Assessing the respect of children’s rights in hospital in the Republic of Moldova
Assessing the respect of children’s rights in hospital in the Republic of Moldova
By: Ana Isabel Fernandes Guerreiro
ABSTRACT This report describes findings and recommendations of the assessment of children’s rights in hospital in the Republic of Moldova that took place as part of overall efforts of the Ministry of Health in improving quality of paediatric care in hospitals (QoC) supported by WHO. In the framework of the assessment of QoC, a set of specific tools were used for the assessment and improvement of the respect of children’s rights in 21 children’s hospitals.
Keywords CHILDREN, HOSPITALIZED PATIENTS’ RIGHTS PEDIATRICS
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CONTENTS Page
Acknowledgement ................................................................................................................ 1 Executive Summary .............................................................................................................. 1 List of annexes ..................................................................................................................... 2 Introduction ......................................................................................................................... 4 Part 1: Work methodology .................................................................................................... 4 Summary Chart 1. General information on the self-evaluation process and work methodologies ............................................................................................................. 6 Part 2: Analysis of the assessment results in hospitals ............................................................ 8 Standard 1. Quality services for children........................................................................ 8 Standard 2: Equality and non-discrimination ................................................................ 11 Standard 3: Play and Learning .................................................................................... 12 Standard 4: Information and participation ................................................................... 13 Standard 5: Safety and environment ........................................................................... 15 Standard 6: Protection ............................................................................................... 16 Standard 7. Pain management and palliative care ........................................................ 17 Part 3: Recommendations for hospitals and Ministry of Health in Moldova .............................. 18 Annexes ........................................................................................................................ 21
Annex 1. Hospital names and abbreviation .................................................................. 21 Annex 2. Standard 1: Quality services for children: 1.1. The hospital/health service ensures that all institutional activities are based on the best evidence available and that staff are adequately trained: inputs from the self-evaluation teams............................... 21 Annex 3. Standard 1: Quality services for children: 1.1. The hospital/health service ensures that all institutional activities are based on the best evidence available and that staff are adequately trained: Children’s and parents’/carers’ views and evaluation ......... 22 Annex 4. Standard 1: Quality services for children: 1.2. The hospital/health service ensures that all types of services provided within the organization are regularly monitored and evaluated: inputs from the self-evaluation teams................................................... 23 Annex 5. Standard 1: Quality services for children: 1.3. The hospital/health service has a Charter on Children’s Rights, in line with the United Nations Convention on the Rights of the Child: inputs from the self-evaluation teams .......................................................... 23 Annex 6. Standard 1: Quality services for children: 1.4. The hospital provides the possibility for parents/carers to stay with their child at all times during hospitalization: inputs from the self-evaluation teams. ........................................................................ 24
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Annex 7. Standard 1: Quality services for children: 1.5. The hospital/health service pays special attention to the rights of adolescents to health care: inputs from the selfevaluation teams ....................................................................................................... 25 Annex 8. Standard 2: Equality and non-discrimination: Right 2.1. The hospital/health service fulfils the rights of access of all children without discrimination of any kind: inputs from the self-evaluation teams. .................................................................................. 25 Annex 9. Standard 2: Equality and non-discrimination: Right 2.1. The hospital/health service fulfils the rights of access of all children without discrimination of any kind: inputs from the self-evaluation teams: Children’s and parents’/carers’ views and evaluation. .... 26 Annex 10. Standard 2: Equality and non-discrimination: 2.2. The hospital/health service delivers a patient-centred care, which recognizes not only the child’s individuality and diverse circumstances and needs, but also those of his or her parents or carers: inputs from the self-evaluation teams. .................................................................................. 26 Annex 11. Standard 2: Equality and non-discrimination: 2.3. The hospital/health service ensures the respect of children’s privacy at all times: inputs from the self-evaluation teams........................................................................................................................ 27 Annex 12. Standard 2: Equality and non-discrimination: 2.3. The hospital/health service ensures the respect of children’s privacy at all times: Children’s views and evaluation. ... 27 Annex 13. Standard 3: Play and Learning: 3.1. The hospital/health service ensures the right to play for all children without discrimination of any kind: inputs from the selfevaluation teams. ...................................................................................................... 28 Annex 14. Standard 3: Play and Learning: 3.1. The hospital/health service ensures the right to play for all children without discrimination of any kind: inputs from the selfevaluation teams: Children’s and parents’/carers’ views and evaluation. ........................ 29 Annex 15. Standard 3: Play and Learning: 3.2. The hospital/health service planning takes into account children’s views of what is needed: inputs from the self-evaluation teams. . 29 Annex 16. Standard 3: Play and Learning: 3.3. The hospital/health service provides complementary play and educational activities: inputs from the self-evaluation teams. .. 30 Annex 17. Standard 4: Information and participation: 4.1. The hospital/health service ensures an environment based on trust, information-sharing, the capacity to listen and sound guidance that is conducive to the child’s effective participation: inputs from the self-evaluation teams. ................................................................................................ 30 Annex 18. Standard 4: Information and participation: 4.2. The hospital/health service ensures that all appropriate staff has the skills to engage in dialogue and informationsharing with children of all ages and maturity: inputs from the self-evaluation teams. .... 31 Annex 19. Standard 4: Information and participation: 4.3. The hospital/health service engages with children for the development and improvement of health care services: inputs from the self-evaluation teams ......................................................................... 32 Annex 20. Standard 5: Safety and environment: 5.1. The hospital/health service infrastructure is designed, furnished and equipped to meet children’s safety and mobility needs: inputs from the self-evaluation teams............................................................... 32 Annex 21. Standard 5: Safety and environment: 5.2. The hospital/health service policies and practice support the best possible nutrition for children: inputs from the selfevaluation teams. ...................................................................................................... 33
Annex 22. Standard 5: Safety and environment: 5.3. The hospital/health service policies and practice ensure a clean environment for children at all times: inputs from the selfevaluation teams. ...................................................................................................... 33 Annex 23. Standard 6: Protection: 6.1. The hospital/health service has in place a system that ensures protection of the right of the child against all forms of violence: inputs from the self-evaluation teams. .......................................................................................... 34 Annex 24. Standard 6: Protection: 6.2. The hospital/health service ensures that all appropriate staff has the adequate skills to protect, treat and refer children who have been a victim of any kind of abuse or unintentional injury: inputs from the self-evaluation teams........................................................................................................................ 34 Annex 25. Standard 6: Protection: 6.3. Clinical research and trials are strictly regulated by hospital/health policy: inputs from the self-evaluation teams. ....................................... 35 Annex 26. Standard 7: Pain management and Palliative care: 7.1. The hospital/health service policy ensures the prevention and management of pain: inputs from the selfevaluation teams. ...................................................................................................... 35 Annex 27. Standard 7: Pain management and Palliative care: 7.2. The hospital’s/health service’s policy and practice ensure that palliative care is provided to all children who face life-threatening illness: inputs from the self-evaluation teams. ...................................... 36
Assessing the respect of children’s rights in hospital in the Republic of Moldova page 1
Acknowledgement This report was written based on the results of the paediatric hospitals surveys in Republic of Moldova that aimed at identifying and assessing gaps between the full respect of children’s rights in hospitals and the actual practice. The assessment was supported by the Ministry of Health and the WHO Regional Office for Europe. The original set of tools developed by the Task Force on Health Promotion for Children and Adolescents in and by Hospitals and Health Services (Task Force HPH-CA) was adapted to the country context. In overall, a process of the assessment and report writing was coordinated by Vivian Barnekow and Aigul Kuttumuratova from Child and Adolescent Health programme of WHO Regional Office for Europe and Larisa Boderscova from the WHO country office. The report was prepared by WHO consultant Ana Isabel Guerreiro. We would like to thank Dr Jarno Habicht and the WHO Country Office team in Moldova and, in particular, Dr Larisa Boderscova, Family and Community Health program officer, for support in data collection and dissemination, as well as for compiling them in summary tables. Special thanks go to the national focal point Dr Ala Cojocaru and the hospital assessment teams for coordinating the process of primary data collection in the project hospitals. This report was produced within the framework of the Biennial Collaborative Agreement (BCA) 2012–2013 signed between the Ministry of Health of the Republic of Moldova and the Regional Office for Europe of the World Health Organization.
Executive Summary The assessment of the respect of children’s rights in 21 hospitals in Moldova was carried out upon recommendation by WHO Regional Office for Europe with the aim to strengthen the evidence and overall recommendations to the Ministry of Health on improving quality of care for children in hospitals in Moldova and, in particular, the area of children’s and parents’/carers’ rights. A set of specific tools were used for the assessment and improvement of the respect of children’s rights in hospitals. The findings and recommendations identified in the assessment of children’s rights in hospitals in Moldova related mostly to the inputs provided by the self-evaluation teams. In future assessments, it is recommended that children and parents/carers play a more significant role in the process. In terms of quality of care, the average answer provided by parents/carers in all participating hospitals was “probably, we received the best care within the existing conditions”. Concerning the respect of specific rights, the main findings include the following: Moldova has not adopted a Charter on Children’s rights in hospitals at national level, that is why it has not been adopted by health facilities and it is not displayed in hospitals; all medical doctors and nurses working in paediatric care have a specialization in paediatrics and health care is delivered in accordance to national guidelines and protocols, although these should be aligned to international standards; relevant statistical data is collected and made available at the Ministry of Health’s website; there are mechanisms in place to ensure that all children have equal access to health services, including specific measures addressing Roma children; and attention is paid to the right to food. The main gaps include: the lack of respect, protection and fulfilment of children’s right to play and learning, information and participation; several actions are missing to ensure the effectiveness of the system in identifying children who have been a victim of abuse and in protecting them against further violence; there are no protocols and procedures for the prevention and management of
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pain in hospital; and there is a need to improve the design and equipment of infrastructures in all participating hospitals.
List of annexes Annex 1. Hospital names and abbreviations Annex 2. Standard 1: Quality services for children: 1.1. The hospital/health service ensures that all institutional activities are based on the best evidence available and that staff are adequately trained: inputs from the self-evaluation teams Annex 3. Standard 1: Quality services for children: 1.1. The hospital/health service ensures that all institutional activities are based on the best evidence available and that staff are adequately trained: Children’s and parents’/carers’ views and evaluation Annex 4. Standard 1: Quality services for children: 1.2. The hospital/health service ensures that all types of services provided within the organization are regularly monitored and evaluated: inputs from the self-evaluation teams Annex 5. Standard 1: Quality services for children: 1.3. The hospital/health service has a Charter on Children’s Rights, in line with the United Nations Convention on the Rights of the Child: inputs from the self-evaluation teams Annex 6. Standard 1: Quality services for children: 1.4. The hospital provides the possibility for parents/carers to stay with their child at all times during hospitalization: inputs from the selfevaluation teams Annex 7. Standard 1: Quality services for children: 1.5. The hospital/health service pays special attention to the rights of adolescents to health care: inputs from the self-evaluation teams Annex 8. Standard 2: Equality and non-discrimination: Right 2.1. The hospital/health service fulfils the rights of access of all children without discrimination of any kind: inputs from the selfevaluation teams Annex 9. Standard 2: Equality and non-discrimination: Right 2.1. The hospital/health service fulfils the rights of access of all children without discrimination of any kind: inputs from the selfevaluation teams: Children’s and parents’/carers’ views and evaluation Annex 10. Standard 2: Equality and non-discrimination: 2.2. The hospital/health service delivers a patient-centred care, which recognizes not only the child’s individuality and diverse circumstances and needs, but also those of his or her parents or carers: inputs from the self-evaluation teams Annex 11. Standard 2: Equality and non-discrimination: 2.3. The hospital/health service ensures the respect of children’s privacy at all times: inputs from the self-evaluation teams Annex 12. Standard 2: Equality and non-discrimination: 2.3. The hospital/health service ensures the respect of children’s privacy at all times: Children’s views and evaluation Annex 13. Standard 3: Play and Learning: 3.1. The hospital/health service ensures the right to play for all children without discrimination of any kind: inputs from the self-evaluation teams Annex 14. Standard 3: Play and Learning: 3.1. The hospital/health service ensures the right to play for all children without discrimination of any kind: inputs from the self-evaluation teams: Children’s and parents’/carers’ views and evaluation Annex 15. Standard 3: Play and Learning: 3.2. The hospital/health service planning takes into account children’s views of what is needed: inputs from the self-evaluation teams
Assessing the respect of children’s rights in hospital in the Republic of Moldova page 3
Annex 16. Standard 3: Play and Learning: 3.3. The hospital/health service provides complementary play and educational activities: inputs from the self-evaluation teams Annex 17. Standard 4: Information and participation: 4.1. The hospital/health service ensures an environment based on trust, information-sharing, the capacity to listen and sound guidance that is conducive to the child’s effective participation: inputs from the self-evaluation teams Annex 18. Standard 4: Information and participation: 4.2. The hospital/health service ensures that all appropriate staff has the skills to engage in dialogue and information-sharing with children of all ages and maturity: inputs from the self-evaluation teams Annex 19. Standard 4: Information and participation: 4.3. The hospital/health service engages with children for the development and improvement of health care services: inputs from the selfevaluation teams Annex 20. Standard 5: Safety and environment: 5.1. The hospital/health service infrastructure is designed, furnished and equipped to meet children’s safety and mobility needs: inputs from the self-evaluation teams Annex 21. Standard 5: Safety and environment: 5.2. The hospital/health service policies and practice support the best possible nutrition for children: inputs from the self-evaluation teams Annex 22. Standard 5: Safety and environment: 5.3. The hospital/health service policies and practice ensure a clean environment for children at all times: inputs from the self-evaluation teams Annex 23. Standard 6: Protection: 6.1. The hospital/health service has in place a system that ensures protection of the right of the child against all forms of violence: inputs from the selfevaluation teams Annex 24. Standard 6: Protection: 6.2. The hospital/health service ensures that all appropriate staff has the adequate skills to protect, treat and refer children who have been a victim of any kind of abuse or unintentional injury: inputs from the self-evaluation teams Annex 25. Standard 6: Protection: 6.3. Clinical research and trials are strictly regulated by hospital/health policy: inputs from the self-evaluation teams Annex 26. Standard 7: Pain management and Palliative care: 7.1. The hospital/health service policy ensures the prevention and management of pain: inputs from the self-evaluation teams Annex 27. Standard 7: Pain management and Palliative care: 7.2. The hospital’s/health service’s policy and practice ensure that palliative care is provided to all children who face lifethreatening illness: inputs from the self-evaluation teams.
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Introduction The Committee on the Rights of the Child, in its General Comment Nº 15 on the right of the child to the enjoyment of the highest attainable standard of health (Article 24 of the Convention on the Rights of the Child, hereafter right to health), interprets children’s right to health “as an inclusive right, extending not only to timely and appropriate prevention, health promotion, curative, rehabilitative and palliative services, but also to a right to grow and develop their full potential and live in conditions that enable them to attain the highest standard of health through the implementation of programmes that address the underlying determinants of health.” Significantly, it also recognizes not only the importance of children’s right to health to the enjoyment of other rights and to children’s achievement of their full potential, but also the dependency of the right to health on the realization of other rights. Children’s rights must be realized in all of children’s life settings. Children’s stay in hospital – as any direct contact of children with the public system – can be regarded as an opportunity to enhance children’s rights, to address the underlying determinants of health and contribute to children’s overall well-being and development. Taking this into account, the aim of this report will be two-fold. Firstly, it aims to present the results on the assessment of the respect of children’s rights in 21 hospitals in Moldova. Secondly, it aims to draw recommendations and identify specific actions for improvement to both health providers and the Ministry of Health (Ministry of Health), by taking into consideration the State’s responsibility and the role of health care services, in line with the respect, protection and fulfilment of children’s right to health. The assessment deals with children’s rights in hospital, but it also tackles some parental rights. Indeed, parents/carers have a fundamental role in promoting the overall healthy child development through early diagnosis of diseases, educating against risky behaviour, teaching healthy eating habits, stimulating learning and enhancing children’s capabilities. For these reasons, to the extent possible, parents/carers should be seen as a partner during children’s hospitalization, their support should be sought and they should be given all information and instruments to be aware of how they can best take care of their child. This includes educating parents/carers on how to take care of a child with a specific illness (including chronic diseases and disabilities), raising awareness where parents’/carers’ behaviour is bad for their child (i.e. smoking), amongst other skills. The report is structured in the following manner: Part 1: Work methodology used for the assessment of children’s rights in hospital; Part 2: Analysis of the assessment results in hospitals. This section includes the information gathered for each of the standards on children’s rights in hospital and the identification of the main areas for improvement in hospital, with concrete examples; Part 3: Recommendations for hospitals and the Ministry of Health in Moldova.
Part 1: Work methodology The assessment of the respect of children’s rights in hospital was carried out upon recommendation by WHO Regional Office for Europe with the aim to strengthen the evidence and overall recommendations to the Ministry of Health on improving quality of care for children in hospitals in Moldova and, in particular, the area of children’s and parents’/carers’ rights.
Assessing the respect of children’s rights in hospital in the Republic of Moldova page 5
A set of specific tools were used for the assessment and improvement of the respect of children’s rights in hospitals. The original Manual and Tools (Task Force on Health Promotion for Children and Adolescents in and by Hospitals and Health Services, International Network of Health Promoting Hospitals and Health Services, 2012) are available in English, but for the implementation in Moldova the set of tools was translated into Romanian. Each tool was prepared for a group of stakeholders, namely a) hospital management, b) health professionals, c) children aged 6-11, d) children and adolescents aged 12-18 and e) parents and carers. The tools aim to assess children’s rights in hospital, in accordance to seven standards, as follows: Standard 1 evaluates the ‘best quality possible care’ delivered to all children, understood as a care that takes into account the clinical evidence available, the respect of children’s rights and patient and family’s views and wishes. Standard 2 evaluates to what extent the health care services respect the principles of equality and non-discrimination of all children. Standard 3 evaluates how play and learning are planned and delivered to all children. Standard 4 evaluates the rights of all children to information and participation in health care decisions affecting them and the delivery of services. Standard 5 evaluates to what extent health care services are delivered in a safe, clean and appropriate environment for all children. Standard 6 evaluates the right of all children to protection from all forms of physical or mental violence, unintentional injury, injury or abuse, neglect or negligent treatment, maltreatment or exploitation, including sexual abuse. Standard 7 evaluates the provision of pain management and palliative care to children. For each standard, several sub-standards and specific questions for the different groups of stakeholders were identified. The questions are adapted to each of the groups, however they aim to address and gather information on the same issues. 21 hospitals participated in the assessment of the respect of children’s rights in hospital (see Annex 1 for list of participating hospitals). The average number of participants was 34,6 per hospital, ranging from 24 participants in SG Hospital and 52 in NMCH Hospital. Participants included hospital management, doctors and nurses from various departments, parents/carers and children, from 6 to 18 years of age. The average number of meetings held per hospital was 4, ranging from 3 in SG and OC hospitals and 8 in NMCH Hospital. In every hospital, both work group discussions and individual interviews took place to assess the respect of children’s rights. Most often, parents/carers participated in focus groups of 8-10 people. Parents’/carers’ and elder children’s consent for participation was obtained in oral form. See Summary Chart 1 for detailed information per hospital. It is important to note that in many cases children and parents did not wish to contribute further and there is some key information missing that could help to understand further the good practices and gaps in relation to the respect of children’s rights in hospitals in Moldova. A suggestion for both Ministry of Health and hospitals is to enhance the culture of child and parents’/carers’ participation in matters affecting the child. Examples will be provided in the report on how to do this. The national focal point was responsible for the overall process of distribution of questionnaires, explaining on how to work with them and present the information, as well as, for the data collection, but in every hospital the director was responsible for the coordination of the process at facility level.
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Summary Chart 1. General information on the self-evaluation process and work methodologies Number of participants 1 AN
Type of participant
32
Regional Hospitals Hospital management, doctors and nurses, mothers and other carers, children Hospital management, doctors and nurses, mothers and other carers, children Hospital management, doctors and nurses, mothers and other carers, children Hospital management, doctors and nurses, mothers and other carers, children Hospital management, doctors and nurses, mothers and other carers, children Hospital management, doctors and nurses, mothers and other carers, children Hospital management, doctors and nurses, mothers and other carers, children Hospital management, doctors and nurses, mothers and other carers, children Hospital management, doctors and nurses, mothers and other carers, children Hospital management, doctors and nurses, mothers and other carers, children
2
CL
36
3
CM
43
4
CR
33
5
ED
31
6
FA
30
7
FR
45
8
GL
41
9
SV
33
10
ST
37
Number Work of methodology meetings 4 Joint group discussion and Individual interviews 5 Joint group discussion and Individual interviews 6 Joint group discussion and Individual interviews 5 Joint group discussion and Individual interviews 4 Joint group discussion and Individual interviews 5 Joint group discussion and Individual interviews 7 Joint group discussion and Individual interviews 6 Joint group discussion and Individual interviews 5 Joint group discussion and Individual interviews 6 Joint group discussion and Individual
Assessing the respect of children’s rights in hospital in the Republic of Moldova page 7
11
TA
29
Hospital management, doctors and nurses, mothers and other carers, children Hospital management, doctors and nurses, mothers and other carers, children Hospital management, doctors and nurses, mothers and other carers, children Hospital management, doctors and nurses, mothers and other carers, children Hospital management, doctors and nurses, mothers and other carers, children Hospital management, doctors and nurses, mothers and other carers, children Hospital management, doctors and nurses, mothers and other carers, children Hospital management, doctors and nurses, mothers and other carers, children Municipal Hospital Hospital management, doctors and nurses, mothers and other carers, children Hospital management, doctors and nurses, mothers and other carers, children Other Hospitals Hospital management, doctors and nurses, mothers and other carers, children
5
12
UG
30
5
13
SD
31
5
14
RZ
28
4
15
SG
24
3
16
OC
25
3
17
HN
30
4
18
IL
30
4
interviews Joint group discussion and Individual interviews Joint group discussion and Individual interviews Joint group discussion and Individual interviews Joint group discussion and Individual interviews Joint group discussion and Individual interviews Joint group discussion and Individual interviews Joint group discussion and Individual interviews Joint group discussion and Individual interviews Joint group discussion and Individual interviews Joint group discussion and Individual interviews Joint group discussion and Individual
19 BL
41
6
20
C
46
7
21 NMCH
52
8
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1
AN
32
Hospital management, doctors and nurses, mothers and other carers, children Hospital management, doctors and nurses, mothers and other carers, children Hospital management, doctors and nurses, mothers and other carers, children Hospital management, doctors and nurses, mothers and other carers, children
4
2
CL
36
5
3
CM
43
6
4
CR
33
5
interviews Joint group discussion and Individual interviews Joint group discussion and Individual interviews Joint group discussion and Individual interviews Joint group discussion and Individual interviews
Part 2: Analysis of the assessment results in hospitals Standard 1. Quality services for children All services provided for children aim at delivering the best quality possible care, by taking into account clinical evidence available, the respect of children’s rights and patient and family’s views and wishes. • The hospital ensures that all institutional activities are based on the best evidence available and that staff are adequately trained. Taking into account the inputs by the self-evaluation teams, it is clear that there is significant attention to provide quality services for children. All participating hospitals deliver health care based on national and international guidelines. The guidelines are developed nationally through ah hoc committees made up by university staff and health professionals, in partnership with the Ministry of Health. All hospitals adapt the national protocols to their own context. All medical doctors and nurses working in paediatric care have a specialization in paediatrics. The main gap identified has been that some of the national guidelines are not in line with the international ones and thus should be adjusted, based on evidence-based medicine principles. In terms of quality of care, the average answer provided by parents/carers in all participating hospitals was “probably, we received the best care within the existing conditions”. Children and parent/carers stated they received good care or the best care in 5 and 7 hospitals, respectively. Other inputs included “doctors did everything necessary and possible”. In 11 hospitals, children aged 12-18 years of age stated that “the hospital should have modern equipment”. See Annexes 2 and 3, for summary of inputs on Standard 1, point 1.1. by self-evaluation team and children and parents/carers, respectively.
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• The hospital ensures that all types of services provided within the organization are regularly monitored and evaluated. All hospitals have in place monitoring and evaluation activities to ensure quality of care for children and relevant statistical data that require the continuous improvement is available at the Ministry of Health website. On the other hand, as far as it was possible to gather most hospitals do not promote patient satisfaction surveys. Children aged 12 to 18 in 7 hospitals had not participated in patient satisfaction surveys. Information gathered from the self-evaluation teams confirms this data. The main actions for improvement identified by the self-evaluation teams included: to promote audits to ensure that health care services are in line with the organizational policy; to revise the statistical forms and the corresponding set of indicators; and to establish an effective system for collecting and presenting patient-satisfaction surveys or other. See Annex 4, for summary of inputs on Standard 1, point 1.2. by self-evaluation team. • The hospital has no a Charter on Children’s Rights in Hospital in line with the United Nations Convention on the Rights of the Child. Moldova has not yet adopted a Charter on Children’s rights in hospitals at national level, as well as it has not been adopted by health facilities and it is not displayed in hospitals. See Annex 5, for summary of inputs on Standard 1, point 1.3. by self-evaluation team. The hospital provides the possibility for parents/carers to stay with their child at all times during hospitalization.
Inputs from the self-evaluation teams show that in principle parents/carers are allowed to stay with the child during procedures, including anaesthesia induction in all hospitals. However, inputs also suggest ensuring that parents are always allowed to stay during procedures. There are no specific inputs to be presented from parents’/cares’ and children’s experiences of staying in the participating hospitals, which would have been important to provide supportive evidence in relation to the fulfilment of this right. In all hospitals, parents/carers are always allowed to stay overnight with the child up to 5 years of age, for free, as well as, to receive free or subsidized meals at the hospital. There is no information to demonstrate whether the parents involved in the assessment had the possibility to stay with their children overnight. Free food is provided to all hospitalized children in all participating hospitals and the menu is prepared by a specialist, either a trained nurse or dietician. See Annex 6, for summary of inputs on Standard 1, point 1.4. by self-evaluation team. The hospital pays special attention to the rights of adolescents to health care. In 12 out of 21 hospitals, there is an adolescent-friendly health service. See Annex 7, for summary of inputs on Standard 1, point 1.5. by self-evaluation team.
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The assessment of Standard 1 on quality services for children in the participating hospitals, shows significant attention to the care of children in Moldova. The main areas for the improvement of this Standard are: To review national guidelines on quality and efficiency of care: National guidelines adopted by hospitals working for children should be in line with international guidelines and be based on evidence-based medicine. Existing protocols that are not in line with such guidelines should be reviewed, nationally. To review existing monitoring and evaluation mechanisms: Attention has been called to the need to revise current statistical data gathered by hospitals and made available on the Ministry of Health’s website, including a revision of the indicators used. The revision should take into account the results of assessments of quality of paediatric care, such as the present one. Additionally, it would be important to include indicators on patient satisfaction. To establish effective systems for collecting and presenting data gathered through children’s and parents’ or carers’ satisfaction surveys or other: Surveys to assess children’s and parents’/carers’ satisfaction with the services provided should be done on a regular basis and the outcomes should contribute to the decisionmaking processes at facility level. There are various degrees of involvement of children and parents, however, it is essential that children and parents/carers participating in patient satisfaction surveys are fully informed about the process, including how their opinions will be used and that they receive information about the outcomes. Ensure that the national Charter on Children’s rights in hospital is adopted by facilities: All hospitals should endorse the Charter that has not been adopted at national level. Once it is adopted, each hospital should prepare work towards the implementation of the Charter. This should be done at two levels. On one hand, it is important to disseminate the contents of the Charter by, among other actions, promoting awareness raising activities for health professionals and making the Charter available to children and parents (i.e. by displaying it in wards, handing out printed information or other methods). On the other hand, hospitals should adopt specific actions to respect each right individually. In line with this, throughout the present report, hospital managers and health professionals will find comments and suggestions, which can be used for the implementation of Charter on Children’s Rights in hospital. To enable at least 1 parent to stay with their child, including overnight stay: At the moment, only parents with children up to 5 years of age are able to stay with their child overnight. It would be important to progressively allow parents of older children, to be able to stay with their child overnight, as well. To ensure that all parents are allowed and encouraged to stay with their child at all times during hospitalization: Parents should be allowed and encouraged to stay with their child at all times, including during procedures, unless it is not in the best interest of the child. Hospitals should progressively enable parents/carers to stay with their child during procedures, as it can be beneficial for child health outcomes, medical staff treating the child and parents/carers alike. More and more, parents/carers are being allowed and encouraged to stay with their child at all times, including during procedures. In some countries and hospitals, parents/carers are also able to accompany their child during anaesthesia induction, but not in all hospitals. Hospitals are promoting parents/carers stay during procedures because it can help to reduce children’s anxiety, by providing comfort to them; parents/carers can often support medical staff in preparing children or helping in procedures; and it may help parents/carers to better understand their child’s condition and how to treat them at home, where applicable.
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To establish adolescent-friendly health services in all hospitals: All hospitals should establish an adolescent-friendly health service and promote, among other, awareness raising materials about facilities, services and health information targeted at adolescents, as well as, other children’s age groups.
Standard 2: Equality and non-discrimination All children should be able to access health care and undergo any type of treatment without discrimination of any kind, irrespective of the child’s or his or her parents/carers’ or legal guardians’ race, colour, sex, language, religion, political or other opinion, national, ethnic or social origin, property, disability, birth or other status. The hospital fulfils the rights of access of all children without discrimination of any kind.
Inputs from the self-evaluation teams in all hospitals demonstrate that all children have equal access to health services, based on non-discrimination principles, as well as, equal access to treatment. Additionally, all hospitals have approved and implemented a policy on nondiscrimination of the Roma population. In all hospitals, children and parents/carers stated that “all children are treated with respect, no one is refused care” and in some hospitals they stated that “everyone in the hospitals is treated equally”. See Annexes 8 and 9, for summary of inputs on Standard 2, point 2.1. by self-evaluation team and children and parents/carers, respectively. The hospital delivers a patient-centred care, which recognizes not only the child’s individuality and diverse circumstances and needs, but also those of his or her parents/carers. The inputs provided by the self-evaluation teams show little attention to this right. In all of the participating hospitals, hospital staff is neither trained to respect and care for patients with cultural differences; or to try to understand and respect culture-specific parenting beliefs and expectations. Furthermore, no hospital provides for qualified interpreters. It would be important to understand both the reason for this lack of attention and whether any children are being affected by these policies. See Annex 10, for summary of inputs on Standard 2, point 2.2. by self-evaluation team. The hospital ensures the respect of children’s privacy at all times. In 9 out of 21 hospitals, children are informed in private areas or in the doctor’s office, in 10 hospitals children are not always informed in private areas and in all hospitals, there is a limited possibility for children to stay in single or double rooms. Children’s and parents’/carers’ inputs demonstrate that there is “limited possibility to be hospitalized in the single or double rooms, no privacy during the examinations and no privacy when the results of the examinations/treatment are communicated”. See Annex 11 and 12, for summary of inputs on Standard 2, point 2.3. by self-evaluation team and children and parents/carers, respectively.
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The assessment of this standard shows attention at policy-making to children’s right to access health care without discrimination of any kind, including provisions for particular groups of children that may be more vulnerable, such as Roma children. On the other hand, at practice levels, some actions are needed for the improvement of services in all hospitals, including: To adopt measures to ensure that all children are able to undergo treatment without discrimination of any kind: All hospitals should increase attention to the treatment of vulnerable groups of children, by ensuring culturally-competent staff and interpreters, where needed. A patient-centred care goes beyond equal access to health care by all groups of children and includes understanding and respecting parents’/carers’ beliefs and expectations. This approach is essential to inform and engage with parents/carers and children in decision-making processes, to improve the child’s hospitalization experience, to improve compliance with treatment, among other issues. To ensure that children’s privacy is respected at all times: All hospitals must ensure, to the extent possible, that every child’s right to privacy is respected. This includes the availability of private areas to examine and inform children and parents/carers, to provide children with the possibility to be examined by a doctor of the same gender and the availability of single and/or double rooms. Standard 3: Play and Learning All children have opportunities for play, rest, leisure, recreation and their rights to education protected, suited to their age and condition, in spite of their health needs. The hospital ensures the right to play for all children without discrimination of any kind. In 8 out of 21 participating hospitals, there is a play space for children. However, other than this, the inputs provided by the self-evaluation teams show little attention to children’s right to play. Play is not guaranteed by all hospitals’ policy; there is no hospital strategy focused on involving play during procedures and treatment; no hospital has Play Specialists or other properly trained staff to assist children during play; health care providers were not trained on how to use different forms of play within therapeutic care; and there are no designated and properly equipped play rooms for children. Children’s and parents’ inputs included: “My child is small to play with other children, I entertain him; in the hospital there is not where to play, my husband brought toys from home (and) I played with other children, mostly in corridors”. See Annex 13 and 14, for summary of inputs on Standard 3, point 3.1. by self-evaluation team and children and parents/carers, respectively. The hospital planning takes into account children’s views of what is needed.
In most participating hospitals there has been no engagement with children for the improvement of play spaces. Only in 4 hospitals (NMCH, BL, HN, AN), nurses ask children what they would like to see different in play rooms. See Annex 15, for summary of inputs on Standard 3, point 3.2. by self-evaluation team. The hospital provides complementarily play and educational activities.
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There are no complementarily play and educational activities in any of the participating hospitals. See Annex 16, for summary of inputs on Standard 3, point 3.3. by self-evaluation team. The main areas identified for the improvement of children’s right to play are: Making available a play room for children: Play and learning have an important role for children’s development and, when in hospital, it is an added value to therapeutic care, which should be recognized. All hospitals should make available a play room or dedicated play space for children. Where hospitals will be preparing the playroom from the beginning, children and adolescents should be able to participate in its preparation and design. The consultation of children and adolescents will contribute greatly to ensure that the playroom will be designed and equipped to meet the needs and expectations of children of different age groups, in particular adolescents, who often feel that they do not have the opportunity for leisure during their stay in hospital. Guarantee Play Specialists and other adequately trained staff to accompany children during their stay in hospital: To the extent possible, hospitals should include Play Specialists in routine staff to assist children. Play Specialists play an important role in therapeutic care by preparing play activities in the Play room or by the child’s bedside, helping children to reduce their anxieties, supporting health staff by using play in the preparation of procedures, among other important activities. Introduce training of staff on how to use different forms of play within therapeutic care: Medical staff across countries is using different forms of play within therapeutic care to help children during their stay in hospital. Play is used to alleviate anxiety and stress, to enable children to cope with pain and to help in the management and outcomes of procedures. All hospitals are encouraged to provide training for their health staff on how to use different forms of play within therapeutic care. Introduce supportive activities such as clown, music, art and pet-therapy: In addition to play, there are other activities that can support children’s therapeutic care. These may include clown, music, art and pet-therapy, among others. Supportive play activities are used within therapeutic care, as described in the point before. Standard 4: Information and participation All children receive information about their health problem, in ways that are understandable to them, can express their views and participate in decision-making about their care and treatment, in a manner consistent with their evolving capacities. The hospital ensures an environment based on trust, information-sharing, the capacity to listen and sound guidance that is conducive to the child’s effective participation.
The inputs provided by the self-evaluation teams and children/parents/carers demonstrate that very little attention is paid to children’s right to information and participation. In all hospitals, health care staff introduce themselves to children and families and wear name badges, but there seems to be no further action towards the respect, protection and fulfilment of this right. Children do not have the right to informed consent and the inputs also suggest that there is little involvement of patients in the decision-making processes regarding their care. There are no
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complaints’ procedures or other mechanisms where children and adolescents can voice concerns about their health care. See Annex 17, for summary of inputs on Standard 4, point 4.1. by self-evaluation team. The hospital ensures that all appropriate staff has the skills to engage with dialogue and information-sharing with children of all ages and maturity.
In all participating hospitals, health care providers have not been trained on how to effectively communicate with children and families about the condition, proposed treatments, etc. See Annex 18, for summary of inputs on Standard 4, point 4.2. by self-evaluation team. The hospital engages with children for the development and improvement of health care services.
Self-evaluation teams report that in all hospitals, children’s participation partly or does not influence decision-making in relation to the improvement of health care services. See Annex 19, for summary of inputs on Standard 4, point 4.3. by self-evaluation team. Significant action must be undertaken towards the improvement of the respect of children’s right to information and participation, namely: Ensure the respect of every child’s right to information: Children’s right to information and participation is essential to their health education and well-being. Children of all ages should be informed, in accordance to their evolving capacities. All hospitals must ensure that every child receives the same care and this includes the respect of their right to information. Health professionals should be able to explain fully to children about their condition, including what is happening to them, which treatments are proposed, options that are available, implications of all the options, treatment side effects, likelihood of discomfort and how to give ‘bad news’. Children and parents/carers should also receive general health promotion-related information and key information about the child’s stay in hospital. Oral information should be complemented with written information in different formats. Provide awareness raising and continuous training for staff on the importance of communicating with children of all ages and how to do this (skills): In order to ensure that all children receive information about their condition, in a manner consistent with their evolving capacities, hospitals should train medical staff on the importance of communicating with children and providing an enabling environment for parents/carers and children of all ages. This is essential to provide children and parents/carers with the necessary information, creating trust between professionals and patients, facilitating children’s participation in health decisions, but also in reducing both parents’/carers’ and children’s anxiety, ensuring their understanding of and compliance with treatments and enjoyment of an overall positive hospitalization experience. Medical staff should also be aware of existing legislation and policy and be encouraged to implement them. Establish criteria on children’s right to informed consent: A hospital policy on informed consent should be adopted by all hospitals, laying out the criteria and establishing an age from when children are able to give their informed consent. This policy should be based on national legislation on informed consent for children.
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Children and parents/carers alike should be supported by health professionals, in order to understand the nature and consequences of the treatment, as well as, the consequences if they refuse that same treatment and therefore be able to make a sound judgment. Where children cannot give informed consent to treatment, they should still receive information about their situation, be able to ask questions and contribute to the decisionmaking process. Promote children’s participating in the improvement of health care services: It is important for hospitals to start engaging with children in decision-making processes concerning the improvement of health care services. Children of different age groups can provide important information about how the services are being implemented, in the identification of good practices and gaps, as well as, patient expectations about the services being provided to them. Any consultation with children must guarantee that they are treated with respected, explained the aims of the evaluation or project, how their views will be used and that they receive information about the outcomes of the consultation. Consultations with children can be done either at health service level (i.e. in primary care facilities or hospitals) or at national level (i.e. in schools). Children can provide key information about health challenges, behaviours and risks; health issues influenced by gender-based differences, cultural norms and socioeconomic status; and needs and expectations of services. This information can be used to inform States and health providers in the planning and implementation of effective health programmes and services.
Standard 5: Safety and environment All services for children are provided in an environment designed, furnished, staffed and equipped to meet their needs. Safety also includes aspects of cleanliness and food. The hospital infrastructure is designed, furnished and equipped to meet children’s safety and mobility needs.
Overall, there is a need to improve the design and equipment of infrastructures in all participating hospitals. In all hospitals, the infrastructure is partly designed, furnished and equipped to meet children’s safety and mobility needs; in most hospitals, safety norms for equipment and materials is only partially respected; and not all hospitals’ infrastructure ensures that children with mobility restrictions are able to access all areas of the buildings. See Annex 20, for summary of inputs on Standard 5, point 5.1. by self-evaluation team. The hospital policies and practice support the best possible nutrition for children.
There is great attention to children’s right to food in all participating hospitals. All hospitals provide free food to all hospitalised children; all hospitals have specially trained staff that is responsible for the development of the menu and food is served timely in all hospitals. Suggested improvements include improvement of the quality of products used, as well as, enhancement of their diversity. See Annex 21, for summary of inputs on Standard 5, point 5.2. by self-evaluation team. The hospital policies and practices ensure effective and strict cleaning services.
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In relation to cleaning, although there seems to be attention as to ensuring effective and cleaning services, the situation is not uniform and some hospitals are, in fact, lacking sufficient number and adequate toilets, hot water and bathrooms for mothers and children. See Annex 22, for summary of inputs on Standard 5, point 5.3. by self-evaluation team. The mains actions towards the improvement of this standard are: Ensuring that hospitals’ infrastructure is designed, furnished and equipped to meet children’s safety and mobility needs: Actions must be undertaken to ensure that hospitals’ infrastructures meet children’s safety and mobility needs. Consulting with children of different age groups and needs is an effective way of ensuring that the hospitals’ infrastructure is appropriate to all children visiting and staying in the hospital. Improvement should also include an assessment to learn whether safety norms for equipment and materials are followed in every hospital and, if not, to improve safety norm-related standards. Consolidate the efficiency of cleaning services and practices: All hospitals are encouraged to continue to maintain high standards of cleaning services and practices and to address the gaps identified by the self-evaluation teams, which were mentioned above. Standard 6: Protection Children are protected from all forms of physical or mental violence, unintentional injury, injury or abuse, neglect or negligent treatment, maltreatment or exploitation, including sexual abuse. The hospital has in place a system that ensures protection of the right of the child against all forms of violence.
Ministry for Social Services and whose protocol is activated upon a child’s admission to hospital. All hospitals adhere to this common mechanism and, in addition, have put in place referral mechanisms with social services, police and other authorities. However, several actions are missing to ensure the effectiveness of the system in identifying children who have been a victim of abuse and in protecting them against further violence. Specifically, no hospital has in place a system to register and monitor cases of children who have been a victim of any kind of abuse; and there is no team or unit within hospitals dealing with child-protection issues. See Annex 23, for summary of inputs on Standard 6, point 6.1. by self-evaluation team. The hospital ensures that all appropriate staff has the adequate skills to protect, treat and refer children who have been a victim of any kind of abuse.
Health professionals working in hospitals have not received training on how to identify and examine children who have been abused. The self-evaluation teams referred that most of the related work is done at Primary Health care-level. See Annex 24, for summary of inputs on Standard 6, point 6.2. by self-evaluation team. Clinical research and trials are strictly regulated by hospital policy.
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As far as it is possible to gather, clinical research is only carried out in 2 hospitals, namely C and NMCH. In both hospitals, children and families have the option to refuse or not to be involved in teaching activities of the hospital and in NMCH there is an Ethics Committee for clinical research and trials. See Annex 25, for summary of inputs on Standard 6, point 6.3. by self-evaluation team. The main improvements towards the respect of the right to protection from all forms of violence are: Consolidation of the existing system of child protection in all hospitals: The effective protection of children, once they reach a hospital, depends on a number of services being available to them, within a functioning system. Where missing, all hospitals are invited to adopt a specific hospital policy on child protection, to register cases of child abuse, to have in place referral systems with relevant authorities and to regularly monitor and evaluate the system in order to ensure its effectiveness. The medical staff must receive training and be able to identify a child, who has been a victim of abuse and how to treat them, but also to know applicable legislation, hospital policy and how to activate the necessary mechanisms, such as referral systems. Ensure that no clinical research and trials are carried out without adequate regulations: All hospitals must ensure that any clinical research and trials carried out within the hospital are clearly regulated by and follow national legislation and hospital policy. Medical staff conducting the research should be made aware of the existing protocols and procedures. To ensure that research complies with national and hospital protocols and regulations, a hospital body should established, such as an Ethics Committee. Ensure the protection of every child participating in clinical research or trials: Children participating in clinical research and trials and their parents/carers should be properly informed about what the research entails, their informed consent should always be requested and they should be given the option to refuse or not to be involved in the teaching activities of the hospital and/or to drop out of the research at any time. Furthermore, medical staff must make sure that children and parents/carers understand all these issues, including their option not to participate in the research. Standard 7. Pain management and palliative care All children have the right to individualized, culturally and age appropriate prevention and management of pain and palliative care. The hospital policy ensures the prevention and management of pain.
At present, there are no protocols and procedures for the prevention and management of pain in hospital. In fact, the protocols are currently being prepared at national level by the Ministry of Health. No health professionals working in hospitals have received training on evidence based pain management. See Annex 26, for summary of inputs on Standard 7, point 7.1. by self-evaluation team. The hospital’s policy and practice ensure that palliative care is provided to all children who face life-threatening illness.
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In 5 hospitals (NMCH, BL, C, HN, AN), there are some elements of palliative care in place, including psychological support to the child’s family (parents/carers). There are no partnerships in place to ensure that palliative care can continue within community services or at home. See Annex 27, for summary of inputs on Standard 7, point 7.2. by self-evaluation team. The protocols and procedures on prevention and management of pain, to be adopted, should be implemented by hospitals by carrying out the following actions, among other: All hospitals should adopt pain management protocols: A functioning pain management system will entail that a number of practices are carried out, including a system to assess and register children’s pain, training of staff in pain management and regular assessment of services, to ensure that they are implemented effectively. Children’s views should be sought when assessing pain services. Introduce an initial and continuous training programme for health care staff in the area of pain management: Medical staff in all hospitals should be trained in the area of pain management, including how to assess and register children’s pain, how to manage painful procedures; and ways to alleviate pain, including alternatives to pain medicine and parents/carers’ support and involvement during procedures. Set up a Unit for Psychological/ Psychiatric Support within hospitals for hospitalised children and their families and to children in the community: Hospitals are encouraged to set up a unit for Psychological/Psychiatric support within hospitals or in partnership with services at community level. This unit should support hospitalised children and families, as well as, other children in need in the community. The availability of this unit to children in the community must include measures to reach out to children in need of support. Build partnerships to provide palliative care in the community services or at home: Establishing partnerships between hospitals and services in the community is essential to prevent the unnecessary hospitalization of children. This may be particularly important for children in vulnerable situations, such as children receiving palliative care. Hospitals may build partnerships with primary care level services or other governmental or nongovernmental organizations working at the community level. Upon existence of the partnership, medical staff should be made aware of it and be able to facilitate the service to children, by referring them.
Part 3: Recommendations for hospitals and Ministry of Health in Moldova Specific actions for improvement of the respect of children’s rights in hospital have been provided throughout this report, for every standard and child right. This final section aims to draw on that analysis and present general guidelines and recommendations for the Ministry of Health and hospitals in Moldova. Recommendations for the Ministry of Health: There are several policies and protocols identified in the assessment of the respect of children’s rights in hospitals in Moldova that have recently been adopted by the MoH. These not include, among other, the adoption of a national Charter on Children’s Rights in Hospital, protocols for the management and prevention of pain and palliative care. In addition to the recently adopted
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policies and protocols, some existing areas need to be strengthened, such as the protection of children who have been a victim of abuse and neglect. The Ministry of Health of Moldova has an opportunity to use available knowledge at international level to implement cost-effective programmes, both to develop the recently adopted policies and protocols and to strengthen existing ones. These include, but are not limited to, existing training packages, clinical protocols, guidelines and experiences of involving children in decision-making processes. Importantly, the Ministry of Health of Moldova collects data from hospitals and makes it available on its website. The Ministry of Health should build on this good practice to improve monitoring and evaluation systems and to plan health policies, by reviewing existing indicators of progress and including data from patient satisfaction surveys. Other recommendations include: Align existing national guidelines with international ones, ensuring that they are based on evidence-based medicine; Allocate budgets to renovate hospital infrastructure and supply necessary hospital equipment; Add children’s rights to the curricula of doctors and nurses specializing in paediatrics; Encourage all hospitals to implement Adolescent Friendly Health Services. Attention to specific child rights in hospital: Right to information and participation: the Ministry of Health, in partnership with other Ministries, should enhance a national cultural on the respect for the views of the child, including providing relevant health-related information to children in different life settings (home, school, hospital), involving children in decision-making processes influencing their health (including treatment) and consulting with children on the design and improvement of health care services; Right to informed consent: the Ministry of Health should adopt legislation to establish national criteria on informed consent for children; Right to play: children who experience hospitalization are in a vulnerable situation and foreign environment. As seen throughout this report, play can have a meaningful role in diminishing children’s anxiety and pain, in contributing to their development and within therapeutic care. The Ministry of Health should fulfil children’s right to play by allocating budgets, facilitating partnerships between relevant organizations and hospitals and/or other measures adapted to the local context.
Recommendations for the hospitals: Enhance the participation of children and parents/carers in assessing and improving hospital services, by means of patient surveys, complaints procedures, suggestion ‘boxes’, ad hoc consultations such as the present one, or other methods. The feedback from children and parents/carers should be used to inform hospital management in drawing hospital policies and planning; Promote continuous training and awareness raising activities for health professionals on specific aspects related to the management of child care. Some needs have been identified in the report, such as the need for training on pain management, how to identify a child who has been a victim of abuse and neglect, communicating with children of different ages, etc; Improve hospital infrastructure, in consultation with children and parents/carers. Particular attention should be paid to the needs of children with different mobility restrictions.
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Attention to specific child rights in hospital: Right to information and participation: Hospital policy and health professionals in daily practice must ensure an environment based on trust, information-sharing, the capacity to listen and sound guidance that is conducive to the child’s effective participation, including information about their health and treatment, involving them in the decision-making process; the possibility to give consent to treatment; and participation in the improvement of health care services; Right to play: Hospitals must undertake to make the necessary provisions for the fulfilment of children’s right to play, including setting up a play room or space for children to play, hiring Play Specialists to assist children, train health professionals how to use play within therapeutic care and engaging with organizations in the community to provide alternative forms of play, such as music, pet and other therapies; Right to protection: the overall system for the protection of children who have been a victim of abuse or neglect should be improved.
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Annexes Annex 1. Hospital names and abbreviation 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Hospital names Regional Hospitals Regional Hospital from Anenii Noi Regional hospital from Ceadir‐Lunga Regional Hospital from Comrat Regional Hospital from Criuleni Regional Hospital from Edinet Regional Hospital from Falesti Regional Hospital from Floresti Regional Hospital from Glodeni Regional Hospital from Stefan Voda Regional Hospital from Straseni Regional Hospital from Taraclia Regional Hospital from Ungheni Regional Hospital from Soldanesti Regional Hospital from Rezina Regional Hospital from Singerei Regional Hospital from Ocnita Regional Hospital from Hincesti Regional Hospital from Ialoveni Municipal Hospitals Municipal Hospital from Balti Municipal Hospital from Chisinau (Ignatenko) Other Hospitals National Institute on MCH Abbreviation AN CL CM CR ED FA FR GL SV ST TA UG SD RZ SG OC HN IL BL C NMCH
Annex 2. Standard 1: Quality services for children: 1.1. The hospital/health service ensures that all institutional activities are based on the best evidence available and that staff are adequately trained: inputs from the selfevaluation teams Examples of Good Practices Health care service delivered to children is based on national and international guidelines (all hospitals); The national guidelines are developed by specialized committees represented by Areas that need improvement Examples of actions for improvement A number of guidelines The national have discrepancies with guidelines are the international updated and adjusted guidelines and need to be to international adjusted based on EBM guidelines based on principles; EBM principles;
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university staff and health professionals, in partnership with the Ministry of Health (at National level) Approved national protocol are adjusted to local/facility level with regard to the facility activities as per the regulation framework of the institution (all hospitals) In all facilities are available adjusted to facility levels’ national protocols (all hospitals); All medical doctors and nurses working in paediatric department have a specialization in paediatrics (all hospitals);
Annex 3. Standard 1: Quality services for children: 1.1. The hospital/health service ensures that all institutional activities are based on the best evidence available and that staff are adequately trained: Children’s and parents’/carers’ views and evaluation Examples of Good Practices Children: “I received good care’ – OC, ED, CM, SD, GL ‘I received best care’ – NMCH, AN, HN, IL, UN, C, BL
Areas that need improvement Parents/carers ‘Probably, we received the best care within the existing conditions’ – average answer from all hospitals – AN, FA, CR, FL ‘Doctors’ did everything necessary and possible’ – C, TA, RZ, SD, SV, HN ‘I am not sure, I am not a doctor, but seems that they did everything correct’ – NMCH, BL, OC, UN, CM Advice on child’s health care support was given verbally – all hospitals No participate in patient satisfaction survey – AN, SD,
Examples of actions for improvement FA, OC, GL, FR, FA, TA, SV, UN, CL, CM, CR: “The hospital should have a modern equipment not” (12‐18 years); Ensure that children and parents/carers participate in patient satisfaction surveys, will be interesting to be involved – all hospitals; Ensure that the outcomes of patient satisfaction survey communicated back to children and parents/carers and contribute to the decision‐making – all hospitals. Approve the Charter on
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OC, HN No information provided on children rights – all hospitals HN, FL, FR, ED, FA, GL, TA: “I didn’t participate in patient satisfaction survey” (adolescent 12‐18 years); Patients had not chance to participate in surveys – all hospitals, some exceptions may be those from NMCH
Children’s Rights at hospitals – all hospitals To make Children’s rights in hospitals. Undertake actions to improve the hospital infrastructure to meet children’s safety and mobility needs, and children with mobility restrictions.
Annex 4. Standard 1: Quality services for children: 1.2. The hospital/health service ensures that all types of services provided within the organization are regularly monitored and evaluated: inputs from the self-evaluation teams. Examples of Good Practices
At facility level exist the registry of clients’ opinion (NMCH, C, BL, IL, SV, ED, OC, FL, FR, SG, HN, CL, CM, CR, UG, TA, RZ) The regular assessment of services ensures effectiveness in protecting children (NMCH, C, BL, HN, IL); The services assessment to ensure quality of the treatment process is in place (all hospitals); The administrative statistics are available for all at Ministry of Health website;
Areas that need improvement The promotion of surveys to assess children’s and parents’ or carers’ satisfaction with the services is not done on regular base; The indicators presented in administrative statistics have to be revised, as not provide the all necessary information The hospital needs improvement of setting and introduction of an effective system of patient satisfaction surveys (all hospitals);
Examples of actions for improvement Improve the process of setting and introduction of an effective system of patient satisfaction surveys; Ensure that the outcomes of patient satisfaction survey communicated back to children and parents/carers and contribute to the decision‐ making at facility level; Facilitate in carrying out of audit to meet health care services in line with the organizational policy; Revision of the statistic forms and the revision of the set of the respective indicators;
Annex 5. Standard 1: Quality services for children: 1.3. The hospital/health service has a Charter on Children’s Rights, in line with the United Nations Convention on the Rights of the Child: inputs from the self-evaluation teams Examples of Good Practices Areas that need improvement Examples of actions for improvement
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The Child Rights’ Charter is not adopted at facility level (all hospitals)
Approval of the Charter on Children Rights’ at facility level; Training for hospital staff on Charter on Children’s Right (all hospitals);
All children on admission are informed about their rights; To approve the Children’s right charter, inform patients about and to place it in the facility (all hospitals); Develop a child‐friendly version of the Charter on Children’s Rights; Adopt, disseminate and make a Charter on Children’s Rights available in the wards; Educate all health care service staff (doctors and nurses) on the Charter and Children’s Right;
Annex 6. Standard 1: Quality services for children: 1.4. The hospital provides the possibility for parents/carers to stay with their child at all times during hospitalization: inputs from the self-evaluation teams. Examples of Good Practices Parents/carers are allowed to stay with the child during procedures, including anaesthesia induction (all hospitals); Parents/carers are always allowed to stay with the child up to 5 years overnight for free (all hospitals); Parents/carers are allowed to receive free or subsidized meals at the hospital as per the methodological norms, staying with children up to 5 years (all hospitals) Free food is provided to all Areas that need Examples of actions for improvement improvement To improve the quality To create the canteen for and diversity of the food parents, if no conditions provided within the to offer meals in ward, for hospital for children; those who want to stay with children older than 5 To allow parents/carers to years; stay with their children why medical procedures, Ensure that parents/carers in ICU. are always allowed to stay with the child overnight for free; Ensure that parents/carers are always allowed to stay with the child during procedures, including injections, blood extraction; Ensure that parents/carers are allowed to receive free
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hospitalized children (all hospitals); All hospitals have specially trained staff (often nurses) or dietician who is responsible for the health menu development.
or subsidized meals at the hospital; To prepare the qualified staff, dieticians, in development of the health menus for hospitalized children.
Annex 7. Standard 1: Quality services for children: 1.5. The hospital/health service pays special attention to the rights of adolescents to health care: inputs from the self-evaluation teams Examples of Good Practices There is adolescent‐ friendly health services in the hospital (in 12 hospitals); At facility level exist the registry of clients’ opinion (NMCH, C, BL, IL, SV, ED, OC, FL, FR, SG, HN, CL, CM, CR, UG, TA, RZ) Areas that need improvement To develop the information materials special oriented to children as those developed are only for adults (all hospitals) The promotion of surveys to assess children’s and parents’ or carers’ satisfaction with the services is not done on regular base; Examples of actions for improvement Improve the process of setting and introduction of an effective system of patient satisfaction surveys; Ensure that the outcomes of patient satisfaction survey communicated back to children and parents/carers and contribute to the decision‐ making at facility level; To continue the development of the YFHS in other than those 12 rayons to improve the adolescents’ access to health services; To develop information materials oriented on children;
Annex 8. Standard 2: Equality and non-discrimination: Right 2.1. The hospital/health service fulfils the rights of access of all children without discrimination of any kind: inputs from the self-evaluation teams. Examples of Good Practices
Areas that need improvement N/A
Examples of actions for improvement N/A
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Annex 9. Standard 2: Equality and non-discrimination: Right 2.1. The hospital/health service fulfils the rights of access of all children without discrimination of any kind: inputs from the self-evaluation teams: Children’s and parents’/carers’ views and evaluation. Examples of Good Practices
Areas that need improvement
All children are treated with respect – all hospitals No one refused in care – all hospitals Everyone in the hospitals are treated equally
Examples of actions for improvement Ensure that children of minority and other status are not discriminated and have equal access to health services; Guarantee competent interpreters in need of case. To use preferred children names
Annex 10. Standard 2: Equality and non-discrimination: 2.2. The hospital/health service delivers a patient-centred care, which recognizes not only the child’s individuality and diverse circumstances and needs, but also those of his or her parents or carers: inputs from the self-evaluation teams. Examples of Good Practices
Areas that need improvement Hospital staff is not trained on respect and care of patients with cultural differences (all hospitals); Hospital does not provide qualified interpreter (all hospitals – in need of case, manage the situation as it is possible). Health professionals are not trained to try to understand and respect culture‐specific parenting beliefs and expectations (all hospitals);
Examples of actions for improvement Special trainings for staff on respect and care of patients with cultural differences (all hospitals); Develop or enhance the program on continuous cultural‐competence training for staff; Ensure religious support is provided by the hospital to families of all faith;
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Annex 11. Standard 2: Equality and non-discrimination: 2.3. The hospital/health service ensures the respect of children’s privacy at all times: inputs from the self-evaluation teams. Examples of Good Practices Children are informed in private areas or in doctor’s office (NMCH, BL, C, IL, HN, FA, SG, SD, SV) Areas that need Examples of actions for improvement improvement Limited possibility to To organize more single hospitalize children in rooms to respect the single or double rooms (all privacy, culture, religious hospitals) beliefs; Children are not always To organize more single or informed in private areas double rooms as to (SR, UG, FL, FR, SG, HN, ST, provide more privacy for AN, CL, CM); hospitalized children; Ensure that children have choice to be examined by the doctor of the same gender; Ensure the right of children to be hospitalized in single or double rooms, upon request; Ensure the right of children to be informed in private areas;
Annex 12. Standard 2: Equality and non-discrimination: 2.3. The hospital/health service ensures the respect of children’s privacy at all times: Children’s views and evaluation. Examples of Good Practices
Areas that need Examples of actions for improvement improvement Limited possibility to be Ensure the right of hospitalized in the single or children to be hospitalized double rooms in single or double rooms, upon request; No privacy during the examinations Ensure the right of children to be informed and No privacy when the results of examined in private areas. the examinations/treatment are communicated
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Annex 13. Standard 3: Play and Learning: 3.1. The hospital/health service ensures the right to play for all children without discrimination of any kind: inputs from the self-evaluation teams. Examples of Good Practices There is a space for play for children (BL, C, NMCH, ST, FA, FR, IL, HN) Areas that need improvement Not all hospitals’ policy guarantees the right to play for children; Play Specialists or properly trained staff to assist children during play are not available (all hospitals); Health care providers were not trained on how to use different forms of play within therapeutic care (all hospitals); No clinical protocols or guidelines on playing with children or game activities for children depends on their age in hospitals (all hospitals); No special staff to play and do different activities with children while staying in hospital (all hospitals, in some cases nurses are more involved in the playing activities); No training for health staff to support the playing activities with children; No designated and properly equipped play rooms for children (all hospitals need to improve the space for playing, it’s equipping and staffing); Health care providers were not trained on how to use different forms of play within therapeutic care; There is no hospital Examples of actions for improvement To improve the conditions for playing for children with limited ability; To train and organize continuous training of hospital staff in child protection; Develop a hospital policy to guarantee the right to play for children; Designate and properly equip (toys, games, music, etc.) the play rooms for children; Assign a Play Specialists/volunteers or properly trained staff to assist children during play; Develop a hospital strategy involving play during procedures and treatment, including clown, music, art, pet‐ therapy for children in the hospital; Equip and supply a play room with toys and games; organize a separate space for play and rest of adolescents (computers, chess, etc.), organize games in the hospital relevant for the age of children/adolescents; It is necessary to include the educational staff with the purpose to plan the playing and educational activities;
Assessing the respect of children’s rights in hospital in the Republic of Moldova page 29
strategy involving play during procedures and treatment (all hospitals); Annex 14. Standard 3: Play and Learning: 3.1. The hospital/health service ensures the right to play for all children without discrimination of any kind: inputs from the self-evaluation teams: Children’s and parents’/carers’ views and evaluation. Examples of Good Practices My child is small to play with other children, I entertain him In the hospital there is nowhere to play, my husband brought toys from home I played with other children, mostly in corridors Areas that need improvement Playing rooms availability Free access to playing room Doctors apply games for assessment procedures and treatment The games and toys have to available for children of different ages Do possible for children to continue the education while in hospital Organize a library in the hospital TV have to be repaired To organize supportive activities such as clown, music, art, pet‐therapy are provided for children in the hospital Examples of actions for improvement Doctors have to use paying techniques during assessment and treatment procedures The paying rooms have to be organized in all hospitals Toys have to be for children of all ages Organize a play room and leisure hours for children in the hospital; Equip and supply a play room with toys and games; Organize a separate space for play and rest of adolescents (computers, chess, etc.) Organize a hospital‐based school; Organize games in the hospital relevant for the age of children/adolescents.
Annex 15. Standard 3: Play and Learning: 3.2. The hospital/health service planning takes into account children’s views of what is needed: inputs from the self-evaluation teams. Examples of Good Practices n/a
Areas that need improvement Opinion of parents and children have to be gathered for the
Examples of actions for improvement To take into consideration children and parents/carers opinion,
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improvement of play spaces, but not (all hospitals, some elements in the national institutions NMCH, C, BL); Children are informed and asked about their opinion and vision on the equipment of the playing rooms (NMCH, BL, ST, FS, C, HN, SV, CM); No counselling with children for the improvement of play spaces (relevant hospitals, in some – nurses are asking children what they would like to see different in paying rooms – NMCH, BL, HN, AN);
view for the improvement of play spaces; Equip and supply a play room with toys and games; organize a separate space for play and rest of adolescents (computers, chess, etc.), organize games in the hospital relevant for the age of children/adolescents;
Annex 16. Standard 3: Play and Learning: 3.3. The hospital/health service provides complementary play and educational activities: inputs from the selfevaluation teams. Examples of Good Practices n/a
Areas that need Examples of actions for improvement improvement At the moment is not Organize a hospital‐based possible to assure the school; continuity of the educational process within hospital premises; No hospital‐based school (all hospitals); No supportive activities such as clown, music, art, pet‐therapy are provided for children in the hospital (related to all hospitals, NMCH, BL, C – sometimes parents organize birthdays for their hospitalized children);
Assessing the respect of children’s rights in hospital in the Republic of Moldova page 31
Annex 17. Standard 4: Information and participation: 4.1. The hospital/health service ensures an environment based on trust, informationsharing, the capacity to listen and sound guidance that is conducive to the child’s effective participation: inputs from the self-evaluation teams. Examples of Good Practices Areas that need improvement Health care staff introduce The inform consent is themselves to children taken only from adults and families and wear (parents/carers); name badges (all The mechanism on hospitals), information of Children’s and children/carer on adolescent’s complaints complaints’ investigation are investigated and is not in place; addressed (all hospitals). The process by which children and adolescents can voice concerns about their health care is not designed and implemented (all hospitals); Most often children’s opinion is not taken in consideration for the decision‐making; Examples of actions for improvement To include parents and children in decision‐ making re their children health; The process by which children and adolescents can voice concerns about their health care have to be developed and implemented; Ensure that children are informed about the medical condition and have the right to give consent to treatment and ask questions;
Annex 18. Standard 4: Information and participation: 4.2. The hospital/health service ensures that all appropriate staff has the skills to engage in dialogue and information-sharing with children of all ages and maturity: inputs from the self-evaluation teams. Examples of Good Practices n/a Areas that need Examples of actions for improvement improvement Health care providers Training for staff in have not been trained on children’s psychology and how to effectively behaviours; communicate with Ensure awareness raising children and families to and continuous training explain the condition, for staff on the proposed treatments, etc. importance of (all hospitals); communicating with patients of all ages and ways to do this (knowledge‐skills);
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Annex 19. Standard 4: Information and participation: 4.3. The hospital/health service engages with children for the development and improvement of health care services: inputs from the self-evaluation teams Examples of Good Practices n/a Areas that need improvement Children’s participation partly or don’t influences decision‐making in relation to improvement of health care services (all hospitals); Examples of actions for improvement Children’s participation have to be taken into consideration and influence the decision‐ making in relation to improvement of health care services; Ensure children’s participation influences the decision‐making in relation to improvement of hospital health care services;
Annex 20. Standard 5: Safety and environment: 5.1. The hospital/health service infrastructure is designed, furnished and equipped to meet children’s safety and mobility needs: inputs from the self-evaluation teams. Examples of Good Practices n/a Areas that need Examples of actions for improvement improvement Lack of medical Undertake actions to equipment provision improve the hospital barriers the infrastructure to meet implementation of children’s safety and children’s right in the mobility needs, and hospital, children with mobility restrictions; The hospital infrastructure Ensure that equipment is partly designed, furnished and equipped to and materials follow meet children’s safety and safety norms; mobility needs (all hospitals); The hospital partly ensures that equipment and materials follow safety norms (SV, CM, CR, OC, ED, HN, UG – in fact, is possible to mention that all hospitals); Hospital practice ensures effective and cleaning
Assessing the respect of children’s rights in hospital in the Republic of Moldova page 33
services, but the situation is not uniform some hospitals are lacking sufficient number and adequate WC, hot water, bathrooms for mothers and children (all hospitals); Not all hospitals’ infrastructure ensures that children with mobility restrictions are able to access all areas of the building (all hospitals);
Annex 21. Standard 5: Safety and environment: 5.2. The hospital/health service policies and practice support the best possible nutrition for children: inputs from the self-evaluation teams. Examples of Good Practices Free food is provided to all hospitalized children (all hospitals); All hospitals have specially trained staff (often nurses) or dietician who is responsible for the health menu development; The food is served timely in all hospitals; Areas that need improvement To improve the quality of products used for the cooking; To make the menu more diverse; Examples of actions for improvement To prepare the qualified staff, dieticians, in development of the health menus for hospitalized children;
Annex 22. Standard 5: Safety and environment: 5.3. The hospital/health service policies and practice ensure a clean environment for children at all times: inputs from the self-evaluation teams. Examples of Good Practices
Areas that need improvement Hospital practice ensures effective and cleaning services, but the situation is not uniform some hospitals are lacking sufficient number and adequate WC, hot water,
Examples of actions for improvement
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bathrooms for mothers and children (all hospitals);
Annex 23. Standard 6: Protection: 6.1. The hospital/health service has in place a system that ensures protection of the right of the child against all forms of violence: inputs from the self-evaluation teams. Examples of Good Practices The policy on protection of children who have been victims of any kind of abuse or violence is partly in place (national level, institutions are functioning using the below references); The common mechanism to solve the violence case between Ministry of Health and Ministry of Social Protection is in place and implemented starting with admission to the hospital (all hospitals); The child‐protective referral mechanisms with social services, police, other authorities in place (all hospitals). Areas that need improvement There is no system to register and monitor cases of children who have been a victim of any kind of abuse, the identification and reference/involvement if the social services is done only in admission department (all hospitals); Health professionals from hospitals were not trained on how to identify and examine children who have been abused, the most work was done with PHC professionals; There is no team or unit within the hospital dealing with child‐protection issues (all hospitals);
Examples of actions for improvement To develop national protocols on child protection for health professionals; To include social assistants in hospital staff with clear duties and responsibilities; A unit dealing with child‐ protection issues have to be organized at facility level; Organize and implement a continuous awareness raising/training courses for staff on how to identify and examine children who have been abused, and on existing protocols (all hospitals); Ensure regular assessment of effectiveness in protecting children of any kind of abuse in the hospital
Annex 24. Standard 6: Protection: 6.2. The hospital/health service ensures that all appropriate staff has the adequate skills to protect, treat and refer children who have been a victim of any kind of abuse or unintentional injury: inputs from the self-evaluation teams. Examples of Good Practices Areas that need Examples of actions for improvement improvement The policy framework is in Organize and implement a place, but no the continuous awareness
Assessing the respect of children’s rights in hospital in the Republic of Moldova page 35
mechanisms of its application into practice Health staff did not receive some special training;
raising/training courses for staff on how to identify and examine children who have been abused, and on existing protocols (all hospitals); Ensure regular assessment of effectiveness in protecting children of any kind of abuse in the hospital
Annex 25. Standard 6: Protection: 6.3. Clinical research and trials are strictly regulated by hospital/health policy: inputs from the self-evaluation teams. Examples of Good Practices Hospital has Ethics Committee for clinical research and trials (NMCH); Children and families have the option to refuse or not to be involved in teaching activities of the hospital (NMCH, C – only these hospitals are university clinics).
Areas that need Examples of actions for improvement improvement The clinical research and To organize within the trials are not regulated by hospitals, all hospitals, hospital policy: no specific Special Research Units (for protocols regulating research in pain clinical research and trials management, most (all hospitals, the research relevant for Medical are done at NMCH); University and NMCH); No Ethics Committee for clinical research and trials at hospital level (is present at Medical University and NMCH);
Annex 26. Standard 7: Pain management and Palliative care: 7.1. The hospital/health service policy ensures the prevention and management of pain: inputs from the self-evaluation teams. Examples of Good Practices n/a Areas that need Examples of actions for improvement improvement The protocols and The protocols and procedures for prevention procedures for prevention and management pain are and management pain not available, but in the have to be developed process of the (national level, process is development; facilitated by Ministry of Health); There is no continuous training for staff on pain
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management (all hospitals, all professionals);
Annex 27. Standard 7: Pain management and Palliative care: 7.2. The hospital’s/health service’s policy and practice ensure that palliative care is provided to all children who face life-threatening illness: inputs from the self-evaluation teams. Examples of Good Practices Palliative care includes psychological support to the child’s family (parents and carers) – some elements are in place (NMCH, BL, C, HN, AN); Areas that need improvement The hospital has NO partnerships in place or partly in place to provide palliative care on the community services or at home (all hospitals);
Examples of actions for improvement Develop, endorse and introduce the national protocols on palliative care, procedures for prevention and management of pain; Set up a Unit for Psychological/ Psychiatry Support within hospitals for hospitalized children and their families, as well as to any other child/adolescent in the community; Build partnerships to provide palliative care on the community services or at home; Develop a “home care” programme for children with terminal illness in order to offer palliative care to the dying child and support his/her family for a long period during and after death; The hospital has to develop partnerships to provide palliative care on the community services or at home.
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ASSESSING THE RESPECT OF CHILDREN’S RIGHTS IN HOSPITAL IN THE REPUBLIC OF MOLDOVA
This report describes findings and recommendations of the assessment of children’s rights in hospital in the Republic of Moldova that took place as part of overall efforts of the Ministry of Health in improving quality of paediatric care in hospitals supported by WHO. In the framework of the assessment of quality of paediatric care in hospitals, a set of specific tools were used for the assessment and improvement of the respect of children’s rights in 21 children’s’ hospitals.
World Health Organization Regional Office for Europe WHOLIS number Original: English
UN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark Tel.: +45 45 33 70 00 Fax: +45 45 33 70 01 Email: contact@euro.who.int Website: www.euro.who.int
The WHO Regional Office for Europe The World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with the primary responsibility for international health matters and public health. The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health conditions of the countries it serves. Member States Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czech Republic Denmark Estonia Finland France Georgia Germany Greece Hungary Iceland Ireland Israel Italy Kazakhstan Kyrgyzstan Latvia Lithuania Luxembourg Malta Monaco Montenegro Netherlands Norway Poland Portugal Republic of Moldova Romania Russian Federation San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Tajikistan The former Yugoslav Republic of Macedonia Turkey Turkmenistan Ukraine United Kingdom Uzbekistan WHOLIS number Original: English ASSESSING THE RESPECT OF CHILDREN’S RIGHTS IN HOSPITAL IN THE REPUBLIC OF MOLDOVA This report describes findings and recommendations of the assessment of children’s rights in hospital in the Republic of Moldova that took place as part of overall efforts of the Ministry of Health in improving quality of paediatric care in hospitals supported by WHO. In the framework of the assessment of quality of paediatric care in hospitals, a set of specific tools were used for the assessment and improvement of the respect of children’s rights in 21 children’s’ hospitals. Assessing the respect of children’s rights in hospital in the Republic of Moldova World Health Organization Regional Office for Europe UN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark Tel.: +45 45 33 70 00 Fax: +45 45 33 70 01 Email: contact@euro.who.int Website: www.euro.who.int Assessing the respect of children’s rights in hospital in the Republic of Moldova By: Ana Isabel Fernandes Guerreiro ABSTRACT This report describes findings and recommendations of the assessment of children’s rights in hospital in the Republic of Moldova that took place as part of overall efforts of the Ministry of Health in improving quality of paediatric care in hospitals (QoC) supported by WHO. In the framework of the assessment of QoC, a set of specific tools were used for the assessment and improvement of the respect of children’s rights in 21 children’s hospitals. Keywords CHILDREN, HOSPITALIZED PATIENTS’ RIGHTS PEDIATRICS Address requests about publications of the WHO Regional Office for Europe to: Publications WHO Regional Office for Europe UN City, Marmorvej 51 DK-2100 Copenhagen Ø, Denmark Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the Regional Office website (http://www.euro.who.int/pubrequest). © World Health Organization 2014 All rights reserved. The Regional Office for Europe of the World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. The views expressed by authors, editors, or expert groups do not necessarily represent the decisions or the stated policy of the World Health Organization. CONTENTS Page Acknowledgement ................................................................................................................ 1 Executive Summary .............................................................................................................. 1 List of annexes ..................................................................................................................... 2 Introduction ......................................................................................................................... 4 Part 1: Work methodology .................................................................................................... 4 Summary Chart 1. General information on the self-evaluation process and work methodologies ............................................................................................................. 6 Part 2: Analysis of the assessment results in hospitals ............................................................ 8 Standard 1. Quality services for children ........................................................................ 8 Standard 2: Equality and non-discrimination ................................................................ 11 Standard 3: Play and Learning .................................................................................... 12 Standard 4: Information and participation ................................................................... 13 Standard 5: Safety and environment ........................................................................... 15 Standard 6: Protection ............................................................................................... 16 Standard 7. Pain management and palliative care ........................................................ 17 Part 3: Recommendations for hospitals and Ministry of Health in Moldova .............................. 18 Annexes ........................................................................................................................ 21 Annex 1. Hospital names and abbreviation .................................................................. 21 Annex 2. Standard 1: Quality services for children: 1.1. The hospital/health service ensures that all institutional activities are based on the best evidence available and that staff are adequately trained: inputs from the self-evaluation teams ............................... 21 Annex 3. Standard 1: Quality services for children: 1.1. The hospital/health service ensures that all institutional activities are based on the best evidence available and that staff are adequately trained: Children’s and parents’/carers’ views and evaluation ......... 22 Annex 4. Standard 1: Quality services for children: 1.2. The hospital/health service ensures that all types of services provided within the organization are regularly monitored and evaluated: inputs from the self-evaluation teams................................................... 23 Annex 5. Standard 1: Quality services for children: 1.3. The hospital/health service has a Charter on Children’s Rights, in line with the United Nations Convention on the Rights of the Child: inputs from the self-evaluation teams .......................................................... 23 Annex 6. Standard 1: Quality services for children: 1.4. The hospital provides the possibility for parents/carers to stay with their child at all times during hospitalization: inputs from the self-evaluation teams. ........................................................................ 24 EUR/00/50 page 2 Annex 7. Standard 1: Quality services for children: 1.5. The hospital/health service pays special attention to the rights of adolescents to health care: inputs from the self- evaluation teams ....................................................................................................... 25 Annex 8. Standard 2: Equality and non-discrimination: Right 2.1. The hospital/health service fulfils the rights of access of all children without discrimination of any kind: inputs from the self-evaluation teams. .................................................................................. 25 Annex 9. Standard 2: Equality and non-discrimination: Right 2.1. The hospital/health service fulfils the rights of access of all children without discrimination of any kind: inputs from the self-evaluation teams: Children’s and parents’/carers’ views and evaluation. .... 26 Annex 10. Standard 2: Equality and non-discrimination: 2.2. The hospital/health service delivers a patient-centred care, which recognizes not only the child’s individuality and diverse circumstances and needs, but also those of his or her parents or carers: inputs from the self-evaluation teams. .................................................................................. 26 Annex 11. Standard 2: Equality and non-discrimination: 2.3. The hospital/health service ensures the respect of children’s privacy at all times: inputs from the self-evaluation teams........................................................................................................................ 27 Annex 12. Standard 2: Equality and non-discrimination: 2.3. The hospital/health service ensures the respect of children’s privacy at all times: Children’s views and evaluation. ... 27 Annex 13. Standard 3: Play and Learning: 3.1. The hospital/health service ensures the right to play for all children without discrimination of any kind: inputs from the self- evaluation teams. ...................................................................................................... 28 Annex 14. Standard 3: Play and Learning: 3.1. The hospital/health service ensures the right to play for all children without discrimination of any kind: inputs from the self- evaluation teams: Children’s and parents’/carers’ views and evaluation. ........................ 29 Annex 15. Standard 3: Play and Learning: 3.2. The hospital/health service planning takes into account children’s views of what is needed: inputs from the self-evaluation teams. . 29 Annex 16. Standard 3: Play and Learning: 3.3. The hospital/health service provides complementary play and educational activities: inputs from the self-evaluation teams. .. 30 Annex 17. Standard 4: Information and participation: 4.1. The hospital/health service ensures an environment based on trust, information-sharing, the capacity to listen and sound guidance that is conducive to the child’s effective participation: inputs from the self-evaluation teams. ................................................................................................ 30 Annex 18. Standard 4: Information and participation: 4.2. The hospital/health service ensures that all appropriate staff has the skills to engage in dialogue and information- sharing with children of all ages and maturity: inputs from the self-evaluation teams. .... 31 Annex 19. Standard 4: Information and participation: 4.3. The hospital/health service engages with children for the development and improvement of health care services: inputs from the self-evaluation teams ......................................................................... 32 Annex 20. Standard 5: Safety and environment: 5.1. The hospital/health service infrastructure is designed, furnished and equipped to meet children’s safety and mobility needs: inputs from the self-evaluation teams. .............................................................. 32 Annex 21. Standard 5: Safety and environment: 5.2. The hospital/health service policies and practice support the best possible nutrition for children: inputs from the self- evaluation teams. ...................................................................................................... 33 Annex 22. Standard 5: Safety and environment: 5.3. The hospital/health service policies and practice ensure a clean environment for children at all times: inputs from the self- evaluation teams. ...................................................................................................... 33 Annex 23. Standard 6: Protection: 6.1. The hospital/health service has in place a system that ensures protection of the right of the child against all forms of violence: inputs from the self-evaluation teams. .......................................................................................... 34 Annex 24. Standard 6: Protection: 6.2. The hospital/health service ensures that all appropriate staff has the adequate skills to protect, treat and refer children who have been a victim of any kind of abuse or unintentional injury: inputs from the self-evaluation teams........................................................................................................................ 34 Annex 25. Standard 6: Protection: 6.3. Clinical research and trials are strictly regulated by hospital/health policy: inputs from the self-evaluation teams. ....................................... 35 Annex 26. Standard 7: Pain management and Palliative care: 7.1. The hospital/health service policy ensures the prevention and management of pain: inputs from the self- evaluation teams. ...................................................................................................... 35 Annex 27. Standard 7: Pain management and Palliative care: 7.2. The hospital’s/health service’s policy and practice ensure that palliative care is provided to all children who face life-threatening illness: inputs from the self-evaluation teams. ...................................... 36
Assessing the respect of children’s rights in hospital in the Republic of Moldova page 1 Acknowledgement This report was written based on the results of the paediatric hospitals surveys in Republic of Moldova that aimed at identifying and assessing gaps between the full respect of children’s rights in hospitals and the actual practice. The assessment was supported by the Ministry of Health and the WHO Regional Office for Europe. The original set of tools developed by the Task Force on Health Promotion for Children and Adolescents in and by Hospitals and Health Services (Task Force HPH-CA) was adapted to the country context. In overall, a process of the assessment and report writing was coordinated by Vivian Barnekow and Aigul Kuttumuratova from Child and Adolescent Health programme of WHO Regional Office for Europe and Larisa Boderscova from the WHO country office. The report was prepared by WHO consultant Ana Isabel Guerreiro. We would like to thank Dr Jarno Habicht and the WHO Country Office team in Moldova and, in particular, Dr Larisa Boderscova, Family and Community Health program officer, for support in data collection and dissemination, as well as for compiling them in summary tables. Special thanks go to the national focal point Dr Ala Cojocaru and the hospital assessment teams for coordinating the process of primary data collection in the project hospitals. This report was produced within the framework of the Biennial Collaborative Agreement (BCA) 2012–2013 signed between the Ministry of Health of the Republic of Moldova and the Regional Office for Europe of the World Health Organization. Executive Summary The assessment of the respect of children’s rights in 21 hospitals in Moldova was carried out upon recommendation by WHO Regional Office for Europe with the aim to strengthen the evidence and overall recommendations to the Ministry of Health on improving quality of care for children in hospitals in Moldova and, in particular, the area of children’s and parents’/carers’ rights. A set of specific tools were used for the assessment and improvement of the respect of children’s rights in hospitals. The findings and recommendations identified in the assessment of children’s rights in hospitals in Moldova related mostly to the inputs provided by the self-evaluation teams. In future assessments, it is recommended that children and parents/carers play a more significant role in the process. In terms of quality of care, the average answer provided by parents/carers in all participating hospitals was “probably, we received the best care within the existing conditions”. Concerning the respect of specific rights, the main findings include the following: Moldova has not adopted a Charter on Children’s rights in hospitals at national level, that is why it has not been adopted by health facilities and it is not displayed in hospitals; all medical doctors and nurses working in paediatric care have a specialization in paediatrics and health care is delivered in accordance to national guidelines and protocols, although these should be aligned to international standards; relevant statistical data is collected and made available at the Ministry of Health’s website; there are mechanisms in place to ensure that all children have equal access to health services, including specific measures addressing Roma children; and attention is paid to the right to food. The main gaps include: the lack of respect, protection and fulfilment of children’s right to play and learning, information and participation; several actions are missing to ensure the effectiveness of the system in identifying children who have been a victim of abuse and in protecting them against further violence; there are no protocols and procedures for the prevention and management of page 2 pain in hospital; and there is a need to improve the design and equipment of infrastructures in all participating hospitals. List of annexes Annex 1. Hospital names and abbreviations Annex 2. Standard 1: Quality services for children: 1.1. The hospital/health service ensures that all institutional activities are based on the best evidence available and that staff are adequately trained: inputs from the self-evaluation teams Annex 3. Standard 1: Quality services for children: 1.1. The hospital/health service ensures that all institutional activities are based on the best evidence available and that staff are adequately trained: Children’s and parents’/carers’ views and evaluation Annex 4. Standard 1: Quality services for children: 1.2. The hospital/health service ensures that all types of services provided within the organization are regularly monitored and evaluated: inputs from the self-evaluation teams Annex 5. Standard 1: Quality services for children: 1.3. The hospital/health service has a Charter on Children’s Rights, in line with the United Nations Convention on the Rights of the Child: inputs from the self-evaluation teams Annex 6. Standard 1: Quality services for children: 1.4. The hospital provides the possibility for parents/carers to stay with their child at all times during hospitalization: inputs from the self- evaluation teams Annex 7. Standard 1: Quality services for children: 1.5. The hospital/health service pays special attention to the rights of adolescents to health care: inputs from the self-evaluation teams Annex 8. Standard 2: Equality and non-discrimination: Right 2.1. The hospital/health service fulfils the rights of access of all children without discrimination of any kind: inputs from the self- evaluation teams Annex 9. Standard 2: Equality and non-discrimination: Right 2.1. The hospital/health service fulfils the rights of access of all children without discrimination of any kind: inputs from the self- evaluation teams: Children’s and parents’/carers’ views and evaluation Annex 10. Standard 2: Equality and non-discrimination: 2.2. The hospital/health service delivers a patient-centred care, which recognizes not only the child’s individuality and diverse circumstances and needs, but also those of his or her parents or carers: inputs from the self-evaluation teams Annex 11. Standard 2: Equality and non-discrimination: 2.3. The hospital/health service ensures the respect of children’s privacy at all times: inputs from the self-evaluation teams Annex 12. Standard 2: Equality and non-discrimination: 2.3. The hospital/health service ensures the respect of children’s privacy at all times: Children’s views and evaluation Annex 13. Standard 3: Play and Learning: 3.1. The hospital/health service ensures the right to play for all children without discrimination of any kind: inputs from the self-evaluation teams Annex 14. Standard 3: Play and Learning: 3.1. The hospital/health service ensures the right to play for all children without discrimination of any kind: inputs from the self-evaluation teams: Children’s and parents’/carers’ views and evaluation Annex 15. Standard 3: Play and Learning: 3.2. The hospital/health service planning takes into account children’s views of what is needed: inputs from the self-evaluation teams Assessing the respect of children’s rights in hospital in the Republic of Moldova page 3 Annex 16. Standard 3: Play and Learning: 3.3. The hospital/health service provides complementary play and educational activities: inputs from the self-evaluation teams Annex 17. Standard 4: Information and participation: 4.1. The hospital/health service ensures an environment based on trust, information-sharing, the capacity to listen and sound guidance that is conducive to the child’s effective participation: inputs from the self-evaluation teams Annex 18. Standard 4: Information and participation: 4.2. The hospital/health service ensures that all appropriate staff has the skills to engage in dialogue and information-sharing with children of all ages and maturity: inputs from the self-evaluation teams Annex 19. Standard 4: Information and participation: 4.3. The hospital/health service engages with children for the development and improvement of health care services: inputs from the self- evaluation teams Annex 20. Standard 5: Safety and environment: 5.1. The hospital/health service infrastructure is designed, furnished and equipped to meet children’s safety and mobility needs: inputs from the self-evaluation teams Annex 21. Standard 5: Safety and environment: 5.2. The hospital/health service policies and practice support the best possible nutrition for children: inputs from the self-evaluation teams Annex 22. Standard 5: Safety and environment: 5.3. The hospital/health service policies and practice ensure a clean environment for children at all times: inputs from the self-evaluation teams Annex 23. Standard 6: Protection: 6.1. The hospital/health service has in place a system that ensures protection of the right of the child against all forms of violence: inputs from the self- evaluation teams Annex 24. Standard 6: Protection: 6.2. The hospital/health service ensures that all appropriate staff has the adequate skills to protect, treat and refer children who have been a victim of any kind of abuse or unintentional injury: inputs from the self-evaluation teams Annex 25. Standard 6: Protection: 6.3. Clinical research and trials are strictly regulated by hospital/health policy: inputs from the self-evaluation teams Annex 26. Standard 7: Pain management and Palliative care: 7.1. The hospital/health service policy ensures the prevention and management of pain: inputs from the self-evaluation teams Annex 27. Standard 7: Pain management and Palliative care: 7.2. The hospital’s/health service’s policy and practice ensure that palliative care is provided to all children who face life- threatening illness: inputs from the self-evaluation teams. page 4 Introduction The Committee on the Rights of the Child, in its General Comment Nº 15 on the right of the child to the enjoyment of the highest attainable standard of health (Article 24 of the Convention on the Rights of the Child, hereafter right to health), interprets children’s right to health “as an inclusive right, extending not only to timely and appropriate prevention, health promotion, curative, rehabilitative and palliative services, but also to a right to grow and develop their full potential and live in conditions that enable them to attain the highest standard of health through the implementation of programmes that address the underlying determinants of health.” Significantly, it also recognizes not only the importance of children’s right to health to the enjoyment of other rights and to children’s achievement of their full potential, but also the dependency of the right to health on the realization of other rights. Children’s rights must be realized in all of children’s life settings. Children’s stay in hospital – as any direct contact of children with the public system – can be regarded as an opportunity to enhance children’s rights, to address the underlying determinants of health and contribute to children’s overall well-being and development. Taking this into account, the aim of this report will be two-fold. Firstly, it aims to present the results on the assessment of the respect of children’s rights in 21 hospitals in Moldova. Secondly, it aims to draw recommendations and identify specific actions for improvement to both health providers and the Ministry of Health (Ministry of Health), by taking into consideration the State’s responsibility and the role of health care services, in line with the respect, protection and fulfilment of children’s right to health. The assessment deals with children’s rights in hospital, but it also tackles some parental rights. Indeed, parents/carers have a fundamental role in promoting the overall healthy child development through early diagnosis of diseases, educating against risky behaviour, teaching healthy eating habits, stimulating learning and enhancing children’s capabilities. For these reasons, to the extent possible, parents/carers should be seen as a partner during children’s hospitalization, their support should be sought and they should be given all information and instruments to be aware of how they can best take care of their child. This includes educating parents/carers on how to take care of a child with a specific illness (including chronic diseases and disabilities), raising awareness where parents’/carers’ behaviour is bad for their child (i.e. smoking), amongst other skills. The report is structured in the following manner: Part 1: Work methodology used for the assessment of children’s rights in hospital; Part 2: Analysis of the assessment results in hospitals. This section includes the information gathered for each of the standards on children’s rights in hospital and the identification of the main areas for improvement in hospital, with concrete examples; Part 3: Recommendations for hospitals and the Ministry of Health in Moldova. Part 1: Work methodology The assessment of the respect of children’s rights in hospital was carried out upon recommendation by WHO Regional Office for Europe with the aim to strengthen the evidence and overall recommendations to the Ministry of Health on improving quality of care for children in hospitals in Moldova and, in particular, the area of children’s and parents’/carers’ rights. Assessing the respect of children’s rights in hospital in the Republic of Moldova page 5 A set of specific tools were used for the assessment and improvement of the respect of children’s rights in hospitals. The original Manual and Tools (Task Force on Health Promotion for Children and Adolescents in and by Hospitals and Health Services, International Network of Health Promoting Hospitals and Health Services, 2012) are available in English, but for the implementation in Moldova the set of tools was translated into Romanian. Each tool was prepared for a group of stakeholders, namely a) hospital management, b) health professionals, c) children aged 6-11, d) children and adolescents aged 12-18 and e) parents and carers. The tools aim to assess children’s rights in hospital, in accordance to seven standards, as follows: Standard 1 evaluates the ‘best quality possible care’ delivered to all children, understood as a care that takes into account the clinical evidence available, the respect of children’s rights and patient and family’s views and wishes. Standard 2 evaluates to what extent the health care services respect the principles of equality and non-discrimination of all children. Standard 3 evaluates how play and learning are planned and delivered to all children. Standard 4 evaluates the rights of all children to information and participation in health care decisions affecting them and the delivery of services. Standard 5 evaluates to what extent health care services are delivered in a safe, clean and appropriate environment for all children. Standard 6 evaluates the right of all children to protection from all forms of physical or mental violence, unintentional injury, injury or abuse, neglect or negligent treatment, maltreatment or exploitation, including sexual abuse. Standard 7 evaluates the provision of pain management and palliative care to children. For each standard, several sub-standards and specific questions for the different groups of stakeholders were identified. The questions are adapted to each of the groups, however they aim to address and gather information on the same issues. 21 hospitals participated in the assessment of the respect of children’s rights in hospital (see Annex 1 for list of participating hospitals). The average number of participants was 34,6 per hospital, ranging from 24 participants in SG Hospital and 52 in NMCH Hospital. Participants included hospital management, doctors and nurses from various departments, parents/carers and children, from 6 to 18 years of age. The average number of meetings held per hospital was 4, ranging from 3 in SG and OC hospitals and 8 in NMCH Hospital. In every hospital, both work group discussions and individual interviews took place to assess the respect of children’s rights. Most often, parents/carers participated in focus groups of 8-10 people. Parents’/carers’ and elder children’s consent for participation was obtained in oral form. See Summary Chart 1 for detailed information per hospital. It is important to note that in many cases children and parents did not wish to contribute further and there is some key information missing that could help to understand further the good practices and gaps in relation to the respect of children’s rights in hospitals in Moldova. A suggestion for both Ministry of Health and hospitals is to enhance the culture of child and parents’/carers’ participation in matters affecting the child. Examples will be provided in the report on how to do this. The national focal point was responsible for the overall process of distribution of questionnaires, explaining on how to work with them and present the information, as well as, for the data collection, but in every hospital the director was responsible for the coordination of the process at facility level. page 6 Summary Chart 1. General information on the self-evaluation process and work methodologies Number of participants Type of participant Number of meetings Work methodology Regional Hospitals 1 AN 32 Hospital management, doctors and nurses, mothers and other carers, children 4 Joint group discussion and Individual interviews 2 CL 36 Hospital management, doctors and nurses, mothers and other carers, children 5 Joint group discussion and Individual interviews 3 CM 43 Hospital management, doctors and nurses, mothers and other carers, children 6 Joint group discussion and Individual interviews 4 CR 33 Hospital management, doctors and nurses, mothers and other carers, children 5 Joint group discussion and Individual interviews 5 ED 31 Hospital management, doctors and nurses, mothers and other carers, children 4 Joint group discussion and Individual interviews 6 FA 30 Hospital management, doctors and nurses, mothers and other carers, children 5 Joint group discussion and Individual interviews 7 FR 45 Hospital management, doctors and nurses, mothers and other carers, children 7 Joint group discussion and Individual interviews 8 GL 41 Hospital management, doctors and nurses, mothers and other carers, children 6 Joint group discussion and Individual interviews 9 SV 33 Hospital management, doctors and nurses, mothers and other carers, children 5 Joint group discussion and Individual interviews 10 ST 37 Hospital management, doctors and nurses, mothers and other carers, children 6 Joint group discussion and Individual Assessing the respect of children’s rights in hospital in the Republic of Moldova page 7 interviews 11 TA 29 Hospital management, doctors and nurses, mothers and other carers, children 5 Joint group discussion and Individual interviews 12 UG 30 Hospital management, doctors and nurses, mothers and other carers, children 5 Joint group discussion and Individual interviews 13 SD 31 Hospital management, doctors and nurses, mothers and other carers, children 5 Joint group discussion and Individual interviews 14 RZ 28 Hospital management, doctors and nurses, mothers and other carers, children 4 Joint group discussion and Individual interviews 15 SG 24 Hospital management, doctors and nurses, mothers and other carers, children 3 Joint group discussion and Individual interviews 16 OC 25 Hospital management, doctors and nurses, mothers and other carers, children 3 Joint group discussion and Individual interviews 17 HN 30 Hospital management, doctors and nurses, mothers and other carers, children 4 Joint group discussion and Individual interviews 18 IL 30 Hospital management, doctors and nurses, mothers and other carers, children 4 Joint group discussion and Individual interviews Municipal Hospital 19 BL 41 Hospital management, doctors and nurses, mothers and other carers, children 6 Joint group discussion and Individual interviews 20 C 46 Hospital management, doctors and nurses, mothers and other carers, children 7 Joint group discussion and Individual interviews Other Hospitals 21 NMCH 52 Hospital management, doctors and nurses, mothers and other carers, children 8 Joint group discussion and Individual page 8 interviews 1 AN 32 Hospital management, doctors and nurses, mothers and other carers, children 4 Joint group discussion and Individual interviews 2 CL 36 Hospital management, doctors and nurses, mothers and other carers, children 5 Joint group discussion and Individual interviews 3 CM 43 Hospital management, doctors and nurses, mothers and other carers, children 6 Joint group discussion and Individual interviews 4 CR 33 Hospital management, doctors and nurses, mothers and other carers, children 5 Joint group discussion and Individual interviews Part 2: Analysis of the assessment results in hospitals Standard 1. Quality services for children All services provided for children aim at delivering the best quality possible care, by taking into account clinical evidence available, the respect of children’s rights and patient and family’s views and wishes. • The hospital ensures that all institutional activities are based on the best evidence available and that staff are adequately trained. Taking into account the inputs by the self-evaluation teams, it is clear that there is significant attention to provide quality services for children. All participating hospitals deliver health care based on national and international guidelines. The guidelines are developed nationally through ah hoc committees made up by university staff and health professionals, in partnership with the Ministry of Health. All hospitals adapt the national protocols to their own context. All medical doctors and nurses working in paediatric care have a specialization in paediatrics. The main gap identified has been that some of the national guidelines are not in line with the international ones and thus should be adjusted, based on evidence-based medicine principles. In terms of quality of care, the average answer provided by parents/carers in all participating hospitals was “probably, we received the best care within the existing conditions”. Children and parent/carers stated they received good care or the best care in 5 and 7 hospitals, respectively. Other inputs included “doctors did everything necessary and possible”. In 11 hospitals, children aged 12-18 years of age stated that “the hospital should have modern equipment”. See Annexes 2 and 3, for summary of inputs on Standard 1, point 1.1. by self-evaluation team and children and parents/carers, respectively. Assessing the respect of children’s rights in hospital in the Republic of Moldova page 9 • The hospital ensures that all types of services provided within the organization are regularly monitored and evaluated. All hospitals have in place monitoring and evaluation activities to ensure quality of care for children and relevant statistical data that require the continuous improvement is available at the Ministry of Health website. On the other hand, as far as it was possible to gather most hospitals do not promote patient satisfaction surveys. Children aged 12 to 18 in 7 hospitals had not participated in patient satisfaction surveys. Information gathered from the self-evaluation teams confirms this data. The main actions for improvement identified by the self-evaluation teams included: to promote audits to ensure that health care services are in line with the organizational policy; to revise the statistical forms and the corresponding set of indicators; and to establish an effective system for collecting and presenting patient-satisfaction surveys or other. See Annex 4, for summary of inputs on Standard 1, point 1.2. by self-evaluation team. • The hospital has no a Charter on Children’s Rights in Hospital in line with the United Nations Convention on the Rights of the Child. Moldova has not yet adopted a Charter on Children’s rights in hospitals at national level, as well as it has not been adopted by health facilities and it is not displayed in hospitals. See Annex 5, for summary of inputs on Standard 1, point 1.3. by self-evaluation team. The hospital provides the possibility for parents/carers to stay with their child at all times during hospitalization. Inputs from the self-evaluation teams show that in principle parents/carers are allowed to stay with the child during procedures, including anaesthesia induction in all hospitals. However, inputs also suggest ensuring that parents are always allowed to stay during procedures. There are no specific inputs to be presented from parents’/cares’ and children’s experiences of staying in the participating hospitals, which would have been important to provide supportive evidence in relation to the fulfilment of this right. In all hospitals, parents/carers are always allowed to stay overnight with the child up to 5 years of age, for free, as well as, to receive free or subsidized meals at the hospital. There is no information to demonstrate whether the parents involved in the assessment had the possibility to stay with their children overnight. Free food is provided to all hospitalized children in all participating hospitals and the menu is prepared by a specialist, either a trained nurse or dietician. See Annex 6, for summary of inputs on Standard 1, point 1.4. by self-evaluation team. The hospital pays special attention to the rights of adolescents to health care. In 12 out of 21 hospitals, there is an adolescent-friendly health service. See Annex 7, for summary of inputs on Standard 1, point 1.5. by self-evaluation team. page 10 The assessment of Standard 1 on quality services for children in the participating hospitals, shows significant attention to the care of children in Moldova. The main areas for the improvement of this Standard are: To review national guidelines on quality and efficiency of care: National guidelines adopted by hospitals working for children should be in line with international guidelines and be based on evidence-based medicine. Existing protocols that are not in line with such guidelines should be reviewed, nationally. To review existing monitoring and evaluation mechanisms: Attention has been called to the need to revise current statistical data gathered by hospitals and made available on the Ministry of Health’s website, including a revision of the indicators used. The revision should take into account the results of assessments of quality of paediatric care, such as the present one. Additionally, it would be important to include indicators on patient satisfaction. To establish effective systems for collecting and presenting data gathered through children’s and parents’ or carers’ satisfaction surveys or other: Surveys to assess children’s and parents’/carers’ satisfaction with the services provided should be done on a regular basis and the outcomes should contribute to the decision- making processes at facility level. There are various degrees of involvement of children and parents, however, it is essential that children and parents/carers participating in patient satisfaction surveys are fully informed about the process, including how their opinions will be used and that they receive information about the outcomes. Ensure that the national Charter on Children’s rights in hospital is adopted by facilities: All hospitals should endorse the Charter that has not been adopted at national level. Once it is adopted, each hospital should prepare work towards the implementation of the Charter. This should be done at two levels. On one hand, it is important to disseminate the contents of the Charter by, among other actions, promoting awareness raising activities for health professionals and making the Charter available to children and parents (i.e. by displaying it in wards, handing out printed information or other methods). On the other hand, hospitals should adopt specific actions to respect each right individually. In line with this, throughout the present report, hospital managers and health professionals will find comments and suggestions, which can be used for the implementation of Charter on Children’s Rights in hospital. To enable at least 1 parent to stay with their child, including overnight stay: At the moment, only parents with children up to 5 years of age are able to stay with their child overnight. It would be important to progressively allow parents of older children, to be able to stay with their child overnight, as well. To ensure that all parents are allowed and encouraged to stay with their child at all times during hospitalization: Parents should be allowed and encouraged to stay with their child at all times, including during procedures, unless it is not in the best interest of the child. Hospitals should progressively enable parents/carers to stay with their child during procedures, as it can be beneficial for child health outcomes, medical staff treating the child and parents/carers alike. More and more, parents/carers are being allowed and encouraged to stay with their child at all times, including during procedures. In some countries and hospitals, parents/carers are also able to accompany their child during anaesthesia induction, but not in all hospitals. Hospitals are promoting parents/carers stay during procedures because it can help to reduce children’s anxiety, by providing comfort to them; parents/carers can often support medical staff in preparing children or helping in procedures; and it may help parents/carers to better understand their child’s condition and how to treat them at home, where applicable. Assessing the respect of children’s rights in hospital in the Republic of Moldova page 11 To establish adolescent-friendly health services in all hospitals: All hospitals should establish an adolescent-friendly health service and promote, among other, awareness raising materials about facilities, services and health information targeted at adolescents, as well as, other children’s age groups. Standard 2: Equality and non-discrimination All children should be able to access health care and undergo any type of treatment without discrimination of any kind, irrespective of the child’s or his or her parents/carers’ or legal guardians’ race, colour, sex, language, religion, political or other opinion, national, ethnic or social origin, property, disability, birth or other status. The hospital fulfils the rights of access of all children without discrimination of any kind. Inputs from the self-evaluation teams in all hospitals demonstrate that all children have equal access to health services, based on non-discrimination principles, as well as, equal access to treatment. Additionally, all hospitals have approved and implemented a policy on non- discrimination of the Roma population. In all hospitals, children and parents/carers stated that “all children are treated with respect, no one is refused care” and in some hospitals they stated that “everyone in the hospitals is treated equally”. See Annexes 8 and 9, for summary of inputs on Standard 2, point 2.1. by self-evaluation team and children and parents/carers, respectively. The hospital delivers a patient-centred care, which recognizes not only the child’s individuality and diverse circumstances and needs, but also those of his or her parents/carers. The inputs provided by the self-evaluation teams show little attention to this right. In all of the participating hospitals, hospital staff is neither trained to respect and care for patients with cultural differences; or to try to understand and respect culture-specific parenting beliefs and expectations. Furthermore, no hospital provides for qualified interpreters. It would be important to understand both the reason for this lack of attention and whether any children are being affected by these policies. See Annex 10, for summary of inputs on Standard 2, point 2.2. by self-evaluation team. The hospital ensures the respect of children’s privacy at all times. In 9 out of 21 hospitals, children are informed in private areas or in the doctor’s office, in 10 hospitals children are not always informed in private areas and in all hospitals, there is a limited possibility for children to stay in single or double rooms. Children’s and parents’/carers’ inputs demonstrate that there is “limited possibility to be hospitalized in the single or double rooms, no privacy during the examinations and no privacy when the results of the examinations/treatment are communicated”. See Annex 11 and 12, for summary of inputs on Standard 2, point 2.3. by self-evaluation team and children and parents/carers, respectively. page 12 The assessment of this standard shows attention at policy-making to children’s right to access health care without discrimination of any kind, including provisions for particular groups of children that may be more vulnerable, such as Roma children. On the other hand, at practice levels, some actions are needed for the improvement of services in all hospitals, including: To adopt measures to ensure that all children are able to undergo treatment without discrimination of any kind: All hospitals should increase attention to the treatment of vulnerable groups of children, by ensuring culturally-competent staff and interpreters, where needed. A patient-centred care goes beyond equal access to health care by all groups of children and includes understanding and respecting parents’/carers’ beliefs and expectations. This approach is essential to inform and engage with parents/carers and children in decision-making processes, to improve the child’s hospitalization experience, to improve compliance with treatment, among other issues. To ensure that children’s privacy is respected at all times: All hospitals must ensure, to the extent possible, that every child’s right to privacy is respected. This includes the availability of private areas to examine and inform children and parents/carers, to provide children with the possibility to be examined by a doctor of the same gender and the availability of single and/or double rooms. Standard 3: Play and Learning All children have opportunities for play, rest, leisure, recreation and their rights to education protected, suited to their age and condition, in spite of their health needs. The hospital ensures the right to play for all children without discrimination of any kind. In 8 out of 21 participating hospitals, there is a play space for children. However, other than this, the inputs provided by the self-evaluation teams show little attention to children’s right to play. Play is not guaranteed by all hospitals’ policy; there is no hospital strategy focused on involving play during procedures and treatment; no hospital has Play Specialists or other properly trained staff to assist children during play; health care providers were not trained on how to use different forms of play within therapeutic care; and there are no designated and properly equipped play rooms for children. Children’s and parents’ inputs included: “My child is small to play with other children, I entertain him; in the hospital there is not where to play, my husband brought toys from home (and) I played with other children, mostly in corridors”. See Annex 13 and 14, for summary of inputs on Standard 3, point 3.1. by self-evaluation team and children and parents/carers, respectively. The hospital planning takes into account children’s views of what is needed. In most participating hospitals there has been no engagement with children for the improvement of play spaces. Only in 4 hospitals (NMCH, BL, HN, AN), nurses ask children what they would like to see different in play rooms. See Annex 15, for summary of inputs on Standard 3, point 3.2. by self-evaluation team. The hospital provides complementarily play and educational activities. Assessing the respect of children’s rights in hospital in the Republic of Moldova page 13 There are no complementarily play and educational activities in any of the participating hospitals. See Annex 16, for summary of inputs on Standard 3, point 3.3. by self-evaluation team. The main areas identified for the improvement of children’s right to play are: Making available a play room for children: Play and learning have an important role for children’s development and, when in hospital, it is an added value to therapeutic care, which should be recognized. All hospitals should make available a play room or dedicated play space for children. Where hospitals will be preparing the playroom from the beginning, children and adolescents should be able to participate in its preparation and design. The consultation of children and adolescents will contribute greatly to ensure that the playroom will be designed and equipped to meet the needs and expectations of children of different age groups, in particular adolescents, who often feel that they do not have the opportunity for leisure during their stay in hospital. Guarantee Play Specialists and other adequately trained staff to accompany children during their stay in hospital: To the extent possible, hospitals should include Play Specialists in routine staff to assist children. Play Specialists play an important role in therapeutic care by preparing play activities in the Play room or by the child’s bedside, helping children to reduce their anxieties, supporting health staff by using play in the preparation of procedures, among other important activities. Introduce training of staff on how to use different forms of play within therapeutic care: Medical staff across countries is using different forms of play within therapeutic care to help children during their stay in hospital. Play is used to alleviate anxiety and stress, to enable children to cope with pain and to help in the management and outcomes of procedures. All hospitals are encouraged to provide training for their health staff on how to use different forms of play within therapeutic care. Introduce supportive activities such as clown, music, art and pet-therapy: In addition to play, there are other activities that can support children’s therapeutic care. These may include clown, music, art and pet-therapy, among others. Supportive play activities are used within therapeutic care, as described in the point before. Standard 4: Information and participation All children receive information about their health problem, in ways that are understandable to them, can express their views and participate in decision-making about their care and treatment, in a manner consistent with their evolving capacities. The hospital ensures an environment based on trust, information-sharing, the capacity to listen and sound guidance that is conducive to the child’s effective participation. The inputs provided by the self-evaluation teams and children/parents/carers demonstrate that very little attention is paid to children’s right to information and participation. In all hospitals, health care staff introduce themselves to children and families and wear name badges, but there seems to be no further action towards the respect, protection and fulfilment of this right. Children do not have the right to informed consent and the inputs also suggest that there is little involvement of patients in the decision-making processes regarding their care. There are no page 14 complaints’ procedures or other mechanisms where children and adolescents can voice concerns about their health care. See Annex 17, for summary of inputs on Standard 4, point 4.1. by self-evaluation team. The hospital ensures that all appropriate staff has the skills to engage with dialogue and information-sharing with children of all ages and maturity. In all participating hospitals, health care providers have not been trained on how to effectively communicate with children and families about the condition, proposed treatments, etc. See Annex 18, for summary of inputs on Standard 4, point 4.2. by self-evaluation team. The hospital engages with children for the development and improvement of health care services. Self-evaluation teams report that in all hospitals, children’s participation partly or does not influence decision-making in relation to the improvement of health care services. See Annex 19, for summary of inputs on Standard 4, point 4.3. by self-evaluation team. Significant action must be undertaken towards the improvement of the respect of children’s right to information and participation, namely: Ensure the respect of every child’s right to information: Children’s right to information and participation is essential to their health education and well-being. Children of all ages should be informed, in accordance to their evolving capacities. All hospitals must ensure that every child receives the same care and this includes the respect of their right to information. Health professionals should be able to explain fully to children about their condition, including what is happening to them, which treatments are proposed, options that are available, implications of all the options, treatment side effects, likelihood of discomfort and how to give ‘bad news’. Children and parents/carers should also receive general health promotion-related information and key information about the child’s stay in hospital. Oral information should be complemented with written information in different formats. Provide awareness raising and continuous training for staff on the importance of communicating with children of all ages and how to do this (skills): In order to ensure that all children receive information about their condition, in a manner consistent with their evolving capacities, hospitals should train medical staff on the importance of communicating with children and providing an enabling environment for parents/carers and children of all ages. This is essential to provide children and parents/carers with the necessary information, creating trust between professionals and patients, facilitating children’s participation in health decisions, but also in reducing both parents’/carers’ and children’s anxiety, ensuring their understanding of and compliance with treatments and enjoyment of an overall positive hospitalization experience. Medical staff should also be aware of existing legislation and policy and be encouraged to implement them. Establish criteria on children’s right to informed consent: A hospital policy on informed consent should be adopted by all hospitals, laying out the criteria and establishing an age from when children are able to give their informed consent. This policy should be based on national legislation on informed consent for children. Assessing the respect of children’s rights in hospital in the Republic of Moldova page 15 Children and parents/carers alike should be supported by health professionals, in order to understand the nature and consequences of the treatment, as well as, the consequences if they refuse that same treatment and therefore be able to make a sound judgment. Where children cannot give informed consent to treatment, they should still receive information about their situation, be able to ask questions and contribute to the decision- making process. Promote children’s participating in the improvement of health care services: It is important for hospitals to start engaging with children in decision-making processes concerning the improvement of health care services. Children of different age groups can provide important information about how the services are being implemented, in the identification of good practices and gaps, as well as, patient expectations about the services being provided to them. Any consultation with children must guarantee that they are treated with respected, explained the aims of the evaluation or project, how their views will be used and that they receive information about the outcomes of the consultation. Consultations with children can be done either at health service level (i.e. in primary care facilities or hospitals) or at national level (i.e. in schools). Children can provide key information about health challenges, behaviours and risks; health issues influenced by gender-based differences, cultural norms and socioeconomic status; and needs and expectations of services. This information can be used to inform States and health providers in the planning and implementation of effective health programmes and services. Standard 5: Safety and environment All services for children are provided in an environment designed, furnished, staffed and equipped to meet their needs. Safety also includes aspects of cleanliness and food. The hospital infrastructure is designed, furnished and equipped to meet children’s safety and mobility needs. Overall, there is a need to improve the design and equipment of infrastructures in all participating hospitals. In all hospitals, the infrastructure is partly designed, furnished and equipped to meet children’s safety and mobility needs; in most hospitals, safety norms for equipment and materials is only partially respected; and not all hospitals’ infrastructure ensures that children with mobility restrictions are able to access all areas of the buildings. See Annex 20, for summary of inputs on Standard 5, point 5.1. by self-evaluation team. The hospital policies and practice support the best possible nutrition for children. There is great attention to children’s right to food in all participating hospitals. All hospitals provide free food to all hospitalised children; all hospitals have specially trained staff that is responsible for the development of the menu and food is served timely in all hospitals. Suggested improvements include improvement of the quality of products used, as well as, enhancement of their diversity. See Annex 21, for summary of inputs on Standard 5, point 5.2. by self-evaluation team. The hospital policies and practices ensure effective and strict cleaning services. page 16 In relation to cleaning, although there seems to be attention as to ensuring effective and cleaning services, the situation is not uniform and some hospitals are, in fact, lacking sufficient number and adequate toilets, hot water and bathrooms for mothers and children. See Annex 22, for summary of inputs on Standard 5, point 5.3. by self-evaluation team. The mains actions towards the improvement of this standard are: Ensuring that hospitals’ infrastructure is designed, furnished and equipped to meet children’s safety and mobility needs: Actions must be undertaken to ensure that hospitals’ infrastructures meet children’s safety and mobility needs. Consulting with children of different age groups and needs is an effective way of ensuring that the hospitals’ infrastructure is appropriate to all children visiting and staying in the hospital. Improvement should also include an assessment to learn whether safety norms for equipment and materials are followed in every hospital and, if not, to improve safety norm-related standards. Consolidate the efficiency of cleaning services and practices: All hospitals are encouraged to continue to maintain high standards of cleaning services and practices and to address the gaps identified by the self-evaluation teams, which were mentioned above. Standard 6: Protection Children are protected from all forms of physical or mental violence, unintentional injury, injury or abuse, neglect or negligent treatment, maltreatment or exploitation, including sexual abuse. The hospital has in place a system that ensures protection of the right of the child against all forms of violence. Ministry for Social Services and whose protocol is activated upon a child’s admission to hospital. All hospitals adhere to this common mechanism and, in addition, have put in place referral mechanisms with social services, police and other authorities. However, several actions are missing to ensure the effectiveness of the system in identifying children who have been a victim of abuse and in protecting them against further violence. Specifically, no hospital has in place a system to register and monitor cases of children who have been a victim of any kind of abuse; and there is no team or unit within hospitals dealing with child-protection issues. See Annex 23, for summary of inputs on Standard 6, point 6.1. by self-evaluation team. The hospital ensures that all appropriate staff has the adequate skills to protect, treat and refer children who have been a victim of any kind of abuse. Health professionals working in hospitals have not received training on how to identify and examine children who have been abused. The self-evaluation teams referred that most of the related work is done at Primary Health care-level. See Annex 24, for summary of inputs on Standard 6, point 6.2. by self-evaluation team. Clinical research and trials are strictly regulated by hospital policy. Assessing the respect of children’s rights in hospital in the Republic of Moldova page 17 As far as it is possible to gather, clinical research is only carried out in 2 hospitals, namely C and NMCH. In both hospitals, children and families have the option to refuse or not to be involved in teaching activities of the hospital and in NMCH there is an Ethics Committee for clinical research and trials. See Annex 25, for summary of inputs on Standard 6, point 6.3. by self-evaluation team. The main improvements towards the respect of the right to protection from all forms of violence are: Consolidation of the existing system of child protection in all hospitals: The effective protection of children, once they reach a hospital, depends on a number of services being available to them, within a functioning system. Where missing, all hospitals are invited to adopt a specific hospital policy on child protection, to register cases of child abuse, to have in place referral systems with relevant authorities and to regularly monitor and evaluate the system in order to ensure its effectiveness. The medical staff must receive training and be able to identify a child, who has been a victim of abuse and how to treat them, but also to know applicable legislation, hospital policy and how to activate the necessary mechanisms, such as referral systems. Ensure that no clinical research and trials are carried out without adequate regulations: All hospitals must ensure that any clinical research and trials carried out within the hospital are clearly regulated by and follow national legislation and hospital policy. Medical staff conducting the research should be made aware of the existing protocols and procedures. To ensure that research complies with national and hospital protocols and regulations, a hospital body should established, such as an Ethics Committee. Ensure the protection of every child participating in clinical research or trials: Children participating in clinical research and trials and their parents/carers should be properly informed about what the research entails, their informed consent should always be requested and they should be given the option to refuse or not to be involved in the teaching activities of the hospital and/or to drop out of the research at any time. Furthermore, medical staff must make sure that children and parents/carers understand all these issues, including their option not to participate in the research. Standard 7. Pain management and palliative care All children have the right to individualized, culturally and age appropriate prevention and management of pain and palliative care. The hospital policy ensures the prevention and management of pain. At present, there are no protocols and procedures for the prevention and management of pain in hospital. In fact, the protocols are currently being prepared at national level by the Ministry of Health. No health professionals working in hospitals have received training on evidence based pain management. See Annex 26, for summary of inputs on Standard 7, point 7.1. by self-evaluation team. The hospital’s policy and practice ensure that palliative care is provided to all children who face life-threatening illness. page 18 In 5 hospitals (NMCH, BL, C, HN, AN), there are some elements of palliative care in place, including psychological support to the child’s family (parents/carers). There are no partnerships in place to ensure that palliative care can continue within community services or at home. See Annex 27, for summary of inputs on Standard 7, point 7.2. by self-evaluation team. The protocols and procedures on prevention and management of pain, to be adopted, should be implemented by hospitals by carrying out the following actions, among other: All hospitals should adopt pain management protocols: A functioning pain management system will entail that a number of practices are carried out, including a system to assess and register children’s pain, training of staff in pain management and regular assessment of services, to ensure that they are implemented effectively. Children’s views should be sought when assessing pain services. Introduce an initial and continuous training programme for health care staff in the area of pain management: Medical staff in all hospitals should be trained in the area of pain management, including how to assess and register children’s pain, how to manage painful procedures; and ways to alleviate pain, including alternatives to pain medicine and parents/carers’ support and involvement during procedures. Set up a Unit for Psychological/ Psychiatric Support within hospitals for hospitalised children and their families and to children in the community: Hospitals are encouraged to set up a unit for Psychological/Psychiatric support within hospitals or in partnership with services at community level. This unit should support hospitalised children and families, as well as, other children in need in the community. The availability of this unit to children in the community must include measures to reach out to children in need of support. Build partnerships to provide palliative care in the community services or at home: Establishing partnerships between hospitals and services in the community is essential to prevent the unnecessary hospitalization of children. This may be particularly important for children in vulnerable situations, such as children receiving palliative care. Hospitals may build partnerships with primary care level services or other governmental or nongovernmental organizations working at the community level. Upon existence of the partnership, medical staff should be made aware of it and be able to facilitate the service to children, by referring them. Part 3: Recommendations for hospitals and Ministry of Health in Moldova Specific actions for improvement of the respect of children’s rights in hospital have been provided throughout this report, for every standard and child right. This final section aims to draw on that analysis and present general guidelines and recommendations for the Ministry of Health and hospitals in Moldova. Recommendations for the Ministry of Health: There are several policies and protocols identified in the assessment of the respect of children’s rights in hospitals in Moldova that have recently been adopted by the MoH. These not include, among other, the adoption of a national Charter on Children’s Rights in Hospital, protocols for the management and prevention of pain and palliative care. In addition to the recently adopted Assessing the respect of children’s rights in hospital in the Republic of Moldova page 19 policies and protocols, some existing areas need to be strengthened, such as the protection of children who have been a victim of abuse and neglect. The Ministry of Health of Moldova has an opportunity to use available knowledge at international level to implement cost-effective programmes, both to develop the recently adopted policies and protocols and to strengthen existing ones. These include, but are not limited to, existing training packages, clinical protocols, guidelines and experiences of involving children in decision-making processes. Importantly, the Ministry of Health of Moldova collects data from hospitals and makes it available on its website. The Ministry of Health should build on this good practice to improve monitoring and evaluation systems and to plan health policies, by reviewing existing indicators of progress and including data from patient satisfaction surveys. Other recommendations include: Align existing national guidelines with international ones, ensuring that they are based on evidence-based medicine; Allocate budgets to renovate hospital infrastructure and supply necessary hospital equipment; Add children’s rights to the curricula of doctors and nurses specializing in paediatrics; Encourage all hospitals to implement Adolescent Friendly Health Services. Attention to specific child rights in hospital: Right to information and participation: the Ministry of Health, in partnership with other Ministries, should enhance a national cultural on the respect for the views of the child, including providing relevant health-related information to children in different life settings (home, school, hospital), involving children in decision-making processes influencing their health (including treatment) and consulting with children on the design and improvement of health care services; Right to informed consent: the Ministry of Health should adopt legislation to establish national criteria on informed consent for children; Right to play: children who experience hospitalization are in a vulnerable situation and foreign environment. As seen throughout this report, play can have a meaningful role in diminishing children’s anxiety and pain, in contributing to their development and within therapeutic care. The Ministry of Health should fulfil children’s right to play by allocating budgets, facilitating partnerships between relevant organizations and hospitals and/or other measures adapted to the local context. Recommendations for the hospitals: Enhance the participation of children and parents/carers in assessing and improving hospital services, by means of patient surveys, complaints procedures, suggestion ‘boxes’, ad hoc consultations such as the present one, or other methods. The feedback from children and parents/carers should be used to inform hospital management in drawing hospital policies and planning; Promote continuous training and awareness raising activities for health professionals on specific aspects related to the management of child care. Some needs have been identified in the report, such as the need for training on pain management, how to identify a child who has been a victim of abuse and neglect, communicating with children of different ages, etc; Improve hospital infrastructure, in consultation with children and parents/carers. Particular attention should be paid to the needs of children with different mobility restrictions. page 20 Attention to specific child rights in hospital: Right to information and participation: Hospital policy and health professionals in daily practice must ensure an environment based on trust, information-sharing, the capacity to listen and sound guidance that is conducive to the child’s effective participation, including information about their health and treatment, involving them in the decision-making process; the possibility to give consent to treatment; and participation in the improvement of health care services; Right to play: Hospitals must undertake to make the necessary provisions for the fulfilment of children’s right to play, including setting up a play room or space for children to play, hiring Play Specialists to assist children, train health professionals how to use play within therapeutic care and engaging with organizations in the community to provide alternative forms of play, such as music, pet and other therapies; Right to protection: the overall system for the protection of children who have been a victim of abuse or neglect should be improved. Assessing the respect of children’s rights in hospital in the Republic of Moldova page 21 Annexes Annex 1. Hospital names and abbreviation Hospital names Abbreviation Regional Hospitals 1 Regional Hospital from Anenii Noi AN 2 Regional hospital from Ceadir‐Lunga CL 3 Regional Hospital from Comrat CM 4 Regional Hospital from Criuleni CR 5 Regional Hospital from Edinet ED 6 Regional Hospital from Falesti FA 7 Regional Hospital from Floresti FR 8 Regional Hospital from Glodeni GL 9 Regional Hospital from Stefan Voda SV 10 Regional Hospital from Straseni ST 11 Regional Hospital from Taraclia TA 12 Regional Hospital from Ungheni UG 13 Regional Hospital from Soldanesti SD 14 Regional Hospital from Rezina RZ 15 Regional Hospital from Singerei SG 16 Regional Hospital from Ocnita OC 17 Regional Hospital from Hincesti HN 18 Regional Hospital from Ialoveni IL Municipal Hospitals 19 Municipal Hospital from Balti BL 20 Municipal Hospital from Chisinau (Ignatenko) C Other Hospitals 21 National Institute on MCH NMCH Annex 2. Standard 1: Quality services for children: 1.1. The hospital/health service ensures that all institutional activities are based on the best evidence available and that staff are adequately trained: inputs from the self- evaluation teams Examples of Good Practices Areas that need improvement Examples of actions for improvement Health care service delivered to children is based on national and international guidelines (all hospitals); The national guidelines are developed by specialized committees represented by A number of guidelines have discrepancies with the international guidelines and need to be adjusted based on EBM principles; The national guidelines are updated and adjusted to international guidelines based on EBM principles; page 22 university staff and health professionals, in partnership with the Ministry of Health (at National level) Approved national protocol are adjusted to local/facility level with regard to the facility activities as per the regulation framework of the institution (all hospitals) In all facilities are available adjusted to facility levels’ national protocols (all hospitals); All medical doctors and nurses working in paediatric department have a specialization in paediatrics (all hospitals); Annex 3. Standard 1: Quality services for children: 1.1. The hospital/health service ensures that all institutional activities are based on the best evidence available and that staff are adequately trained: Children’s and parents’/carers’ views and evaluation Examples of Good Practices Areas that need improvement Examples of actions for improvement Children: “I received good care’ – OC, ED, CM, SD, GL ‘I received best care’ – NMCH, AN, HN, IL, UN, C, BL Parents/carers ‘Probably, we received the best care within the existing conditions’ – average answer from all hospitals – AN, FA, CR, FL ‘Doctors’ did everything necessary and possible’ – C, TA, RZ, SD, SV, HN ‘I am not sure, I am not a doctor, but seems that they did everything correct’ – NMCH, BL, OC, UN, CM Advice on child’s health care support was given verbally – all hospitals No participate in patient satisfaction survey – AN, SD, FA, OC, GL, FR, FA, TA, SV, UN, CL, CM, CR: “The hospital should have a modern equipment not” (12‐18 years); Ensure that children and parents/carers participate in patient satisfaction surveys, will be interesting to be involved – all hospitals; Ensure that the outcomes of patient satisfaction survey communicated back to children and parents/carers and contribute to the decision‐making – all hospitals. Approve the Charter on Assessing the respect of children’s rights in hospital in the Republic of Moldova page 23 OC, HN No information provided on children rights – all hospitals HN, FL, FR, ED, FA, GL, TA: “I didn’t participate in patient satisfaction survey” (adolescent 12‐18 years); Patients had not chance to participate in surveys – all hospitals, some exceptions may be those from NMCH Children’s Rights at hospitals – all hospitals To make Children’s rights in hospitals. Undertake actions to improve the hospital infrastructure to meet children’s safety and mobility needs, and children with mobility restrictions. Annex 4. Standard 1: Quality services for children: 1.2. The hospital/health service ensures that all types of services provided within the organization are regularly monitored and evaluated: inputs from the self-evaluation teams. Examples of Good Practices Areas that need improvement Examples of actions for improvement At facility level exist the registry of clients’ opinion (NMCH, C, BL, IL, SV, ED, OC, FL, FR, SG, HN, CL, CM, CR, UG, TA, RZ) The regular assessment of services ensures effectiveness in protecting children (NMCH, C, BL, HN, IL); The services assessment to ensure quality of the treatment process is in place (all hospitals); The administrative statistics are available for all at Ministry of Health website; The promotion of surveys to assess children’s and parents’ or carers’ satisfaction with the services is not done on regular base; The indicators presented in administrative statistics have to be revised, as not provide the all necessary information The hospital needs improvement of setting and introduction of an effective system of patient satisfaction surveys (all hospitals); Improve the process of setting and introduction of an effective system of patient satisfaction surveys; Ensure that the outcomes of patient satisfaction survey communicated back to children and parents/carers and contribute to the decision‐ making at facility level; Facilitate in carrying out of audit to meet health care services in line with the organizational policy; Revision of the statistic forms and the revision of the set of the respective indicators; Annex 5. Standard 1: Quality services for children: 1.3. The hospital/health service has a Charter on Children’s Rights, in line with the United Nations Convention on the Rights of the Child: inputs from the self-evaluation teams Examples of Good Practices Areas that need improvement Examples of actions for improvement page 24 The Child Rights’ Charter is not adopted at facility level (all hospitals) Approval of the Charter on Children Rights’ at facility level; Training for hospital staff on Charter on Children’s Right (all hospitals); All children on admission are informed about their rights; To approve the Children’s right charter, inform patients about and to place it in the facility (all hospitals); Develop a child‐friendly version of the Charter on Children’s Rights; Adopt, disseminate and make a Charter on Children’s Rights available in the wards; Educate all health care service staff (doctors and nurses) on the Charter and Children’s Right; Annex 6. Standard 1: Quality services for children: 1.4. The hospital provides the possibility for parents/carers to stay with their child at all times during hospitalization: inputs from the self-evaluation teams. Examples of Good Practices Areas that need improvement Examples of actions for improvement Parents/carers are allowed to stay with the child during procedures, including anaesthesia induction (all hospitals); Parents/carers are always allowed to stay with the child up to 5 years overnight for free (all hospitals); Parents/carers are allowed to receive free or subsidized meals at the hospital as per the methodological norms, staying with children up to 5 years (all hospitals) Free food is provided to all To improve the quality and diversity of the food provided within the hospital for children; To allow parents/carers to stay with their children why medical procedures, in ICU. To create the canteen for parents, if no conditions to offer meals in ward, for those who want to stay with children older than 5 years; Ensure that parents/carers are always allowed to stay with the child overnight for free; Ensure that parents/carers are always allowed to stay with the child during procedures, including injections, blood extraction; Ensure that parents/carers are allowed to receive free Assessing the respect of children’s rights in hospital in the Republic of Moldova page 25 hospitalized children (all hospitals); All hospitals have specially trained staff (often nurses) or dietician who is responsible for the health menu development. or subsidized meals at the hospital; To prepare the qualified staff, dieticians, in development of the health menus for hospitalized children. Annex 7. Standard 1: Quality services for children: 1.5. The hospital/health service pays special attention to the rights of adolescents to health care: inputs from the self-evaluation teams Examples of Good Practices Areas that need improvement Examples of actions for improvement There is adolescent‐ friendly health services in the hospital (in 12 hospitals); At facility level exist the registry of clients’ opinion (NMCH, C, BL, IL, SV, ED, OC, FL, FR, SG, HN, CL, CM, CR, UG, TA, RZ) To develop the information materials special oriented to children as those developed are only for adults (all hospitals) The promotion of surveys to assess children’s and parents’ or carers’ satisfaction with the services is not done on regular base; Improve the process of setting and introduction of an effective system of patient satisfaction surveys; Ensure that the outcomes of patient satisfaction survey communicated back to children and parents/carers and contribute to the decision‐ making at facility level; To continue the development of the YFHS in other than those 12 rayons to improve the adolescents’ access to health services; To develop information materials oriented on children; Annex 8. Standard 2: Equality and non-discrimination: Right 2.1. The hospital/health service fulfils the rights of access of all children without discrimination of any kind: inputs from the self-evaluation teams. Examples of Good Practices Areas that need improvement Examples of actions for improvement N/A N/A page 26 Annex 9. Standard 2: Equality and non-discrimination: Right 2.1. The hospital/health service fulfils the rights of access of all children without discrimination of any kind: inputs from the self-evaluation teams: Children’s and parents’/carers’ views and evaluation. Examples of Good Practices Areas that need improvement Examples of actions for improvement All children are treated with respect – all hospitals No one refused in care – all hospitals Everyone in the hospitals are treated equally Ensure that children of minority and other status are not discriminated and have equal access to health services; Guarantee competent interpreters in need of case. To use preferred children names Annex 10. Standard 2: Equality and non-discrimination: 2.2. The hospital/health service delivers a patient-centred care, which recognizes not only the child’s individuality and diverse circumstances and needs, but also those of his or her parents or carers: inputs from the self-evaluation teams. Examples of Good Practices Areas that need improvement Examples of actions for improvement Hospital staff is not trained on respect and care of patients with cultural differences (all hospitals); Hospital does not provide qualified interpreter (all hospitals – in need of case, manage the situation as it is possible). Health professionals are not trained to try to understand and respect culture‐specific parenting beliefs and expectations (all hospitals); Special trainings for staff on respect and care of patients with cultural differences (all hospitals); Develop or enhance the program on continuous cultural‐competence training for staff; Ensure religious support is provided by the hospital to families of all faith; Assessing the respect of children’s rights in hospital in the Republic of Moldova page 27 Annex 11. Standard 2: Equality and non-discrimination: 2.3. The hospital/health service ensures the respect of children’s privacy at all times: inputs from the self-evaluation teams. Examples of Good Practices Areas that need improvement Examples of actions for improvement Children are informed in private areas or in doctor’s office (NMCH, BL, C, IL, HN, FA, SG, SD, SV) Limited possibility to hospitalize children in single or double rooms (all hospitals) Children are not always informed in private areas (SR, UG, FL, FR, SG, HN, ST, AN, CL, CM); To organize more single rooms to respect the privacy, culture, religious beliefs; To organize more single or double rooms as to provide more privacy for hospitalized children; Ensure that children have choice to be examined by the doctor of the same gender; Ensure the right of children to be hospitalized in single or double rooms, upon request; Ensure the right of children to be informed in private areas; Annex 12. Standard 2: Equality and non-discrimination: 2.3. The hospital/health service ensures the respect of children’s privacy at all times: Children’s views and evaluation. Examples of Good Practices Areas that need improvement Examples of actions for improvement Limited possibility to be hospitalized in the single or double rooms No privacy during the examinations No privacy when the results of the examinations/treatment are communicated Ensure the right of children to be hospitalized in single or double rooms, upon request; Ensure the right of children to be informed and examined in private areas. page 28 Annex 13. Standard 3: Play and Learning: 3.1. The hospital/health service ensures the right to play for all children without discrimination of any kind: inputs from the self-evaluation teams. Examples of Good Practices Areas that need improvement Examples of actions for improvement There is a space for play for children (BL, C, NMCH, ST, FA, FR, IL, HN) Not all hospitals’ policy guarantees the right to play for children; Play Specialists or properly trained staff to assist children during play are not available (all hospitals); Health care providers were not trained on how to use different forms of play within therapeutic care (all hospitals); No clinical protocols or guidelines on playing with children or game activities for children depends on their age in hospitals (all hospitals); No special staff to play and do different activities with children while staying in hospital (all hospitals, in some cases nurses are more involved in the playing activities); No training for health staff to support the playing activities with children; No designated and properly equipped play rooms for children (all hospitals need to improve the space for playing, it’s equipping and staffing); Health care providers were not trained on how to use different forms of play within therapeutic care; There is no hospital To improve the conditions for playing for children with limited ability; To train and organize continuous training of hospital staff in child protection; Develop a hospital policy to guarantee the right to play for children; Designate and properly equip (toys, games, music, etc.) the play rooms for children; Assign a Play Specialists/volunteers or properly trained staff to assist children during play; Develop a hospital strategy involving play during procedures and treatment, including clown, music, art, pet‐ therapy for children in the hospital; Equip and supply a play room with toys and games; organize a separate space for play and rest of adolescents (computers, chess, etc.), organize games in the hospital relevant for the age of children/adolescents; It is necessary to include the educational staff with the purpose to plan the playing and educational activities; Assessing the respect of children’s rights in hospital in the Republic of Moldova page 29 strategy involving play during procedures and treatment (all hospitals); Annex 14. Standard 3: Play and Learning: 3.1. The hospital/health service ensures the right to play for all children without discrimination of any kind: inputs from the self-evaluation teams: Children’s and parents’/carers’ views and evaluation. Examples of Good Practices Areas that need improvement Examples of actions for improvement My child is small to play with other children, I entertain him In the hospital there is nowhere to play, my husband brought toys from home I played with other children, mostly in corridors Playing rooms availability Free access to playing room Doctors apply games for assessment procedures and treatment The games and toys have to available for children of different ages Do possible for children to continue the education while in hospital Organize a library in the hospital TV have to be repaired To organize supportive activities such as clown, music, art, pet‐therapy are provided for children in the hospital Doctors have to use paying techniques during assessment and treatment procedures The paying rooms have to be organized in all hospitals Toys have to be for children of all ages Organize a play room and leisure hours for children in the hospital; Equip and supply a play room with toys and games; Organize a separate space for play and rest of adolescents (computers, chess, etc.) Organize a hospital‐based school; Organize games in the hospital relevant for the age of children/adolescents. Annex 15. Standard 3: Play and Learning: 3.2. The hospital/health service planning takes into account children’s views of what is needed: inputs from the self-evaluation teams. Examples of Good Practices Areas that need improvement Examples of actions for improvement n/a Opinion of parents and children have to be gathered for the To take into consideration children and parents/carers opinion, page 30 improvement of play spaces, but not (all hospitals, some elements in the national institutions NMCH, C, BL); Children are informed and asked about their opinion and vision on the equipment of the playing rooms (NMCH, BL, ST, FS, C, HN, SV, CM); No counselling with children for the improvement of play spaces (relevant hospitals, in some – nurses are asking children what they would like to see different in paying rooms – NMCH, BL, HN, AN); view for the improvement of play spaces; Equip and supply a play room with toys and games; organize a separate space for play and rest of adolescents (computers, chess, etc.), organize games in the hospital relevant for the age of children/adolescents; Annex 16. Standard 3: Play and Learning: 3.3. The hospital/health service provides complementary play and educational activities: inputs from the self- evaluation teams. Examples of Good Practices Areas that need improvement Examples of actions for improvement n/a At the moment is not possible to assure the continuity of the educational process within hospital premises; No hospital‐based school (all hospitals); No supportive activities such as clown, music, art, pet‐therapy are provided for children in the hospital (related to all hospitals, NMCH, BL, C – sometimes parents organize birthdays for their hospitalized children); Organize a hospital‐based school; Assessing the respect of children’s rights in hospital in the Republic of Moldova page 31 Annex 17. Standard 4: Information and participation: 4.1. The hospital/health service ensures an environment based on trust, information- sharing, the capacity to listen and sound guidance that is conducive to the child’s effective participation: inputs from the self-evaluation teams. Examples of Good Practices Areas that need improvement Examples of actions for improvement Health care staff introduce themselves to children and families and wear name badges (all hospitals), Children’s and adolescent’s complaints are investigated and addressed (all hospitals). The inform consent is taken only from adults (parents/carers); The mechanism on information of children/carer on complaints’ investigation is not in place; The process by which children and adolescents can voice concerns about their health care is not designed and implemented (all hospitals); Most often children’s opinion is not taken in consideration for the decision‐making; To include parents and children in decision‐ making re their children health; The process by which children and adolescents can voice concerns about their health care have to be developed and implemented; Ensure that children are informed about the medical condition and have the right to give consent to treatment and ask questions; Annex 18. Standard 4: Information and participation: 4.2. The hospital/health service ensures that all appropriate staff has the skills to engage in dialogue and information-sharing with children of all ages and maturity: inputs from the self-evaluation teams. Examples of Good Practices Areas that need improvement Examples of actions for improvement n/a Health care providers have not been trained on how to effectively communicate with children and families to explain the condition, proposed treatments, etc. (all hospitals); Training for staff in children’s psychology and behaviours; Ensure awareness raising and continuous training for staff on the importance of communicating with patients of all ages and ways to do this (knowledge‐skills); page 32 Annex 19. Standard 4: Information and participation: 4.3. The hospital/health service engages with children for the development and improvement of health care services: inputs from the self-evaluation teams Examples of Good Practices Areas that need improvement Examples of actions for improvement n/a Children’s participation partly or don’t influences decision‐making in relation to improvement of health care services (all hospitals); Children’s participation have to be taken into consideration and influence the decision‐ making in relation to improvement of health care services; Ensure children’s participation influences the decision‐making in relation to improvement of hospital health care services; Annex 20. Standard 5: Safety and environment: 5.1. The hospital/health service infrastructure is designed, furnished and equipped to meet children’s safety and mobility needs: inputs from the self-evaluation teams. Examples of Good Practices Areas that need improvement Examples of actions for improvement n/a Lack of medical equipment provision barriers the implementation of children’s right in the hospital, The hospital infrastructure is partly designed, furnished and equipped to meet children’s safety and mobility needs (all hospitals); The hospital partly ensures that equipment and materials follow safety norms (SV, CM, CR, OC, ED, HN, UG – in fact, is possible to mention that all hospitals); Hospital practice ensures effective and cleaning Undertake actions to improve the hospital infrastructure to meet children’s safety and mobility needs, and children with mobility restrictions; Ensure that equipment and materials follow safety norms; Assessing the respect of children’s rights in hospital in the Republic of Moldova page 33 services, but the situation is not uniform some hospitals are lacking sufficient number and adequate WC, hot water, bathrooms for mothers and children (all hospitals); Not all hospitals’ infrastructure ensures that children with mobility restrictions are able to access all areas of the building (all hospitals); Annex 21. Standard 5: Safety and environment: 5.2. The hospital/health service policies and practice support the best possible nutrition for children: inputs from the self-evaluation teams. Examples of Good Practices Areas that need improvement Examples of actions for improvement Free food is provided to all hospitalized children (all hospitals); All hospitals have specially trained staff (often nurses) or dietician who is responsible for the health menu development; The food is served timely in all hospitals; To improve the quality of products used for the cooking; To make the menu more diverse; To prepare the qualified staff, dieticians, in development of the health menus for hospitalized children; Annex 22. Standard 5: Safety and environment: 5.3. The hospital/health service policies and practice ensure a clean environment for children at all times: inputs from the self-evaluation teams. Examples of Good Practices Areas that need improvement Examples of actions for improvement Hospital practice ensures effective and cleaning services, but the situation is not uniform some hospitals are lacking sufficient number and adequate WC, hot water, page 34 bathrooms for mothers and children (all hospitals); Annex 23. Standard 6: Protection: 6.1. The hospital/health service has in place a system that ensures protection of the right of the child against all forms of violence: inputs from the self-evaluation teams. Examples of Good Practices Areas that need improvement Examples of actions for improvement The policy on protection of children who have been victims of any kind of abuse or violence is partly in place (national level, institutions are functioning using the below references); The common mechanism to solve the violence case between Ministry of Health and Ministry of Social Protection is in place and implemented starting with admission to the hospital (all hospitals); The child‐protective referral mechanisms with social services, police, other authorities in place (all hospitals). There is no system to register and monitor cases of children who have been a victim of any kind of abuse, the identification and reference/involvement if the social services is done only in admission department (all hospitals); Health professionals from hospitals were not trained on how to identify and examine children who have been abused, the most work was done with PHC professionals; There is no team or unit within the hospital dealing with child‐protection issues (all hospitals); To develop national protocols on child protection for health professionals; To include social assistants in hospital staff with clear duties and responsibilities; A unit dealing with child‐ protection issues have to be organized at facility level; Organize and implement a continuous awareness raising/training courses for staff on how to identify and examine children who have been abused, and on existing protocols (all hospitals); Ensure regular assessment of effectiveness in protecting children of any kind of abuse in the hospital Annex 24. Standard 6: Protection: 6.2. The hospital/health service ensures that all appropriate staff has the adequate skills to protect, treat and refer children who have been a victim of any kind of abuse or unintentional injury: inputs from the self-evaluation teams. Examples of Good Practices Areas that need improvement Examples of actions for improvement The policy framework is in place, but no the Organize and implement a continuous awareness Assessing the respect of children’s rights in hospital in the Republic of Moldova page 35 mechanisms of its application into practice Health staff did not receive some special training; raising/training courses for staff on how to identify and examine children who have been abused, and on existing protocols (all hospitals); Ensure regular assessment of effectiveness in protecting children of any kind of abuse in the hospital Annex 25. Standard 6: Protection: 6.3. Clinical research and trials are strictly regulated by hospital/health policy: inputs from the self-evaluation teams. Examples of Good Practices Areas that need improvement Examples of actions for improvement Hospital has Ethics Committee for clinical research and trials (NMCH); Children and families have the option to refuse or not to be involved in teaching activities of the hospital (NMCH, C – only these hospitals are university clinics). The clinical research and trials are not regulated by hospital policy: no specific protocols regulating clinical research and trials (all hospitals, the research are done at NMCH); No Ethics Committee for clinical research and trials at hospital level (is present at Medical University and NMCH); To organize within the hospitals, all hospitals, Special Research Units (for research in pain management, most relevant for Medical University and NMCH); Annex 26. Standard 7: Pain management and Palliative care: 7.1. The hospital/health service policy ensures the prevention and management of pain: inputs from the self-evaluation teams. Examples of Good Practices Areas that need improvement Examples of actions for improvement n/a The protocols and procedures for prevention and management pain are not available, but in the process of the development; There is no continuous training for staff on pain The protocols and procedures for prevention and management pain have to be developed (national level, process is facilitated by Ministry of Health); page 36 management (all hospitals, all professionals); Annex 27. Standard 7: Pain management and Palliative care: 7.2. The hospital’s/health service’s policy and practice ensure that palliative care is provided to all children who face life-threatening illness: inputs from the self-evaluation teams. Examples of Good Practices Areas that need improvement Examples of actions for improvement Palliative care includes psychological support to the child’s family (parents and carers) – some elements are in place (NMCH, BL, C, HN, AN); The hospital has NO partnerships in place or partly in place to provide palliative care on the community services or at home (all hospitals); Develop, endorse and introduce the national protocols on palliative care, procedures for prevention and management of pain; Set up a Unit for Psychological/ Psychiatry Support within hospitals for hospitalized children and their families, as well as to any other child/adolescent in the community; Build partnerships to provide palliative care on the community services or at home; Develop a “home care” programme for children with terminal illness in order to offer palliative care to the dying child and support his/her family for a long period during and after death; The hospital has to develop partnerships to provide palliative care on the community services or at home. The WHO Regional Office for Europe The World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with the primary responsibility for international health matters and public health. The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health conditions of the countries it serves. Member States Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czech Republic Denmark Estonia Finland France Georgia Germany Greece Hungary Iceland Ireland Israel Italy Kazakhstan Kyrgyzstan Latvia Lithuania Luxembourg Malta Monaco Montenegro Netherlands Norway Poland Portugal Republic of Moldova Romania Russian Federation San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Tajikistan The former Yugoslav Republic of Macedonia Turkey Turkmenistan Ukraine United Kingdom Uzbekistan WHOLIS number Original: English ASSESSING THE RESPECT OF CHILDREN’S RIGHTS IN HOSPITAL IN THE REPUBLIC OF MOLDOVA This report describes findings and recommendations of the assessment of children’s rights in hospital in the Republic of Moldova that took place as part of overall efforts of the Ministry of Health in improving quality of paediatric care in hospitals supported by WHO. In the framework of the assessment of quality of paediatric care in hospitals, a set of specific tools were used for the assessment and improvement of the respect of children’s rights in 21 children’s’ hospitals. Assessing the respect of children’s rights in hospital in the Republic of Moldova World Health Organization Regional Office for Europe UN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark Tel.: +45 45 33 70 00 Fax: +45 45 33 70 01 Email: contact@euro.who.int Website: www.euro.who.int