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Description
To increase the access of uninsured vulnerable persons to evidence-based preventive services - from small urban and isolated rural areas in Arad counties (Mișca, Apateu communities), Brașov (Rupea, Homorod, Bunești and Ticuș localities) and Caraș-Severin ( Slatina-Timiș and Armeniș localities), communities with a population of about 18,000 inhabitants, of which a relatively large percentage of the Roma population (about 10%).
Summary of project results
The project aimed to increase access of vulnerable populations to evidence based preventive medical services.
Romania is among the European countries with low healthy life expectancy, a situation largely attributed to the lack of prevention policies, particularly in the area of primary prevention for non-communicable diseases. This gap in prevention policies stems from deficiencies at multiple levels: lack of up-to-date knowledge, including evidence-based clinical guidelines to support prevention policies; insufficient training capacity for primary healthcare teams; limited information platforms for both medical professionals and the general population; slow integration of prevention policies into the national health agenda; absence of a prevention culture at the population level.
The project builds on previous national experiences, such as the RO19.04 project, during which CNSMF and its partners developed an evidence-based primary prevention model between 2014 and 2017. This initiative resulted in the creation of the 2016 Prevention Guide, a primary prevention module incorporated into a practice software, and an implementation network comprising 100 practices, with 250 family doctors and nurses trained through the project. However, the activities initiated under the RO19.04 project have not received adequate funding over the past five years since the project''s conclusion. Recognizing this gap, the current project has identified the need to address two key priorities: first, to review and update the clinical prevention guidelines, and second, to focus on identifying appropriate and incentive-based mechanisms for reimbursing prevention services provided in family medicine offices, while also monitoring the quality and population impact of these services. The underlying assumption is that these measures will encourage the provision of integrated primary preventive services, ensure a more equitable offering of prevention services, and identify the most effective ways to enhance access to these services for vulnerable populations.
The project strategy was built around the involvement of the CNSMF, the only organization of family doctors in Romania with key expertise in defining evidence-based recommendations and clinical guidelines using internationally agreed methodologies. This core competence was complemented by the expertise of two local grassroots civic organizations, the Public Health Directorate in Arad County, and, last but not least, Professor Nanna Lien from the University of Oslo, Institute of Basic Medical Sciences.
To define the systems approach of the project strategy, the project team consulted with the relevant target groups, aiming to reach a very sound understanding of the journey. This included: vulnerable persons; the frontline medical professionals (and their frustrations and desires to improve the professional support offered); the decision makers at different levels (local/ county / national) – needing support in shaping possible prevention policies, strategies and tools and as last but not least, political decision-makers interested in the effectiveness of public policies (i.e. health prevention policies), meaning positive effects on the health of the population.
The proposed project addressed the Priority Sector: Social Inclusion, Youth Employment, and Poverty Reduction, aligning with the objective of the European Public Health Challenges Program Area and its Support Areas: Prevention of Non-Communicable Diseases, Universal Access to Health Services, and Strengthening Primary Health Services at the health systems level.
The project was also relevant to the health policies of the Romanian state, particularly the National Health Strategy 2014–2020, as it promoted evidence-based prevention services to be implemented at the primary healthcare and community levels.
Furthermore, the project was highly relevant to the needs of its final beneficiaries—vulnerable populations, such as individuals from rural or remote areas, those living in isolated settlements, or areas where homes are located far from health infrastructure and services, as well as Roma communities in these remote regions. The project met these needs by offering evidence-based prevention services, including risk assessment through Point of Care Testing (POCT)—which eliminates the need for beneficiaries to travel to urban areas or pay for private laboratory services—and counseling services.
The project also addressed the critical need for developing prevention services at the primary healthcare (PHC) level. These services, implemented at a level that has been historically underfunded and underdeveloped in Romania, are essential for increasing both the equity and effectiveness of the health system as a whole.
The project updated the Clinical Prevention Guideline for Children following a systematic review of international literature. This included incorporating updated recommendations based on newly published guidelines and systematic reviews, as well as formulating new clinical recommendations, such as those addressing prematurity. The revised guideline was finalized in the summer of 2023, edited, and uploaded to the project website. A dissemination work plan was developed to promote the updated guideline, including its publication in electronic format.
In parallel, efforts were made to integrate the updated guidelines into the Prevent Tool, a software used by family doctors. This process involved organizing numerous consultations with family doctors to identify and correct errors still present in the software and ensure its alignment with the updated guidelines.
Another significant project activity was the reorganization of the CNSMF educational platform for doctors. This involved drafting a work plan, initiating and completing updates to the platform. In plus, a new educational platform for nurses was developed. Preparations included identifying and listing the necessary tools to be procured for implementation.
Lastly, an information platform for educating the population, the INFO Prevent Platform, was conceptualized. This involved thorough documentation, planning discussions, and defining the required tools for implementation. Volunteer experts were recruited to develop the IT platform, contributing to the realization of this initiative aimed at increasing public awareness and education on preventive healthcare.
Preparation for the trainings delivered to PHC professionals involved the development of a comprehensive training curriculum, creation of training materials, and completion of accreditation procedures. The key activities included: 1. Developing a National Curriculum for integrated prevention services covering all age groups (children and adults). 2. Creating Training Materials focused on child prevention, tailored to different age categories. These included EMCD-type courses hosted on the educational platform for doctors, as part of the accreditation application submitted to the Romanian College of Physicians (CMR). 3. Implementing Accreditation Procedures for distance medical education (EMCD) trainings at the Romanian College of Physicians. This involved submitting the required documentation in collaboration with Transylvania University of Brașov.
As a result of the accreditation process, the basic training course for family doctors and medical assistants from pilot and neighboring localities was organized on July 22, 2023. The training, delivered online, had 19 participants, in addition to project team members.
Follow-up specialized training courses were conducted on August 7, further enhancing the capacity of healthcare professionals to deliver integrated prevention services.
The project successfully facilitated the procurement of seven point-of-care medical prevention kits, each equipped with a digital EKG, an ambulatory blood pressure monitor (ABPM), a pulse oximeter, a fetal Doppler, a tester and tests for a complete blood lipid profile (including HDL, total cholesterol, and triglycerides), a glucometer with tests for serum glucose, and urinary tests. These kits were distributed to the seven selected primary healthcare (PHC) teams to enhance their capacity for providing preventive services.
Community outreach activities were implemented in the pilot communities using a methodology designed to engage vulnerable populations effectively. These activities included drafting, discussing, and finalizing communication plans tailored to each community, meeting with key stakeholders such as former mayors of the target localities, and organizing community meetings in Slatina-Timiș, Vânători, and Ucea. Furthermore, visits were conducted to rural communities such as Viscri and Ticuș/Ucea in Brașov County. Additionally, a meeting was held with the Arad District Health Authority team and the regional coordinator from the partner DSP Arad.
A significant milestone of the project was the negotiation, definition, and signing of inter-organizational partnerships with local authorities and other key stakeholders. These partnerships were followed up by the provision of preventive services in the communities and laid the groundwork for engaging residents from remote rural communities in preventive healthcare services on the long run. The services were delivered in two stages: the first stage consisted of an initial consultation to assess disease risks, while the second stage involved counseling sessions aimed at mitigating identified risks.
As a result, 550 individuals received preventive services and counseling, including 120 individuals of Roma ethnicity, highlighting the project''s focus on reaching vulnerable and underserved populations.
Work on defining the Strategy for Monitoring the implementation and ongoing review of clinical guidelines was conducted with the support of the Norwegian partner from Oslo University. This activity included defining the interactions between the experts involved in this task and those working on related activities (e.g., A3, A7), establishing a work and meeting schedule, organizing bimonthly online meetings, and coordinating the visit of the Norwegian expert to Romania from December 13-15, 2023. The visit was highlighted by the presentation of the synthesis of the monitoring strategy and its recommendations at the Conference for the Dissemination of Project Results in Bucharest.
Activity 7 was comprehensive, encompassing research, communication, and advocacy. It involved high levels of interaction and collaboration among the experts working on this component, including meetings, data collection from the provision of preventive services, data analysis, and the preparation of a detailed report.
This policy advocacy activity focused on developing tools to ensure the sustainable implementation and potential adoption of preventive services as formal prevention policies. The specific tools developed include: 1. A cost analysis document for preventive services. 2. County-level action plans for primary prevention, which outline institutional responsibilities at the county level for implementing preventive services at the community and PHC levels. 3. The dissemination of this county-level model for prevention action plans by the DSP Arad partner to over 60 institutions and organizations. 4. The development of two contract proposals to facilitate the continued provision of preventive services for vulnerable groups at the community level. 5. The drafting of a Position Paper on Prevention, disseminated by the DSP Arad partner to over 60 organizations.
The dissemination of project results was further supported through the promotion of project activities and outcomes on the project’s Facebook page and website, which included the collection of photos, preparation of texts, and sharing of design ideas. Additionally, the End-of-Project Conference was organized to promote and advocate for the emerging public policy recommendations identified during project implementation.
The End-of-Project Conference took place on December 14, 2023, with the support of the Embassy of Belgium in Bucharest, which hosted the event. The conference benefited from the participation of prominent representatives, including The Romanian Presidency, The Embassy of Belgium and H.E. the Ambassador of the Kingdom of Belgium to Romania, The Ministry of Health (MoH), including the Executive Director of the Program Implementation Unit and grant monitor, The Ministry of Finance, The Director for Contracting within the National Health Insurance House (NHIH), Representatives from WHO and UNICEF, including the Health Specialist of UNICEF, The Vice-President of the Romanian College of Physicians, The President of the Order of Nurses and Midwives from Romania, DSP Arad, Health journalists, including representatives from Radio Romania Actualități, the project promoter and other project partners. Although the Norwegian Embassy was also invited, it was unable to attend due to multiple commitments during that period. This activity was instrumental in promoting the project''s results and advocating for the integration of preventive services into public health policy.
Project outcomes are:
1. Improved Access to Updated Evidence-Based Information on Prevention Services
The project increased access for both the general population and medical professionals to updated, evidence-based information on prevention services through the following resources:
- The Prevention Guideline for Children https://cnsmf.ro/download/ghid-preventie-copil_vol-6-2023.pdf
- The education platform for the family doctors https://edu-cnsmf.ro/
- The education platform for nurses https://asistenti.edu-cnsmf.ro/
- The education platform for the general population https://info-prevent.ro/
2. Delivery of Integrated Prevention Services to Target Populations
Integrated assessment and counseling services, aligned with the evidence-based prevention guideline, were provided to 550 individuals from target rural communities, including 120 Roma persons.
Key activities included:
- Capacity Building of Rural Primary Healthcare Teams:
- Seven rural primary healthcare teams, consisting of family doctors and nurses, were trained in general and specialized prevention services.
- Medical equipment for point-of-care (POC) medical examinations was provided to these teams.
- Community Outreach and Service Delivery:
- Vulnerable rural communities were engaged, and health risk assessments and counseling services were effectively delivered to 550 individuals, including 120 individuals of Roma ethnicity.
3. Enhanced institutional capacity for prevention services monitoring and policy development
The project strengthened the capacity of District Health Authorities to monitor the need for prevention services, with a focus on vulnerable populations, and to develop and advocate for public health prevention policies. Key achievements included:
- Development of Health Policy Tools:
- A strategy for monitoring the implementation and continuous adjustment of clinical guidelines.
- A cost analysis for prevention services.
- County-level prevention action plans outlining institutional responsibilities.
- Models of contracts for reimbursing prevention services through local governments.
- A policy brief on prevention services.
- An advocacy plan to emphasize the importance of prevention in national health policies.
- Partnership Building:
- Partnerships were negotiated and concluded with specific local governments and district health authorities to support prevention service delivery.
- Dissemination of Project Results:
- Project outcomes were shared through dedicated websites and Facebook pages.
A national-level conference was organized, featuring the participation of major national decision-makers, to promote and advocate for the project’s findings and recommendations.
Summary of bilateral results
The project was carried out in partnership with The Institute of Basic Medical Sciences of the University of Oslo and also with the Directorate of Public Health Arad, the Slatina-Timiș Mutual Aid Association and the "Viscri Únce" Association Brașov. The Norwegian partners actively contributed to activity no. 6 - defining the Strategy for monitoring the implementation of clinical guidelines, Professor Nanna Lien together with Mrs. Silvia Cutinho contributing.