Hospital Master Plan

NHMP
Republic of Moldova
Ministry of Health
National
Hospital Master Plan
2009 - 2018
Final Report
top consult kln GmbH

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NHMP
Index
Page
Initial Situation and Assignment
Executive Summary
As-Is-Analysis
3.1
3.1.1
3.1.2
3.1.3
3.1.4
3.2
3.2.1
3.2.2
3.3
17
Environmental and Market Analysis
17
Geography and Sociodemography ................................................................17
Economics and Infrastructure .......................................................................19
Healthcare System Organisation ...................................................................21
Healthcare Financing ....................................................................................23
As-Is Analysis of Hospitals in Moldova
26
Rural Hospitals in Moldova ..........................................................................26
Hospitals in Chisinau ....................................................................................36
Results and recommendations
40
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

5.1
5.1.1
5.1.2
5.2
5.2.1
5.2.2
5.2.3
5.3
5.3.1
5.3.2
5.3.3
5.3.4
5.3.5
5.3.6
5.3.7
99
Investment in Staff
102
Estimations for salaries of hospital staff .....................................................102
Educational and further needs.....................................................................103
Investment in Building Structures
105
Investment in Building Construction ..........................................................105
Investment in building Structures Technical Systems .............................107
Medical gas supply............................................................................................
Investment in building structures electric systems...................................123
Investments in Medical Technology
132
General ........................................................................................................134
Transit Hospitals .........................................................................................135
Local Hospitals ...........................................................................................136
Specialized Care Hospitals..........................................................................141
High Specialized Care Hospitals.................................................................149
Centres of Excellence..................................................................................158
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

6.1
6.2
6.3
6.3.1
6.3.2
6.3.3
6.4
6.5
7.
174
Ambulant Primary care

174
Emergency Care
175
Rescue Services
176
Existing Systems .........................................................................................178
Regulations and Operation..........................................................................179
Recommendations .......................................................................................180
Rehabilitation
180
Alternative use of Infrastructure
183
Timeframe for implementation

7.1
7.2.
7.2.1
7.2.2
7.3
7.3.1
7.3.2
187
Short-Term Changes (1. phase)

187
Mid-term changes (2. + 3. phase)
187
Second phase (2010 2011) .......................................................................187
Third phase (2012 2013) ..........................................................................188
Long-term changes (4. + 5. phase)
188
Fourth phase (2014 2016) .......................................................................189
Fifth phase (2017 2018) ..........................................................................189
Appendices

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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 consultant company top consult kln GmbH should be given the contract to develop a Hospital Master Plan for Moldova.
top consult kln GmbH is an architectural and technical consulting company specialised
in Hospital Planning including mechanical and electrical engineering division. The company consists of experienced planners, medical experts, specialists in investment and costing, 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 location 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 costefficient 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 between 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, reduce of costs)
- Centralisation of the difficult (difficult treatments should be executed at specialized hospitals, only there it is reasonable to keep equipment and specially trained personnel in reserve)
- Separation of different forms of emergency care (emergency care has to be executed as
necessary for the individual case, this means raise of quality and reduce of costs)
- More out-patient care and emphasis on primary care (out-patient care for rehabilitation
etc. and better primary care reduce expensive hospital services)
- Less in-patient care and a significant reduction in the average length of stay in hospital
(in-patient care and long stay at the hospital means highest costs per day)
- Day-care (reduce of hotel-services in hospitals means reduce of costs and appropriate
individual supply for the patient by the family)
- Day-surgery (costs result only for surgery, not for hotel-services)
- New less invasive treatment modalities (reduce of necessary wound healing time after
surgical interventions means reduce of costs at the hospital and earlier return to work of
the patient)
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- Emphasis on reconstructive surgery increasing quality of life (especially after defacing

injuries reconstructive surgery can cause considerable bettering of quality of life and by
that reduce necessary medical and psychological treatment)
- New potent drugs (pharmaceutical progress can accelerate recovery and reduce adverse
effects of therapy and by that raise quality of life for the patients)
Medical technology is advancing at an increasing speed. Many laboratory tests can now
be analysed in a decentralised fashion in the doctors office, while other more complicated
analyses are centralised. The new imaging techniques, such as MRI, have greatly improved 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 people 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 organisation needs to become more and more flexible.
There will be more severely ill patients in the secondary hospitals. That will have an impact 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 hospitop consult kln GmbH
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tal care was the idea of ensuring a bed for every patient, indifferent of hospital services.
Therefore huge hospitals have been created countrywide with a large bed capacity. The
medical services and the related costs didnt play a primer role. Costs have been covered
by the state budget, such as subvention. Because of a lack of competition, the healthcare
systems in the former communist countries have lost the affiliation to the development
registered in the West-European countries.
The modern Western systems are well structured population- and services-based systems.
The efficiency of the services is gaining more and more in importance, so that hospitals
are forced to supply high quality services for a payable price.
It is obvious, both from a medical point of view as from an economical, that the present
situation needs to be changed.

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Executive Summary
Chap. 1
1.
Initial situation
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 Master 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 local 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 development of hospital services, where quality has to defeat habit. Trends in medical development are more minimal invasive techniques in surgical procedures, more option
for treating elderly, as well as the development in pharmacological active substance for
different diseases like Parkinsons diseases. Trend in treatment is ambulant treatment as
many as possible and as outpatients procedure and less hospital treatment. Consequently
customs have to be allowed, but required new adjustments have to be developed and
spread over the whole country. For that purpose, mechanisms have to be established, so
that these new adjustments can be put into practice by everybody. Incentives can be set
and reprehensions can be given in order to put these adjustments into effect. Examples
for these are European hospitals. In most of the European countries the length of stay
dropped by optimising organisational processes. Incentives were set by budget- regulations and controlling activities. In consequence the demand of inpatients-beds decreased, 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 significant reduction in the average length of stay in hospital, daycare, day-surgery, new
less invasive treatment modalities, medical technology advancing at a rapid speed, rising 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 without defined functionality. Medical services and the related costs were not the main focus. 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 allegiance 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
8.
As-Is-Analysis
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 diagnoses, diagnostic activities and surgical treatment for each hospital. Besides this, the building and technical situation as well as the medical-technical situation were viewed. The
summary is gathered in a portfolio-analysis with market attractiveness - containing aspects of demographic, competition, morbidity rate and location - and competitive advantages - 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 healthcare services is needed.
Conclusion of that only can be that hospitals in Moldova are at the moment economically inefficient and concerning building quality and medical infrastructure in bad circumstances.
Chap. 4
9.
Prognosis of needs for hospital healthcare services -general comments
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 economical 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 accessibility 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 horizontal 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 establish the approved hospital models and standard levels of therapy. There are four different healthcare service levels - basic hospital healthcare, offered by local hospitals, specialised 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 specialised 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 hospitals 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 nursing 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 elaborated 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 requirement 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 investments 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 possibilities 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 medical trends and consequences of changes within the financing system have been considered 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 progress, infrastructural effects, and general medical effects - including ambulatory treatment. An estimated tendency implies that many patients, who seek care in Chisinau today, 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 order 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 quantop consult kln GmbH
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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 Germany, 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 social aspects into account.
Chap. 5
23.
Resulting investment needs
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, medical-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 technical standards (lack of thermal insulation, low efficiency of technical equipment, etc.).
Nowadays, the hospitals need for a great improvement in air-conditioned rooms, elevators, and standards for technical equipment has increased, although during the last decades, 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 sufficient standard.
27.
The necessary investments until 2013 sum up to 636.987.308 . Until 2018 a total investment of 1.112.873.779 has to be made. All costs are up to date, but a prognosis for
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NHMP
the duration of the NHMP cant be made dependably, because the development of costs
(especially in the building sector) is not reliable.
28.
Further investment is required. One being a monitoring system for cases of all hospitals.
The Ministry of Health would have to steer the development and investments. This
could begin with a regular collection of basic data and develop to a monitoring system
that made continuous detailed analysis possible. This should be introduced as the first
step of the NHMP.
Chap. 6
29.
Effects concerning other providers
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 dayclinics, family medical centres, as well as home care. The main focus should be patients
with chronic diseases. Additionally some ambulant primary care institutions should be
equipped in order to carry out basic surgical procedures (see chapter 4.3.2) which
wouldnt have to be followed by a hospital stay. Hospitals and ambulant primary care
institutions should cooperate closely. It would be necessary to apply general definitions
for the classification of patient treatment within institutions of ambulant primary care or
confinement to hospital.
30.
On behalf of medical structure emergency care services would be provided by specialized 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 services which would have to be established. Close cooperation between all emergency departments 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 conditions 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. Emergency 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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NHMP
32.
Rehabilitation is done currently within Moldovas acute care hospitals followed by an

increase in the average length of stay. Effective rehabilitation is based upon general
standards and requires special medical infrastructure, as well as special building requirements. 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 patients 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 recruited 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 introduce 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, betop consult kln GmbH
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NHMP
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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As-Is-Analysis
Since the Republic of Moldova claimed independence in 1991 there has been civil and political conflict in the breakaway district of Transnistria, a district located east of the river Dniester. In international view this conflict has not yet been resolved and the district of Transnistria remains effectively outside of central governmental control. Within the perspective of
healthcare planning and funding, Transnistria is not supported by central government initiatives 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 equipment are in bad condition.
3.1
Environmental and Market Analysis
3.1.1
Geography and Sociodemography
Moldova is a landlocked country in Southeast-Europe. It borders on the Ukraine in the east
and north and on Romania in the west. Moldova covers more than 33,800 km and is the most
densely populated country of the former Soviet Union. At the time of independence the population 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 million people. A combination of decreasing birth rates and increased mortality has been contributing 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 contrast different other sources predict an increase in population for the next years. Approximately 46% of the population live in urban areas. The largest city is the capital city of Chisinau (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. Increasing 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 economy, which included the establishment of the Moldavian currency, privatisation of many enterprises, removing export controls and freeing interest rates. Internal and neighboring economic 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 development since the beginning of the 2000s, Moldova remains the poorest country in Europe,
with an estimated yearly per capita gross national income of US $ 1,100 in 2006. Today, more
than a quarter of the population lives below the poverty line (CIA World Fact book, January
2008). Income inequality between rural an urban population is high. The rural population
compromises over two-thirds of the poor. An estimated one quarter of Moldovas economically 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 economy. Even though the Gini coefficient (measuring the level of income inequality with 1 indicating 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 indicates 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 structural adjustment package with the International Monetary Fund was agreed upon. Still, market-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 included. 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 dependent 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 healthcare system structure of the former Soviet Union which was highly centralized with key decision-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 countrys 35 districts right of the Dnjester river.
Each district has a hospital (exception: Dubasari) and state institutes concentrated in Chisinau
provide specialised care at the national level. In 1997 Moldova had one of the most extensive
networks of health facilities and staff in either Western Europe or the countries of the former
Soviet Union (source: WHO Healthcare Systems in Transition, Moldova 2008). This high
level of healthcare provision was supposed to be kept through the financial crisis in the 1990s
but the severe fiscal crisis in 1998 finally led to reductions in the number of hospital beds,
activity levels and personnel.
Mandatory social health insurance has been operating since 2004. Financing the 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 immunization) 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 implemented 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 expenditures, 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 capita 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 revenues allocated to the health sector through central budgets, employer and employee contributions to the National Health Insurance Company and private out of pocket payments. Additionally 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 governmentfunded 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, emergency care and hospital treatment of Tuberculosis, HIV, cancers, asthma and mental disorders) 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 possibilities on a two-dimensional scale. The two dimensions used are market attractiveness (displaying 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 variables 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 possible (see chapter 3.2.2).
The variables used to measure Market Attractiveness are demography, competition, morbidity, and location. Competitive advantage was measured using the variables construction, technical infrastructure, medical technical supply, further supply, and medical spectrum.
Each of these variables was divided into sub-criteria which were the actual base of analysis
and which were averaged to each criterion's score. The variables score was then weighted on
a scale from one to ten. Within the criteria used to measure Competitive Advantage the variable "Medical Spectrum" was given the highest weight (4.0) because the base of hospital service 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 competitive disadvantage if scored low. Due to the same arguments "Technical Infrastructure" and
"Further Supply" was weighted relatively low. The variables defining Market Attractiveness
are weighted more equally. The variables "Demography" and "Morbidity" were given higher
weights (3.0) because these variables cannot be changed by the hospital nor by the healthcare
system. On the other hand "Competition" and "Location" are also interpreted as external vari-

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ables but they might be influenced at least by the healthcare system. Thus these two variables
were weighted a little less (2.0).
The sub-criteria and scoring model of classic portfolio analysis for healthcare are described in
more detail within the following paragraphs.
The analysis of each sub-criteria awarded points of one to six where one is the worst and six
is the best. The average of these sub-criterias points was then multiplied by the criterias
weight. The sum of all weighted variables was divided by 10 and resulted in the final points
for market attractiveness or competitive advantage. These values were transferred into a twoway-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.
Market Attractiveness
Criteria
A
B
C
D
Demography
Competition
Morbidity
Location
Weights
3,0
2,0
3,0
2,0
10
Score
3,60
Points
(1 = bad 6 = good) Results
3,0
2,5
4,0
5,0
9,0
5,0
12,0
10,0
36
Competitive Advantage
Points
Weights (1 = bad; 6 = good) Results
Criteria
A
B
C
D
E
Construction
Technical Infrastructure
Medical-technical Supply
Further Supply
Medical Spectrum
Score
2,0
1,5
2,0
0,5
4,0
10,0
2,91
4,3
3,7
3,0
3,5
1,8
8,7
5,5
6,0
1,8
7,2
29,1
Figure 5: Criteria used for portfolio analysis

(figures are examples)
Each criterion was evaluated for each hospital separately using the same set of decision variables 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 hospital 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 hospitals serve a population which is larger than 150,000.
Population:
Up to 50,000 1 point
50,001 75,000 2 points
75,001 100,000 3 points
100,001 125,000 4 points
125,001 150,000 5 points
150,001 and more 6 points
Figure 6: Points awarded for the criterion "population"
The criterion of "Competition" was measured using two criteria: number of medical departments and medical technology.
A two step approach was used evaluating "Medical Departments". As task of the As-IsAnalysis 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 medical 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 criterion "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 competitor (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 prevalence of the district. Points were given using the scales below and averaged in order to get the
criterion's final point value.
Incidence:
Up to 1,500 cases per 10,000 population 1 point
1,501 2,250 cases per 10,000 population 2 points
4,501 and more cases per 10,000 population 6 points
Figure 7: Points awarded measuring the district's incidence.
Prevalence::
Up to 5,000 cases per 10,000 population 1 point
9,001 and more cases per 10,000 population 6 points
Figure 8: Points awarded measuring the district's prevalence.

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The fourth criteria measuring "Market Attractiveness" was the hospital's location. The aspects
used were reachability, road condition, and sign posting. In case the reachability was poor,
road condition was bad and there were no signs directing the patients to the hospital, one to
two points were given. If the reachability was good, roads were bad and signs aware posted
three to four points were awarded. Good reachability and road conditions but bad signs accounted 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.
The first criterion used for "Competitive Advantage" was "Construction" measuring the buildings' 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 improved 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 supply, 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 optically 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 point
Technically functional but not up to standard
2 points
Technically functional, not up to standard but updateable 3 points
Defective or non-functional but up to standard
4 points
Technically/optically up to date but functionally not useful 5 points
Technically/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 nonmedical 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 Spectrum". 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 number 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 depending 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 district has one hospital usually located within the districts capital. Hospitals located in Transnistria 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 infrastructure (roads, public transport etc.) and means of individual transportation.
20 district hospitals are sized 100 to 250 beds, 14 are sized 251 to 500 beds, and the Regional
Hospital in Balti (see Nomenclator Nr. 133, March 27, 2008) has 1,105 beds and is therefore
the largest acute care hospital in the country. Most hospital beds (appr. 7,054) are provided in
Chisinau.

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Number of beds
751 to 1.250
501 to 750
251 500
100 to 150
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 hospital 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
0
Anenii Noi
Balti
Basarabeasca
Briceni
Cahul
Cantemir
Calarasi
Causeni
Ciadir Lunga
Cimisla
Comrat
Criuleni
Donduseni
Drochia
Edinet
Falesti
Floresti
Glodeni
Hincesti
Ialoveni
Leova
Nisporeni
Ocnita
Orhei
Rezina
Riscani
Singerei
Soldanesti
Soroca
Stefan Voda
Straseni
Taraclia
Telenesti
Ungheni
Vulcanesti
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 investment needs.
All hospitals outside Chisinau are located in sites which are valued rather positively averaging 3.64 which make "Location" the criterion with the best average value for "Market Attractiveness". 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, medicaltechnical supply and further supply. It can be concluded that no large differences were inspected 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 measuring points to each hospital for certain criteria:
All hospitals located in Chisinau were awarded with six points for the criterion of "Demography", 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 hospitals 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 particular 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 & Orthopaedics, 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 Chisinau 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 equipment 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 "Medical-technical Supply" are just above average.
Portfolio-Analysis
0
0
IMSP SCR
IMSP Centrul de Chirurgie a Inimii
IMSP Institutul de Neurologie
ICSOMC
IMSP SCRC "Em.Coaga"
Maternitatea Nr.2
IMSP Institutul Oncologic
IMSP CNSPMU
SCTO
IMSP Institutul de Cardiologie
IMSP SCBI ''Toma Ciorb''
IMSP Spitalul Clinic Municipal nr. 1
IMSP SCM "Sfntul 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 Chisinau are comparable to most rural hospitals in terms of building condition and level of services
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provided, the Republican Clinical Hospital is able to provide a higher level of healthcare services to its patients. In comparison to most other hospitals its medical equipment is more advanced, 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 Palestine - 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 wellcommunicated 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, function, and organisation from countries in transition in Central / Eastern Europe (Decentralisation, cooperation and competition have to be implemented)
Day and ambulatory care systems are the major factors of the change in hospitals (reduce 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 hospital 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 Moldovan 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 soviet 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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Prognosis of needs for healthcare services
Planning means setting standards: hospital planning as well as e.g. finance planning or legislation 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 provide equal or similar conditions of life and healthcare for the population (see: sources, Appendix 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 specifications)
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 different systems a new standard can be created. The continuation of the unimproved hospital structure 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 services to the population. The benefit of the Transit hospitals, proposed by the consultant additionally, is mainly closing the gap of care for people who do not need acute stationary treatment. 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 running 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 adequate 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 accomplishes 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 changing the organisational structure by the creation of well-supported common territorial administration, organisation and usage of administrative resources. This effect can easily be illustrated 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 supplies than each hospital of its 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 comparable.
In accordance with the above-mentioned proposals, the total surface area of Moldova is divided 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 potential. 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 assumed 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 (km)
existing population
inhabitants per km
estimated population for 2013
estimated population for 2018
In short, surface area and population development for each zone can be summarized as follows: by building these zones, the hospital care for the population will be established or adjusted according to the necessities (see allocation table, Appendix 8.2 + 8.3)

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Healthcare
Surface
Population
Inhabitants
Population
Population
Zone
Area km
2007
per km
2013
2018
3,213
263,700
82.1
254,207
246,296
4,12
321,700
80.2
310,119
300,468
2,424
284,500
117.4
274,258
265,723
2,724
264,200
97.0
254,662
246,763
3,225
298,100
92.4
287,369
278,726
2,799
240,300
85.9
231,650
224,441
3,101
345,400
111.4
332,963
322,603
1,886
165,400
87.7
159,446
154,484
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
Healthcare
Zone 1
Healthcare
Zone 2
Healthcare
Zone 3
Healthcare
Zone 4
Healthcare
Zone 5
Healthcare
Zone 6
Healthcare
Zone 7
(excluding
Bender)
Healthcare
Zone 8
Healthcare
Zone 9
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 between 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 km. 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 situation 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 between 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 existing 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 service 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 qualified 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 medical-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 cooperation general regulations between the hospitals have to be arranged - like the use of the equipment, 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 treatment is ruled by these criteria.
Overall 10 Centres of Excellence located in Chisinau, as well as 2 Centres for Highly Specialised Medical Care in Balti and Cahul will be most useful due to the existing geographic infrastructure and local-custom situations, and also on the basis of the existing and projected population 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 Monoprofile Specialised Hospitals, which are also to be operated under common management, providing 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 district (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 decisions 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 justified 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 1
Scenario 2
Scenario 3
Scenario 4
Maximum medical
care / Centres of
Excellence
Maximum medical
care / Centres of
Excellence
Maximum medical
care / Centres of
Excellence
Maximum medical
care / Centres of
Excellence
High specialised
medical care
High specialised
medical care
Specialised medical
care
Local level hospitals

and basic medical care
Specialised medical
care



Gateway hospitals

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Scenario 1: Go to the centre / Dual system

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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, paediatry) 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 standards today keeps the volume of investment in medical technology in each area to a minimum, 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 associated anticipated improvement of transportation. Emergency care cannot be guaranteed
locally or within the maximum acceptable duration of care by the tending decline in the number 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 contract: 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 areasand from the
References Hospitals to the Community Hospitals can hardly be fulfilled by this scenario.

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Scenario 2: Close to the patient

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Scenario 2 is characterised by a three-level hospital structure - local, specialised and maximum 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 Hospitals 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 services 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 developed.
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 different hospitals have to be anticipated.

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Scenario 3: Centre in the zone

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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 unchanged. Compared to the second scenario, the fundamental difference is that a greater number of Specialised Medical Care centres, each with one or two additionally created treatment 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 patients 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 increased coordination efforts.

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Scenario 4: Combined care

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Scenario 4 is a four-level system structure - local, specialised, highly specialised and maximum 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 Hospitals 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 reduction 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 structural and medical resources, high cost-effectiveness and efficiency could be provided. By improved 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 districts.
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 compared 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 Hospital 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 expected 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 sustainability 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 evaluated. 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 concerned. 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 scenario 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 scenarios 3 and 4 scored almost equally with regard to the goals of healthcare provision and quality
of care.
Goals of Healthcare Provision and Quality of Care
Goals
+++
++
1. Decentralization of special care to healthcare zones

2. Bundling health care 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
Scenario 1
Scenario 3
Scenario 2
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.
Economic Goals
Goals
+++ ++
--
---
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
Scenario
Scenario
Scenario 3
Scenario 4
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 scenarios 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. personnel) 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, elevatop consult kln GmbH
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tors, technical and medical equipment etc.. All costs are measured in todays 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 todays
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 excellence. 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 excellence, 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 complicated cases that would overburden specialised care need to be treated in centres of excellence.
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 solution 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
Investment costs
1,223,437,000
62,169,800
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 hospitals would have to be upgraded, but to a higher level of medical competence and equipment. Therefore, the necessary investment would be slightly lower than in Scenario 2, however running costs would be the highest.
As shown in the appendix Scenario 3 requires
Investment costs
1,214,837,000
63,359,800

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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 standards. 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
Investment costs
1,133,427,000
55,491,800
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 possible 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 regarded 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 running 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 investments 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 administration, which is managed by a chief physician and by an administrative CEO. Hereby, synergy 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 assume 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 hospitals would each have a considerable number of beds and patients - different from the situation 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 departments and the deciding board. Therefore, to build an adequate partner for the CEO, the executive 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 physicians 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 regularly 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 economical 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 because 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 insurance 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 hospital 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
Legal
Hospital 1
Quality
Management
Hospital 2
Chief Physician
Department A
Chief Nurse
Department A
Chief Physician
Department A
Chief Nurse
Department A
Human
Resources
Finance &
Controlling
Chief Physician
Department B
Chief Nurse
Department B
Chief Physician
Departmet B
Chief Nurse
Department B
Business
Strategy
Patient
Management &
Medical
Controlling
Chief Physician
Department C
Chief Physicians
Department C
Chief Physician
Department C
Chief Nurse
Department D
IT &
Communications
Logistics
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, regulation, 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 protection 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 insurances No. 1593-XV from 26.12.2002;
- Law about implementation of mandatory medical insurances and creation of funds of mandatory 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 Republic of Moldova;

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- Governmental Decision No. 594 from 14.05.2002 for approving the Regulation about the establishment 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 Integrated 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 restructuring 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 circumstances by new policy). On the other hand, does a stable basis provide better grounds for systematic development of an existing structure? It is much more challenging to improve an everchanging 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 documents 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 coordination of the healthcare institutions of the integrated healthcare system:
- Draft normative act on the creation of the fund for compensation of damages caused to patients 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 constitution 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 effective, 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, otherwise 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 whoever intends to support inpatient services in Moldova.
The hospital committee would be the perfect institution to discuss complex and fundamental issues 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 required background.
With the establishment of a strong health insurance and the results of the NHMP, the need to create 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 financed 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 amending 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 public 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 population 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 donators. 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 cant 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 government (steering committee, see 4.1.6.2). Only bigger investments like CT or MRI, which are covered by countrywide investment plans, may be promoted.
On the other hand, the hospitals need to be able to decide about lower-level investments individually and in consideration of local aspects in order to stay flexible and e.g. use special qualifitop consult kln GmbH
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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 expenses 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 patient, 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 estimation 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 highquality 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 anaesthesia as well as in aftertreatment-care with the option of treating elderly, as well as the development in pharmacological active substance for different diseases like Parkinson's diseases. Following 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
Population
bed
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
7,8
Zone 5
298.100
895
248.916
31.897
7,8
Zone 6
240.300
930
208.891
27.299
7,7
Zone 7
345.400
700
185.789
25.234
7,4
Zone 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
Cahul
127.600
123.800
1.105
456
302.737
101.978
32.592
12.635
9,3
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, StefanVoda) to 1,089 (Zone 3: Drochia, Floresti and Soroca). 6,834 beds were allocated solely to Chistop consult kln GmbH
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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 effects)
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 population by 2018 had to be estimated differently depending on the living area (rural vs. urban). Chisinau, 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 1980s 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 ambulatory 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 outpatients. 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 hospital. The number of cases in Moldova treated in this way up until now is minor. The expected ambulatory 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 accessibility, were taken into account. In total the ambulatory effect is estimated to lead to a decrease 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 different 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 assumptions 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 estimated to be 30 % of today's cases treated in Chisinau and Balti, referred to all patients and hospitals 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 determining 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 further 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.
Movement Effects
cases to be treated in
rural hospitals
%
abs.
Chisinau
30,0%
68.783
Balti
30,0%
9.778
% of cases that will be treated within the rural zones 1 to 9
3
4
5
6
7
8,0%
19,0%
22,5%
22,5%
10,0%
55,0%
19,0%
2,0%
Chisinau
Balti
1
3,5%
12,0%
2
4,5%
12,0%
Chisinau
Balti
tot.
1
2.407
1.173
3.581
amount of cases that will be treated wihtin the rural zones 1 to 9

2
3
4
5
6
7
3.095
5.503
13.069
15.476
15.476
6.878
1.173
5.378
1.858
196
0
0
4.269
10.880
14.926
15.672
15.476
6.878
8
10,0%
9
0,0%
8
6.878
0
6.878
9
0
0
0
Figure 17: Assumptions of the Movement Effect
All analysis was done distinguishing between three different levels of care: basic care, specialised 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 General 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 provided 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 displays the assumed allocation of levels of care by medical department as a rough overview.
Basic Care
Specialized Care
Maximum Care /
Centers of Excellence
(CE)
Medical
Departments
General Medicine,
General Surgery,
Gynecology / Obstetrics,
Pediatrics
Basic Care plus

additional medical
profiles
Highly-specialized Care
plus special medical
profiles provided by CE
only
Diagnostics
& Therapy
Basic diagnositcs &

therapy (ECG, general
methodologies)
Expertknowledge
Basic standard
knowledge in general
departments
14.09.2009 11:41
Well-established
standardized diagnostics
and therapy (Endoscopy,
echocardiography,
minimal-invasive
technics)
Medical knowledge in
specialized fields needed
Highly-specialized
methods and technologies
(CT; cardiac-catheter, and
others , partly in
developement)
Experts and researchers
needed for innovative
methods (CE)
TOP Consult Kln GmbH
Figure 18: Definitions of levels of care
Distribution of Cases by Level of Care

Percentage of Level of Care
Basic
Specialized
Maximum Care
General
Medicine
55,0%
35,0%
10,0%
Cardiology
55,0%
35,0%
10,0%
GastroentePulmono- Infectious
rology
logy
Diseases
55,0%
50,0%
60,0%
35,0%
40,0%
30,0%
10,0%
10,0%
10,0%
Surgery
60,0%
30,0%
10,0%
Trauma &
Ortho
40,0%
50,0%
10,0%
Gyn /
Urology Obstetrics Pediatrics
60,0%
55,0%
40,0%
30,0%
35,0%
50,0%
10,0%
10,0%
10,0%
NeuOphthal- Otolarynrology
mology
gology
20,0%
45,0%
40,0%
50,0%
35,0%
50,0%
30,0%
20,0%
10,0%
Dermatovenerology
10,0%
75,0%
15,0%
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. Theretop consult kln GmbH
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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 maximum care cases.
Chisinau
Balti
Cahul
Distribution of Maximum Care Cases to Centers of Excellence

% of Rural Maximum Care treated in Chisinau, Balti & Cahul
1
2
3
4
5
6
7
40,0%
40,0%
40,0%
70,0%
90,0%
100,0%
100,0%
60,0%
60,0%
60,0%
30,0%
10,0%
0,0%
0,0%
0,0%
0,0%
0,0%
0,0%
0,0%
0,0%
0,0%
8
100,0%
0,0%
0,0%
9
10,0%
0,0%
90,0%
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 average length of stay varies greatly depending on many aspects of the healthcare system, e.g. Israel: 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 (reduced by 24 % in 2018 compared to 2007) will be enough to serve the estimated demand of inpatient 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 received, 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 Cahul.
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 necessary 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 Chisinau, Balti and Cahul. The proportion of maximum-care beds in these cities is about 30 % (Cahul), 68 % (Balti) and 24 % in Chisinau.
Cahul
Balti
HC-Zone 9
HC-Zone 8
HC-Zone 7
Basic Care
HC-Zone 6
HC-Zone 5
Specialised Care
HC-Zone 4
Maximum Care
HC-Zone 3
HC-Zone 2
HC-Zone 1
0
200
400
600
800
1000
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 development 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 basis 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 HillBurton formula, which originated in the USA in the 1960s. 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 available, 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 effects another strong aspect is to build Competence-Centres, looking for the total disease by different 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 incontinence-disease in the genitourinary system, Traumatology / Orthopedics / Neurosurgery for backbone 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 department. 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, Gynaecology & Obstetrics, Paediatrics and provide mostly basic care and basic treatment. Transit Hospitals and Local Hospitals offer basic treatment and basic care. Besides basic care and basic medical treatment Specialised Hospitals have in addition special departments such as Cardiology,
ENT, and Urology and accordingly more medical equipment. Highly Specialised Hospitals, Centres 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 European 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, rheumatology or nephrology are not listed separately for the highly specialised hospitals and are an integral 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 Excellence. Complementary treatment of the malignant illness will be performed in Centres of Excellence / 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 hospital. Diagnostics of heart disease depends on the diagnostic intensity - basic diagnostics with ultrasound 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 catheterisation 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. Especially 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 patients 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 personnel 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 areas, where the patient stays for several hours, are specialised on after operation-procedures monitoring. 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 departments depending on the patient's co-morbidity and treatment. Highly Specialised Hospitals, Centres 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 according to the patients 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 diseases 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 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 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 hospitals and hospitals of the different ministries are also not included in the analysis and recommendations.
Most of the hospitals shall have their own blood bank. Smaller hospitals, which use blood preservations 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 returned within a defined time period. A special transport service - depending on the basic necessity 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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NHMP
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 average of 43.5 beds per 10,000 inhabitants is defined for Moldova in 2013. In 2018 this will decline 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 hospital 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 situation 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 services 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 according to the above-mentioned calculation premises is compared to basic departments and specialised 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. Monoprofile 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 statistic 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, gynaecology & obstetrics and paediatrics. About 32 % (2013) and 31 % (2018) are planned for
specialised departments like Cardiology, Neurology, Traumatology / Orthopaedics and ENT.
Department
Cardiology
Dermatovenereology
Gastroenterology
General surgery
Gynaecology & Obstetrics
Infectious disease
General Medicine
Neurology
Ophthalmology
ENT
Paediatrics
Pulmonology
Traumatology / Orthopaedics
Urology
Proportion of total
bed capacity
6%
2%
2%
20%
range of beds
15 to 90
10 to 25
15 to 70
10 to 380
13%
1%
29%
8%
2%
3%
8%
1%
15 to 280
10 to 30
20 to 150
10 to 80
10 to 30
10 to 60
15 to 120
15 to 45
6%
3%
25 to 90
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 Chisinau General Medicine includes other conservative sub-disciplines, if these are too small to
form their own departments. General Surgery likewise includes other operating subdisciplines, 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 according 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 medical equipment. Besides this, some additional definitions are made by architectural structure.
One criterion is the economical size of wards - mainly limited by personnel resources - requiring 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 different hospital types. Additionally the various inputs derived from interviews and data provided by local experts are also integrated.
Staff requirements were estimated for physicians, nurses, medical assistants (functional diagnostics, 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 professional 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 relevantly 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 utilisation 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.
2013 / 2018
physicians
253
nurses
84
medical assistants
2500
others
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 technical equipment, highly specialised hospitals have a multiplier of 1.1 and Centres of Excellence 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
Transit Hospitals
Local Hospitals
Specialised Hospitals
Highly Specialised
Hospitals and Centres of Excellence
and University Hospitals
beds per physicians

2013
2018
4,3
-4,4
3,7
4,1
3,5
beds per nurses

2013
2018
1,4
-1,4
1,2
1,4
1,2
beds per
medical assistants
2013
2018
42,0
-43,0
37,0
40,4
34,8
beds per others

2013
2018
3,4
-3,4
3,0
3,2
2,8
3,7
3,2
1,2
1,1
36,8
31,7
2,9
2,5
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 guarantee 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 department 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 hospitals 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 & Obstetrics 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 examinations. 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 Paediatrics) and additional departments such as ENT, Ophthalmology, Urology or Cardiology,
Gastroenterology et. al. Total number of staff is about 5704, of which 22 % are physicians, 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 hospitals. In this case one hospital has a surgical focus; the other hospital has a more conservative 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 support 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, Gynaecology & Obstetrics , and Paediatrics and additional departments like the specialised hospitals. 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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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 between 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 m 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 Master 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 insurance 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
Healthcare Zone 2
60,618,549.20
Healthcare Zone 3
72,249,839.20
Healthcare Zone 4
52,445,105.20
Healthcare Zone 5
60,782,331.60
Healthcare Zone 6
54,826,019.80
Healthcare Zone 7
41,030,596.20
Healthcare Zone 8
47,814,869.22
Healthcare Zone 9
60,879,942.00
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 monitoring
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 assistants (functional diagnostics, operating-room staff, medical-technical staff) as well as administrative and other staff (e.g. kitchen, laundry and transportation staff and others). No different
salaries for these groups were available.
costs per year
physicians
nurses
others
4.000
2.340
2.560
For the actual imponderables all costs are measured in todays prices, a projection over 10 or
more years seems too unreliable. As a result, changes in financing, cost development and further 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 personnel has to be educated in the use of the new technology which is relevant for their individual tasks. This includes the use of computers and relevant software as well as the use of complex 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 hospitals 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 working 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 medical 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 (intensive care, intermediate care, surgery care, day care, home care, etc.) specific training programmes 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 agreements 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 medical 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 differentiating 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 Transition, 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 quality 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 interrelation 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 indepth theoretical and practical knowledge. All practical education is provided during daily
hospital work where experienced students complete a few years of specialised practical training. 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 Moldovan 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 cooperation 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 administrative 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 working 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 naturally 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 combination with thermal insulation, industrial process and control and energy recovery provide
the opportunity for considerably reducing the rise in energy consumption. This means maximum 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 consultant recommends a special sequence of investments.
We strongly recommend all hospital managements that future building investments be preceded 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 hygienic 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 western standards, we have made the following correlations (see sources: appendix 8.14).
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Transit hospital, 60 beds
75 m gross floor area per bed
Local Level Hospital
Specialised Care Hospital
Highly Specialised Care Hospital
Centre of Excellence, University
The standards of gross floor areas for each level were deduced from detailed room und functional 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 attachments.
Costs for m 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 aspects, 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 continual reliable supply cannot be guaranteed with the existing systems. Due to breakdowns 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 inadequate.
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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 almost sterile air on specifically defined areas. The resulting requirements depend on the function 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 relation 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 diseases 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 supply sources. The systems can then also be designed to be smaller, and will therefore be operated in the optimum operating range of the pumps, which will minimise wear and energy consumption. 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 divided 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 necessary number of tapping points per floor will be provided. In order to avoid the contamination 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 service. 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 require 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 possible, 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 washstands 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 considerations 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 70/50C (supply/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 energy costs. The temperature level of the static heating should be 55 C/40 C.

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HV heating supply
HR heating return
H heating element (radiator)
K heating boiler
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 control 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 temperature 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 usually amortised within 1 to 2 years. The radiators used are flat radiators with the hygiene certificates required for hospitals. Special hygiene radiators will be provided for areas with particularly 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

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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 supply of almost sterile, vertical, low-turbulence air while maintaining a specific flow direction. Suitable air passages include so-called laminar air flow (LAF) ceilings. Contamination of the air in the immediate area of operating and instrument tables would
result in direct or indirect contamination of the operating theatre environment, emphasising 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 alloplastic materials.
This results in the following main points for the implementation in operating theatre functional 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 conversions.

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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 instrument 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 ceiling 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, operating staff and anaesthesia staff. Special consideration should be given to the following:
o
Persons remaining or equipment set up in the border area between the lowturbulence clean air area and the turbulent room air area,
The spatial restriction of the clean air area due to the temperature difference between the incoming air and room air,
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 m / h can be assumed as a
guideline value, while a minimum outside air volume flow of 800 m / 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, particles lying on fixed surfaces are not stirred up. The air supplied as LAF can, for energy reasons, 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 installation 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 purposes 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 minimum 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 sealing 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 ventilation 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 exhaust 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 systems 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 patients 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 aircondition 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 requirement, 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 carried out direct via the relevant ventilation systems by heats of air/water cooling. The ventilation units will be installed in an internal central ventilation room. This arrangement will reduce 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 condensation 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 installed in the central ventilation room, since the heat-exchangers can also be installed internally. 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 escape routes without outside windows. These will consist of ducting systems with a fire resistance 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 service 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.
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 deactivated
After the flushing phase of 120 seconds, the pressure regulation (2) is activated and a constant over-pressure
built up
Figure 33: Pressurised smoke protection system in the internal stairwell

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5.2.2.5 Regulation equipment

In order to reduce complex cabling, the regulation equipment should be actuated and controlled by s BUS system. The EIB BUS system is recommended. With this system, the conventional 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 controlled 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 dooropeners.
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 connection 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 extraction, 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 pressurised 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 shutoff 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 consumers will be less than 15 seconds.
The interface for both types of power supply will be the main distribution center for the hospital 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 system).
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 automatic 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 supply [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, factoryfinished NP and CP distribution boards on the relevant floors, which will be installed in separate 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 reclosed 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 operations 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 protective 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 installation 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
waiting rooms, corridors (during daytime), daytime
lounges, staff rooms, bathrooms and restrooms
corridors in the operating theater, reading lights, simple medical examinations, general lighting
corridors at night
technical rooms
bureaus, preparatory and recovery rooms
medical examinations and treatment
Mean luminance on the ground

200
300
50
100
500
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 reinforced 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 reinforcement 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 equipotential 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 integrated 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 protectors (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 hospitals fire protection
strategy, which does not only take the room conditions into account but also specifies the extent 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 elevators, 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 installed 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:
Speed :
Lifting height.
Stops :
Shaft doors:
Clear door width:
Clear door height
Cabin :
Cabin dimensions:
Cabin door:
Cabin panel:
Control type:
External call operating/display elements:
Mains connection:
Cabin equipment:
1600 kg
>= 0.6 m/s
Basement to maximum floor
each floor, single-sided
fully-automatic sliding door,
Door panels with stainless steel V2A
1400 mm (dimension in unfinished state)
in edged construction
1400 x 1600 x 2200 mm
1 item in construction and size as shaft doors, with electronicallycontrolled door drive and light barrier for passage securing.
1 part as wall panel made from stainless steel V2A,
with short-stroke buttons, digital level display
Microcomputer control as group control
Panel made from stainless steel V2A with operating and display
elements integrated in the box frame profile. The external call operating 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.
230/400 V, 50 Hz
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 rubtop consult kln GmbH
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Portal:
Legislation:
ber, Hand bar, single-sided (longitudinal side), stainless steel

V2A,
Round pipe D = 34 mm
External portal made from stainless steel V2A, enclosure frame,
filled out completely against concrete side walls and sealed to the
concrete walls all round.
European Lift Directive 95/16/EC EN81
Bed lift
Load-bearing capacity:
Speed :
Lifting height
Stops :
Shaft doors:
Clear door width:
Clear door height:
Cabin:
Cabin dimensions:
Cabin door:
Cabin panel:
Control type:
External call operating/display elements:
Mains connection:
Cabin equipment:
Portal:
Legislation:
12.
2000 kg
>= 1.0 m/s
basement to maximum floor
each floor, single-sided
as two-part, fully-automatic sliding door,
Door panels with stainless steel V2A
in edged construction
1500 x 2700 x 2200 mm
1 item in construction and size as shaftdoors, with electronicallycontrolled door drive and light barrier for passage securing.
1 part as wall panel made from stainless steel V2A,
with short-stroke buttons, digital level display
Microcomputer control as group control
Panel made from stainless steel V2A with operating and display
elements integrated in the box frame profile. The external call operating 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.
230/400 V, 50 Hz
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 rubber, Hand bar, single-sided (longitudinal side), stainless steel
V2A,
Round pipe D = 34 mm
External portal made from stainless steel V2A, enclosure frame,
filled out completely against concrete side walls and sealed to the
concrete walls all round.
European Lift Directive 95/16/EC EN81
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 technology 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. Medical 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 patients bodily functions, such as dialysis machines, medical ventilators and heartlung machines
Medical monitors allow medical staff to measure a patients 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 technology 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 develop 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 architecture, 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 maintenance of all patient care equipment
Inventory allocation analysis to determine the usability of existing equipment for allocation 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 economic 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 Procedures in Medicine (ICPM) from the World Health Organisation, no such standards are provided 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 estimate 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 ceilingsuspended 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 gynaecology
Treatment and examination rooms for medical, surgical, and gynaecology are planned in the consultation 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 examination equipment.
Medical Equipment
ECG unit
Spirometer
Pulse oximeter
Examination Light
Examination table
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Blood pressure measuring device
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 equipment 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 fluoroscopy 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 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 gynaecology and newborn departments.
5.3.3 - 1.10 Delivery

The delivery section is to be equipped with single patient delivery rooms with the appropriate equipment 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
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 contain 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 examination equipment and furnishing, similar to the Transit hospitals.
Medical Equipment
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 intensive 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 operating 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 intensive 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 prescriptions 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 included (depending on the necessary function of the hospital):

Medical Equipment
Examination Light
Mobile x-ray unit
X-ray film screen
Medical furniture
Lung ventilator
chairs and cubicles. Dialysis beds with dialysis machines and a central water preparation unit are
planned in the general medicine department.
Medical Equipment
Examination lights
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 projector, 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:
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

page 142
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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 potential.
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:
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 necessary 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 analyser, 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

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 trolley with lifter
Cutting table with suction
Autopsy table
Wet specimen cabinet, with exhaust
Medical furniture

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
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X-ray film screen
Fluoroscopy unit

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 appropriate equipment and furnishings.
Medical Equipment
Examination Light
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

a rest room.
Medical Equipment
Examination Light
CTG equipment
Colposcope
Infrared coagulator
Patient scale
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Medical furniture

A physiotherapy department with normal underwater and hydro-electric baths is planned. The department 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
Infrared heater

The department is to also contain a patient examination room with appropriate basic medical examination equipment and furnishing, similar to the Transit hospitals.
Medical Equipment
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 intensive care area there are ceiling-suspended supply units and appropriate incubators.
Medical Equipment
Ceiling medical supply unit
Infant scale
Milk pump, electric
Incubator
Transport incubator

Intensive care wards 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.

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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
Blood gas analyser
5.3.4 - 2.06 Infectious diseases

Special diagnostic rooms with infection control concerning the prevention of the spreading of infection, 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 prescriptions is not planned.

Medical Equipment
2 steam sterilizers with 6 - 8 sterilisation units, with loading documentation system
Sterilization computer system
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:

Medical Equipment
Examination Light
Mobile x-ray unit
X-ray film screen
Medical furniture
Lung ventilator
Medical Equipment
Examination lights
Medical furniture

Medical Equipment
Nd:YAG laser system
Ophthalmoscope
Ophthalmoscope, indirect
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Lensometer
Line skiascope
5.3.5 - 1.02.07 ORL

Medical Equipment
Audiometry unit
Rhinomanometer
Tympanometer

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 stations, 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 department is to also serve the cardiology department.
Medical Equipment
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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Medical Equipment
Bodyplethysmograph
Blood gas analyser
Bronchoscopy equipment
All endoscopic examinations are to take place in the endoscopy department.

Examination and diagnostic rooms for examinations such as long term PHmetry, with ceilingsuspended supply units as well as examination lights are planned in the department. Endoscopic examination 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
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
Electronystagmograph (ENG)
Medical furniture

Medical Equipment
Mobile x-ray unit
X-ray film screen
Examination table
Examination light
Surgical tools, etc.
Autologous blood donation equipment
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Blood refrigerator
Apheresis equipment
5.3.5 - 1.02.22 Urology

examination. The urology department is to have its own rooms for performing transurethral resection
operations.
Medical Equipment
Examination light
Examination table
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 examinations and a central cleaning and disinfection area.
Medical Equipment
Endo video unit
Flexible endoscopes for all endoscopy procedures (bronchoscopy, colonoscopy, rectoscopy, gastroenteroscopy, etc.)
Integrated cold light generator and suction pumps
Image documentation systems
Cleaning and disinfection unit

The laboratories of the High Specialised Care Hospitals include specialized diagnostic devices for:
- haematology,
- immunology,
- toxicology,
- bacteriology,
- virology and
- serology
These analytical equipment and automatic analysers are at a very high standard of technology.
Medical Equipment
page 152
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5.3.5 - 1.05 Blood bank

Medical Equipment
Blood refrigerator
Apheresis equipment

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 trolley and lifter
Autopsy table
Medical furniture

Additional to the radiology department of the Specialised Care Hospitals with X-ray equipment, fluoroscopy 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
Angiocardiography system and software
Angiography table

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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Medical Equipment
Examination Light
Patient monitor
Medical furniture
Light source
Central CO2 and medical gases supply
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

a rest room.
Medical Equipment
Examination Light
CTG equipment
Colposcope
Infrared coagulator
Patient scale
Reanimation unit for infants

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Medical Equipment
Medical bathtub
Infrared heater

Each department of the hospital is to have its own specialised patient ward, containing a patient examination room with appropriate basic medical examination equipment and furnishing, similar to the
Transit hospitals.
Medical Equipment

On the intensive care ward, every bed will be 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.
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
Examination table
Examination Light
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 department.
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 department should be located near the intensive care department.
Medical Equipment
Infant scale
Milk pump, electric
Incubator
Transport incubator

Special diagnostic rooms with infection control concerning the prevention of the spreading of infection, equipped with basic diagnostic devices.
Medical Equipment
Examination Light
Instrument stand
Examination table
Treatment cabinet
Patient scale
5.3.5 - 5.01 Pharmacy

In the pharmacy, an issuing and storage area for medicines is provided.

page 156
NHMP

Medical Equipment
3 or 4 steam sterilizers upon requirement, each with 6 - 8 sterilisation units, with loading documentation system Sterilization computer system
Film welding device
Worktable

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NHMP
5.3.6
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 diagnostics.

Medical Equipment
Examination Light
Mobile x-ray unit
X-ray film screen
Medical furniture
Lung ventilator
Medical Equipment
Examination lights
Medical furniture

Medical Equipment
Nd:YAG laser system
Ophthalmoscope
Ophthalmoscope, indirect
Lensometer
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NHMP
Line skiascope
5.3.6 - 1.02.07 ORL

Medical Equipment
Audiometry unit
Rhinomanometer
Tympanometer

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 stations, 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 department is to also serve the cardiology department.
Medical Equipment
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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NHMP

Medical Equipment
Bodyplethysmograph
Blood gas analyser
Bronchoscopy equipment
All endoscopic examinations are to take place in the endoscopy department.

Examination and diagnostic rooms for examinations such as long term PHmetry, with ceilingsuspended supply units as well as examination lights are planned in the department. Endoscopic examination 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
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
Electronystagmograph (ENG)
Medical furniture

Medical Equipment
Mobile x-ray unit
X-ray film screen
Examination table
Examination light
Surgical tools, etc.
Autologous blood donation equipment
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Blood refrigerator
Apheresis equipment
5.3.6 - 1.02.22 Urology

examination. The urology department is to have its own rooms for performing transurethral resection
operations.
Medical Equipment
Examination light
Examination table
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 examinations and a central cleaning and disinfection area.
Medical Equipment
Endo video unit
Flexible endoscopes for all endoscopy procedures (bronchoscopy, colonoscopy, rectoscopy, gastroenteroscopy, etc.)
Integrated cold light generator and suction pumps
Image documentation systems
Cleaning and disinfection unit

Additional to the laboratory functions of the High Specialised Care Hospitals, the diagnostic equipment are very specialized. Devices are envisaged for:
- haematology,
- immunology,
- toxicology,
- bacteriology,
- virology and
- serology
- microbiology department
These analytical equipment and automatic analysers are at a very high standard of technology.
Medical Equipment
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NHMP
5.3.6 - 1.05 Blood bank

Medical Equipment
Blood refrigerator
Apheresis equipment

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 trolley and lifter
Autopsy table
Medical furniture

Additional to the radiology department of the Specialised Care Hospitals with X-ray equipment, fluoroscopy unit, Angiography and Computer tomography workplaces, Angiocardiography and Magnetic
Resonance Imaging equipment is also to be provided.
Medical Equipment
RF and magnetic shielding
Standard hardware and software
Patient camera and control unit, supervising monitor
High pressure injector
Angiocardiography system and software
Angiography table

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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.
Medical Equipment
Examination Light
Patient monitor
Medical furniture
Light source
Central CO2 and medical gases supply
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
a rest room.
Medical Equipment
Examination Light
CTG equipment
Colposcope
Infrared coagulator
Patient scale
Reanimation unit for infants

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Medical Equipment
Medical bathtub
Infrared heater

Each department of the hospital is to have its own specialised patient ward, containing a patient examination room with appropriate basic medical examination equipment and furnishing, similar to the
Transit hospitals.
Medical Equipment

On the intensive care ward, every bed will be 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.
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
Examination table
Examination Light
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 department.
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 department should be located near the intensive care department.
Medical Equipment
Infant scale
Milk pump, electric
Incubator
Transport incubator

Special diagnostic rooms with infection control concerning the prevention of the spreading of infection, equipped with basic diagnostic devices.
Medical Equipment
Examination Light
Instrument stand
Examination table
Treatment cabinet
Patient scale
5.3.6 - 5.01 Pharmacy

In the pharmacy, an issuing and storage area for medicines is provided.

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Medical Equipment
3 or 4 steam sterilizers upon requirement, each with 6 - 8 sterilisation units, with loading documentation system Sterilization computer system
Film welding device
Worktable

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NHMP
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, vacuum, power, gas suction, etc.
Clinical chemical analyser - for the analysis of glucose, uric acid, urea, triglycerides, cholesterol, sodium 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 vagina 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 babys 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 patients 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 medical 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 department
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 pressure, temperature
Patient scale scale for the measuring of the weight of a patient
Pulse oximeter device for indirectly measuring the oxygen saturation of a patients 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 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 airway 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 sterile
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 neurons 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 documentation 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
Film welding device standard continuous sealing machine with cutter, work table including measuring 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 department
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, noninvasive 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
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Rhinomanometer - a device used to measure nasal inspiratory flow and pressure
Standing centrifuge, cooling - device used for the separation of biological substances of differing densities, 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 scanner, ENT - imaging device using ultrasound wave technology for image reconstruction, 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
Nd:YAG laser system - for laser intervention and treatment
PHmetry equipment equipment used for gastroenterology diagnosis
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 hospitals 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 clinicsystem 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 Transit 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 example:
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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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, secondary 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 assessment 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 general 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 standard 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 patients 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 transportability 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 emergency care services according to their medical orientation. Hospitals with specialised nonsurgical 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 departments 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 transporting 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 centre for emergency care could be introduced in order to ensure the best treatment as fast as possible, 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. Johns) 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
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 patients own activity. The aim of these activities is to aid patients recovery and reduce requirements 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 economic 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 inefficiencies. 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 rehabilitative 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 knowledge.
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 provided. Indications for rehabilitation include e.g. myocardial infarction (cardiologic rehabilitation), 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 physiotherapists. 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 services. Another option is professional rehabilitative home care. While the patient has the benefit 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 provider. 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 purposes, 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 nonstationary 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, longterm 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 social 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 healthcarezones 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 reasonably 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 minimum 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 additional first step activity in the North. Calarasi, Criuleni and Cimislia will take some pressure 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 Gargausian 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 specialised 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 necessary from medical view. Investments in Ungheni, Leova and Orhei shall also be made to increase 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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NHMP
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 Contagioase 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 progress 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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NHMP
Modernise
Phase 1
legislation
Set up admini-
stration on
healthcare zone level
Centralise university
administration
Introducing
monitoring system
Equipe Gateway Hospitals in
Phase 2
Donduseni, Riscani,
Nisporeni Soldanesti,
Straseni, Basarabeasca,
Ialoveni, Cantemir, Taraclia
Equipe Calarasi, Criuleni,
Cimislia, Stefan-Voda,
Ceadar-Lunga
Create and upgrade
Phase 3
Specialised and High

Specialised Hospitals.
Equipe Glodeni, Singerei,
Ungheni, Leova, Anenii Noi,

Causeni, Vulcanesti
Equipe Institulul Neurologie &
SCMC Ignatenco
Phase 4
Consolidate basic and
specialised healthcare
provision in rural Moldova
Invest in Local Hospitals in
Chisinau
Phase 5
Invest into the modernisation

of the hospitals of Chisinau
(Institulul Oncologic, Inst.
Cardiologie, DDVR, CNSPMU,
Spital Clinic al MS)
Ongoing actualisation of the National Healthcare Masterplan is strongly recommended!
2009
MONAT
2010
2011
2012
2013
2014
Figure 39: Timeframe for Implementation

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2015
2016
2017
2018
NHMP

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NHMP

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NHMP

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NHMP

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Initial Situation and Assignment

Prognosis of needs for healthcare services

4.1 Recommendations for structural changes

Resulting Investment Needs

Effects on other Providers

Ambulant Primary care

Timeframe for implementation

Short-Term Changes (1. phase)

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Initial Situation and Assignment

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)

February, 18, 2009 (see appendix 8.12)

INTERNATIONAL TRENDS IN HEALTH CARE

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

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

Prognosis of needs for hospital healthcare services -general comments

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

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

Resulting investment needs

Effects concerning other providers

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

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Environmental and Market Analysis

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Figure 1: Basic Population Data.

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Figure 2: Economical Figures Republic Moldova

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

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Healthcare System Organisation

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Figure 2: Health system organisation of Moldova

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

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Figure 4: Healthcare Financing Flow Chart

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As-Is Analysis of Hospitals in Moldova

Rural Hospitals in Moldova

3.2.1.1 Description of the Approach

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

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Weights (1 = bad; 6 = good) Results

Figure 5: Criteria used for portfolio analysis

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Figure 6: Points awarded for the criterion "population"

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

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

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

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3.2.1.2 Summary of Results

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Figure 10: Hospital Location and Size in Moldova