Integrated community health in Romania Putting local authorities in the driving seat

1. Integrated community health in Romania Putting local authorities in the driving seat NicusorFota, CRED Foundation Manfred Zahorka, Swiss TPH

2. Background More than 20 years after the communist period and major reforms in the health care system, Romania still has (figures from 2012) • The highest infant mortality within the EU (9,0‰) – with considerably higher rates in rural versus urban environments (11,8‰ vs 7,7‰); • 7% of the pregnant women don’t consult a doctor before delivery and 23% do not more than 1-3 antenatal consultations during pregnancy; • Romania is amongst the countries with the highest burden of disease figures for ischemic heart disease and stroke in the EU.

3. Contributing factors: Limitations in health seeking behaviour vs. low access to care • Low level of mothers’ education: 25% of mothers of deceased infants were illiterate or maximum elementary school; • Contextual factors, such as economic crisis and high opportunity costs in rural areas limits access to health and social services; • Health insurance coverage is widely available, but 10% - 15% of the population is not insured or is not registered with a GP; • Capacity to manage chronic health conditions limited at community level (quantity and availability, type of available services, quality).

4. Systems response • Well-developed network of family physician cabinets, but still limited access to care particularly in rural areas and for marginalized groups; • Community nurses for outreach services are available only in few communities: 1 community nurse for 10’000 rural population on a national average; • Current working patterns of health and social extension workers are oriented towards sectorial policies and there is little collaboration and coordination of services at the community level; • Decentralization of services leaves local governments with new responsibilities but low managerial capacity; • But: New opportunities for community services in the Romanian National Strategy for Health 2014-2020.

5. The “Widening Access to Health and Social Services” program The Romanian and Swiss Governments jointly fund the development and dissemination of sustainable models for better integrated health and social services in rural areas of Romania through: • developing functional, integrated and locally managed models for different types of contexts; • increasing access to health care through close collaboration between health, social and other services available at community level; • putting local authorities in the driving seat to develop and implement local solutions to local health and social problems.

6. Intervention • Integrated care conference in Bucharest to share experience; • Build capacity with local authorities; • Use a health rather than a care based approach; • Strengthen collaboration between medical and social services; • Bring community actors together, strengthen the collaboration, and integrate available experiences.

7. Beneficiaries • Population of rural communities and small towns with low development indicators, vulnerable groups, people living below the poverty threshold; • Local actors through capacity building and management support; • Regional and national government through the development of evidence based interventions for dissemination to other interested communities.

8. Approach • Strengthen the capacity of local authorities (and partners) to create social protection plans based on population needs, develop project proposals for funding, implement and evaluate interventions; • Identify best proposals amongst the ones submitted by training participants; • Funding pilot community health projects interventions based on proposals developed and managed by local actors; • Establish a coaching system to provide guidance to the local authorities in the process of implementation; • Follow up intervention with operations research to document evidence; • Capitalization, dissemination and scale up measures/projects.

9. Expected outcomes • Disadvantaged groups have better access to and make equal use of health services at community level; • Models for integrated health and social services for disadvantaged groups are available and are utilized at local levels; • Local authorities are empowered to conceptualize, 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 indicators.

10. Training Program for local authorities • Module I : The legal framework regarding social and medical services and institutional capacity building at local level; • Module II: Project development. Strategic analysis. Operational planning (I); • Module III: Operational planning (II): Project team. Project budget plan. Project monitoring and evaluation plan.

11. Outcomesand Highlights • 61 participants from three districts and 18 communities ; mayors, vice-mayors, community nurses, community social workers; • The training activities are built in a modular way so that learning of methods is mixed with on-site application and continuous peer review mechanisms; • Coaching activities during on-site application ascertains translation of concepts into technical proposals; • The local focus moves communities away from “one-size-fits-all” mechanisms supported through vertical interventions to more client oriented, needs based policies and interventions with local authorities having a much stronger leadership role. • Current focus of participants is on social inclusion for the elderly as well as women and children,

12. Lessons Learnt: • Decentralization of services has increased managerial responsibilities for local authorities without imbedding new responsibilities into administrative structures  some capacity building for organizational development might be needed; • improving communication and information sharing of social and health extension workers is essential to provide effective outreach services for vulnerable groups  team building and tools for better cooperation; • the role of family physicians needs to be strengthened to improve community outreach services  collaboration with local stakeholders.

13. Next steps - Roadmap • Completion of the capacity building program with local authorities; • Conduct a baseline survey within the participating and control communities; • Identify winning proposals and conclude implementation contracts; • Support local project implementation through coaching, peer exchange and peer review mechanisms; • Accompany implementation with operations research; • Identify effective interventions and disseminate.

14. Acknowledgements • We would like to acknowledge the support of the Swiss-Romanian Cooperation Programme to Reduce Economic and Social Disparities within the Enlarged European Union with its Thematic Health Fund out of which this program is funded. • We acknowledge the contributions of the various stakeholders to this program in particular the Romanian Ministry of Health and the Swiss Contribution office in Bucharest.

15. Thankyouverymuchforyourattention