Strengthening local capacity to implement integrated community health services in rural Romania
- Inequitable care access and wide health disparities, particularly affecting rural and vulnerable populations.
- Limited provision of outreach and community services in rural areas and fragmentation with social services.
- Limited managerial capacity within rural municipalities to fulfil their mandate of organizing community health services.
- Through strengthening leadership capacity of local leaders, the initiative hopes to improve health and social services delivery within local communities.
- A longstanding international partnership built from experience collaborating on other projects was important for establishing the initiative.
- Training was necessary to strengthen the management skills of local leaders to enable them to assess, coordinate and manage delivery of health and social services orientated to community needs.
- Integration of health, social and community services at the local level was encouraged to support a comprehensive response to community needs, particularly for underserved groups.
In 2008, despite a well-developed primary care system, rural and other vulnerable populations throughout Romania experienced poor care access and wide health disparities. Outreach and community-based health services were limited and social services lacked coordination with the health system. Responsibility for managing health services was largely decentralized, but local governments were described to face capacity constraints in effectively organizing and managing community services, hindering their ability to address problems.
In 2010, the Government of Romania, together with the Swiss Agency for Development and Cooperation, developed an action plan strategizing how to work with local authorities to support implementation of community-based services targeted to rural and vulnerable populations. The approach being pursued has five key stages:
1) build local leaders’ capacities through training;
2) fund promising community health project proposals developed by training-programme participants;
3) facilitate implementation of projects through guidance and coaching;
4) conduct monitoring and evaluation for projects and document experiences;
5) share knowledge with other communities to encourage widespread adoption of successful strategies.
Local leaders identified through a two-step sensitization and selection process were invited to participate in a capacity-building training programme. A total of 61 communities across three districts expressed interest and were invited to a conference on integrated community care. Of the 61 communities, 18 were selected for capacity-building training. As part of the training process, each community developed a coordinated/integrated community health project proposal. Based on merit, seven out of the 18 project proposals were granted funding. As the initiative enters its third stage, funded proposals will be implemented by local authorities who will be coached throughout the implementation process and guided through any difficulties. Monitoring and evaluation of projects will be required to enable assessment of outcomes and implementation research will be conducted to document processes, experiences and lessons learned. Successful strategies will be shared to allow scale-up to other communities and greater roles for local authorities in leading community health services are being supported by the National Strategy for Health 2014–2020.
The Swiss Agency for Development and Cooperation initiated planning of the initiative as part of a long-term development partnership with the Government of Romania. The Government of Romania played a leading role in driving the initiative forward and making necessary funds available; Swiss funds were also put forward to support activities. Selected through a competitive open bid, the CRED Foundation and Swiss Tropical and Public Health Institute were mandated to manage the initiative and support the Romanian Ministry of Health in concept development, capacity-building, coaching and implementation research. Both organizations report to Romanian and Swiss governments under the terms of their contracts. Over time, local leaders will be expected to utilize their strengthened capacities built through the initiative to lead delivery of community health and social services for their communities.
As projects are still in the early implementation stage, outcomes have not yet been reported. It is expected that the initiative will improve care access for rural and vulnerable populations and reduce health disparities between urban and rural communities.
This case was prepared as part of a larger effort by the WHO Regional Office for Europe and published (2016) in the document, "Lessons from transforming health services delivery: Compendium of initiatives in the WHO European Region".
© Copyright World Health Organization (WHO), 2016
The methodology used for the development of this case is slightly different from the templates used on the IntegratedCare4People web platform, in particular in the analysis of enabling factors and barriers to change.
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*CRED Foundation **Swiss Tropical and Public Health Institute