USAID/Romania Strategic Objectives 3.4 and 3.2 Close-Out Report SO 3.4: Reformed Child Welfare and Women’s Health Care (FY 2002-2007) (FY 2002-06: Increased Effectiveness of Selected Social and Primary Health Care Services for Targeted Vulnerable Populations) SO 3.2: Improve the Welfare of Children and Women in Romania (FY 1998- 2001) USAID Cost: $89,776,000 of which SEED = $ 76,996,000 DA = $ 5,608,000 CSH = $ 4,000,000 ESF = $ 3,172,000 1. Principal Implementing Partners Health • JSI Research @ Training Institute • University Research Co. • Abt Associates • Society for Education on Sexuality and Contraception (SECS) • Romanian Association against AIDS (ARAS) • Population Service International (PSI)/Romania • Youth for Youth Foundation • Eastern European Institute for Reproductive Health • National Federation of Organizations for People Living with HIV/AIDS (UNOPA) • Ministry of Public Health (MOPH) • International Orthodox Christian Charities (IOCC) Child Welfare • World Learning • World Vision • Holt International Children’s Services • Bethany Christian Services • Special Olympics Romania Foundation • Motivation Foundation Romania • 75 other grantees, including: Pentru Copiii Nostri, SERA, International Foundation for Child and Family; Save the Children Romania; Pestalozzi, Fundatia de Sprijin Comunitar, Ovidiu Rom. Other • Romanian Orthodox Church (ROC) • New Horizon Foundation • UNICEF • World Bank 2. Summary of the Impact of USAID Assistance 2 Strategic Objective 3.4, “Reformed Child Welfare and Women’s Health Care,” compliments the Mission’s other strategic objectives. This strategic objective (SO) contributed to the E&E Bureau’s Social Transition Goal, Enhanced ability of all persons to enjoy a better quality of life within market economies and democratic societies. The SO focused on systemic reform and increased effectiveness of women’s health and child welfare services. Two major programs were launched during the strategy. The “ChildNet” program addressed child welfare concerns and the “Romanian Family Health Initiative” dealt with reproductive health. Romania, during the communist era, was subjected to a pro-natalist policy that banned family planning and resulted in one of the highest maternal mortality rates in the world, many of the deaths associated with unsafe abortions. Unwanted pregnancies resulted in children being abandoned by their families and placed in state institutions. In 1990, there were 170,000 children in more than 700 institutions, with few social services to help the families and children in need. Health Romania’s infant, child (under-five) and maternal mortality rates have all decreased significantly since the early 1990s. Romania has also made significant strides in improving reproductive health and family planning services. Health programs increased the use of modern family planning methods, enhanced prenatal and postnatal care, combated stigma and discrimination towards people living with HIV/AIDS, and helped family planning NGOs to become self-sustaining. The Government of Romania (GOR) has steadily increased its commitment to reproductive health care, endorsing a national family planning strategy, and integrating family planning services into primary health care. Standards of care for general practitioners to provide contraceptives were developed and implemented. The number of family planning providers in primary health care centers increased from 240 in 2000 to 5,170 in 2006. The Ministry of Public Health (MOPH) allocation for national family planning has risen from $100,000 in 2001 to more than $1 million in 2005. In 2007, the Ministry allocated $1.2 million to provide free contraceptives for low income and rural women. 240 1,080 3,310 5,171 4,313 2,311 240 192,873 205,037 184,511 153,042 54,942 18,050 685 736 1,099 1,156 1,176 1,058 883 2000 2001 2002 2003 2004 2005 2006 Number of FP providers in P HC trained by the project Number of active users of FP services, within the N atio nal F P pro gram (free contraceptives) A bo rtio n rate (per 1,000 live births) The National Family Planning Program 3 More than 40percent of women of reproductive age now use modern contraceptives that were illegal only 15 years ago. From 2000 to 2006, abortion rates declined from more than 1.2 abortions per live birth to less than 0.68 abortions per live birth. This remarkable progress establishes Romania as the leader in reproductive health in the Black Sea Region. Romania has begun to decentralize its health system and focus on reforming and strengthening primary health care and its procedures. USAID supported the improvement of financial systems in 23 hospitals across Romania. USAID also helped develop legislative guidelines for health reform, private health insurance, primary health care, and hospital accreditation. American advisors further assisted the Ministry to develop streamlined protocols for general practitioners on preventive care and treatment of chronic diseases. Child Welfare The Romanian child welfare reform programs succeeded in changing the nature of the social sector. Over 400 new community-based services—which did not exist in 1990—now support over 70percent of the children needing social services. The number of children in institutions fell from 170,000 in 1989 to less than 26,000 in 2007. Large institutions closed their doors: those with more than 100 children decreased from 700 in 1990 to only 27 today. Moreover, most children still living in residential institutions enjoy far better living conditions. The majority of the institutions provide family-type care, with less than 12 children in each institution and staff who establish more supportive relationships. The foster care system, developed rapidly after 1997 and currently provides care to 19,000 children. At the same time, USAID helped Romania to decentralize its child welfare system—the first system of services in Romania to undergo this major reform. As a result, counties are now making the major decisions about developing their child welfare services. Children in Orphanages and in Community Care 0 10 20 30 40 50 60 70 80 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Number of Children in 000s Children in Orphanages Children in Community Care 4 This was a significant step in child welfare reform that contrasts with 1990 when five different national ministries were responsible for child welfare. In addition, the central government now funds significant reforms in county programs. Since 2001, the GOR has allocated, annually, over $5 million to NGOs to develop community welfare services. The SO 3.4 programs solidified the results achieved during 17 years of assistance in health and child welfare reform and left behind a strong legacy. The programs combined reducing the number of children in institutions with decreasing the number of unwanted pregnancies in order to reduce the number of abandoned children and abortions. While we did not change the strategic objective, we were flexible in the type of activities undertaken, and took advantage of the constantly evolving Romanian environment. To contribute to the strategic objective, four intermediate results were identified: 1) Improved legal, regulatory, and policy framework; 2) Improved mobilization, allocation and use of social sector resources; 3) Increased access to quality integrated services; and, 4) Increasing citizens’ awareness of their rights and responsibilities in the social sector. The unexpected cut of the FY 2007 USAID funds meant that we were only able to achieve three of the four intermediate results. With less funding, the SO team was unable to complete assistance to increase citizens’ awareness of their rights and responsibilities in the social sector. 4. Summary of Principal Projects and Results Health USAID launched the Romanian Family Health Initiative (RFHI), in partnership with the MOPH and JSI, to train health professionals in reproductive care, increase the demand for contraceptive services, and provide contraceptive supplies for under-served groups of women. This comprehensive program dramatically increased users of modern contraceptives from less than 20,000 to over 200,000 between 1999 and 2004. Moreover, it contributed to dramatic reductions in the abortion and maternal mortality rates during the same period. A. Training health care professionals and conducting supportive supervision In Romania, most women receive their primary health care services from family doctors. RFHI successfully integrated family planning into more than 80 percent of primary health care services nation-wide by training more than 5,200 family doctors and 3,500 nurses to provide family planning services. B. Focus on Low Income and Roma women In October 2004, RFHI expanded its scope of activities to include low-income women in 11 urban areas, as well as in Roma rural communities. Communities became more aware—and more committed to helping these disadvantaged groups, and inter-disciplinary teams forged consensus about health priorities in each community. To more effectively assist Roma beneficiaries, RFHI supported the MOPH in training more than 190 Roma Health Mediators, who acted as cultural liaisons between the Roma and health and social service providers. Mediators promoted the use of and facilitated access to family planning services in Roma communities. C. Post-Abortion Care and Post-Partum Family Planning Services 5 This program reached women immediately following labor and delivery, as well as those having an abortion. With its focus on under-served groups, it educated women as well as health care providers about family planning, HIV/AIDS, and STI prevention. Nearly 60,000 women in maternity wards were included in the program. D. Logistic Management Information System (LMIS) To ensure the availability of free contraceptives at primary health care centers, RFHI developed a three-tired national LMIS that enabled program directors to forecast contraceptive need based on data from the local health centers. RFHI also helped to improve reproductive health information, safe motherhood practices, develop systems for the early detection of cervical and breast cancer, and address family violence. E. Public Outreach and Communication RFHI launched a six-part TV mini-series, “Real Women,” that was broadcast on national TV to inform women about modern contraception and women’s health,. The mini-series won two international awards for its effectiveness, as well as, the quality of its production. F. Preventing and Detecting Cancer RFHI also supported free Pap testing and screening for low-income and rural women. These women became more aware of the importance of prevention and early detection of cancer. Public health institutions joined a forum with the scientific community and civil society to reach people never before exposed to basic prevention services. G. Fighting HIV/AIDS and Domestic Violence Romania’s unique HIV/AIDS profile, with an unusually high proportion of those infected being children infected in the late 1980s and early 1990’s, coupled with discrimination, requires creative interventions. RFHI launched major awareness campaigns under the slogan “Open Your Heart!” Romanian NGOs implemented several education programs for youth. RFHI increased public awareness and helped service providers recognize the signs of domestic violence. RFHI supported a National Coalition of 30 NGOs fighting domestic violence by providing technical assistance to strengthen its management. In 2006, the GOR recognized the Coalition, which enabled it to advocate and lobby more effectively for reforms. In 2005, USAID created a partnership (Global Development Alliance) with the Romanian Orthodox Church (ROC), the Ministry of Education and the International Orthodox Christian Charities (IOCC) to change Romanians’ attitudes about HIV/AIDS and domestic violence. The partnership promoted responsible preventive behaviors, combated discrimination, and supported social inclusion of survivors of domestic violence. The program benefited from the ROC’s unique communication and institutional network and its capacity to reach places untouched by any other assistance. More than 2,100 priests and religion teachers were trained to educate parishioners and school children about HIV/AIDS and family violence. A guide for religion teachers was developed and used for planning HIV/AIDS and domestic violence sessions in schools. Also, another guide was specifically designed to help priests organize awareness raising activities in their parishes. Compassion and tolerance for victims and preventive responsible behaviors were reinforced through various community activities such as: youth initiative clubs, philanthropic committees, or community outreach and service pilot projects initiated by non-governmental 6 organizations. The ROC initiative provides a very important complementary effort to the HIV/AIDS and family violence activities implemented by the GOR and NGOs. I. NGO Sustainability and Development To ensure long-term, self-sustaining NGOs in the field of reproductive health, RFHI provided partner NGOs with the tools necessary to access public and private funding, including EU structural funds. This effort helped build a solid financial base and implement strategic plans. J. Health Reform USAID also supported a major program to support the MOPH’s reforms to improve the quality of primary health care. University Research Corporation (URC), our implementing partner, helped craft secondary legislation for key laws which had been passed, including private health insurance. URC also developed a health policy toolkit for the Ministry to use for improving local health care facilities, and pilot programs in three cities to address quality of care and clinical performance. Child Welfare USAID’s work in child welfare evolved from humanitarian assistance and isolated pilot projects into a systematic program of reform with the development of community services, and concluded with an umbrella partnership program. Each program was informed and guided by the previous one and the rapidly changing child welfare environment. In 2001, USAID launched the $16.5 million ChildNet program. ChildNet is a partnership between USAID, the GOR, and World Learning to provide grants, training and technical assistance to NGOs providing community welfare services for children with disabilities, infants abandoned in maternity hospitals and youth graduating from state orphanages. A. Humanitarian Response In 1991, USAID responded to the tragedy of more than 170,000 children abandoned in institutions with humanitarian assistance, seeking to improve the conditions in the state-run orphanages and the lives of the children. In addition, it supported NGOs that developed and provided innovative services. Isolated pilot projects increased the ability of NGOs to demonstrate quality services, and helped establish models of good practice. However, these had little impact on the larger system. B. Decentralization of the Child Welfare System During 1996, the Romanian and American governments agreed that substantial reform of the child welfare services was necessary. In close coordination with other donors (UNICEF, World Bank), USAID helped the GOR develop legislation that created the Department of Child Protection and decentralized child welfare, transferring responsibility to the county authorities. C. Creating Community Child Welfare Services In 1998, USAID funded World Vision, Bethany and Holt to pilot innovative services in three counties (Iasi, Cluj and Constanta). The three NGOs successfully reintegrated children into the community, and prevented other children from being abandoned in the institutional system, demonstrating that non-residential services were far cheaper and much more effective than the residential alternative. They introduced alternative services and helped to close some of the large institutions. This approach was later expanded to include 7 a focus on the quality of the services. An evaluation indicated that the three counties averaged 21 percent less institutionalization than other counties in the period 1997−2000. The ChildNet grants created over 300 community services in 38 of Romania’s 41 counties and in Bucharest. According to periodic reviews by World Learning and the National Authority for the Protection of Children, 90percent of the services created were run by counties or NGOs and were sustainable. More than 19,000 children and their families received services during ChildNet and the services created continue to provide support to additional children as a legacy of USAID’s assistance. D. Development of Child Welfare Services Standards Several advisors drafted legislation regarding child welfare service standards. Fourteen standards were legislated with ChildNet support. As the program approached closure, the technical assistance component focused more on the philosophy of ensuring permanency planning for all children separated from their families. E. Strengthening Child Welfare NGOs As closure of the ChildNet approached, the project tightened its focus on NGO sustainability and civil society development. All 75 ChildNet grantees received technical assistance, and 45 grass-roots organizations received training in fundraising, constituency building and providing professional services in accordance with the standards. In addition, USAID supported the creation of a strong NGO Federation that currently includes over 100 member organizations country-wide. Corporate social responsibility was an area supported by ChildNet as a solution for funding of the services created by the NGOs. Support to United Way Romania resulted in a comprehensive long-term development plan. The organization has expanded every year, from funding three pilot services in 2004 to 15 services in 2006. F. Training Child Welfare Professionals and Civil Servants During 1998 and 1999 about 60 high-level civil servants traveled to the United States to study governmental structures and child welfare services. Participants returned with a new vision and began making changes without any additional funding. Most of these individuals continue as reformers. Furthermore, ChildNet trained more than 9,000 child welfare professionals and mayors. Success Stories 1. Open Your Eyes! Open Your Heart! More than eight million people educated in Romania’s AIDS awareness campaign http://www.usaid.gov/stories/romania/fp_romania_aids.html 2. Live-Saving Health Seminars Come to Romania Forty-year-old woman from rural village survives cancer through early detection http://www.usaid.gov/stories/romania/ss_romania_cancer.html 3. Emergency Assistance In Romania’s Countryside 24-year-old firefighter provides emergency treatment to save lives with USAID help. http://www.usaid.gov/stories/romania/fp_romania_firefighter.html 4. Partnership Prevents Child Abandonment USAID helps poor families reintegrate children and provide alternatives to orphanages. 8 http://www.usaid.gov/stories/romania/cs_romania_adoption.html 5. Prospects for the Future RFHI is part of the National Reproductive Health Strategy and is well integrated in the programs of the Ministry of Public Health. The program left behind a pool of health care workers providing family planning services, and an accredited Romanian NGO on providing training in reproductive health. The increased use of contraceptives by the public health system and the private market, together with the decrease in abortion, demonstrates that women have changed their attitudes and behavior regarding modern contraception. The main challenge family planning programs face is funding. The GOR’s willingness to continue to allocate funds for reproductive, while positive to date, is not certain. Moreover, the Ministry is still reluctant to contract for reproductive services from NGOs. Regarding child welfare, there are reasonable prospects for the reforms to be sustained. Most of the large orphanages have either been closed or no longer provide residential services. Some of them are being used for other services, such as day care and rehabilitation centers for disabled children. The institutionalization of children is now less acceptable than it was ten years ago. The attitudes of the authorities in charge of child welfare have changed dramatically. Stronger professional associations of social workers are empowered to advocate for better and more professional services. However, the danger of under-funding of the new community services may still lead to a decrease in the quality of care provided. The possible decrease in resources for the NGOs after the departure of the major donors remains a concern. Romania has not yet developed a solid infrastructure of private support for civil society. The contracting for child welfare services from NGOs by local governments is still in its early stages. People are still learning how to use the the 2percent law that allows individual citizens to fund the NGOs of their choice. The partnership USAID developed with the Romanian Orthodox Church to fight HIV/AIDS and family violence leaves behind a network of professional trainers with strong community links and an increased capacity within the Church to mobilize communities to address HIV/AIDS, family violence, or other social issues. The training curricula and the manuals on HIV/AIDS, domestic violence and community development, and the guides for priests and teachers are valuable tools that will be used in future activities. The main challenge for the ROC in the coming years is to raise funds from local resources to sustain their social activities, especially in sensitive areas such as HIV/AIDS and domestic violence. 6. Lessons Learned for Other Programs: The long-term success of these social programs can be attributed to four factors: A. Build Partnerships involving the Government Both the ChildNet and RFHI program were based on firm partnerships with the GOR. This approach established mutual trust, and increased USAID’s influence in developing policy. Long-term sustainability also was a result of this approach. B. Foster Donor Collaboration When donors speak with one voice, assistance can more easily achieve intended results. A common donor agenda helps pave the way to major policy changes. For example, donors 9 agreed that the large orphanages should be closed and the partnership enabled them to leverage considerable political and professional pressure to bring this about. In turn, this partnership enabled the GOR to address the concerns of the international community that had been shocked by pictures of the children in the large orphanages in the early 1990s. Good communication among donors helps to avoid overlaps and wasted resources. C. Forge Stakeholder Consensus Bringing together local civil society, government, international organizations and private businesses ensured efficient and effective collaboration. This avoided overlaps of different programs and helped leverage support and funds for USAID funded programs. D. Reach Out to Multiple Interest Groups While preventing health and social problems such as HIV/AIDS and family violence has been seen as the domain of health and social welfare professionals, the churches also make important contributions to the protective factors that help community members become healthy and responsible individuals. A comprehensive approach to the awareness and prevention of HIV/AIDS and family violence requires the involvement and effective partnering of multiple groups in society. 7. Performance Indicators: Health: SO 3.4 indicator: Abortion rate The abortion rate was used in years where the contraceptive prevalence rate (CPR) was not available because it can be calculated only through reproductive health surveys. The abortion rate is collected through official health statistics. A review of abortion rates and the CPR in Romania, as well as anecdotal experience, indicates a strong inverse relationship between them. An increase in CPR is associated with a decrease in the abortion rate. The abortion data were interpreted with care, as we suspected that official statistics under-report the number because the abortions performed in private health clinics are often not reported so that the doctors can avoid paying some income taxes. Nevertheless the decrease in abortions is obvious in both the official statistics and survey data. IR 3.4.1 indicator: Five items comprising the improved legal, regulatory and policy framework for health care The five items were: approval of the National Reproductive Health Strategy; approval of technical norms for FP program; Logistics and Management Information system in place to track contraceptive supplies; access of uninsured population to FP services; standard guidelines issued on family planning services, pre and post natal care, and post abortion contraception. Data were collected annually from official documents issued by GOR and MOPH. IR 3.4.2 indicator: Annual budget allocations for the family planning program The annual budget allocation influences the progress of the program. Changes in the allocation reflect the importance given to family planning among the public health issues and the availability of funds. The data were collected annually, based on official documents issued by the MOPH. I.R. 3.4.3 indicator – A weighted score reflecting access to services This weighted score takes into account the importance of various reproductive health areas based on a clearly defined weighting scheme. It reflects the availability of trained providers that offer integrated reproductive health services in primary health clinics. The data are 10 collected from the standard training sheets used throughout the project. The data was reviewed by trained database managers. Child welfare: SO 3.4 Indicators: 1. The proportion of children having an open case with the county receiving alternative welfare services that meet the national standards of the Romanian National Authority. USAID assistance focused on the development of a network of alternative child welfare services capable of preventing child institutionalization and supporting the reunification of children with their biological families or with another permanent family. The results achieved were measured in annual surveys conducted by the National Authority for Child Protection. 2. Child Institutionalization rate: Proportion of children living in state-run institutions. Data were provided annually by the National Authority for Child Protection. IR 3.4.1 indicator - Improved legal, regulatory and policy framework. USAID assistance helped the development of the legislation that allowed for the decentralization of child welfare services (1996) and the development of child welfare service standards and procedures to guide the increase in quality of the newly created community￾based services (2001 – 2007). The indicator was a measure of the drafting, passage and implementation of legislation concerning the standards of child welfare care. Information was provided in the ChildNet quarterly reports. IR 3.4.2 indicator - Improved mobilization, allocation and use of social sector resources. USAID assistance focused on the closure of state-run institutions through the creation of alternative child welfare services at the community level. This indicator was measured by the number of state-run institutions caring for institutionalized children. Data were provided by the National Authority. 8. Evaluations and special studies • Mid-term Project Assessment of the RFHI – performed in April 2004 • Romania: Scaling up integrated family planning services; case study developed by Deliver project, November 2006 • Holt International Children’s Services – ten years of assistance in Romania – an evaluation of USAID-funded services • Correll, L. et al, USAID and Child Welfare Reform in Romania: Challenges, Successes and Legacy, July 2006 • USAID Strengthening Roma Communities in Romania, Management Systems International • Fern Greenwell – Child Abandonment in Romania, 2001 Reports are on file with CDIE in USAID/Washington at http://dec.usaid.gov. 9. Final reports of contracts, grants; and cooperative agreements RHCRP - implemented by URC, RFHI - implemented by JSI, ChildNet – implemented by World Learning, and World Vision and Bethany Christian Services. Reports are on file with CDIE in USAID/Washington at http://dec.usaid.gov. 11 10. Contact names and addresses of names and contact points a. U.S. JSI Research @ Training Institute: www.romania.jsi.com University Research Co., LLC: www.urc-chs.com Abt Associates Inc.: www.abtassociates.com World Learning International: www.worldlearning.org b. Romanian Society for Education on Contraception and Sexuality (SECS): www.secs.ro Romanian Association against AIDS (ARAS): www.arasnet.ro Population Service International (PSI)/Romania: www.psi.org/ Youth for Youth Foundation: www.y4y.ro National Federation of People Living with HIV/AIDS organizations (UNOPA): www.unopa.ro National Authority for the Protection of Children’s Rights: www.copii.ro Ministry of Public Health: www.ms.ro