Designing integrated care services in the Republic of Moldova – experiences of the Healthy Life Project

Abstract

Driven by the increase of non-communicable diseases (NCDs) worldwide, WHO has launched its Global Framework for Integrated People centred Health Services (IPCHS) during the 2016 World Health Assembly [1]. This approach combines the horizontal integration of health, social and community services centred around people’s needs with the vertical organization of a specialized referral system with the aim to improve the quality of live for patients suffering from chronic disease – as well as for the people who take care of them. Health promotion and NCD risk reduction play an important role in this approach. The Republic of Moldova supported by the Swiss Cooperation Office (SCO) through the Healthy Life Project, is working to decentralize and integrate the management of NCDs; to improve the quality of integrated services; to reduce NCD risk and to strengthen peoples’ health-seeking behavior. Initial data show that there are significant gaps in terms service quality, such as insufficient medical equipment (24% in health centres (HC) and 37% in family doctors’ offices (FDO)) and particularly for medical supplies (44% HC and 75% FDO) [2]. There are some weaknesses in clinical consultations but clinical history taking and recording was quite common. Health promotion activities are limited, particularly in FDOs with more than a third (37.5%) not having a plan or training staff to carry out respective activities. The Healthy Life Project combines risk reduction and demand side interventions (health promotion, risk reduction and improved health-seeking behavior), with improved targeting of provider services (community nursing, care-taker support, better self-management, improvement of quality of care, service integration, people-centred planning of health interventions). Integrating people centred services means amongst others to be highly familiar with peoples’ needs (both patients and care-providers), to plan and evaluate services in a participatory manner; prioritize targeted interventions; provide high quality services and foster partnering amongst and across service providers, patients, care-takers and communities in the wider sense. Community nursing plays a key role in integrated care systems by forming the interface between community and people’s needs, coordinating and informing service providers, participatory services planning for patients in need (case-management) and helping patients and care-takers to self-manage their conditions. The Healthy Life project supports the development of a consistent community nursing concept and helps build staff capacity with regards to integrated care. Local authorities play a key role in prioritizing the health of their people and mobilizing expertise to reduce public health risk factors and establish healthy communities. Linking health, social and complementary services (e.g. palliative care, physical and social mobilization of chronically ill) in one planning framework improves responsiveness of services to people’s needs (e.g. case management). The project supports the development of health and service profiles to identify priorities and needs in terms of information gasps, areas to promote health, but also the identification of relevant services at community and rayon levels, which will lead to health action plans guiding priority activities. With regards to quality of care, basic equipment that is needed to implement the key clinical protocols at PHC level will be provided to the pilot rayon’s. This will be accompanied by capacity building measures and the introduction of peer exchanges as well as facility-based continuous quality improvement “projects”. Capacity building on updated NCD guidelines (e.g. WHO PEN protocols are another important pillar towards quality of care. The 2017 quality of care study shows that up to 28% of primary care facilities have not received any training on relevant guidelines during the last year with a clear geographic disadvantage of the north of the country. Main focus is to provide comprehensive services for the management of NCDs and to reduce the likelihood of unnecessary hospitalization [3]. The Viatasan project supports the newly created National Agency for Public Health and its substructures by building expertise in health promotion and risk reduction activities at national and rayon levels. This expertise will strengthen intersectoral planning (e.g. with health, social, community and other relevant services and together with people’s representatives), coordination and implementation capacity of Rayon Health Councils based on jointly developed health action plans. Jointly with the National Agency for Public Health highly practical and skills based training activities in health promotion will be conducted to enable rayon and community level actors to plan, implement and evaluate their own health promotion activities. Community interventions such as local health promotion activities, interventions towards the development of “healthy communities” are also supported in form of small projects. The Healthy Life Project supports the Moldovan Government to strengthen its primary care services to cope with the increasing burden of NCDs. Using the conceptual framework of “Integrated People centred Health Services (IPCHS)” promoted by WHO it facilitates the reform of services, and the empowerment of patients, care-takers, families and communities to be knowledgeable about health risk and individual risk behavior in order to form a care partnership, with the aim of improving quality of life. Local authorities play a strong role to organize and provide coordinate platforms for interventions from health, social and complementary services and create healthy communities. The primary health team in health centers and family doctor’s offices are the health experts to manage NCDs, reduce the likelihood of hospitalization and coordinate expert services around patient’s needs following a more patient centred and less professional group centred approach.