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.

Background The public primary healthcare system in Greece has not been fully developed and is delivered by urban and rural health centers, outpatient departments in public hospitals and the recently established first-contact and decentralized local primary care units. The aim of this study was to develop a valid and reliable measurement tool for conducting periodic user experience evaluation surveys in public Primary HealthCare facilities in Greece such as outpatient clinics of public hospitals and health centers. Methods A mixed methods approach was applied. In particular, the methodology of developing and validating the tools included three steps: (a) establishment of the theoretical background/literature review, (b) qualitative study: development of the tools items and establishment of the face validity and (c) quantitative study: pilot testing and establishment of the structural validity and estimation of the internal consistency of the tools. Two patient focus groups participated in qualitative study: one visiting health centres and the other visiting the outpatient clinics of public hospitals. Quantitative study included 733 Primary Health Care services’ users/patients and was conducted during August–October 2017. Exploratory and confirmatory factor analysis was performed to check for structural validity of the tools, while Cronbach’s alpha coefficients were estimated to check for reliability. Results Confirmatory factor analysis confirmed almost perfectly the presumed theoretical model and the following six factors were identified through the tools: (a) accessibility (three items, e.g. opening hours), (b) continuity and coordination of care (three items, e.g. doctor asks for medical history), (c) comprehensiveness of care (three items, e.g. doctor provides advices for healthy life), (d) quality of medical care (four items, e.g. sufficient examination time), (e) facility (four items, e.g. comfortable waiting room) and (f) quality of care provided by nurses and other health professionals (four items, e.g. polite nurses). Conclusions We have developed reliable and valid tools to measure users’ experiences in public Primary HealthCare facilities in Greece. These tools could be very useful in examining differences between different types of public Primary Health Care facilities and different populations. Electronic supplementary material The online version of this article (10.1186/s12875-019-0935-6) contains supplementary material, which is available to authorized users.

BackgroundMoldova is the poorest country in Europe. Economic constraints mean that Moldova faces challenges in protecting individuals from excessive costs, improving population health and securing health system sustainability. The Moldovan government has introduced a state benefit package and expanded health insurance coverage to reduce the burden of health care costs for citizens. This study examines the effects of expanded health insurance by examining factors associated with health insurance coverage, likelihood of incurring out–of–pocket (OOP) payments for medicines or services, and the likelihood of forgoing health care when unwell.MethodsUsing publically available databases and the annual Moldova Household Budgetary Survey, we examine trends in health system financing, health care utilization, health insurance coverage, and costs incurred by individuals for the years 2006–2012. We perform logistic regression to assess the likelihood of having health insurance, incurring a cost for health care, and forgoing health care when ill, controlling for socio–economic and demographic covariates.FindingsPrivate expenditure accounted for 55.5% of total health expenditures in 2012. 83.2% of private health expenditures is OOP payments–especially for medicines. Healthcare utilization is in line with EU averages of 6.93 outpatient visits per person. Being uninsured is associated with groups of those aged 25–49 years, the self–employed, unpaid family workers, and the unemployed, although we find lower likelihood of being uninsured for some of these groups over time. Over time, the likelihood of OOP for medicines increased (odds ratio OR = 1.422 in 2012 compared to 2006), but fell for health care services (OR = 0.873 in 2012 compared to 2006). No insurance and being older and male, was associated with increased likelihood of forgoing health care when sick, but we found the likelihood of forgoing health care to be increasing over time (OR = 1.295 in 2012 compared to 2009).ConclusionsMoldova has achieved improvements in health insurance coverage with reductions in OOP for services, which are modest but are eroded by increasing likelihood of OOP for medicines. Insurance coverage was an important determinant for health care costs incurred by patients and patients forgoing health care. Improvements notwithstanding, there is an unfinished agenda of attaining universal health coverage in Moldova to protect individuals from health care costs.

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This paper presents briefly the suggested national human resources for health strategy for Greece, which is based on a rapid assessment of the current situation and drafted around 5 domains/strategic key areas: planning, skills and distribution, retention, governance and government health priorities. It provides an overview of the national context including demographic challenges, health status of the population and emerging health issues as well as health system organizational characteristics and policies with an impact on human resources for health strategy. The main objectives and the guiding principles of the suggested national strategy are explained and proposals for the way forward to successfully implement it are discussed.