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Description
Official health statistics show that the Romanian health system is still facing important challenges with some of the worst indicators across the European Union. These figures include a particular mix of morbidity and mortality indicators that are on one hand specific to developed countries such as high mortality by chronic diseases, and on the other hand, indicators specific to developing countries including the resurgence of infectious diseases like tuberculosis and sexually transmissible diseases and lack of basic medical services such as primary and community care especially in rural and remote areas. The National Health Strategy 2014-2020 propose measures to reverse the pyramid of services and to gradually ensure wider coverage of the population health needs through the services at the foundation of the system. The Strategy particularly focuses on strengthening community care, primary care, and specialized ambulatory care.
The project is aiming to strengthen primary healthcare (including community care) in order to bring the health services, close to the people in need, the especially vulnerable population living in rural areas. This way, the project will try to reach, as much as possible, the general goal of obtaining universal access to healthcare and reducing the social inequalities in health with emphasis on the health status of vulnerable population (including the Roma population). The project in implemented by the National Institute of Public Health in partnership with the Norwegian Institute of Public Health, the Norwegian Directorate of Health, the National Institute for Maternal and Child Health “Alessandrescu-Rusescu” and the World Health Organization. The project will explore the best practices and knowledge of the Norway partners in order to be adjusted for Romania. This collaboration will contribute to programme objective on bilateral relations to strengthen and extending the collaboration between Beneficiary State and Norway.
Summary of project results
The main goal of the National Health Strategy adopted in January 2015 was the socio-economic inclusion of the Roma ethnic group, to reach a level similar to that of the general population and to ensure equal opportunities by initiating and implementing policies and programs in areas such as: education, vocational training and employment, health, housing and small infrastructure, culture, social infrastructure, prevention and combating discrimination. The strategy also aims to involve central and local public authorities, Roma representatives and civil society in activities aimed at increasing the socio-economic inclusion of the Roma population.
The PDP1 project aimed to improve equitable access to Primary Health Care (PHC) services by integrating the services provided, with a special focus on health promotion and preventive services
Based on the guidelines and priority areas set out in the National Health Strategy, Regional Health Service Plans were prepared in 2016 for the eight regions of the country.
Official health statistics show that the Romanian health system still faces significant challenges with some of the worst indicators in the EU. These figures include a particular mix of morbidity and mortality indicators, which are on the one hand specific to developed countries such as high mortality from chronic diseases and on the other hand specific to developing countries including the resurgence of infectious diseases such as tuberculosis and sexually transmitted diseases and the lack of basic health services such as primary and community care, especially in rural and remote areas.
Life expectancy at birth, a composite indicator showing the quality of life of the population, although it has had a positive trend in recent decades, both for men (from 65.7 in 1994 to 72.2 in 2014) and for women (from 73.3 in 1994 to 79.2 in 2014), is still lower than the European Region average (72.2 years compared to 80.9 years EU27 in 2014). Life expectancy at birth is higher in urban than rural areas in Romania, with significant differences between Romanian regions in terms of the amplitude of the urban/rural gap.
Infant mortality has also shown a decreasing trend in the last decade, reaching a low of 8.3 deaths per 1000 live births in 2014, mainly due to the decrease in post-neonatal mortality, but it remains the highest rate among EU27 countries and 2.3‰ higher than the EU average (3.7‰ in 2014). The risk of death is higher in rural compared to urban areas and varies widely between counties. A significant proportion of deaths under one year of age occur at home.
The burden of disease in Romania has evolved from a pattern dominated by maternal and child health and communicable diseases to one in which chronic and non-communicable diseases dominate. Cardiovascular diseases and cancer are the most frequently recorded causes of death. Infectious diseases account for only 1% of deaths.
As highlighted in the National Health Strategy 2014-2020, the capacity of the health information system to collect, process, analyze and report health data is currently limited, thus requiring special studies and consequently funding sources to collect and analyze morbidity data or data related to health behaviors. Special studies are also needed to collect data related to ethnicity. For example, reliable data related to health status and determinants is currently very low for the Roma population. There are no official statistics on the health status of the Roma population, so the indicators reported by various international or national organizations represent only estimates.
The project will support increased access to health services in 7 counties through health promotion and integrated prevention services (such as community centers). The project will develop a model of good practice for community health care, improving access to health services (especially prevention and health promotion) for the population in vulnerable communities. The project will develop models of integrated community centers, which will subsequently be replicated and implemented under the Small Grants Scheme No. 1 in counties other than the 7 counties initially covered by the project.
The project results were obtained through the following activities:
A1 - European Health Examination Survey (EHES).
The European Health Examination Survey (EHES) was conducted by examining the health status of the population using the methodology applied at the European Union level at the national level. The study included 2 large age groups: adults and children.
PP and P1 designed a representative sample for children and translated the existing documents. An initial training for interviewers was carried out. External experts supported the project team in choosing between different options for organizing the study, as well as in developing procurement documents. A database was created, this data was validated and the data was analyzed, based on which the two surveys were developed and printed. The main users of these documents are clinicians, public health specialists and local and high-level decision-makers.
A2 - Community Health Needs Assessment & County Health Profile
This activity was carried out with internal and external experts who developed the study methodology, collected data from the territory, developed and printed the research study Community Health Needs Assessment. The application for the local health profile was developed and training for the use of this application was also provided, data collection and analysis was carried out in the selected pilot county, and a database with indicators related to the health profile of the UAT in the selected county was created.
A3 - Feasibility study for the creation of the cause of death registry
In this activity, the methodology for the feasibility stage of the death registration model was developed, a working visit to Norway was organized, and dissemination workshops were organized for network coordinators from all 42 DSPs. The activity was completed by piloting the research study for the cause of death registration model in one county and producing the study report, as planned. Two training courses on the coding of causes of death were also developed for doctors and for the staff from the public health departments responsible for coding, as planned.
A4 - Development of an integrated model of community-based services
For this activity, 5 case studies were developed: Romania, Norway, Slovenia, Hungary and the Netherlands uploaded to the project website. There were numerous online meetings with international partners, exchanges of experience with visits to Norway and Romania together with WHO partners, workshops based on which guides were developed and printed on community care, mother and child, monitoring and prevention of communicable diseases.
A5 - Tools for family doctors development/adjustment/updating of existing guidelines – 3 clinical prevention guidelines for maternal and child health were developed and printed, Clinical prevention guidelines for family doctors
A6 - Development of curricula, educational and training materials (textbooks, guidance, e-learning sessions) as part of the YSRHL model
A Prevention Guide on Reproductive Health in Young People was developed, printed and distributed, which was also posted on the website https://www.insmc.ro/publicatii-pentru specialisti/ghiduri/
A7 - Development/updating of the existing clinical prevention guide and tools with new modules, extension of the guide and PREVENT IT
The Prevent IT solution was modernized with new modules and licensed on all its users'' platforms. Compatibility with all IT applications of the family doctors participating in the project was ensured. The extended IT solution was piloted and the appropriate adjustments were made.
A8 - Development of tools for monitoring community health care services
The following documents were printed and distributed in the 7 project counties: 1. Community Care Manual in 1000 copies, 2. Standardized registration forms in 4020 copies
A9 - Developing a methodology for evaluating the impact of health education campaigns promoting health in communities and schools
Romanian experts with the support of colleagues from the Norwegian Institute of Public Health and the Norwegian Directorate of Health have developed a methodology for evaluating the impact of health education campaigns promoting health in communities and schools.
A10 - Development of a training curriculum to improve the skills of community school nurses on an e-learning platform
Training curricula were developed and uploaded to the e-learning platform under the School Nurses section https://e-learning-pdp1.insp.gov.ro/categorie-curs/asistenti-medicali-scolari/ . The manual was uploaded to the project website and printed in 500 copies
A11 - Design and implementation of materials for adult health promotion campaigns at national level
2 adult health promotion campaigns were carried out using the produced videos. 25005 adult beneficiaries were reached.
A12 - Design and implementation at national level of health promotion campaigns for maternal and child health
The “Healthy Choices” Manual was translated.
A13 - Tools for volunteer educators
During this activity, the manual for volunteers and educational materials were developed, a training course for trainers was held for DSP staff, a training curriculum was developed, and a volunteer training course was organized. A health promotion campaign “Prevention of teenage pregnancy” was organized, 480 posters “I PROTECT MYSELF - I CHOOSE RESPONSIBLY” were produced and distributed.
A14 - Training for professionals from County Public Health Directorates and Public Authorities
3 training sessions were organized for professionals from public health departments and at the central level.
Visits were organized to Oslo in Norway for the mayors of the 7 beneficiary counties
A15 - Community team development: training for family doctors
Clinical prevention guidelines were developed and 100 family doctors enrolled.
A16 - Community team development: training for community nurses and midwives employed in the community healthcare network
Course curricula were developed and training sessions were organized for community nurses on the use of the AMCMSR.GOV.RO application.
A17 - Community team development: training for health mediators
Course curricula were developed for regional courses and training sessions were held. A visit of community teams to Oslo was also held.
A18 - Training for Central Authorities
A training session was held for people from central authorities, a study visit to Spain took place and a national workshop was organized.
A19 - Training for the Youth Sexual and Reproductive Health Learning Model (YSRHL)
For this activity, servers were purchased for the development of the e-learning platform https://elearning.insmc.ro/ where the courses were held. Course support materials were developed.
A20 - Comparative study of payment models for preventive services in Europe
Case studies were conducted and a report was developed in electronic format https://proiect-pdp1.insp.gov.ro/wp-content/uploads/2024/05/Review-of-payment.pdf
A21 - Development and adoption of standards for the establishment of school clinics
The proposal for minimum standards for the operation of school clinics was developed and submitted to the Ministry of Health.
A22 - Proposal to improve and consolidate preventive activities in the Framework Contract of the National Health Insurance House and the Ministry of Health
A proposal was made to amend the terms of the Framework Contract regarding preventive consultation at the level of primary health care - family medicine.
A23 - IT PREVENT solution and clinical guides implemented in 100 family doctor''s offices
100 new MF offices enrolled in the project, which received purchased and distributed medical equipment and kits. Integrated preventive consultations were carried out at the level of all family doctor''s offices in the project. A total of 9000 integrated preventive consultations were carried out using the IT Prevent solution, of which 4878 consultations for adults and 4122 consultations for children. A final report was prepared to evaluate the implementation of the recommendations of the clinical prevention guide in family medicine through the audit method.
A24 - Creation of functional structures in schools, according to the existing regulations, in 7 counties
Equipment was purchased and distributed to 45 localities of the project.
A25 - Building capacity for monitoring and evaluation activities at the community level
Community teams were developed in 84 localities from the 7 beneficiary counties in the project. https://proiect-pdp1.insp.gov.ro/wp-content/uploads/2024/03/Raport-vizite-ME.pdf
A26 - Identifying incentives to motivate participation in screening programs
Case studies of good practices were carried out to identify incentives to motivate population participation in screening programs.
A27 – Advertising
The promotion and advertising of the project were carried out by holding a launch conference and a project closing conference, developing visual identification graphics and promotional materials, creating banners, brochures, flyers, posters, roll-ups in electronic format, creating a website, a Facebook page, and holding a conference to disseminate results.
Through the actions carried out, the project contributed to improving policies and services for disease prevention by developing primary care and community health care services, respectively to developing integrated community centers by improving existing ones and to strengthening evidence-based policies at all levels of health care, including assessing the health needs of the population and establishing a registry of causes of death.
The European Health Examination Survey (EHES) was conducted, an active assessment obtained by examining the health status of the population using the methodology applied at the national level at the European Union level. The results allow for the correct assessment of the health needs and services of the population, fundamental in the subsequent design of the system, based on evidence and comparable with the values from other European countries, provide quantitative information on the prevalence of major risk factors, especially for non-communicable diseases in Romania and can predict the real needs for health services for the insured and uninsured population, implicitly and a solid basis for the better financial allocation of limited resources. The study included 2 large age groups: adults (based on the EU methodology) and children (adapting the EU methodology for adults).
The feasibility study was carried out, based on which the cause of death registry was developed.
An integrated model of community-level services was developed by developing Guidance Tools for Primary Health Care, prevention guides for prenatal care, rickets, iron deficiency anemia, curricula, educational and training materials through e-learning, development/updating of the existing clinical prevention guide and tools with new modules, expansion of the PREVENT IT guide and application.
Also, community health care monitoring tools were developed to increase the quality of community health care services provided to vulnerable populations, the community team (nurse and health mediator), standardized registration forms for places where IT equipment and software are not yet available, methodologies for assessing the impact of health education and health promotion campaigns in communities and schools, and training curricula to improve the skills of community health nurses who will work in schools on an e-learning platform.
For information and publicity, materials for health promotion campaigns for adults, for maternal and child health were developed and implemented at national level.
Volunteers were trained to participate in community-based health promotion campaigns. For this purpose, a manual and educational materials were developed and printed for volunteers who carried out health promotion campaigns in each of the 84 beneficiary communities together with community teams.
Family doctors from the communities selected in the project received training on the implementation of the modernized model of preventive services for adults and children, the guides and tools, as well as the process of joining the PREVENT network.
Also, trainings were organized on the use of the online application AMCMSR.GOV.RO developed by the Ministry of Health, computer skills, team development and communication skills, first aid for community nurses, midwives and health mediators.
Trainings were held to be better informed and become more aware of the importance of community care activities, for participants from central authorities from the Ministry of Health, the Ministry of Labor and Social Justice, the Ministry of Education, the National Health Insurance House, etc.
Regarding the sexual and reproductive health of young people (e.g. contraception, sexually transmitted diseases, HIV/AIDS, family planning, gender issues), training materials were developed and uploaded to the e-learning platform, which were accessed by 500 users among school doctors, family doctors, community nurses.
Standards were developed for the establishment of school health clinics.
Case studies with good practices from other countries were conducted in order to identify incentives to motivate the population to participate in screening programs.