Challenges and Strategies of the SRC programme in Romania and the Republic of Moldova
Prevention of Chronic Diseases in Transition Countries
Von Lina Langer / Schweizerisches Rotes Kreuz SRK
Romania and the Republic of Moldova are confronted with a high burden of non-communicable diseases. In partnership with the Romanian NGO FSM the Swiss Red Cross is working in the North East of Romania and in the bordering Moldova with a comprehensive approach.
The fall of the Berlin Wall, the dissolving of the Soviet Union and the end of the Cold War has led to economic, social, cultural and political transition in South-Eastern Europe and the countries of the Former Soviet Union. This transition period is characterized by:
- Growing disparities in the social and economic situation of people
- A deteriorating health status of the majority of the population and increasing disparities between transition countries and Western Europe, as well as between and within the transition countries
- A sudden rise in unemployment and poverty
- Disrupted social security and health care systems and public infrastructures
- The collapse of a system of beliefs and values
On the example of cardiovascular diseases the figure 1 below demonstrates the disparities between transition countries like Russia or Romania and between these countries and EU countries.
Disparities are not only in health but also in economic and social aspects. With a population of 21.5 Million Romania is the second biggest consumer market in Eastern Europe and is attracting foreign investors. Therefore economic development was on an upward trend since the prospect of EU membership/accession process started and since joining the EU. However the regional disparities in economic and public infrastructure development are extreme and this corresponds with regional disparities in labour migration, unemployment, quality of life. E.g.: unemployment rate can vary from 2.1 % in ‘Very High developed’ areas to 11.2 in Vaslui – in the North East.; infant Mortality rate can be nearly double: from 10.5 in Times (West ‘very high developed’) to 19.71 in Botosani (North East, ‘very low developed’).
In the Republic of Moldova similar disparities are particularly between the rural areas and the capital Chisinau. The trends in life expectancy at birth for the general population followed the socio-economic decline after 1989. Following independence, there was a sharp fall in all health indicators in Moldova, and average life expectancy fell from 69.0 in 1989 to 65.9 years in 1995. Though In Moldova life expectancy improved from 1996 onwards, and in 2006 was 68.5 years it still remains one of the lowest in European Region.
Romania and Republic of Moldova – similar problems and challenges
Although the two countries are very different regarding Geography, the size of the population, recent history and culture, similarities in problems exist in a way that allows the SRC programme to work with a cross-border approach.
Both countries are confronted with:
- high level of labour migration which leaves children and elderly abandoned and neglected and producing social and health related problems
- alcohol and other substance abuse as signs for destructive health behavior
- domestic violence
- serious problems of the transition period in the health system: lack of resources, shortage of material, decaying infrastructure and health workers leaving for work abroad
- lack of professionalism and client orientation low work ethos securing services only for those who can pay extra
- lack of an integrated and implemented health promotion programme.
The SRC/FSM programme is implemented in rural areas and identified during a pilot phase as major problems: Dominant social problems in rural areas are the social and health consequences of labour migration, the underdevelopment of public infrastructure with problems in transport and communication, the situation of elderly and chronically sick and the limited access to education and information – particularly for women.
Prevention of Chronic/non-communicable diseases: Challenges
Fact and Figures
The statistical data displayed in Figures 1, 2 and 3 (only visible in the print version of the MMS Bulletin) are highlighting the situation and the disparities in the two transition countries compared to Western European countries:
- Diseases of the circulatory system are the main causes of death both in Moldova and Romania, followed by cancer, diseases of the digestive system and injury and poisoning;
- Romania and the Republic of Moldova have one of the highest levels of cardiovascular diseases in the European Region.
However, the levels are estimated to be much higher as it is assumed that the quality of the data captured in the health system is poor.
- Romania has the highest cervical cancer mortality rate in the region.
- Among cancer-related deaths, mortality from cervical cancer is twice as high in Romania than in the EU average.
Selected data from the lifestyle survey in 8 countries of the former Soviet Union showed for the Republic of Moldova:
- Moldovans had the highest alcohol consumption of the eight countries surveyed and connected to high alcohol consumption chronic liver disease and cirrhosis is a very significant overall cause of mortality. Additionally it has the highest chronic liver disease mortality rates both among men and women in the region.
- The highest rate of cardiovascular mortality among women.
- Deaths related to breast and cervical cancer is increasing, e.g. between 1990 and 2000, breast cancer mortality increased by 7%.
Additionally to the gap in the health situation compared to Western European countries Moldavians and Romanians have a double burden regarding their health risks: to get sick or die from non-communicable disease and from infectious diseases. However the mortality rates from chronic (non-communicable) diseases are much higher and are a more pressing problem to address.
Prevention of Chronic diseases: Challenges
The SRC programme in MD and RO is confronted with challenges common in all transition countries – like corruption – and specific challenges for the two countries – like a very high labour migration.
Corruption is widespread which makes the access to preventive services – if they exist – not affordable for those who cannot provide the ‘under the table payments’ or have no means for transport. Both countries have no tradition of democratic participation and self-help or social movements which could challenge the political elites and the corruption on the political level and in public administration including the health system.
More specific for the two countries compared to transition countries like Russia or the middle Asian post communist countries are the increase of complexity due to the extraordinary labour migration and the entering of the EU in Romania and the conflict in the Republic of Moldova with the separatist East of the country (Transnistria).
Labour Migration: Rural communities are facing fast social change due to labour migration of the majority of the working population aged 18-45 years which increases social fragmentation and inequalities.
Labour Migration is affecting poor, underdeveloped rural areas more, as more people are unemployed and therefore have or want to leave the villages to seek work abroad. Particularly after January 2007 – when Romania entered the EU – the increase of elderly, children and youth left behind in the village could be noticed with health and social consequences for the individual and for the community as a whole. As a further consequence the number of men and women in Reproductive Age decreased.
The influx of transfer money (remittances) from those working abroad leads to problems not seen before: children, youth and women with enough money to buy alcohol, cigarettes and junk food and to show off with most modern and flashy clothing, mobile phones and cars. The consumption of alcohol as one sign of self-destructive behaviour is increasing and the consumers are getting younger and more and more girls and women are among them. The transfer money is not changing the lack of perspectives for young people to have a job and employment and does not satisfy the emotional needs of those left alone. Violence against women is still more accepted in rural areas and the increase in violence is often connected with the increase in alcohol consumption.
Besides the effects on social change in the villages, labour migration is also one reason for a shortage of health workers. However a survey showed that important reasons for nurses to leave the country are unsatisfying working conditions, decaying infrastructure of health facilities and lack of material.
Lack of modern public infrastructure in the rural areas like safe water, canalisation, sewage systems and roads are affecting negatively the quality of life and the health conditions. In rural areas up to 95% or more of the population has no access to running water, canalization or hygiene facilities like toilets and bathrooms in the house. Particularly for women caring for a family and elderly it is a special burden to carry to the house each drop of water needed for washing, cooking and cleaning in buckets from the village well. In one of the SRC projects women are trained as home helpers and basics in nursing to care for the elderly and chronically sick in their neighbourhood. One of the work is carrying the buckets of water to the elderly in the house.
Private investment to produce working places in rural areas does nearly not exist as a consequence of the lack of roads, efficient communication and sufficient energy. This leads to huge social and geographical disparities in living conditions and development as economic development with new companies and workplaces is mainly centred around the bigger cities or – like in Moldova in and close to the capital Chisinau.
Due to a weak political system laws are not implemented - mostly because of a lack of implementation regulations and enforcement of the laws. Additionally the allocation of resources is not based on priorities for Prevention and the current global financial crisis adds to a general shortage of resources. The Public Health Insurance - which plays a major role in Prevention in Western Europe - is in Romania in financial deficits.
EU regulations in different fields have to be applied which makes processes more complex but often trained professionals and relevant structures are not yet available. E.g. the decentralization in health and education means that the local community is responsible for major tasks which in the past were regulated on a central/national level. But the mayors and members of the village councils are not prepared to take over specialized duties and supervisory functions. Thus decentralization and privatization leads again to disparities and inequalities in the access to public services as the access is either depended on favourable geographic location (e.g. cities) or dependent on enough individual resources like money and private transport.
Lack of critical consumers and strong consumer lobby organizations and limited access to neutral, unbiased information about products leads to a dominance of lobbyism of companies in the relevant fields like nutrition, tobacco and health products. Both countries have not yet a developed and strong consumer movement demanding rights. This is part of having no tradition for self-help, self-organization and participation.
Limited access to information and knowledge is an additional challenge to prevention and health promotion. The SRC/FSM study in 2008 with 287 women in the rural areas of the districts Botosani and Iasi (Romania) revealed:
a lack of awareness, knowledge and practices in women’s health: cervical and breast cancer prevention, HIV/AIDS, STI prevention and Health Behaviours;
- over the half of the respondents had been never tested for HIV and over 60% had never been consulted about STI;
- a high prevalence of smoking, exposure to secondhand smoke, alcohol abuse and domestic violence.
Prevention of Chronic diseases: Strategies
According to the results of social epidemiology and social science research the root causes of most chronic diseases are a complex and inter-related mix of factors. Take as an example the case of cardiovascular diseases: In countries where it has been most intensively studied, it could be shown that it is higher among the poor and in those whose control over their life is constrained, defined by social position and unemployment. It is also higher in smokers, those who are overweight, those with diets high in fat and low in fruit and vegetables, and those with inadequately controlled hypertension. It can also be associated with heavy alcohol consumption. All of these factors are common in transition countries leading to the high observed levels of cardiovascular diseases. Additionally, despite the widely common opinion that chronic diseases affect mainly high income countries, in reality 80% of chronic disease deaths are in low and middle income countries like the transition countries.
A combination of a poor socio-economic situation with unemployment and lack of resources or not sufficient access to resources – like transport and education – can be the reasons for self-destructive behaviour. This combination is predominant in the rural areas where the programme works and strategies can tackle part of these factors in a Prevention and Health Promotion programme. Some of the structural factors the programme cannot address like modern public infrastructure. Take the example of the prevention of cervix cancer for women in Romania: even if the preventive measures should be free on the paper, the obstacles are high: Maybe kilometers of muddy field paths to walk, with no frequent public transport, family doctors restrictive and reluctant to write the referral to the specialist, no money to travel to the hospital for a pap smear and no money to pay the extra (under the table) money.
The SRC programme is taking into account these insights and applies a strategy which is tackling structural and individual factors.
The SRC Integrated Family Health and Community Development in North-East of Romania and the Republic of Moldova
‘Integrated’ means an interprofessional und intersectoral approach with all the activities and interventions take place on different level of the community; involving and addressing all kind of members: women, youth, men, and children. All levels are interconnected and different methods are applied and different professions involved – e.g. nurses and social workers – and across sectors and institutions, e.g. education/school and public administration/village council.
In community groups, in the schools, in training and workshops and local and regional awareness campaigns the 5 major strategies are implemented and will take effects in a synergistic way.
1) Increase knowledge and achieve health literacy: Health Literacy - is more than purely to acquire knowledge. It is the ability of individuals to obtain and understand health information and services in order to make appropriate decisions. It includes also understanding risks and recognizing biases or manipulations in information – e.g. in advertisements about products and the media and to know about and demand the rights as consumer. It also includes communication, coping and caring skills, e.g. how to cope with stress of the ‘normal’ everyday life. In the face of a strong and powerful lobbyism and with limited access to non-biased information it is particularly important in the SRC project to provide neutral information and learn how to get them. To provide this non-biases information modules for major health topics are developed – among them topics like ‘Women’s Health’, ‘Healthy Eating’ or ‘Alcohol – know your limit’.
Trainers are trained and manuals will be developed for the use in the community groups and schools. The topics were selected during participatory workshops together with the women’s groups and with the health professionals trained in Health promotion of the SRC programme.
2) Empower and activate the self-help potential of the community members – particularly women who play as mothers and parent a crucial role in the early forming of attitudes and behaviour of children and youth. The work of the SRC/FSM project is initiating and supporting community groups by helping to find a location in the community and helps in the renovation and equipping of these community rooms/centres that the groups can meet regularly. It proved to be crucial and one the prerequisites to have an own place to meet for developing an identity as group of the community as well as stability. Besides the activation and participation one of the most important functions of the groups are for the women to get out of the daily routine and have a place for reducing stress. In this way the group meetings are crucial for the emotional and psychological wellbeing as one factor for prevention.
The group members are also involved together with teachers and pupils in extracurricular activities of the schools, during international Awareness Days and the yearly Summer Schools.
Since April 2008 27 women and youth groups were established with the support of SRC/FSM.
The emphasis on children and youth is based on knowing, that attitudes and behaviour are formed in these early stages of life.
Based on the problems caused by labour migration and the wish of women to avoid having to leave the country for work, the project is also supporting ideas for income generating projects.
Within the coming years the SRC programme is planning to give support in realizing these projects and putting ideas into actions.
3) Capacity building/improve the qualification of the service providers and lay persons alike. Trainings for nurses and team trainings of health personnel with social workers are regularly organized for different topics in health education and health promotion as well as communication skills. Nurses are trained as trainers in the health education modules. In weekly lectures and workshops trainers will be able to work with the community group members for problem identification, lifestyle changes and improved health behaviour. The Peer Education project is training youth and teachers to carry on health messages and knowledge to other classes, schools and peers.
4) Awareness raising activities connected with International Awareness Days on community level and regional as well as cross border campaigns with 100 schools together with local and regional partners reached in 2008 7000 children and youth. Regular activities are workshops, School Health Days and the yearly Summer Schools which has always a major topic – in 2009 the problem of alcohol with the campaign title: ‘Alcohol – know your limit’.
5) Initiate and support networks and connect to movements of civil society and self help organization. Building up regional and cross-border networks of Community groups between Romania and the Republic of Moldova is aiming to increase power and impact by facilitating exchange of experiences and learning. In the first cross-border exchange 130 women met in October 2009 from 18 groups from Romania and the Republic of Moldova.
The programme is also facilitating inter-professional and intersectoral cooperation by offering team trainings for Family Doctors (FD), Community nurses (AMC), Social Workers, Roma Mediators, Specialists and all actors in the community.
Integrated approach: example on the topic ‘Prevention of Alcohol abuse among youth’
The example how the project is tackling the increasing Alcohol problem in the villages – as one cause of developing a chronic disease – shall demonstrate the described integrated approach:
Community nurses and social workers are trained in the module ‚Alcohol’ with strong emphasis on prevention and how to deal with youth to prevent early abuse. After training and supervision they are carrying the knowledge and the training abilities as trainers into the schools and the community groups.
In the community groups women as mother are trained to deal with the topic in their families and in their neighborhood.
Schools and teachers take part in the preparation and executing of campaigns and pupils are supported to develop campaign materials.
Awareness material like Graphic and paintings for posters and other information material is produced by the children and youth. In contests organized by the project the best art work is awarded and children are participating at the summer school where the topic will be again developed with youth from both countries thus adding an intercultural dimension. Pupils are learning and get insight how cultural norms are forming the attitude and behaviour regarding ‘Alcohol’.
In the peer education training the topic is carried in classes of the schools by peers.
The Community Police and other partners are involved in awareness campaigns for the topic drinking and driving and violence connected to drinking.
The visibility and impact on the regional level is ensured through the dissemination of the posters and other awareness material based on the art work of the children and youth. Local, regional and national agencies are supporting the dissemination by using the material.
Sustainability is secured by developing a manual with all materials – including audio-visual material like DVD with films and spots – at the end of the project with all feedback and improvements from all beneficiaries and partners included and applied.
The increasing knowledge and insight about social and economic factors for the developing of chronic diseases are putting the integrated approach in the forefront of primary prevention.
Health literacy and citizen’s participation is getting increasingly important in complex societies facing strong lobbyism from producers. Additionally there is a trend to observe in Romania and Moldova that social and economic problems are medicalized or defined as individual problems and a case for psychologists. This trend is not addressing the social and economic root causes of chronic diseases but ‘doctors’ on the symptoms of the problems.
The ‘ideal’ healthy person, who wants to stay healthy, is not consulting a doctor or a hospital but is caring about the lifestyle, is doing moderate sport, balancing diet and stress, is in a community group, association or club to enjoy the social activities and common interests and is an informed consumer and active citizen to regularly go for the preventive health check-ups.
The interventions need also in transition countries to be increasingly in education, supporting self-help, strengthening citizens’ and consumer’s activation to demand a functioning preventively oriented public health structure and access to unbiased information.
* Lina Langer is a medical doctor and a sociologist M.A. She graduated in Political Science and Sociology at the University of Konstanz and Bielefeld and in Medicine at the University of Köln/Germany in 1987. She worked as sociologist for the German Federal Centre of Health Education in Köln. As coordinator of the Bonn University Hospital Cancer Center she was leading the campaign ‘Europe against cancer’ financed by the EU. Since 1996 she is working for different donors in transition countries in Asia/Central Asia and South/Eastern Europe as consultant and as Coordinator of programmes with emphasis on Health and women’s issues. She is responsible for the programme of SRC in Romania and the Republic of Moldova since 2005. Contact: email@example.com
Integrated Family and Community Health Initiative
Swiss Red Cross, in partnership with the Romanian NGO FSM, is implementing since April 2008 the second Phase of the “Integrated Family and Community Health Initiative” with emphasis on: Supporting community groups, strengthening Self-Help, increasing Health Literacy of community members and support groups to network regionally and cross-border. Another major aim is to increase the competences of Professionals in Health Promotion and to empower women to realize their own income generating projects to decrease labour migration. An integrating approach is applied to reach the whole community – women, men, adolescents and children and all ethnic groups - in cooperation with the mayors, councils and schools. Beneficiaries are the people in rural areas of North East of Romania and in bordering Moldova which comprises approximately 2,5 million people. An average of 2.25 % of the direct beneficiaries is members of the Roma population. Since April 2008 700 professionals were trained, 450 community members are actively involved in 25 Community Groups and 7500 pupils participated in Awareness campaigns with the schools and in collaboration with the educational authorities. 110 pupils are attending the yearly SRC/FSM Summer School and 130 women of the community groups in Romania and Moldova participated in the first cross-border exchange. Currently 100 elderly are cared for by 86 women who were trained by SRC/FSM as Home Care helpers.