“I will declare another war — one on corruption and informal payments.”  The new Minister of Health promises salary increases for doctors.

– Recently, you declared on the social networks “a war on indifference, arrogance, and lack of education that some of your colleagues   —  doctors and medical assistants display with their patients.” How will you achieve this, in the context of a health professionals human resource crisis?

– It’s simple. First, health professionals have to be accountable, and not in a financial sense. They have to realize that people are watching them closely. And I will declare another war, a war on corruption and informal payments. This behavior of our colleagues affects the image of all health professionals, even those that do their job with dedication and competence. Bad news and a bad name travel fast… It’s one of the responsibilities of institution managers to eradicate inappropriate communication with patients, offensive familiarity, and outright insolence.  A health professional must be respectful with the patient, regardless of the latter’s education or studies. Society also needs to keep an eye on those who manifest inappropriate behavior and help us to eradicate these practices. The existing ethics committees in medical institutions can question the unhealthy behavior of team members and organize communication trainings. First, though, one needs to recognize there is a problem and only then things can be fixed. Sometimes, the patient’s behavior is inappropriate, under the influence of physical pain. It is our job as doctors to manage all types of conflict, even though they do not teach this in the university. It’s not normal for doctors and patients to be in conflict as they are not on opposite barricades. One cannot fight disease in a situation of conflict. In the end, we will find the right methods to improve this situation, even in cases where health professionals do not understand our message. Even with the risk to lose human resources. I am confident that we will not use our most valuable resources, but only those that bring a bad image to the health sector. Perhaps their rude behavior is on par with their competence  — below criticism.

– You mentioned this war on corruption, but doctors’ salaries are very low. Usually, this is their excuse. And many choose to go abroad for this reason.

– Yes, due to miserly salaries, many health professionals accept informal payments including cash envelopes or other forms of payment. There are also those who exclusively offer services this way and the patient has no other choice. It is well known where such practices take place. There are also those who, forced by their material penury, accept money from their patients as a sign of gratitude, in order to survive.   I don’t justify neither group. Yes, I agree that it is difficult, but it is not impossible. There are many countries who have been through this situation, confronted these bad practices and overcame them. 
Of course I will start with salary increases. Soon, we will surprise the health professionals on this topic. We will do it piecemeal because we do not have funds for overnight salary increases in order to match salaries in Germany or at least those in Romania. But we found financial resources and hope to offer a significant raise, not only 100-200 lei (€ 5-10), to the contentment of health professionals (doctors, nurses and other staff). I have not previously made this news public, as we were busy to identify sources, adding up numbers, and only now I can see it is possible. Together with salary raises, we will introduce other incentive policies. For example, we will raise the one-time subsidy of 45,000 lei (€ 2 998) for doctors and 36,000 lei (€ 1 839) for medical and pharmaceutical staff with medium specialization to 120,000 lei (€ 6 129) and 96,000 lei (€ 4 903) respectively. We will keep looking for other methods. During last week’s visit to Bucharest together with other ministers, we discussed project proposals with our Romanian counterparts. We discussed a potential cooperation on medicines with representatives of the Ministry of Health and the Ministry of Labor and Social Justice. In particular, selecting reimbursed products through the international mechanism HTA (Health Technology Assessment); developing an electronic monitoring system for the stocks and disposables by the Agency of Medicines and the National House of Medical Insurance, collecting and disposing of expired drugs in order to protect the environment, and studying the possibility of common procurement of some medication, together with Romania. Another subject on the agenda was how to transform migration into circular work mobility through bilateral agreements on a series of specialties, seasonal or unqualified labor as well as highly specialized medical training. We are also analyzing the possibility of completing a part of the residency program [in Romania] for our residents. This would offer our doctors and residents the possibility to practice in better conditions as well as earn more, because Romanian salaries are considerably higher. At the same time, they can return home and share their knowledge and practices.

– We understand the actions you started now. Many people have sat in this chair before you: when you got to the Ministry, in what state did you find this institution?

– I grew up in this system. I have a long work experience with the ministry, in particular implementing primary health care reforms as one of the most important and successful reforms of the ’90s-2000’s. What I can tell you is that I found the ministry in a deplorable state, below my expectations.  In recent years, much has been destroyed: reforms that were not thought through and poorly implemented, a diminishing number of health professionals, unplanned preparation of health workers, suspect procurements, and inefficient spending. On the topic of efficiency — in our country we have 12 maternities in the district hospitals where the number of yearly registered births is between 45 and 300, due to the population decline.  In these cases, we have to think if we need a maternity in every district, or perhaps it’s more useful to have ambulance cars that will immediately transport the future mom to a better equipped hospital. When there are only 45 births in a year, that means a birth once in eight days, leading to decreased medical competence. I should clarify that this statement should not be misunderstood as an intent to close hospitals. However, if we have inefficient sections, we should transfer them elsewhere, and organize other sections that are in more demand, such as geriatry, palliative care, rehabilitation linked to population aging and increase in chronic disease. 

– You have mentioned the ambulance. They have been mentioned multiple times in the public space lately, including dramatic situations when the doctors arrived too late. What will you do to change things?

– First, we have to apply the protocol to screen calls received to 112. Then, we have to apply a protocol to classify critical, urgent and non-urgent requests. We also have to apply algorithms for different scenarios. It is necessary to return a call to monitor the situation before the ambulance arrival. The practice to place all calls in a common queue is not found anywhere in the world. If a well trained person manages the case (you probably have seen that in the movies), and if they call back monitoring the patient from the distance before the ambulance’ arrival, we can avoid tragedies. And in the cases of a heart attack or a stroke, time is of critical importance. We have to analyze the geographic distribution, the staff numbers, the ambulance cars, and ask ourselves  — do we need such a big institution which manages more than half a billion lei (more than € 25 536 ), has insufficient health professionals and ambulance cars? Or is it better to return to the older, regional way which did a much better job at managing the service.

– You mentioned that you have set three priorities: paying salaries, human capital and the quality of medicines. Let’s stop at the last one. In an interview for ZdG, a neurologist argued that most hospitals in Moldova use inefficient medication, that are very expensive. How will you fix this?

– These tasks are in the competence of the Agency of Medicines. We have new leadership, foreign experts contracted through international donors’ assistance. First, we have to reevaluate the cost of drugs. In our pharmacies, these are often higher than in other neighbouring countries. We should ensure that the essential drugs included in the World Health Organization’s list are accessible to the population, both by price and distribution. Today, we still have many localities that do not have a pharmacy. Subsequently, due to the difficulty of transport to district centers, people can interrupt treatments. Secondly, the quality of drugs brought in the country is important. We have to use a mechanism that guarantees the quality of drugs given the registration procedure. As for hospital medication, public procurements complicate the problem because the cheapest medication wins the tender. Still, the procurement law leaves a space to link price, efficiency and quality. The law does not force you to choose the cheapest medication, you have to choose the one that is most cost-efficient and be able to prove this cost efficiency.

– We talked about the human resource shortage. This is particularly a problem in villages and especially in cardiology. You have also addressed the issues previously. How can we bring back the doctors who leave Moldova ? Can we do this?

– I think a part of them would return. On June 8, when the new government was voted, I have received many messages. Those who left know that things won’t change rapidly in the country, but they wish for stability here, and for certainty that their country is growing into a true democracy. Doctors have written about their thoughts to return home, where they have parents, children, houses. Perhaps more importantly is to keep those that are still here and that newly join the ranks of the medical profession. We will probably change the registration into the residency program, mirroring how it is done abroad.  Often, young specialists do not follow the state distribution to remote rural places due to bad infrastructure. We are currently analyzing the possibility for young specialists to live in district centers and daily commute to work. It is cheaper for a village to pay for a 14-15 km commute than to afford not having a doctor at all. Plus, that same district center also has other amenities for families and children — lyceums, musical or sport schools, cinema, and sometimes theaters. 

– We spoke earlier about the attitude of doctors towards patients, but there is also the reverse side of the coin. There have been cases where doctors were beaten by patients…

– There is the law and the criminal code which makes specific prescriptions for punishment of those abusing a health worker  — from large fines to five-year terms in jail. I believe we have to be more persistent when we defend a health professional. As I said, I side with the victim, be it the patient or the health professional. We have many cases of aggression, violence especially in emergency care. Many are in shock: how do doctors survive in emergency care, with 24 hour shifts. By the end of those shifts, they are completely exhausted, and possibly prone to errors. At the moment, medical errors are a tabu in our system, we do not discuss it. In the world, a large number of deaths are a result of medical errors. For example, in the classification of mortality in the U.S., death due to medical errors comes third after cardiovascular disease and oncological disease. Around 240,000 cases per year [of medical errors] in the U.S. In Moldova, we do not have a single case…. 

– By the way, we don’t have a law on malpraxis…

– We don’t. And the ministry made a big mistake to switch to the private practice of the family doctor, not having this law. In practice, they threw all responsibility on the family doctor, leaving them to face problems alone.

– Returning to the residents, how can they be convinced to stay in Moldova?

– A policy of punishments does not lead to good results. You are aware that the Ministry of Health initiated a vendetta against young medical graduates. Lawsuits are requesting the reimbursement of the studies funded from the public budget in cases when the young grads did not move according to the regional distribution. These are big amounts to refund, around 250 000 lei (€ 12 768). Nobody thought about the fact that if a young doctor had this money, he never would have left, because he could make a living here. The result of this policy is ugly and painful, creating an adverse reaction. Until now, around 400 000 lei (€ 20 429) were returned to the treasury, but many other lawsuits are ongoing. In the meantime, last year multiple young doctors abandoned the health system as a form of protest. Many have migrated above, without the intent to return. I have spoken to many of them and I know that they were offended by the selective nature of this measure. Why only doctors were paid, whereas many other professions are paid for by public money: teachers, engineers, lawyers, social workers, etc. My opinion is that youth can only be motivated through incentive policies, such as work environment, salaries, professional development.

– What is the state of these lawsuits?

– Each lawsuit is at a different stage. We try to negotiate personally with each of them, to obtain a commitment to return, in case they are studying abroad. For those who lost in trial and there is a judge’s execution, unfortunately, we cannot intervene. If there is a definitive ruling, we have to obey and execute it. I am sorry, but we are just left to collect the results of explosions set in motion by our predecessors.

– Should government members have a separate clinic, hospital and doctors? What is the international experience?

– There aren’t hospitals for the government or for the members of parliament, in other countries. This is a soviet heritage that we kept. In the first years of independence, the Druc Government attempted a transfer, but later on, things returned to their older course. I believe that if the deputies, government members, and other state dignitaries would attend regular institutions alongside citizens, these institutions would be today in a better condition.

– Which doctors do you and your family choose?

– We go to regular doctors, at the sector clinic and state institutions. Recently, we hospitalized mother for several days at a municipal institution. I want to tell you that I always prefer public institutions for my family and that I consider doctors in the public sector very good professionals, whereas hotel-like conditions do not have such a critical influence, just perhaps a more comfortable stay.

– Thank you.