The percentage of people (2 years of age and older) who discontinued dental consultations at least once was 14.5%
(see Table 13.8).
Category Total number of people (in 1000s)
People who discontinued
service (in 1000s) Per cent
Altogether 37 479.5 a 5 447.1 14.5
Urban areas b 23 035.7 3 709.3 16.1
Table 13.8. People who discontinued dental services at least once in 2004
Table 13.9. Reasons for discontinuing dental services
a The Polish population 2 years of age and older.
b Towns and cities.
Source: Central Statistical Offi ce (2007a:261–264). Reproduced with the permission of the copyright holder.
a Towns and cities.
Note. The Central Statistical Offi ce included three additional categories – lack of time (too busy), fear and other reasons – but they were excluded from Table 13.9.
Source: Central Statistical Offi ce (2007a:265–268). Reproduced with the permission of the copyright holder.
Category
People (in 1000s) who discontinued dental services Total number of people
Reason
Lack of money Long waiting time Distance too long Did not know a good dentist
Total 5 447.1 2 545.6 685.4 78.3 5.7
Urban areas a 3 709.3 1 799.7 451.7 29.9 4.0
Rural areas 1 737.8 745.9 233.7 48.3 1.8
Age groups
--Sometimes people discontinue going to a dentist because they are simply frightened or are too busy to go. However, 46.7% of Polish people who had gone to a dentist and then stopped declared that they had to discontinue going because of the cost. Also, 26.9% of these people did not want to wait too long, 11.4% stopped going because of too long a distance to travel to a dentist and 5.7% did not know a good dentist (see Table 13.9).
In 1999, a new universal health insurance system was introduced in Poland by a law on universal health insurance (National Assembly, 1997a) that included comprehensive solutions on access to health care services fi nanced by a public payer. Because earlier solutions for access were incremental, inconsistent and vague, the new solutions introduced together with universal health insurance were a very distinctive break with the past.
Because free access to health care services was recognized as one of the most important social rights, comprehensive solutions for the new health system were worked out carefully. It was also decided that mandatory participation would be complemented by the option of voluntary access to health care services, which was recognized as a safety valve. In this way, all those interested, whose free access to health care services was unintentionally denied, got an opportunity to join the system. After the new system was introduced, however, it occurred that some groups were not included and that the voluntary insurance did not protect everybody against exclusion from the system. For example, the children of uninsured parents, the homeless and youngsters kept in holding facilities (different from prisons) were not included in the system on a mandatory basis, and these people had no ability to pay contributions to join the system voluntarily.
Members of some excluded groups informed policy-makers that their rights were violated. Some so-called silent groups, however, did not effectively protect their free access to health care, which required that decision-makers be informed indirectly, by health care providers, researchers or NGOs. All information on unintentional exclusions was analysed to identify new social groups, so that they could be insured mandatorily. Therefore, the number of groups listed had to be increased – from 17 in the fi rst legal act on universal health insurance to 35 in the next acts on universal health insurance (Mokrzycka, 2007).
Decision-makers also realized that not all social groups of excluded people could be named. A legal act, introduced in 2004, therefore provided an additional safety valve to protect the very poor from exclusion (National Assembly, 2004). In September 2007, the solution was modifi ed to better meet their needs. Because of it, all the poorest people (insured and uninsured) got free access to health care.
Lessons learned
References
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Because access to dental services is limited in Poland, additional solutions were introduced to provide poor people with better access to these services. In the case of treating teeth, only standard services are fi nanced by a public payer; for children younger than 18 years old, pregnant women and people with psychiatric disorders, the scope of services provided is broader.
Many people with an economic status that is average or higher ask for services beyond the standard provided. In such cases, however, they were obliged to cover all costs of the services – the National Health Fund did not cover the part of their treatment equal to the costs of basic services. This solution was expected to help secure public resources for services offered to poor people who could not afford the out-of-pocket costs of extra services.
Unfortunately, this formal solution was ineffective, leading dentists and patients to often agree on the following informal solution: dentists charged their patients only for the costs of extra, out-of-pocket services – less the cost of standard treatment.
In such cases, the dentist obtained the balance of money from the National Health Fund. Because of the informal solution, the solution presented was recently replaced by a new one. Nowadays, in case of dental services that are more expensive than the standard cost, the National Health Fund covers expenditures equal to the cost of standard services.
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14. Republic of Moldova: children living in poverty – implications for the health system
Ala Nemerenco State University of Medicine and Pharmacy “Nicolae Testemitanu”
Challenges in the transition to a market economy, slowed economic growth and the rise of unemployment have led to the deterioration in the quality of life for the majority of the Republic of Moldova’s people. Children, who represent the most vulnerable group and are exposed to a variety of social risks, have been most affected. This case study analyses child poverty in the Republic of Moldova, provides an overview of key indicators for child health, describes how efforts to provide health insurance coverage and strengthen primary health care can improve the health of disadvantaged children, and briefl y introduces issues related to public expenditure and the new National Health Policy in relation to this topic. It also discusses lessons learned for scaling up the health system’s ability to meet the needs of vulnerable children.
In the Republic of Moldova in 2002–2003, 53% of the country’s children lived in poverty, compared with 43% of the entire population. The country’s children face a higher risk of poverty than the overall population and are also more deeply situated beneath the poverty line than are adults. Currently, social transfers given to families with children do not signifi cantly reduce poverty. Poverty and increased family instability have led to a rise in the number of children left without care.
Since the implementation of mandatory health care insurance in 2004, children are insured by the state. Every child is under the supervision and monitoring of a family physician, according to the approved standards for their age. When required, the family physician refers a child to specialized ambulatory medical services and conventional hospital care (outpatient and inpatient) services, as well as to tertiary care. Strengthening primary health care is a priority for the national health system.
Both mandatory health care insurance and the strengthening of primary health care can increase children’s access to medical care, including access for children from socioeconomically disadvantaged households.
The Government of the Republic of Moldova recognizes the civil, political, social and cultural rights of children and has undertaken many activities in the past decade to safeguard and improve the health and social needs of this sociodemographic group. The current situation, however, calls for further attention, and it is hoped that implementation of the new National Health Policy will contribute to this over the course of its 15-year term.
The following lessons have been learned about how the health system can better meet the needs of children living in poverty in the Republic of Moldova. Through the health system’s stewardship role, the existing legislative framework needs to be analysed and, if necessary, laws and policies need to be modifi ed, to ensure that children living in poverty and their families have access to health and social services. Strengthening health service delivery will require increases in the availability of disaggregated data on the health status of children living in poverty and will also require improvements in the quality of primary health care services and interventions that target children and adolescents. Investments in both human resources and
Summary
Republic of Moldova
Socioeconomic and policy context
In the Republic of Moldova, on 1 January 2008, the total registered population was 3 572 703 people, which includes 882 682 children (24.7% of the population). For the purposes of this study and in accordance with the defi nition given in the United Nations Convention on the Rights of the Child, the use of the word “children” refers to human beings less than 18 years of age. Of these children, 316 276 (35.8%) live in urban areas and another 566 406 (64.2%) live in rural areas (Moldova Statistics, 2008).
After 10 years of continuous and sharp decline, the Moldovan economy started to recover in 2000. Between 2000 and 2006, growth in GDP averaged 5.7% a year. Although infl ation receded, it remained in the two-digit range. Also, the national currency remained relatively stable against key foreign currencies. According to the medium-term expenditure framework for 2007–2009, annual growth in GDP is projected to be 6% yearly, based on expectations of growth in the service, industrial and agricultural sectors (Ministry of Finance, 2006).
A salient feature of the Moldovan economic and social situation is the large migration of Moldovan citizens seeking employment opportunities abroad. In 2005, the number of emigrants was 705 500 (Ratha & Xu, 2008). As of mid-2006, about a quarter of the economically active population was employed abroad (IOM, 2007). In 2006, the National Bank of Moldova estimated remittances to be over 35% of the GDP, compared with 31% in 2005. These remittances have contributed signifi cantly to the resumption of economic growth and have mitigated poverty (Government of the Republic of Moldova, 2007a:2).
Poverty in the Republic of Moldova is measured on an annual basis, and measurements are based on Household Budget Survey data from the National Bureau of Statistics. The extreme poverty line is based on the monetary value of a food basket, defi ned in terms of minimal daily use of calories, amounting to 2282 kcal per person per day (the food basket value is calculated according to the minimum existence level). In 2005, the extreme poverty line amounted to MDL 279 (US$ 22) per month, with about one in six citizens (16%) living in extreme poverty. The absolute poverty line is estimated on the basis of expenditures for total consumption, which raises the value of the food poverty line by supplementing it with nonfood items and services. The absolute poverty line for 2005 was estimated at MDL 354 (US$ 28) per month, with about one in three citizens (29%) living in absolute poverty (Government of the Republic of Moldova, 2007a:99–100). According to the 2005 Household Budget Survey data, 23% of the population lived below the relative poverty line in 2005 (Government of the Republic of Moldova, 2007a:100).