Developing guidelines to reduce under-five child mortality in the Republic of Moldova
- Elevated rates of child mortality in home settings, particularly for vulnerable groups.
- Out-of-date practices for detecting and treating childhood illness, with an overemphasis on clinical assessment.
- Limited education for providers and parents regarding childhood illness.
- The government developed an under-five child mortality reduction initiative and established new standards and protocols for the observation of childhood illness.
- Research conducted prior to the initiative identified the root causes of problems and provided evidence of the need to act.
- Guidance and support from the Ministry of Health led to coordinated intersectoral action.
- Educating and expanding providers’ competencies challenged pre-held attitudes regarding the detection and treatment of childhood illness.
- Joint-sector delivery by health providers and social workers facilitated more comprehensive and coordinated care for patients.
- National ownership over the initiative was important; activities were fully integrated into national standards and supported with legislation.
Despite declining child mortality in the Republic of Moldova throughout the 2000s, child mortality rates remained above the WHO European Regional average in 2010: 12 per 1000 live births compared to 8 per 1000 live births. The main cause of mortality was respiratory disease, specifically pneumonia. Vulnerable populations (such as children from rural areas, low socioeconomic families and migrant populations) were disproportionally affected. Newborn care was largely reliant on out-of-date practices, overemphasized clinical assessment, and failed to adequately recognize wider risk factors (such as the home environment). Insufficient continuing education for providers relating to childhood illness hindered timely diagnostic treatment, as did the lack of parent education on early warning signs.
The government developed an under-five child mortality reduction initiative through intersectoral collaboration across ministries and enacted regulation in 2010 to provide a framework for action. The initiative is aiming to reduce hospital admissions and increase preventive measures for at-risk children by broadening the care continuum and incorporating social services. Specific social support services are now targeted to the under-five population living in vulnerable households (such as legal advice, assistance with medical and legal documentation, unemployment assistance and food aid). The initiative has also reorganized providers to encourage joint-sector delivery between health and social sectors. All at-risk children are now recorded in a database and assessed and managed by health providers and social workers cooperating in teams. An initial assessment using a government-defined questionnaire is carried out. A more comprehensive assessment then follows, enabling development of a personalized care plan based on individual needs. Reassessments are then conducted monthly (or more frequently if warranted). New screening protocols are used to guide symptom assessment in community settings. A simplified three-category model is applied to determine intervention: 1) immediate hospitalization, 2) outpatient treatment, or 3) specialized care at home. This model has supported increased responsiveness to children’s symptoms. Development partners supported initial training of providers; however, the initiative is now fully self-sustaining and embedded within the health system and legislative structure.
The Ministry of Health conducted initial research on the causes of at-home child mortality and led necessary changes through a top-down approach. Understanding that the complex, multifactorial nature of the key problems warranted intersectoral action, the Ministry of Health formed collaborative partnerships with other ministries (including the Ministry of Labour and Social Security and the Ministry of Internal Affairs) and international partners to facilitate implementation of the initiative. NGO Lumos and UNICEF provided technical and training support during the initial phases. Today, the Ministry of Health continues to oversee implementation of activities and monitor outcomes for the initiative.
The initiative built on the progress in under-five child mortality rates achieved through the Integrated Management of Childhood Illness (IMCI) Strategy to decrease at-home child mortality through increasing social support to vulnerable families. For the first time in 20 years, at-home child mortality accounted for 15% of all-child mortality, down from approximately 25%.
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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Ministry of Health