Scaling up Youth Friendly Health Services in Moldova: a Working Paper
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V.Chandra-Mouli, Department of Child and Adolescent Health and Development, June 2010.
Scaling up youth friendly health services in Moldova: A working paper
In this paper I have outlined ways and means by which the vision of Moldova's Ministry of Health to extend health services to young people in Moldova could be realized. This paper builds on the inputs and outputs of a two-day workshop on planning for a project on increasing access to information and services to young people organized by the Swiss Development Cooperation in Chisinau, Moldova on 1-2 June 2010. In preparing this paper, I drew heavily upon the rich knowledge and understanding of the following persons: 1. Dr Galina Lesco Head of the Neovita Youth Friendly Health Centre 2. Dr Victoria Ciubotaru, Head of the Monitoring and Assessment Service, National Centre of Reproductive Health and Medical Genetics 3. Dr Valeriu Sava Head of the department, Health Financing Policy Department, Ministry of Health, Republic of Moldova. I also consulted with, and drew upon the inputs of colleagues from my own organization, other UN agencies the Swiss Agency for Development Cooperation. 1. Dr Pavel Ursu, Head of the WHO Country Office, Moldova; Dr Larisa Boderscova, National Professional Officer, Health Systems,Family and Community Health. WHO Country Office, Moldova; and Dr Valentina Baltag, Regional Adviser Adolescent Health and Development, EURO 2. Ms Sandie Blanchet, Deputy Representative, UNICEF, Moldova and Ms Larisa Lazarescu-Spetetchi, UNICEF, Moldova. 3. Dr Boris Gilca, Assistant Representative, UNFPA, Moldova. 4. Ms Anne Hassberger, Health Programme Manager, Swiss Development Corporation, Headquarters; Ms Georgette Bruchez, Country Director, Swiss Development Corporation, Moldova and Ms Angela Gheletcaia, National Programme Officer, Health, Swiss Development Corporation, Moldova. I have been associated with the development of youth friendly health services in Moldova and drew upon two documents which I have contributed to: 1. Quality standards of youth friendly health services in the Republic of Moldova (2009) 2. Case study on Youth Friendly Health Services in Moldova (2009). Finally, I drew upon the growing evidence base on overcoming constraints to delivering effective health services and improving access to health services to populations in general and to young people in particular.
The current situation on youth friendly health services in Moldova Youth friendly health services are being provided in ten districts and two municipalities of Moldova by centres which were set up between 2003 and 2005, and have received financial support from UNICEF, the GFATM and other sources. The 27 Reproductive Health Offices and the three Women's Health Centres in the country have also received some support on responding to young people, and do so to a greater or lesser extent. The National Centre of Reproductive Health and Medical Genetics provides technical support to all these institutions. Its work is overseen by a coordination committee set up by the Ministry of Health.
The Ministry of Health's vision on extending friendly health service provision to young people across the country The Ministry of Health's vision to extend friendly health service provision to young people in the country, was described in a presentation made by Dr Rodica Scutelnic of V.Chandra-Mouli, Department of Child and Adolescent Health and Development, June 2010. the Ministry of Health, at the two-day planning workshop that I referred to earlier. One of its key considerations is to make existing health staff and existing health facilities more friendly (i.e. responsive) to the special needs of young people. The Ministry of Health proposes to engage the following health service providers to provide first-level services: . Family doctors (there are around 2000 of them in the country), . School nurses (most schools have one, and there are around 30-40 schools in each district) . Outpatient units of district hospitals (there is one hospital in each district). They would provide information and education, primary-level counselling and health services, and refer patients who needed more specialized care elsewhere. They would also identify those young people who are more vulnerable than others and refer them for health and social services. The Ministry of Health proposes to engage the following health service providers to provide secondary-level services: . The 12 existing youth friendly health centres . The 47 existing Reproductive Health Offices . The 3 existing Women's Health Centres They would provide information and education, secondary level counselling and health services to all adolescents and to especially vulnerable ones who have been referred to them from the primary level. They would also refer those patients who need specialized care to government-run social welfare agencies and NGOs who provide complementary services. The coordination committee of the Ministry of Health, the National Centre of Reproductive Heath and Medical Genetics will provide both first and second level providers with the support they need to carry out their tasks. Staff from medical and nursing colleges will also be drawn in to provide support. The Ministry of Health will carry out the following functions at the national level: Leadership and management: . Develop norms for health service provision at the primary, secondary and referral levels, as well as systems for referral. . Develop systems for outreach service provision. . Develop systems for anonymous care provision, in special situations. . Develop mechanisms to gather age and sex disaggregated information on service utilization. . Carry out studies periodically on strengthening and improving health systems for adolescents. Financing arrangements: . Assess the cost and the cost effectiveness of approaches to provide adolescents with health services. . Strengthen and improve insurance mechanisms. . Develop mechanism to draw upon resources available with local authorities and social insurance mechanisms to support vulnerable individuals and families. . Draw upon the support of NGOs and volunteers from the community. Human resource development: . Build the capacity of service providers to deal with adolescents. . Develop guidelines and protocols for case management. . Modify the curriculum in medical and nursing schools. V.Chandra-Mouli, Department of Child and Adolescent Health and Development, June 2010.
Practical considerations in translating the Ministry of Health's proposal to extend the reach of friendly health services to young people across the country, into action: The Ministry of Health has laid out a clear vision of what it wants to see happen across the country. It's proposal outlines which health service providers and which health service delivery points are to be involved. It outlines which health services are to be provided at the primary and secondary levels and reiterates that the required quality of health service provision will need to meet that outlined in the document: Quality standards of youth friendly health services in the Republic of Moldova (2009). Finally, it lists what it needs to do at the national level to create an enabling environment for the other players to make their contributions. A key consideration in moving ahead from the 12 youth friendly health centres that are operating today in 10 districts and 2 municipalities to literally hundreds of family doctors offices, hundreds of school clinics, tens of Reproductive Health Offices and tens of district hospitals is how this will be done. In the section that follows, I have laid out some key decisions to be considered/actions to be taken.
1. Drawing upon the lessons learned in scaling up other health innovations in the country, and in strengthening and sustaining the youth friendly health centres It would be useful to carry out three preparatory steps. Firstly, useful lessons could be learned from the way in which the family doctor model was conceived, piloted and then scaled up across the country. Secondly, it would be useful to draw out the lessons from the way in which the network of 12 youth friendly health centres have learned from and with each other - an excellent model of collaborative learning. Thirdly, the quality assessment carried out in 2009 indicated that only four of the 12 youth centres were operating very well. It would be useful to determine why they were doing so and why the others were not doing so well.
(Note: It must be stressed that while we seek to draw out useful lessons from the youth friendly health centres in Moldova, every effort must be made to draw upon the lessons that have already been learned. These are summarised well in the analytic case study titled Youth Friendly Health Services in Moldova (2009) written by S Bivol, R Thomson and D Pejic with the support of WHO's European regional office).
2. Defining the actions and the ongoing functions to be carried out at the national level, and putting in place the institutional arrangements needed to ensure that the national scale up effort is driven in a systematic and concerted manner The following actions will need to be carried out 1. Review laws and policies and revise those that hinder the provision and utilization of health services 2. Review and revise insurance and other financing arrangements to ensure that they do not hinder the utilization of health services 3. Provide guidance on actions to be taken by the institutions charged with leading the scale up effort at the district level 4. Provide guidance on actions to be taken by health facility managers 5. Develop/ adapt self learning materials, teaching materials and guidelines for health facility staff 6. Develop /adapt informational materials for young people and community members In addition, the following ongoing functions will be required to support the scale up effort in the districts: V.Chandra-Mouli, Department of Child and Adolescent Health and Development, June 2010.
. ensure that the relevant authorities in the districts and the health facilities have the resources they need to deliver health services to young peoples, including: adequate staff; guidelines and standard operating procedures; educational materials; equipment, medicines and other supplies; The Ministry of Health has proposed that the National Centre of Reproductive Health and Medical Genetics will play a central role is supporting the scale up effort. This decision needs to be confirmed and communicated to all the relevant stakeholders. Also, the Ministry of Health should ensure that the body has the expertise and the resources needed to carry out the actions and ongoing functions. Another potential resource is the National Centre for Preventive Medicine, which has branches at the district level. It would be useful to identify in what way they could contribute to this effort, and to make the needed institutional arrangements for this.
3. Defining the actions and the ongoing functions to be carried out at the district level, and putting in place the institutional arrangements to ensure that district- based institutions have the authority and the capacity to lead the scale up effort At the district level, the following actions will need to be carried out: 1. Orient and engage the relevant district leaders. 2. Orient and engage district health management teams. 3. Conduct a district-level mapping exercise. 4. Develop a district scale up plan. 5. Orient health facility managers. In addition, the following ongoing functions will be required to support implementation and monitoring: . act as a bridge between the national level and health facilities, thereby helping to ensure that health facilities have the resources they need to deliver health services to young peoples, including: adequate staff; guidelines and standard operating procedures; educational materials; equipment, medicines and other supplies; . facilitate stronger working relationships among managers of health facilities, between managers of health facilities and service providers in other sectors (e.g. social welfare sector) and with NGOs, . support health facility managers to carry out assessments of the quality of health service provision, and to use these findings to address gaps and areas of weakness; . support health facility managers to carry out the essential actions in their health facilities and in the community. To lead the scaling up effort at the district level, a high profile and respected champion is needed to carry out actions 1-2 and the first bulleted ongoing function. The Ministry of Health will need to identify a suitable body. One candidate is the chief of the Family doctors office. To provide ongoing support for implementation and monitoring, it would be useful to involve the Youth Friendly Health Centres as a resource (as has been proposed by the Ministry of Health). Once these decisions are made, it would be important that the identity of these two bodies and the roles that they will play is made known to all the relevant stakeholders. In addition, it would be important to ensure that they have the technical expertise and the resources (including human resources) to fulfil their roles.
4. Defining the actions and ongoing functions to be carried out at the health facility level, and empowering health facility managers to drive the quality improvement process V.Chandra-Mouli, Department of Child and Adolescent Health and Development, June 2010.
At the health facility level, the following actions will need to be carried out: 1. Orient health facility staff 2. Carry out a quality assessment of the health facility to determine areas where the quality is low (in relation to the standards). 3. Develop a plan to improve quality. In addition, the following ongoing functions will need to be carried out: . work with the district authorities to ensure that the health facility has the essential resources to deliver health services to young peoples, including: adequate staff; guidelines and standard operating procedures; educational materials; equipment, medicines and other supplies; . support health facility staff to perform effectively; . ensure that the health facility is young people-friendly; . build and maintain relationships with community-based organizations in the catchment area of the health facility. Health facility managers need to be empowered and supported to lead the quality improvement effort in their health facilities. To begin they will need to be given clear guidance on what to do. With time, they will need to be given the opportunity to learn from each other's efforts and the space to innovate.
5. Scaling up in a phased manner both in terms of districts and in terms of health facilities within each district While the long term aim needs to be to make all the family doctors offices, school clinics and school clinics in the country friendly to young people, it would be important to do this in a phased manager. Here is a possible way forward: . 2010: define the actions and the ongoing functions to be carried out at the national, district and health facility levels, and put in place the institutional arrangements required to ensure that they are carried out. . 2011: support scaling up efforts in 4 districts (beginning with those districts and municipalities in which effectively functioning youth friendly health centres exist) and prepare for scaling up in 4 additional districts. . 2012: review the experiences of scaling up in 4 districts and scale up further in the districts building on the lessons learned; initiate scaling up in 4 districts in which preparatory work was done; initiate preparatory work in 8 additional districts. . 2013: review the experiences of scaling up in 8 districts and scale up further in the districts building on the lessons learned; initiate scaling up in 8 districts in which preparatory work was done; initiate preparatory work in 16 districts. In this way, the scaling up can proceed in a phased manger, carefully linked to a review process which will ensure that lessons learned are gathered and built upon.
6. Engaging NGOs currently working with Most At Risk Populations (MARP) to reach out to Most At Risk Adolescents (MARA) and set up functional linkages between them and youth centres in those districts where scaling up is occurring All young people need health information and services. Some young people are more vulnerable than others because they are growing up in poverty, without parental support or in homes where parental alcohol abuse or chronic illness mean that they do not get the care and support they need. Further some groups of young people are at greater risk because they are practising risky behaviours - injecting drug users, men who have sex with men, and sex workers and their clients. V.Chandra-Mouli, Department of Child and Adolescent Health and Development, June 2010.
An essential ingredient of the scale up effort should be that in every district, functional linkages should be set up between the youth centre and the one or more NGOs working with MARP, encouraging them to address MARA as part of their work.
7. Using measurement to shape scaling up efforts at national, district and health facility levels. Measurement will seek to determine the following issues: National District Health Catchment level level facility level area of health facility Implementation: Yes Yes Yes Yes Whether planned activities have been implemented at the national, district and health facility levels Quality: Yes Yes Whether these activities have led to improvements in quality of health service provision Utilization: Yes Whether this improvement in quality led to improved health service utilization by young people Coverage: Yes What proportion of the young people who require a marker health service do in fact obtain it It will need to be used to shape and reshape the effort.
What will be achieved as a result of the scale up effort ? In terms of process, the following results will be achieved through this initiative. 1. Useful lessons will be drawn out from other successful initiatives to scale up health innovations in Moldova. 2. The actions and the ongoing functions to be carried out at the national level to ensure that the national scale up effort is driven in a systematic and concerted manner will be defined and the institutional arrangements for this put in place. 3. The actions and the ongoing functions to be carried out at the district level to lead the planning, implementation and monitoring of the scale up effort will be defined, and the institutional arrangements put in place to ensure that district-based institutions have the authority and the capacity to lead the scale up effort. 4. The actions and the ongoing functions to be carried out at the health facility level will be defined, and health facility managers empowered and supported to drive the quality improvement process in their health facilities. 5. A phased scale up effort will occur in the country with a systematic increase in the number of districts covered, as well as the number of health facilities (family doctors offices, school clinics and district hospitals) covered in each district. V.Chandra-Mouli, Department of Child and Adolescent Health and Development, June 2010.
6. As an essential ingredient of the scale up effort, NGOs currently working with Most At Risk Populations (MARP) will be engaged to reach out to Most At Risk Adolescents (MARA) and functional linkages set up between them and youth centres in those districts. As a result of this, a growing number of young people in Moldova will obtain the health information and services they need from existing health workers and health facilities at the primary level which have been made more friendly (i.e. responsive) to them. (Note: One gap in this paper is that it has addressed only primary level services but not referral level services. This would be important to consider as well).
Annex - A status report on youth friendly health centres in Moldova In terms of geographical location, ten of the twelve youth friendly health centres in Moldova are located in districts (one in each), with nine located in the administrative centres of the districts. Two are located in municipalities. In terms of setting, the twelve youth friendly health centres are located in family doctors offices or in outpatient departments of district hospitals. In terms of staffing profile, all of them have one gynaecologist, who in most cases works part time in the youth centre and part time in another institution, such as the Reproductive Health Office, and at least one nurse. Some of them have a psychologist who has been drawn from the education sector and some of them have a social worker. In terms of infrastructure, the youth centres' buildings are in reasonably good condition. In many cases, they were repaired/renovated with funds provided by donors in the first half of the previous decade. In terms of basis amenities, all of them have running water, functional toilets, electricity and heating. In terms of equipment, all have the basic medical equipment needed for their work. In terms of medicines and supplies, UNFPA continues to provide them with condoms. All other medicines and supplies are obtained using funds allocated to the centres or obtained from other sources such as the Reproductive Health Office or the district hospital. Substantial external funding - which had been provided by UNICEF and GFATM - ended in 2006. Since then - before the advent of the insurance system - funding for the running costs of the youth friendly health centres (for staff salaries, for upkeep of infrastructure, for basis amenities, for the purchase and upkeep of equipment, and for medicines and supplies) were borne by the organization which housed them. As the insurance system is gradually applied, funding from this source is covering a growing share of these costs. In terms of activities that the youth friendly health centres, provide counselling and health services to address pregnancy prevention and prevention care, sexually transmitted infections prevention and management, and other issues such as menstrual care. They carry out education programmes in schools and other education institutions on various health issues. Finally, they raise awareness and understanding on the needs and problems of young people through ongoing communication with the local media. In two settings, the centres have working relationships with NGOs which work with Most at Risk Adolescents (injecting drug users, men who have sex and with men and sex workers), and thereby extend their reach to these population groups. In terms of payment for services, before the advent of the insurance system, young people did not have to pay for services. Now things have changed. Initially, the youth friendly health centres were considered part of primary health care. All individuals below the age of 18 could obtain the services free of charge. Individuals above the age of 18 who were students, as well as pregnant women, could also obtain services free of charge. With time, the youth friendly health centres are being considered as specialized V.Chandra-Mouli, Department of Child and Adolescent Health and Development, June 2010. ambulatory care, individuals who are referred to the centre from family doctors can obtain services free of charge. If not, they are required to pay for services. In terms of results achieved, there is no evidence to suggest that the youth friendly health centres have contributed to improving health outcomes. They have contributed to increase health service utilization in their catchment areas. The heads of the youth friendly health centres say that they believe that their clients are practising safer behaviour (but this is anaecdotal). They also say that that parents and teachers are more supportive to the provision of health services for young people and that social welfare staff are engaging with them to address the social needs of clients. Finally, there are clear outcomes in terms of improvement in the quality of health service provision, as confirmed by the quality assessment exercise carried out in 2009.