Swiss-Moldovan Cooperation: The Healthy Life Project to Reduce the Burden of NCDs

Swiss-Moldovan Cooperation: The Healthy Life Project to Reduce the Burden of Non-Communicable Diseases

Ministry of Health, Labour and Social Protection of the Republic of Moldova

Swiss-Moldovan Cooperation: The Healthy Life Project to Reduce the Burden of NonCommunicable Diseases p. 6

Advocacy and policy dialogue

p. 8

Promoting a people-centred approach

Russia

p. 10 Intersectoral collaboration for healthy communities

Kiev

p. 14 Supporting the public health reform

Ukraine

p. 16 Mobilizing communities Bratislava ChiČ™inău

Vienna Budapest

Hungary

Moldova Romania Bucharest

Black Sea Bulgaria Sofia Rome Ankara

Turkey

Athens

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Mediterranean Sea

Athne

Swiss-Moldovan Cooperation: The Healthy Life Project to Reduce the Burden of NonCommunicable Diseases (NCDs) Why is it so important to tackle NCDs in Moldova?

Disease prevalence from the four main NCDs (cardiovascular diseases, cancers, diabetes and chronic respiratory diseases) is very high in Moldova. NCDs are estimated to account for 90% of all deaths in the country, with more than 50% of the population suffering from NCDs and up to a quarter succumbing before reaching the age of 70 years. Many of these deaths can be attributed to heavy alcohol and tobacco consumption, but also to unhealthy nutritional practices (high consumption of salt and fried food) and physical inactivity. There is a significant and growing gender gap in life expectancy: 66.8 for males and 75.1 years for females in 2019, with men under the age of 70 having a much higher risk of premature death due to NCDs than women (53% vs. 29% in 2016).

Established in 2016, the Swiss Agency for Development and Cooperation (SDC)’s Healthy Life Project draws on the WHO Global Action Plan on NCDs, the Swiss Foreign Health Policy, and national policy documents. It operates in partnership with the Ministry of Health, Labour and Social Protection (MoHLSP), while the implementation is facilitated by the Swiss Tropical and Public Health Institute (Swiss TPH).

The Healthy Life Project is committed to improving access to quality health services for NCD patients, with a special focus on the most vulnerable groups, as well as to ensure public health interventions so that citizens take greater responsibility for their own health. Hereby, the Swiss Cooperation supports the Government and the people of Moldova as they strive for improving health, living conditions and well-being.

Located in Eastern Europe, Moldova is a small landlocked country that neighbours Romania and Ukraine with an estimated population of 3.5 million. Agriculture is the most prominent industry,

accounting for 40% of the national GDP, and over 60% of the population live in rural areas. About one third of the active Moldovan labour force has migrated permanently or temporarily in the last decade. Remittances from Moldovans abroad accounted for 16.2% of the country’s GDP in 2018, the twelfth-highest percentage in the world.

Although it is the poorest country in Europe, Moldova has made progress in reducing poverty and promoting inclusive growth since the early 2000s.

Moldova inherited a highly centralized, hospital-centred health system from the Soviet Union. Upon gaining its independence in 1991, a major health sector reform process was initiated and Moldova has developed a family medicine focused Primary Health Care (PHC) system with ambulatories and single practices.

However, the system is largely focused on care for acute illnesses rather than the prevention and management of NCDs. Moreover, due to migration the health sector lost 7% of its medium qualified medical staff and 6% of its nurses between 2011 and 2016 – with many more health staff in the system already close to or above the retirement age.

SDC has been supporting the Government of Moldova in its development of the health sector for almost 20 years. In order to tackle the challenge of NCDs and to reach the SDG target on universal health coverage (UHC), SDC is engaged in improving the quality of and access to PHC services, shifting the focus from disease-centred to patient-centred care, increasing health awareness, promoting healthy behaviour, and strengthening accountability mechanisms.

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Swiss-Moldovan Cooperation: The Healthy Life Project

The Healthy Life Project seeks to: ––Reinforce the importance of family medicinefocused PHC and improve the quality of care, including rolling out WHO's Package of Essential Non-Communicable Disease Interventions (WHO PEN) ––Strengthen the National Agency for Public Health (NAPH) to introduce modern health promotion and effective behaviour communication techniques ––Build capacity of Local Public Authorities to promote health in community settings (e.g. through workplace and school-based interventions) ––Strengthen the Public Health Councils at district level as a platform for intersectoral collaboration.

––Promote district profiles to give an evidencebase to health planning, and engage civil society platforms for greater social accountability ––Create models of integrated community medico-social services addressing the needs of the elderly and patients with multimorbidity

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What is the Healthy Life Project all about?

The Healthy Life Project works at national, district (‘raion’), facility and community level. Moreover, it operates at the complex intersection between the health and the social sector – with close links to the decentralisation process and Local Public Authorities, the Ministry of Education, Medical University Training colleges, School of Management in Public Health, Association for Family Medicine and Association of Nurses.

The work at district level is focused on the 10 districts of Falesti, Ungheni, Stefan Voda, Cahul, Orhei, Criuleni, Taraclia, Vulcanesti, Edinet and Briceni.

“In Moldova, family doctors are the first counterpart for patients suffering from NCDs. The Healthy Life Project strengthened their capacities in different ways including introducing important tools like the PEN protocols. Through the integrated care model and the development of the legal framework for community nurses, the high burden of family doctors could be spread on several shoulders to the benefit of their patients.”

Dr Tatiana Zatîc Head of the Department for Primary (Medical), Emergency and Community Care, Ministry of Health, Labour and Social Protection

What is unique about the Swiss approach to addressing the burden of NCDs? The Healthy Life Project works in an evidencebased, intersectoral and interdisciplinary manner, pursuing several interrelated, complementary interventions. It is sensitive to political economic influences; the importance of gender-specific approaches for addressing the specific NCD risk patterns and health needs of men, women, boys and girls; and the need to improve provider-patient communication and foster team work across the different professions at primary care level. The Healthy Life Project is driven by the knowledge that Integrated Patient-Centred Health Services (IPHCS) holds the key to ensuring social inclusion and that fewer people are left behind.

“The Swiss Cooperation Office in Moldova promotes actions to enhance health literacy and healthy behaviour among people, and stimulating them to play an active role with regard to their own health. At the same time, this needs to go hand in hand with better access to quality integrated health services and cost-effective allocation of resources, focused on prevention and early detection of diseases.”

What is the rationale behind the Healthy Life Project?

The Swiss portfolio assists the Government of Moldova in its ambition to achieve UHC – thus increasing access and quality of health care, with particular attention to reducing NCDs. The Agenda 2030 is holistic and reflects the close linkages between income, education, living and working conditions, which are highly relevant for people’s wellbeing all over the world. SDC starts from the understanding that progress in health, and the reduction of NCD risk factors like smoking, alcohol consumption, poor diet and physical inactivity, can only be achieved by engaging many other sectors beyond health – including social affairs, education, town planning, community development, governance, amongst others. Specifically, the project promotes the health related targets linked to SDG3.4 to reduce premature mortality from NCDs and promote mental health and well-being, the education targets linked to SDG5, and the transparency targets linked to SDG16.

Dr. Valeriu Sava SDC, National Program Officer for Health 5

Swiss-Moldovan Cooperation: The Healthy Life Project

Advocacy and policy dialogue The case for investing in NCDs The burden of NCDs strains the well-being of the population, health systems working to treat patients, and causes a significant loss of economic productivity: it has been estimated that for every 10% increase in NCD mortality, economic growth is reduced by 0.5%. In 2018, WHO made the global case for investing in NCDs, showing that a 15 per cent reduction in premature mortality could be achieved by 2030 in low- and middle-income countries by spending just an additional $1.27 per person per year. Addressing NCDs not only improves health and saves lives, but increases workforce participation and productivity, and protects people from unexpected health costs.

Potential cost saving 24%

The Healthy Life Project has supported the National Health Insurance Company in Moldova to assess the range, number and cost of services provided by PHC teams to patients with hypertension; as well as financial access related to the cost of antihypertensive (AHT) drugs and their reimbursement. The project also demonstrated that significant additional long-term investment is needed to ensure patient access to reimbursed AHT drugs and made an assessment of the potential cost-savings of a mandatory generic substitution policy.

Generic substitution 5%

Original drugs, no generics 4%

Potential cost savings of the mandatory generic substitution of AHT drugs as % of pharmacy AHT drug sales

Generics 66%

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Building stronger institutions for sustainability Beyond the training of teams of healthcare providers and social workers, as well as community mobilisation to increase knowledge about NCD risk factors in the general population, the Healthy Life Project works to build the capacity of key institutions in Moldova. These include, for example, the National Agency for Public Health (NAPH) in Chisinau and its decentralised structures in the districts. Institutional capacity development needs to be made explicit so it can be effectively planned and tracked. In the area of health promotion, clearer roles and responsibilities have been defined following

a capacity needs assessment. In addition, arrangements for coordination between different entities and the rules for their cooperation have been set to allow greater accountability.

By establishing a trustful relationship, the agency has started to actively call for institutional capacity building, so that attention can be focused on underlying challenges, such as organizational structure, legal mandate, and institutional arrangements. “Swiss support gives important emphasis to organisational development and change management, thus creating more robust institutions with the leadership and capacity to facilitate system-wide reform�.

Dr. Ala Curteanu Healthy Life Project Team Leader

The Healthy Life Project strengthens community intersectoral teams to provide integrated care.

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Swiss-Moldovan Cooperation: The Healthy Life Project

Promoting a people-centred approach Improving the quality of care With almost 60% of Moldova’s population living in rural areas, primary healthcare is essential to make healthcare more accessible.

The Healthy Life Project assessed the quality of care at primary level at baseline. To address identified deficiencies in 10 pilot districts, 278 triage rooms of 66 health centres and affiliated offices of family doctors received a set of basic equipment for early diagnosis and identification of NCD-related problems, with staff being trained in use and maintenance. Additionally, the project developed a practical guide for adult examination techniques in triage rooms in PHC institutions.

People at risk of or suffering from NCDs require long-term care that is proactive, patientcentred, communitybased and sustainable.

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A major step was the introduction of the WHO PEN protocols in the pilot districts. The training process was designed in three stages with training of trainers (1st stage), training for pilot district representatives (2nd stage) and cascade trainings (3rd stage). At the end of 2019, 201 family doctors and 412 family nurses have been reached by this cascade training. Moreover, guidelines on patient education for hypertension, diabetes type 2 and angina pectoris have been elaborated and rolled-out.

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Swiss-Moldovan Cooperation: The Healthy Life Project

Intersectoral collaboration for healthy communities Introducing the concept of integrated care In many cases the limited success of the health sector to achieve positive results in NCDs prevention and management is influenced by social factors and the poor socio-economic status of the target population. The Healthy Life Project promotes a people-centred approach to address the needs of chronic patients and their families, by stimulating the collaboration between the health and social sectors and expanding outreach services, with special focus on social inclusion and the needs of the most vulnerable.

The intention behind integrated care is to spread the task of supporting patients across a wider multidisciplinary team, involving medical, social and educational sectors, and bringing them at one table. Local authorities like mayors play

Improving patient access to services in remote areas is a key component of the integrated care concept.

a leading role in that approach as organisers of integrated people-centred community services.

In the three pilot districts of Falesti, Ungheni and Orhei, a common assessment of people with NCDs and elderly was carried out to identify those with complex needs and to provide multisectoral support. The team of community social worker, medical assistant, community nurse, family doctor, and other professionals relevant to the case established what kind of support the person needed and took the next steps of intervention (e.g. referring for social benefits and services, including family support, personal assistance, health and social home care services). For complex interventions a case management approach was applied.

“To reduce the burden of NCDs, we need to work on prevention, and to be able to do this, intersectoral collaboration is crucial. In the area of child protection, we are already very successfully working with multidisciplinary teams and can draw on our experience. Communication and exchange, mutual trust and respect are key.�

Emilia Ciobanu Head of the Social Assistance, Child and Family Protection Department of Falesti

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“Family doctors and their staff are dealing with a lot of work and are often overloaded.

In the past, communication with social services was sometimes difficult or did just not happen. But thanks to the project’s efforts, the relationship between healthcare providers and social workers has changed a lot. We work together as equal partners and meet weekly, or even daily to discuss our cases. Through our joint collaboration, we could identify a number of problems and solve them.”

Dr. Valeriu Boboc Head of the Health Centre in Bocsa

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Swiss-Moldovan Cooperation: The Healthy Life Project

Improving patient access: Ms Elena's story

The Healthy Life Project encourages people to take responsibility for their health by improving the access to information and services.

––In total the three pilots have jointly identified 722 persons with NCDs (582 women, 140 men) who gave cause for concern about their wellbeing and need for additional support for their health and social problems.

––Initial common assessment was recommended for around 50% of these persons (372 persons: 284 women, 88 men).

––As a result of the initial assessment, 25% of people with NCD (94 persons) were referred to social benefits and 17% (65 persons) had case management opened and connection to social services ensured.

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According to the action plan on integrating services at community level, all persons aged 60+ from 6 communities in Falesti district were registered and had their health assessed.

In Rediul de Jos the community medical assistant (CMA) observed during one of her home visits that Ms Elena, suffering from hypertension and diabetes, could only move with difficulty. In addition to the health assessment, she noticed Ms Elena’s house being in a critical condition with a damaged roof, as well that this elderly woman was struggling alone, living on a small pension and having no help in her daily life.

The CMA shared her observations with the social worker during their weekly meeting and both professionals visited Ms Elena at home to make an initial common assessment.

The risk situation was confirmed and the team decided to open a case to plan an individualised intervention, drawing on both health and social services. The case was discussed in the meeting of the community’s multidisciplinary team, including the mayor, community services councillors, representatives of home care services, and needed actions were identified. Ms Elena was referred for some additional medical investigation and provision of reimbursed drugs, assisted to apply for means-tested social benefit and received financial support from the mayoralty for renovating her roof. She was registered for monitoring visits by the CMA and involved in community events by volunteers responsible for the region.

“The very fruitful cooperation with the social worker makes my work much easier.

Together, we are able to better support people. Often in the villages people neglect their health state. Thanks to the project, we go and find them, we go to their houses and we identify the health issue at the beginning. Now, we have the equipment to measure the blood pressure and blood sugar at home, this is of great value for the patients as they are often limited in their mobility.”

Marina Bîlici Community medical assistant for Rediul de Jos and Rediul de Sus

“I did not expect the visit of the CMA. Although I urgently needed to see the family doctor, this was difficult, and I postponed the visit until I would find someone to help me. I was surprised that the CMA asked me about my life and how I get along. I would otherwise never have mentioned to a doctor or medical worker that I need help or that I did not have enough income to cover even the most basic needs.”

Ms Elena Beneficiary

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Swiss-Moldovan Cooperation: The Healthy Life Project

Supporting the public health reform Health promotion At national level the Healthy Life Project is working with the National Agency for Public Health (NAPH) to build its capacity to prepare national communication campaigns based on evidence and social marketing principles (i.e. partnering with a creative agency, using formative research insights for message development, and testing messages with consumer panels). The project supported the NAPH in creating and launching two health communication campaigns on reducing salt intake and trans fatty acids. Based on evidence from the survey on dietary salt intake (2018) and on the local urban food environment (2016) led in Moldova by WHO, the campaign produced videos and animated spots, which were broadcasted on TV and online platforms. The target audience spanned men and women aged 18-70+ in rural and urban areas, with a special focus on changing eating and cooking behaviours and the gender issues around this.

In addition a new Health Promotion and Behaviour Change training course was established, involving representatives from the MoHLSP, NAPH, Medical University, Medical Colleges and NGOs. A national trainer team exists from across all these institutions, and the course is now running for local health promotion practitioners in the country.

Reach of the salt reduction campaign The project is reaching out to the larger population through awareness raising campaigns that target both male and female audiences, including TV spots, social media and community events.

––The video spots achieved a cumulative TV market rate of 75.8% ––The spots were viewed 16.5 million times on TV and more than 40 000 times on social media channels ––Every day, about 900 000 people watched the spots on TV and more than 37 300 on social media ––Audio spots were broadcasted on four radio stations, which covered 61% of radio listeners in Moldova ––More than 500 Facebook and Instagram users took the online salt consumption test, most of them being women aged 18-34 years

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––With a total market share of 77.8%, the campaign reached a large part of the population

Reach of the trans fatty acid campaign ––The video spot was broadcasted on 8 TV channels with national coverage.

––The spot had a coverage of 1,667,958 people or 93% of the audience of these channels ––On average, one person watched the video 7.98 times ––The radio spot was broadcasted 1010 times on 8 national channels and was heard daily by 173,206 persons ––For print media, 10 documents were developed that were picked up by 26 online news portals; on average, each material being read by 500 visitors of each portal ––The video from Comedy Zebra Show (influencers) was watched at least 1 time by 1,538,485 people, the video accumulating 631,988 unique views, 17,000 likes and 7,100 shares ––The total market share of the campaign was 93%

Health Profile development The project reinforced the NAPH to organise and lead the process of Health Profile development.

The WHO Health Profile concept provides an assessment of the health status and determinants of health, including risk factors, in a given administrative-territorial unit. In tandem, the capacity of local public health experts was increased to analyse and interpret the Health Profile indicators. At district level, multisectoral teams reviewed and discussed the Health Profiles which are now used as a planning tool to improve the reach and coordination of health promotion activities in each district. The most important indicators and time trends of Health Profiles were further disseminated at village level to help close the information gap on evidence-based health issues and priorities by bringing the data to the lowest level of action for health promotion, the communities.

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Swiss-Moldovan Cooperation: The Healthy Life Project

Mobilizing communities Building intersectoral platforms – Health in all Policies approach In 20 pilot villages, strategies are deployed to build community-wide coalitions on health promotion.

Capacity-building initiatives with mayors and community leaders emphasized the role of local policy-making in shaping health-promoting environments for the population. Local NGOs were capacitated to serve as a voice of the community and claim greater accountability in health at local level. Public authorities and civil society groups then conducted joint review of community health priorities and teamed-up to design and collaboratively implement local health promotion projects.

More than 250 local decision-makers have consolidated their knowledge of the social, economic and environmental determinants of health, and the importance of intersectoral collaboration for health promotion and integrated, people-centred NCD services.

Increased level of awareness of the risks factors that influence the life style at community level constitutes the basis of a possible behaviour change.

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Inclusive community engagement With health communication, the project went the last mile and delivered health education seminars in rural communities, adapting the language (Romanian or Russian) to the location, and the topics to be gender-specific. By June 2019, these seminars had reached 7,904 persons (5,445 women and 2,459 men), 20% of the participants met at least one vulnerability criteria.

To empower patients with NCDs, the project piloted Chronic Disease Self-Management Programmes (CDSMP) in 5 rural communities.

Running for 6 weeks at a time, two trained facilitators – chronic patients themselves – guide group discussions about small lifestyle changes achieved. The CDSMP is based on behaviour changes techniques such as goal setting (by developing weekly action-plans), social support, self-monitoring and feedback. The evaluation of this intervention revealed a statistically significant increase of participants’ self-efficacy score, from 5.33 before the intervention to 8.32 afterwards.

Self-efficacy plays a significant role in mediating behaviour change and this result suggests the intervention increased participants’ abilities to make positive lifestyle changes regarding to their chronic conditions.

“We provided all our patients with NCDs with the flyers and invited them to the seminars on diabetes, hypertension and healthy nutrition that were held in the cultural centre of Peresecina. These seminars involved all public bodies (mayoralty, church, schools) and were very well received. Participants appreciated that the experts came to their village, giving them the feeling that their health is taken seriously. We have many requests for further seminars, especially on stress reduction.”

Dr. Varvara Iurcu Family Doctor and Head of Peresecina Primary Health Care Centre

“My wife and I participated in the selfmanagement programme and we learnt a lot about healthy nutrition, physical activity and stress reduction and their influence on our health. We remind and motivate each other to stick to the tasks we defined in our action plans, like morning gymnastics or having enough sleep. As one result, we banned the salt shaker from the table. My blood pressure has reduced since I started the programme.”

Dumitru Tiganas Participant of the self-management programme, Ohrincea

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Swiss-Moldovan Cooperation: The Healthy Life Project

Building the evidence base The work of the Healthy Life Project is informed by latest evidence from the international literature, as well as baseline surveys conducted at the outset. A Quality of Care study was conducted as a controlled facility-based survey across 20 districts of Moldova. The final sample included 60 public facilities, 54 adjacent pharmacies, 182 observations of consultations for hypertension, ischemic heart disease, and diabetes.

Key findings included: � Family doctors generally had only modest knowledge about NCDs, scoring an average of 8 out of 13 on essential questions � The quality of clinical consultations for diabetes, cardiovascular and hypertension left room for improvement e.g. for hypertension 26/39 points obtained on average � No health promotion materials were present in 1 out of 3 family doctor offices � Absence of essential diabetes medicine in 31% of rural versus 3% of urban pharmacies � 38% of family doctor offices and 20% of health centres operate without regular participation in quality improvement meetings The publication can be viewed here: https:// www.ncbi.nlm.nih.gov/ pubmed/31164125

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Additionally, a large household survey was undertaken to measure knowledge, attitudes and practices related to NCDs and their associated risk factors. This survey was carried out across 47 villages in 20 districts. 930 respondents took part, with 509 participants in the 18-44 age group (54.7%) and 421 in the 45-69 age group (45.3%).

Women represented 54.6% of the sample and men 45.4 %.

Key findings included: � For both diabetes and cardiovascular diseases, approx. 25% of respondents could not name any risk factors. This rate increased to 32% when asked to name early symptoms – with important differences between men and women requiring gender-specific responses � 3 out of 5 adults who consumed alcohol more than five times a week did not perceive it as a health risk � Average BMI among all respondents was 27.2, categorised as "overweight” � Almost a third of respondents had never had their blood sugar tested � 34% of respondent had a confirmed diagnosis of hypertension; 15.3% had a confirmed diagnosis of diabetes; and 16% had a confirmed diagnosis of a cardiovascular disease � 3 out of 4 respondents reported having a medical health insurance. Enrolment was lower among the 18-44 age group (62.8%) than the 45-69 age group (85.5%) � About half of respondents lived in a household that included 1-3 people above 60 years of age

“Being selected and trained as facilitators makes us very happy and proud to be able to give back to our community. It is great to see how motivated people are now. For example, the walk to the nearby lake has become popular for promenades in the evening. And we have many registrations for the next workshops, even from other communities. Our mayor is actively participating in all the meetings and supports us a lot, for example with the creation of a park with some sport equipment that is currently built by volunteers of the community.�

Svetlana Catan, Svetlana Colesnic, Valentina VĂŽntu Course facilitators, Boscana

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Ministry of Health, Labour and Social Protection of the Republic of Moldova

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