BackgroundUniversal Health Coverage seeks to assure that everyone can obtain the health services they need without financial hardship. Countries which rely heavily on out-of-pocket (OOP) payments, including informal payments (IP), to finance total health expenditures are not likely to achieve universal coverage. The Republic of Moldova is committed to promoting universal coverage, reducing inequities, and expanding financial protection. To achieve these goals, the country must reduce the proportion of total health expenditures paid by households. This study documents the extent of OOP payments and IP in Moldova, analyses trends over time, and identifies factors which may be driving these payments.MethodsThe study includes analysis of household budget survey data and previous research and policy documents. The team also conducted a review of administrative law intended to control OOP payments and IPs. Focus groups, interviews, and a policy dialogue with key stakeholders were held to validate and discuss findings.ResultsOOP payments account for 45 % of total health expenditures. Sixteen percent of outpatients and 30 % of inpatients reporting that they made OOP payments when seeking care at a health facility in 2012, more than two-thirds of whom also reported paying for medicines at a pharmacy. Among those who paid anything, 36 % of outpatients and 82 % of inpatients reported paying informally, with the proportion increasing over time for inpatient care. Although many patients consider these payments to be gifts, around one-third of IPs appear to be forced, posing a threat to health care access. Patients perceive that payments are driven by the limited list of reimbursable medicines, a desire to receive better treatment, and fear or extortion. Providers suggested irrational prescribing and ordering of tests as drivers. Providers may believe that IPs are gifts and do not cause harm for patients and the health system in general.ConclusionsEfforts to expand financial protection should focus on reducing household spending on medicines and hospital-based IPs. Reforms should consider ways to reduce medicine prices and promote rational use, strengthen administrative controls, and increase incentives for quality health care provision.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-015-0984-z) contains supplementary material, which is available to authorized users.

We live in an increasingly interconnected world, with many organizations operating across countries or even continents. To serve their global user base, organizations are replacing their legacy DBMSs with cloud-based systems capable of scaling OLTP workloads to millions of users.CockroachDB is a scalable SQL DBMS that was built from the ground up to support these global OLTP workloads while maintaining high availability and strong consistency. Just like its namesake, CockroachDB is resilient to disasters through replication and automatic recovery mechanisms.This paper presents the design of CockroachDB and its novel transaction model that supports consistent geo-distributed transactions on commodity hardware. We describe how CockroachDB replicates and distributes data to achieve fault tolerance and high performance, as well as how its distributed SQL layer automatically scales with the size of the database cluster while providing the standard SQL interface that users expect. Finally, we present a comprehensive performance evaluation and share a couple of case studies of CockroachDB users. We conclude by describing lessons learned while building CockroachDB over the last five years.

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