Healthy communities – how intersectoral partnerships and greater accountability are tackling the burden of NCDs to improve health in rural Moldova
Moldova tackles the problem of NCDs
Von Ala Curteanu, Constantin Rimis, Oleg Lozan, Diana Berari, Leah F. Bohle, Florence Sécula, Helen Prytherch
Like many countries, the Republic of Moldova faces a growing non-communicable disease (NCD) mortality and morbidity burden. Disease prevalence from the four main NCDs (cardiovascular diseases, cancers, diabetes and chronic respiratory diseases) is very high, while the probability of dying of these four diseases between ages 30 and 70 years is 26%. Health-seeking behaviour of the population in Moldova is characterized by higher trust on hospital-based and specialised care, low sense of responsibility of one’s own health and low empowerment of individuals for self-care and self-education in health, with marked gendered differentials.
Measuring the level of sugar in blood of locals from Peresecina village, Orhei raion during a community mobilization seminar on diabetes organized by Healthy Life project. Photo taken by Diana Berari, community coordinator of Healthy Life project.
Moldova has become one of the poorest countries in Europe
The Republic of Moldova became independent in 1991 with the dissolution of the Soviet Union. After the collapse of the Soviet Union the rather small Moldovan economy was abruptly cut off from its traditional sales market. The effective secession of the Russian-speaking region Transnistria from the Republic of Moldova in 1992, where most of Moldovan industry was located, has further weakened Moldova's economy and lead to political instability. Since gaining independence, the formerly prosperous Soviet republic thus declined and became one of the poorest countries in Europe.
The country has become a parliamentary republic and has embarked on an ambitious economic reform and transition towards a market-oriented economy. Although the 2000s have improved the economic growth and in 2009 the economic growth was one of the highest in the European region, Moldova still faces significant economic challenges. These have been exacerbated in 2015 by a large-scale banking fraud that has impacted the economic and political stability and lead to further impoverishment and disenfranchisement of the population and acute financial crisis. According to the latest Public Opinion Barometer, only 18% are satisfied with their quality of life and 73% have incomes that barely cover or do not cover minimum living expenses.
Poverty has a negative impact of the health status of the population
As well as causing socio-economic hardship transition impacted the health status of the population negatively. Moldova is now facing a double epidemiological burden as rates of communicable diseases have increased since independence while non-communicable diseases, such as cardiovascular diseases and cancers, are also on the rise. Although in recent years life expectancy has regained its pre-independence level, it is still low relative to other countries of the European Region and mortality rates are higher for the working-age population.
Locals from Albota de Sus village, Taraclia raion learn how to measure correctly the blood pressure within a community mobilization seminar organized by Healthy Life project. Photo taken by Diana Berari, community coordinator of Healthy Life project.
Rural poverty and the related migration of large segments of the population remain central development issues in Moldova. For lack of income opportunities, over a million people have left Moldova to work abroad, leaving frequently children and the elderly behind thus exacerbating social difficulties.
The Moldovan Ministry of Health, Labour and Social Protection is actively leading large reforms of its public health, primary care and regionalization of the hospital care service to move towards a more family medicine-focused health systems where the role of narrow specialists is less emphasized, and to adapt the inherited Semashko system with its extensive infrastructure of sanitary-epidemiological stations to better respond to the rising challenge of NCDs.
The 2007 National Health Policy, the 2013 National Public Health Strategy and the 2012 National Strategy for the prevention and control of NCDs are the main policies establishing the strategic directions for public health actions. Based on these documents, more specific national programmes have been developed, addressing the main NCDs and risk factors (i.e. tobacco, alcohol, nutrition, diabetes, cancer and cardiovascular disease) as well as maintaining progress on communicable disease (i.e. immunization, HIV/AIDS, tuberculosis).
The new National Health Policy and the "Healthy Life Project" aim to involve the citizens
The Swiss Agency for Development and Cooperation supports the national reform agenda through the “Healthy Life Project”. Key focus areas of this support include strengthening primary health care, working more closely with the social sector, and more closely involving citizens in decisions related to their health, as well as building the capacities of local public authorities and district-level Public Health Councils to include health in all sectors and facilitate the understanding of each sector’s role in planning and implementing health promotion activities.
So far progress towards a more inter-sectoral way of working has been rather limited and there is still a very strong legacy of verticality and vertical programmes. It is further the case that Moldova has typically taken a top down approach to the roll out of reforms and strategies, with little participation encouraged on the part of citizens. However, also here reform is underway with the change-process at the National Agency for Public Health (NAPH) which is the central public health institution acting under the Ministry of Health, Labour and Social Protection. The mandate of the NACP is to respond to the public health status of the population, develop national guidelines, and provide methodological support to the public health service on disease prevention, health protection, health promotion and surveillance (WHO-Euro 2018).
The burden of NCDs
A household controlled survey was conducted by the Healthy Life Project in 2017 to assess the knowledge, attitude and practices (KAP) of the general population regarding selected non-communicable diseases (NCDs) and its associated risk factors, healthy lifestyle, citizens’ right to health and health care seeking. It had a particular focus on ischemic heart disease, hypertension and diabetes and its associated risk factors. The survey was conducted in 10 target and 10 control raions with 930 respondents (45% female; 55% male).The overwhelming majority of respondents (92.4%) had visited a primary health care facility (PHC) in the past; however, a great gender difference could be observed with many more female respondents having visited a PHC in the past 3 years compared to male. Also the pattern of accessing a PHC differed with gender, with the majority of women visiting a PHC for a preventive check-up (57.9% compared to 48.3% male) compared to men visiting a PHC due to illness (52% compared to 39.3% female).
A total of 34% had a confirmed diagnosis of hypertension with average blood pressure among the older age group of participants (45-69 years of age) being 139/87 mmHg, equaling results of the WHO STEPS survey (World Health Organization (WHO), Regional Office for Europe, 2014, p. 66) The survey participants reported of a confirmed diagnosis of diabetes of 15.3% and 16% were diagnosed with a cardiovascular disease (CVD). Overall, one third of respondents never had their blood sugar tested, with the majority of respondents considering themselves at risk for hypertension and CVD (46.9% and 44.8%), but less than one third perceiving to be at risk to develop diabetes (28.7%).
Risk factors to develop an NCDs include limited physical activity, dietary intake and overweight, tobacco and alcohol consumption, and low health literacy among others.
Understanding the importance of the body mass index in order to prevent/manage diabetes during a community mobilization seminar organised in Toderesti village, Ungheni raion by the Healthy Life Project. Photo taken by Diana Berari, community coordinator of the Healthy Life project.
The average of respondents was overweight (in line with the BMI classification). Tobacco consumption was high with over 50% of respondents currently smoking with great regional differences (81% in the North, 49.2% in the Centre and 31% in the South of the country). A total of 50% tried to quit smoking in the past, whereas only a small number were seeking advice from a health care provider. A total of 74% respondents consumed alcohol at least 1-3 times per week, whereas the great majority (67%) never tried to reduce their intake and 28% tried to do so. Only a quarter of respondents reported to eat vegetables and fruits five times per week, with more than half consuming fried food several times a week and 41.5% using salt several times per day. Overall, physical activity was low with less than 50% spending less than 60 minutes walking on a typical day and one third sitting for 3-8 hours. More than one third of respondents never received a dietary advice, and 70% of participants never received advice on alcohol or tobacco consumption by a health care provider. Overall more than 50% of participants with diabetes, CVD or hypertension state that their chronic condition prevented them from living a happy and active life.
Overall lack of knowledge, information and health literacy
Knowledge related to risk factors of diabetes was rather low with women knowing many more risk factors than male respondents and over one third could not name any early symptoms of diabetes. Almost one quarter of respondents could not name a single risk factor related to CVDs or early symptoms with 23% of male respondents not able to name any symptoms of CVDs. Complications caused by hypertension were well known with only 18.4% of respondents not able to name possible complications. Overall, knowledge related to risk factors of diabetes and CVD and complications related to hypertension was higher among women than men.
A high number of survey participants with diabetes (74%), as well as a high number of respondents with CVD (76%) had never received any related educational activities in regard to their disease. The great majority of survey respondents (68.3%) – independent of being diagnosed with diabetes or not - reported of a lack of information. Among respondents with hypertension, 38% perceived to have received enough information, whereas 56% did not so. Almost all participants (90.2%) indicated the wish to receive more information on hypertension.
Presentation by Ala Curteanu at the MMS Symposium 2018 © Network Medicus Mundi Switzerland
Overall the survey results show that prevalence of diagnosed diabetes, hypertension and CVD and related risk factors among respondents is high. Participants’ lack of knowledge related to risk factors and complications caused by the three focus NCDs is comparably low. Sharing of information related to NCDs by health care providers shows room for improvement. Overall, many respondents lack a healthy diet and physical activity and consumption of alcohol and tobacco is rather high and not necessarily perceived as unhealthy. Increasing the health literacy of the overall population as well as those directly affected from the three tracer NCDs through a variety of channels could have a positive impact on the lives of the people in the Republic of Moldova and could contribute in reducing morbidity and mortality in the country.
Evidence-based approaches: Health Profiles and Intersectoral Planning
Health profiles were initially introduced in Moldova by the World Health Organization in 2013. The Health Profile is the WHO-developed instrument (set of indicators) that allows to evaluate the health status of the population and the factors that determine it in terms of statistical indicators for monitoring the health status, socio-economic, well-being and the quality of the environmental factors, to elaborate proposals and recommendations for situation recovery, rising awareness for Local Public Authorities, decision makers, as well as for public opinion in the specific region. The national ”Guide on health profiles development” was approved by the Ministry of Health and includes: the description of the district (rayon); demographic and socio-economical context; population health status; risk factors and health promotion; life and work environment; infrastructure of health services. Each domain has specific indicators to be collected, analyzed and monitored. The Healthy Life Project organized the revision of the national experience on health profiles and supported developing the list of the 42 indicators and data base for the health profiles indicators spesific for non-communicable diseases for the period of 2013-2017. When the information generated is presented in a user-friendly way and tailored to the core interests and objectives of other sectors it is an excellent tool for dissecting the socio-economic determinants of poor health and harnessing the engagement of different sectors in addressing them.
This tool improves the link between local authorities’ institutions and services, motivate inter-institutional and intersectoral cooperation. This helps local public authorities on creating the common community values, empower the community by identifying their needs for health; improve efficient planning and use of limited resources; ensure transparency in decision-making; synchronize the decisions of the authorities and the expectations of the citizens; strengthen the partnerships and cooperation between different community representatives; stimulate community participation in development and decision-making process; enhance the skills and legitimacy of local government authorities.
Capacity building, health promotion - learning how to plan successfully a project on health promotion during a workshop organised by Healthy Life project. Photo taken by Cristina David, communication specialist of the project.
Representatives of the health, social and education sectors, as well as the district administration, police force and church are supported to jointly examine the health profile of their district, to extrapolate the health profile data to their own locality, and to then establish community-based teams like Territorial Public Health Councils and local group of interest to raise awareness of NCD risk and increases diagnosis and care-seeking.
The training module on health planning and intersectoral collaboration for the promotion of healthy lifestyles was developed and piloted by the School of Management in Public Health. The course was then rolled out – building leadership capacity of the Local Public Administrations (LPA) and Multidisciplinary Teams in health promotion and behavior change. The seminars aimed on improving the capacity of the local intersectoral teams on the identification of the key stakeholders involved in public health actions, their understanding of the process, using of health profiles for community health development, especially for health planning, as well as integration in local and regional health promotion plans.
Once established, community teams- often under the leadership of local mayors- pool scarce, but nonetheless available, resources from their various sectors to help change unhealthy lifestyle and behaviours. Examples include the initiation of sports events; involving teenagers as champions of a healthy lifestyle; engaging priests in the promotion of a simple local diet and moderate alcohol consumption; as well as the creation of platforms where people suffering from chronic diseases can exchange with the general public about danger signs and the importance of screening, medicine adherence and of following any advised behavior change.
The high level of interest for LPA training courses among participants on the one hand and the low level of knowledge of public health issues among representatives of non-medical sectors, on the other hand, reveals the need for a better synchronization of educational efforts with the decision factors at national and district level, as well as identifying optimal ways of involving the non-health sectors in primary and continuing education in this field.
While the Raion Public Health Councils are established and functioning, there is a need to broaden the understanding of the mandate and capacities of this structure at the raion level as well as to strengthen its role in disease prevention, health promotion, governance and communication for public health.
The institutionalization of health profiles is challenging within the ongoing reform of the public health sector, when the number of employees was reduced and their analytical skills to analyze data is low. The process of data collection from other sectors, beside the health sector (education, social, etc.) is long and time consuming. Even though there are responsible persons it is still difficult to manage the process of data collection, analyzing, interpreting of the Health Profiles indicators.
Lessons learnt include that it is critical to first understand what each sector is actually tasked to do in the community, and then in a next step to think through how they can promote health through routine activities that they would anyway carry out. This avoids activities only taking place on an ad hoc basis, or when additional funding can be mobilized, but facilitates that they occur regularly and ultimately start to become institutionalized.
WHO-Euro 2018 Organization and financing of public health services in Europe: Country report Moldova http://www.euro.who.int/en/publications/abstracts/organization-and-financing-of-public-health-services-in-europe-2018
Ala Curteanu, SDC Healthy Life Project, Republic of Moldova. Ala Curteanu is a Medical Doctor with a specialisation in paediatrics and neonatology and with a rich experience in public health and scientific research, as well as in project management, including senior project management positions for national institutions, bilateral cooperation and multilateral organizations, such as the UN. In the period 2006-2014 she was the manager of the “Modernising Perinatal care in Moldova” project implemented by the Swiss TPH Institute. Currently she leads the Project Facilitation Unit of the „Healthy Life. Reducing the burden of noncommunicable diseases“ Project (2016-2020) implemented by the SwissTPH. Email
Constantin Rimis, SDC Healthy Life Project, Republic of Moldova; Oleg Lozan, School of Management in Public Health, Chisinau; Diana Berari, SDC Healthy Life Project, Republic of Moldova; Leah F. Bohle, Swiss TPH; Florence Sécula, Swiss TPH; Helen Prytherch, Swiss TPH.