The intermediate result of an ongoing study: Integrating long-term care for elderly populations in rural Romania

Can new models of health care provision in Romania help to close the gap in the ageing communities?

Von Florence Sécula, Nicusor Fota & Manfred Zahorka

Although legislation is quite favourable of local integration of health and social services, in practice the capacity of local authorities and other bodies at community level to coordinate multidisciplinary services is low. The mechanisms of coordination remain unclear.

Can new models of health care provision in Romania help to close the gap in the ageing communities?

Bestepe, Tulcea district in Romania, where the project described is set, just showing and everyday live scene with two local women. (Photo: Swiss TPH)

The World Health Organisation (WHO) estimates that the world population above the age of 60 years will increase by 2050 to 2.2 billion people. The resulting increase in NCDs calls for the focus of care shifting from single disease specific models towards managing long term conditions increasing the quality of life of people and improving their functional ability for an active participation in life. This requires a coordinated and integrated response of health and social service providers, as well as complementary activities from the community side.

What the legislation arranged....

In Romania, community health and social services are delivered following sectorial policies and there is little collaboration and coordination of services. In its National Strategy for Health 2014-2020 the Romanian Government addresses these discrepancies and paves the way towards better integration of services. The Community Health Care Framework law discussed at the beginning of 2016 foresees that community medical care service providers are to collaborate with social services in an integrated multidisciplinary team where family medicine units cooperate with other health, social, educational and NGO structures to improve the quality of life, particularly of the most vulnerable groups. Health services are complemented by community health and school mediators.  Additionally, the responsibility for the actual provision of social services moves from the county to the community level.

....is not (yet) feasible in the communities

A recent study showed that social work in communities is rather limited to the payment of social benefits and the bureaucracy involved. Although social workers would appreciate working more with the communities, their ability to do so is limited by the available time and staff. Home visits are mostly done by community nurses. Although their work is highly appreciated by villagers, their equipment to deal with home based care situations is relatively low. Coordination with family health practices is also limited, amongst others due to different working routines. Communication platforms or databases, through which treatment information can be shared, rarely exist.

Home care - Vratsa. Galina Ilieava, nurse and Tsvetelina Mitova, home helper are visiting Tsvetana Kostova, 81 years old woman from village Zgorigrad /Vratsa region, Bulgaria. (Photo: Alfred Mikus, Belarus/ © SRC)

 

New role for social services?

Focus group discussions show that villagers are generally satisfied with the social services they receive. The classic understanding seems to be that these services are more or less linked to organise payment of social benefits. Community nursing is highly appreciated by most, but more or complementary services are requested. In contrast to family doctors, many community nurses live in the village they work in, which provides for the close contact between nursing and people and the willingness to work extra hours from time to time and in case of emergencies. Family doctors offer their services mostly in larger villages, with some mobile clinics also in smaller settlements. However, their fixed office hours limit their availability for emergency services.

The situation of most people are aggravated by little economic opportunities within the village, other than small scale agriculture and the frequently cited opportunities for tourism, which is weakly developed in most places. This leads to short or long term outmigration of labour, leaving children and the elderly behind. Most villages provide elementary schooling and some services for the elderly.  A variety of private, NGO or church initiatives exist to address the gaps left by official service providers, particularly for child fostering and elderly care. Some community centres exist – for mobilising the elderly, or taking care of children – with the new national strategy supporting the development of new ones. Some church based organisations have developed more people centred approaches by mapping peoples’ conditions and needs for their parish and organising the required services.  

Big issue: Nobody is responsible

Service integration is a concept used by most interviewees and most local authorities consider many services as part of the network to be coordinated, including health, education, security, NGO and private services. One of the big remaining issues is the lack of a strategic approach towards planning and monitoring of targeted interventions to satisfy people’s needs. Local authorities do not necessarily consider provider coordination as their task and delegate this to the individual provider. A natural coordinator could be the family physician as his task is to ascertain the necessary health interventions for their patients. However, the fact that they mostly do not live in the same communities than their patients and fixed office hours limits their availability for that task. In its community strategy, the Romanian government favours the creation and strengthening of community centres to create one-stop shops for services. A few limited sized projects have generated some evidence and best practices of how this could work.

(Photo: © SRC Belarus)


Next steps in order to achieve an integrated approach

With the support of the Swiss Government as part of its contribution to assisting the new EU member states the Romania Ministry of Health launched theWidening Access to Health and Social Services” program, which supports the capacity of local authorities to address social and health related inequalities through and integrated approach. A particular focus is on people with long term health conditions, chronic diseases, and the elderly who can frequently not reach health facilities easily. Strategic components of this program are:

  • Building capacity of local authorities in order to better fulfil the mandate given to them by government to provide social services and to coordinate providers at community level.
  • Explore and further develop concepts of community care centres as a means to facilitate access to and better coordinate services to the people.
  • Community empowerment to assess population needs in health and social services and the development of complementary services were needed.
  • Develop local integrated care interventions and better coordinate service providers for the benefit of people with long term care needs for most in need populations.

(Photo:  © SRC Belarus)

 

Political will needs to be matched with sufficient resources

In seven communities within three different counties, representatives of local authorities were trained in developing local social policies and conceptualising, implementing and monitoring local projects. A team of social scientists supports and coaches local authorities through all stages. Following the capacity building stage, the planning and implementation of local projects has only started early to mid-2016 and results will be evaluated after 1.5 year period. However, first results show that the political will of bringing integrated services closer to the people needs to be matched with sufficient resources and the building of capacity with local authorities to cope with the additional tasks involved. The tradition of organising health and social services along sectoral lines is still prevailing in many cases and service coordination – although obvious for many of the interviewees – is nobodies’ responsibility. Part of the current intervention is to create communication platforms for local authorities, NGOs and other actors at community level to exchange experiences and best practices in order find local solutions for local problems. The coaching team contributes to this knowledge sharing process.       

An intermediate conclusion is certainly that based on the limited resources on the service provider side as well as the lack of capacity for service users to cover opportunity costs for service utilisation there is an urgent need for improving the complementarity of available services, their coordination, outreach services to better focus on people’s needs. Community health assessment and priority setting, involving population representatives or self-help groups is essential to better define and coordinate services fitting to individual needs. Strengthening self-care abilities of patients and their families, better accessibility of a wider mix of services and preventive care measures are needed, in particular to the chronically ill. Mapping of needs, community health and social care profiles, proper interventions planning, implementation, monitoring and evaluation helps to identify and share best practices for the benefit of those most in need.

 

Florence Sécula, Nicusor Fota & Manfred Zahorka

Manfred Zahorka, MD, MPH, EOQ-Auditor
Senior Public Health Specialist at the Swiss Tropical and Public Health Institute,
Head of Sexual and Reproductive Health Unit, Swiss Centre for International Health.


Florence Sécula, MDev; Project Associate
Social Development Specialist.


Nicusor Fota, Project Coordinator
CRED Foundation, Romania Swiss Centre of Health Sector Development, Bucharest, Romania.

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