Reaching marginalised populations with intersectoral and interdisciplinary approaches
Integrated community health services in rural Romania
Von Nicusor Fota & Manfred Zahorka / Schweizerisches Tropen- und Public-Health Institut (Swiss TPH)
Swiss TPH and CRED Foundation Romaniacollaborate since 2003 for the strengthening of the Romanian health sector in various areas. The current project is oriented towards the development and dissemination of sustainable models for better integrated health and social services in rural areas of Romania in line with the Romanian Government National Strategy for Health 2014 – 2020. The intervention, which is financed by the Romanian MoH and supported through Swiss cohesion funds, builds capacity at the level of local authorities to plan, monitor and evaluate community level health projects targeted to the specific needs of marginalised populations at community level.
Although considerable improvement in people’s health has been achieved in Romania following more than 20 years of health sector reform and the transition from communist to market economy in the 1990s, the country still has one of the highest infant mortality rates within the EU (9.4‰ in 2011) – with considerably higher rates in rural versus urban environments (11.8‰ in rural versus 7.5‰ in urban areas). Maternal mortality rates in rural areas are 30% higher than in urban settings(national rate 14.8 per 100’000 live births in 2011).
Background – Access to health care services at community level in Romania
A variety of contributing factors influence the access to care particularly of rural populations. The transition from ambulatory based care to a peripheral health system dominated by private general practitioner (GP) cabinets which contract there services to health insurance companies, has increased the accessibility of health care services in the rural areas due to a larger spread of health care workers to smaller communities (1000 inhabitants and below). In spite of the well-established GP system, there is still limited access to care particularly in rural areas and especially for marginalized groups such as pregnant women and children, the elderly and specific population groups (e.g. Rroma). Related factors are gaps in health insurance coverage (still 10% - 15% of the population is either not insured or does not register at a GP’s office), the lack of outreach services (community nurses are clustered in certain areas and not available everywhere and GPs do not generally provide home visits) and relatively high opportunity costs for patients (transport, cost of leaving the family, etc.), which are aggravated due to the economic crisis.
Gaps in health seeking behaviour of rural populations, particularly of vulnerable groups also influence access to care. 25% of mothers of deceased infants are illiterate or only have primary level of schooling. Although the number of pregnant women not consulting their doctor is relatively low (7%), the quality of actual pregnancy risk monitoring is limited for quite a number of pregnancies – 23% of pregnant women consult their doctor only 1-3 times during pregnancy. At the same time 70% of maternal deaths occur with mothers, who never saw a doctor during their pregnancies. The capacity to manage chronic health conditions at community level is also limited in terms of availability, type of service and quality.
Health system response to the needs of rural communities and especially for vulnerable groups is limited
Although GP cabinets are widespread and some physicians even offer services at several small communities (below 1000 inhabitants, which is the critical size for the existence of GP cabinets), the incentive system for GPs does not encourage home visits, preventive care and other community oriented services. The fee for service contracts of GPs with health insurance companies include only few home visits, which are not enough to cover the needs in many geographic areas. Community midwifes have been widespread in the 1960s but where consecutively abandoned since the 1970s. Community health work was re-introduced through community nursing around the year 2000, but is still limited to geographic areas with marginalised populations and low income areas. Although paid for by the Romanian MoH, community nurses are linked to local authorities at community levels with no or weak upward hierarchical links and representations limiting their ability to shape their professional environment. Other services at community level are social workers and Rroma mediators, who assist population groups in need.
Promoting ante-natal care visits for pregnant women; CRED Romania 2007, www.cred.ro
Community services are frequently funded through vertical governmental programs, defining their role at community level through national regulations and guidelines. The lack of managerial skills at the level of local authorities and the low priority allocated to health issues and preventive care on one side and little to no communication and coordination between service providers on the other, leads to ineffective and fragmented services.
There have been a variety of interventions to close this gap in services in the past lead by local funding through the MoH and the Ministry of Social Affaires as well as international institutions such as UNICEF, UNFPA, and various European governments through development programs. However, the sustainability of these measures has been limited.
The goal of this intervention planned and executed by the Romanian MoH together with the Swiss Development Cooperation funded through cohesion funds is to develop and disseminate sustainable models for better integrated health and social services in rural areas of Romania through:
- developing functional, integrated and locally managed models for community health systems;
- increase access to health care through close collaboration between health, social services and other services available at community level;
- Improve management of chronic illnesses and health risks, such as NCDs, perinatal health conditions, Tb and others.
The beneficiaries of the intervention are the population of rural communities and small towns with low development indicators, vulnerable groups and people living below the poverty threshold. This effect will be achieved amongst others through the strengthening of local authorities and actors with capacity building and management support measures. Regional and national governments will be supported through the development of evidence based interventions for dissemination to other interested communities.
Closing the health services’ gap through integrating community care services – the new approach within the framework of the Romanian National Health Strategy 2014-2020
The new vision of the Romanian Government includes the development of sustainable integrated socio-medical organizational structures –Community Care Centres - to be developed at community level. These Community Care Centres would provide basic needed services such as services to vulnerable groups (mother and children, elderly, MDRTB patients, persons with disabilities, persons with rare diseases, persons with mental health problems, primary prevention for non-communicable diseases, etc.).
The present intervention funded jointly by the Romanian and Swiss governments promotes local authorities to be the driving forces for the integration and management of sustainable community health interventions according to the needs of its population and in line with Romanian government strategies.
Initially and through a sensitization process of the judet (district) authorities, a group of communities will be identified to participate in a capacity building procedure. This step will train local authorities, community leaders and other relevant actors to assess health needs of its population, prioritise, plan and manage the integration of available services as well as monitor and evaluate their performance. Based on government priorities, the local authorities will propose community health projects, from which a selection of proposals (those proposals, which are evaluated best) will be funded and monitored by the authorities above. Proposals shall bring community actors together - such as general practitioners, community nurses, social services, Rroma mediators - strengthen the collaboration, and integrate available experiences (other projects, NGOs providing services etc.). Suggested activities will strengthen collaboration between medical and social services in order to reach marginalized populations with information and services. Additional to the care perspective of classic health care providers, proposals may also focus on more health related matters such as health information, promotion, and preventive activities, particularly in view of early detection and management of chronic conditions.
Community health interventions will be accompanied by a “coaching system” helping the actors in terms of information, management, documentation, generation of evidence through operations research etc. in a view of capitalising the experience for future dissemination of lessons learnt. In a second phase of the intervention, measures for scaling up of experience will be considered as well as the integration of the generated experience into other governmental projects
Community nurse doing community sensitization, CRED Romania 2007, www.cred.ro
Expected results and current outcomes of the intervention are:
- Disadvantaged groups have better access to and make equal use of health services at community level;
- Management of chronic illnesses and health risks, such as NCDs, perinatal health conditions, Tb and others, has significantly improved and patients are better followed;
- Models for integrated health and social services for disadvantaged groups are available and are utilized at local levels;
- Local authorities are empowered to conceptualise, set up and manage intersectoral health related projects and are actively acquiring funding for interventions;
- Government authorities dispose of a set of evidence based local health interventions to improve local health indicato
At present the above concept is finalised in collaboration with local partners and evidenceon successful measures at local regional and international levels are collected and documented as a “tool box” with local “champions” to be used for training purposes. The sensitization at district level as well as the identification of pilot communities is on-going. In parallel the materials and curriculum is prepared for the capacity building measures and the concept of “coaching” local actors is further developed. The capacity building procedures will start in July 2013 with a start of pilot projects foreseen in fall 2013.
*Nicusor Fota is the Director of CRED Foundation in Bucharest/Romania and works for more than 10 years in various areas of health systems support with the Romanian MoH. Contact: firstname.lastname@example.org
*Manfred Zahorka is the head of the sexual and reproductive health unit of the Swiss TPH and works amongst others on community health and access to health services in Eastern Europe and Central Africa. Contact: email@example.com