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Swiss TPH in Moldova 20 years of partnership: from building systems to creating impact

Building a health system that supports people from birth to elderly age

Twenty years ago, Swiss TPH established a point of presence in the Republic of Moldova. Since then, it has gained deep insight into the country’s legislation and local systems, and built a strong network of partners and experts. Throughout this period, the institute has worked with the Ministry of Health and the Medical University on mandates from the Swiss Agency for Development and Cooperation (SDC), WHO and UNICEF, alongside multisectoral mandates involving the Ministry of Labour and Social Protection and the Ministry of Education. Partnerships with local public authorities have supported greater localisation, while academic exchange has generated peer-reviewed research. Together, these efforts have helped one of Europe’s poorest countries build a more modern health system and advance on its path towards EU membership.

Swiss TPH in Moldova – 20 years of partnership

Strengthening Moldova’s health system across the life cycle Over twenty years, working across various projects, Swiss TPH has supported Moldova to strengthen its health system across the entire life cycle.

Healthy Generations Adolescent health 2011 –2020 2006 –2014

Modernising Perinatal Health Mothers and newborns

since 2016 ongoing

Healthy Life Non-communicable diseases

A newborn in care at a Moldovan neonatal unit. Two decades ago, many babies like her would not have survived their first weeks of life. Photo credit: Swiss TPH

Swiss TPH in Moldova – 20 years of partnership

Building a health system

The starting point

In 2006, Moldovaʼs health system was still working through the disruption that followed independence. Although maternal and perinatal care was regionalised in 1998, the delivery remained fragmented. Referral systems between primary healthcare facilities and maternity hospitals were weak. Modern equipment was scarce, especially in district facilities. Clinical practice was not consistently guided by evidence-based protocols. Health professionals in peripheral facilities had limited access to current knowledge and continuous training. There was no focus on health promotion at the time. Chronic diseases were treated, if at all, only when patients were already in an advanced stage and being treated in hospital – not prevented, nor managed at the community level, and not approached as something a patient could help manage themselves. Health workers and social workers operated in separate silos. Youthfriendly services were not a concept yet. Swiss TPH came to this context with experience from neighbouring countries, including similar perinatal health programmes in Ukraine and Romania, and a long tradition of strengthening health systems together with local partners, while taking the local context into account.

Swiss TPH in Moldova – 20 years of partnership

The starting point

A healthy start in life: perinatal and childcare

The Modernising Perinatal Health programme, implemented from 2006 to 2014, addressed an urgent need: a perinatal system that struggled to save the most vulnerable babies, with neonatal mortality rates higher than in neighbouring European countries. Swiss TPH supported the Moldovan health authorities to modernise a regionalised perinatal care system with three levels of care with modern equipment and an upgraded neonatal transport system, mirroring models used across European health systems. Alongside this, the project introduced or institutionalised a telemedicine network linking second level perinatal centers to the tertiary Mother and Child Institute; a simulation training centre for emergency obstetric and neonatal care; evidence-based clinical protocols aligned with European practice; a national health technology management system, which improved medical equipment procurement, maintenance, and training; biomedical engineering as a new academic discipline at the Technical University of Moldova as part of capacity strengthening; and a follow-up centre for premature children for early intervention.

Swiss TPH in Moldova – 20 years of partnership

Health workers at the Neonatal Intensive Care Unit, Mother and Child Institute, Chișinău follow updated clinical protocols introduced through Swiss TPH support. Today, evidence-based practice is the norm across all levels of perinatal care. Photo credit: Swiss TPH

The programme contributed to lasting changes in the way perinatal care is delivered in Moldova. Between 2006 and 2020, infant mortality fell by 29%; neonatal mortality declined by 9% over the same period, indicating the effectiveness and sustainability of the package of interventions now fully managed by the government healthcare system. A healthy start in life

Falling mortality, 2006–2020

Project start 2006

2020: 8.8 2020: 6.4

Figure 1: Neonatal mortality declined from 7.0 to 6.4 per 1,000 live births, and infant mortality from 12.4 to 8.8 per 1,000 live births, between 2006 and 2020. The temporary uptick in 2008 reflects Moldovaʼs alignment with the World Health Organization (WHO) definition of a live birth, requiring the registration of all babies born at 22 weeks of gestation or weighing 500 g or more. Babies that had previously been excluded from the statistics – and who were most at risk of death – were now included, which increased reported mortality rates despite no deterioration in care. Both rates continued to decline on this new, internationally comparable basis. Source: Statistical yearbooks of the Moldovan health system.

Swiss TPH in Moldova – 20 years of partnership

The most striking change came for the most vulnerable. Survival rates for very low birth weight babies rose sharply: for those under 1,000 grams, from 5.4% in 2005 to 47% in 2013; for babies between 1,001 and 1,500 grams, from 60% to 85%.

Survival rates for very low birth weight (1000–1500g) babies before and after the modernization of Moldovaʼs regionalised perinatal care system

Alexandru Magulciac, head of neonatal intensive care unit at the Mother and Child Institute, recalls the shift after a training exchange in Switzerland. Cases of severe congenital malformation, he noted, had previously been considered untreatable in Moldova; after the exchange, neonatologists began consulting surgeons in Chișinău and managing cases that had previously been transferred or lost.

Multidisciplinary teams train together on emergency obstetric and neonatal care at the Simulation Training Center, Mother and Child Institute, Chișinău. Photo credit: Swiss TPH

Swiss TPH in Moldova – 20 years of partnership

A healthy start in life

Reaching young people: adolescent health

In the early 2000s, young people made up nearly a quarter of Moldovaʼs population. They faced health challenges including sexual and reproductive problems, substance abuse, mental health disorders, and suicide – but the Moldovan health system had not yet fully moved beyond the Soviet-era focus on disease control, which paid little attention to the needs of specific target groups, in this case young people aged between 10 and 24 years. A public health reform launched in 2010 had begun to address this, but coverage remained partial, and the care available to young people was uneven. Through the Healthy Generations project (2011–2020), Swiss TPH provided technical and management backstopping to the Moldovan NGO “Health for Youth” to scale up youth-friendly and gender-sensitive health services nationwide. The goal was to make health services accessible, confidential, and welcoming for adolescents, with particular attention to the most vulnerable. The project operated across sectors in health, education and social services. Healthcare providers, youth workers and school nurses gained skills in good practices for building trust and communicating with girls and boys as well as young men and women. Access to youth-friendly health services increased substantially, from 5% in 2011 to 24.4% in 2020. The

Swiss TPH in Moldova – 20 years of partnership

Photo credit: Swiss TPH

number of youth-friendly health centres grew from 12 in 2011 to all 37 centres being contracted nationally by the National Health Insurance Company in 2014, meaning these services are no longer dependent on donor funding. Today, the network has grown to over 40 centres. Beyond service use, there were measurable health outcomes for young people. The incidence of sexually transmitted infections among adolescents aged 15 to 19 declined as the network expanded. The service standards and regulatory framework introduced through the work were aligned with WHO and European public health guidance, and adolescent health was integrated into national health strategies and programmes.

Reaching young people

Care across the life course: including adults and elderly people In Moldova, as across Europe, the leading causes of illness and early death today are non-communicable diseases (NCDs), including cardiovascular disease, diabetes and stroke. When work in this area began, the Moldovan health system was not equipped to manage NCDs. Primary care facilities lacked basic equipment. Family doctors were overwhelmed. Nurses did not yet take on the routine NCD tasks they manage in many European systems. Health promotion was not a priority, and patients had limited practical knowledge about the health conditions they were living with. The Healthy Life project, which Swiss TPH is implementing since 2016 with the Moldovan health and social welfare authorities, addresses these gaps, at the level of health facilities, communities, and national policy. It does so with a focus that would have been unthinkable two decades ago: not just treating disease, but preventing it, managing it in the community, and integrating health with social care to address peopleʼs needs holistically. In primary care, the work centred on the WHO Package of Essential NCD Interventions (PEN), a standard set of tools that allow family doctors and nurses to identify, treat and follow up the most common chronic conditions at the local clinic, without sending people to the 16

Swiss TPH in Moldova – 20 years of partnership

hospital. Swiss TPH focused on PEN protocols 1 and 2, which cover the integrated management of hypertension and diabetes as well as health education and counselling on healthy behaviours. The PEN protocols have now been rolled out to every district in Moldova, reaching close to 2ʼ000 family doctors, 1ʼ500 nurses, and managers of 290 health facilities. Equipment to support this, including blood pressure monitors, glucometers, the basics needed to keep chronic patients on the right track, was provided to 236 facilities in Moldova, plus nine in Transnistria. Nurses, in particular, took on a larger share of routine NCD work and home-visits, freeing family doctors to focus on more complex cases. A budget analysis carried out alongside this work showed: the cost of training family doctors on the PEN protocols was fully offset by a reduction in referrals to hospitals. Better care at the local clinic meant fewer people needed to be referred upwards – at lower cost to the system overall.

of primary healthcare facilities now meet minimum quality standards of care and apply the PEN protocols to prevent and manage NCDs

At local level, the work brought authorities and civil society actors together to promote healthy communities. Health seminars and behaviour change interventions have shaped improved cooking practices and group exercise activities as people gain a better understanding of NCD risk factors. National awareness campaigns reached 1.67 million people, with activities Care across the life course

in 100 rural localities. The change is shown in a population survey: the share of people who could correctly answer questions on NCDs and their risk factors rose from 21% in 2017 to around 60% in 2024. Over time, these surveys show that the proportion of participants reporting fast food consumption declined from 50% in 2017 to 30% in 2024. Tobacco consumption fell sharply across all demographics, dropping from 18% in 2017 to 12% in 2024. At the policy level, the project supported the Government of Moldova to develop the newly established National NCD Programme (2023 – 2027) and provided inputs to the National Programme for Active and Healthy Ageing (2023–2027). Regulations have been brought into line with EU standards, for example for community social assistance services and day care for the elderly and people with disabilities. In addition, national regulations have been introduced with new limits on trans fats, salt and sugar in everyday food products. Complementary steps have also been introduced to target younger generations – for example, through healthier school meals.

Flexible support in times of emergency In spring 2020, the COVID-19 pandemic placed immense pressure on health and social systems, disproportionately affecting people with multiple morbidities, vulnerable populations, and members of the diaspora that were forced to return to Moldova due to the lockdown. People aged 60 and above accounted for 32% of pandemic-related fatalities. Frontline health and social care workers faced high exposure and shortages of protective equipment and medical supplies, leading to their prioritisation in the national vaccination campaign alongside people at increased risk. At the height of the pandemic, family doctor teams focused largely on COVID-19 diagnosis, treatment, home monitoring, and contact tracing, while hospital capacity constraints required many patients to be managed at home. Routine care for chronic conditions was disrupted, and mobility restrictions accelerated the shift to remote consultations. The pandemic underscored the importance of community collaboration between health and social services, and of chronic disease self-management.

32%

of pandemic-related fatalities in Moldova were people aged 60 and above with chronic conditions

Project interventions and support The Healthy Life project adapted its district- and community-based interventions to help maintain essential health and social services during the pandemic. It supported remote consultations for COVID-19 screening and chronic disease management, provided protective equipment and sanitising materials to frontline workers, and strengthened public health capacity through laboratory support. The project also promoted patient self-management, reaching 342 participants in 20 communities, and contributed to national and international assessments of healthcare quality, resilience, and continuity of essential services.

342

participants in 20 communities trained in patient self-management

Swiss TPH in Moldova – 20 years of partnership

Shaping systems through partnership – and closeness to Europe

Over two decades, the partnership between Swiss TPH, the Government of Moldova and SDC has helped transform how Moldova cares for its population at every stage of life: A baby born in Moldova today has a far better chance of surviving and thriving than her mother did. While still not perfect, many young people can access youth-friendly health centres. People with disabilities and the elderly can be visited at home by a team that gives attention to both their health and social situations. In particular, communities have grown in capacities and skills – with 85 out of the 105 communities that took part in the projectʼs small grants scheme going on to successfully acquire further funding from the Government of Moldova under the “European Village” programme. Resilient community networks and solidarity have been essential factors in Moldovaʼs hosting of such a high number of up to 100ʼ000 refugees fleeing the war in neighbouring Ukraine. The journey has also moved Moldova measurably closer to European standards in health and social care, with Swiss public investment translated into European-standard health-care for one of the continentʼs poorest countries and a candidate for European Union membership.

Swiss TPH in Moldova – 20 years of partnership

Acknowledgement Swiss TPH acknowledges and is grateful for the collaboration to all its partners at the Ministry of Health, National Agency of Public Health, the Ministry of Labour & Social Protection, the Ministry of Education, local public authorities, regional public health councils, Swiss Agency for Development and Cooperation (SDC), World Health Organization, United Nations Children’s Fund (UNICEF), World Bank, the State Medical and Pharmaceutical University “Nicolae Testemitanu”, the Institute of Maternal and Child Health, the Universities with Social Work Departments, including State University of Moldova, Pedagogical State University “Ion Creanga”, Free International University of Moldova, State University from Balti “A.Russo” and medical colleges, the School of Public Health, Congress of Local Authorities from Moldova (CALM), the National Institute for Administration and Public Management, and many others.

Swiss TPH in Moldova – 20 years of partnership