Reducing the Burden of Non-Communicable Disease in Moldovan communities – the role of community nursing

摘要

Detection, treatment and management of NCDs have become increasingly the focus of the Moldovan health system. The important role of community medical assistants (CMA) for a more horizontal approach to primary care and its response to the NCD epidemic is receiving growing attention. In reality, however, their role within family medicine teams is not well described. Clear regulations and specific job profiles are under-developed and training curricula diverse. The present assessment analyses current work profiles and perceptions of CMAs with a view of strengthening their role in the management of a multi-disciplinary response to NCD prevention, care and case management at the level of Moldovan communities. Methods included a review of literature and the Moldovan regulatory environment, key informant interviews, a multiple choice questionnaire, short reports by community medical assistants on daily activities and focus group discussions. From a total of approximately 22,000 nurses in Moldova 683 are registered to be working as CMAs. Only 18% of those (n=132) are working full time in their profession. The majority work in family doctor’s practices with a shared portfolio of working as a family doctor’s medical assistant and as a CMA. A small percentage works for national NGOs particularly for those, which deliver publicly funded services like home care, palliative care, community mental health care and youth friendly health care services. A separate budget for community NCD prevention and care with the National Health Insurance Company (NHIC) does not exist. More than two-thirds of the survey respondents have a minimum level of knowledge in CN but only 11% of respondents recognize the underlying core competencies. CMA activities are currently regulated by a Ministry of Health order (from 2014) that speaks only to the main work tasks, attributions, organization and groups of beneficiaries, but lacks a clear delineation. This lack of delineation and the tendency for the role to be only a part time one, is exacerbated by the low value that family doctors attach to community outreach activities. It is only recently that the process of developing a professional profile of community nursing and the related qualification standards has started. A community social assistance service was set-up in 2008 but so far with little multi-sectoral collaboration at a larger scale. However, pilot models of collaboration between CMA and community social assistance are being explored, learning also from relevant aspects in Romania as well as Bosnia-Herzegovina. Some conclusions and lessons learnt are: Community nursing is a critical link for a multi-disciplinary response to NCD prevention and care at local level; Professional profiles are needed to delineate a clearer role for community interventions in terms of disease management as well as primary and secondary prevention; Community nursing in collaboration with community social assistance could create a Basic Collaborative Onsite as a step to integrated NCDs services; Funding community nursing through family doctors’ practices remains problematic and may constrain the full potential of community nursing; Speciality training and Continuing Professional Education options to ensure a pipeline of community nurses are urgently needed.