Enforcement of public health policies and regulations

The enforcement of public health policies and regulations is done jointly by the public health service (the SSPHS) and by other services and agencies. The NCPH and territorial Centres of Public Health have special units responsible for environment and health issues and the surveillance of environmental factors influencing health. Data collection on environmental factors is carried out as part of “socio-hygienic monitoring”. The monitoring of air pollution and water quality is also carried out jointly by the SSPHS, “Hydrometeo” and the Ecological Inspectorate of the Ministry of Environment. The SSPHS is responsible for monitoring the quality of drinking-water, surface water and water in recreational areas and for monitoring indoor air pollution.

The surveillance of food safety and quality is carried out jointly by the SSPHS, the National Food Safety Agency, and the National Agency for Consumer Protection under the Ministry of Economy. The National Food Safety Agency is an administrative authority acting nationally and is responsible for the implementation of state policy in the area of food safety. It was created in 2013 and is directly under the government. The SSPHS is responsible for the surveillance of food for special nutritional purposes, food supplements, nutritional and health claims, the evaluation and registration of new products before they enter the market, and for the epidemiological investigation of foodborne diseases.

The National Agency for Consumer Protection (NACP) under the Ministry of Economy was created in 2011, through the reorganization of the former state inspectorate for market supervision, metrology and consumer protection. The NACP is responsible for the implementation of state policies in the area of consumer protection and for the enforcement of respective legislation.

The surveillance of occupational health and workplace safety is carried out by the SSPHS in collaboration with the Labour Inspectorate under the Ministry of Labour, Social Protection and Family. The SSPHS monitors adherence to occupational health legislation and evaluates temporary disability and occupational diseases. The NCPH has a registry of occupational diseases. It produces an annual report on workers’ health in relation to risk factors at their workplaces, which is published in the journal Labour Security and Hygiene and on the NCPH web site. Employers are obliged to organize periodic medical examinations of their employees and to cover all the costs of such examinations.

The SSPHS and the police share the responsibility for protecting the population against exposure to second-hand smoking. A joint order of the Ministry of Health and the Ministry of Interior was signed, outlining the procedures for working together and reporting on the process of enforcing the law on tobacco control.

Intersectoral collaboration and partnerships

The Centres of Public Health collaborate locally and nationally with other services and sectors. National and municipal or district Councils for Public Health are a useful instrument for addressing public health emergencies. There are also protocols between services on the periodic exchange of information of common interest and in emergencies. Biannual reports on the environment and health are produced jointly by the Ministry of Health and the Ministry of Environment.

National public health programmes are developed by intersectoral working groups that are established by Ministry of Health order. Technical working group meetings are the most frequently used formal mechanism for collaboration in problem formulation; this involves all relevant stakeholders and non-governmental organizations (NGOs). Informal discussions and personal relationships between the members of working groups are often used and are valuable resources in the clarification and formulation of health determinants and other public health policies. Draft documents are officially consulted with central authorities before being endorsed by government.

Different mechanisms for collaboration between the Ministry of Health and other stakeholders, both formal and informal, are in place. Cross-sector national coordination councils have been established under the leadership of the deputy prime minister responsible for the social sector, acting as the consultative body for the government on specific public health issues (e.g. tobacco, alcohol and nutrition). Their role is to contribute to the intersectoral development, implementation, and monitoring and evaluation of interventions. The council meetings are very useful mechanisms for collaboration and discussion of public health issues between the main stakeholders. They benefit from broad participation by ministries, academia, NGOs and the mass-media. Workshops, table-top exercises, drills and round tables with the participation of the main stakeholders are other mechanisms to achieve their involvement in public health matters. The National Health Forum that takes place annually brings together high-level decision-makers and allows for a discussion of the main health subjects, including noncommunicable diseases and their risk factors. Collaboration with international organizations (e.g. WHO, WB and UNICEF) is based on bilateral agreements.

Training

The training of specialists for the public health service is performed by the State University of Medicine and Pharmacy “Nicolae Testemitanu”. The training curriculum for specialists in hygiene and epidemiology in the Faculty of Public Health takes six years. During the first three years pre-clinical subjects are studied, while in the following three years students study the public health disciplines more extensively, including general hygiene, environmental hygiene, occupational hygiene, food hygiene, children and adolescents’ hygiene, epidemiology, microbiology, social medicine, sanitary management, health promotion and health education, and laboratory services.

During the sixth year of study students learn about epidemiological surveillance of population health and health determinants. The six years of study are followed by the residency stage, lasting two years, at the National Centre of Public Health and the Chisinau Municipal Public Health Centre. Training curricula cover traditional topics such as hygiene and the epidemiology of infectious diseases, but there is very little about modern public health, such as the epidemiology of noncommunicable diseases, health behaviours and risk factors, health promotion and health education and empowering people to live a healthier life.

Following the residency stage, students can enrol in three-year doctoral (PhD) studies, followed by postdoctoral studies leading to habilitation, similar to the academic training pathways in France, Switzerland, Germany and Poland. Postgraduate education programmes for doctor’s degrees in public health are delivered and managed by the relevant departments of the State Medical University.

The training process for medical specialists in public health is illustrated in Figure 6-3.

Figure 6-3

Training process for medical specialists in public health. Source: Authors’ compilation

The managers of public health and health care facilities, as well as other specialists such as lawyers, statisticians and IT technicians, graduate from the School of Public Health Management, established in 2003 at the State Medical University (the State University of Medicine and Pharmacy “Nicolae Testemițanu”). The School is a member of the Association of Schools of Public Health in the European Region (ASPHER) and offers a two-year Masters training programme for medical and non-medical health professionals.

Postgraduate training courses in public health, including hygiene, microbiology, epidemiology and health management, are available for medical professionals at the same university. Short-term training courses for mid- and high-level degree professionals were developed at the NCPH on specific topics, according to a programme for continuous professional development (mainly for specialists from municipal and rayon Centres of Public Health). Additional training opportunities are provided through national and regional seminars, conferences and national and international workshops. In the national public health laboratories, job skills training is widely available for district-level personnel.

Specialists with college degrees, such as assistants of epidemiologists, hygienists and lab technicians, graduate from medical college following a four-year training programme.

Working conditions

There are many reasons why public health is not an attractive area of work for young doctors and mid-level professionals, including low levels of salary, weak mechanisms for motivation and encouragement, and continuous internal reorganizations, with subsequent reductions in the number of staff.

One challenge is the changing functions of the public health service. Health inspection used to be one of the key functions of the public health service (previously the sanitary-epidemiological service). However, in the context of reducing the number of agencies with inspection functions in recent years, the functions related to food safety, the working environment, and radio-nuclear safety have been transferred from the public health service to other agencies and the number of staff responsible for inspections has been reduced; this has led many professionals to reconsider their career in public health. While new functions, such as health promotion and health education, were introduced into the public health service, only a few professionals are charged with these functions in each of the districts. They usually come from within the public health service and they have the same background in hygiene, epidemiology and surveillance, with a consequent lack of understanding and practical skills in modern public health. When the new functions were introduced, staff were not provided with support, training or any other meaningful initiative to empower them with new knowledge and skills. Horizontal cooperation between district Centres of Public Health is missing and there is no peer support or joint development of functions and performance.

Recruiting and retention mechanisms for the public health workforce are also underdeveloped. Young doctors, after graduation, take part in interviews organized by the Ministry of Health and the Medical University, based on which they are dispatched for their residency programme to different Centres of Public Health. When the proposed post is not accepted by the physician, the Human Resources Department of the Ministry of Health looks for other options to deal with this issue. However, there is no transparent employment mechanism that would allow competition for posts. There is no well-developed system for career progression and qualified public health staff are moving into other areas of the economy or migrating to other countries.

The low salary is the key demotivating factor for recruiting and retaining professionals in the public health workforce. Public health workers are typically employed on permanent contracts with personal job descriptions. The advantages of this type of employment include a high level of job security and a stable salary. On the other hand, there tends to be a lack of competition, a lack of interest in career development, and resistance to change. The salary is fixed and not dependent on performance.

The salaries of public health professionals are paid from the state budget, based on Government Decision No. 381/2006 on the conditions of personnel remuneration in budgetary establishments (annex No. 3), a regulation that sets out salaries, bonuses and salary supplements. The salary is determined by the level of education (secondary professional education or higher), work experience, hazard pay, and the coverage of underserved populations. The salary level within the public health service is one of the lowest in the public sector and very low compared to curative health care services. It is becoming more and more difficult to keep staff motivated and prevent them from leaving. As mentioned above, all units of the public health service use the policy of “vacant staff positions” to provide their staff with 1.25 or 1.5 posts to boost their salaries.

The employment of public health staff is regulated by the 2009 Law on the State Supervision of Public Health and by the Ministry of Health Order No. 139 from 15 October 2015 on the recruitment of health workers. The Chief State Sanitary Physician is named and dismissed by the government. Deputies of the Chief State Sanitary Physician, as well as the chief state sanitary physicians of districts and municipalities and their deputies, are appointed and dismissed by the Minister of Health, following recommendations by the Chief State Sanitary Physician. Public health professionals in district or municipal Centres of Public Health are employed by the head of the centre, who is also the Chief State Sanitary Physician of the respective territory. As mentioned above, young specialists are assigned to work at a specific Public Health Centre for their residency training. After completing their residency programme, they are employed by the Ministry of Health or other medical institutions.

According to data from the National Bureau of Statistics (National Bureau of Statistics, 2015), the average monthly salary in the health and social sector in 2015 (MDL 5518) was 19% higher than the average monthly salary in the economy overall (MDL 4611). Comparing salaries within the health sector, however, the lowest salary was received by public health professionals. The average monthly salary of public health professionals with higher degrees was MDL 3513 in 2015, 37% lower than for the health sector in general. In the same year, the average monthly salary of a young public health doctor in the first five years of employment was MDL 1676, which was lower than the minimum guaranteed wage (MDL 2100) approved by the government in 2016 (Government of Moldova, 2016b).

Information systems

Data on the public health workforce are collected through the national health information system for human resources. The system is paper-based and includes annual data collection and the compilation of data in statistical reports on human resources. The Human Resources Department of the Ministry of Health collects all the data. A separate database on the public health workforce is kept by the National Centre of Public Health but this database is not accurate and does not contain critical data that can be used for policy development and planning the public health workforce. The current system does not disaggregate data by factors such as age, gender, educational level or professional categories. An electronic information system for monitoring human resources in the health system was recently created and is now run by the Ministry of Health.

So far, surveys to assess the job satisfaction of public health workers and their capacities to carry out public health operations have not been conducted. This makes it difficult to develop appropriate strategies and interventions to improve their satisfaction and performance.

Human resources policies

In April 2016 the government approved the strategy and action plan on the development of human resources in the health system for the years 2016–2025. The strategy emphasizes that human resources are one of the fundamental components of the health system. It set out the following main objectives:

• improving the management of human resources;
• generating an adequate quality and quantity of medical staff according to the needs of the health system;
• developing and maintaining a modern human resources management system, sustainable funding for training, maintenance and developing human resources in health; and
• developing and implementing effective mechanisms for the retention of health workers and the management of staff mobility.

The strategy describes the general situation of the health workforce, but does not contain any specific provisions related to the public health workforce.

The National Public Health Strategy for 2014–2020, adopted in 2013, envisages strategic interventions to strengthen the public health workforce. The Action Plan of the Strategy includes activities such as:

• evaluating the needs of the providers of public health services;
• the development, approval, and implementation of a methodology for strategic planning of human resources in public health;
• the revision of the professional training route in public health at all the training stages;
• adjusting training programmes to align with international ones; and
• the development and implementation of performance-based payroll systems.

At the time of writing (June 2017), these activities were at different stages of implementation.

In view of an anticipated shortage of medical specialists, in 2011 the “Development Strategy of the State University of Medicine and Pharmacy ‘Nicolae Testemitanu’ for 2011–2020” was approved. The main objective of the strategy is to increase the quality of medical and pharmaceutical education and the development of a qualified medical workforce, including the public health workforce, for the next decade, by aligning training processes with international standards and European requirements.

Accreditation of health care institutions

The national system for the evaluation and accreditation of health care providers and the principles for improving the quality of medical and pharmaceutical services were established by the 2001 Law No. 552 “on Evaluation and Accreditation in Health”. In 2002, the National Assessment and Accreditation Council in Health (CNEAS) was established. CNEAS is governed by a presidium chaired by a Deputy Minister of Health and includes associations of insurers, professions and patients. The National Council for Evaluation and Accreditation in Health is responsible for the development of regulations and guiding principles and for setting up committees and groups of experts for evaluation and accreditation. There are three types of committee: for health care facilities, pharmaceutical institutions and public health institutions. The National Assessment and Accreditation Council performs the following main functions:

• it informs relevant institutions about the requirements for assessment and conditions for accreditation;
• it assesses compliance by health care facilities;
• it develops recommendations for compliance with accreditation standards; and
• it takes decisions on the accreditation of institutions in the health sector and issues certificates of accreditation.

The procedure for accreditation is divided into two parts. In the first part, the procedure is initiated with the application for accreditation, the receipt of the necessary documentation from the Council and a self-evaluation. In the second part, an assessment of quality insurance systems of health facilities takes place, followed by a comprehensive report that includes recommendations and the decision on accreditation.

The checklist for the self-assessment of Public Health Centres is completed by a designated working group that includes the quality manager of the institution, representatives of the audit department, lawyers and other professionals. Members of the Accreditation Commission are represented by experts in different areas, including management, laboratory services, epidemiology of communicable diseases and nosocomial infections, and health protection (environment health, child and adolescent health, occupational health). They conduct the assessment of the institution by examining its procedures and mechanisms and observing the activities being performed. Following the assessment, the members of the Accreditation Commission present their conclusions and, in general, the Certificate of Accreditation is issued to the institution.

All health facilities, including all Public Health Centres, have to undergo an accreditation process every five years. The results of the evaluation and accreditation of medical facilities, including Public Health Centres, are updated quarterly on the Ministry of Health (www.ms.gov.md) and CNEAS web sites (www.cneas.ms.md). The fee for the evaluation of institutions is established by law and needs to be paid by the institutions before the evaluation and accreditation take place. Although no Centre of Public Health has ever lost its accreditation, in some cases there were delays in receiving the accreditation, such as when the accreditation commission identified areas of non-compliance and a certain time was given for solving these issues.

The National Centre of Public Health, in addition to being accredited by CNEAS, is also accredited by the National Council for Accreditation and Attestation in the field of research. This accreditation process is similar to the accreditation in the health sector and includes self-assessment and expert evaluation.

Public health laboratories are also accredited by the National Accreditation Centre (MOLDAC) that assesses conformity of performance and undertakes accreditation and annual supervision of quality systems. Based on this type of accreditation, laboratories of Public Health Centres can provide services to other agencies, such as the National Agency for Food Safety.

Reference laboratories of the National Centre for Public Health are often involved in external quality control programmes conducted by the World Health Organization, especially for communicable diseases such as measles, rubella, rotavirus, poliomyelitis and influenza.

Performance measurement

With the exception of the laboratory service, where the quality management system is one of the key components of its activities, there is no systematic assessment of performance. Information on the activities of individual public health institutions is published on their respective web sites (covering such issues as their mission, structure, services provided, events, seminars, conferences, courses and activity reports).

The first systematic analysis of public health operations, services and activities in the Republic of Moldova (WHO, 2012a) was carried out in 2011–2012, using the WHO Europe self-assessment tool for essential public health operations. This assessment was conducted through the joint efforts of the WHO Regional Office for Europe, the WHO Country Office in Moldova, the Moldovan Ministry of Health, the National Centre of Public Health, and representatives of sub-national Centres of Public Health and health facilities.

The National Public Health Strategy for 2014–2020 was developed based on the WHO European Action Plan for Strengthening Public Health Capacities and Services (WHO, 2012b). It establishes a set of indicators for the monitoring and evaluation of the public health service. However, due to a general lack of a monitoring and evaluation system and limited capacities, these indicators are not being used for monitoring and evaluation.

Another weak point is the management, monitoring and evaluation of specific public health programmes. While there are clear rules and requirements established by the government in 2007 for the development of policy documents, there are no regulations that would establish procedures for the regular monitoring and evaluation of public health policies and programmes. Each policy establishes its own evaluation rules and timeframes. The overall coordination and evaluation of health policies is the responsibility of the Ministry of Health.

Continuous professional development

Medical doctors, medical assistants and laboratory staff are required to engage in continuous professional development, during which they must accumulate a specified number of credits, set out in a 2011 Ministry of Health Order. Compulsory continuous professional development for medical doctors, including public health specialists, consists of participation in trainings, seminars, conferences and round tables, and the publication of articles, monographs or books. Medical doctors have to accumulate 325 credits over five years, including 250 credits for continuous medical education (at national or international level) and 75 credits for participation in different research fora or conferences. Medical staff with mid-level education have to accumulate 200 credits (150 plus 50). Every five years specialists can apply to a commission established by the Ministry of Health to confirm their grade or receive a higher grade. However, there is no performance management system for public health professionals or other health workers.

Conclusion and outlook

The public health service in the Republic of Moldova represents a large network of Public Health Centres with representation in every district. The centres are coordinated and managed directly by the Ministry of Health through its Directorate of Public Health and a Deputy Minister of Health who is also the Chief State Sanitary Physician. The National Centre for Public Health provides technical and methodological support both to the district or municipal Centres of Public Health and to the Ministry of Health and its Directorate of Public Health. For the Ministry of Health, coordination of all these activities involves a huge effort, in view of its limited capacities in terms of human and financial resources.

The current public health service, a successor of the sanitary epidemiological service, remains focused on the control of communicable diseases, sanitary hygiene and laboratory services, even though new functions of public health, such as health promotion, disease prevention and monitoring and assessment of population health, have been introduced. The continued focus on traditional functions of public health has several reasons, including the limited allocation of staff positions to the new functions, the traditional professional background of staff, the non-existent training of staff to carry out the new functions, and the overall unattractiveness of public health due to low salaries compared to other health workers.

The capacity of public health professionals dealing with infectious diseases and noncommunicable diseases (NCDs) is spread unevenly. There is a predominance of staff involved in health protection activities and, in some territories, in the control of communicable diseases, compared to a very low number of untrained public health workers in the areas of disease prevention and health promotion. Competency to monitor and evaluate the NCD burden is a concern throughout the country. There is no system to evaluate the performance of the public health service, with the exception of laboratory services where a quality management system is in existence.

Currently, the public health service faces serious financial problems, due to low levels of spending. Despite scarce financial resources, there are well organized diagnostics, investigations and interventions in the areas of environmental health and communicable diseases. In the last few years the control of key NCDs and NCD risk factors has been improved through strengthening national health policies and legislation, as well as by improving risk factor surveillance. This was made possible through financial support by external donors and technical support by the World Health Organization. Weaknesses of national programmes include their governance mechanisms and the monitoring and evaluation of interventions. There is no clear division of responsibilities and a lack of coordination mechanisms; another weak point is a lack of financial resources. Consequently, many national programmes in the area of public health are poorly implemented.

Despite some political instability in recent years, as a result of frequent changes of government after November 2014 and unfavourable economic conditions, public health remains a priority area in the health sector. Life expectancy at birth dropped by 0.4% in 2014 compared to 2013 (WHO, 2017) and there were increased discrepancies in life expectancy between rural and urban populations and between males and females. Smoking rates among men are very high (44%), while 56% of the population was overweight or obese in 2014 (WHO, 2017). There are also very high rates of alcohol consumption per capita, amounting to 16.8 litres of pure alcohol per year in 2008–2010 (WHO, 2014).

One of the priority areas for the government for the years 2016–2018 is “Modernizing health services, including the surveillance of the state of public health through its regionalization, to improve coordination among all levels of local health care”. The ultimate purpose is to make the public health service more effective and efficient. The first step in the reorganization of the public health service started in July 2016 with the regionalization of public health laboratories. These will be concentrated in ten regions instead of having 36 laboratories. The second phase was anticipated to be initiated in 2017 with the regionalization of Public Health Centres, also in ten regions.

In the process of the regionalization of public health laboratories many barriers have become apparent, including lack of financial resources; lack of transport of tests from the rayons to the regions; lack of qualified personnel (partly due to the government moratorium on employing staff); low salaries and lack of motivation. There is considerable opposition to the reform, from both inside and outside the system. The number of employees was not reduced, but instead they were asked to move from the rayon to the region. This was not well accepted and a lot of complaints came from trade unions and local public authorities.

Many challenges lie ahead for strengthening the public health service in Moldova. There is a need to integrate all essential public health functions and operations; to distribute the functions and responsibilities at all levels appropriately; to reorient the focus of the public health service from a supervising and control service to a more collaborative one that engages in partnerships with health care services and other sectors; and to ensure an appropriate education and ongoing training in public health and upgrade skills in health promotion and disease prevention. Finally, it will be important to improve the attractiveness of the public health service by increasing salaries to the level of other health services, such as specialized and primary health care.