Parteneri
Chapter 8. The Abortion Costs and Financing
Chapter 8. The Abortion Costs and Financing
Findings
The requested abortion was free of charge in Moldova until 1998. However, the majority of women (67%) as revealed by the Study carried out in 1997, had to pay unofficially the medical staff (with money or presents).
The regulations approved in 1997 sets the price for abortion (from 37 to 65 lei) Nowadays this procedure is provided against for money and is not covered by NHIC. The implementation of the health insurance system and the decision to ban the provision of abortion services in out-patient facilities considerably increased the cost of abortion, especially after the including of the daily bed cost into this price. The money goes to budget of health care facilities.
In 2005, in the Single Program of the compulsory health care insurance, on the List of the most frequent illnesses and estates that need immediate or unconditioned hospitalization of the insured people (Annex nr. 4 to the Single Program) O00-O99 XIV division. Pregnancy, delivery, postnatal period, pregnancy termination through abortion has been included: extra uterine pregnancy, spontaneous abortion, medical abortion, septic abortion, pregnancy evolution termination, complications generated by abortion, ectopic and molar pregnancy. At the same time, the Abortion is not included into the List of illnesses which allow direct visits of the insured people to the specialized doctor from rayon or municipal health care facility. (Annex 5).
The assessment team aimed at estimating the abortion price in rayons, municipals, and towns, the knowledge, attitude and opinions about these prices of the community members and service providers, the access to abortion services in terms of price, including those of the women belonging to the socially vulnerable layers and teenagers.
As well, one of the objectives was to evaluate how the mechanisms stipulated in the single Program function and if Decision of the Moldovan Government nr. 1291 of November 22, 2004 on approval of the single Program is respected, the level of its knowledge among providers and community members.
In most of the visited institutions, the price list was not displayed, and the patients did not know exactly how much they had to pay for the abortion: „The doctor is going to tell us”. Usually women find out the price for abortion from each others. During the interview the reported abortion price varied from 100 lei to 1000 lei, in average 200 lei.
True Life Story:
Young woman aged 18: „2 years ago I had an abortion. I asked for money from my mother who was in Italy. I paid the cashier 200 lei for the abortion. The doctor recommended me a pill, which would protect my cervix, which cost me 100 dollars. At the end I thanked the doctor, giving him 200 lei. He told me not to do abortions any more, but I do not know how to protect myself from unwanted pregnancies, we did not discuss that.”
The informal charge for the late abortion varies from 300 to 500 dollars. The providers admit that women are not always informed about the existent abortion mechanism during the second semester of pregnancy; hence they don’t obtain the necessary information from women.
The opinions about the costs of abortion varied too: from people who consider that they should be as expensive as possible, so that women could not resort to abortion, to the opinion that they should be free of charge, especially for women from villages.
Some community members declared that the abortions should be much more expensive than the charge for contraception; Thus, women will use the contraception and will not resort to abortion.
In some visited health care facilities the price list for the services was displayed. But, during the evaluation it was noticed that only the price for the procedure was displayed in a visible place, 35 lei, while in fact the patients paid bigger sums, which included the investigations, hospitalization and anaesthetic. In such a way, patients are misinformed even in the institutions where the price list was displayed. The patients pay the hospital cashier for the service, being given the receipt.
Thus, the prices for the procedures observed during the evaluation varied from:
- 250 lei in the division of a rayon hospital (60 lei for curettage, 60 lei for hospitalization, 19 lei for ultrasound services, 37 lei for laboratory investigations, 76 lei for anesthetics);
- 76 lei in the division of a rayon hospital (76 lei for curettage, if the patient presents the insurance policy, which allows not to pay the hospitalization cost);
- 165 lei in the division of a municipal hospital (35 lei for aspiration, 119 lei for hospitalization, 11 lei for investigation, the payment for the local anesthetics is not charged , for the general one – additional 60 lei);
- 46 lei in the division of an institution of a republican level, with or without general anesthetic - 52 lei;
- 57 lei for mini-abortion and 67 lei - up to 12 weeks of gestation in the division of a perinatal center;
- 254 lei (100 lei for out-patient investigation, 119 lei for hospitalization (stayed in the clinic for 2 hours , paid 35 lei for the procedure).
So, it was noticed that the prices charged for the abortion services are different in the health care facilities of the same level. Both providers and hospital managers could not explain clearly these price differences.
The pointed variations are partly explained by the fact that some of the hospital heads decided not to include in the price for the abortion the payment for the hospitalization, others – decreased it by 50-60%. These decisions were taken individually by the local management.
The same, in one of the visited rayons, the representatives of the insurance company decided to give the women who ask for abortion an insurance policy, which exempt them from the hospitalization cost.
The abortion prices are regulated by the following documents:
- The Unified Catalogue of the tariffs for the medical and sanitary services provided by the republican, municipal and rayon public health care facilities.
- Medical and economic standards of investigations and treatment
An analysis of these documents revealed a variety of definitions and payments which are recommended to be collected from the population:
In the opinion of the health managers and providers, the real cost of abortion is much higher. But not a single visited institution did the economic calculations which would allow to estimate the real cost of abortion or draw conclusions which of the used methods is more cost-efficient for the system of services provision.
In the medical and economic standards a calculation of the abortion cost is presented, with the following components included (Table 7): Table7.
It is not clear whether this sum will be included or not in the payment charged for the abortion, because, actually, the charged price was attested only for the procedure itself , without including these components.
The providers were dissatisfied because the work of doctor was not taken into account in this calculation. The doctors, unanimously, mentioned that they are not remunerated at all for the paid services. . Most of them consider that because of the low salaries and the lack of financial motivation many abortions are not recorded. The phenomenon of the informal payment, directly to the provider, in addition to the sums paid to the cashier, or fully for the unregistered abortion, avoiding the official payment, is spread.
Quote, doctor: „The registered abortion is a source of income for the hospital, those unregistered- for the doctors”.
Though aware of the fact that 50% of the accumulated sums shall be given to the doctors who provide paid services, not a single head of the hospital applies this into practice. The facilities that provide abortion services do not benefit from any amount for investments in repair works or medical equipment. The renovations are usually made on the money gathered from the medical staff, including that raised from the patients. According to the affirmation of a provider, the decision is made on common consent „Today we are not going to register two abortions as we must buy paint for the repairs”.
As for the expenses related to the free-of-charge abortions provided to women from socially vulnerable groups, during the evaluation it was noticed that they are totally supported by the hospitals. The changes introduced in the single Program referring to abortion are not known by the heads of the hospitals or the doctors, the local representatives of NHIC, practically, did not do anything in order to inform the providers and the population about those stipulations. In such a way, the sums for the treated cases are often not refunded to hospitals from the Company’s sources. The mechanism is neither known, nor definitely established.
In some institutions immediate surgeries are done only to only uninsured women with ectopic pregnancies, then a petition is addressed to NHIC on the bases of the hospital certificate, the insurance policy is given for those days and the cost for treatment is refunded.
The abortion-related conditions stipulated in the single Program, including the costs for the medically and socially indicated abortion or hemorrhage caused by the spontaneous abortion are not refunded.
As doctors from one of the rayons declared, the women that do not have a insurance policy and have a medical emergency must pay, but if they do not have money, as a rule, escape from the medical institution, but then, with the help of the hospital jurist, through the Court, they are forced to pay „ an administrative fine”.
As well, as it has been mentioned, the teenagers who, by definition, must benefit from insurance policies, pay fully for the services in all cases of abortion. Here is an example of a young woman from another rayon, at 12 weeks of gestation who requested abortion in one of the divisions of the municipal hospital; the doctors declared that in order to have a free of charge abortion she had to have an appointment card from the family doctor and should have addressed exclusively a rayon institution or one institution of the republican level.
So, it was established that both the mechanism for free of charge abortions for teenagers or insured women and the refunds to health institutions for the treated medical emergencies related to abortion or socially and medically indicated abortions is confusing, unknown, and poorly established.
Recommendations
- To improve the financial management of the abortion services, using a part of financial sources obtained from abortion services for investments in equipment and remuneration of doctors.
- To display at a visible place the price list for the abortion procedure and the post abortion contraception, as well as the information about the free of charge services offered to the women from the socially vulnerable groups.
- One of the criteria of the unity accreditation should be the display of the services prices and the rate of the abortions covered by NHIC for the specified categories of patients.
- To inform the patients about the free of charge services, provided to women from the socially vulnerable groups and teenagers through MoF, FDA, FPC, GO, display the information in the respective medical institutions, and publish it in mass-media.
- To define and unify the costs for abortion, correlating them with the clinical standards.
- To calculate the real cost of abortion, including all the necessary components and the doctors’ work.
- To compare the number of abortion cases for the medical and social reasons with the number of cases registered at the national Company of medical insurance.
- To carry out a case study of the planning and abortion service financing in the Republic of Moldova.