Abstract
Introduction: In partnership with the Ministry of Health (MoH) and the Ministry of Labour and Social Protection (MoLSP), local public authorities, practitioners and civil society, NCD patients, formal and informal carers, Moldova is taking strides to ensure health and social services better meet the needs of vulnerable persons with chronic conditions. This is critical given the multiple crises facing the country and demographic changes (aging, high out-migration).
To better integrate care the SDC Healthy Life project has built capacities and undertakes advocacy, including through participatory Policy Round table events, changes in legislative and normative acts, in line with EU succession, while also supporting practical application, interdisciplinary coordination and interventions across the health and social sectors.
Methods: The project established a system for continuous support in implementation of integrated community care models for persons with noncommunicable diseases to be better cared for in their own communities. The process includes sectoral training of the Primary Health Teams (managers, family doctors, community nurses), training of the multidisciplinary community teams, support in development and implementation of the Plans for Integration of Community Care Services, practical support and supervision, collection of data and assessment of results.
Multidisciplinary teams now apply integrated care that touch prevention, treatment, long-term care, home care, and primary palliative care. Learning from experiences in the social sector (e.g. with vulnerable children) common working tools and procedures are used to assess the needs of NCD patients and involve them along entire intervention process, as well as align eligibility criteria for health and social support, coordination within case management, data exchange, reciprocal referral, and joint follow-up and assessment of results.
Results: After a range of introductory activities involving both MoH and MoLSP, all 35 districts of Moldova and 70 community teams have been involved in capacity building activities and supervision towards more integrated care.
In the period of 2020-2023 sectorial training was delivered to 1.513 primary health care professionals and intersectoral to 709 members of community teams. The regular support in implementation is ensured for all teams. Additionally, these were supported to develop action plans that are implemented using a cascade principle to new pilot communities.
Results from 2022 show that coordination of casework has improved, the roles and responsibilities of each actor are better known, the inefficiencies and duplications have been reduced. However, there are differences between the progresses made according to the level of interest, noting that there is a strong human factor to the issue of case management.
Conclusions: Strengthening leadership and capacity of local implementers and promoting team approaches is fundamental. Successful districts have also applied the approach during the pandemic to maintain home visits to NCD patients that were high risk and could not visit health facilities.
Further investments need to be made to better train professionals in integrated care principles, teamwork and communication, as well as meaningful collaboration with communities. Institutionalization of the developed training modules and interdisciplinary learning and work also remain pivotal, along with the approval of legal and normative frameworks to support integrated care.