WITH DEFICIENCES OF VIEW
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The beneficial impact of the implementation of the audit recommendations consisted in the elaboration and approval of the strategic health policies in the context of the implementation of measures for the prevention and control of diabetes.
The Court of Accounts of the Republic of Moldova (CoARM) reached such a conclusion, after examining, on November 29, the Follow-up Audit Report on the implementation of the recommendations approved by Decision no. 1 from January 31, 2019 “On the Performance Audit Report on the implementation of the action plan of the National Program for the prevention and control of diabetes during 2017-2018 (1st semester)”.
The audit evaluated the measures taken by the entities involved, with the analysis of the level of implementation of the recommendations submitted by the Court of Accounts. Thus, were analyzed samples from 18 entities of different levels and was assessed the expected impact of the measures taken on the actual benefit of the patient of medical services and self-monitoring devices.
The national diabetes prevention and control program has been approved for a period of 5 years. The scope of the previous audit included the activities for the period 2017-2018 (1st semester). The implementation of the audit recommendations, within the present follow-up mission were evaluated in the light of the measures undertaken by the institutional system, for the last three years of implementation of the National Program.
On average, the level of implementation of the audit recommendations was 65%, namely: fully implemented - 20 recommendations, partially - 31 recommendations, and 4 recommendations were not implemented.
The elaboration and approval of strategic policies in the field of health, following the implementation of audit recommendations, were aimed at protecting the population from financial risks, contributing to reducing the burden for people with diabetes, with the state assuming these expenses.
In this context, starting with 2022, will be ensured the access of about 119.0 thousand people with diabetes to self-control devices and insulin analogues. They will be issued through pharmacies, based on the prescription prescribed by the family doctor or specialist, and reimbursed from the Compulsory Health Insurance Funds CHIF). These actions will contribute to facilitating access at the national level and to fully benefit from insulin analogues and medical devices, according to the needs of the person with diabetes, increasing adherence to treatment.
The approval of the new compensation mechanism for insulin analogues and medical devices on an outpatient basis will exclude shortcomings identified by the previous audit, such as: unfair and uneven distribution of medical devices and will eliminate the difficulties encountered by medical institutions in planning, their distribution and record.
In 2022 for the compensation of medical devices and insulin analogues, under the conditions of compulsory health care insurance, there is an increase in expenses, which will amount to about 100 million lei.
Also, based on the recommendations of the Court of Accounts, the Ministry of Health jointly with the National Medical Insurance Company undertook a set of systemic and complex measures aimed at reducing the financial burden of people affected by diabetes. Thus, about 100 thousand adult patients with diabetes benefited from medical devices (tests, glucometers and lancets), amounting to 23.0 million lei. Likewise, 800 children with diabetes were provided with sensors and insulin pens. At the same time, from CHIF were financed the expenses for the compensation of injectable and oral antidiabetic preparations, prescribed and released for about 16.0 thousand unique beneficiaries, in the amount of 292 million lei.
By implementing the audit recommendations, there is an improvement in the involvement of local public authorities in the implementation of the National Program, some of them refer to the local approval of the Territorial Program for the prevention and control of diabetes, two level II LPAs have allocated financial means for the realization of the National Program, and other 4 LPAs initiated the process of assessing the needs and the necessary measures in this respect.
The audit found that some problematic situations persist. During the implementation of the audit recommendations, there is a lack of assurance or partial assurance of the need for self-monitoring devices for adults treated with insulin, children and pregnant women. Thus, although these medical devices increase the efficiency of treatment by constantly monitoring blood glucose levels, it was found that:
- 3523 people with diabetes did not receive tests for blood glucose or were given insufficient amounts. Only 86 patients were fully insured as required;
- Of the 815 children registered with diabetes, 513 children were fully provided with self-monitoring tests and only 503 benefited from a glucometer, which represents 62% of their total.
With regard to the benefit of insulin-dependent individuals to effective treatment with insulin analogues, the present audit established that 2700 people with type I diabetes or 82% (out of 3250 people evaluated) had access to this type of treatment.
Regarding the evaluation of the investigations necessary for pregnant women to identify gestational and pre-existing diabetes, the National Medical Insurance Company, as a result of the performed verifications, established the non-compliance in some cases with the provisions of the National Clinical Protocol. At the same time, this audit evaluated 807 medical records and established that the pregnant women had not undergone the necessary investigations within the set deadlines, namely:
- at the first visit, for the medical record, up to 12 weeks of pregnancy:
- 68 pregnant women were not subjected to a biochemical blood test to determine their blood glucose levels;
- 695 pregnant women did not perform the oral glucose tolerance test to identify pre-existing diabetes;
- at 24-28 weeks of pregnancy:
- 138 pregnant women were not subjected to the mandatory biochemical examination;
- 588 pregnant women did not screen for gestational diabetes.
The Court of Accounts notes that some recommendations aimed at improving the management and control system of the National Program have not been fully implemented, this process being also influenced by the COVID-19 pandemic. Also, in order to implement the recommendation of the Court of Accounts, the State Tax Service performed thematic controls of the aspects found during the previous audit. These refer to the sale of insulin analogues with the obtaining by an economic operator of illegal revenues in the amount of 0.5 million lei. As a result of the verifications regarding the commercial addition applied to the pharmaceutical products, the State Tax Service applied sanctions to the economic operator, in the amount of 62.0 thousand lei.
Finally, the Court of Accounts concluded that the measures taken to implement the recommendations were systemic and focused on increasing the access of people with diabetes to effective treatment. The beneficial impact achieved indicates the increased attention of the state by approving national policies related to the strategic priorities of compensation of insulin analogues and medical devices for determining blood sugar.
At the same time, the follow-up audit established the persistence of shortcomings found in the previous audit, which were conditioned by the insufficiency of monitoring and control measures, in terms of achieving the indicators and actions set out in the National Program and the responsibility of providers of medical services in ensuring citizens' access to some state-guaranteed medical services.
Thus, the specialized central public authority and medical institutions are to intensify and contribute to improving the health of the population.
