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Background The aim of this study is to determine the feasibility of implementing and evaluating the World Health Organization Package of Essential Non-communicable Disease Interventions (WHO PEN) approach in primary healthcare in the Republic of Moldova. Methods According to our published a priori methods, 20 primary care clinics were randomized to 10 intervention and 10 control clinics. The intervention consisted of implementation of adapted WHO PEN guidelines and structured training for health workers; the control clinics continued with usual care. Data were gathered from paper-based patient records in July 2017 and August 2018 resulting in a total of 1174 and 995 patients in intervention and control clinics at baseline and 1329 and 1256 at follow-up. Pre-defined indicators describing assessment of risk factors and total cardiovascular risk, prescribing medications and treatment outcomes were calculated. Differences between baseline and follow-up as well as between intervention and control clinics were calculated using logistic and linear regression models and by assessing interaction effects. Results Improvements were seen in recording smoking status, activity to measure HbA1c among diabetes patients and achieving control in hypertension treatment. Improvement was also seen in identification of patients with hypertension or diabetes. Less improvement or even deterioration was seen in assessing total risk or prescribing statins for high-risk patients. Conclusions It is feasible to evaluate the quality and management of patients with non-communicable diseases in low-resource settings from routine data. Modest improvements in risk factor identification and management can be achieved in a relatively short period of time. [ABSTRACT FROM AUTHOR]

Despite the appreciation of inter-sectoral cooperation in integrated community care by decision makers and practitioners from health (65.5%) and social care (72.4%) qualitative data from districts piloting Integrated Care Models show that medical and social sectors continue to approach beneficiaries separately with little outreach support, large differences in understanding the nature of inter-sectoral collaboration, rather referral of cases between sectors than joint assistance and no substantial difference in satisfaction of NCD patients and their families. The Swiss funded second phase of the Healthy Life Project (HLP) supports MoH to develop and apply integrated care at district and community levels based on the experience and evidence generated in phase one. The main principle when scaling up integrated community care approaches to new districts was to ensure multidisciplinary collaboration in all stages, and communities involving community nurse and social worker as core team. Other relevant sectors to respond to the needs of vulnerable NCD patients, like police, education, as well as NGOs and volunteers, and representatives of the Local Public Authority were mobilised. Knowledge transfer, developing a common vision for integrated community services and strengthening critical functions, like community nursing, to engage in preventive care, following up NCH patients and supporting vulnerable groups are critical. Peer to peer support and the organisation of study visits between districts and communities with existing experience in integrated community services and working with multidisciplinary teams helped strengthen the practical abilities of new adopters. Practitioners that already applied integrated community care helped new districts to develop their own model of IC based on the data from local health profiles and a community assessment of existing resources. HLP supported local public authority to complement missing resources (equipment to monitor and provide outreach services, community facilities, etc.) as well as with coaching and supervision activities provided by international and project experts and experienced districts professionals. Districts Councils of Public Health are a well-established forum for inter-sectoral decision making. HLP strengthened their capacity to create and review evidence, analyse data, monitor progress, assess results and make appropriate adjustments to the local integrated care solutions. Continued capacity building for all sectors involved, the institutionalisation of developed training modules, the adaptation of existing regulations and the development of appropriate regulatory framework for Integrated Care at district and national levels are required to strengthen the sustainability of the approach. The tested approach to integrated community care requires resources and time that usual are not available within the project-based initiatives. Thus, strong partnerships with public structures and academia are necessary to ensure transparency and continuity of the learning process. The capacity building process for integrated community care is complex including all elements of transferring theoretical and practical knowledge as well as the application of working tools and procedures in real life to build IC models that work in specific community situations involving existing resources and capacities. [ABSTRACT FROM AUTHOR]

An increased burden of non-communicable diseases (NCDs) and the likelihood of premature death in rural Moldova caused the Ministry of Health, Labour and Social Protection (MHLSP) to explore new directions in PHC service provision. Supported by Swiss Development Cooperation (SDC), the MHLSP developed and tested an integrated people centred health services (IPCHS) models in 38 communities from three raions since 2019. The Healthy Life Project used a continuous quality improvement (CQI) approach to facilitate conceptualisation and implementation of targeted multi-sectoral intervention involving key stakeholders at local level, to address people's health and social needs. This included an extensive capacity-building component for health and social care workers, other sectors and Local Public Authorities (LPAs). The project aims at to reduce the burden of NCDs in rural Moldova. A district and community intervention is combined with health promotion and health education with positive effects on patients' health and wellbeing. The project worked with PHC centres, social workers and their reference structures, LPAs and Public Health Commissions, with NGOs, formal and informal carers, volunteers. It targets the patients with NCDs, including elderly, living in rural communities. Development of the project started in 2018 and pilot raions were supported with two half year funding cycles (small grant schemes) in 2019 and 2020. A total of 32 health offices and 6 integrated community centres where supported to facilitate integrated care, based on capacity building of PHC teams (PEN protocols, peer groups, community nursing), 48 community multidisciplinary teams (Case Management) and LPAs (coordination role). Policy work improved intersectorial collaboration and development of decentralised approaches. More than 2000 NCD patients were reached leading to more than 1300 integrated assessments and intervention for 400 NCD patients with complex needs. This has benefited from consistent support of the MHLSP. Capacity building at all levels and policy work increases the chances for sustainability. Continuous funding for medico-social services beyond using existing resources and the potential cost-saving effects of preventive approaches may be an issue in the future. Nationwide dissemination of IPCHS is envisaged in Moldova. However, substantial capacity building efforts will be needed. The project will support this development for the next few years. IPCHS has great potential to reach people with complex needs in rural areas. Results from practice shows substantial amount of uncovered needs and that long-term case-management for NCD patients is relatively new. Evidence from implementation was used for policy development. The motivated local teams are essential to lead innovations, to improve and better target the needs of NCD patients. Although the presented work is not based in a proper research setting, the many small studies (needs assessments) and accompanying qualitative research show the positive effects of community integrated services on remote living NCD patients and their caretakers. Setting up ICPHS at raion and community levels is a complex undertaking. A variety of entry points have to be used to address the full complexity of people's needs. Regional and local leadership structures are needed to create a decentralised approach, closer to the people. [ABSTRACT FROM AUTHOR]

Noncommunicable diseases (NCDs) are a growing challenge in the Republic of Moldova. A previously reported pilot cluster randomized controlled trial aimed to determine the feasibility of implementing and evaluating essential interventions for NCDs (e.g. cardiovascular risk scoring, hypertension management, statin treatment, etc.) in primary health care in the Republic of Moldova, with a view toward national scale up. One-year follow-up data (previously published) demonstrated modest improvements in NCD risk factor identification and management could be achieved. Herein, we report the second-year follow-up data and conclude that sustainable improvements in NCD risk factor control (e.g. hypertension control) can be achieved in primary health care in low resource settings by adapting existing resources (e.g. WHO PEN) and conducting focused clinical training and support. If scaled to a national level, these improvements in risk factor control could significantly translate to reductions in premature mortality from NCDs.

Introduction: Nearly 90% of all deaths in the Republic of Moldova are caused by non-communicable diseases, the majority of which (55%) are caused by cardiovascular diseases (CVD). In addition to reducing premature mortality from CVD, it is estimated that strengthening primary healthcare could cut the number of hypertension-related hospital admissions and diabetes-related hospitalisations in half. The aim of this evaluation is to determine the feasibility of implementing and evaluating essential interventions for the prevention of CVD in primary healthcare in the Republic of Moldova, with a view towards national scale-up., Methods and Analysis: A national steering group including international experts will be convened to adapt WHO Package of Essential NCD Intervention from Primary Healthcare in Low Resource Settings protocols 1 and 2 to the health system of the Republic of Moldova, develop and conduct training of primary healthcare workers and test a core set of indicators to monitor the quality of care and change in clinical practice. To evaluate the impact of this pilot implementation, a pragmatic, sequential mixed methods explanatory design, composed of quantitative and qualitative strands of equal weight, will be used. Twenty primary healthcare centres will be selected and randomised to the training and implementation arm (n=10) and the usual care arm (n=10). At baseline and 12 months follow-up, a standardised data collection form will be piloted to extract data directly from patient paper records in order to estimate the change in clinical practice. Semi-structured interviews and interclinic peer workshops will be conducted at 12 months follow-up, and qualitative data collected from these formats will be analysed thematically for explanatory themes that relate to the quantitative findings., Ethics and Dissemination: Ethical review and approval has been obtained. Findings of the evaluation will be shared in a project report to key stakeholders, presented back to participants and written into a manuscript for an open access peer-reviewed scientific journal., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.)

Objective: To evaluate the prevalence and causes of blindness and visual impairment, the prevalence of diabetes mellitus and diabetic retinopathy among people aged ≥50 years in the Republic of Moldova using Rapid Assessment of Avoidable Blindness plus Diabetic Retinopathy ('RAAB+DR') techniques., Materials and Methods: 111 communities of people aged ≥50 years were randomly selected. In addition to standard RAAB procedures in all people with diabetes (previous history of the disease or with a random blood glucose level >11.1 mm/L (200 mg/dL)), a dilated fundus examination was performed to assess the presence and the degree of diabetic retinopathy using the Scottish DR grading system., Results: 3877 (98%) people out of the 3885 eligible people were examined. The prevalence of blindness was 1.4% (95% CI 1.0% to 1.8%). The major causes of blindness and severe visual impairment were untreated cataract (58.2%), glaucoma (10.9%), and other posterior segment causes (10.9%). The estimated prevalence of diabetes was 11.4%. Among all people with diabetes, 55.9% had some form of retinopathy, and sight threatening diabetic retinopathy affected 14.6%., Conclusions: The RAAB+DR survey in the Republic of Moldova established that untreated cataract is the major cause of avoidable blindness in rural areas. This needs to be tackled by expanding the geographical coverage of cataract surgical services., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)