could take the less

complicated cases, which would otherwise be treated in high specialised hospitals. Only com-

plicated cases that would overburden specialised care need to be treated in centres of excel-

lence.

As explained in annex 9 “Financial comparison of scenarios” this would require 4,183 beds in

centres of excellence, plus 4,325 beds in specialised care hospitals and 6,407 beds in local

hospitals. As quite a lot of hospitals would have to be “upgraded”, investment for this solu-

tion would be high, on the other hand, running costs for personnel would be lower than in

Scenario 1, because not so many people are employed at centres of excellence.

As shown in the appendix, Scenario 2 requires



Scenario 3 also consists of three levels of care, but “highly specialised hospitals” could take

more of the difficult cases, additionally there are more specialisations in these hospitals. So as

explained in appendix 9 this would require 3,458 beds in centres of excellence, 3,250 beds in

highly specialised care hospitals and 8,207 beds in local hospitals. In this scenario less hospi-

tals would have to be “upgraded”, but to a higher level of medical competence and equip-

ment. Therefore, the necessary investment would be slightly lower than in Scenario 2, how-

ever running costs would be the highest.

As shown in the appendix Scenario 3 requires



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Scenario 4 finally consists of four levels of care, as the “Transit Hospitals” in the long run

will be taken out of the acute medical treatment for the population, but as explained in chapter

6.5, will require special tasks as long-term care, rehabilitation, and social cases etc.

At the moment infrastructure in Moldova is not at the same level as Western European stan-

dards. The Transit hospitals have to provide basic care for an intermediate time period until

they are no longer needed for that purpose. However with the progression of welfare and

medical improvement in the country one can assume that the number of beds will be further

reduced in the long run. This will have the most important effects on the future personnel

costs.

As explained in appendix 9, Scenario 4 will require 3,458 beds in centres of excellence, 1,450

beds in high specialised care hospitals, 3,600 beds in specialised care hospitals and 4,665

beds in local hospitals. 1,742 beds will be located in Transit hospitals that, as declared, can be

attached to other benefits for the population.

In this scenario throughout all medical levels only the effectively required number of beds is

foreseen, thus an economically optimal care can be reached.

This is also shown in the cost situation as follows

As shown in the appendix Scenario 4 requires



Scenario 4 represents the economically and medically optimal solution for the hospital

healthcare aspects in Moldova because all required services are fulfilled on the lowest possi-

ble and adequate level. Equal access and cost-efficient treatment are secured.

In addition to the amount for building investment and annual personnel, costs for maintenance

of medical and technical equipment would have to be included. As these costs can be re-

garded as proportional to the investment amount, they do not influence the relation between

the scenarios, so they can be neglected at this point.

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These costs (like the costs for personnel) have to be refinanced by the cash budget of the run-

ning system. (see chap. 5.1 – 5.4).

4.1.5. Recommended Organisational Structures in the Healthcare Zones

Based on the task of guaranteeing improved and equal access of the population to quality

hospital care services for all citizens, the consultant recommends a vertical structure for the

administration as follows (see: “Diagram of Organisational Structures for Hospitals in

Moldova” at the end of this chapter).

The Ministry of Health has to prepare legislation and make fundamental decisions and

changes of guidance.

This concerns especially

• The decision to build a horizontal structure as proposed

• The preparation of the legal necessities

• The establishment of a common health insurance fund and the decision about the

method of financing it (tax financed or financed by contributions or a combination of

contributions with benefits for special groups, for example, retirees)

• The control of medical and economic results of the hospitals by means of a monitoring

system

• The fixing and updating of a requirement plan for the zones and hospitals as a basis

for all promotion of investments based on the monitoring results

• Heading the regular negotiations between healthcare insurance funds and the hospitals

about costs of therapy, refunding of expenses, etc..

As explained in chapter 4.1.6.2, the consultant recommends installing a steering committee to

integrate the national aspects of hospital services. In each zone a Healthcare Council shall be

established. These district healthcare councils are important for the coordination of invest-

ments and decisions about district priorities. The coming together of all shareholders in the

healthcare sector combines actions, visions and definite measures. The zonal Healthcare

Councils form the link between the Ministry and the hospitals.

The Healthcare Councils are made up of representatives from

• Ministry of Health

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• Townships in the Zone

• Hospitals

• Other providers in the healthcare sector

Their main tasks are to:

• Build consistent cooperation between the ministry and hospitals

• Guide the use of the investment capital within the zone

• Introduce zonal interests to the nationwide decisions

• Introduce and balance local interests in the zonal decisions

• Introduce and balance functional and economic aspects of different providers in the

zone

• Elect the chief executive officer (CEO) for the hospital.

In each healthcare zone the existing hospitals should be assembled under one zonal admini-

stration, which is managed by a chief physician and by an administrative CEO. Hereby, syn-

ergy effects in contrast to local administration could be optimised.

This means in detail:

• Common administration and organisation

• Common use of resources (technology and staff)

• Common supplies.

All hospitals services could be synchronised, and cooperation instead of competition would

lead to better service. It is essential for good functionality that the created zones are of about

equal size with regard to population, area, economic and social comparability (see 4.1.2). An

adequate infrastructure has to be provided to make cooperation effective.

The proposed Two-Leader-Model for the healthcare zones combines economical and medical

expertise while ensuring a minimum bureaucratic burden. Good cooperation between Hospital

Chief Physician and CEO for each healthcare zone is crucial.

The situation at Balti and Cahul differs from the rural conditions because these hospitals as-

sume central functions for the complete North and South of Moldova, respectively. As highly

specialised hospitals, they provide all special therapies except specialties that occur so sel-

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dom; excellent therapy is provided by university hospitals. Besides this, the quantity of beds

is sufficient to create single administration.

At Chisinau the creation of a University Centre will suggest creating a common management

for all hospitals included as well as one for all local (municipal) hospitals. Many of these hos-

pitals would each have a considerable number of beds and patients - different from the situa-

tion in the rural zones.

Therefore the common administration for the university centre as well as for the municipal

hospitals may be reduced to main aspects such as the CEO-tasks like

• Quality management

• Legal aspects

• Personnel

• Business strategy

• IT and communications

• Finance and controlling

• Patient management and medical controlling

• Central purchasing, logistics

Concerning medical aspects, the centralised function of an executive hospital chief physician

would probably mean too much distance and abstraction between the interests of the depart-

ments and the deciding board. Therefore, to build an adequate partner for the CEO, the execu-

tive hospital chief physician should be one of the heads of the medical departments (primus

inter pares), but the medical aspects of the subjects should be regulated by the chief physi-

cians at the clinics. There is no question that the responsibility for therapies always remains

with the physician. We recommend that the executive hospital chief physician should be regu-

larly elected by the board of chief physicians of the departments (a mandate of 2 years seems

approved and is recommended). Thus, an equivalent representation of medical and economi-

cal interests is secured. The permanent occupation of the position by a once-elected person, as

foreseen by the existing prescription is not recommended from the view of the consultant be-

cause by this a permanent preferential treatment for special hospitals is more probable.

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In addition, not forgetting that the National Health Insurance needs a strong counterpart on

the side of the hospitals, the consultant recommends that a hospital federation be established

as explained in chapter 4.1.6.

As already mentioned, the National Health Insurance will be one of the influential partners in

the hospital system. Contracts between the insurance (possibly also additional private insur-

ance companies) and the hospitals have to be made according to the chosen hospital system.

The health insurance system will also be necessary as a regulating element for access to hos-

pital services. This can, for example, mean that the doctors will be committed to send patients

to local hospitals if specialised treatment is not necessary.

As long as the hospitals are not yet able to earn their running costs by covering their expenses

from insurance or private patients, it would be necessary and useful if the Government were

to make decisions regarding investments and cost management.

Ministry of Health

Healthcare Councils for each zone

(communal representatives)

Hospital Chief Physician CEO

Finance & Controlling

Human Resources

Patient Management &

MedicalControlling

Business Strategy

LogisticsIT & Communications

Chief Nurse Department A

Chief PhysicianDepartment A

Chief Nurse Department B

Chief PhysicianDepartmet B

Chief Nurse Department D

Chief PhysicianDepartment C

Chief Nurse Department A

Chief PhysicianDepartment A

Chief Nurse Department B

Chief PhysicianDepartment B

Chief PhysiciansDepartment C

Chief PhysicianDepartment C

Hospital 2Hospital 1

QualityManagementLegal

Diagram of Organizational Structures for Hospitals in Moldova

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4.1.6 Legal consequences

In order to put the positive results of the NHMP into effect step by step, it has to become clear

how these changes need to be implemented. The basis for a process of change is a rule, regula-

tion, law or order which everyone can rely upon and on which any further steps can be built.

4.1.6.1 Present situation: Legal framework

Several laws, governmental decisions and ministerial orders form the legal basis for health pro-

tection in the Republic of Moldova. The most important are:

- Law of health protection No. 411-XIII from 28.03.1995;

- Law about the mandatory medical insurance No. 1585-XII from 27.02.1998;

- Law about the size, the way and the terms of payment of premiums of mandatory medical in-

surances No. 1593-XV from 26.12.2002;

- Law about implementation of mandatory medical insurances and creation of funds of manda-

tory medical insurances for the year 2003 No. 264-XV from 26.06.2003;

- Law about pharmaceutical activity No. 1456-XII from 25.05.1993;

- Law about medications No. 1409-XIII from 17.12.1997;

- Law about the evaluation and accreditation in health No. 552-XV from 18.10.2001;

- Law about sanitary-epidemiological insurance of population No. 1513-XII from 16.06.1993;

- Law about organ transplants and human tissues No. 473-XIV from 25.06.1999;

- Law about blood donation No.1458-XII from 25.05.1993;

- Governmental Decision No. 950 from 07.09.2001 about foundation of the National Company

of Medical Insurances;

- Governmental Decision No.43 from 21.01.2002 for approving the Regulation about conditions

of mandatory medical insurance for foreign citizens and stateless persons who are in the Re-

public of Moldova;

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- Governmental Decision No. 594 from 14.05.2002 for approving the Regulation about the es-

tablishment and administration of mandatory medical insurance system funds;

- Governmental Decision No 1128 from 14.10.2004 about the elaboration and implementation

of the automatic informational system “Mandatory medical insurance”;

- Governmental Decision No. 1128 from 14.10.2004 about approving the Concept of the Inte-

grated Medical Informational System;

- Governmental Decision No 487 from 19.06.2001 about approving the national plan of action

for health in relation with environment;

- Governmental Decision No. 1235 from 22.12.1998 about the national programme of oral

health for children for years 1998-2007;

- Governmental Decision No. 1000 from 28.09.1998 about the national programme of education

for population health and promotion of healthy living;

- Order of the Ministry of Health about perfection of activity regarding sanitary authorisation of

objects No. 07.00 from 30.10.00;

- Order of the Ministry of Health about the plan and the programme of actions for the restructur-

ing of hospital services in Chisinau and the organisation of Specialised Performance Medical

Centres No. 15 from 27.01.2003.

For the NHMP some of these regulations are more important than others (see bold ones above).

4.1.6.2 Hospital Law, Legal development

In spite of the fact that some issues (especially concerning health insurance finance - see 4.1.7)

are established by law, there are still several fundamental topics open to short-notice changes.

This may be convenient on the one hand (flexibility and quick adaptation to changing circum-

stances by new policy). On the other hand, does a stable basis provide better grounds for system-

atic development of an existing structure? It is much more challenging to improve an ever-

changing basis than having a perhaps small, but strong foundation to build on.

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The Institutional Development Plan 2009-2011 of the Ministry of Health reveals policy docu-

ments planned for the near future some of which might be relevant and important to the creation

of a hospital law. The following drafts are to be understood as part of the regulation and coordi-

nation of the healthcare institutions of the integrated healthcare system:

- Draft normative act on the creation of the fund for compensation of damages caused to pa-

tients during healthcare service provision;

- Draft normative act on General Hospital Plan;

- Draft normative act on the Public-Private Partnership Development in the Healthcare System;

- Draft normative act on the Regulations for selecting patients for expensive treatments abroad;

- Draft normative act on the Palliative Service Regulations;

- Draft normative act on the Regulations for conducting prevention, diagnostic, treatment and

rehabilitation clinical studies;

- Draft normative act on the Diabetology Service Regulations;

- Draft normative act on the approval of standards for the provision of community-based and

home care and palliative healthcare services.

Item two in particular could be a starting point for a hospital law. But the point is that the consti-

tution of Moldova, and so the parliament, requires health to be regulated by organic law. Organic

laws form the foundation of a government and consist of a number of fundamental regulations

that have constitutional force and overrule subordinated laws.

Therefore it could become difficult, and even impossible, to establish a separate regular hospital

law. All fundamental issues have to be integrated into an existing organic law like No. 411 (law

on health protection).

To prepare the legal necessities it would be very helpful to establish a hospital committee in the

Ministry of Health, consisting of experts from the ministry and external advisors. This should be

responsible for the development of inpatient/hospital services.

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1. The hospital committee should be able to function, should be manoeuvrable, agile and ef-

fective, following the idea of a guidance committee.

2. Out of a bigger, more strategically oriented group, a smaller operational working group of

up to 5 people should be nominated. The working group should meet regularly and have

very close communication with the guidance committee, which can meet on demand, oth-

erwise perhaps three times a year.

3. The hospital committee should certainly be involved in all topics related to hospital and

inpatient services in order to ensure that one concerted direction is being followed by who-

ever intends to support inpatient services in Moldova.

The hospital committee would be the perfect institution to discuss complex and fundamental is-

sues like a hospital law. Due to the broad experience, function and expertise of the committee

members – and here especially the national ones are important– such an issue will have the re-

quired background.

With the establishment of a strong health insurance and the results of the NHMP, the need to cre-

ate an appropriate counterpart on the side of the hospitals becomes more and more important.

A hospital federation is usually not a big administrative entity. In fact, is it a small but competent

and helpful unit for the hospitals of the country. It supports the hospitals on all levels with regard

to legal advice, strategic considerations, financial and budgetary responsibilities (consultancy for

preparing the negotiations with CNAM - National Health Insurance). It is also concentration

power and a democratic means of shaping political opinion. A hospital federation represents its

members, takes action and exercises influence on important topics for the hospitals. It is also fi-

nanced by its members.

The establishment of a hospital federation would be an essential point for a hospital law.

All the specific details need to be discussed and decided on before establishing or rather amend-

ing a law.

Proceeding on the results of the NHMP, smaller aspects can then be considered and a stable legal

basis for inpatient services developed.

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In addition the structure, tasks and responsibility of the zonal healthcare councils have to be

fixed by law.

4.1.7 Hospital Financing

4.1.7.1 Present situation

Today there is a dual financing structure for hospital services in Moldova. Services expenditure is

paid for by the National Health Insurance (CNAM), whereas infrastructure investment, new

buildings and technical equipment are financed by the government. In the case of the hospitals at

republic level, it is the Ministry of Health, for municipal and district hospitals it is the local pub-

lic authorities.

Before the introduction of National Health Insurance in 2004, hospital services were exclusively

financed by the local authorities. After 2004 the laws 847 (latest version from 2007) and 397 (see

chapter 4.1.6 ff) were updated and as a result the local authorities basically remained in charge of

the infrastructure finance assignment but lacked the resources for proper funding. Their own

budget is far too small.

A modification of law 847 made direct co-funding possible (inter-budgetary relations between

state and local budgets). In practice, the local authorities calculate their demand for the upcoming

year and apply to the Ministry of Finance for funding. The Ministry of Finance then allocates a

determined sum (approximately 1 million Lei per year per district, overall about 3.9 million €

p.a.). In this context, the Ministry of Health has a monitoring function, making sure that the funds

are not used for other purposes.

Still the problem of inadequate funding remains. Based on the idea of centralised funding and

referring to a government decision of the year 2006, the Ministry of Health has started co-funding

the hospitals of three selective pilot districts in Moldova (Calarasi, Glodeni, Ciadir Lunga). The

funds can only be used for technical equipment and the amount is restricted.

In a very few exceptional cases and very much dependent on the inter-personal relations of the

decision makers at the local authorities, significant investments in hospital infrastructure could be

implemented. Still, for the majority of the Moldovan municipalities, all sources of funding

(budget of the local authority itself, funding from the state budget - Ministry of Finance, selective

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funding by Ministry of Health etc.) provide only part of the amount needed for reconstructing,

reequipping and modernising the hospitals in Moldova.

The main current problem is the investment backlog, which has built up over the last decades. It

is normal to expect a basic renovation of hospitals every 20 to 25 years. This deficit cannot be

compensated by normal financial resources.

For example: In Germany investments for hospitals in the Eastern federal states were (within

1991 to 2000) promoted by the government with 43. bn €. The hospitals themselves invested

about 20 % in addition, making a total of 52 bn €. Applied to Moldova on the basis of the popula-

tion figures (80 million / 3.5 million), this would mean a required investment of 230 million €

p.a.

On the other hand: if the relation of the gross domestic product (GDP) (2,400 bn € / 3.23 bn €) is

taken as the measure it would mean an investment of only 7 million € p.a.

This comparison makes the gap between structural necessities and economic possibilities visible.

This justifies and emphasises the demand for financial support by the World Bank and other do-

nators. The purpose of such external promotion however, can only establish a solid basis of

buildings and medical equipment - the running costs must be refinanced by the system itself and

efficiency can’t be raised if technical necessities are missing.

4.1.7.2 Recommendations

First it is necessary to bring the hospitals up-to-date as regards the quality of buildings, technical

and medical equipment. Surely, as explained, this cannot work without external promotion. After

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

structure.

To avoid local double or lack of promotion, basic investments should be steered by the govern-

ment (steering committee, see 4.1.6.2). Only bigger investments like CT or MRI, which are cov-

ered by countrywide investment plans, may be promoted.

On the other hand, the hospitals need to be able to decide about lower-level investments indi-

vidually and in consideration of local aspects in order to stay flexible and e.g. use special qualifi-

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cations of the physicians. Therefore the zonal healthcare councils need be able to make financial

decisions for their zone too. Therefore annually a certain investment sum has to be provided for

the zones. All this just concerns investment.

It seems essential that running costs for operating the hospitals have to be covered by billing the

patients (direct payment by private patients for special services like 1-bed-room or refund of ex-

penses by compulsory health insurance). The system of calculation can be configured differently.

For example introducing a “symbolic fee” or “entrance-money” as e.g. exercised in Germany

does not mainly serve to limit unnecessary visits to the doctor but simply to reduce public costs at

the expense of the patients. The consultant therefore can not recommend this, already because the

expenses for charging are relatively high in relation to the results.

In most Western countries the DRG-system (Diagnosis related groups) seems to be becoming

established in the short to medium term and is used in different ways. In Germany it is used as a

full payment system for hospitals. By that hospitals are not paid for the length of stay of the pa-

tient, instead payment depends upon the co-morbidity of the patient as well as the classification

of difficulty of the necessary treatment. Additionally treatment which does not necessarily need

to be performed by hospitals was shifted to other forms like day-surgery. In this way it has been

possible to considerably reduce the length of stay (and costs) for the patients.

Besides this, e.g. target agreements between hospital management and chief physicians develop

additional opportunities for savings. These systems are developing internationally and have to be

observed and evaluated on a continuous basis.

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Figure 15a: Location of Hospitals in Moldova

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4.2 Estimating the Demand for Healthcare Services

One of the important tasks of the NHMP is to estimate the demand for public inpatient hospital

services in Moldova in 2018. In order to raise acceptance, the new NHMP has been set up in such

a way that implementation will take place in two phases - phase 1 will be finalised in 2013,

whereas phase 2 will be final in 2018.

A lot of assumptions had to be made in order to be able to integrate various aspects into the esti-

mation model, due to the fact that the data provided by local partners and the Ministry of Health

was rather vague. The model is described in the following chapter.

4.2.1 Description of the Approach

Each hospital in Moldova is classified according to the structures described in chapter 4.1., which

is based on the approach of four different healthcare service levels, where economical and high-

quality medical services are required. In order to identify the future size of each hospital, the bed

capacity and the medical spectrum of all Moldavian hospitals were analysed, as far as data was

available. In addition, medical trends and consequences of the changes in the financing system

were drawn upon and considered for the final conclusion. On hand there are trends in diseases

treatment, e.g. more minimal-invasive techniques in surgical procedures, or changing in anaes-

thesia as well as in aftertreatment-care with the option of treating elderly, as well as the develop-

ment in pharmacological active substance for different diseases like Parkinson's diseases. Follow-

ing these changing and respecting the knowledge of the medical departments a large diversifying

took place in between the last 20 years. On the other hand trends in the kind of medical supply

changes from inpatients to outpatients care and ambulatory care, this means ambulant treatment

as many as possible also for outpatients procedure and less hospital care (ambulatory preliminary

hospital care).

Base data for the estimation of demand were the F-30 documents dated 2007 provided by the

local project leaders. These documents showed the distribution of beds and cases per medical

speciality as well as the average hospital stay and the complications for every hospital in

Moldova, though complications were not defined in detail. Following the basic idea of building

administrative healthcare zones - as described above - and based on the estimation on a per-zone

view, the focus on single hospitals is eliminated. Exceptions were made for Balti and Cahul

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which were classified as single hospitals and Chisinau which was categorised as one healthcare

zone.

Estimations were also performed by medical department. In detail these are the departments of

General Medicine / Internal Medicine, Cardiology, Pulmonary Diseases, Infectious Diseases,

Traumatology and Orthopaedics, Urology, Gynaecology and Obstetrics, Paediatrics, Neurology,

Ophthalmology, Otorhinolaryngology (ENT), and Dermatovenerology. Departments with less

number of patients like hepatology or stomatology which were not analysed in detail, but shown

in the F30documents, were mostly included in the departments of General Surgery or General

Medicine for this analysis. Special departments not subsumed in Internal Medicine for instance

are Gastroenterology or Pulmonology.

In 2007 a total of 538,840 cases and 16,342 beds were reported in the F-30 documents. Out of

these totals 264,337 (49 %) cases and 7,951 (49 %) beds were allocated to rural hospitals (every

hospital outside Chisinau but Balti and Cahul). The average length of stay was reported to be 8.2

days in total and varied between 7.4 days in healthcare zones 2, 7 and 8, and 9.3 days in Balti.

Zone Populationbed

capacity inpatient care days cases total

length of stay

Zone 1 263.700 985 227.406 29.135 7,8

Zone 2 321.700 1.015 236.902 31.920 7,4

Zone 3 284.500 1.089 265.837 32.463 8,2

Zone 4 264.200 775 229.275 29.509 7,8Zone 5 298.100 895 248.916 31.897 7,8Zone 6 240.300 930 208.891 27.299 7,7Zone 7 345.400 700 185.789 25.234 7,4Zone 8 165.400 512 129.973 17.559 7,4

Zone 9 285.100 1.050 270.250 39.321 6,9

Chisinau 717.900 6.834 1.984.716 229.276 8,7

Balti 127.600 1.105 302.737 32.592 9,3Cahul 123.800 456 101.978 12.635 8,1

Figure 16: Beds, care days, cases and length of stay for healthcare zones in Moldova 2007

Source: F-30 documents

In rural Moldova the bed capacity per healthcare zone ranged from 512 (Zone 8: Causeni, Stefan-

Voda) to 1,089 (Zone 3: Drochia, Floresti and Soroca). 6,834 beds were allocated solely to Chis-

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inau (only hospitals subject to this analysis are included). The density of beds (measured as per

10,000 population) varied between 20.3 in healthcare zone 7 (Anenii-Noi, Ialoveni, Criuleni and

Straseni) and 38.3 in zone 3 for rural Moldova. Regarding international bed capacity one can

differ between 20 to 30 beds per 1. 000 inhabitants like Finland, Norway, turkey or Netherlands,

between 40 to 60 beds per 1.000 inhabitants like Belgium with an European average of 41beds

per 1.000 inhabitants.

The approach to estimate the demand for inpatient healthcare services in 2013 as well as in 2018

integrated various different assumptions in addition to specific medical data:

• Demographic and technical effects (like access to technical progress, infrastructural ef-

fects)

• General medical effects - including ambulatory potential

• A movement effect demonstrating that many patients who seek care in Chisinau today

will stay in their home district as quality of care improves in rural Moldova

• Cases for each medical department are distributed differently by level of care

• Since Maximum Care is only provided in Chisinau, Balti and Cahul, the respective cases

have to be distributed to one of these hospitals

• In order to calculate the amount of beds needed, the average length of stay and utilisation

are assumed per medical department.

Based on data published by the United Nations (UN) (Source:

http://www.unhabitat.org/habrdd/conditions/easteurope/moldova.htm) the growth of the popula-

tion by 2018 had to be estimated differently depending on the living area (rural vs. urban). Chisi-

nau, Balti and Cahul were defined as urban areas. Following the UN-data the population in the

cities is supposed to grow by 15.4 % while the rural population will decrease by 6.6 % by 2018

(8.4 % and -3.6 % for 2013, respectively). Today Moldova's population is relatively young but

life expectancy is constantly increasing and many people tend to move back to the country as

living conditions improve. In general older people require more healthcare thus we estimated the

increase of inpatient cases due to the aging of the population to be 2 % per year.

Improvement in medical technical infrastructure and the quality of inpatient healthcare provision

will encourage those patients to use the hospitals close to where they live who so far had sought

care elsewhere (e.g. Chisinau) or were not / could not be treated. General research and experience

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showed that this trigger effect is able to increase the demand for inpatient healthcare services in

rural hospitals substantially, leading to a yearly increase of around 5 %. In Western European

countries the change from the surgical open technique in the 1980’s to the endoscopic technique

as today's standard for cholecystectomy, for example, led to a reduction in the average length of

stay. Another example is the minimal invasive arthroscopic technique which induced the ambula-

tory surgery of meniscus injury.

In general two medical effects lead to decreasing inpatient care. The first is ambulatory potential,

meaning patients who have so far been treated as inpatients will or should be treated as outpa-

tients. This trend can be seen in most Western European countries especially in cases of basic

surgery where the patient is sent home right after surgery without an overnight stay in the hospi-

tal. The number of cases in Moldova treated in this way up until now is minor. The expected am-

bulatory potential is to be 5.5 % today. A constant increase of 7.5 % per year was recognised

within the analysis. Specific national and district assumptions, e.g. general infrastructure and ac-

cessibility, were taken into account. In total the ambulatory effect is estimated to lead to a de-

crease of inpatient cases of 7.7 % by 2013 and a decrease of 11.1 % by 2018.

The second effect showing a negative trend in inpatient cases is the decreasing prevalence of the

Moldovan people. Recent medical data estimates the prevalence to decrease by 0.3 % per year.

Assuming an arithmetical development this will lead to a decrease in cases by 1.5 % by 2013 and

2.8 % by 2018.

Another demographic and general effect is the migration effect inside the country leading to dif-

ferent demands on healthcare services throughout the country. We estimated this to be around

1 % of the rural population moving to the cities.

The sum of all effects accounts for an estimated increase of cases in the cities of 31.5 % and of

19.5 % in rural Moldova by 2013. By 2018 the increase of inpatient cases is estimated at 57.8 %

in the cities and at 35.8 % in rural Moldova.

In addition to these basic assumptions the estimations of future demand include some further as-

sumptions which reflect specific aspects of the situation in the Republic of Moldova. They reflect

the Republic's economic and social centralisation in Chisinau and the resulting habits of the

population, as patients tend to travel to Chisinau to seek care instead of consulting hospitals

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which are located close to where they live (effect represented by the movement effect and the

distribution of maximum care cases to the Centres of Excellence).

The movement effect estimated how many cases will be treated in rural hospitals which are today

treated in Chisinau or Balti because of insufficient treatment possibilities in the districts. Based

on the results of the site visits and the interviews with local experts this number of cases is esti-

mated to be 30 % of today's cases treated in Chisinau and Balti, referred to all patients and hospi-

tals regarded for this study. Since the patients who will seek care back in their home districts are

distributed unequally throughout the country, a ratio was developed for each healthcare zone de-

termining how many patients will go back to each healthcare zone. In general the assumption is

made that the closer the zone is to Chisinau and / or Balti, the more patients receive medical

treatment in these cities nowadays and thus the more patients will go back to their home districts

the closer the respective healthcare zone is located to Chisinau / Bali. For example; healthcare

zone 5 (Orhei, Rezina, Soldanesti and Telenesti) is located relatively close to Chisinau and fur-

ther away from Balti. Therefore the ratio of those cases which will move back to zone 5 from

Chisinau was set to 22.5 % (of the above mentioned 30 %) and for those which will move back

from Balti to only 2 %. The following table displays the assumed percentages and cases for the

movement effect.

% abs.Chisinau 30,0% 68.783

Balti 30,0% 9.778

1 2 3 4 5 6 7 8 9Chisinau 3,5% 4,5% 8,0% 19,0% 22,5% 22,5% 10,0% 10,0% 0,0%

Balti 12,0% 12,0% 55,0% 19,0% 2,0%

1 2 3 4 5 6 7 8 9Chisinau 2.407 3.095 5.503 13.069 15.476 15.476 6.878 6.878 0

Balti 1.173 1.173 5.378 1.858 196 0 0 0 0tot. 3.581 4.269 10.880 14.926 15.672 15.476 6.878 6.878 0

% of cases that will be treated within the rural zones 1 to 9

cases to be treated in rural hospitals

Movement Effects

amount of cases that will be treated wihtin the rural zones 1 to 9

Figure 17: Assumptions of the Movement Effect

All analysis was done distinguishing between three different levels of care: basic care, special-

ised care and maximum care. Basic diagnostics and therapy using general methods and basic

standard knowledge is provided on the basic care level, usually within the departments of Gen-

eral Medicine, General Surgery, Gynaecology & Obstetrics as well as Paediatrics. Specialised

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care is provided using well established more complex diagnostics and therapy in more specialised

medical departments with more specialised staff (see figure 18). Maximum care will only be pro-

vided in Chisinau (Centre of Excellence and / or University hospitals), Balti and Cahul using

highly specialised methods and technologies and expert medical staff. The following table dis-

plays the assumed allocation of levels of care by medical department as a rough overview.

14.09.2009 11:41 TOP Consult Köln GmbH

Basic Care

Diagnostics & Therapy

Specialized CareMaximum Care /

Centers of Excellence (CE)

Expert-knowledge

Medical Departments

Basic diagnositcs & therapy (ECG, general

methodologies)

Basic standard knowledge in general

departments

General Medicine, General Surgery,

Gynecology / Obstetrics, Pediatrics

Well-established standardized diagnostics and therapy (Endoscopy,

echocardiography, minimal-invasive

technics)

Medical knowledge in specialized fields needed

Basic Care plus additional medical

profiles

Highly-specializedmethods and technologies(CT; cardiac-catheter, and

others , partly in developement)

Experts and researchers needed for innovative

methods (CE)

Highly-specialized Care plus special medical

profiles provided by CE only

Figure 18: Definitions of levels of care

General Medicine

Cardi-ology

Gastro-ente-

rologyPulmono-

logyInfectious Diseases Surgery

Trauma & Ortho Urology

Gyn / Obstetrics Pediatrics

Neu-rology

Ophthal-mology

Otolaryn-gology

Dermato-vene-rology

Basic 55,0% 55,0% 55,0% 50,0% 60,0% 60,0% 40,0% 60,0% 55,0% 40,0% 20,0% 45,0% 40,0% 10,0%Specialized 35,0% 35,0% 35,0% 40,0% 30,0% 30,0% 50,0% 30,0% 35,0% 50,0% 50,0% 35,0% 50,0% 75,0%Maximum Care 10,0% 10,0% 10,0% 10,0% 10,0% 10,0% 10,0% 10,0% 10,0% 10,0% 30,0% 20,0% 10,0% 15,0%

Percentage of Level of CareDistribution of Cases by Level of Care

Figure 19: Distribution of cases by care level and medical department

Since maximum care will only be provided in Chisinau, Balti and Cahul, the estimated demand

for maximum care in each healthcare zone was distributed to the providers of maximum care in

these cities. The assumptions used to distribute maximum care cases follow a similar approach as

was used with the movement effect. The closer a healthcare zone is located to one of the cities

providing maximum care, the higher the ratio of maximum care cases which will be treated in

this district. For example; healthcare zone 5 (Orhei, Rezina, Soldanesti and Telenesti) is located

relatively close to Chisinau, further away from Balti and even further away from Cahul. There-

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fore an estimated 90 % of the maximum care cases out of this zone will be treated in Chisinau,

10 % in Balti and none in Cahul. The following table displays the assumed distribution of maxi-

mum care cases.

1 2 3 4 5 6 7 8 9Chisinau 40,0% 40,0% 40,0% 70,0% 90,0% 100,0% 100,0% 100,0% 10,0%

Balti 60,0% 60,0% 60,0% 30,0% 10,0% 0,0% 0,0% 0,0% 0,0%Cahul 0,0% 0,0% 0,0% 0,0% 0,0% 0,0% 0,0% 0,0% 90,0%

% of Rural Maximum Care treated in Chisinau, Balti & CahulDistribution of Maximum Care Cases to Centers of Excellence

Figure 20: Distribution of Maximum Care Cases to the Centers of Excellence

In addition to the described assumptions to estimate the demand for inpatient cases, assumptions

concerning the average length of stay and utilisation were used to derive the amount of beds

needed per medical department and healthcare zone. Both figures were derived separately for

each medical department over all care levels. An average length of stay of 6.2 days was assumed

and approved by data provided by the German Department for Statistics. Internationally, the av-

erage length of stay varies greatly depending on many aspects of the healthcare system, e.g. Is-

rael: 4.1 days, Azerbaijan: 15,5 days (Source: WHO Regional Office for Europe health for all

database). Utilisation was approached the same way and an average utilisation of 81.9 % p.a. was

assumed and approved by the data provided by the German Hospital Association. 365 care days

per year were assumed. This number of average utilisation also contains the emergency-beds.

Therefore a good degree of capacity utilisation can be defined at above 80 %. In Western Europe,

the utilization varies greatly depending on many aspects of the healthcare system, e.g. Turkey:

58,8 %, Israel: 93,0 %) (Source: WHO Regional Office for Europe health for all database).

All assumptions were integrated into the model to prognosticate future healthcare demand and

the results were calculated step by step. The results will be discussed in more detail in the next

chapter

4.2.2 Summary of Results

It is important to note that these theoretically calculated estimations of the amount of beds (re-

duced by 24 % in 2018 compared to 2007) will be enough to serve the estimated demand of inpa-

tient healthcare services in Moldova as long as the assumed average length of stay (6.2 days) as

well as utilisation (81.9 %) are met by the hospitals. According to the data the consultant re-

ceived, today Moldova provides inpatient acute care services for 539,000 patients using more

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than 16,300 acute beds, leading to figures for utilisation and average length of stay well below

the target efficiency which was assumed while estimating the need of beds.

Around 63 % of the so calculated beds will emerge in rural Moldova including Balti and Cahul.

Most cases will have to be treated in basic care (50 %) followed by 38 % in specialised care and

12 % in maximum care. Outside Chisinau, maximum care will only be provided in Balti and Ca-

hul.

Based on the provided data and the estimations as explained before almost 17 % of all hospital

beds are estimated within the department of General Internal Medicine and around 22 % of all

beds are estimated in General Surgery. The remaining hospital beds are within further medical

departments according to the model's assumptions. Around 60 % of beds are going to be neces-

sary outside Chisinau. Around 50 % of all beds are going to be required for basic care, 38 % for

specialised care and 12 % for maximum care. Maximum-care beds will only be provided in Chis-

inau, Balti and Cahul. The proportion of maximum-care beds in these cities is about 30 % (Ca-

hul), 68 % (Balti) and 24 % in Chisinau.

0 200 400 600 800 1000

HC-Zone 1HC-Zone 2HC-Zone 3HC-Zone 4HC-Zone 5HC-Zone 6HC-Zone 7HC-Zone 8HC-Zone 9

BaltiCahul

Basic Care

Special ised Care

Maximum Care

Figure 21: Estimated beds for inpatient hospital care in Moldova 2018 (without Chisinau)

The following allocation of beds to each hospital is generally based on the calculated demand but

takes different further assumptions into account.

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4.3. Recommendations for Hospitals

The main intention of the calculations for the NHMP is to provide affordable healthcare services

with a highly qualified medical service level and accessibility even for handicapped or elderly

people.

The following recommendations for the hospitals were calculated on the basis of the assumptions

for healthcare zones - as shown in chapter 4.1. Also assumptions were made on general effects

such as demographic and medical changes - shown in chapter 4.2. - as well as on the develop-

ment of cases from 2006 to 2007. According to the terms of reference as part of the contract and

to the client some additional assumptions have to be considered. For the recommendation of the

NHMP, the existing structure of hospitals, personnel and resources has to be included. Also the

change in direction must be gradually implemented step by step, in order to raise the acceptance

for the new master plan.

Initiated by a rather vague performance data base covering the last two years - provided by local

partners - all calculations are based on the number of beds. Cases are derived from the calculation

of beds whereas an average length of stay as well as average utilisation was predicted on the ba-

sis of international standards because there are inefficiencies in Moldova which mean that the

country has not yet reached comparability.

In most European countries theoretical calculations of hospital treatment are based on the Hill-

Burton formula, which originated in the USA in the 1960’s. The determinants in the formula are

inhabitants, length of stay, frequency of hospital use and utilisation of beds. In Germany various

modifications of the Hill-Burton formula are used, taking additional factors such as demographic

evaluation, a morbidity factor evaluated by experts or benchmark data into account. According to

the Hill-Burton formula calculation, cases, length of stay and utilisation of beds lead to required

beds for NHMP. As neither data for morbidity nor data for frequency of hospital use were avail-

able, these could not be taken into account. In general, hospital treatment is caused by the acute

illness of a patient, often independently of pre-existing diseases. In many cases, elderly patients

in particular have more than one illness. Besides treatment of the acute illness, additional existing

illnesses e.g. hypertension, diabetes or renal failure have to be looked after during the hospital

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stay. This so-called co-morbidity is reflected in the intensity of care and the number of medical

and nursing staff involved, and is finally manifested in treatment expenses.

Following the additional assumptions mentioned above a double tracked time line is developed.

An intermediate scenario up until 2013 and a final scenario (2018) are described (see chap. 4.1.)

4.3.1. Description of the approach

4.3.1.1Hospital structure

Economy of the healthcare system implies an appropriate use of synergetic effects. It means that

personnel and infrastructure capabilities are not wasted and encompasses the assumptions of the

healthcare service levels in the form of four different types of hospitals. Besides synergetic ef-

fects another strong aspect is to build Competence-Centres, looking for the total disease by dif-

ferent departments, so the patient gets the required therapy more quite in time with less length of

hospital stay and by that with reduced costs. Main focus for those Competence-Centres is for

example Gastroenterology / Visceral Surgery, Gynaecology / Urology / Neurology for inconti-

nence-disease in the genitourinary system, Traumatology / Orthopedics / Neurosurgery for back-

bone diseases, or Cardiology / Heart Surgery for coronary illness.

The definition is based on general, international criteria for different hospital structures. These

hospital types differ by hospital size or number of beds, by medical departments, by medical

technical equipment which influences the medical services and by available medical knowledge.

Based on economical aspects not each hospital has all different kind of special medical depart-

ment. In most European countries basic care is provided in small hospitals, specialised care in

larger hospitals and high-specialised care in Centre of excellence or in University hospitals. For

Moldova the consultant developed an individual hospital structure (see chapter 4.1.3.), which

provides an economic as well as high qualified medical service with access for everybody. All

types of hospitals have at least four basic departments, i.e. Internal Medicine, Surgery, Gynaecol-

ogy & Obstetrics, Paediatrics and provide mostly basic care and basic treatment. Transit Hospi-

tals and Local Hospitals offer basic treatment and basic care. Besides basic care and basic medi-

cal treatment Specialised Hospitals have in addition special departments such as Cardiology,

ENT, and Urology and accordingly more medical equipment. Highly Specialised Hospitals, Cen-

tres of Excellence and University Hospitals offer mostly specialised treatment. Patients who are

admitted to these types of hospitals are transferred to district hospitals - either local or specialised

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hospitals - once the highly specialised treatment is completed (see figure 22) like in many Euro-

pean countries. As a result, less basic care needs to be provided by these three types of hospitals

(Highly Specialised Hospitals, Centres of Excellence and University Hospitals). Some special

departments such as neurosurgery, cardiac surgery, transplantation surgery, oncology, rheuma-

tology or nephrology are not listed separately for the highly specialised hospitals and are an inte-

gral part of the Centres of Excellence or in so-called mono-profile hospitals in Chisinau.

For example: Cholecystectomy will be performed in local hospitals. If the bile duct also has to be

removed, patients will be treated in specialised hospitals. If the required treatment is the result of

a malignant illness, patients will be treated in highly specialised hospitals or Centres of Excel-

lence. Complementary treatment of the malignant illness will be performed in Centres of Excel-

lence / University hospitals. Another example is that of a severe cold, which will be treated in the

Internal Medicine department of the Transit or the local hospital, severe pneumonia in a patient

who has suffered an infarction within the past few months will be treated in a specialised hospi-

tal. Diagnostics of heart disease depends on the diagnostic intensity - basic diagnostics with ultra-

sound is performed in specialised hospitals, based on the medical equipment required, right-heart

catheterisation is performed in specialised and highly specialised hospitals and left-heart cathe-

terisation as well as heart rhythm surgery is provided only in Centres of Excellence / University

Hospitals.

Figure 22 shows the flowchart for the cooperation between the different hospital types. Espe-

cially this cooperation considers the co morbidities of the patients as described before.

Some special aspects need to be mentioned separately: Intensive Care and Intermediate Care are

not considered separately, because they have the same function - to care for a Patient who needs

at least more observation or who requires an artificial respirator and 24/7 care . The number of

beds for intensive-care-units (IUC) depends on medical criteria and on experience for those pa-

tients needing intensive-care. This means patient staying in the intensive care in a local hospital,

would not be at the IUC in a high-specialised hospital. IUC are expensive / cost-intensive units,

by that in the last 10 years Intermediate-Care (IMC) were established. IMC-units have mostly the

same medical technology like ICU, they differ by a lack on respiratory possibilities. By that per-

sonnel staff is less intensive as well as for nurses as for physicians. ICU has a physician 24/ 7

hours all over the year, IMC have different models depending the size of the IMC-unit. Besides

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this in most European countries special recovery-rooms have been installed. These recovery ar-

eas, where the patient stays for several hours, are specialised on after operation-procedures moni-

toring. The effect is a reduction of the required beds in intensive or intermediate care. In general

these departments have about 3 % each of all hospital beds, and are assigned to different depart-

ments depending on the patient's co-morbidity and treatment. Highly Specialised Hospitals, Cen-

tres of Excellence and University Hospitals should have both - Intensive Care and Intermediate

Care - depending on the patient's condition step-by-step care is possible. The distinction between

Intensive Care and Intermediate Care is made on the one hand on the basis of the treatment ac-

cording to the patient’s co-morbidity and the medical equipment and on the other hand on the

basis of the staff.

Increasing costs in healthcare in general and specially in hospital care utilisation of bed capacity

get focused. Consequently medical departments with a low utilisation of beds were subsumed in

superordinate centers respectively illnesses which do not require a special medical equipment are

treated in normal hospitals / medical departments. Examples are departments for Infectious dis-

eases or burn-units

Changings in hygienical circumstances will require less Departments for Infectious Diseases. By

that Departments for Infectious Diseases are only provided in certain specialised hospitals. These

departments have a limited number of beds for selected patients. In general the majority of cases

will be allocated to Internal Medicine, where the patients can be treated. For the contagious

phases of acute infectious diseases patients have to be isolated in a separate room. In any case

hygienic standards always have to be respected. In the event of an epidemic / pandemic threat a

total ward or a total hospital has to be isolated.

Departments for Geriatrics will be provided mostly in specialized hospitals and a few number of

beds in high-specialised hospitals as a centre of competence. Elderly patients require Depart-

ments for Geriatrics will be provided mostly in specialized hospitals and a few number of beds in

high-specialised hospitals as a centre of competence. Elderly patients requires hospital treatment

mostly with acute illness, most treatment can be done in the family centres. Following this most

of the treatment can be done in internal departments of the hospitals, only a few needs specialized

treatment in geriatrics. Also special geriatric rehabilitation after a long illness as to be integrated

hospital treatment mostly with acute illness, most treatment can be done in the family centres.

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Following this most of the treatment can be done in internal departments of the hospitals, only

few patients need specialized treatment in geriatrics. Also special geriatric rehabilitation after a

long illness has to be integrated.

For lack of Data some special institutes / hospitals were not analysed in detail. Among those are

special sanatoria for tuberculosis and a hospital for Narcology (a special withdrawal hospital) and

Psychiatry. All Hospitals according to contract were analysed. For some hospitals with special

tasks even at the end of the evaluation-period no or no usable data were available. Private hospi-

tals and hospitals of the different ministries are also not included in the analysis and recommen-

dations.

Most of the hospitals shall have their own blood bank. Smaller hospitals, which use blood preser-

vations more rarely, shall store a certain number of blood bottles and elements of blood e.g.

Thrombocyte, Fresh Frozen Plasma and others. Blood bottles which are not used should be re-

turned within a defined time period. A special transport service - depending on the basic neces-

sity of blood bottle changing - with a qualified transport system needs to be established.

Chemical laboratories will be available 24 hours only in specialised hospitals. Local and Transit

hospitals will have access to a blood gasanalyzer at night und during the weekends / holidays (see

details in chapter 5.3 and in the appendix 1).

The mapping of each hospital is reported in appendix 8.1.

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Figure 22: Flowchart showing path of patient through different hospitals and the collaboration of hospitals

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4.3.1.2 Allocation of beds

The allocation of beds is determined on the basis of international results published by the

WHO. The main criteria were the population including changes, existing hospitals and the

density of hospital beds per healthcare zone. To provide high quality healthcare service which

is accessible for every citizen and in accordance with the European-orientated quota, an aver-

age of 43.5 beds per 10,000 inhabitants is defined for Moldova in 2013. In 2018 this will de-

cline to 37.4 beds per 10,000 inhabitants. In comparison, Italy, Switzerland and the United

Kingdom all have 32 to 40 beds per 10,000 inhabitants.

The range of beds per 10,000 inhabitants for Moldova is between 26.7 (2013) / 18.6 (2018)

(Zone 7) and 79.9 / 61.1 (Balti). The high density of beds in Balti results from the function of

this hospital as a highly specialised hospital covering the total northern part of Moldova with

18 hospitals and hence a large medical catchment. Referring to the region covered by the hos-

pital of Balti the numbers average to 37,7 / 31,8 beds. The amount of beds thus calculated is

allocated to the healthcare zones and then to the locations on the basis of the results from the

As-Is-Analysis (Chap. 3).

The special situation for Bender has to be mentioned. Bender faces a special political situa-

tion and is close to Anenii Noi. It is located on the border between Moldova and Transnistria

under the governance of Transnistria, but it has to be included in the NHMP. Healthcare ser-

vices for the population of Bender have to be provided by the local hospital at Bender.

The allocation of beds to different departments is based on the frequency of diseases - e.g.

diseases treated by internal medicine or diseases treated by surgery. Also the results from the

estimated demand for healthcare service (Chap. 4.2) are included. The rate calculated accord-

ing to the above-mentioned calculation premises is compared to basic departments and spe-

cialised departments and adjusted to the correlation of 2007 data from the client.

The following list shows the allocation of beds based on the department structure. Mono-

profile hospitals have a special allocation of beds, mostly allocated to sub-disciplines and

corresponding wards are available. In the following figure the allocation of beds is shown

(mono-profile hospitals not included because if these were regarded, that would lead to statis-

tic distortions- see Figure 23).

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Based on these facts about 64 % beds in rural districts and 36 % in Chisinau are calculated in

the NHMP for 2013, and about 60 % and 40 %, respectively, for 2018. Approximately 68% in

2013 and 69 % in 2018 are for basic departments like internal medicine, general surgery, gy-

naecology & obstetrics and paediatrics. About 32 % (2013) and 31 % (2018) are planned for

specialised departments like Cardiology, Neurology, Traumatology / Orthopaedics and ENT.

Department Proportion of total

bed capacity range of beds Cardiology 6% 15 to 90 Dermatovenereology 2% 10 to 25 Gastroenterology 2% 15 to 70 General surgery 20% 10 to 380 Gynaecology & Obstet-rics 13% 15 to 280 Infectious disease 1% 10 to 30 General Medicine 29% 20 to 150 Neurology 8% 10 to 80 Ophthalmology 2% 10 to 30 ENT 3% 10 to 60 Paediatrics 8% 15 to 120 Pulmonology 1% 15 to 45 Traumatology / Ortho-paedics 6% 25 to 90 Urology 3% 10 to 60

Figure 23 Range of beds and proportion of total bed capacity by department (2018)

Detailed information can be found in the appendix 8.1 as well as in the allocation plans for

2013 (appendix 8.2) and 2018 (appendix 8.3).

In some specially identified hospitals (marked by asterisks in the allocation tables) in Chisi-

nau General Medicine includes other conservative sub-disciplines, if these are too small to

form their own departments. General Surgery likewise includes other operating sub-

disciplines, paediatrics in these hospitals also includes neonatology. Detailed information can

be found in the legend of each allocation plan.

The departments were determined following the quota of beds per 10,000 inhabitants and ac-

cording to the type of hospital (see chap. 4.3.1.1; criteria for departments by different hospital

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types). In addition medical range varies depending on the hospital structure and on the medi-

cal equipment. Besides this, some additional definitions are made by architectural structure.

One criterion is the economical size of wards - mainly limited by personnel resources - requir-

ing about 30 beds. Generally, wards are assigned to departments, but due to economical size

and the need to use resources effectively two departments may in some cases have to share

one ward.

4.3.1.3. Allocation of Staff

Estimations were also made for the staff requirement per hospital. This demand for different

professional groups is based on the estimated beds and differs per hospital type. As described

at the beginning of chapter 4.3 the entire analysis is based on beds. In consideration of these

circumstances, the number of cases, the average length of stay and utilisation of beds lead to

the number of beds, which in its turn leads to the staff requirement. Approved data provided

by the German Hospital Institute as well as the experience of the consultants from earlier

analysis of comparable studies and benchmark data of the consultant were adapted to the dif-

ferent hospital types. Additionally the various inputs derived from interviews and data pro-

vided by local experts are also integrated.

Staff requirements were estimated for physicians, nurses, medical assistants (functional diag-

nostics, operating-room staff, medical-technical staff), administrative and other staff (e.g.

kitchen, laundry and transportation staff and others) per hospital as well as per healthcare

zone. To ensure highly qualified medicine some structural aspects due to the different profes-

sional groups must be taken into consideration. For every professional group at least one well

trained leading person has to be available 24 hours a day every day. Medical trainees and

trained auxiliary staff have to be integrated and their work supervised by the leading expert.

With increasing experience trainees can begin to perform their duties independently. At the

moment there is a prescription by the ministry that a physician should care for 13 to 15 beds

and an assistant for 14 to 16 beds. The consultant is convinced that these numbers are rele-

vantly too high, especially regarding that the length of stay will reduce considerably and more

efficiency and quality of care will lead to a relevant raise of stress for the personnel.

Calculations for 2013 give an average length of stay of about 7.2 days and an overall utilisa-

tion of beds of about 82 %, for 2018 the average length of stay is about 6.2 days due to the

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development in healthcare services and optimisation of processes for example implementation

of clinical pathways. Additional details are shown in the following figure.

physicians nurses medical assistants others 2013 / 2018 253 84 2500 200 Figure 24: Average cases per staff per year Due to the co-morbidity of patients and an increase in diagnostics with a higher level of tech-

nical equipment, highly specialised hospitals have a multiplier of 1.1 and Centres of Excel-

lence of 1.3. The total basis is shown in figure 25. Details for each hospital are to be found in

Appendix 8.1.

The transfer of personnel according to the changing demand between the hospitals has to be

made in coordination with the employee representation.

Hospital type beds per phy-

sicians beds per nurses beds per

medical assistants beds per others 2013 2018 2013 2018 2013 2018 2013 2018

Transit Hospitals 4,3 -- 1,4 -- 42,0 -- 3,4 -- Local Hospitals 4,4 3,7 1,4 1,2 43,0 37,0 3,4 3,0 Specialised Hospitals 4,1 3,5 1,4 1,2 40,4 34,8 3,2 2,8 Highly Specialised Hospitals and Cen-tres of Excellence 3,7 3,2 1,2 1,1 36,8 31,7 2,9 2,5 Centres of Excellence and University Hos-pitals 3,1 2,7 1,0 0,9 37,3 26,8 2,5 2,1 Figure 25: Beds per staff belonging to different professional groups

Besides the absolute number of staff a personnel structure has to be implemented. To guaran-

tee a high quality of medical treatment, experienced physicians must have at least 5 years

selected experience. This is necessary on all levels of hospital services for all heads of de-

partment and senior physicians. The same has to be taken into consideration for nurses and

medical assistants.

4.3.2 Summary of the results

In the following all results for each hospital structure is shown (see also Chapter 4.3.1, 4.3.1.1, 4.3.1.2 and Appendix 8.1, 8.2 + 8.3).

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Transit hospital:

Hospital size varies between 60 and 200 beds in 2013, in 2018 Transit hospitals will

have another function. All Transit hospitals have four departments providing basic

care. These four departments are Internal Medicine (20 to 85 beds), Surgery (10 to 60

beds), Gynaecology & Obstetrics (15 to 30 beds) and Paediatrics (15 to 25 beds). The

hospitals are equipped with basic medical equipment e.g. ECG. Besides the first basic

medical check to decide what kind of treatment is necessary for the patient, these hos-

pitals are mainly responsible for nursing of chronical patients and social cases.

Local hospital: Hospital size varies between 175 and 265 beds in 2013 and in 2018. All local hospitals

have also the four basic departments (Internal Medicine, Surgery, Gynaecology & Ob-

stetrics and Paediatrics. The hospitals are equipped with basic medical equipment e.g.

ECG, basic X-ray as well as equipment for ultrasound and general medical examina-

tions. The main function is medical treatment, as well as medical care after complex

treatment in specialised or highly specialised hospitals. Total number of staff is about

8317, of which 15 % are physicians, 60 % nurses, 2 % medical assistants and 23 %

others.

Chisinau has to be considered separately. Hospitals in Chisinau are either Republican

hospitals, municipal hospitals or belong to specific ministries. The medical structure

of the hospitals shows university characteristics or general or specified departments or

mono-profiles, The classification of the municipal hospitals as local hospital was done

due to investment aspects as well as regarding the existing study.

Specialised hospital: Hospital size varies between 300 and 400 beds. All specialised hospitals have the four

basic departments (Internal Medicine, Surgery, Gynaecology & Obstetrics and Paediat-

rics) and additional departments such as ENT, Ophthalmology, Urology or Cardiology,

Gastroenterology et. al. Total number of staff is about 5704, of which 22 % are physi-

cians, 61 % nurses, 2.1 % medical assistants and 15.3 % others.

Due to the size of the hospitals, healthcare zones 1 and 3 each have 2 specialised hos-

pitals. In this case one hospital has a surgical focus; the other hospital has a more con-

servative focus like Internal Medicine with different specialisations, or Neurology.

The corresponding hospital has a bridgehead function for the basic departments, where

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external medical experts come at fixed times and in emergency cases in order to sup-

port local physicians.

High Specialised/ Centre of Excellence/ Universities: Hospital size varies between 190 and 900 beds. Depending on the structure, some of

the so-called mono-profile hospitals belong to the University Hospitals. In other cases

they will also have the four basic departments Internal Medicine, Surgery, Gynaecol-

ogy & Obstetrics , and Paediatrics and additional departments like the specialised hos-

pitals. Very rare diseases are treated at the University Hospitals. The main difference

of the university to the other types of hospitals is the fact that they provide medical

education and training as well as medical research. Total number of staff is about 7248,

of which 25 % are physicians, 46 % nurses, 2 % medical assistants and 27 % others.

The mapping of each hospital with all details is shown in appendix 8.1.

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5 Resulting Investment Needs

As shown in chap. 4.1.4.5 scenario 4 would be most the suitable and efficient solution for the

Moldovan situation. This solution was proposed by the consultant in December 2008. On the

part of the Ministry of Health scenarios 2 and 4 were favoured under aspects of realisation. It

was therefore taken as a basis for a detailed calculation of costs.

For each hospital the necessary gross floor area was calculated by the number of beds and the

gross floor area per bed, differentiated by the level of care. In order to calculate the necessary

investments, the documents provided by the client were evaluated. Evident differences be-

tween facts and figures were eliminated, but in some points reservations have to be made

about the reliability of the material.

For each hospital, costs were ascertained differently for building, central building equipment

and medical equipment and added up to obtain the total costs for investment. These results

were summed up for each healthcare zone and finally as the total for Moldova.

Total sum was rounded up to 1,112 billion €. This includes

• Investment for building

• Costs for central building equipment

• Costs for medical equipment.

Planning costs are not included in these investment sums. They can normally be estimated at

about 10% of the investment.

Costs for m² per new building were calculated at 800 €, costs for renovation at 450 €. The

costs for central building equipment such as air conditioning, elevators, transformers etc.

were calculated at 20 % of building costs.

As explained earlier the costs per bed for Transit hospitals have been calculated at 10,000 €,

because only basic investments have to be made here for maintaining basic treatment until

these houses are rededicated for other purposes.

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These figures are up to date, but a dependable projection for the runtime of the Hospital Mas-

ter Plan cannot be made, because the development of costs, especially in the building sector,

is not reliable. We therefore urgently recommend a regular update of the Hospital Master

Plan, a period of maximum 5 years seems realistic for this..

This applies especially to the costs for the maintenance of buildings, medical and technical

equipment as well as personnel. They normally have to be refinanced by the cash budget of

the running system. E.g. one has to face about 5% of investment for medical equipment as

annual maintenance costs. Special regular negotiations between hospitals and health insur-

ance companies as funding agencies are necessary to take local specialities and circumstances

into consideration and keep cost at the lowest possible level without losing quality of care.

All figures regarding investments were assembled in the Allocation plans (appendix 8.7 and

8.8).

• for intermediate situation 2013

• for final situation 2018.

Hereby the costs for the intermediate situation (2013) all included in the cost for 2018

Here are the costs for each hospital and each healthcare zone, differentiated

By investment:

• investment for building

• costs for central building equipment

• costs for medical equipment

• total costs (investment)

By personnel

• costs p.a. physicians

• costs p.a. nurses

• costs p.a. others

• costs p.a. staff total

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In short, in order to fulfil the NHMP the following investments need to be made:

Healthcare Zone 1 69,136,650.00 €









Balti 86,778,068.81 €

Chisinau 449,806,530.00 €

Cahul 56,505,278.00 €

TOTAL INVESTMENT 1,112,873,779.00 €

A detailed time schedule for these costs is presented in appendix 8.4.

For an overview of the timeframe:

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Phase 1 2009 Legal system, costs for monitor-

ing

Phase 2 2010 - 2011 272,933,742 €

Phase 3 2012 - 2013 364,053,566 €

Phase 4 2014 - 2016 294,184,241 €

Phase 5 2017 - 2018 181,102,230 €

5.1 Investment in Staff

5.1.1 Estimations for salaries of hospital staff

The estimation of salaries relies on information from the client. The following salaries are

taken as basis for the different professional groups. Other personnel includes medical assis-

tants (functional diagnostics, operating-room staff, medical-technical staff) as well as admin-

istrative and other staff (e.g. kitchen, laundry and transportation staff and others). No different

salaries for these groups were available.

physicians nurses others

costs per year 4.000 € 2.340 € 2.560 €

For the actual imponderables all costs are measured in today’s prices, a projection over 10 or

more years seems too unreliable. As a result, changes in financing, cost development and fur-

ther education are disregarded. In 2013 a total of around 55,316,687 € will need to be spent

for the total staff, and this will rise to about 57,231,946 € in 2018. Of this total about 28 % are

allotted to physicians, about 49 % to nurses and 23 % to others. About 31 % of the total cost s

fall upon Local Hospitals, about 29 % upon Specialised Hospitals, about 11 % upon highly

specialised Hospitals and about 29 % upon Centres of Excellence and University Hospitals.

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5.1.2 Educational and further needs

Salary costs in general are one of the most important drivers of healthcare costs. But in order

to be able to implement the proposed system of high quality medical services further activities

concerning the education and training of medical staff have to be implemented.

To facilitate the start of the new healthcare system as smoothly as possible the existing per-

sonnel has to be educated in the use of the new technology which is relevant for their individ-

ual tasks. This includes the use of computers and relevant software as well as the use of com-

plex medical technology and the ability to interpret outcomes (e.g. CT / MRT-images). This

technical knowledge should be imparted before the corresponding technology is implemented.

On-site visits especially in rural Moldova demonstrated that today's daily practice does not

comply with modern medical standards (see Appendix 8.7). Hygienically the majority of hos-

pitals did not meet the necessary requirements in order to be able to provide high-quality

medical services as planned. New organisational rules will change the personnel's daily work-

ing habits. To meet the requirements of the current hygienic and medical standards it will be

essential for the hospital's staff to comply with these rules. Thus physicians, nurses and medi-

cal assistants need to be trained in applying defined standards for daily medical procedures

(e.g. clinical pathways per diseases).

Medical training for physicians is particularly needed in more specialised medical fields such

as cardiology, neurology, gastroenterology and palliative care and the more complex surgical

medical fields. In addition, nurses will need to receive training in medical fields such as

stroke care and palliative care as well as nursing management. Operating Staff have to be

educated in using new technology and procedure standards. Due to further specialisation (in-

tensive care, intermediate care, surgery care, day care, home care, etc.) specific training pro-

grammes should be introduced especially for the nursing staff.

In order to coordinate this process for the whole Republic centralised responsibilities will

ensure the required quality and efficiency. Quality standards based on international agree-

ments will be assured by accountable trainers who should be trained intensively in foreign

institutions (e.g. during residencies or observations) or by foreign trainers. Training on medi-

cal technology could be offered by the companies which deliver these technologies.

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In order to keep the system running, continuing and sustainable medical training and further

education which comply with international or European standards should be introduced. Most

European countries have their own prescriptions for education in healthcare professions dif-

ferentiating between educations / training and professional development. On the other hand

physicians, nurses and medical technical assistants can work in most countries of the world,

depending on legal arrangements regarding the examination. For international methods of

medical education and professional ongoing education see: WHO: Health System in Transi-

tion, e.g. France 2004, Netherlands 2004, Norway 2006. University education will remain

centralised in Chisinau and provided by the Republic Hospital and those institutions which

together will represent the medical university center in order to be able to provide high qual-

ity medical education. In most European university systems medical education is split into a

theoretical part and a practical part. The theoretical part generally provides the students first

with basic but broad medical knowledge. It gives the students an understanding of the interre-

lation of different physiological, biochemical and anatomic fields. After this first theoretical

medical basis the students usually specialise in different medical fields in order to gain in-

depth theoretical and practical knowledge. All practical education is provided during daily

hospital work where experienced students complete a few years of specialised practical train-

ing. In Germany they are then allowed to run their own practice or be fully employed by a

hospital. This educational system has proven to be internationally successful and the Moldo-

van medical education system shall be adapted to international standards.

Once the medical education standard is set nationwide the adoption of new medical trends

and methods will be feasible. In most European medical universities, education and research

are closely linked but they are financed separately from the provision of healthcare services

and are administered and supervised by different ministerial institutions. As far as Moldova is

concerned, the focus should first be set on medical education, before the development of

medical institutes with a focus on research and development is introduced.

In general, close cooperation with different European or international universities will allow a

faster and more efficient introduction of modern educational standards. At the same time co-

operation will offer the possibility to Moldovan students to complete parts of their education

abroad more easily.

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High standard medical education needs to be supported by a sufficient amount of administra-

tive personnel which is exclusively responsible for the educational tasks of the university

clinics, representing the Faculty of Medicine. These administrative services include student

services such as Student Advisory Services, Libraries, Computer Labs and Student Councils.

Nowadays the risk that students choose their place of employment elsewhere instead of work-

ing in Moldova after finishing their education is said to be relatively high. Thus the very basis

of the new system of hospital healthcare provision is at risk. One possible way to reduce this

risk is to provide good education inside Moldova and to ensure good working conditions for

physicians and medical personnel at the Republic's hospitals.

5.2 Investment in Building Structures

Status and structure of the existing hospitals is generally inadequate with regard to technical

standards. Lack of thermal insulation, technical equipment with low efficiency factors etc.

mean pollution by waste of energy although many up-to-date hospital standards have not been

provided up until now.

Today hospitals have a need for much more air conditioning, elevators etc. which will natu-

rally raise the specific demand for electrical and thermal energy.

This does not mean however that energy consumption will rise at the same rate.

Today modern techniques like block heating stations, use of geothermy, solar power in com-

bination with thermal insulation, industrial process and control and energy recovery provide

the opportunity for considerably reducing the rise in energy consumption. This means maxi-

mum protection of the environment by use of modern technologies. The necessary increase in

investment is usually compensated within a few years by the reduction in running costs.

Special analysis (e.g. feasibility studies) has to be made before execution of each project to

receive optimal results.

5.2.1 Investment in Building Construction

Moldovan hospital buildings are generally in poor condition. There is a need to rebuild or

renovate them within a period of about 10 years.

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Visits to the hospitals have shown that the necessary standards of building construction and

building equipment are often either non-existent or they cannot be achieved by renovation.

E.g. corridors must as a standard be so wide that two beds can pass each other, this means a

measurement of 2.25 m net. Doors for patient rooms must be at least 1.25 m wide, otherwise

beds cannot be moved in and out. Doors for patient bathrooms must be at least 88.5 cm wide,

or they cannot be used with wheelchairs. Showers can only be used by handicapped persons

without help if the barrier is not higher than 2 cm. In order to reach these standards many

conversions have to be made; this explains the relatively high proportion of unusable spaces

and the high renovation costs.

For some hospitals, especially in Chisinau, special studies have been made since 2006. Some

urgent renovations also need to be done immediately. In chapter 7 of the NHMP the consult-

ant recommends a special sequence of investments.

We strongly recommend all hospital managements that future building investments be pre-

ceded by individual long-range hospital master plans. To ensure Western European standards

we emphasise that before any building activities are started, detailed descriptions have to be

made for each room (schedule, room data sheet).

Examples for standard room equipment are added for (see appendix 8.7).

• Intensive Care Unit: patient rooms

• Intensive Care Unit: reanimation room

• Emergency Department: Aseptic treatment room.

To calculate investments, the state of construction, technical infrastructure and further supply

were abstracted to a score number (see 4.2.1). This was weighted to obtain data for usable

ground floor areas and new building areas.

Necessary investments for buildings consist in particular of providing the required floor space

for qualified medical services and patient accommodation as well as establishing modern hy-

gienic requirements.

According to the level of treatment, different gross floor areas are required in the hospitals.

Therefore, based on space allocation plans developed for different types of hospitals at west-

ern standards, we have made the following correlations (see sources: appendix 8.14).

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• Transit hospital, 60 beds 75 m² gross floor area per bed



• Local Level Hospital 80 m² gross floor area per bed

• Specialised Care Hospital 84 m² gross floor area per bed

• Highly Specialised Care Hospital 90 m² gross floor area per bed

• Centre of Excellence, University 115 m² gross floor area per bed

The standards of gross floor areas for each level were deduced from detailed room und func-

tional programmes developed by the consultant and international standard programmes (see

“sources”, Appendix 8.14). Detailed data sheets for each hospital are to be found in the at-

tachments.

Costs for m² per new building were calculated at 800 €, costs for renovation at 450 €. The

costs for central building equipment such as air conditioning, elevators, transformers etc.

were calculated at 20 % of building costs. This data is - as already mentioned - up to date but

is must be adjusted to the national cost statistics on an ongoing basis.

5.2.2 Investment in building Structures – Technical Systems

5.2.2.1 General assessments and bases

The existing technical building supply systems do not comply with the European technical

guidelines and EN-standards, and are in need of extensive renovation. From economic as-

pects, it is recommended that the complete technical building supply systems be converted

according to more energy-efficient aspects, or if necessary replaced. This applies in detail to

the following areas of the technical building equipment:

1. The heating systems are in a dilapidated condition due to their advanced age. A con-

tinual reliable supply cannot be guaranteed with the existing systems. Due to break-

downs in the heating supply, this can result in severe shortages in winter, considerably

limiting the supply to patients and impairing working requirements.

2. In the case of the ventilation systems, it must be assumed that hygiene safety is inade-

quate.

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3. The sanitary systems are reliant on the existing fresh water supply. From a technical

and hygienic point of view, the existing supply is to a large extent no longer usable.

In view of the above points described in brief, the complete technical building systems must

be thoroughly renovated or replaced. The status of the technology of the individual works is

described in more detail below, since modern hospital hygiene concentrates its interest in al-

most sterile air on specifically defined areas. The resulting requirements depend on the func-

tion in question, and differ from room to room.

In addition to the technical hospital requirements, the technical building systems must also

comply with the “normal” conditions. These consist essentially of:

• Operating safety

• Fire safety

• Comfort criteria

• Minimum energy consumption to achieve the defined objectives

• Heat recovery optimised for net energy recovery

• Optimisation of investments and operating costs

• Ease of operation and maintenance

In comparison, patients’ rooms comply with the standard requirements, without risks in rela-

tion to the building equipment. The main requirement must be the comfort considerations of

patients. In the case of patients with reduced immune defence, or patients with infectious dis-

eases transmitted by air, special requirements must be defined. These include for example the

following room uses:

• Sterile care of patients following bone marrow transplants

• Heart catheter laboratories, angiography rooms

• Patient rooms for patients following organ transplants

• Intensive care wards

• Operating theatres

• Inhalation cabins and isolation rooms for infectious patients (tuberculosis)

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5.2.2.2 Sanitary facilities

The supply of a hospital with fresh water takes place from the existing fresh water supply

pipe. In this case, a preliminary check must be made to ensure that this fresh water complies

with the hygiene requirements. If this is not the case, the required fresh water quality must be

ensured by means of suitable water treatment systems. Reliable separation of fresh water from

non-potable water must be provided. Storage spaces for the supply of fresh water should not

be planned for from the hygiene point of view, although they may become necessary if an

independent supply is required. The storage spaces should then be designed, with regard to

materials and installation, so as to avoid the proliferation of micro-organisms. In some areas

of a hospital, the supply of water with special requirements must be ensured. These water

qualities included for example:

• fully-desalinated water (kitchen areas, dialysis treatment)

• softened water

• water from reverse osmosis treatment systems

Separate water treatment systems will also have to be set up in order to achieve these water

qualities.

Waste water treatment systems are also an essential part of hospital equipment, in order to

disinfect infectious waste water. Technical hygiene regulations require that such waste water

is sterilised thermally. This is done by heating the waste water up to 134 °C using live steam,

and maintaining it at this temperature for 30 minutes. The waste water must then be cooled

down to a temperature of 35 °C before allowing it into the drainage system.

In view of the expected problems with the water supply pressure on the upper floors, the cold

water system can be equipped with suitable pressure booster systems. The distribution of

these pressure booster systems should be carried out over individual building areas, which

offers the advantage that the supply reliability is ensured by having several independent sup-

ply sources. The systems can then also be designed to be smaller, and will therefore be oper-

ated in the optimum operating range of the pumps, which will minimise wear and energy con-

sumption. This will also reduce the number of “dead spaces” in the cold water system.

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In the installation of warm water systems, the increased risk of infection by aerosols carrying

legionella must be considered. Warm water storage tanks should consist of stainless steel

tanks with anti-legionella circuits. In the case of extensive systems, the heating should be di-

vided between several central fresh water heaters, in order to reduce the length of piping. In

general, these systems must be designed so that as little heated fresh water as possible is

stored, and this is heated up to 60 °C.

Figure 26: overview of legionella frequency

The material of the water supply pipes should be selected so as to exclude the possibility of

the formation of micro-organisms because of the pipe material. All cold water pipes must also

be laid at an adequate distance away from heat sources, and insulated, in order to prevent the

multiplication of micro-organisms facilitated by warming. Ring mains should be installed

wherever possible in order to ensure an adequate exchange of water. This method of laying

will almost completely excluded supply areas and end sections containing stagnating water.

For the installation of the warm water systems, and in accordance with the current status of

the technology, circulation pipes must be provided with only short distances to tapping points.

In these circulation pipes, the temperature must not fall below 55 °C. Thermostatic circuit

control valves must be installed in the use circulation systems. These measures will ensure a

hydraulically balanced system in which the water is flowing continuously. This guarantees

freedom from legionella and the direct availability of warm water at every tap.

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Figure 27: Illustration of a circulating system

The extinguishing water supply is provided via dry uptake pipes inside the building. The nec-

essary number of tapping points per floor will be provided. In order to avoid the contamina-

tion of the fresh water system through the use of wet fire-extinguishing pipes, it is advisable

to provide dry pipes, which can be supplied if necessary outside the building by the fire ser-

vice. The possibility also exists of putting the dry fire-extinguishing pipe under water pressure

at a defined point if necessary by means of a short hose connection to the fresh water system.

This connection would also be made by the fire service. These possibilities nevertheless re-

quire the approval of the responsible fire safety authority, although they provide increased

hygiene safety of the fresh water system.

The waste water disposal takes place via supply channels and underground pipes to the point

of connection to the main drainage system. Drainage of basement floors below ground level is

carried out by waste water lifting systems. Here too the pipes must be kept as short as possi-

ble, and several systems planned for different parts of the building. Dirty water containing fat

from the kitchens will be fed by special waste water pipes to a fat separator, from where it

will be fed into the district waste water system. The fat separator should be installed outside

and below ground if possible.

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Figure 28: Fat separator with lifting system

The fixtures and fittings will be designed with purely hygienic aspects in mind. The wash-

stands installed will be white, smooth and made of sanitary porcelain, without an overflow.

An overflow would create the possibility of contamination. The fittings will be wall fittings

with temperature restriction. The warm water temperature immediately before mixing at the

tap must still be at least 55 °C. Wall fittings with swivelling taps and waste water connections

must also be provided for medical facilities such as dirty room combinations / work tables.

5.2.2.3 Heating systems

Since the heating systems in general are greatly in need of renovation due to their age and the

equipment concerned, it would be more advisable, taking into account economic considera-

tions such as energy consumption and system wastage, to replace the existing systems. In

order to provide the necessary temperature level to the sensitive areas of dynamic heating and

warm water treatment, these areas should be supplied at a temperature level of 70/50°C (sup-

ply/return).

For the system of static heating, a separate boiler system will be provided for the required

heat on the basis of condensing appliance technology. This is advisable in order to increase

the energy yield of the natural gas, and at the same time achieve savings in the primary en-

ergy costs. The temperature level of the static heating should be 55 °C/40 °C.

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Figure 29: Piping layout using the Tichelmann system

The supplies to the static heating of the floors are balanced hydraulically by regulating valves.

On the floors themselves, the heating distribution is carried out by means of the so-called

“Tichelmann system” (see Figure 1). In this system, the total pipe length of the supply and

return of each radiator is equal, and the pressure loss therefore also approximately equal. This

enables the system to dispense with complex hydraulic regulation and additional circuit con-

trol valves within the floors.

For further energy-saving, every radiator is equipped with a thermostat valve for individual

regulation of the room temperature. In this case, consideration should be given to the use of

electronic thermostat valves, which enable detection of open windows by means of the tem-

perature drop in the window area. By means of this detection, the thermostat valve closes if

the windows are opened. This solution offers an enormous potential saving in energy costs for

the area of heat supply. The higher investment costs for electronic thermostat valves are usu-

ally amortised within 1 to 2 years. The radiators used are flat radiators with the hygiene cer-

tificates required for hospitals. Special hygiene radiators will be provided for areas with par-

ticularly sensitive hygiene requirements.

All central heating units (heating boilers, heating pumps etc.) and main heating distributors

(supply and return distributors) should be installed in separate heating rooms located outside

the building. These heating rooms offer the advantage that the resulting exhaust gases can be

fed directly to the outside, without having to run a separate exhaust gas chimney over the roof

of the building. This will avoid inconvenience and discomfort for the patients due to exhaust

gas flows and short-circuits to the air-conditioning systems. All supply lines will led into the

building in a concrete channel, easily accessible for inspection, constructed below ground

HV – heating supply HR – heating return H – heating element (radia-tor) K – heating boiler

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level. Existing basement floors will also be cleared of unnecessary piping by this procedure,

so that a clear and restructured supply system can be created.

5.2.2.4 Ventilation systems

In close cooperation between planners, hospital hygienists and clinicians, the occupational

medical and/or infectious necessity of a ventilation system must be carefully considered from

the following points of view:

- Ensuring physiological work requirements (air-conditioning by regulation of heat and

humidity and the removal of hazardous materials such as anaesthetic gases, odours).

- Avoidance of airborne transmission of pathogens into the protection zone by the sup-

ply of almost sterile, vertical, low-turbulence air while maintaining a specific flow di-

rection. Suitable air passages include so-called laminar air flow (LAF) ceilings. Con-

tamination of the air in the immediate area of operating and instrument tables would

result in direct or indirect contamination of the operating theatre environment, empha-

sising the preventive importance in the case of aseptic interventions subject to the risk

of infection, such as operations on large bones and joints or the implantation of al-

loplastic materials.

This results in the following main points for the implementation in operating theatre func-

tional departments: Low-turbulence (turbulence level over 5 %), large-area LAF systems with

terminal filter stage of class H14 and with fabric outlet are superior to other systems in terms

of ventilation and provide high hygiene safety with regard to the screening of operating and

instrument tables against microorganisms given off into the room air. Such systems should

therefore be selected as a matter of preference in the case of new construction and conver-

sions.

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Figure 30: Air supply and ventilation of an operating theatre

1. The size of the ceiling field must be designed so that the areas particularly in need of

protection – the operating area, the standing positions of the operating team, the instru-

ment tables – can be placed reliably in the clean air stream, i.e. the size of the ceiling

field depends on the type of operations being performed. In general, this requires a ceil-

ing area of 3.2 x 3.2 m. It is also advisable to mark the effective area of the ceiling field

on the floor, in order to provide a visual aid for the positioning of operating tables, op-

erating staff and anaesthesia staff. Special consideration should be given to the follow-

ing:

o Persons remaining or equipment set up in the border area between the low-

turbulence clean air area and the turbulent room air area,

o The spatial restriction of the clean air area due to the temperature difference be-

tween the incoming air and room air,

o Due to the reliable screening by adequately dimensioned ceiling fields with LAF,

their additional cost can be compensated for by savings on the peripheral systems.

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2. Compliance with these requirements necessitates a high overall volume flow. With a

ceiling field size of 3.2 m x 3.2 m, a volume flow of 6,000 m³ / h can be assumed as a

guideline value, while a minimum outside air volume flow of 800 m³ / h is sufficient as

replacement for fresh air.

The remaining air supplied can consist of circulating air treated by having been filtered

in three stages. In this way, the energy requirement can be reduced significantly.

Figure 30a: System schematic of a circulating air system with humidification and cooling

For large ceiling fields (larger than 3 m x 3 m) with skirting of at least 5 to 50 cm in length,

the flow speed of the incoming air should be approx. 0.20 m / s. At such flow speeds, parti-

cles lying on fixed surfaces are not stirred up. The air supplied as LAF can, for energy rea-

sons, be supplied to the ante-rooms by means of overflow openings.

3. In all other areas and rooms of the OP department, the ventilation system can be

equipped with normal basic ventilation plus area temperature control, in order to ensure

static overpressure compared to the outside area. This removes the necessity for the in-

stallation of S-filters, i.e. classes F8 or F9 are sufficient for the incoming air. This also

applies for corridors to the sterile materials supply areas of the operating rooms, as long

as no unprotected storage of sterile materials takes place in this area.

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4. Ingress of dust into the ventilation system must be restricted to the necessary minimum

by suitable filtering of the outside air.

5. The concept of mild air-conditioning technology includes the consistent separation of

the functions of heating, cooling and ventilation. Air should serve primarily for the pur-

poses of ventilation and screening against micro-organisms. The temperature control

can be carried out most economically by means of heating and cooling surfaces.

6. The number of persons present in the operating theatre must be restricted to the mini-

mum necessary. The number of doors opening directly into the operating theatre should

as a rule be no more than three. Automatic sliding doors can be advantageous in this

case.

7. A requirement for the acceptance of a ventilation system is that it passes the filter seal-

ing seat and the leak test according to VDI 2083/3. This test should be carried out at

least at intervals of 2 years or after surgery at the end filter stage. The flow conditions

along the edge of the zone of protection of the LAF ceiling should be checked at least

quarterly using flow tubes.

According to the currently still valid DIN 1946, an annual hygiene check is required for

rooms with low-turbulence air supply systems and three-stage filtering.

All interior rooms are ventilated by means of an intake and exhaust system. A central ventila-

tion unit equipped for heat recovery is provided for this purpose, so that in winter, the cold

outside air is pre-heated before the actual heating battery by using the heat energy of the ex-

haust air.

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Figure 31: Principle of heat recovery

A separate ventilation system must be planned for each individual usage unit. This has the

advantage that independent regulation equipment can be used for every individual unit, e.g.

laboratories, patients’ rooms and kitchen areas. This offers advantages not only in terms of

regulation technology, but also in terms of energy. The total air volumes required are thereby

reduced, which has a positive effect on the system investment and operating costs. The sys-

tems can also be switched on and off individually as required.

For the laboratory areas, a separate central ventilation system with the corresponding filter

stages in the supply and exhaust air must be used, in order to prevent any unfiltered escapes

of chemicals and other airborne substances from the laboratory area. For this purpose, the

laboratory areas will be maintained at negative pressure. Airlocks will therefore be necessary

in some cases for the laboratory areas.

Airlocks will be required in other areas of the hospital as follows:

Isolation rooms (negative pressure in the patient’s room)

Emergency rooms for patients with contagious infectious diseases

Clean rooms

Cooling will be necessary for various areas generating internal heat loads from medical and

EDP equipment, such as MRT, cooling cell and server rooms. So as not to have to air-

condition these areas by means of the ventilation equipment, individual room circulating air

cooling units with individually adjustable room temperature will be provided for rooms with

high internal heat loads. This ensures that in every room, only the actual internal and external

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heat load occurring at any specific time will be cooled. This reduces the overall cooling re-

quirement, and therefore also the size of the cooling machinery and the actual consumption of

cooling energy. The supply to the circulating air cooling units will be provided, depending on

the room requirements, from a central cooling water system or by installed multi-split cooling

systems with inverter technology. This allows the possibility of providing cooling and heating

simultaneously with one unit.

Figure 32: Schematic of a multi-split system

For areas with higher hygiene requirements, such as operating theatres, cooling will be car-

ried out direct via the relevant ventilation systems by heats of air/water cooling. The ventila-

tion units will be installed in an internal central ventilation room. This arrangement will re-

duce the duct dimensions for the outside and exhaust air, since the air intake can take place

immediately at the units by connection to the outside wall. This also overcomes the condensa-

tion problem of outside air intake ducts running inside the building, and reduces the shaft

cross-sections required. The exhaust air is also blown out in the immediate vicinity of the

units via the roof, or if possible through the building outer walls. A cooling machine will be

provided to cover the required cooling of the circulating air cooling units. This should be in-

stalled in the central ventilation room, since the heat-exchangers can also be installed inter-

nally. The heat-exchangers will be designed as so-called ‘quiet runners’, in order to keep the

noise emissions low.

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Smoke extraction systems must be provided for internal halls, stairwells and emergency es-

cape routes without outside windows. These will consist of ducting systems with a fire resis-

tance of at least 90 minutes. This system is actuated by the fire-alarm system. In the event of

smoke within the area to be cleared, the system will be brought into operation for this area. In

order to reduce the investment and operating costs, it could be established in conjunction with

the relevant fire safety authority that in the event of fire, only one floor would have to be

cleared of smoke. This is quite reasonable, since experiences in hospitals with ceilings as

horizontal fire sections show that a fire or smoke development as a rule occurs only on one

floor. In order to allow the fire service the possibility of specific smoke extraction, a fire ser-

vice operating panel should be provided at the fire-fighting point. The division of the building

into fire sections must be taken into account in this respect.

A further possibility for extraction of smoke from stairwells, and thus for keeping escape and

rescue routes free of smoke, lies in the use of a pressurised smoke protection system. This

will save the costs of ducting systems, which would no longer be required.

Figure 33: Pressurised smoke protection system in the internal stairwell

• Smoke detection by smoke alarm (5) or manual actuation (3)

• The control unit (11) in the control centre starts the following programme running:

• The air supply fan draws in fresh air (9+10) and transports it into the escape and rescue routes

• The drive (1) in the roof area opens the window completely

• The alarm siren (7) sounds • The flashing light (8) flashes • The door-closers (6) are switched off,

the doors close • The ventilation switches (3) are deacti-

vated • After the flushing phase of 120 sec-

onds, the pressure regulation (2) is ac-tivated and a constant over-pressure built up

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5.2.2.5 Regulation equipment

In order to reduce complex cabling, the regulation equipment should be actuated and con-

trolled by s BUS system. The EIB BUS system is recommended. With this system, the con-

ventional individual control, through to individual room regulation can be combined with

heating and electrical regulation, without having to install two or more systems next to each

other. Building control equipment should also be installed. The advantage of building control

equipment is that the regulation processes and the registration of error messages can be con-

trolled and registered centrally. With building control equipment, the individual parts of the

system can be optimised in relation to the theoretical layout after commissioning, depending

on the conditions encountered in practice. Substantial energy savings can therefore also be

made here.

Figure 34: EIB system schematic – building automation

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Medical gas supply

Central facilities for medical gas supply in the hospital represent the current status of the

technology.

The pressurised air system must consist of compressors, cooling dryers and filters. Breathing

air units to EN 737 must also be installed. For the technical pressurised air, a separate system

will be constructed, in order to be independent of the medical pressurised air. In sterilisation

areas, technical pressurised air connections will be required for cleaning pistols and door-

openers.

Vacuum systems must be provided for emergency reception and the rooms of the intensive

care ward. In order to comply with EN737, an oxygen switching device with a third connec-

tion for a third independent supply source will be required. The oxygen and anaesthetic gas

switching device also requires a so-called emergency feed point in case of accidents.

For all pipelines (oxygen, pressurised air 5 and 8 bar, nitrous oxide, anaesthetic gas extrac-

tion, vacuum), special copper piping of the quality SF-Cu F 30 to DIN 1786 must be used,

which complies with the increased requirements for medical gas supply systems. A high level

of cleanliness and complete absence of grease are also required. The connecting elements

must also be made of copper.

Every floor of the care departments will be provided with a separate floor shut-off box with a

visual and acoustic warning in the event of failure of the gas supply. If one floor shut-off box

is not in the field of view of the nurses’ desk, an additional warning signal will be provided in

the nurses’ room. The floor shut-off boxes can be equipped with a maximum of three pressur-

ised gases, or two pressurised gases and vacuum. In the operating theatre department, the wall

connection points of two operating theatres will be controlled by a shut-off unit. The ceiling

supply units of all operating theatres will be controlled by a further shut-off unit. Two shut-

off boxes must also be planned for smaller operations in emergency reception.

The equipment to be provided in the operating theatres for the extraction of anaesthetic gas

and air motor exhaust air will be led out over the roof via a separate piping network through

the ventilation shaft.

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5.2.3 Investment in building structures – electric systems

1. Central power supply

The power supply for hospitals is an independent supply system. The power supplied by the

(local) utility will be fed into a separate service entrance equipment room.

The relevant capacity will still be broken down into the demand for the normal power supply

(Normal Power NP) and the safety power supply (Critical Power CP).

Figure 35: Example for Power Distribution in Hospitals

The CP demand for the elevators and the safety lighting will be covered by a diesel aggregate

nearby the central transformer. The starting time for the load transfer to all connected con-

sumers will be less than 15 seconds.

The interface for both types of power supply will be the main distribution center for the hos-

pital building which is equipped with an independent, fully automatic change-over device.

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The entire electric network shall be designed and laid out as a TN-S system (5-conductor sys-

tem).

2. Low-voltage switchgear/safety power supply

The change-over to the safety power supply, which guarantees 24 hours of operations, will

take less than 15 sec.

The following consumers will be connected with the safety power supply:

- safety devices,

- safety lighting,

- electro-medical rooms of Group 2 (if any),

- electric facilities for the medical gas supply,

- elevators for the fire department and for beds,

- paging, alarm and warning systems.

3. Main distribution board for the buildings

A main distribution board with a 5-conductor system (TN-S) and an independent, fully auto-

matic change-over device will be mostly installed in the basement of the hospital or a separate

building for power distribution. There are two separate rooms (one for the general power sup-

ply [NP] and one for the safety power supply [CP]). The distribution boards on the individual

floors as well as those for the technical equipment and for the elevators will be supplied from

here in a star-like fashion.

4. Low-voltage installation systems

The main lines from the main distribution in the hospital will be installed, as a standard, on

separate cable routes for the NP and CP networks, respectively, with E 90 or E 30 cables to be

used for the safety supply.

The electric equipment on the individual levels is to be supplied from separate, factory-

finished NP and CP distribution boards on the relevant floors, which will be installed in sepa-

rate distributor compartments. The installation of both distribution boards in one room will be

admissible, if the distribution from there remains within the same fire compartment.

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The distribution boards on the individual floors will always be installed on top of each other

at each level, so that all electric cables (for the NP and CP systems separate from each other)

can be housed in a vertical duct. However, the openings in the ceilings will have to be re-

closed again for fire protection purposes.

The rooms of the areas to be supplied with power shall be sub-divided (by the client or user)

into application groups. The different application groups should be supplied with power in

accordance with the local directives and regulations.

Additional equipotential bonding:

The potential differences must not exceed 10 mV in those rooms, where intra-cardiac opera-

tions are performed. Mobile electro-medical appliances shall be equipped with equipotential

bonding bars, which are to be installed in each socket of the IT system.

Figure 36: Example for IT system with insulation monitoring in operating rooms

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Figure 37: Medical IT system including an insulation fault location system in an intensive care unit As a matter of principle, only NYM cables shall be laid, while shielded cable must always be

used in rooms that are intended for measurements of body (action) voltages. Line systems in

rescue paths will be separated from the latter under fire protection aspects.

Residual Current Devices (RCDs) shall be preferred for personal security purposes. All pro-

tective devices must ensure the overload selectivity, both in the normal operating mode and in

the emergency power mode.

Concealed material in standard design will be used for all wiring accessories in the patients’

rooms, in the offices as well as in treatment and ancillary rooms. Concealed equipment will

be installed in wet rooms, exposed equipment in wet-room design in the technical rooms and

basements. Separate power circuits will be installed for the lighting and for the sockets.

Cable penetrations through fire compartments shall be re-closed, so that they are fire-resistant

and smoke-tight.

Installation systems will be installed in all patients’ rooms, which allow the separate installa-

tion of power-operated, communication and gas equipment. In addition to that, the supply

systems will include the indirect general lighting and the reading lights.

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5. Lighting systems

The lighting will be designed and installed in accordance with the state-of-the-art. According

to EN 12464-1, the following values for the luminance have been stipulated for the hospital

(extract):

Room & lighting designation Mean luminance on the ground waiting rooms, corridors (during daytime), daytime lounges, staff rooms, bathrooms and restrooms

200

corridors in the operating theater, reading lights, sim-ple medical examinations, general lighting

300

corridors at night 50 technical rooms 100 bureaus, preparatory and recovery rooms 500 medical examinations and treatment 1000

In order to be able to maintain operations in the event of a breakdown/power cut, a part of the

general lighting in the following areas will be supplied with power from the safety network

after a maximum change-over time of 15 sec:

- traffic zones

- rooms of application group 1

- technical rooms

The rescue sign lamps will be supplied from the CP network.

The technical rooms, the bathrooms and the restrooms will be equipped with damp-proof light

fixtures.

Built-in light fixtures will be installed in the rooms with suspended ceilings.

Electronic ballasts will be installed (if economically justified), when strip lights are used as

light fixtures.

The restrooms will be equipped with presence detectors for energetic reasons.

6. Lightning protection and grounding systems, overvoltage

The lightning protection system will be designed and installed in accordance with DIN VDE

0185-2, section D.2.

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The lightning conductors on the roof will be installed with a mesh size not exceeding 10 m x

10 m. Roof installations will be separately protected by lightning spikes.

The reinforcement bars will be used as down conductors and the reinforcement steel in rein-

forced concrete floors and ceilings will be joined to each other and to the down conductors. In

order to do so, additional connecting lines will be laid and tied to the reinforcement bars or

rebar mats. Inspection joints that are easily and safely accessible for the regular checks shall

be installed for measurements and tests.

The reinforcement of the foundation slab will serve as grounding system, and the reinforce-

ment of strip or individual foundations will be integrated into the grounding system.

Soldering lugs for the equipotential bonding connections will be installed in the technical

rooms.

All electrically conductive installation systems as well as all metal parts of the electric and

grounding systems will be connected with the external lightning protection system via an

equipotential bonding strip or via spark gaps for the purpose of establishing the main equipo-

tential bonding, so as to avoid potential differences. The lightning protection equipotential

bonding will be installed in the basement, with the power and weak current cables being inte-

grated into this system via lightning stroke current and over-voltage down conductors.

The internal lightning protection shall be implemented by way of suitable over-voltage pro-

tectors (coarse, medium and fine protection).

7. Telecommunication system/EDP system

The telecommunication system will be housed in a separate distribution compartment, where

a distributor for the telecommunication and EDP systems with the relevant patch fields will

be put up and from where the structured cabling extends to the individual levels.

As a matter of principle, the nursing stations, the doctors’ offices and the operating theater

rooms will be equipped with a telecommunication connection and a double EDP connection.

Further connections can be added at each level with a DECT network. The cables for data and

voice transmission facilities at the individual floors will be installed as category 6 with 4 twin

connector copper lines and include RJ 45 twin connector sockets in modular design.

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8. Fire alarm system

The fire alarm system will have to give due consideration to the hospital’s fire protection

strategy, which does not only take the room conditions into account but also specifies the ex-

tent of the monitoring. The division of the hospital into fire compartments will also have to be

taken into account.

Automatic smoke detectors are required, as a minimum, in the corridors as well as in the

technical and storage rooms for personal protection, while the machine rooms for the eleva-

tors, the technical & installation shafts, the air-conditioning & ventilation systems as well as

the intermediate ceiling areas will be included into the monitoring. Non-automatic fire alarms

will be installed along the rescue paths near exits and fire extinguishing appliances.

The fire alarm groups will be connected with a fire alarm center (BMZ). The equipment and

facilities installed and deposited there, such as the control panel for the fire department, the

route card collection and the key cabinet, will have to be agreed with the relevant authorities.

Functional endurance cables will be installed for selecting the fire control.

9. Nurse call system

Each nursing ward will be equipped with a system in busbar technology, to which at least all

patients’ rooms can be connected, including the wet cells, the working and daytime lounges

as well as all restrooms for the patients. It is intended to install an inter-ward connection and

display. Once a call has been made, it will be indicated visually in the corridors as well as

visually and acoustically in the bureaus.

The room terminals will be equipped with voice transmission facilities, so that the personnel

can communicate among each other, while hand-held units without voice transmission, but

with call & light buttons as well as a soothing lamp will be available at the bed itself.

The integration of this equipment will have an impact on the workflow in the nursing ward

and should therefore be agreed with the management.

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10. Fault alarm system

The most important fault alarms from the central power supply, from the air-conditioning and

ventilation systems, from the medical gas supply and from the elevators will be indicated

visually and acoustically in a central place via the direct digital control (DDC) equipment.

11. Elevators

Minimum one elevator each for beds and passengers that can reach all levels should be in-

stalled at a central position in the main building. The exact specification for the hospital is

depending to the scale of the hospital.

For reasons of a comfortable running quality, the elevators will be equipped with cable drives

and frequency control. The elevators will be connected with the safety power supply.

Standard descriptive dates are shown hereafter.

Passenger lift Load-bearing capacity: 1600 kg Speed : >= 0.6 m/s Lifting height. Basement to maximum floor Stops : each floor, single-sided Shaft doors: fully-automatic sliding door, Door panels with stainless steel V2A Clear door width: 1400 mm (dimension in unfinished state) Clear door height 2200 mm (dimension in unfinished state) Cabin : in edged construction Cabin dimensions: 1400 x 1600 x 2200 mm Cabin door: 1 item in construction and size as shaft doors, with electronically-

controlled door drive and light barrier for passage securing. Cabin panel: 1 part as wall panel made from stainless steel V2A,

with short-stroke buttons, digital level display Control type: Microcomputer control as group control External call operating/display elements: Panel made from stainless steel V2A with operating and display

elements integrated in the box frame profile. The external call op-erating and display element such as cabin panel must be mounted flush and easily removable for maintenance in the box frame. A cut-out must be provided in the concrete, including 2 empty pipe connections each to the shaft.

Mains connection: 230/400 V, 50 Hz Cabin equipment: Side walls and front wall comprising stainless steel panels the

same size, brushed, 1 mirror on one side, cabin high, b=50 cm Baseboard made from stainless steel V2A Door sills made from extruded aluminium section, suspended

ceiling made stainless steel panels with integrated light box and fluorescent lamps as illumination (indirect) Ventilator, Floor rub-

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ber, Hand bar, single-sided (longitudinal side), stainless steel V2A,

Round pipe D = 34 mm Portal: External portal made from stainless steel V2A, enclosure frame,

filled out completely against concrete side walls and sealed to the concrete walls all round.

Legislation: European Lift Directive 95/16/EC EN81 Bed lift Load-bearing capacity: 2000 kg Speed : >= 1.0 m/s Lifting height basement to maximum floor Stops : each floor, single-sided Shaft doors: as two-part, fully-automatic sliding door, Door panels with stainless steel V2A Clear door width: 1500 mm (dimension in unfinished state) Clear door height: 2200 mm (dimension in unfinished state) Cabin: in edged construction Cabin dimensions: 1500 x 2700 x 2200 mm Cabin door: 1 item in construction and size as shaft doors, with electronically-

controlled door drive and light barrier for passage securing. Cabin panel: 1 part as wall panel made from stainless steel V2A,

with short-stroke buttons, digital level display Control type: Microcomputer control as group control External call operating/display elements: Panel made from stainless steel V2A with operating and display

elements integrated in the box frame profile. The external call op-erating and display element such as cabin panel must be mounted flush and easily removable for maintenance in the box frame. A cut-out must be provided in the concrete, including 2 empty pipe connections each to the shaft.

Mains connection: 230/400 V, 50 Hz Cabin equipment: Side walls and front wall comprising stainless steel panels the

same size, brushed, 1 mirror on one side, cabin high, b=50 cm Baseboard made from stainless steel V2A Door sills made from extruded aluminium section, suspended

ceiling made stainless steel panels with integrated light box and fluorescent lamps as illumination (indirect), Ventilator, Floor rub-ber, Hand bar, single-sided (longitudinal side), stainless steel V2A,

Round pipe D = 34 mm Portal: External portal made from stainless steel V2A, enclosure frame,

filled out completely against concrete side walls and sealed to the concrete walls all round.

Legislation: European Lift Directive 95/16/EC EN81

12. Further equipment

Further equipment and features can be fitted later without great expense and at any time, since

all levels are accessible via the vertical shafts.

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5.3 Investments in Medical Technology Medical technology refers to the diagnostic and therapeutic application of science and tech-

nology to improve the management of health care. A high level of health care can be

achieved with appropriate medical equipment planning for the diagnosis, monitoring and

treatment of medical conditions. These devices must be designed in accordance with rigorous

safety standards to ensure that the well-being of the patient is always at the forefront. Medi-

cal equipment is classified into four main classes according to levels of risk. Each piece of

equipment can also be categorised into various groups, some of which are listed below:

• Diagnostic equipment refers to all medical imaging machines used to aid the diagnosis

process, including x-ray machines, ultrasound, CT scanners and MRI machines

• Therapeutic equipment includes infusion pumps and medical lasers

• Life support equipment refers to equipment used to maintain a patient’s bodily func-

tions, such as dialysis machines, medical ventilators and heart–lung machines

• Medical monitors allow medical staff to measure a patient’s medical state, monitoring

vital parameters such as ECG, EEG, respiration and blood pressure

• Medical laboratory equipment allows for the automated analysis of samples of blood,

urine, etc.

The following medical equipment plan has been developed for the planning of medical tech-

nology throughout the various hospitals of the National Hospital Master Plan of Moldova. It

lists the various medical equipment and furnishings required at the different levelled hospitals

at a basic level, providing an overview of how the functions of these hospitals are fulfilled

with respect to medical technology. A brief description of this equipment is given at the end

of this chapter. A more detailed plan must be created per hospital as the next step after the

completion of the Master Plan, including item specifications, required quantities and costs per

unit item.

The medical equipment plan has been developed in such a way so as to maintain a high level

of equipment performance to promote quality patient health care and to ensure the safety of

both patients and employees.

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Scope of the Plan

To determine the required level of medical technology per hospital of the proposed National

Hospital Master Plan and estimate the basic medical equipment required, as well as to de-

velop effective processes to ensure the safe and proper use of this equipment in patient health

care.

Medical Equipment Management Plan

Following the National Hospital Master Plan, a detailed medical equipment management plan

must be developed consisting of the following:

• Comprehensive study of the processes of the given hospital system in accordance with

the type of hospital, matching health technology and clinical services to the needs of

the hospital, long-term planning and budgeting

• Detailed plan of how the level of medical technology impacts design, basic architec-

ture, functional space relationships, and mechanical, sanitary, heating and electrical

systems

• Facility evaluation assessing space design in accordance with clinical and technical

requirements and department layout to promote efficient staff, patient and supply flow

patterns

• Needs assessment and the creation of a realistic equipment budget, customised per

room and department of each hospital

• Develop policies and procedures governing the acquisition, inspection and mainte-

nance of all patient care equipment

• Inventory allocation analysis to determine the usability of existing equipment for allo-

cation in a new or renovated location, based on safety, reliability and standardisation

• Ensure that all proposed equipment complies with the Safe Medical Devices Act

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• Ensure that a special training programme for employees and staff be carried out for

the necessary medical equipment, addressing equipment capabilities, uses, limitations,

basic operating and safety procedures, emergency response, user errors and failures

Economic requirements for the installation of large-scale medical equipment

The distribution of large-scale medical equipment throughout the hospitals of the National

Hospital Master Plan has been developed in accordance with latest figures of the Organisation

for Economic Cooperation and Development (OECD) standards for countries with an eco-

nomic status similar to or higher than that of the Republic of Moldova. These figures are

taken at approx. 120,000 patients per CT scanner, 520,000 patients per MRI unit and 350,000

patients per Angiocardiography unit. With reference to the International Classification of Pro-

cedures in Medicine (ICPM) from the World Health Organisation, no such standards are pro-

vided for basic diagnostic equipment as they are required by each hospital.

At this stage of the plan a statistical distribution of this type of equipment serves as an esti-

mate only. Following the Master Plan, each hospital will need to be individually evaluated

with respect to the demands of the equipment, average no. of patients, etc. in order for a more

detailed plan to be made.

5.3.1 General

The estimate is based on square meter data of the architectural plans and is divided into:

• building-related medical equipment and

• mobile medical equipment and furnishings

Organisation of the departments is done in accordance with DIN 13080 (Division of Hospitals

in Functional Areas and Functional Sections).

Not included in the calculation of costs are consumables and computer equipment, except for

the PACS system for radiology and the PDMS system for the intensive care ward.

Equipment listed in this estimate is taken according to EU-standards. European manufacturers

were taken as a basis for pricing purposes.

A short description of the equipment listed below per hospital is given in Appendix 1.

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5.3.2 Transit Hospitals

The Transit Hospitals provide for primary patient care including general medicine and minor surgery. Medical Equipment Examination Light Examination table Blood pressure measuring device ECG unit Medical furniture incl. cabinets and cupboards Mobile equipment incl. stands, dressing trolleys

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5.3.3 Local Hospitals

The Local Hospitals provide for primary patient care including general medicine, general surgery, gynaecology / obstetrics and paediatrics. The following departments are also included in these hospitals at a basic level: 5.3.3 - 1.01 Emergency care

Emergency care includes planned shock rooms provided with examination lights and ceiling-suspended supply units and an X-ray room. Assigned to the X-ray department is an admission ward with beds and simple monitoring units. Medical Equipment Examination Light Medical supply unit, ceiling ultrasound-diagnostic-systems Mobile x-ray unit X-ray film screen Patient bed and bedside table Patient monitor with basic parameters such as respiration and ECG Medical furniture Lung ventilator 5.3.3 - 1.02.01 / 1.02.04 / 1.02.06 Consultation clinics for medical, surgical and gynaecol-

ogy

Treatment and examination rooms for medical, surgical, and gynaecology are planned in the consulta-tion clinic. These are provided with the necessary special examination and treatment equipment, such as treatment chairs and cubicles. Medical Equipment Gynaecological examination chair Examination lights Examination tables and chairs Medical furniture 5.3.3 - 1.03 Functional diagnostics

Examination areas for basic functional diagnostics (ECG, spirometry, etc.) with appropriate examina-tion equipment. Medical Equipment ECG unit Spirometer Pulse oximeter Examination Light Examination table

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Blood pressure measuring device ultrasound-diagnostic-systems Medical furniture incl. cabinets and cupboards Mobile equipment incl. stands, dressing trolleys 5.3.3 - 1.05 Laboratory

The central laboratory should be provided with laboratory furniture and necessary analytical equip-ment and analysers for basic diagnostics for haematology and clinical chemistry. Medical Equipment Laboratory work table Haematology analyser Blood scale mixer Blood gas analyser Clinical chemical analyser Blood refrigerator No special blood bank is necessary 5.3.3 - 1.06 Pathology

Facilities for the storage and transport of a number of bodies. Medical Equipment Mortuary refrigerator Mortuary trolley with lifter Medical furniture 5.3.3 - 1.07 X-ray diagnostics

The X-ray diagnostics department is made up of standard X-ray equipment for extremities and fluo-roscopy equipment, including the associated examination rooms. In addition to this, a waiting and recovery area are planned. Medical Equipment X-ray diagnostic system, incl. wall stand for chest diagnostics X-ray film screen Fluoroscopy unit 5.3.3 - 1.09 Operation department

Each operating theatre is to be provided with the same equipment, ceiling-suspended operating light, anaesthesia supply units, surgical supply units, as well as an operating table system. Rooms for preparation are to be provided. These rooms have a wall-mounted supply unit, as well as the appropriate equipment and furnishings. Pre and postoperative monitoring is to be provided on the walls to monitor patients before and after an operation and during recovery, so that they can be resuscitated in the event of an emergency.

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Medical Equipment Examination Light Ceiling medical supply unit, anaesthesiology Ceiling medical supply unit, surgery Operating table, mobile Wall-mounted medical supply unit Patient bed and bedside table Patient monitor Medical furniture Central gas supply via wall sockets with O2, medical compressed air The operation department is to also have an emergency section, and should be located near the gynae-cology and newborn departments. 5.3.3 - 1.10 Delivery

The delivery section is to be equipped with single patient delivery rooms with the appropriate equip-ment and furniture such as delivery beds, pre-monitoring examination rooms with CTG equipment and a rest room. The delivery area is to be complemented by C-section operating theatres; these are equipped in the same way as the operating theatres. Medical Equipment Examination Light Ceiling medical supply unit, anaesthesiology Ceiling medical supply unit, surgery Operating table, mobile Reanimation unit with heat mats Delivery equipment, incl. bed, etc. CTG equipment Ultrasound equipment Cold light generator Transmitted light microscope Colposcope Infrared coagulator Patient scale Medical furniture 5.3.3 - 1.13 Physiotherapy

A physiotherapy department with normal underwater baths is planned. The department is also to con-tain rooms for heat therapy, massage rooms as well as gymnastic rooms with diverse equipment, e.g. mats, bicycles, etc. Medical Equipment Trolley with bathing assistance equipment Gymnastic room equipment (walking bar, bicycle, mats, etc.) Infrared heater Treatment table, electric

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5.3.3 - 2.01 Normal Care

In reference to the Master Plan, each normal ward has been planned with 28-35 beds. Every bed has an adjustable back rest and is height-adjustable. Otherwise, only simple examination equipment is provided in these areas. The department is to also contain a patient examination room with appropriate basic medical examina-tion equipment and furnishing, similar to the Transit hospitals. Medical Equipment Patient bed and bedside table Basic examination equipment such as blood pressure measuring device, etc. 5.3.3 - 2.02 Newborn Ward

On the newborn ward, some of the rooms are equipped as simple patient/baby rooms and in the inten-sive care area there are ceiling-suspended supply units and appropriate incubators. In the milk kitchen, equipment is provided for preparing milk bottles and milk. Medical Equipment Infant scale Reanimation unit with heat mat Milk pump, electric Incubator 5.3.3 - 2.03 Intensive care

The Intensive care wards are set up with special hospital beds and an emergency surgical room. The emergency surgical room is similar to an operating theatre with ceiling-suspended operating lights and supply units for anaesthesia and a supply unit for surgery. This ward should be located near the operat-ing theatres. On the intensive care ward, every bed will be equipped with a supply unit, patient monitoring and infusion therapy equipment. One lung ventilator is located on the ward. The laboratory for the inten-sive care ward is equipped for blood gas measurement. Medical Equipment Patient bed Patient monitor, intensive care: non-invasive Examination table Examination Light Central gas supply via wall sockets with O2 and medical compressed air – in each patient room Infusion equipment (pump and stand) Blood gas analyser Medical furniture Lung ventilator 5.3.3 - 5.01 Pharmacy

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In the pharmacy, an issuing and storage area for medicines is provided. The making up of prescrip-tions is not planned. 5.3.3 - 5.02 Central sterilization department

Worktables for the preparation of non-sterile products, a 2-door washing machine and packaging area as well as sterilizers are planned in the non-sterile area of the central sterilisation department. Medical Equipment Washer / disinfector Steam sterilizer with 4 – 6 sterilisation units, with loading documentation system Sterilization computer system Sterilization accessories Film welding device Worktable

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5.3.4 Specialized Care Hospitals Specialised Care Hospitals fulfil all diagnostic and therapeutic functions of Local Hospitals, and are equipped minimally as such. In order to acquire a higher level of diagnostic standards however these hospitals are equipped with a higher level of medical technology as required. The following specialized departments may be in-cluded (depending on the necessary function of the hospital): 5.3.4 - 1.01 Emergency care

Emergency care includes planned shock rooms provided with examination lights and ceiling-suspended supply units and an X-ray room. Assigned to the X-ray department is an admission ward with beds and simple monitoring units. Medical Equipment Examination Light Medical supply unit, ceiling Mobile x-ray unit X-ray film screen Patient bed and bedside table Patient monitor with basic parameters such as respiration and ECG Medical furniture Lung ventilator 5.3.4 - 1.02.01 / 1.02.04 / 1.02.06 Consultation clinics for medical, surgical and gynaecology

Treatment and examination rooms for medical, surgical, and gynaecology are planned in the consulta-tion clinic. These are provided with the necessary special examination and treatment equipment, such as treatment chairs and cubicles. Dialysis beds with dialysis machines and a central water preparation unit are planned in the general medicine department. Medical Equipment Gynaecological examination chair Examination lights Examination tables and chairs ultrasound-diagnostic-systems Medical furniture Dialysis machine Osmosis unit Patient recliner Patient monitor Infusion equipment 5.3.4 - 1.02.03 Ophthalmology

In addition to general eye diagnostics, special examination rooms for ophthalmologic diagnostics are provided, with an examination unit with slit lamp, refractometer, ophthalmometer, and other such eye examination devices.

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Medical Equipment Refraction and examination unit with slit lamp, applanation tonometer, ophthalmometer, chart projec-tor, phoropter and patient chair Ophthalmoscope Lensometer Line skiascope Projection perimeter, direct, automatic Trial lens case incl. trial frame Eye equipment accessories (eye chart, etc.) An ophthalmology department is envisaged in the following Specialised Care Hospitals: Ocnita, Singerei, Soroca, Ungheni, Orhei, Hincesti, Anenii Noi, Causeni, Comrat 5.3.4 - 1.02.07 ORL

Special examination rooms for Ear, Nose and Throat diagnostics, including ENT diagnostic unit. Medical Equipment ENT diagnostic unit incl. chair Ultrasound scanner, ENT Electrosurgical unit Stroboscope, evaluation unit incl. cold light generator Laryngeal pharyngeal rhinoscope Audiometry unit Rhinomanometer Tympanometer An ORL department is envisaged in the following Specialised Care Hospitals: Ocnita, Singerei, Soroca, Ungheni, Orhei, Hincesti, Anenii Noi, Causeni, Comrat 5.3.4 - 1.02.08 Dermatology / Venereology

General diagnostic rooms for dermatology, allergology and venereology, and specialised treatment rooms for light and laser therapy including the necessary equipment. Medical Equipment CO2 laser system UV light therapy Dermatoscope Examination light Examination table Medical furniture A dermatology, allergology and venereology department is envisaged in the following Specialised Care Hospitals: Ocnita, Singerei, Soroca, Ungheni, Orhei, Causeni, Comrat 5.3.4 - 1.02.10 Cardiology

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The cardiology department is to contain cardiac catheterisation examination units with associated analysis and measuring stations, right heart catheterisation, as well as a recovery area. This department is to be located close to the x-ray department. Medical Equipment Echocardiogram, colour doppler ECG unit Ergometer Patient bed Patient monitor for right heart catheterisation, with invasive pressure measurement Pulse oximeter Blood gas analyser from laboratory to analyse oxygenation status A cardiology department is envisaged in the following Specialised Care Hospitals: Edinet, Singerei, Floresti, Ungheni, Orhei, Hincesti, Anenii Noi, Causeni, Comrat 5.3.4 - 1.02.10 Gastroenterology

Examination rooms with ceiling-suspended supply units for the endoscopes, as well as examination lights and appropriate video endoscopes are planned in the department. The video endoscopes are prepared in machines within the department. Including diagnostic rooms for endoscopy (standard for a central endoscopy department) Medical Equipment Ceiling medical supply unit for endoscopes Video endoscope unit with appropriate endoscopes Examination light Examination table Drying cabinet for endoscopes Medical furniture A gastroenterology department is envisaged in the following Specialised Care Hospitals: Edinet, Floresti, Ungheni, Orhei, Hincesti 5.3.4 - 1.02.10 Pulmonology

Special examination rooms with equipment for lung function measurement. Medical Equipment Ergospirometry meter Bodyplethysmograph Blood gas analyser located in either the intensive ward or laboratory A pulmonology department is envisaged in the following Specialised Care Hospitals: Floresti, Orhei 5.3.4 - 1.02.15 Neurology

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Special diagnostic rooms for electromyography and electroencephalography including evoked poten-tial. Medical Equipment Electroencephalograph (EEG) with evoked potential Electromyograph (EMG) Medical furniture A neurology department is envisaged in the following Specialised Care Hospitals: Edinet, Singerei, Floresti, Ungheni, Orhei, Hincesti, Anenii Noi, Causeni, Comrat 5.3.4 - 1.02.17 Trauma / Orthopaedics

Special examination rooms for the treatment of wounds and injuries. When required, with special rooms with x-ray diagnostics. Medical Equipment Mobile x-ray unit X-ray film screen Examination table Examination light Dressing table and cabinets Surgical tools, external fixtures, etc. Extension table and plastering equipment Cell saver A trauma / orthopaedics department is envisaged in the following Specialised Care Hospitals: Ocnita, Singerei, Soroca, Ungheni, Orhei, Hincesti, Anenii Noi, Causeni, Comrat 5.3.4 - 1.02.22 Urology

Special diagnostic rooms where necessary, with examination equipment for urologic and urodynamic examination. All Transurethral resection operations to take place in the septic operation theatres of the operation department Medical Equipment Examination light Examination table Electrosurgical equipment Flexible sterile endoscopes Urological instruments Medical furniture A urology department is envisaged in the following Specialised Care Hospitals: Ocnita, Singarei, Soroca, Ungheni, Orhei, Hincesti, Anenii Noi, Causeni, Comrat 5.3.4 - 1.05 Laboratories

In the laboratories, the individual departments are provided with laboratory furniture, and the neces-sary analytical equipment and analysers.

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The laboratories of the Specialised Care Hospitals include specialized diagnostic devices for: - general laboratories, - haematology, - clinical chemistry, - immunology and - toxicology

Medical Equipment Standard laboratory devices incl. centrifuges, vacuum pumps, water baths, blood scale mixer Reagent refrigerator Laboratory refrigerator and deep freezer Functional workplaces with cleaning table units Ultrasound cleaning basin, digital Special analysers for different diagnostic applications incl. blood gas analyser, clinical chemical ana-lyser, haematology analyser 5.3.4 - 1.05 Blood bank

In the blood bank, the blood transfusion and sample preparation and cooling departments include fixed laboratory devices, blood-taking beds, as well as the appropriate centrifuges and fridges. Medical Equipment Bed and chair for taking of blood samples Standing centrifuge, cooling Bench-top centrifuge, cooling Blood refrigerator Functional workstation 5.3.4 - 1.06 Pathology

A storage option for a number of bodies as well as autopsy rooms with appropriate autopsy tables are planned in the pathology department. Medical Equipment Mortuary refrigerator Mortuary trolley with lifter Cutting table with suction Autopsy table Wet specimen cabinet, with exhaust Medical furniture 5.3.4 - 1.07 X-ray diagnostics In addition to the standard X-ray equipment and fluoroscopy unit, angiography and CT workplaces are also to be provided. Medical Equipment Computer tomography scanner Angiography system and software Angiography table X-ray diagnostic system, incl. wall stand for chest diagnostics

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X-ray film screen Fluoroscopy unit 5.3.4 - 1.09 Operation department

Each operating theatre is to be provided with the same equipment, ceiling-suspended operating light, anaesthesia supply units, surgical supply units, as well as an operating table system. Preparation rooms are to be provided. These rooms have a supply unit on the wall, as well as the ap-propriate equipment and furnishings. Pre and postoperative monitoring is to be provided on the walls to monitor patients before and after an operation and during recovery, so that they can be resuscitated in the event of an emergency. Medical Equipment Examination Light Ceiling medical supply unit, anaesthesiology Ceiling medical supply unit, surgery Operating table, mobile Wall-mounted medical supply unit Patient bed and bedside table Patient monitor Medical furniture Light source Endo-video unit with documentation system Minimally Invasive Surgery (MIS) equipment The Operations department is to be located in the same building as the laboratory department to allow for quick examination of samples taken from the endoscopy. Minimally invasive surgery can also be performed in the operating theatres. Septic and aseptic operating theatres are available. 5.3.4 - 1.10 Delivery

The delivery section is to be equipped with single patient delivery rooms with the appropriate equip-ment and furniture such as delivery beds, pre-monitoring examination rooms with CTG equipment and a rest room. The delivery area is to be complemented by C-section operating theatres; these are equipped in the same way as the operating theatres. Medical Equipment Examination Light Ceiling medical supply unit, anaesthesiology Ceiling medical supply unit, surgery Operating table, mobile Delivery equipment, incl. bed, etc. CTG equipment Ultrasound equipment Cold light generator Transmitted light microscope Colposcope Infrared coagulator Patient scale

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Medical furniture 5.3.4 - 1.13 Physiotherapy

A physiotherapy department with normal underwater and hydro-electric baths is planned. The de-partment is also to contain rooms for heat therapy, massage rooms as well as gymnastic rooms with diverse equipment, e.g. mats, bicycles, etc. Medical Equipment Medical bathtub Patient lifter with stretcher and seat Trolley with bathing assistance equipment Gymnastic room equipment (walking bar, bicycle, mats, etc.) Infrared heater Treatment table, electric 5.3.4 - 2.01 Normal Care

In reference to the Master Plan, each normal ward has been planned with 28-35 beds. Every bed has an adjustable back rest and is height-adjustable. Otherwise, only simple examination equipment is provided in these areas. The department is to also contain a patient examination room with appropriate basic medical examina-tion equipment and furnishing, similar to the Transit hospitals. Medical Equipment Patient bed and bedside table Basic examination equipment such as blood pressure measuring device, etc. 5.3.4 - 2.02 Newborn Ward

On the newborn ward, some of the rooms are equipped as simple patient/baby rooms and in the inten-sive care area there are ceiling-suspended supply units and appropriate incubators. In the milk kitchen, equipment is provided for preparing milk bottles and milk. Medical Equipment Ceiling medical supply unit Infant scale Reanimation unit with heat mat Milk pump, electric Incubator Transport incubator 5.3.4 - 2.03 Intensive care

Intensive care wards with special hospital beds and an emergency surgical room. The emergency sur-gical room is similar to an operating theatre with ceiling-suspended operating lights and supply units for anaesthesia and a supply unit for surgery.

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On the intensive care ward, every bed is equipped with a supply unit, as well as respiratory, patient monitoring and infusion therapy equipment. The laboratory for the intensive care ward is equipped for blood gas measurement. Medical Equipment Patient bed, intensive care Patient monitor, intensive care Examination table Examination Light Ceiling medical supply unit, anaesthesiology Ceiling medical supply unit, surgery Infusion equipment (pump and stand) Blood gas analyser 5.3.4 - 2.06 Infectious diseases

Special diagnostic rooms with infection control concerning the prevention of the spreading of infec-tion, equipped with basic diagnostic devices and an examination and treatment room. Medical Equipment Examination Light Instrument stand Examination table Functional workstation, washer, disinfection equipment, etc. Treatment cabinet Patient scale Disinfectant dosing device Urine bottle and bedpan stand With hand-disinfection basins in the changing room An infectious diseases department is envisaged in the following Specialised Care Hospitals: Edinet, Singerei, Floresti, Ungheni, Orhei, Anenii Noi, Causeni, Comrat 5.3.4 - 5.01 Pharmacy

In the pharmacy, an issuing and storage area for medicines is provided. The making up of prescrip-tions is not planned. 5.3.4 - 5.02 Central sterilization department

Worktables for the preparation of non-sterile products, a 2-door washing machine and packaging area as well as sterilizers are planned in the non-sterile area of the central sterilisation department. Medical Equipment Washer / disinfector 2 steam sterilizers with 6 - 8 sterilisation units, with loading documentation system Sterilization computer system Sterilization accessories Film welding device Worktable

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5.3.5 High Specialized Care Hospitals In order to acquire a high specialized level of diagnostic standards these hospitals are equipped with an even higher level of medical technology to that of the Specialised Care Hospitals, providing state of the art medical equipment and a higher level of medical diagnostics. The two High Specialised Care Hospitals in Balti and Cahul contain all of the following departments: 5.3.5 - 1.01 Emergency care


Treatment and examination rooms for medical, surgical, and gynaecology are planned in the consulta-tion clinic. These are provided with the necessary special examination and treatment equipment, such as treatment chairs and cubicles. Medical Equipment Gynaecological examination chair Examination lights Examination tables and chairs ultrasound-diagnostic-systems Medical furniture 5.3.5 - 1.02.03 Ophthalmology

In addition to general eye diagnostics, special examination rooms for ophthalmologic diagnostics are provided, with an examination unit with slit lamp, refractometer, ophthalmometer, and other such eye examination devices. Medical Equipment Nd:YAG laser system Refraction and examination unit with slit lamp, applanation tonometer, ophthalmometer, chart projec-tor, phoropter and patient chair Ophthalmoscope Ophthalmoscope, indirect

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Lensometer Line skiascope Projection perimeter, direct, automatic Trial lens case incl. trial frame Eye equipment accessories (eye chart, etc.) 5.3.5 - 1.02.07 ORL

Special examination rooms for Ear, Nose and Throat diagnostics, including ENT diagnostic unit. Medical Equipment ENT diagnostic unit incl. chair Ultrasound scanner, ENT Electrosurgical unit Stroboscope, evaluation unit incl. cold light generator Laryngeal pharyngeal rhinoscope Audiometry unit Rhinomanometer Tympanometer 5.3.5 - 1.02.08 Dermatology / Venereology

General diagnostic rooms for dermatology, allergology and venereology, and specialised treatment rooms for light and laser therapy including the required equipment. Medical Equipment CO2 laser system UV-A and UV-B light therapy Dermatoscope Examination light Examination table Medical furniture 5.3.5 - 1.02.10 Cardiology and Catheterisation

The cardiology and catheterisation department is to contain cardiac catheterisation examination units, a 1-level examination area and a 2-level examination area with associated analysis and measuring sta-tions, right heart and left heart catheterisation, as well as a recovery area. This department is to be located close to the x-ray department. The angiocardiography equipment of the x-ray diagnostics de-partment is to also serve the cardiology department. Medical Equipment Echocardiogram, colour doppler ECG unit Ergometer Patient bed Patient monitor for heart catheterisation with physiological parameter measurement incl. invasive pressure Pulse oximeter Blood gas analyser to analyse oxygenation status

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5.3.5 - 1.02.10 Pulmonology

Special examination rooms with equipment for lung function measurement. Medical Equipment Ergospirometry meter Bodyplethysmograph Blood gas analyser Bronchoscopy equipment All endoscopic examinations are to take place in the endoscopy department. 5.3.5 - 1.02.10 Gastroenterology

Examination and diagnostic rooms for examinations such as long term PHmetry, with ceiling-suspended supply units as well as examination lights are planned in the department. Endoscopic ex-amination is carried out in the central endoscopy department, which should be located close by. A separate room is to be used for ERCP, including an x-ray worktable, necessary endoscopes, etc. Medical Equipment Ceiling medical supply unit for endoscopes Examination light Examination table PHmetry equipment 5.3.5 - 1.02.15 Neurology

Special diagnostic rooms for electromyography, electroencephalography including evoked potential and electronystagmography. Medical Equipment Electroencephalograph (EEG) with evoked potential, incl. trolley and PC Electromyograph (EMG) Electronystagmograph (ENG) Medical furniture 5.3.5 - 1.02.17 Trauma / Orthopaedics

Special examination rooms for the treatment of wounds and injuries. When required, with special rooms with x-ray diagnostics. Medical Equipment Mobile x-ray unit X-ray film screen Examination table Examination light Dressing table and cabinets Surgical tools, etc. Extension table and plastering equipment Autologous blood donation equipment

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Blood refrigerator Apheresis equipment 5.3.5 - 1.02.22 Urology

Special diagnostic rooms where necessary, with examination equipment for urologic and urodynamic examination. The urology department is to have its own rooms for performing transurethral resection operations. Medical Equipment Examination light Examination table Electrosurgical equipment Medical furniture Urological measuring station Urologic C-arm 5.3.5 - 1.04 Endoscopy

All endoscopic examination is to take place in the endoscopy department. This department is to be made up of separate septic and aseptic examination rooms for all interdisciplinary endoscopic exami-nations and a central cleaning and disinfection area. Medical Equipment Endo video unit Flexible endoscopes for all endoscopy procedures (bronchoscopy, colonoscopy, rectoscopy, gastroen-teroscopy, etc.) Integrated cold light generator and suction pumps Image documentation systems Cleaning and disinfection unit 5.3.5 - 1.05 Laboratories

The laboratories of the High Specialised Care Hospitals include specialized diagnostic devices for: - general laboratories, - haematology, - clinical chemistry, - immunology, - toxicology, - bacteriology, - virology and - serology

These analytical equipment and automatic analysers are at a very high standard of technology. Medical Equipment Standard laboratory devices incl. centrifuges, vacuum pumps, water baths, blood scale mixer Reagent refrigerator Laboratory refrigerator and deep freezer Functional workplaces with cleaning table units

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Ultrasound cleaning basin, digital Special analysers for different diagnostic applications incl. blood gas analyser, clinical chemical ana-lyser, haematology analyser 5.3.5 - 1.05 Blood bank

In the blood bank, the blood transfusion and sample preparation and cooling departments include fixed laboratory devices, blood-taking beds, as well as the appropriate centrifuges and fridges. Medical Equipment Bed and chair for taking of blood samples Standing centrifuge, cooling Bench-top centrifuge, cooling Blood refrigerator Functional workstation Apheresis equipment 5.3.5 - 1.06 Pathology

A storage option for a number of bodies as well as autopsy rooms with the appropriate autopsy tables are planned in the pathology department. Medical Equipment Mortuary refrigerator Mortuary trolley and lifter Cutting table with suction Autopsy table Wet specimen cabinet, with exhaust Medical furniture 5.3.5 - 1.07 X-ray diagnostics

Additional to the radiology department of the Specialised Care Hospitals with X-ray equipment, fluo-roscopy unit, Angiography and Computer tomography workplaces, Angiocardiography and Magnetic Resonance Imaging equipment is also to be provided. Medical Equipment MRI unit, 1.5 Tesla incl. anaesthesia machine, coil stand and cabinet RF and magnetic shielding Standard hardware and software Patient camera and control unit, supervising monitor High pressure injector Computer tomography scanner Angiocardiography system and software Angiography table 5.3.5 - 1.09 Operation department

Each operating theatre is to be provided with the same equipment, ceiling-suspended with an operating light, anaesthesia supply units, surgical supply units, as well as an operating table system.

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Preparation rooms are to be provided. These rooms have a supply unit on the wall, as well as the ap-propriate equipment and furnishings. Pre and postoperative monitoring is to be provided on the walls to monitor patients before and after an operation and during recovery, so that they can be resuscitated in the event of an emergency. Medical Equipment Examination Light Ceiling medical supply unit, anaesthesiology Ceiling medical supply unit, surgery Operating table, mobile Wall-mounted medical supply unit Patient bed and bedside table Patient monitor Medical furniture Light source Endo-video unit with documentation system Minimally Invasive Surgery (MIS) equipment Central CO2 and medical gases supply The Operations department is to be located in the same building as the laboratory department to allow for quick examination of samples taken from the endoscopy. The operations department is to have special operating theatres specifically for minimally invasive surgery. Septic and aseptic operating theatres are available. 5.3.5 - 1.10 Delivery

The delivery section is to be equipped with single patient delivery rooms with the appropriate equip-ment and furniture such as delivery beds, pre-monitoring examination rooms with CTG equipment and a rest room. The delivery area is to be complemented by C-section operating theatres; these are equipped in the same way as the operating theatres. Medical Equipment Examination Light Ceiling medical supply unit, anaesthesiology Ceiling medical supply unit, surgery Operating table, mobile Delivery equipment, incl. bed, etc. CTG equipment Ultrasound equipment Cold light generator Transmitted light microscope Colposcope Infrared coagulator Patient scale Reanimation unit for infants

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5.3.5 - 1.13 Physiotherapy

A physiotherapy department with normal underwater and hydro-electric baths is planned. The de-partment is also to contain rooms for heat therapy, massage rooms as well as gymnastic rooms with diverse equipment, e.g. mats, bicycles, etc. Medical Equipment Medical bathtub Patient lifter with stretcher and seat Trolley with bathing assistance equipment Gymnastic room equipment (walking bar, bicycle, mats, etc.) Infrared heater Treatment table, electric 5.3.5 - 2.01 Normal Care

In reference to the Master Plan, each normal ward has been planned with 28-35 beds. Every bed has an adjustable back rest and is height-adjustable. Otherwise, only simple examination equipment is provided in these areas. Each department of the hospital is to have it’s own specialised patient ward, containing a patient ex-amination room with appropriate basic medical examination equipment and furnishing, similar to the Transit hospitals. Medical Equipment Patient bed and bedside table Basic examination equipment such as blood pressure measuring device, etc. 5.3.5 - 2.03 Intensive care

Intensive care wards with special hospital beds and an emergency surgical room. The emergency sur-gical room is similar to an operating theatre with ceiling-suspended operating lights and supply units for anaesthesia and a supply unit for surgery. On the intensive care ward, every bed will be equipped with a supply unit, as well as respiratory, pa-tient monitoring and infusion therapy equipment. The laboratory for the intensive care ward is equipped for blood gas measurement. The intensive care ward is to also have a neonatological section with special monitoring and lung function equipment for newborns, ceiling suspended supply units and appropriate incubators. Medical Equipment Patient bed, intensive care Patient monitor, intensive care Examination table Examination Light Ceiling medical supply unit, anaesthesiology Ceiling medical supply unit, surgery Infusion equipment (pump and stand) Blood gas analyser Neonatological incubator with monitor Transport incubators from the neonatology department

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Monitors for newborns Lung ventilator 5.3.5 - 2.04 Dialysis and nephrology

Dialysis beds with dialysis machines and a central water preparation unit are planned in the depart-ment. Medical Equipment Dialysis machine Osmosis unit Patient recliner Patient monitor Infusion equipment 5.3.5 - 2.05 Neonatology

In the neonatology department, some of the rooms are equipped as simple patient/baby rooms, with a neonatology intensive care section as part of the intensive care department. The Neonatology depart-ment should be located near the intensive care department. In the milk kitchen, equipment is provided for preparing milk bottles and milk. Medical Equipment Ceiling medical supply unit Infant scale Reanimation unit with heat mat Milk pump, electric Incubator Transport incubator 5.3.5 - 2.06 Infectious diseases

Special diagnostic rooms with infection control concerning the prevention of the spreading of infec-tion, equipped with basic diagnostic devices. Medical Equipment Examination Light Instrument stand Examination table Functional workstation, washer, disinfection equipment, etc. Treatment cabinet Patient scale Disinfectant dosing device Urine bottle and bedpan stand 5.3.5 - 5.01 Pharmacy

In the pharmacy, an issuing and storage area for medicines is provided.

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5.3.5 - 5.02 Central sterilization department

Worktables for the preparation of non-sterile products, a 2-door washing machine and packaging area as well as sterilizers are planned in the non-sterile area of the central sterilisation department. Medical Equipment Washer / disinfector 3 or 4 steam sterilizers upon requirement, each with 6 - 8 sterilisation units, with loading documenta-tion system Sterilization computer system Sterilization accessories Film welding device Worktable

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5.3.6 Centres of Excellence The Centres of Excellence are essentially High Specialised Care Hospitals that furthermore provide medical care on highest level. These Centres also provide the highest level of specialized medical di-agnostics. 5.3.6 - 1.01 Emergency care


Treatment and examination rooms for medical, surgical, and gynaecology are planned in the consulta-tion clinic. These are provided with the necessary special examination and treatment equipment, such as treatment chairs and cubicles. Medical Equipment Gynaecological examination chair Examination lights Examination tables and chairs ultrasound-diagnostic-systems Medical furniture 5.3.6 - 1.02.03 Ophthalmology

In addition to general eye diagnostics, special examination rooms for ophthalmologic diagnostics are provided, with an examination unit with slit lamp, refractometer, ophthalmometer, and other such eye examination devices. Medical Equipment Nd:YAG laser system Refraction and examination unit with slit lamp, applanation tonometer, ophthalmometer, chart projec-tor, phoropter and patient chair Ophthalmoscope Ophthalmoscope, indirect Lensometer

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Line skiascope Projection perimeter, direct, automatic Trial lens case incl. trial frame Eye equipment accessories (eye chart, etc.) 5.3.6 - 1.02.07 ORL

Special examination rooms for Ear, Nose and Throat diagnostics, including ENT diagnostic unit. Medical Equipment ENT diagnostic unit incl. chair Ultrasound scanner, ENT Electrosurgical unit Stroboscope, evaluation unit incl. cold light generator Laryngeal pharyngeal rhinoscope Audiometry unit Rhinomanometer Tympanometer 5.3.6 - 1.02.08 Dermatology / Venereology

General diagnostic rooms for dermatology, allergology and venereology, and specialised treatment rooms for light and laser therapy including the required equipment. Medical Equipment CO2 laser system UV-A and UV-B light therapy Dermatoscope Examination light Examination table Medical furniture 5.3.6 - 1.02.10 Cardiology and Catheterisation

The cardiology and catheterisation department is to contain cardiac catheterisation examination units, a 1-level examination area and a 2-level examination area with associated analysis and measuring sta-tions, right heart and left heart catheterisation, as well as a recovery area. This department is to be located close to the x-ray department. The angiocardiography equipment of the x-ray diagnostics de-partment is to also serve the cardiology department. Medical Equipment Echocardiogram, colour doppler ECG unit Ergometer Patient bed Patient monitor for heart catheterisation with physiological parameter measurement incl. invasive pressure Pulse oximeter Blood gas analyser to analyse oxygenation status

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5.3.6 - 1.02.10 Pulmonology

Special examination rooms with equipment for lung function measurement. Medical Equipment Ergospirometry meter Bodyplethysmograph Blood gas analyser Bronchoscopy equipment All endoscopic examinations are to take place in the endoscopy department. 5.3.6 - 1.02.10 Gastroenterology

Examination and diagnostic rooms for examinations such as long term PHmetry, with ceiling-suspended supply units as well as examination lights are planned in the department. Endoscopic ex-amination is carried out in the central endoscopy department, which should be located close by. A separate room is to be used for ERCP, including an x-ray worktable, necessary endoscopes, etc. Medical Equipment Ceiling medical supply unit for endoscopes Examination light Examination table PHmetry equipment 5.3.6 - 1.02.15 Neurology

Special diagnostic rooms for electromyography, electroencephalography including evoked potential and electronystagmography. Medical Equipment Electroencephalograph (EEG) with evoked potential, incl. trolley and PC Electromyograph (EMG) Electronystagmograph (ENG) Medical furniture 5.3.6 - 1.02.17 Trauma / Orthopaedics

Special examination rooms for the treatment of wounds and injuries. When required, with special rooms with x-ray diagnostics. Medical Equipment Mobile x-ray unit X-ray film screen Examination table Examination light Dressing table and cabinets Surgical tools, etc. Extension table and plastering equipment Autologous blood donation equipment

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Blood refrigerator Apheresis equipment

5.3.6 - 1.02.22 Urology

Special diagnostic rooms where necessary, with examination equipment for urologic and urodynamic examination. The urology department is to have its own rooms for performing transurethral resection operations. Medical Equipment Examination light Examination table Electrosurgical equipment Medical furniture Urological measuring station Urologic C-arm 5.3.6 - 1.04 Endoscopy

All endoscopic examination is to take place in the endoscopy department. This department is to be made up of separate septic and aseptic examination rooms for all interdisciplinary endoscopic exami-nations and a central cleaning and disinfection area. Medical Equipment Endo video unit Flexible endoscopes for all endoscopy procedures (bronchoscopy, colonoscopy, rectoscopy, gastroen-teroscopy, etc.) Integrated cold light generator and suction pumps Image documentation systems Cleaning and disinfection unit 5.3.6 - 1.05 Laboratories

Additional to the laboratory functions of the High Specialised Care Hospitals, the diagnostic equip-ment are very specialized. Devices are envisaged for:

- general laboratories, - haematology, - clinical chemistry, - immunology, - toxicology, - bacteriology, - virology and - serology - microbiology department

These analytical equipment and automatic analysers are at a very high standard of technology. Medical Equipment Standard laboratory devices incl. centrifuges, vacuum pumps, water baths, blood scale mixer

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Reagent refrigerator Laboratory refrigerator and deep freezer Functional workplaces with cleaning table units Ultrasound cleaning basin, digital Special analysers for different diagnostic applications incl. blood gas analyser, clinical chemical ana-lyser, haematology analyser 5.3.6 - 1.05 Blood bank

In the blood bank, the blood transfusion and sample preparation and cooling departments include fixed laboratory devices, blood-taking beds, as well as the appropriate centrifuges and fridges. Medical Equipment Bed and chair for taking of blood samples Standing centrifuge, cooling Bench-top centrifuge, cooling Blood refrigerator Functional workstation Apheresis equipment 5.3.6 - 1.06 Pathology

A storage option for a number of bodies as well as autopsy rooms with the appropriate autopsy tables are planned in the pathology department. Medical Equipment Mortuary refrigerator Mortuary trolley and lifter Cutting table with suction Autopsy table Wet specimen cabinet, with exhaust Medical furniture 5.3.6 - 1.07 X-ray diagnostics

Additional to the radiology department of the Specialised Care Hospitals with X-ray equipment, fluo-roscopy unit, Angiography and Computer tomography workplaces, Angiocardiography and Magnetic Resonance Imaging equipment is also to be provided. Medical Equipment MRI unit, 1.5 Tesla incl. anaesthesia machine, coil stand and cabinet RF and magnetic shielding Standard hardware and software Patient camera and control unit, supervising monitor High pressure injector Computer tomography scanner Angiocardiography system and software Angiography table

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5.3.6 - 1.09 Operation department

Each operating theatre is to be provided with the same equipment, ceiling-suspended with an operating light, anaesthesia supply units, surgical supply units, as well as an operating table system. Preparation rooms are to be provided. These rooms have a supply unit on the wall, as well as the ap-propriate equipment and furnishings. Pre and postoperative monitoring is to be provided on the walls to monitor patients before and after an operation and during recovery, so that they can be resuscitated in the event of an emergency. Medical Equipment Examination Light Ceiling medical supply unit, anaesthesiology Ceiling medical supply unit, surgery Operating table, mobile Wall-mounted medical supply unit Patient bed and bedside table Patient monitor Medical furniture Light source Endo-video unit with documentation system Minimally Invasive Surgery (MIS) equipment Central CO2 and medical gases supply The Operations department is to be located in the same building as the laboratory department to allow for quick examination of samples taken from the endoscopy. The operations department is to have special operating theatres specifically for minimally invasive surgery. Septic and aseptic operating theatres are available. 5.3.6 - 1.10 Delivery

The delivery section is to be equipped with single patient delivery rooms with the appropriate equip-ment and furniture such as delivery beds, pre-monitoring examination rooms with CTG equipment and a rest room. The delivery area is to be complemented by C-section operating theatres; these are equipped in the same way as the operating theatres. Medical Equipment Examination Light Ceiling medical supply unit, anaesthesiology Ceiling medical supply unit, surgery Operating table, mobile Delivery equipment, incl. bed, etc. CTG equipment Ultrasound equipment Cold light generator Transmitted light microscope Colposcope Infrared coagulator Patient scale Reanimation unit for infants

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5.3.6 - 1.13 Physiotherapy

A physiotherapy department with normal underwater and hydro-electric baths is planned. The de-partment is also to contain rooms for heat therapy, massage rooms as well as gymnastic rooms with diverse equipment, e.g. mats, bicycles, etc. Medical Equipment Medical bathtub Patient lifter with stretcher and seat Trolley with bathing assistance equipment Gymnastic room equipment (walking bar, bicycle, mats, etc.) Infrared heater Treatment table, electric 5.3.6 - 2.01 Normal Care In reference to the Master Plan, each normal ward has been planned with 28-35 beds. Every bed has an adjustable back rest and is height-adjustable. Otherwise, only simple examination equipment is provided in these areas. Each department of the hospital is to have it’s own specialised patient ward, containing a patient ex-amination room with appropriate basic medical examination equipment and furnishing, similar to the Transit hospitals. Medical Equipment Patient bed and bedside table Basic examination equipment such as blood pressure measuring device, etc. 5.3.6 - 2.03 Intensive care

Intensive care wards with special hospital beds and an emergency surgical room. The emergency sur-gical room is similar to an operating theatre with ceiling-suspended operating lights and supply units for anaesthesia and a supply unit for surgery. On the intensive care ward, every bed will be equipped with a supply unit, as well as respiratory, pa-tient monitoring and infusion therapy equipment. The laboratory for the intensive care ward is equipped for blood gas measurement. The intensive care ward is to also have a neonatological section with special monitoring and lung function equipment for newborns, ceiling suspended supply units and appropriate incubators. Medical Equipment Patient bed, intensive care Patient monitor, intensive care Examination table Examination Light Ceiling medical supply unit, anaesthesiology Ceiling medical supply unit, surgery Infusion equipment (pump and stand) Blood gas analyser Neonatological incubator with monitor Transport incubators from the neonatology department Monitors for newborns

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Lung ventilator 5.3.6 - 2.04 Dialysis and nephrology

Dialysis beds with dialysis machines and a central water preparation unit are planned in the depart-ment. Medical Equipment Dialysis machine Osmosis unit Patient recliner Patient monitor Infusion equipment 5.3.6 - 2.05 Neonatology In the neonatology department, some of the rooms are equipped as simple patient/baby rooms, with a neonatology intensive care section as part of the intensive care department. The Neonatology depart-ment should be located near the intensive care department. In the milk kitchen, equipment is provided for preparing milk bottles and milk. Medical Equipment Ceiling medical supply unit Infant scale Reanimation unit with heat mat Milk pump, electric Incubator Transport incubator 5.3.6 - 2.06 Infectious diseases

Special diagnostic rooms with infection control concerning the prevention of the spreading of infec-tion, equipped with basic diagnostic devices. Medical Equipment Examination Light Instrument stand Examination table Functional workstation, washer, disinfection equipment, etc. Treatment cabinet Patient scale Disinfectant dosing device Urine bottle and bedpan stand 5.3.6 - 5.01 Pharmacy

In the pharmacy, an issuing and storage area for medicines is provided.

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5.3.6 - 5.02 Central sterilization department

Worktables for the preparation of non-sterile products, a 2-door washing machine and packaging area as well as sterilizers are planned in the non-sterile area of the central sterilisation department. Medical Equipment Washer / disinfector 3 or 4 steam sterilizers upon requirement, each with 6 - 8 sterilisation units, with loading documenta-tion system Sterilization computer system Sterilization accessories Film welding device Worktable

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5.3.7 University Hospitals The University Hospitals are essentially Centres of Excellence that furthermore provide for a learning environment including medical research and training. These Centres also provide in their specialised disciplines the highest level of medical diagnostics and treatment.

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Item Descriptions Local Hospital

Blood gas analyser – analyser for measuring pH and blood gas Blood pressure measuring device – digital device for measuring maximum and lowest blood pressure Blood refrigerator – for the storage of blood bags (500 mL) Blood scale mixer – device used for the weighing and steady mixing of blood Ceiling medical supply unit – ceiling-mounted supply unit for oxygen, medical compressed air, vac-uum, power, gas suction, etc. Clinical chemical analyser - for the analysis of glucose, uric acid, urea, triglycerides, cholesterol, so-dium and potassium Cold light generator – as a light source for endoscopy Colposcope – a lighted magnifying instrument used in gynaecology to examine the tissues of the va-gina and the cervix CTG equipment – Cardiotocograph for the monitoring of the fetal heart Delivery equipment – special equipment used in giving birth, such as delivery bed, etc. ECG unit – for measuring the electrical activity of the heart Examination Light – wall / ceiling mounted / on stand light for treatment and examination Examination table – patient table for examination and treatment Film welding device - general for sterilisation according to international standards Fluoroscopy unit – x-ray imaging device with image intensifier for the diagnostics in the abdominal area Haematology analyser – analyser for measuring blood count, etc. Incubator – used in neonatology for keeping the baby’s temperature constant Infant scale - scale for the measuring of the weight of infants Infrared coagulator – device for the coagulation of tissue by means of infrared radiation Infrared heater – infrared heating device used for heat therapy treatment Infusion equipment (pump and stand) – infusion pump for infusing fluids and medication into a pa-tients circulatory system Laboratory work table – work space used in the laboratory department Lung ventilator – to provide mechanical ventilation for patients in intensive care Medical furniture – furniture comprised of table, cabinets, cupboards, basins, etc. in the various medi-cal rooms of the hospital Milk pump, electric – electrical breast pump for extracting milk Mobile x-ray unit – mobile x-ray imaging system for use in clinical wards outside the x-ray depart-ment Mortuary refrigerator – refrigerator for the storage of corpses Mortuary trolley with lifter – trolley to transport corpses Operating table, mobile – mobile patient table used in the operating theatres Patient monitor - basic colour universal monitor with parameters such as ECG, pulse rate, respiration Patient monitor, intensive care: non-invasive – ECG, pulse rate, respiration, non-invasive blood pres-sure, temperature Patient scale – scale for the measuring of the weight of a patient Pulse oximeter – device for indirectly measuring the oxygen saturation of a patient’s blood Reanimation unit with heat mats – reanimation unit with heat mats, suction unit, oxygen supply, etc. Spirometer – device for measuring the amount of air inspired and expired by the lungs Steam sterilizer with sterilisation units, with loading documentation system, accessories and computer system Transmitted light microscope – microscope system using transmitted light Treatment table, electric – electrically operated patient examination and treatment table ultrasound-diagnostic-systems and Ultrasound equipment – imaging devices using ultrasound wave technology for image reconstruction Washer / disinfector – washer and disinfection system for instruments and endoscopy equipment X-ray diagnostic system, incl. wall stand for chest diagnostics X-ray film screen – x-ray screen for the viewing of x-ray images

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Specialised Care Hospitals

Angiography system – x-ray based imaging device for detailed information of the state of body tissue, with table Audiometry unit – audiometer system for the testing of hearing Autopsy table – table for performing human autopsies Bench-top centrifuge, cooling – device used for the separation of biological substances of differing densities, bench-top model, with refrigerator Bodyplethysmograph - a compartment device for studying alveolar pressures, lung volumes, and air-way resistance Cell saver – for washing and filtering of blood during an operation in order that it can be given back to the patient CO2 laser system – for laser intervention and treatment Computer tomography scanner –sliced imaging system for radiology Cutting table with suction – table used for cutting tissue in pathology, with suction unit Dermatoscope – device for the examination of skin lesions Dialysis machine – machine used to filter a patients blood to remove excess water and waste when a patients kidneys do not function properly Disinfectant dosing device - microprocessor controlled dosing device for the production of disinfectant solution for instruments and surfaces Drying cabinet for endoscopes – cabinet used for the storage of endoscopes to keep them dry and ster-ile Echocardiogram, colour doppler – ultrasound technique to image 2-dimensional slices of the heart, with blood flow assessment and cardiac tissue Electroencephalograph (EEG) with evoked potential – recording device of electrical activity of neu-rons on the scalp, with response to a stimulus Electromyograph (EMG) - technique for evaluating and recording the activation signal of muscles Electrosurgical unit – high frequency surgery device for cutting tissue and coagulating blood Endo-video unit with documentation system – endoscopy video unit with image recording and docu-mentation system ENT diagnostic unit incl. chair – examination and treatment unit for use in the ear, nose and throat department with optical instruments, cleaning basin, etc. Ergometer - An instrument for measuring the amount of work done by a muscle or group of muscles Ergospirometry meter - diagnostic procedure to continuously measure respiration and gas metabolism during ergometer exercise Extension table and plastering equipment Film welding device – standard continuous sealing machine with cutter, work table including measur-ing guide and film roll magazine Flexible sterile endoscopes - flexible endoscopes for use in various endoscopy procedures Gynaecological examination chair – special examination chair for use in gynaecology Laboratory refrigerator and deep freezer – refrigerator and freezer to be used in the laboratory depart-ment Laryngeal pharyngeal rhinoscope – instrument for examining the nasal cavity Lensometer - instrument to measure the power of an existing lens Line skiascope – to measure the refractive behavior of the eye Ophthalmoscope – a lighted instrument used to examine the eye Osmosis unit – for the preparation of water for use in dialysis Patient lifter with stretcher and seat – device for lifting patient Patient monitor, intensive care, for right heart catheterisation: ECG, pulse rate, respiration, non-invasive blood pressure, intravenous blood pressure Projection perimeter, direct, automatic - a perimeter that uses a spot of light as a target that can be adjusted rapidly (size, brightness, and colour), moving silently at any desired speed Reagent refrigerator – refrigerator for the storage of reagents Refraction and examination unit with slit lamp, applanation tonometer, ophthalmometer, chart projec-tor, phoropter and patient chair

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Rhinomanometer - a device used to measure nasal inspiratory flow and pressure Special analysers for different diagnostic applications incl. blood gas analyser, clinical chemical ana-lyser, haematology analyser Standard laboratory devices incl. centrifuges, vacuum pumps, water baths, blood scale mixer Standing centrifuge, cooling - device used for the separation of biological substances of differing den-sities, standing model, with refrigerator Stroboscope, evaluation unit incl. cold light generator – device for examining the vocal chords Tympanometer - to measure the sound transmission properties of the middle ear ultrasound-diagnostic-systems and Ultrasound equipment – imaging devices using ultrasound wave technology for image reconstruction Ultrasound scanner, ENT - imaging device using ultrasound wave technology for image reconstruc-tion, used in ear nose and throat applications UV light therapy – skin treatment procedure using UV light Wet specimen cabinet, with exhaust – storage cabinet for wet specimens with exhaust fan

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High Specialised Care Hospitals / Centre of Excellence

Apheresis equipment – device for filtering blood during an operation, separating out one particular constituent in order that it can be given back to the patient Autologous blood donation equipment – equipment for the removal and reinfusion of a patients own blood Bronchoscopy equipment – equipment used for visualising the airways Electronystagmograph (ENG) - a method for measuring the electrical activity of the eye muscles High pressure injector - microprocessor-controlled contrast medium injector with volume, flow and time control Minimally Invasive Surgery (MIS) equipment – laparoscopic surgery tools Monitors for newborns – basic colour universal monitor with parameters such as ECG, pulse rate, respiration MRI unit, 1.5 Tesla incl. anaesthesia machine, coil stand and cabinet Nd:YAG laser system - for laser intervention and treatment PHmetry equipment – equipment used for gastroenterology diagnosis ultrasound-diagnostic-systems and Ultrasound equipment – imaging devices using ultrasound wave technology for image reconstruction Ultrasound scanner, ENT – ultrasound equipment used in Ear, Nose and Throat procedures Urologic C-arm – urethral x-ray equipment Urological measuring station – special diagnostic equipment used in urology UV-A and UV-B light therapy – used in dermatology for special skin therapy applications

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5.4 Further investment needs

5.4.1 Data Management

Regarding the necessity of constantly collecting and updating the data from all included hos-

pitals the consultant urgently recommends a basic Data Management to be installed at all

hospitals.

The profit of this technique is

o getting complete patient data as

• date of admission

• date of discharge

• the resulting length of stay

• sex, age

• indication, department

• primary and secondary diagnosis

• place of residence (catchment area)

• insurance status (compulsory or private, supplementary insurance)

o reliability of collected data

o basis for a testing mechanism

In order to steer the distribution of public monies by The World Bank or other financiers

more justly, it is necessary that correct patient -movements and -treatments are documented

electronically without gaps so that they become easier to analyze.

The master plan can only in this way be steadily tested and adjusted. Differences between the

predictions and estimations are minimized and tendencies of the structural development of the

hospitals become evident. The program to be selected is extendable as a complete “clinic-

system” and therefore is not an additional burden for the hospitals.

5.4.2 Other investments

There is not only a demand for restructuring and optimizing hospital services.

Additional investments are necessary for

• Emergency care

• Rescue services

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• Nursing services

• Treatment of chronic diseases

• Palliative medicine

• Education of medical personnel

• Health Insurance

• Nursing Care Insurance

These requirements have to be regarded especially in cooperation between the Ministry of

Health and the Ministry of Social Affairs. Some of the listed tasks, such as the treatment of

chronic diseases or palliative medicine could in future additionally be taken over by the Tran-

sit Hospitals.

Besides the investment for buildings, technical and medical infrastructure, maintenance costs

and operation costs there would be a great need for investment in the infrastructure for exam-

ple:

• streets,

• public transport,

• energy supplies,

• orderly disposal of medical wastes

For example district cooperation of the hospitals in the healthcare-zones postulates a network

of streets, transport and communication systems, in such a way as to make synergy effects

possible. As these necessities are mainly attached to other responsibilities, quantification is

not possible in the hospital master plan.

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6 Effects on other Providers In the following some aspects on other providers or other functional allocations are made.

Financial aspects are not part of the Master Plan.

6.1 Ambulant Primary care

Ever since ambulant primary care was first mentioned, many definitions of what primary care

means and comprises have been added. One possible definition looks at staff, another takes

medical specialities into account, yet another is orientated to the set of activities such as the

level of care, or is specified by attributes (IOM definition). Overall the basic definition is that

primary care offers healthcare to consumers. With this approach primary care has a wide

scope of healthcare services covering patients of all ages, it provides medical treatment to

patients with multiple chronic diseases as well as to patients seeking to maintain optimal

health, and it also contains aspects of preventive care. Part of the prevention process is for

example immunisation, secondary prevention of complications of chronic diseases, prenatal

care and nutrition aspects. In many cases primary care is the first point of contact for advice

and / or care of patients. Another characteristic is a high degree of continuity in the care of

patients by the Primary Care Trust (PCT). This trust forms the liaison between primary, sec-

ondary and social care and often works in the preparation and follow-up of inpatient care.

Based on the role of primary care the medical team must be adequately staffed - either only

nurses or nurses and physicians. The main task of primary care is simple diagnostics and

therapeutics, for example checking blood pressure and blood sugar, taking blood samples,

giving injections, caring for wounds, pressuring ulcers and performing a health risk assess-

ment for the patient. Therefore the recommendation is that primary care should be staffed by

nurses. Should the required treatment be more complicated, primary care will recommend that

the patient sees his / her family doctor.

In recognition of the tasks of primary care general conditions have to be defined. These gen-

eral conditions include standard treatment protocols, 24 hours service, 24 hours access to

medical advice, provision of essential drugs or continuing management of chronic illness.

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Moldova has introduced primary care in many rural districts, which are equipped with stan-

dard medical equipment and staffed mostly by nurses.

6.2 Emergency Care

In providing access to healthcare services two aspects have to be taken into account. General

medical treatment can be divided into elective cases and emergency cases. The latter has to be

ensured for all the citizens of the Republic of Moldova. Medical help has to be provided

within an achievable time in order to safeguard the patient’s health. Depending on the cause

and severity of an acute illness, emergency patients may have to be hospitalised.

Some general conditions have to be fulfilled for hospitals specialised in emergency care.

These include special departments with appropriate medical equipment, and medically trained

staff (physicians, nurses as well as medical assistants such as theatre nurses) as well as

knowledge of emergency treatment, also the building structure with emergency rooms and

intensive-care wards. The chief physician is responsible for the medical treatment as well as

the advanced professional training for all persons involved.

Basically all hospitals will provide emergency care. Transit Hospitals and the Local Hospitals

have to ensure cardio-pulmonary stability, the possibility to triage patients and the transport-

ability of the patient.

In line with the developed concept of acute-care inpatient healthcare services, emergency care

services are provided in dependence of the specialising direction of the Specialised Hospitals.

Every specialised hospital will be able to provide basic emergency care within their general

medicine and general surgery departments. They will also be able to provide additional emer-

gency care services according to their medical orientation. Hospitals with specialised non-

surgical departments will be able to treat more complex emergency cases in these medical

fields (severe gastrointestinal bleeding, myocardial infarction, strokes, cases of poisoning

etc.). Hospitals with specialised surgical departments on the other hand will be able to provide

more complex emergency services in surgical medical fields (bone fractures, spinal injury,

abdominal trauma, face trauma etc.).

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If necessary these specialised departments will be supported by the specially identified de-

partments in Chisinau as well as in Balti and in Cahul, where emergency cases will also be

treated. This specialised service can be performed either by sending out medical experts to

support local experts treating emergency patients who cannot be transported or by transport-

ing the emergency patient to another hospital with the required knowledge once the patient is

vitally stable. A third option would be to implement telemedicine, which would allow experts

to support treatment almost regardless of their location.

In all cases a well functioning emergency care system needs to be linked to international

standards for emergency care. Close coordination between different providers of emergency

care is essential as well as cooperation with providers of rescue services. A coordinative cen-

tre for emergency care could be introduced in order to ensure the best treatment as fast as pos-

sible, it should be linked to the central rescue services centre, or both tasks could be provided

by one centre. It has to be known where the experts for certain complex cases are located,

what kind of medical equipment is necessary for the treatment of each case and where it can

be found. Furthermore all of these aspects have to be coordinated and brought together in

order to treat the patient properly.

If installed properly, a coordinative system as described above, supported by telemedicine and

communication infrastructure should be able to work more efficiently and more effectively in

a small country like the Republic of Moldova. Providing every kind of technology and expert

knowledge for every possible case in every hospital will be redundant. Patients will be treated

on a high quality level in less time. Even in cases of disaster management this coordinative

centre for emergency care should be able to provide the best possible emergency care service.

6.3 Rescue Services

The civil rescue service has the task of helping, round-the-clock, in medical emergencies of

all kinds – injuries, poisoning and illnesses –by deploying certified specialist rescue staff and

suitable rescue equipment quickly and properly in order to save life.

This common theme in medicine is demonstrated by the Star of Life. The Star of Life is

shown here, each of the 'arms' of the star representing one of the following 6 points. These 6

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points are used to represent the 6 stages of high quality pre-hospital care (see chart 38), which

are:

1. Early Detection - Members of the public, or another agency, find the incident and

understand the problem

2. Early Reporting - The first persons on scene make a call to the emergency medical

services and provide details to enable a response to be mounted

3. Early Response - The first professional rescuers arrive on scene as quickly as possible,

enabling care to begin

4. Good On Scene Care - The emergency medical service provides appropriate and timely

interventions to treat the patient at the scene of the incident

5. Care in Transit - the emergency medical service load the patient in to suitable transport

and continue to provide appropriate medical care throughout the journey

6. Transfer to Definitive Care - the patient is handed over to an appropriate care setting,

such as the emergency hospital, in to the care of physicians

F 38 The “Star of Life”

As shown, the goal of rescue services is arranging for timely transfer of the patient to the next

point of definitive care. This is mostly the nearest emergency hospital, or the hospital which

can care for the patient.

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In most places in the world, rescue service is summoned by members of the public or other

emergency services, businesses or authority via an emergency telephone number which puts

them in contact with a control facility, which will then dispatch a suitable resource to deal

with the situation.

A variety of differing philosophical approaches are used in the provision of rescue services

around the world. In general though they can be put into one of two categories; one

physician-led and the other paramedic-led with accompanying physician oversight, these

models are typically identified by their locations of origin.

6.3.1 Existing Systems

The European or Franco-German model, which is also used in Austria and parts of

Switzerland, is physician-led, with doctors responding directly to all major emergencies

requiring more than simple first aid. In some cases in this model, such as France, paramedics,

as we understand them, do not exist at all. The term 'paramedic' is used generically in France,

and those with that designation have training that is similar to a U.S. EMT-B. The team's

physicians and in some cases, nurses, provide all medical interventions for the patient, and

non-medical members of the team simply provide the driving and heavy lifting services.

In other applications of this model, as in Germany, a paramedic equivalent does exist, but is

sharply restricted in terms of scope of practice; Advanced Life Support (ALS) procedures are

reserved to special trained paramedics, in other cases it is not permitted to perform ALS

unless the physician is physically present, or in cases of immediate life-threat. Ambulances in

this model tend to be better equipped with more advanced medical devices, in essence,

bringing the "emergency department" to the patient. High-speed transport to hospitals is

considered, in most cases, to be unnecessarily unsafe, and the preference is to remain and

provide definitive care to the patient until they are medically stable, and then accomplish

transport. Alternatively if the patient is transportable, he can be brought to a nearby small

hospital for stabilisation of the cardio-pulmonary situation. In this model, the physician and

nurse may actually staff an ambulance along with a driver, or may staff a rapid response

vehicle instead of an ambulance, providing medical support to multiple ambulances.

The Anglo-American model, utilises trained technicians, usually referred to as paramedics, to

staff ambulances, which may be classified according to the varying skill levels of the crews.

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Here it is rare to find a physician actually working in the pre-hospital setting. More typically,

they provide medical oversight for quality of the work of emergency medical technicians and

paramedics. It is accomplished in terms of off-line medical control, with protocols or

'standing orders' for certain types of medical procedures or care. In case of on-line medical

control the technician must establish contact with the physician, usually at the hospital, and

receive direct orders for various types of medical interventions. Patients may be treated at the

scene up to the level of the technician's skill set, and then transported to hospital, but in many

cases, the limited skill set of the technician and the needs of the patient will result in the rapid

and timely transport of the patient to a hospital where definitive care will begin. As a new

development in the Anglo-American model, some paramedics in some jurisdictions (U.K.,

South Africa, Australia) are evolving beyond the level of technician, and being permitted to

provide more definitive primary care to patients, often including suturing, detailed

assessment, in some cases limited authority to prescribe medications (usually from a limited

list), and to function as independent practitioners in their own right.

6.3.2 Regulations and Operation

In many Western European countries the rescue service is regulated by laws. The countries

delegate the duties by law to the administrative districts or towns. To comply with this

requirement, the local authority districts themselves engage staff and equipment of the rescue

service or transfer this to the fulltime forces of its fire brigade or award the rescue service to

organisations under private law who provide its services mostly as a charitable association

(the most frequent model in Germany) or private-economic enterprises e.g.: German Red

Cross or Maltese (St. John’s) emergency services.

The control facility, which receives the emergency call (normally a standard emergency call

number like 112 in Germany is installed countrywide), clarifies using standard questions,

whether only transport to hospital and first aid by ambulance men is required or if an

emergency doctor should be sent to the patient. In this case an ambulance vehicle and a doctor

from the next hospital are sent out simultaneously to provide first medical aid (so-called

“rendezvous system”).

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6.3.3 Recommendations

The consultant has detected that the legally established system does not work as envisaged.

Therefore the consultant recommends installing the European system because this provides

important advantages especially in Moldova.

Each hospital is able to provide first aid and by that serve as a location for rescue services.

The distances between hospitals make sure that patients reach qualified care within less than 1

hour and with the advancement of the infrastructure this time will be reduced to less than ½

hour. At least as long as the infrastructure is not optimally updated it may take slightly longer

to reach the patient. If an emergency doctor sees the patient as early as possible first qualified

medical aid can reduce the risk of secondary complications.

It must also be taken into consideration that the education of rescue personnel to a level at

which they can fulfill the tasks of a fully functioning rescue system will take some years.

During that time the availability of emergency doctors is necessary in order to provide

qualified first treatment. If after some time the qualification of the emergency technicians has

improved so much that they can take on more medical tasks, it may be possible to gradually

reduce the requests for the emergency doctors. So optimal service for patients can be

combined with a long-term reduction of costs.

For liability reasons the assignment of responsibility should be regulated by law.

6.4 Rehabilitation

Rehabilitation is defined as restoring the patients´ somatic, functional and social health by

applying physiotherapy, occupational therapy and clinical psychology to increase the pa-

tients´ own activity. The aim of these activities is to aid patients´ recovery and reduce re-

quirements for acute medical service as well as the costs for chronic treatments. Patients who

recover quickly can return to work earlier; thus rehabilitation supports the total national eco-

nomic efficiency.

Today medical rehabilitation in Moldova is provided mainly in acute-care hospitals mostly

after surgical interventions or at home where the patient is looked after by his/her family.

Both methods of rehabilitation are not efficient and effective for the following reasons:

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Providing medical rehabilitation in acute-care hospitals is usually too expensive. Patients who

are in rehabilitation in acute-care hospitals block hospital beds which as a result cannot be

used to provide acute care. But since rehabilitation is usually reimbursed at a lower rate than

acute care, acute-care beds should be used to treat acute-care patients to avoid such ineffi-

ciencies. Less acute care beds will be needed when rehabilitative cases are treated in separate

institutions; this will save costs and help the staff to focus on their competencies. Many reha-

bilitative care methods in an advanced state of the patient could be applied on an outpatient

basis, which would further reduce costs compared to specialised rehabilitative hospitals or

departments for inpatient rehabilitation. In most cases, rehabilitative care by family members

at home does not ensure a good quality of care because of a lack of equipment and knowl-

edge.

Rehabilitation is to be differentiated according to the underlying disease, to different phases

of rehabilitation, as well as to the type of or the location where rehabilitation service is pro-

vided. Indications for rehabilitation include e.g. myocardial infarction (cardiologic rehabilita-

tion), stroke (neurological rehabilitation), malignant tumours (oncologic rehabilitation) and

hip joint endoprothesis (orthopaedic rehabilitation) as well as geriatric rehabilitation with

different, special aspects. The different phases of rehabilitation cover acute rehabilitation

(starting during intensive care), early rehabilitation, three phases of continuative rehabilitation

and post-rehabilitation support. International Classification of Functioning, Disability and

Health (ICF) from the WHO are one of the measurements to assign patients to the required

rehabilitation phase.

Methods of rehabilitation in the different phases include:

• Occupational therapy, therapy aimed at giving people "skills for the job of living" or "the

skills for employment."

• Neurocognitive Rehabilitation, a rehabilitation methodology utilised for cognitive and / or

motricity diseases.

• Physical therapy, treatment aimed at the attainment or recovery of optimal

neuromusculoskeletal function

• Physical medicine and rehabilitation, a branch of medicine dealing with restoration of

function despite physical disability. Development of a person to his fullest physical,

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psychological, social, vocational, and educational potential consistent with his

physiological or anatomical impairment

• Psychiatric rehabilitation, a branch of psychiatry dealing with restoration of mental health

and life skills after mental illness

• Rehabilitation (neuropsychology), therapy aimed at improving neurological function that

has been lost or diminished by disease or traumatic injury

• Stroke rehabilitation, the process of recovering from a stroke

• Vocational rehabilitation, the continuous and coordinated process of rehabilitation which

involves the provision of vocational guidance, vocational training and selective

placement, designed to enable a person with a disability to secure and retain suitable

employment.

Rehabilitation involves standardisation in treatment meaning specially trained medical staff,

medical equipment, building infrastructure and a treatment plan (special exercises, frequency

of applications, etc.). Staff employed in medical rehabilitation has special training rather than

belonging to special professional groups. These could be occupational therapists or physio-

therapists. Additional physicians specialised in internal medicine and / or orthopaedists as

well as psychologists will complete the therapeutic team.

The structure of the buildings has to be adapted to the defined requirements for the special

treatment. So e.g. underwater and hydro-electric bath, swimming-pools for aqua-training,

rooms for heat therapy, massage rooms and special gymnastic rooms with special equipment

are required.

As an example of a well functioning rehabilitation service, different methods of providing

rehabilitative care have been introduced in Germany in recent years with the goal of saving

costs by ensuring a high quality of care. In 2005 Germany had about 21.2 beds for 10.000

inhabitants, for rehabilitation purposes, the average length of stay was about 26 days, and the

utilisation of beds about 73 %. Rehabilitative care has been moved out of acute-care hospital

systems in order to shorten the average length of stay by not blocking "expensive beds" with

"low-cost patients". This is done by building specialised rehabilitation clinics which are

sometimes affiliated to acute-care hospitals in order to share support and administrative ser-

vices. Another option is professional rehabilitative home care. While the patient has the bene-

fit of his private surroundings, a professional mobile physiotherapy provider visits the patient

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regularly and provides professional rehabilitative care in the patient's home. When the patient

is able to move by himself he can join ambulatory rehabilitation in the office of the same pro-

vider. These ambulatory and mobile care providers are either private businesses or run by

charitable institutions. Both are often at least partly paid for by the patient's insurance.

6.5 Alternative use of Infrastructure

At the moment several social tasks are being provided by the healthcare system, especially by

hospitals. For economic reasons it will be necessary to make a clear cut between healthcare

and social demands. During or after reconstruction of the hospital system some areas will be

freed up for other functions. These areas could be used for other medical or non-medical pur-

poses, such as:

Day surgery, also referred to as ambulatory surgery, same-day surgery or outpatient surgery

does not require an overnight hospital stay of the patient. The purpose of outpatient surgery is

to keep healthcare costs down.

The establishment of ambulatory surgery is due to the necessity to decrease healthcare cost.

As a result outpatient surgery has grown in popularity. Often treatment is done in much more

luxurious settings than a hospital; therefore it is often preferred by patients for minor surgical

procedures.

Indications for outpatient treatment can be e.g. explantation of osteoplastic material after bone

injury, endoscopic diagnostics as well as excision of breast tissue in the context of cancer or

adenotomy in ENT, cataract procedures in ophthalmology. It is important to recognise that

these patients are regularly healthy persons without important additional illness.

Some structural aspects have to be considered, if ambulatory treatment is to be successful.

Outpatient treatment relies on physicians who have medical experience of those patients and

their treatment as well as on trained staff. Another aspect is improved (minimal invasive)

technology and building structure. The same hygienic standard and facilities (including a

recovery room) as in hospitals need to be made available. In any case before the patient can

go home without risk he has to stay in the outpatient facility for a few hours after treatment.

Besides that in case the patient needs to be treated in hospital as well because of

complications, he must be able to reach qualified medical care at any time when he is home.

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Rehabilitation services as declared in chap. 6.3 can be located in convenient buildings of

former Transit hospitals or disused parts of other hospitals.

Long-term-care as well as geriatrics for special elderly e.g. with dementia illness is a variety

of services for patients with a chronic illness or disability to enable them to care for

themselves for long periods of time. It meets both the medical and non-medical requirements

of people in general.

It is common for long-term care to provide custodial and non-skilled care, such as assisting

with normal daily tasks like dressing, bathing, and eating. Increasingly, long-term care

involves providing a level of medical care that requires the expertise of skilled practitioners to

address the often multiple chronic conditions associated with older populations. Long-term

care can be provided at home, in the community, in assisted living or in nursing homes. It

may be needed by people of any age, even though it is a common need for senior citizens.

The Centre for Medicare and Medicaid Services in US estimates that about nine million

people over the age of 65 in the US need long-term care in 2006 and it will be about 12

million by 2020. It is anticipated that most will be cared for at home; family and friends are

the sole caregivers for 70 % of the elderly. A study by the U.S. Department of Health and

Human Services says that people who reach age 65 will likely have a 40 % chance of entering

a nursing home. About 10 % of the people who enter a nursing home will stay there five years

or more.

National governments have responded to growing long-term care needs at several levels.

Most Western European countries have put in place a mechanism to fund formal care and, in

a number of Northern and Continental European countries, arrangements exist to at least

partially fund informal care as well. Some countries have had publicly organised funding

arrangements in place for many years: the Netherlands adopted the Exceptional Medical

Expenses Act (ABWZ) in 1967, and in 1988 Norway established a framework for municipal

payments to informal caregivers (in certain instances making them municipal employees).

Other countries have only recently put in place comprehensive national programs: in 2004,

for example, France set up a specific insurance fund for dependent older people. Some

countries (Spain and Italy in Southern Europe, Poland and Hungary in Central Europe) have

not yet established comprehensive national programs, relying on informal caregivers

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combined with a fragmented mix of formal services that varies in quality and by location.

(Saltman et al. 2006). Germany implemented the so called "Pflegeversicherung" in 1995, for

financing the care of elderly, either at home by family members or private providers or living

in nursing homes.

The consultant recommends to install a system of ambulatory nursing providing non-

stationary help (at home: like making injections, bandaging etc.) for the patients or

handicapped and elderly persons too. This ambulatory nursing service can be staffed with

hospital nurses. Alternatively private providers with qualified personnel are conceivable.

Palliative care (from Latin palliare, to cloak) is defined by WHO as "an approach that

improves the quality of life of patients and their families facing the problems associated with

life-threatening illness." It contents any form of medical care or treatment for reducing the

severity of disease symptoms, rather than striving to halt, delay, or reverse progression of the

disease itself, whether or not there is hope of a cure. Palliative treatments are also used to

alleviate the side effects of curative treatments, such as relieving the nausea associated with

chemotherapy. An increasing part of palliative care is observed in paediatrics for children

with cancer; it asks for special services and special trained medical staff. Beside that the term

palliative care is used in other aspects with chronical illness like progressive neurological

conditions. Mostly patients are in special hospital departments with trained nurses, less

physicians' treatment is asked.

Increasing focus on a patient's quality of life during the past twenty years raises demand for

palliative care. Most care is done as inpatient services due to the status of the patient, but also

ambulatory palliative services may be implemented. In this case the patient stays at home and

palliative nurses support the families' daily care. In a final state and if no stationary medical

treatment is necessary the patient may pass into hospice care which delivers palliative care to

those at the end of life.

Hospice is a type of care and a philosophy of care which focuses on the palliation of a

terminally ill patient's symptoms. These symptoms can be of physical, emotional, spiritual or

social nature. The concept of hospice as a place to treat the incurably ill has been evolving

since the 11th century. The modern hospice began to emerge in the 17th century, but many of

the foundational principles by which modern hospices operate were pioneered in the 1950s by

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Dame Cicely Saunders in the United Kingdom. Although the movement has met with some

resistance, hospice has rapidly expanded through Western Europe, the United States, and

elsewhere. With the growing importance of palliative medicine one must assume that also the

demand for hospices will increase in future.

Elderly care is the fulfillment of the special needs and requirements that are unique to senior

citizens. This broad term encompasses such services as assisted living, adult day-care, long-

term care, nursing homes, hospice care, and in-home care.

Traditionally elder care has been the responsibility of family members and was provided

within the extended family home. Increasingly in modern societies, elder care is now being

provided by state or charitable institutions. The reasons for this change include decreasing

family size, the greater life expectancy of elderly people, the geographical dispersion of

families, and the tendency for women to be educated and work outside the home. Although

these changes have affected European and North American countries first, it is now

increasingly affecting Asian countries also. In most western countries, elder care facilities are

freestanding assisted-living facilities, nursing homes, and continuing care retirement

communities. For example in Germany in 2005 were about 91.8 beds / places per 10.000

inhabitants for elderly care available, in Netherlands 104.5, in Norway about 88.7 and in

Switzerland 116.7.

Beside the other listed aspects there are social reasons that require additional care. As the so-

cial systems and the socioeconomic structure in Moldova are not very developed yet, there is

a demand for intermediate or continuous housing for people without social and financial

background. It will be much less expensive to provide the necessary supply for these people

in a social housing than in a hospital because their demands are quite different. Mainly they

do not need medical aid but social mentoring and attendance. This should be provided by

some social workers and trained personnel, who are much less expensive than the complete

medical personnel that has to be available in a hospital.

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7. Timeframe for implementation

7.1 Short-Term Changes (1. phase)

At the beginning of establishing the new structure of the hospital system, it will be necessary

to modernize hospital (and healthcare) legislation. To avoid frequent changes in the system, it

is recommended that a consensus be negotiated.

Besides that, the new common hospital administration (see Chapter 4.1.5) in the healthcare-

zones will have to be built up in addition to the central administration of the university centre

in Chisinau.

Additional a monitoring system has to be installed to give the Ministry the possibility of rea-

sonably steering future investments.

7.2. Mid-term changes (2. + 3. phase)

Until about 2013 it will be necessary to upgrade capacities in basic care and specialised care

at some point all over the country, so that the pressure of patients' numbers on the centres can

be reduced. Especially future Transit Hospitals will have to be taken into account - a mini-

mum quality have to be provided here, otherwise these mostly smaller hospitals would no

longer be accepted at a time when the healthcare system cannot cope without their capacity

(e.g. before a sufficient reduction of a common length of stay).

7.2.1 Second phase (2010 – 2011)

Transit Hospitals have to be equipped in Donduseni, Riscani, Nisporeni, Soldanesti, Straseni,

Ialoveni, Basarabeasca, Cantemir and Taraclia.

As Balti has already reached some centrality, it seems reasonable to regard Ocnita as an addi-

tional “first step activity” in the North. Calarasi, Criuleni and Cimislia will take some pres-

sure off, if the increased attractiveness of the hospitals makes more patients from the external

parts stop before they reached Chisinau. Stefan-Voda is included in this phase because of its

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distance to the centre; building up Ceadar-Lunga is the first step in strengthening the Gargau-

sian territories.

In Chisinau the Republican Hospital and ICSOMC (+IMSP SCRC E. Cotaga) were already

covered by a special analysis and should be accessed immediately for their central functions.

7.2.2 Third phase (2012 – 2013)

After providing better first care over the country it makes sense to create and upgrade special-

ised and high specialised hospitals. This means further reduction of the pressure on Chisinau.

At Chisinau itself, quality of care is normally slightly better than in the countryside, so it

seems acceptable to prefer the rural communities.

In this phase we recommend making the necessary high specialised investments in Balti and

Cahul. As Balti has to be reduced in capacity it make sense to invest in Glodeni and Singerei

at the same time, so that people will not be so tempted to go to Balti even if this is not neces-

sary from medical view. Investments in Ungheni, Leova and Orhei shall also be made to in-

crease the attractivness of rural districts. The proposed investments at Aneni Noi and Causeni

at this phase help postpone the decision as to whether a new hospital is necessary for Bender

or not. As it is positively assumed that the district of Vulcanesti has meanwhile taken benefit

from industrialization, it is proposed to make the necessary investments at this phase.

In Chisinau IMSP Institutul de Neurologie and IMSP SCMC V. Ignatenco (+ IMSP Spitalul

Clinic Municipal de Copii Nr. 1), which have already been analysed separately, should be

accessed.

Naturally the NHMP has to be updated, if the the political and economic situation develops

differently to the prognosis.

7.3 Long-term changes (4. + 5. phase)

If the above mentioned recommended steps are followed, the quality of rural care meanwhile

should be a lot better than today. However, there are still problems to be resolved, especially

if the infrastructure of the country has not become as advanced as necessary - and the quality

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of care therefore has to be upgraded in the rest of the hospitals to make the system work as

planned.

7.3.1 Fourth phase (2014 – 2016)

It has to be presumed that the margin of Chisinau hospitals will meanwhile have shrunk due

to the progress of the others. The consultant therefore proposes to concentrate investment at

this phase on the consolidation of basic and specialised healthcare in the rest of the hospitals

in rural districts, as well as local hospitals at Chisinau. This concerns in the countryside:

Briceni, Edinet, Falesti, Drochia, Rezina, Soroca, Floresti, Telenesti, Hincesti, Comrat as well

as at Chisinau: IMSP SCBI Toma Ciorba, IMSP Spitalul Clinic Municipal No 1, IMSP SCM

Sfintul Arhangel Mihail, SCM Sf. Treime, IMSP Spitalul Clinic Municipal De Boli Contagio-

ase de Copii.

7.3.2 Fifth phase (2017 – 2018)

At this final phase necessary investments for the modernisation of Chisinau hospitals have to

be made. The proposal to postpone these tasks until 2017 is motivated by the fact that the

average building and medical quality today is comparatively better than in the other parts of

the country. However, on the other hand, the attraction of Chisinau is reduced on long terms if

rural people in phases (1) to (4) have learned by experience that “their own hospital just

around the corner” has the same building conditions, medical and service quality as those in

Chisinau, that they have preferred up until then. This concerns IMSP Institutul Oncologic,

SCTO, IMSP Institutul de Cardiologie , DDVR, IMSP CNSPMU, MSP Spitalul Clinic al MS.

Having fulfilled the NHMP until 2018 and working on the assumption that the necessary pro-

gress in the infrastructure and welfare has been reached, it will be possible to omit the Transit

Hospitals from the system of acute care and make them take over the functions as described in

Chapter (6.5). In any case, at that time it will be essential to update the NHMP. This will be

the only way that a comparison between the reached status and future needs can be made and

a new agenda can be fixed.

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MONAT2009

Phas

e 1

2010 2011 2012 2013 2014 2015 2016 2017 2018

Phas

e 2

Phas

e 3

Phas

e 4

Phas

e 5

• Moderniselegislation

• Set up admini-stration on healthcare zone level

• Centralise universityadministration

• Introducing• monitoring system

• Equipe Gateway Hospitals in Donduseni, Riscani, Nisporeni Soldanesti, Straseni, Basarabeasca, Ialoveni, Cantemir, Taraclia

• Equipe Calarasi, Criuleni, Cimislia, Stefan-Voda,Ceadar-Lunga

• Create and upgradeSpecialised and HighSpecialised Hospitals.

• Equipe Glodeni, Singerei, Ungheni, Leova, Anenii Noi,Causeni, Vulcanesti

• Equipe Institulul Neurologie &SCMC Ignatenco

• Consolidate basic and specialised healthcareprovision in rural Moldova

• Invest in Local Hospitals inChisinau

Invest into the modernisationof the hospitals of Chisinau(Institulul Oncologic, Inst.Cardiologie, DDVR, CNSPMU, Spital Clinic al MS)

Ongoing actualisation of the National Healthcare Masterplan is strongly recommended!

Figure 39: Timeframe for Implementation

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Republic of Moldova Ministry of Healthold.ms.gov.md/_files/8201-1-Hospital%20Master%20P… · · 2011-04-01NHMP top consult kşln GmbH page 1 Republic of Moldova Ministry of Health