CZU 303.4:328.185:343.352 M 45
This publication represents synthesis of the results of the research conducted by Transparency International – Moldova in 2006. It is published with financial support of the United Nations Development Programme (UNDP) and Stability Pact Anticorruption Initiative for Southeast Europe (SPAI). Opinions expressed herein are of their authors and do not necessarily reflect opinions of the donors.
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Measuring Corruption: from Study to Study Transparency InternationalMoldova. – Ch.: Bons Offices, 2007. – 59 p. ISBN 978-9975-80-028-0 300 ex. 303.4:328.185:343.352
Copyright © Transparency International – Moldova, 2006 All rights reserved Transparency International-Moldova, 2006 Str. 31 august 98, MD-2004, Chisinau, Moldova tel/fax: (373-22) 237876 www.transparency.md E-mail: office@transparency.md ISBN 978-9975-80-028-0
Table of contents 1. Opinions of household members regarding unofficial payments in the health care system
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2. The results of the focus group discussions among representatives of public healthcare institutions and healthcare-related business regarding corruption in the healthcare system
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3. Express Survey of the Beneficiaries of Services Provided by the Labor Inspection
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4. Annexes
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1. Opinions of household members regarding unofficial payments in the health care system 1.1 Organization of the sociological research Goal of the survey The goal of the survey consists in studying the situation regarding the access of the population to the health services in the Republic of Moldova, analysis of the personal perceptions and experiences of the respondents with regard to the corruption in the health assistance system, identification of domains, sectors affected more by this phenomenon, as well as formulation of proposals to remedy the situation.
Structure of the questionnaire As basis for undertaking this survey was the questionnaire of the representatives of households, which includes 35 questions and is structured in 3 compartments: – General data on respondents (age, sex, education, place of residence, income); – Use of health services and access to them; – Perceptions and experiences of the respondents on corruption in health assistance.
1.2 Methodology of the survey – Volume of the sample: 1375 households; – Margin of error: 5%; – Random, stratified, multistage sample; – Stratification criteria: three geographic zones – North, Centre and South, residential environment, size of the urban locality 2 types and those rural 3 types;
Measuring Corruption: from Study to Study
– The sample was established based on the list of localities of every rayon and selected in a random way. According to the indicated criteria, 86 localities were selected. In each locality, depending on the urban or rural environment, two types of routes were used, at the households from the blocks and houses on the land, via the random route method, the persons were interviewed as per the method of the most closer date of birth, with the age over 18 years; – Period of collecting data: 15 May – 2 June 2006; – The quality of the data collection and veracity of the interviews was assured by the group of controllers, as well as via the method of statistical comparison.
1.3 Results of the survey 1.3.1 Characteristics of Respondents Residential Environment Depending on the residential environment, the majority of respondents (60.7%) are from rural area, and 39.3% – from urban environment. Urban 39.3%
Age Groups of the Respondents
Rural 60.7%
Depending on the age criteria, the respondents were distributed as follows: the highest share is represented by the persons of the age of 45–59 years old (30.3%), 30–44 years old (24.8%), 60 years and more (23.3%). Additionally, 21.6% of persons of the age between 18 and 29 years old participated in the questioning.
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Gender of the Respondents Out of total respondents, females represent 63.6%, males – 36.4%.
Education of the Respondents The results of the survey show that 43.1% of interviewed persons have secondary education or uncompleted secondary education, 22.5% – vocational education and 20.2% – higher education.
Incomes of the Respondents The monthly incomes of the questioned households were divided as follows:
Measuring Corruption: from Study to Study
1.3.2 Use of the health services and access to them How do the respondents estimate their health? (% of respondents)
The results of the survey show that 31% of respondents consider that their health state is very good and good, 44% – satisfactory, 21% – bad and only 4% – very bad.
Depending on age, the health state was estimated worst by the respondents of the age of 60 and more, 53.1% of them remarking that it is bad and very bad and only 11.3% – good and very good. The women estimate their health worse than men: 27.8% of women consider that their health state is very good and good (37.3% of men consider in this way) and 27.9% of them consider that their health state is bad and very bad (20.2% of men estimate it in this way). The persons from families with high monthly incomes estimated the health state, generally, as good and very good (70.9% of respondents with such incomes) and satisfactory (29.1%), not invoking the estimation of the health as bad and very bad. Almost all the questioned persons (97%) consider that it is important for them to have a healthy life style.
Information on possession of health insurance policy
Do you have an obligatory medical insurance? (% of respondents)
Being requested to answer if they hold mandatory health insurance policy, 65% of respondents confirmed this. Depending on residential environment, the population from villages has the least number of
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mandatory health insurance policies (62% of respondents in rural environment). From the point of view of income, the persons with high income have the least number of such policies (63.6% of respondents with such income). In the profile of age category, the largest number of holders of the mandatory health insurance policy is represented by the pensioners (94%), persons of the age between 18 and 29 years old have this policy in proportion of 54%. Regarding the voluntary possession of health insurance policy only 2.9% of those interviewed said that they have such a policy, but 60.6% of respondents did not answer this question, eventually, because of ignorance of existence of facultative health insurance. The interviewed persons were requested also to answer the question related to the number of their household’s members, who hold the mandatory health insurance policy. The answers of respondents (see the table below in the profile of category of persons) show that the unemployed persons that are not officially registered and persons hired without a labor contract have the least number of policies. At the same time, we could conclude, once again, that the level of information of respondents with regard to the mandatory health insurance policy is insufficient, especially, the respondents do not know that the children of the age below 18 years old (both those that are not engaged in education and pupils in the secondary and vocational education with full day attendance), students in universities with full attendance, as well as unemployed persons officially registered are insured by the state.
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Category of persons
How many persons are in your household? (average)
How many of them have a mandatory health insurance policy? (average)
Ratio between the average number of persons that have the policy and the average number of persons in the household, %
1. Persons employed based on a labour contract
0.81
0.71
87.7
2. Persons employed without any labour contract
0.34
0.08
23.5
3. Unemployed persons:
1.72
0.89
51.7
– Children with the age below 18 years old that are not involved in education
0.21
0.05
23.8
– Pupils, including from vocational education with full attendance, students in universities with full attendance, post university residents
0.61
0.28
45.9
– Invalids, pensioners, pregnant women and on maternity leave
0.58
0.51
88
– Unemployed persons registered officially
0.05
0.01
20
– Unemployed persons nonregistered officially
0.27
0.04
14.8
2.87
1.67
58.2
Total
Among the main causes of the lack of the mandatory health insurance policy, the respondents invoked that the policy costs too much (56%) and they do not need it (33%). There are still persons that do not know that they must have such a policy (6%) and do not know where to buy it (3%).
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What health institutions the population addresses?
If you do not have an obligatory medical insurance, what’s the reason? (% of respondents)
When they are in need of health care, about 96% of representatives of households appeal usually to the health assistance institutions. Out of the questioned persons that appeal to health services, 93% appeal usually to the public health institutions and 7% – to those private.
The women prevail in the total of persons that appeal to the public and private health institutions; their share is 64% and 59% respectively of respondents. When giving the reason why they appeal to private health institutions, the respondents indicated pre-eminently the advanced quality of health services, performance of the equipment and high receptivity of doctors . At the same time, a part of respondents consider that they save their time in this way, but others appeal to the private health assistance because they do not have the mandatory health insurance policy. In case you address a private medical institution, why do you do so? (% of respondents)
It is a question with multiple answer (maximum 2), therefore the amount of respondents� answers outruns 100%. 10
Measuring Corruption: from Study to Study
How well is the population informed about the provision of health services? Within the survey, it was found that: • 88% of those questioned know that in order to access the public health assistance institutions they should register with the family doctor; • 60% of respondents affirm that they know what services provides the mandatory health insurance policy; • 53% of respondents know that the majority of services provided based on the mandatory health insurance policy is offered free of charge only based on cross-reference of the family doctor or doctor specialist; • 58% of those interviewed know that the specialists in the health assistance institutions are obliged to inform the patients which services are free of charge and which are offered against a payment. However, being requested to indicate which of the health services are offered free of charge based on the insurance policy in 2006, many of respondents did not answer correctly. Thus, only 30% of those interviewed indicated that the services of application and change of gypsum are free of charge, 35% – gynecological control for women and urological control for men. At the same time, almost one third of respondents could not answer this question that attests the fact that the level o information of the population on this subject is insufficient.
What hinders the access of the population to the services of the public medical institutions? Among the main obstacles in their access to medical services the participants to the survey invoked the high cost of health services not covered by the policy (average – 3.94), long „queues” to the doctors (3.71) and the fact that you have to give a bribe: money, gifts, services (3.56). The seriousness of the barriers was estimated at a scale from 1 to 5, where 1 means that the indicted reason is not a barrier, 5 – is a major barrier. 11
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The main barriers in accessing public medical institutions
1.3.3 Perceptions of Corruption in Healthcare How often are informal payments in the healthcare system? How often do you have to pay unofficially in the healthcare system? (% of respondents)
About 60% of the interviewed persons within the survey consider that in the health assistance institutions in the Republic of Moldova, they resort to unofficial payments all the time, very often and often. Only 6.6% of respondents have the opinion that they never resort to such payments.
In which sectors/structures of the health assistance are unofficial payments more frequent?
Note. Within the survey, as unofficial payments were considered the provision of money to the employees of the health assistance system without receiving any receipt from the pay desk of the health institution, as well as provision of gifts, services, advantages to these employees.
The respondents specified among such health sectors/structures hospitals, polyclinics, emergency/ ambulance and councils dealing with the attribution of invalidity.
It is a question with multiple answer (maximum 2), therefore the amount of respondents� answers outruns 100%.. 12
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In what medical sectors/structures do people have to pay unofficially the most often? (% of respondents)
Among the representatives of medical professions, in favor of which they resort to unofficial payments more often – there were indicated the surgeons (54.3% of respondents), family doctors (31.9%), gynecologists (28.4%), obstetricians (27.1%) . Being requested to specify the forms of corruption that are not directly related to bribery (money, gifts, services) and observed in the health assistance sector, the respondents invoked: • Relatives/ family relations the so called nepotism; • „Strings” (connections) in the medical system; • Theft of medicines with later sale of these; • Imposing repeated consultations against payment; • Theft or incorrect and non-transparent distribution of medical humanitarian assistance, as well as sale of this assistance via drug stores; • Imposing the patient by the doctor to buy drugs from him; • Prescription by the doctors of medicines that are not useful for the patient in order to increase the sales of drug stores with which they have relations etc.
Ibidem. 13
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1.3.4 The Experience Related to the Corruption in the Healthcare The most frequently visited medical institutions According to the results of the survey, among health assistance institutions contacted more often by the respondents during the last 12 months are the state polyclinics, state hospitals and emergency/ambulance. Visits of household members to health assistance institutions State polyclinics State hospitals State emergency/ambulance Private polyclinics Commission on examination of drivers Private hospitals Other, please specify Council of attribution of invalidity Military commissariats Centers of preventive medicine (Sanitary and epidemiological) Private emergency/ambulance Ministry of Health (licensing, accreditation) National Company of Health Insurance
828 344 120 78 20 19 15 10 9 7 7 4 3
Medical institutions where unofficial payments are the most frequent According to the answers of the representatives of the households that have contacted medical institutions during the last 12 months, they paid unofficially most often in the state polyclinics (average – 3.5 times per year), military commissariats (3 times) and state hospitals (2.25 times). Taking into account that among these respondents there were no persons that affirmed the fact that they paid in such structures as councils of attribution of invalidity, centers of preventive medicine, Ministry of Health and National Company of Health Insurance, these institutions were not included in the estimation of bribe frequency (see the diagram below). 14
Measuring Corruption: from Study to Study
How often did you pay unofficially in medical institutions?
Total amount of unofficial payments As per the results of the survey, about 73% of the representatives of the households have appealed to the health institutions for consultations or services during the last 12 months. Out of these, about 36% paid unofficially to the employees of these institutions. The total value of the unofficial payments in the field of health assistance during the last 12 months constituted about 153 million lei. The largest part of these payments was made in state hospitals and polyclinics (41.7% and 38.7% respectively of the total value). In average per a questioned household, the unofficial payments offered to the employees in health assistance constituted 19% of expenditures for the health services covered during the last 12 months (in average per one household in the country, – about 5% of such expenditures).
What service was the unofficial payment for? As per the results of the survey, the households paid unofficially most often in order to establish good relations with the doctor and to be protected by him/her in future (average – 2.6 times per year per household). At the same time, about 2 times per year they paid unofficially in order to assure the care of the patients by the medical assistant and nurse, in order to make analyses, as well as to receive a cross-reference to another doctor specialist. 15
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It should be remarked that 65.5% of respondents, who paid unofficially, did this from their own initiative, but 34.5% were imposed to do it. What did you pay unofficially for?
Willingness to give a bribe The results of the survey attest a high availability of the respondents to give bribes to the employees from the health assistance system. Thus, only 14.5% of those questioned are not willing to pay a bribe, while 34.1% and 50.7% of respondents respectively answered that they would pay for sure or would do this depending on the situation. What will you do if you have to solve an urgent problem regarding the health of one your family members?
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Measuring Corruption: from Study to Study
It should be mentioned that, depending on the age, the persons of the age between 18 and 29 years old are the most willing to give a bribe, 47% of whom mentioned that they would give a bribe for sure and 48% would act depending on the situation. The persons of the age over 60 years old have the lowest willingness to give bribes – 21% of whom said that they would give a bribe and 54% – depending on the situation. Depending on the income, the representatives of the households with high incomes are more disposed to pay a bribe, 54.9% of whom said that they would pay for sure and 41.2% – depending on the situation.
Possibility to choose freely the specific medical institution and the doctor About 27% of respondents to the survey remarked that there were cases when they wanted to obtain medical services based on the mandatory health insurance policy in another medical institution than that of residence, but they were not able to do it because of the restrictions imposed by the legislative provisions regarding the mandatory health insurance. Being asked if they would agree to pay more for the mandatory health insurance policy and to have the possibility to choose freely the medical institution and doctor, 35% of those interviewed answered affirmatively. In this context, depending on the age, the persons of the age between 18-29 and 30-44 years old are more willing to pay additionally (43% and 42% of respondents of this age respectively). From the point of view of incomes, the persons from the households with high incomes are more disposed to pay more (47% of respondents with such incomes). Regarding the fact how much more would they be ready to pay for this, the majority of respondents (63%) indicated that they are disposed to pay up to 10%more, and 27% – by 10–20% more.
How much would you agree to pay?
In the profile of different categories of incomes, the majority of 17
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respondents are disposed to pay up to 10% more for the mandatory health insurance policy and to have the possibility to choose freely the medical institution and doctor. However, the majority of those who chose this option of answer were representatives of the households with very low incomes (71%), the share of the respondents with low, medium and high incomes that answered so, being of 64%, 56% and 50%respectively. About 29% of respondents with low and medium incomes and 25 % of respondents with high incomes are ready to pay with 10-20% more (see the table below). If you agree to pay more, how much more? (% of respondents) Monthly incomes of the households Very low low medium high
With up to 10% more 73.0 64.3 56.1 50.0
With 10-20 % more 22.5 29.2 29.3 25.0
With 20-40 % more 4.5 6.5 10.6 16.7
Other
NŞ/ NR
0 0 3.3 8.3
0 0 0.8 0
NŞ/ NR 100 100 100 100
Within the survey, the respondents were requested to answer which should be the salary of an average doctor in comparison with the salary of a policeman or teacher in a secondary school. There opinions referred mainly to two options: „the same salary” and „twice higher salary”. Thus, in average, according to the respondents, the salary of a doctor should be at least 1.5 times higher than the salary of a policeman and at least 1.4 times higher than the salary of a teacher. (% of respondents)
Policeman Teacher in a secondary school
Half of the salary
The same salary
Twice higher salary
Three times higher salary
Other options
3.5% 3.3%
42.5% 57.1%
42.6% 29.2%
8.7% 8.1%
2.9% 2.2%
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Measuring Corruption: from Study to Study
Causes of corruption in the healthcare system and how corruption can be eliminated Being requested to indicate which are the main causes of corruption in the health care system, the respondents remarked the following (importance of the causes was estimated at a scale from 1 to 6, where 1 means that the answer option is not a cause of corruption, 6 – is a very important cause). What are the causes of corruption in healthcare?
Among the most efficient modalities to fight against corruption in medicine, the participants to the survey invoked more severe sanctioning of the corrupted persons, hardening the control on the employees in this system; increasing the salaries of the medical staff. Also, compliance with a code of conduct by the employees of the health care institutions and ample information of population about the new system of health insurance are considered efficient. (The efficiency was estimated at a scale from 1 to 6, where 1 means inefficient measures, and 6 – means very efficient).
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Confronting corruption in the healthcare system How efficient are the following measures in fighting corruption?
Within the interviews, the respondents were requested to tell concrete cases of corruption, which they or their family members faced. Further, we present some examples given by the respondents through different sectors/ domains/institutions, in which medical services are provided. Hospitals: • Interview 782, operator code 28: „My mother was placed in a hospital. She is pensioner. If she did not give money to the nurse for her to make injections, the nurse was saying that she could not find the vein. After she gave the money to her, she found it immediately”. • Interview 105, operator code 7: „My husband had to have a surgery and the doctor told us without any shame how much the operation costs and what products we had to bring him from the countryside”. • Interview 791, operator code 28 „My husband needed an operation. The doctor did nothing till I sold the pig and gave him the money”. • Interview 754, operator code 28: „my mother broke her leg. Even if she had the policy they did not do the operation till the children came and gave everything needed …”. 20
Measuring Corruption: from Study to Study
• Interview 503 operator code 21: „In the case of the hand injury, they asked money for gypsum, though the application of gypsum is covered by the insurance policy”. • Interview 422, operator code 20: „They operated appendicitis and she paid for the change of the dressing”. • Interview 1190, operator code 32: „The doctors do so as they want to. Bad attitude in the hospital for children in Floreşti – they do not provide any help if you do not pay a bribe”. • Interview 446, operator code 20: „The doctor, who made the operation to a relative of mine, asked us to bring him some products”. • Interview 531, operator code 4: „The doctor did not want to make the operation to one of my acquaintances. He asked for a bribe of 2000 lei. He did not have the money and died”. • Interview 637, operator code 8: „In 2003, at the republican hospital, a bribe of USD 200 was paid to the surgeon for an operation at lungs”. • Interview 804, operator code 28: „A neighbour went to take out the gypsum at the leg. The doctor told him to come next day, because he was in a hurry to go to an operation. As soon as he gave him the money, the doctor took out the gypsum and the operation waited”. • Interview 197, operator code 10: „One of my acquaintances was placed in a hospital and was not cured. They did not even let him go home, because he did not want to pay unofficially the doctor”. Polyclinics: • Interview 90, operator code 22: „In order to receive the sick-leave certificate till complete rehabilitation, I paid additional 100 lei and gave a box of candies as a gift”. • Interview 221, operator code 13: „In order not to stay in a queue for some stamps at the polyclinic, I gave 50 lei to the doctor and I passed immediately.”. • Interview 509, operator code 21: „I had a simple allergy, but it did not pass. The doctor proposed me a medicine of 100 lei, telling me 21
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that it could not be found in drug stores, but, actually, after several days, it could be found in drug stores at a price of 15-20 lei”. Obstetrics and gynecology: • Interview 104, operator code 7: „Last year, I appealed to a gynecologist for a medical control and he told me to buy him a box of chocolates and a drink when I come next time in 2 days for the results of the analysis, because he did not receive such kind of attention for long time”. • Interview 813, operator code 8: „In 2006, at the Centre of Mother and Child I paid 150$ for the operation at birth, 200 lei for the anesthesiologist, 200 lei for the midwife”. • Interview 799, operator code 28: „The doctor asked money for medical assistance at birth. I gave birth at the Centre of Mother and Child. I gave the pension of my parents and everything I saved to buy something for the child. When I gave him the money I told him the origin of this money and he, with cynicism, threw back 50 lei, telling me that this is for the transport ticket back. What offence…”. • Interview 155, operator code 9: „When I gave birth to my last child, the doctors mocked me as they wanted and took a lot of money”. • Interview 182, operator code 10: „At the birth of my child, they asked for a certain amount of money. I paid everybody from the nurse to doctors. Otherwise, they would not even look at me.”. • Interview 1312, operator code 28: „After the difficult birth, as long as I stayed in bad, until I paid, nobody brought me a glass of water, moreover about other care”. • Interview 1337, operator code 30: „In the case of a birth, an urgent caesarean was needed in order to save the child. The doctor asked 200$. If we did not pay, he would not make the operation”. Oncology: • Interview 106, operator code 7: „My sister was sick of cancer. The doctors knew that she would not survive, but asked 600 lei for „good” medicines”. She died the same day. 22
Measuring Corruption: from Study to Study
• Interview 427, operator code 20: „I paid a lot of money for the operation, consultation and dressing at the oncology hospital, even though I had the policy and reference from the doctor”. • Interview 752, operator code 28: „The doctors oncologists should forestall the patient’s relatives that there is no chance of survival, but they don’t and so they spend thousands of lei without any use, borrow money just to make them content”. Emergency/ambulance: • Interview 609, operator code 25: „The ambulance refused to take me to the hospital, telling that there is nothing urgent, but after I paid, they took me”. • Interview 421, operator code 20: „The doctors from the emergency asked money, even if I did not get to the hospital”. • Interview 364, operator code 16: „One of my friends is in Italy for long time. In winter, her daughter got sick and grandmother called the ambulance. When the doctor found out from the girl that her mother is in Italy, he told the grandmother that the girl needed an operation, but the grandmother did not allow it. Now, the girl is quite well and without operation”. Commissions of examination of vitality (invalidity certificate issuance) • Interview 780, operator code 28: „The person that had to receive an invalidity group brought a pig alive and received the group”. • Interview 761, operator code 28: „The neighbour paid money to receive the invalidity group. And now is working in Italy. Where is the justice?” • Interview 801, operator code 28: „My husband is very sick, he must have an invalidity group, but we have no money to pay. So, he is tormenting himself. I do not have money and cannot approach anybody”. And others … • Interview 759, operator code 28: „In order to obtain a reference to Chişinău you have to pay something. Otherwise, they make you travel several times to rayon and back, so as the cost is higher”. 23
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• Interview 1270, operator code 33: „The doctor from the commission of examination of drivers asked money from a driver who did not drink, threatening that he could make him guilty”. • Interview 757, operator code 28: „If you give money to the commission of examination of drivers, you could pass without staying in queue, even if you have a health problem”. • Interview 152, operator code 9: „When making the analysis to find out the group of blood, I paid them to make it faster. The doctors were not ashamed and put the money in the pocket”. • Interview 749, operator code 28: If you pay the health commission at the military commissariat, you can save your son from military service”.
Some generalizations and conclusions As a result of the survey, the following was concluded: • The level of information of the population on mandatory health insurance system is insufficient – a part of respondents could not answer, but others answered wrongly the question regarding the services provided within this system. • 65% of respondents hold the mandatory health insurance policy. The population from villages has the least number of mandatory health insurance policies (62% of respondents in rural environment). Also, the persons with high incomes have the least number of such policies in comparison with persons from other categories of incomes (63.6% of respondents). • Among the main causes of the lack of mandatory health insurance policy, the respondents invoked: the policy costs too much and they do not need it. There are still persons who do not know that they must have such a policy and do not know where to buy it. • One of the main barriers in accessing the health services of the public health institutions along with the high cost of health services not covered by the mandatory health policy, long „queues” to doctors, is considered the fact that you have to pay a bribe to the employees in this field. 24
Measuring Corruption: from Study to Study
• About 60% of respondents consider that in the health assistance institutions they resort to unofficial payments all the time, very often and often. • The institutions/structures, where they resort more often to informal payments, are considered: hospitals, polyclinics, emergency and councils of attribution of invalidity, and representatives of health professions that resort more often to such payments are – surgeons, family doctors, gynecologists, and obstetricians. • About 73% of the representatives of the households have appealed to the health institutions for consultations or services during the last 12 months. Among the more often contacted institutions are state polyclinics, hospitals and emergency/ambulance. • About 36% of the representatives of the households that contacted health assistance institutions paid unofficially the employees of these institutions. They paid most often in state polyclinics (average – 3.5), military commissariats (3 times) and state hospitals (2.3 times). • The total value of the unofficial payments in the field of health assistance during the last 12 months constituted about 153 million lei. The largest part of these payments was made in state hospitals and polyclinics (41.7% and 38.7% of the total value respectively). • 65.5% of respondents, who paid unofficially, did this from their own initiative, and 34.5% were imposed to do it. • The availability to give bribes to the employees of the health assistance is very high – 34.1% of respondents answered that they would pay for sure and 50.7% – depending on the situation. • The respondents invoked among other forms of corruption that are not directly related to the bribery: relatives/ family relations, the so called nepotism, „strings” in the health system, theft of medicines with later sale of these, imposing repeated consultations against payment, theft or incorrect and non-transparent distribution of medical humanitarian assistance, as well as sale of this assistance via drug stores, prescription by the doctors of medicines that are not useful 25
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for the patient in order to increase the sales of drug stores with which they have relations. • There is a potential of increase of contribution of the population to the mandatory health insurance funds – about 35% of those interviewed agreed to pay more for the mandatory health insurance. Under the aspect of incomes, the persons from the households with high incomes are more disposed to pay more. The forerunner conditions for this are the possibility to choose freely the medical institution, doctor, health services and possibility to accumulate the unused means by the payer. • The respondents consider that the main causes of corruption in health assistance are the small salaries of the employees in this field, the fact that the corrupted persons are not put under responsibility; corruption in this sector is already a tradition and insufficient awareness of the population about the new system of mandatory health insurance. • Among the most efficient modalities to fight against corruption in medicine, there were invoked more severe sanctioning of the corrupted persons, hardening the control on employees in this system; increasing the salaries of the medical staff. Also, compliance with the code of conduct by the employees of the health assistance institutions and ample information of population about the new system of health insurance are considered efficient.
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2. The results of the focus group discussions among representatives of public healthcare institutions and healthcare-related business regarding corruption in the healthcare system The following information represents the result of a group discussion held in Chisinau in September 2006. 9 representatives of the medical institutions, pharmaceutical business and production of medical equipment, as well as trade unions in this field participated to this focus group. Within the focus group, more subjects have been discussed: some activity results of the mandatory health insurance system and problems related to the operation of this system, corruption manifestations in the field of health assistance system and possible ways of diminution of this phenomenon.
1.1 Mandatory Health Insurance System: Achievements and Problems During two years, the mandatory health assistance insurance system is applied in the Republic of Moldova and some conclusions regarding its operation could be made. The participants to the discussion remarked that among the advantages of this system is the provision of the access to health services for the vulnerable layers of the population (the system is based on the principle of solidarity), initiation of the drugs compensation process, improvement of the financing of the medical institutions, change of the remuneration way of the medical staff that allowed the increase of the salaries, etc. The prioritization of the primary medicine was mentioned among the pluses of this system, the importance of which for the health of the nation also from the cost-efficiency point of view is confirmed by the international practice. 27
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At the same time, the participants to the focus group identified a set of problems in the operation of the mandatory health insurance system. a) First of all, the attention was drawn to the financial incapacity of the system to insure a vast variety of services. Some experts expressed their concern related to the fact that the Universal Programme for 2007 does not have integral financial coverage, even if the increase of the contribution to the mandatory health insurance system was envisaged. This could generate a possible shortage of health services, formation of exaggerated waiting lists, which could influence the increase of the unofficial payments in health assistance system – „we must be honest and inform the population that, today, out of the whole package of health services, we could cover, let’s suppose, about 60%, and these 60% we will be covered completely at the highest level and so on, but the other services till we reach a particular level, you shall take on yourselves.” The participants to the discussion remarked that the expansion of the services from the Universal Programme shall be made very carefully, covering them financially based on the increase of the contributions to the mandatory health insurance system. „We hope that the package of investigations and drugs will increase. Actually, this percentage given for the medicine is very low. In other European countries, 8%, 9%, 12% are allocated, but we allocate only 4%. This is a very low percentage”. b) Among other stringent problems of the health assistance system, the following have been remarked: • The existing drugs compensation system has some lacunas that hinder the beneficiaries’ access to these drugs. The socially vulnerable groups of the population can not pay the difference between the price and compensated part, because it implies high expenditures, but the prescribed compensated drugs based on the recipes are not bought in drug stores by the end. In this context, the experts’ proposals were different: some of them consider that the drugs should be compensated integrally, others – the patients should cover a part of expenditures in order to appreciate this product – „If we wish to have the problem of the neighbors in Romania with long queues 28
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•
•
•
•
at the drugstores, the compensation should be of 100%, but if we want the patients to take care of their own health, the compensation should be nominative and at a level equal to half of the price, not more. He/she should pay, irrelevant of the fact how much costs the medicine, if it costs 2 or 200 lei .. for him/her to know the price of the drug and to prevent him/her from throwing it away or selling it. This is the problem”; The mandatory insurance policy covers, usually, the cheapest and not every time the most efficient drugs. The patient has no possibility to choose a particular medicine based on this policy, even provided he shall pay additionally a part of its cost; The funds allocated by NCHI per person do not cover the expenditures related to the administration, maintenance and modernization of the medical equipment – „an institution with huge problems related to the housekeeping needs a maintenance ... I am not talking about the medical equipment, which is not envisaged in the payment of the treatable case”; There are difficulties in contracting resources necessary for high quality health services provision because their costs have been estimated taking into consideration the situation in 1998 – „we contract based on an average that was estimated at old prices, for example, a case of pneumonia costs 1000 lei, which is unreal. One thousand lei includes the accommodation costs of the hospital, medicines etc. and, very often, the institution, taking in consideration the Law on Public Procurement is forced not by a particular person but by the laws and our system to purchase cheap medicines, the cheapest to pass the tender”. „There is a difference between the real costs of our health assistance system and costs we are covered with… How can a case of birth be paid at such an amount, without taking into consideration the rate of inflation that was never taken into consideration in the health assistance system? We work with the same costs as these were in 1998 and, thus, the patient is right saying that he/she paid”; There are cases when the family doctors or specialists in the medical institutions in rayon’s „block” the patients in the regions even if they 29
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have no possibility to provide a necessary treatment in order not to loose the funds of the Mandatory Health Insurance Fund. „The family doctor does not have to be too restrictive and too permissive, to keep the patient too long, when other specialists should be involved. The doctors – specialists should treat the patient, let him leave when other specialists are needed, not consume medical services uselessly... This depends on many things, his/her education, and his /her capacity to estimate the reality, his /her ability to investigate on site, on the equipment, and distribution”. • If he medical institutions provide assistance to the uninsured persons, the financial means from the National Campaign of Health Insurance (NCHI) are not allocated to these institutions – „We can not refuse to provide medical help, but the expenditures are not covered”; • When the persons in regions have a an insurance policy and need hospital assistance are hospitalized without the reference of the family doctor/ medical specialist, NCHI does not finance these institutions; • Waiting list – these exist also in other countries and are considered a normal practice. However, when providing health services based on these lists, interested persons could resort to informal payments to urge, facilitate the procedure – „There is a waiting list. It is an indirect conditioning of the patient. If I was told that I will pas the following investigation in a month, I may want to pass it sooner and I will have to pay officially at the pay-desk or unofficially in order for me to be transferred somehow in another list”. c) The participants to the discussion devoted separate time to the multiple concerns of dissatisfaction of the holders of the mandatory health insurance policy regarding the operation of the system of health insurance: • Within the mandatory health insurance, the patients can not choose the medical institution, family doctor and medical specialists (in the Republic of Moldova, the family doctor can be changed once a year, in other countries, for example in Romania – 5 times); • The insured persons have no possibility to accumulate a part of contributions to the mandatory health insurance fund if they did not ben30
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efit of health services during a period of time, as well as they have no possibility to use these funds as they wish – „abroad, as we well know, the health insurance policy paid by us is my budget. If I did not use it this year, it is transferred to the next year …”; • The attitude of the doctors towards the patients that pay for the services included in the Universal Programme is better as compared with those to whom these services are offered based on the mandatory health insurance policy; • In order to reach a specialist doctor, the patient should pass through a bureaucratic and difficult system, where the family doctor is associated with a dispatcher „he does not treat, but gives you the reference from one side to another, to third and fourth side.”; • Access to some analysis, investigations, is possible usually, during a particular period of time (ex.: the blood for analysis is received from 7 to 10 o’clock). This situation is specific for the public medical institutions, which, pre-eminently, due to financial considerations, can not provide such services during the whole working day – „we can not turn on the equipment to operate for a single analysis. We take a set of analysis and load the whole equipment that is planned, modernly computerized and make the full set of analysis”.
2.2. Corruption in Health Assistance System and Ways of Diminishing this Phenomenon The majority of participants to the discussion admitted the existence of corruption in health assistance system, remarking that, most often, it manifests as bribe – way of „thanking” the doctor by the patient for the provided services. One of the participants denied the presence of corruption phenomenon in health assistance – „generally, I do not see corruption in medicine, nowadays, in our country, talking about the corruption in medicine, this is like talking about a thief of a duck or goose and to make him/ her criminal”. Talking about the modalities of reduction of corruption in the health assistance system, the interlocutors remarked the following: 31
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Adequate remuneration of the employees in the health assistance system. The majority of participants remarked that the introduction of some criteria of correct evaluation of the performance of the doctors and increase of salaries would be a way to diminish the informal payments in the health assistance system. During the discussion, it was remarked that the salaries in health assistance should be increased and this is confirmed by the results of Transparency International – Moldova research (representatives of the households consider that the salaries of an average doctor should be by about 1.5 times higher than the salary of a policeman, by 1.4 times higher than the salary of a teacher). But, also, the responsibility of the medical staff should be increased. Nowadays, we can not rely only on the public funds for health assistance to increase the salaries, including due to the possible consequences of inflation. The medical institutions shall use more rationally the available financial means, especially, by promoting an efficient financial management, which would implicitly lead to the increase of the remuneration of the employees. During the discussion, references were also made to other sources of increase of the doctors’ remuneration based on the experience of other countries: – „attachment score”, „bonuses for fidelity”; „cotes for quality”, which envisages the possibility to transfer by the particular of a certain percentage (0.2% – 0.5%) of the mandatory health insurance policy value to the account of a particular doctor; – Official payments at the payment desk of the medical institution (by establishing a maximum limit), out of which a part remains at the institution, but the other part is paid to the personnel that served the patient; – Official nominal payment made at the pay-desk of the medical institution by the patients indicating the concrete beneficiary of the payments, etc. In this context, it was mentioned that the national legislation on donations and sponsorship does not create sufficient stimulations for businesses to get involved in charity activities in health assistance field. The introduction 32
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of the exemption from the income tax in case of some donations, sponsoring the medical institutions could favor the contribution of businesses and solve some financial problems of these institutions. The right to choose the doctor and medical institution. The representatives of the medical institutions attested that there is a need for a larger freedom to choose the medical institutions and doctors by the patients. This could contribute to a competition among medical institutions in provision of high quality health services and, as a result, to the improvement of the financial situation of the professional providers. In this context, the example of Romania in the primary medicine was appreciated – the patients have the right to choose the family doctor and, in case, they are not satisfied by his/her performance, they can choose another family doctor. However, a limited number of patients can be serviced by a doctor in order to not affect the quality of services. In these conditions, each doctor tends to keep his/her patients and to attract other new patients because his/her income depends directly on this fact. There are several risks in achieving this objective: – Over – demand of the doctors considered to be good; – Race after the number of patients to the determent of health services quality; – The flow of patients from a doctor to another is a thing that can not be controlled presently – „for example, in Lithuania, Romania, Baltic Countries, it is allowed to transfer from the family doctor many times per year, but only once it is allowed to do it free of charge, other times you have to pay already”. The doctors remarked that the reduced technical-informational possibilities of the medical institutions, nowadays, are one of the barriers in the possible appliance of the right to choose the medical institution and doctor. Some medical institutions use computerized systems of evidence of the provided services, flow of patients; – this facilitates the activity of the family doctors, preparation of reports, as well as makes the personnel policy more efficient. Because such institutions are presently very few, additional 33
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work shall be done to establish and consolidate the informational databases of the medical institutions, as well as to establish a unified database, even if this will imply additional expenditures for the health assistance system. Increase of the medical institutions autonomy. According to the participants to the discussion, this measure is necessary both to increase the efficiency of the financial resources administration „to invest where is strictly necessary, to motivate the personnel” and to the de-bureaucratization of the system. The centralization creates many problems – „there is a problem in the Ministry of Health, the decentralization of the system in generally, elimination of old requirements. We, in fact, passed to a new system of insurance, keeping the rules of the game and the old regulations from the old system. A reference with 200 signatures, 70 stamps, 70 opened doors create difficulties in activity.” Rigorous control of the personnel engaged in the health assistance system. The participants to the discussion attested that there is a control on behalf of NCHI regarding „the standards of treatment”, but this is different from the supervision and monitoring of the employees, especially from the point of view of the possible unofficial payments, impolite behavior, superficial attitude. In this context, they made references to the experience of Estonia, where, in addition to the application of the treatment guidelines and medical audit, monthly telephonic surveys of the patients (beneficiaries) of the medical institutions are performed to analyze doctors’ behavior and to which extent the access to health services is ensured. Continuous information about the patient’s rights and obligations, mandatory health assistance insurance, unofficial payments in medicine. The interlocutors attested that both the beneficiaries of the mandatory health assistance system and those that are directly involved in the provision of health services very often are not informed, prepared for the system to be operational. There are different ways of informing both the public and the employees in the health assistance system. Some of them are applied, but not sufficiently. Particularly, this is related to the radio and television programme, seminars, lessons for public and system’s employees, promotional materials – booklets, newspapers, folders, etc. 34
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3. Express Survey of the Beneficiaries of Services Provided by the Labor Inspection Within the Plan of verification of the execution by the Ministry of Economy and Trade of the provisions of the Action Plan for the implementation of the National Strategy on preventing and fighting against corruption during 5 months of 2006, the express survey on perceiving the corruption phenomena within the ministry’s subdivisions by the businesses and society was envisaged to be performed by Transparency International – Moldova (TI‑Moldova). In order to select the sample of the respondents, TI-Moldova requested from the Ministry of Economy and Trade the organizational chart of this institution and registries of beneficiaries of services provided by MET subdivisions during the last 3 months (March – May 2006). As of June 10, 2006, the Ministry of Economy and Trade submitted to TI-Moldova only the Registry of the evidence of reports of TLI Chisinau (Labor Inspection, Labor Protection Division and Labor Relations Division) containing about 230 addresses of businesses that were subject of LI controls, or which benefited of this institution’s services. The interviewers of TI-Moldova visited those 230 addresses indicated in the Registry of the Labor Inspection (LI) and found only 50 economic agents. Assuming that the Registry of the LI contains the legal addresses of businesses and the addresses of physical persons being different, TIMoldova resorted to Moldtelecom Information Service, website www.yellowpages.md and VARO catalogue of goods producers and services providers and found physical addresses of additional 20 respondents. Thus, the total number of questioned persons is of 70, which is 30% of the beneficiaries of the LI services during the last 3 months, which allows us to say that the selected sample is representative from the point of view of a sociological research. 35
The fact that some addresses could not be found physically seemed a bit doubtful. Thus, the buildings on the following addresses were not found: 27/1 Ştefan cel Mare bd (Registration Number 181, Labour Relations Division); 59/b Ion Creangă str. (Registration Number 301, Labor Relations Division), 31 Calea Moşilor str. (Registration Number 140, Labor protection Division). Additionally, the Registry contains references to the same businesses, indicating different addresses. During the questioning, there were cases when businesses denied the fact that they had any contacts with the LI during the last 3 months, though these were indicated in the Registry of the LI, or being found via different ways, they said that they had not performed any activity for a year and a half and could not have any controls from the LI. These facts could have an objective explanation, and however, in order to avoid some cases of abuse of power, deserve to be investigated. The express survey questionnaire contains both closed questions, where the respondents had to choose from the proposed options, and open questions, where they were requested to give examples (see the attached questionnaire). The questioning was conducted during 19-22 July 2006 on the territory of Chisinau municipality. The goal of the questioning is evaluation of the quality of the services provided by the Labor Inspection, under the Ministry of Economy and Trade of the Republic of Moldova. The assurance of confidentiality was promised to the respondents. Without making any comments, TI-Moldova shows below the answers of the respondents.
If you have any objections related to the quality of provided services, please specify them? In the opinion of the majority of respondents that provided an explicit answer to this question, the main objection to the LI consisted in the lack of clear information related to the LI’s requirements towards the businesses, controls’ criteria, etc. The list of answers of the respondents wishing to answer to this question is indicated below: Interviewer #8 Hostile attitude 36
Measuring Corruption: from Study to Study
Interviewer #8 The quality of services is below the medium level Interviewer #11 Very rude behavior Interviewer #11 Provocation of breaches Interviewer #11 They behave themselves as if you were already sentenced for a crime Interviewer #11 Preliminary interested in finding the breaches Interviewer #4 Do not provide consultations on problems Interviewer #7 Very obtrusive Interviewer #10 Do not offer solutions, but only look for shortcomings Interviewer #3 Do not provide information on requirements Interviewer #4 Some requirements are impossible to be performed Interviewer #4 Bring requirements not expedient for small business Interviewer #4 Vagueness of brought requirements, resulting form the imperfect labor legislation Interviewer #5 Are co-interested (are not loyal) Interviewer #3 Do not provide training, few information Interviewer #5 Follow one single goal – to punish Interviewer #6 Elaboration of instructions, recommendations are not performed Interviewer #7 Insufficient professionalism Interviewer #7 Ask too much from enterprises that do not correspond to the reality Interviewer #7 The goal of the control is the fine Interviewer #10 Inadequate attitude Interviewer #10 They insist on the problems 37
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Interviewer #2 Are weakly prepared, incompetent Interviewer #4 Selective knowledge of the legislation (they know only what is related to the punishment) Interviewer #6 They behave themselves as if you are guilty Interviewer #3 Provide insufficient information and assistance Interviewer #1 They catch of everything Interviewer #4 Do not have working practical experience related to production Interviewer #6 Provide insufficient services (didactic, illustrative materials, etc.) Interviewer #2 They do not answer the questions Interviewer #1 They inform us insufficiently A recommendation for LI would be raising public awareness on the information related to the LI activity, LI requirements, criteria of performed controls etc. through mass-media, publications, workshops and meetings with businesses, mainly representatives of small business. Sometimes, the businessmen are asked to make unofficial payments or gifts to obtain different services. Other times, the people should pay in order to avoid problems with the control bodies. But, in other cases, they have to pay in order to obtain some favors. During the last three months, did you (or anybody from your company) pay unofficially or give gifts to the employees of the Labor Inspection? Even if the majority of respondents said that they did not resort to unofficial payments or they refused to answer this question, 5 respondents affirmed that they made unofficial payments and indicated the exact amount paid during 3 months: MDL1500, USD100, MDL2000, MDL1000 and MDL7000. Guarantying you once again with all the responsibility of anonymity, could you please indicate a concrete case that happened to you or your 38
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colleagues with the employees of the Labor Inspection during the last year. The list of answers of the respondents wishing to answer this question is indicated below: Interviewer #1 We had not such cases, because we protracted and they became sick and tired and did not come any more. The gentlemen from LI could be divided into 5 categories: 1) those, who verify, give advice and do not punish too much, 2) those, who, when they come second time already say that they will punish, 3) those, who punish as per the breaches, 4) those, who via different methods try to come to this, and 5) those, who do everything to make you give them something. Interviewer #4 We faced a situation forced by the employees of the LI – either they perform the detailed control with all the consequences (fine) or they perform unofficial verification and show us the shortcomings with unofficial reward for their services. Interviewer #5 They came, showed the identity card and started to ask the documents on salaries, contracts, labor books. They found breaches and we had to pay a bribe. Interviewer #5 Our company performed construction works in Bălţi municipality, where the works were finished on March 31, 2006, but on June 2, 2006, the LI inspector, N. Prepeliţa (?),performed a control at this building site and prepared a report. So far, it is not clear for us, what was his report based on. 39
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Interviewer #8 Not every time, the work of the LI’s inspectors is based on the norms of the labor legislation, because the main goal is – to show in the act as many breaches as possible, even those that could be disputed, or the law’s norm allows double interpretation. And, vice versa, in the case the citizens address a claim on breaches of their rights by their employees, the LI limits itself to the official notification „they did not submit the documents” or „the employer does not have the documents”. The enforcement of the administrative responsibility is not part of the LI competence. Interviewer #7 LI does not clarify why the salary was delayed or any other problem (reason), but they punish immediately. Generally speaking, we pay them to avoid larger and more often controls. Otherwise, they never let us in peace. Interviewer #7 In case of a delay in paying the salaries, the employees of LI, advise the employees to file a case in court against the employer and ask for a fine in the amount 10 times higher than their salary, thus depriving us of the possibility to pay the salaries to other employees. Interviewer #10 I did not pay bribes, but I gave gifts and made some signs of attention. Sometimes, I had to pay for them not to come or for them to inform me beforehand about their visit. This depends on personal relations and attitude. Interviewer #10 I would not like to comment. Actually, there is not much to be said. It is obvious that you have to pay. It is true that they do not ask you directly, but otherwise, it is not possible. You may pay to someone additionally and this does not change the situation at all, but you feel calmer.
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Interviewer #6 I do not have any special for LI, because they are all the same. We, businesses, should be very careful with all the state inspectors. You know, there is accidental and purposeful guiltiness. I think that every human being could become guilty accidentally. LI just gives you a period of time to solve the apparent problem. Anyway, I do not feel comfortable, when I have relations with any civil servants, because every time they do their best to find something wrong. It could barely happen for them to leave without finding anything. Interviewer #6 During the control, there were discussions at the professional level with many indications and proposals for improvement. The result of the control based on a petition was declared legal, correct as per the court decision. Interviewer #3 As a result of an unplanned control, a light breach was found and indicated. These shortcomings were related to the lack of knowledge about some normative documents. As a result of which, I had to solve the problem via the “well known way�. Interviewer #3 I will not say, because I do not want to have problems. Interviewer #1 I had a control from LI, but it was good. The control was challenged by an ex-employee, who broke the sewing machine, left the job and did not take his salary, but however he wrote a claim. Interviewer #1 In our case, we followed the law and won the trial and did not pay anything. They are so small, that even if they take bribes, the amount is small. 41
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Interviewer #2 For a very small deviation, they establish a fine from MDL4-5 thousand. They hang on everything. They have rules that are not related to the legislation. Interviewer #4 I had to make a gift in order to make them less demanding (box of candies). Interviewer #4 We had to pay unofficially in order to avoid the problem. Interviewer #11 I serve the controllers because I want, because I think I should be hospitable. Interviewer #12 Two years ago, an employee of LI was having his birthday. He made some observations. We gave him a bribe in the amount of MDL300. Could you please indicate a case of corruption, which happened to you in 2006 in relation with any other public institution. The list of answers of the respondents wishing to answer this question is indicated below: Interviewer #4 In 2005 at Customs (excessive, incorrect requirements – I paid a tax of 10% for reclassification of the terms of delivery (incoterm) (gave a bribe of one hundred euro). The person responsible for this problem was our partner, who did not submit the insurance.
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Interviewer #4 The road police requested a bribe, even if I did not break the rules of the road traffic (2006). The customs service withdrew the money without any record under the pretext that they found breaches – indication of the currency in the declaration – Moldovan lei is not a currency. Interviewer #4 I had to pay unofficially in the hospital in order to receive qualified medical assistance (2006). Interviewer #5 I gave money unofficially at the Department of Standardization in order to correct some mistakes that they found. Interviewer #5 The bribes to the road-transportation police: our drivers face this every day. Interviewer #5 The fiscal inspectorate – in order to make the control at the enterprise faster, from own sources, I bought them construction materials in the amount of MDL3 thousand. Interviewer #8 The employee tried to perform the work on the press for himself (for the house) without having the access and permission and without notifying the manager. Doing this, he suffered a trauma of the finger. Afterwards, he tried to present the situation so as he obtained this trauma during the execution of the task. During the examination of the situation, it was found out that the employee himself was guilty (the victim). Lying (without taking into consideration the violation of the security technique and working discipline) he tried to obtain monetary compensation in addition to the 43
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amounts accrued on the sick-leave account. LI sorted out this situation, after submission of all the materials. Interviewer #8 I paid bribes repeatedly, but I refuse to say anything concretely. Interviewer #7 They came from LI. After they found something, they made us understood that we have to „pay” in order to make them to „forgive” these mistakes. Interviewer #7 The economic police and road police take unofficial payments. They perform controls very often in order to find reasons for unofficial payments. All the time, they find reasons to be paid additionally. Interviewer #7 At the polyclinic, the family doctor requests unofficial payments or I give them on my own initiative for better treatment. Interviewer #10 In the education system people pay to pass the admission to an institution of prestige, to purchase some additional materials (manuals), for additional lessons, etc. Interviewer #10 Educational institutions. They request payments for everything possible. In addition, I observed a lot of corruption in justice. Interviewer #10 The majority of cases of corruption are registered in education and medicine.
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Interviewer #6 At a medical institution, they took out a tick via surgery. During the whole provision of the services, the doctor was saying that this should be done not here, but in other medical institution (about 5-6 times). I understood the situation, but I did not pay him anything. Interviewer #6 Everybody knows my conflict, which lasts 4 years with Mr. PleĹ&#x;ca, Minister of Defence, as physical and legal person, and as minister of defence. The conflict appeared with regard to a plot of land that I bought, but PleĹ&#x;ca wanted to take it. They have an enormous number of civil, administrative and penal records. Because I am right all the judicial processes are on my side. But this is linked to time, nerves, and money. I have written to all the instances, starting from the President of the country, Parliament, Government, central and local administration, but unfortunately, the conflict continues because he is a person with a high position and money. Interviewer #6 During 15 years of my activity, I had to contact many people. And, I assure you that what is happening is not normal. The corruption will not be eliminated, because it is related to all the state institutions, from the low to the highest level. I had a case, when I saw a person with mask entering a point o sale. When I declared to the police, they said to leave this situation as nothing happened, because they also have shortcomings in their activity, and if the case would be registered, there would be high noise, and they would be checked by the prosecutor’s office. And, they are sick and tired of it, because it is an armed attack. Interviewer #6 I gave one thousand USD to the economic police in order to avoid the examination of some deviations in my activity. 45
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Interviewer #6 There are with all the state institutions: obtaining the authorization, ecologic, sanitary problems, etc. Interviewer #3 There are many cases, but I do not want to talk about them. Interviewer #1 I had concrete cases at the territorial cadastral body, when they resorted to bribes. Interviewer #1 The economic police may come once a year or half a year at the shop and can take goods without paying, and in exchange for this, they do not verify us, giving the reason that they also have needs. They allow it to some businesses, to others – not. In order to sell alcohol one needs to have a surface of 50m2, but they allow some people to sell it without having this surface. They allow everything to some businesses, nothing to others. Interviewer #2 Depending on the possibility, sometimes, I offer small presents to the employees of the control bodies on my own initiative. Interviewer #2 The authorization was at the city hall for prolongation, but during this time, a person from the police came and asked us to pay a fine, even though the whole situation was explained to him. Interviewer #11 We installed an apparatus of cold water outside. The controller from the Sanitary and Epidemiological Control did not like the working conditions and started to write the record for the fine. I gave him MDL100 and he left. 46
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But, after a period of time, he came again and started to write the record. When I asked him: “But, the control was already conducted and I gave you already MDL100”, he answered me: „But, this was previous time”. Interviewer #11 Next to the bar, I built a parking lot for several cars following all the requirements of the law. Once, a car of the road police came on the sidewalk and blocked the parking entrance. I approached and asked them to park the car in the parking lot free of charge in order to liberate the entrance. In a very rude way they requested my documents and documents on the bar and parking. When I brought and showed them, the policeman gripped the file with documents and tried to take them in the car. But, when I did not give them, he pushed me and I almost fell down. I filed a case in the court against them, and after long drudgeries, I won the case. That policeman was fired. Interviewer #12 I refused to pay a bribe for faster processing of the documents, which were at the Rîşcani court office. Interviewer #12 A year ago, an employee from the police office on Munceşti street came and asked paint for the office reparation. Then, he bought the paint and left. But, later, he came with a record already prepared and established a fine for not following the labor rules. We paid the fine. After this, this police office initiated a penal process on our firm, which was cancelled by the court of the sector. Interviewer #12 At the Department of Statistics, in order to give a balance sheet, I had to give gifts, because they were finding deviations from the norm at every step.
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Conclusions Results of the express opinion poll of the beneficiaries of services of the Labor Inspection (LI) realized by TI-Moldova allow to ascertain the following: • The data entered to the Register of economic agents controlled by LI are worrying: legal addresses of some economic agents differ from the physical addresses which made finding them impossible; some addresses from the Register do not exist at all; some economic agents denied being controlled by LI during the interview, despite the fact that they were entered to the Register, while others said that they had ceased their activity long ago and therefore could not be controlled by LI. These facts could have objective explanation, but have to be checked to avoid eventual administrative abuses; • Economic agents are insufficiently informed of the LI’s activity; most of them complain of the lack of clear information regarding the LI’s controls, in particular requirements for economic agents, criteria of controls, etc. It is noteworthy that the activity of LI should not be reduced to simple discovery of irregularities and sanctioning, this institution should pay more attention to informing, guiding economic agents, small businessmen mostly, regarding compliance with the legislation in this field through mass-media, publications, workshops, meetings. • The questionnaire that served as a basis for the opinion poll can be used during realization of similar opinion polls in other state institutions to learn the opinions of beneficiaries about quality of the services rendered and existence of unofficial relations between institutions and beneficiaries (clients). It is expedient to conduct such opinion polls regularly to analyze the dynamics of the situation, which could be useful while analyzing corruption risks in state institutions.
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Annexes
1. Questionnaire for households I. Data about the respondent 1. Age Years 18–24 25–29 30–39 40-49 50–59 More than 60
%
2. Sex Masculine Feminine
3. Studies Medium incomplete Medium Medium, specialized Higher, including incomplete
4. Do you live in urban or rural area? urban rural
5. What income does your family have? (one answer) Very low incomes Lower than average incomes Average incomes More than average incomes 49
6. Make an approximate estimation of the spending of your household/ family for medical services (drugs, treatments, etc) during the last 30 days (during the last month) |__|__| lei.
II. Using the medical service and the access to them 6. How do you evaluate your health condition? Very good Good Satisfactory Bad Very bad NA
8. Do you consider the healthy way of life to be important for you? (%) Yes No
9. Do you have... Yes
No
Obligatory medical insurance Optional/voluntary medical insurance
10. If you do not have an obligatory medical insurance, what’s the reason? It costs too much
1
I don’t need it
2
I don’t know where to get it
3
I didn’t know I was obliged to have this kind of insurance
4
Other (specify)_________
|__|__| 50
Measuring Corruption: from Study to Study
11. Fill in the next table by the category of people Howe many of How many them do have an persons are in obligatory mediyour hosehold? cal insurance? Persons employed under a labor contract
|__|__|
|__|__|
|__|__|
|__|__|
|__|__|
|__|__|
– invalids, pensioners, pregnant women in maternity leave
|__|__|
|__|__|
– unemployed workers officially registered
|__|__|
|__|__|
– unregistered unemployed workers
|__|__|
|__|__|
Total
|__|__|
|__|__|
Persons employed without a labor contract Unemployed persons: – Children up to 18 unrolled in any educational institutions – Pupils, including those with specialized middle education with a daily frequency, students from higher education, with a daily frequency, rezidents of the post universitary education
12. When you or someone from your household need medical assistance, do you usually appeal medical institutions? Yes No
13. What types of medical institutions do you usually appeal? Public/state medical institutions
Go to the 15th question
Private medical institutions 51
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14. In case you appeal to the private medical institutions, why do you do so? The services are of a higher quality The equipment/ instruments are more performing The costs for the treatment are less The doctors are more receptive I do time economy I do not have an obligatory medical insurance Other, specify
15. Did you know... Yes
No
That you have to be registered at a family doctor ? The services the obligatory medical insurance offers? That most of the medical services offered on the basis of an obligatory medical insurance are for free only at the presence of the family doctor’s assignment? That the specialists from the medical institutions are obliged to put at their patients assignment what services (investigations, analyzes) are for free and which of them have to be paid?
16. Underline which from the next services are for free on the basis of the obligatory medical insurance for the year 2006 Gynecological control (for women)/urological control (for men) Calling the ambulance (urgent medical assistance) Dental prosthesis Application and changing the gyps Analyzes (including general blood analyze, leucocytes, urine analyze, discovering intestinal parasites) Injections Urgent hospitalizing Cosmetic services Prophylactic stomatological assistance for children up to 18 years old, pregnant women (dental extractions, applying prophylactic remedies ) and urgencies (applying temporary stopping, abscess treatment , acute eye ball treatment) 52
Measuring Corruption: from Study to Study
17. Have there been cases when you wanted medical services at another institution than you usually frequent , but you couldn’t because of the restricted rules imposed by the medical insurance? Yes No
18. In what manner the next moments are an obstacle for your accession to the public medical institutions (1 – it’s not an obstacle; 2 – it’s a big obstacle)? Transportation difficulties to the medical institution Inconvenient working programme of the doctors The big tails at the doors The high price for the medical services not outside the insurance The fact that you have to give bribes (presents, services) Other, specify
III. The perceptions and personal experiences regarding the corruption in the health security sector Attention! By informal payment (not official) we mean offering money to the employers from the health security sector without receiving the facture, so as offering presents, services, advan 19. What’s your opinion, how frequent the informal payments are used (money, presents, services) for solving problems into health security institutions from the Republic of Moldova (1 – never, 2 – sometimes , 3 – often, 4 – very often, 5 – always, 9 – NA/RA)? Never Sometimes Often Very often Always NA 53
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20. What’s your opinion, what are the sectors of health care where the bribes (money, presents, services) are used more often? Policlinics Ambulances Hospitals Military committees Invalidity offering Council The Ministry of healthcare (licensing, accreditation) Centers for medical prevention The National Medical Insurance Company Driver examination Committee Other, indicate
21. In your opinion what medical professionals take informal payments (money, presents, services) more often? Family doctors Gynecologists Obstetricians Radiologists Oncologists Dentists Anesthesiologists Surgeons Orthopedists Endocrinologists Podiatrists Otolaryngologists Others, indicate
22. What’s your opinion, which of the next categories get more informal payments from their patients? Clinical /hospital administration (chiefs of the hospitals, bookkeepers) Ordinary doctors Medical assistants Hospital medical sisters Other, specify 54
Measuring Corruption: from Study to Study
23. What forms of corruption (not necessary bribes), in your opinion, are manifested in the health care sector? 24. Have you personally or someone from your family contacted medical institutions for consultation or medical services during the last 12 months? (%) Yes No
25. Fill in the next table Have you How many tiHow many paid unoffici- mes have you times have ally? unofficially Total, you contacpaid (without lei ted the next having the Yes No institutions? facture in return)? Policlinics Ambulance Hospitals Military committees Councils of attributing the invalidity level The Ministry of Health (licensing, accreditation) Centers for medical prevention (Sanepid) National Medical Insurance Company Drivers Examination Company Other, specify
26. What have you unofficially paid for? For a surgery at the hospital To insure that care is taken of the patient by the medical stuff To avoid long queues in policlinics 55
Transparency International-Moldova For a treatment in a policlinic For urgent services of the ambulance, incl. transportation to the hospital To make good contacts with the doctor to be protected in the future To receive a medical certificate/bulletin To get a recipe for recompensed drugs To do analyzes To obtain a certificate of invalid person To obtain medical assistance during delivery To get a guide certificate to another doctor Other, specify
27. When paying unofficial you did it : On your own initiative You’ve been forced to
28. Estimate the proximate costs of your family/household for medical services during the last 12 months for unofficial payments (money, presents, services)_____? 29. Could you tell of a case of corruption in the health security sector you, your family members or your acquaintances faced? 30. How would you proceed if you have to solve an urgent problem of health of yours or your family members? (%): I would give bribes to the medical personnel I won’t give bribes It depends on the situation
31. What are the causes of corruption from the health security sector? (1 – there are no causes, 6 – it’s a very important cause) Low salaries of the doctors The greed of the doctors It’s a tradition to bribe Nepotism, clanship relationships The population knows the obligatory medical insurance Corrupted persons are nor punished 56
Measuring Corruption: from Study to Study Medical institutions do not offer enough information about their activity (they didn’t use the measures from the institution’s budget, the humanitarian aid received and its utilization, what are the results of the controls, how the patient’s complaints have been solved, etc) Other, specify
32. How efficient the next anticorruption measures are? (1 – inefficient, 6 – very efficient) Increase of the medical personnel’s salaries Sanctioning the corrupted persons Transparency of the budget of the medical institution Hardening the control upon the employers from the health security sector The transparency of the use of the humanitarian help Obeying the medical behavior code by the doctors Developing anti-corruption companies at schools, universities, medical institutions Mass/information about the new system of medical insurance (radio and TV emissions, talk shows, public discussions, special rubrics in the press, etc) Offering the patient the possibility to choose the medical institution, the doctor, the insurance Other, specify
33. How do you think the average salary of a doctor should be in comparison with the salary of a… Half a salary
The same salary
Policeman A secondary school teacher
Twice the salary
Three times salary
Other options, indicate
34. Would you agree to pay more for the medical insurance and to have the right to chose the medical institution and the doctor? (%) Yes No 57
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35. If yes , how many times? With not more than 10% With 10-20% With 20-40% Other, indicate
2. Questionnaire for the beneficiaries of services of the Labor Inspection 1. Did you have contacts with the representatives of the Labor Inspection during the last 3 months? A) Yes B) No (If not, the interview ends) 2. Do you think their attitude towards you was respectful? A) Yes B) No 3. How would you assess the professional qualities of the services rendered? A) high B) medium C) low 4. What would be your objections regarding quality of the services, if any? 5. How would you compare the officials of the Labor Inspection you had contacts with, with those of the Ministry of Internal Affairs, for instance? A) not corrupt at all B) less corrupt C) same corrupt D) more corrupt E) N/A 6. In some cases, business people are asked to pay unofficially or to give presents to obtain some services. In other, they have to pay to avoid problems with controlling bodies. And sometimes they have to pay to obtain some advantages. Did you (or anyone else from your company) pay unofficially or give presents to the officials of the Labor Inspection during the last 3 months? 58
Measuring Corruption: from Study to Study Body/ services/ field
How many contacts did you have with the Labor Inspection?
Did you pay unofficially?
How many times did you pay unofficially?
The total amount in MDL (during 3 months)
7. If you paid unofficially, did you do it on your own initiative or the official hinted at unofficial payment? A) ‌ on my own initiative B) ‌ the official hinted at it 9. Could you tell us of a specific case that happened to you or your colleagues concerning an official of the Labor Inspection during the last year? 10. Could you tell us of a case of corruption that happened to you in 2006 concerning any other state institution?
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