Ministry of Health
Republic of Moldova
Mid-Term Review
UNICEF – Government of Moldova Country Programme of Cooperation 2007-2011
Leadership Area
Adolescent Health and Development
Chisinau 2009
Acknowledgements
Technical working Group at the Ministry of Health
Rodica Scutelnic, head Mother and Child Department, Ministry of Health
Galina Morari, deputy head, Mother and Child Department, Ministry of Health
Lilia Oleinic, Mother and Child Department, Ministry of Health
Lilia Gantea, Department of Economy, Finances, Accountability and Management, Ministry of
Health
Anatol Nacu, main specialist in psychiatry, Ministry of Health
Lidia Cunicovschi, main specialist in pediatric psychiatry, Ministry of Health
Mihail Oprea, deputy director, National Dispensary of Narcology
Filip Gornea, main specialist in traumatology, Ministry of Health
Galina Obreja, Health Protection and Preventive Medicine Department, Ministry of Health
Victoria Ciubotar, National Center of Reproductive Health
Galina Lesco, Youth Friendly Clinic “Neovita”
Additional consultations
Otilia Scutelniciuc, National Center of Management in Health,
Varfolomei Calmic, National Center of Preventive Medicine
Larisa Boderscova, WHO Moldova
Eugenia Parlicov, Ministry of Education and Youth
Ala Holban, Child High Level Group
Irina Malanciuc, Child High Level Group
Domnica Griu, SCNPDC/GMICM
UN Agencies:
ILO-IPEC Moldova
IOM Moldova
UNDP Moldova
WHO Moldova
WB Moldova
Other International Agencies:
EU Delegation in Moldova
Every Child Moldova
Swedish International Development Agency
Soros Foundation-Moldova
Swiss Agency for Development and Cooperation
UNICEF
Larisa Lazarescu-Spetetchi, Chief HIV/AIDS and VA programme,
Sergiu Tomsa, HIV/AIDS Officer
Author: Stela Bivol, MD, MPH, consultant for UNICEF Moldova
2
TABLE OF CONTENTS
Acronyms ........................................................................................................................................5
Introduction ...................................................................................................................................6
Methods ..........................................................................................................................................7
Summary Findings ........................................................................................................................8
Adolescent Health ........................................................................................................................17
General health ............................................................................................................................17
Substance use in youth ...............................................................................................................19
Tobacco ..................................................................................................................................19
Alcohol ...................................................................................................................................21
Drug use and drug-related problems ......................................................................................21
Services available to drug users .............................................................................................24
Gaps ........................................................................................................................................25
Recommendations ..................................................................................................................26
Reproductive Health and Youth ................................................................................................27
Sexually Transmitted Infections.............................................................................................27
HIV .........................................................................................................................................27
Sexual behavior ......................................................................................................................28
Condom use ............................................................................................................................28
Sexual and physical violence .................................................................................................29
Adolescent Pregnancies and Contraception ...........................................................................29
Access to youth friendly services ...........................................................................................31
Health and life skills education ..............................................................................................31
Gaps ........................................................................................................................................32
Recommendations ..................................................................................................................32
Mental Health ............................................................................................................................34
National statistics ...................................................................................................................34
Mental services for children and adolescents in Moldova .....................................................35
Suicide ....................................................................................................................................36
Gaps ........................................................................................................................................37
Recommendations ..................................................................................................................38
Injuries and intoxications ...........................................................................................................39
Gaps ........................................................................................................................................40
Recommendations ..................................................................................................................41
Adolescent development ..............................................................................................................42
School environment ...................................................................................................................42
Family environment ...................................................................................................................43
Child violence and abuse........................................................................................................43
Poverty .......................................................................................................................................44
Employment ...............................................................................................................................45
Migration ...................................................................................................................................46
Leisure and Access to Services ..................................................................................................48
Participation and Empowerment ................................................................................................50
Recommendations ......................................................................................................................51
Youth Policies and Budgeting.....................................................................................................53
National Policies related to Youth Health and Development ....................................................53
Health Expenditures and Budget Flows.....................................................................................56
Effects of financial crisis on national spending for health .........................................................57
Gaps ...........................................................................................................................................58
Donor Mapping ..........................................................................................................................59
Consultations with Adolescents ..................................................................................................59
References.....................................................................................................................................67
3
LIST OF FIGURES
Figure 1. Self-perceived health status, youth aged 15-24 years, Republic of Moldova 2008 .......17
Figure 2. Geographic distribution of youth aged 15-24 years who consider their health status
excellent (în %) ......................................................................................................................17
Figure 3. Results of prophylactic exams in children 0-18 years, new cases in 1,000 examined
children ...................................................................................................................................18
Figure 4. Substance use in youth aged 15-24 years, comparison years 2006 and 2008, in % ......19
Figure 5. Prevalence of lifetime and present smoking in school adolescents aged 13-15 years,
comparison 2004 and 2008, Republic of Moldova, in % .......................................................20
Figure 6. Cannabis and ecstasy lifetime use, comparison between Moldova and EU countries,
2008 ........................................................................................................................................22
Figure 7. Prevalence on opioid drug use, comparison between Moldova and European countries
average, year 2007..................................................................................................................22
Figure 8. Prevalence of HIV, Hepatitis B and C and Syphilis in Injecting Drug Users,
beneficiaries of Harm Reduction Projects, 2007 ....................................................................24
Figure 9. Incidence of syphilis and gonorheea, youth aged 15-19 years, year 2006 .....................27
Figure 10. Main indicators of knowledge and sexual behaviors in youth aged 15-24 years,
comparison years 2006 and 2008 ...........................................................................................28
Figure 11. Age-standardized birth rate, 15-19 year old group, Republic of Moldova, 2006, per
1,000 livebirths .......................................................................................................................30
Figure 12. Age-specific Abortion Rate, (in 1,000 women), DHS, 2005 .......................................30
Figure 13. Prevalence of mental disorders total population, comparison of Moldova with new EU
and CIS countries, years 2004-2007, in % .............................................................................34
Figure 14. Structure of mental disorders new cases in 2008, Republic of Moldova, age 0-18 years
................................................................................................................................................35
Figure 16. Suicide rate for population aged 15-19 (per 100,000 relevant population), Moldova, 36
Figure 17. Number of suicide attempts in the age group 0-18 years, Republic of Moldova, years
2007-2008, absolute numbers ................................................................................................37
Figure 18. Perception about household livelihood, rural youth, 15-30 years, year 2008 ..............45
Figure 19. Unemployment rate, comparison of 16-24 years group and total population, year
2007, in % ..............................................................................................................................45
Figure 20. Leisure time, geographic distribution, youth 15-24 years, 2008..................................49
Figure 21. Access to services in the past year, youth 10-24 years, Republic of Moldova, year
2005 ........................................................................................................................................50
Figure 22. The distribution of insurance holders and use of services by population categories,
Republic fo Moldova, year 2008 ............................................................................................56
Figure 23. Budgetary priorities of national health programmes for years 2008-2010 ..................57
LIST OF TABLES
Table 1. Proportion of condom use at last sex and consistent condom use in the last 12 months,
15-24 years, Republic of Moldva 2008, in % ........................................................................29
Table 2. General incidence of trauma and intoxication cases in children (0-18 years), Republic of
Moldova, years 2004-2008 .....................................................................................................39
Table 3. Places of trauma occurrence in children aged 0-18 years, Republic of Moldova, years
2004-2008...............................................................................................................................40
Table 4. Mortality due to drowning and poisoning, absolute numbers, 0-18 years, Republic of
Moldova, 2004-2008 ..............................................................................................................40
Table 5. Willingness to participate in community life, youth aged 15-24 years, 2008 .................50
Table 6. Results of participation programmes implemented by UNICEF in the years 1999-2003
................................................................................................................................................51
4
ACRONYMS
CRC
Committee on the Rights of the Child
EU
European Union
GP
General Practitioner
HIF
Health Insurance Fund
HIV
Human Immunodeficiency Virus
HR
Harm Reduction
IDU
Injecting Drug User
KAP
Knowledge Attitudes and Practices
MARA
Most at Risk Adolescents
MIA
Ministry of Internal Affairs
MEY
Ministry of Education and Youth
MOH
Ministry of Health
MTR
Mid-Term Review
NGO
Non-Governmental Organization
PLWH
People Living with HIV
STI
Sexually Transmitted Infections
TWG
Technical Working Group
VIPP
Visualization in Participatory Programs
YFS
Youth Friendly Service
5
INTRODUCTION
The Country Programme of Cooperation between UNICEF and the Government of Moldova
(CPC 2007-2011) is now on its third year in 2009. One of the requirements of the UNICEF
Executive Board as reflected in the Master Plan of Operation is to conduct a Mid Term Review
(MTR) halfway through the programme. The MTR is planned as a six-month review and
forward-looking analysis exercise which focused on a number of selected leadership areas,
including education, community based services and adolescent health and development. This
present report focuses on the leadership area of adolescent health and development.
Adolescence is a formative period of live, marked by the transition from dependence to greater
autonomy. As adolescents begin to exercise increasing levels of responsibility for their own
lives, they also expose themselves to greater risks. Substance misuse (tobacco, alcohol and other
drugs), STIs, HIV, teenage pregnancies, mental health issues, violence and injuries, social
integration problems, low level of participation, stigma and discrimination are some of the risks
adolescents of Moldova face. Across the region there is an evidence of earlier sex, unprotected
sex and sex with multiple partners. Adolescents are the least likely to know where to get
preventive services, and the least likely to seek diagnosis and treatment for sexually transmitted
infections, including HIV. Moldova is not an exception. The family, school and community
actors often lack knowledge and capacities to discuss with adolescents issues of sexuality and
reproductive health, or those related to risk behaviours such as substance misuse, violence,
trafficking in human beings.1
Traditionally, adolescents in Moldova have not been the focus of investment or concern of the
public institutions. National development efforts require the active participation of young
people, but few sustained efforts exist to enhance their capacities or to address effectively the
risks they face. There is limited evidence of effective strategies for programming with
adolescents, and the practices that proved to be efficient in producing results are insufficiently
used and not nationally scaled-up. National Development Strategy objectives around education,
health and employment all require attention to adolescents’ concerns. Government policies on
youth, education, health and social protection take some of these into account, and further
initiatives to work with young people are supported by donor community and civil society. 2
A recent report of the Committee on the Rights of the Child (CRC) mentioned the various
measures taken by the Moldovan Government to improve adolescents sexual and reproductive
health, and the establishment of the network of health care services for adolescents but expressed
serious concern: a) at the absence of an effective adolescents health promotion strategy and
programme and a comprehensive child and adolescent mental health policy; b) with the
increased alcohol consumption and drug use among adolescents, the high rate of teenage
pregnancy and abortions as well as rates of suicide; c) about the increased rates of sexually
transmitted infections (STIs), including HIV/AIDS, and the lack of respect for confidentiality in
relation to the HIV status of patients and d) that the principle of non-discrimination is not fully
respected in practice, and that children from socially disadvantaged families, children with
disabilities, children with HIV/AIDS or children belonging to a different ethnic group or holding
different religious views may face discrimination.3
This present report represents an in-depth examination of problems faced by adolescents in
Moldova to ensure that their rights, needs and interests are properly understood and addressed by
Government, civil society and international community. A cross-sectoral analysis of issues
related to adolescents health and well-being would allow for building on and scaling-up existing
good practices, and formulation of recommendations for improving adolescents’ health and
development, and making them partners in social and economic development.
6
METHODS
Consultations with National Counterparts, NGOs and other partners
Following the decision of the Mid-Term Review Steering Committee from April 7, 2009 a
technical working group (TWG) at the Ministry of Health (MoH) was established. The TWG has
identified the priority areas for detailed analysis and commissioned main specialists in these
areas to develop short reports summarizing national data and identifying gaps and opportunities
for future programming. In addition, representatives of the Ministry of Education and Youth
(MEY) and local NGOs were invited to the TWG meetings. The preliminary findings were
reviewed with MoH and presented at the MTR Steering Committee meeting on July 23, 2009.
Desk review
Desk review included identification and in-depth analysis of studies and surveys conducted in
the area of adolescent health and development. The data from these studies was used to
corroborate national statistics and fill the information gaps where national statistics were missing
or had limitations. Where possible, the national statistics were compared with data from other
countries in the European region, in order situate Moldovan adolescents’ problems in a European
context.
Consultations with Young People
With the purpose to bring the opinions of the adolescents themselves in this situation analysis,
adolescents were consulted regarding the problems that they personally face and those that their
adolescent peers are confronted with. Four workshops were conducted, of which two on the right
bank of Nistru (Balti and summer camp in Hincesti) and two in the Transdniestrian region
(Tiraspol and summer camp) with a total of 41 participants (18 girls, 23 boys). Participatory
techniques were used, such as VIPP cards to identify personal problems and adolescent
problems, voting to prioritize problems from a predetermined list and focus group discussion
regarding empowerment, school, leisure and participation, access to services and vulnerable
adolescents.
Consultations with other Donors
International donors that work in Moldova were asked by email to fill in a short form about their
programmes related to adolescent health and development that they financially support in the
years 2007-2011. The form asked for main activities, total budget and identification of UNICEF
role in the areas they support.
7
SUMMARY FINDINGS
1. Adolescent Health
According to a survey, the majority of Moldovan adolescents perceive themselves as having
excellent or good health. At the same time, the analysis for the present report identified a number
of problems related to lifestyles and specific health issues. These areas include substance use,
sexual behaviors and transmission of sexually transmitted infections (STIs) and HIV, unwanted
adolescent pregnancies and contraception, mental health and suicide, injuries and intoxications.
Tobacco
A quarter of youth aged 15-24 years and every tenth adolescent of 13-15 years smoke at present,
and over half of them started smoking before the age of 10 years. In addition, more than 70% of
adolescents are exposed to passive smoking. Even though Republic of Moldova has passed the
law enforcing the WHO Framework Convention on Tobacco Control, the enforcement
mechanisms do not work in case of ban to cigarette selling to minors and exposure to passive
smoking in public places. In addition, Moldova has one of the lowest prices to cigarettes in
Europe and this is demonstrated to be the most important factor determining adolescent smoking.
The vast majority of smoking adolescents would like to quit smoking, yet smoking cessation
programmes are virtually lacking.
Alcohol
The majority Moldovan youth aged 15-24 years consume alcoholic drinks, and over half
experience binge drinking every month. At the same time youth do not perceive excessive
alcohol consumption as a problem. There are no national alcohol prevention and consumption
reduction programmes in youth.
Drugs
The prevalence of injection drugs is high compared to other European countries. National
statistics underreport the extent of drug use in adolescents, but some surveys in adolescents show
a higher opioid use in Moldova compared to European countries. However, the overall number
of drug users is not known, as there are no official estimations of the number of injecting drug
users in the Republic of Moldova. Primary prevention of drug use is limited and there are limited
treatment options available to drug users in both public and private sectors. Methadone
substitution treatment covers insufficiently those in need, with only 222 patients receiving it.
Injecting drug use is associated with high transmission risk for HIV, hepatitis and Sexually
Transmitted Infections (STIs) even among beneficiaries of harm reduction programmes.
Although there is an extensive network of harm reduction services in the country, the range of
services they provide is limited due to shrinking financing in the past years and they have an
insufficient coverage of adolescents. Given that HIV transmission in IDUs is presently linked to
indirect sharing and high-risk sexual behaviors, this will likely translate in higher HIV/STI
transmission rates in the future.
STIs and HIV
The incidence of STIs in Moldova is very high, compared to other European region countries
and the knowledge about STIs is low in youth aged 15-24 years. Heterosexual transmission of
HIV infection continues to increase in Moldova. Efforts of informing about HIV show some
positive progress, and the proportion of youth having correct knowledge about HIV transmission
increased in 2008. Yet tolerant attitudes towards People Living with HIV (PLWH) continue to be
alarmingly low at 10%, despite the significant efforts to decrease stigma towards PLWH. HIV
counseling and testing among adolescents continues to be low and the uptake of the number of
clients linked to opening the network of Voluntary Counseling and Testing (VCT) centers in the
past years did not translate yet into an increase of the proportion of adolescents taking an HIV
test.
8
Sexual behaviors
The percent of young women that did not have sex before 19 remained stable in the past 17 years
and the mean age at first sexual contact among adolescents aged 15-24 years in 2008 was 16.6
years. Yet, when youth do start sexual life, the sexual practices are not always safe. Every sixth
single youth had non-permanent sexual partners in the past year and every fifth single youth had
two or more sexual partners in the past year. Only half of youth of 15-24 years reported condom
use at last intercourse. Around 5% of youth aged 15-24 years have reported sex initiation
through forced sex and a total of 4% of women in general have reported sexual abuse in their
lifetime.
Adolescent Pregnancies and Contraception
Moldova ranks first among SEE, CEE and CIS regions regarding the lowest reported average age
at first birth. Some 5% of youth aged 10-24 years that experienced pregnancy, usually an
unwanted one, with only 7% of them ending with birth. The high number of unwanted
pregnancies shows a lack of knowledge and practice about contraception. In fact, the best known
and practiced options continue to be coitus interruptus and condoms.
Access to preventive and reproductive health information and services
The courses of life-skills based education have been introduced in schools in 2005 for a short
time as a mandatory course, withdrawn after two months and reintroduced on an optional basis.
There is no monitoring and evaluation system in place to assess coverage, effectiveness and
quality of the taught courses. A total of 12 youth-friendly clinics exist, which serve some 70,000
youth annually. Yet, there is insufficient geographic coverage, as well as insufficient range of
services provided by the existing ones, such as STI management and contraception services. The
most at-risk adolescents do not seem to use the existing services and the existing clinics do not
have outreach programs to most at risk adolescents. Voluntary counseling and testing for HIV
and Hepatitis B and C is nationally available starting with 2008, but the uptake in the number of
clients linked to opening the network of VCT centers did not translate yet into an increase of the
proportion of adolescents taking an HIV test.
Mental Health
Moldova has a high prevalence of mental health disorders in the total population, compared to
EU countries, but the difference in classifications used by European countries and Republic of
Moldova provides caution about comparability between countries. Most disorders in adolescents
up to 18 years are of non-psychotic nature, such as depression, neurosis and the national experts
in psychiatry consider that the main factors that lead to mental disorders are conflicts in the
family, family separation and parent migration, and conflicts at school. There is insufficient
information regarding the burden, distribution, structure, and underlying causes of mental
disorders in adolescents in the Republic of Moldova.
There are no financed interventions to prevent mental disorders in adolescents. The mental
health system is still oriented towards clinical management of mental health disorders in
specialized institutions, be it psychiatric hospital or special institutions for children, rather than
long-term community programmes to help family and community reintegration. Most
adolescents with mental health disorders receive treatment on an outpatient basis, but there is a
shortage of specialists for children and adolescents, especially in rural areas. Community
services exist only in several locations and their coverage with services is limited. The mental
health services are overly medicalized and there are no national counseling services available to
adolescent outside psychiatric system.
9
Suicide
Moldova has a high suicide rate among the general population. The average suicide rate among
the age group 15-19 years was on a decreasing trend in the period 1998-2002, but the number of
suicides in the age group 0-18 years has increased sharply again in 2008, compared to 2007.
Twice more girls compared to boys have attempted suicide in 2008. Suicide statistics are not accurate
and there are discrepancies between data collected by various agencies. There is no national
suicide prevention programme.
Injuries and intoxications
Moldova ranks 4th in the European region in mortality rate due to external causes of death in the
general population. The incidence of trauma and intoxications among 0-18 year olds is around
5,000 per 100,000 population equivalent to some 40,000 cases annually, accounting for 28.2% of
the total reported number of injuries and intoxications. By far, most cases of trauma in children
and adolescent occur at home, thus parental or care giver supervision is a critical point for
interventions. National data related to causes, underlying circumstances and risk factors leading
to high injury rates is not available. In addition, there are no specific injury preventing
programmes, and little is done to provide for safe environments for children and teenagers.
2. Adolescent development
Adolescent general development is influenced to a great extent by the environment in which
adolescents live, such as families, schools, communities and by opportunities in non-formal
education, work and leisure, access to services and participation in community life.
School environment
Data regarding the conditions in schools and the effects of the educational process on the health
and development of adolescents is limited and requires further investigation. From the existing
data, it appears that many schools do not offer proper hygiene and safe environments to school
children and do not offer access to children with special needs. In addition, the school curriculum
overburdens the children and requires reshaping. All these shortcomings affect negatively the
adolescent health and contribute to development of various health conditions and an increased
chronic morbidity. The lack of health and life-skill based education, as well as participation at
school, also negatively affects the full development of children and young people.
Family environment
The adolescents consulted for this report identified most frequently family situation as a major
problem. It is either incomplete families (migrated parents or single-parent families), alcohol use
by parents, poor families, that all conduct to receiving insufficient attention, affection and
supervision from their parents, as well to conflict situations with parents and sometimes familybased violence. This initial problem that leads then to other types of problems: drop out or lack
of interest in school, communication problems with peers and adults, risky behaviors, such as
substance abuse and sexual behavior, conflict with the law, lack of interest and motivation to
participate in community life or access services. The desk review of existent studies revealed an
insufficiency in parenting skills. Some parents use abusive methods to educate their children.
Poverty in rural areas seem to often result in limited or no time for homework or leisure, as
children have to work at home or at the farm.
Poverty
Some studies show that 38% of rural youth live below or at subsistence level. Poverty in itself
affects the development of children and adolescents in many ways. On one hand, it affects the
access to food, and health care, as well as opportunities for education, leisure and participation;
on the other hand it influences the family in which the adolescents live, by sending parents away
to find work or by determining parents to neglect children in favor of struggling to cover basic
needs. Some parents might not cope with the continuing stress to provide for a living and could
10
start abusing alcohol and have other behaviors that affect the relationship with their adolescent
children.
Youth employment
There is a disproportional high unemployment rate in youth, compared to the general population,
with only 27% of young people being employed. The high unemployment rate among youth
cannot be explained totally by a lack of jobs, but more likely by a disparity between the
expectations of youth towards remuneration and a low level of offered salary. The fact that there
are many vacant positions that are not filled for long times confirm this hypothesis. In addition,
there is a discrepancy between the enrolment plan by specialties in universities and the actual
demand on the job market, showing inefficiencies in the transition from education to labor.
Entrepreneurship continues to be a limited option, with only 3% of youth engaging in such
activities and the existing national programme of economic empowerment is in great demand.
Migration
Up to half of rural youth lives in a family with one or no parent due to migration. Although they
might have a better financial situation compared to their peers, the lack of parental supervision
leads to increased vulnerability. Some risks include dropping out, earlier sexual initiation,
addictive behaviors, such as drinking and smoking, gambling, internet games, and psychoemotional and adaptation problems. The economic crisis will affect further family situation by
decreasing remittances, and bringing back migrant parents who have lost their connection to
their children. Since unemployment rate might increase, this will have a negative impact on
family relations as well.
Leisure and Access to Services
Adolescents have limited opportunities to engage in development activities outside school. Most
rural youth spend time at home, visit friends or just hang around parks and public spaces. A
much lower proportion is engaged in some development activities. The vast majority of both
urban and rural youth mention going to discos and bars as the most frequent activity, a third of
youth participate in activities at Culture Houses, while only 10% of rural youth were aware and
5% participate in new services, such as youth resource centers, youth organizations operating
various youth activities such as HV/AIDS and health education, family planning, helping with
disabilities.
Access to youth-friendly services continues to be limited. Among adolescents who had health
problems in during 12 months, only half have accessed medical services, a third mentioning
distrust in medical personnel, lack of money, and fear about confidentiality break.
Participation
Participation in community life is not high on the priority list of youth. Only 15% would be
willing to participate in community life, a third said that they are not willing, and 42% said they
cannot participate. At the same time, the community offers children very few activities in which
they can get involved and the existing ones do not meet adolescent’s needs and interests. In the
period 1999-2003, UNICEF has implemented a successful youth participation programme. Some
350 Youth Councils and 82 Youth Resource Centers are active as of date. Unfortunately, at the
end of the programme few of these initiatives were taken over by local authorities, because of a
lack of implementation mechanism and financial support required. Participation at school is
limited or non-existent.
3. Results of consultations with youth
Adolescents from general and vulnerable groups from the right bank and Transdniestrian region
were consulted in order to identify and prioritize problems. The following problems emerged:
11
1. Family-related (communication problems with parents, migration and family-based
violence)
2. School-related (quality of education and teaching methods, subjective grading system,
differential and discriminatory attitude of teachers and school abandonment)
3. Limited leisure opportunities
4. Tobacco, alcohol and drug abuse
5. Discrimination based on socio-economic status by peers and teachers
6. Juvenile delinquency
7. Geographic placement of their region (rural adolescents)
When scaling a predetermined list of problems personally affecting adolescents, the following
problems were ranked most important, in decreasing order:
1. Substance abuse
2. Communication with parents
3. General health status
4. Leisure and extracurricular activities
5. School and continuation of studies
6. Employment opportunities
7. Juvenile delinquency
When ranking a predetermined list of problems affecting in general adolescents in their
community, the distribution was somewhat different, as follows:
 Communication with parents and teachers
 Substance abuse
 Sexual relationships and sexual education
 Leisure and extracurricular activities
 School and continuation of studies
The difference between the two categories is that a new problem emerged on third place when a neutral
environment was ensured: many adolescents perceive sex education and sexual relationship as one of the
most important problem for them, but they cannot identify it as personally affecting them because of the
taboo that covers this subject. This indicates again to the lack of sex education in schools and at home and
the discomfort to discuss such topics publicly.
Empowerment
Most adolescents felt they could not solve their problems by themselves alone, but their parents
could help them to solve some. For family-related problems, friends are the ones they could
share their problems with. Vulnerable adolescents felt they or their families are not empowered
to change their situation. Adolescents could not identify services outside their family and their
immediate network that could help them solve their problems.
Vulnerable adolescents
Participants were asked to identify most vulnerable adolescents in their community, according to
their own definition of vulnerability. It is of note that adolescents from vulnerable groups
mentioned a wider range of vulnerability factors, but the leading ones were related to family
situation, while the adolescents from general population mentioned more frequently adolescents
with disabilities and special needs.
4. Youth Policies and Financial Allocations
Moldova has a number of policies in the area of youth development and health (listed below). Most
problematic areas in adolescent health discussed in the situation analysis are included in national
policies, such as reproductive health issues, lifestyle behaviors (substance use, HIV, STIs) and
12
mental health. Only injury prevention and management is not reflected sufficiently in the
national policies.
 Youth Law, 1999.
 Second National Youth Strategy 2009-2013 and Budgeted Plan of Action for 2009
 Local youth Agendas to implement the National Youth Strategies in 32 raions
 National Programme for Economic Empowerment of Youth 2008-2010
 National Policy on Health 2007-2021
 National Strategy on Reproductive Health (approved in 2005)
 National Programme on Promoting Health 2007-2015
 National Programme on Prevention and Control of HIV and STIs for 2006-2010
 National Programme on Mental Health for years 2007-2011
Although policies in health are youth-sensitive and include most of the necessary activities
necessary for improving the main problematic areas related to youth health, they are not intended
to reach the most vulnerable adolescents and their implementation lags behind. For instance,
there is no harm reduction or drug rehabilitation programme for minors. There is no monitoring
system permitting to evaluate the annual budget allocations, the level of implementation or the
effectiveness of these programmes until after their end. Usually the activities that are not
implemented relate to preventive and health promotion activities, as well as conducting specific
situation analysis in the content areas. The budget allocations usually do not cover fully the
necessary activities and the national health budget is mostly oriented towards hospital and
primary care services, rather than preventive and health promotion activities.
Health expenditures and budget flows
The main source of funding in the health sector is by far the Health Insurance Fund (HIF),
accountable for 83% of total health budget in 2008. The main beneficiaries of health services are
people ensured through employment, people with disabilities and retired people. While children
and student youth account for 40.3% of insured people, they use only 13.3% of health services.
The public budget that is administered by the Ministry of Health (MoH) is mainly dedicated to
administrative spending necessary for the MoH and some republican institutions in direct
subordination to MoH, of which most funds are spend on human resources and capital
investments and equipment, while procurement of services and goods is around 28%.
There is evidence that economic crisis affects the central budget, and starting with mid 2009 a
20% budget cut for children rehabilitation services and 33% cuts for the national programmes is
being implemented. The economic crisis already affected contributions to HIF, in July 2009 a
25% reduction of health insurance tax contributions and 34% reduction of transfers from the
central budget were reported.
5. Main achievements in the area of adolescent health and development
The government has initiated and implemented some important reforms in the area of adolescent
health and developed a legal and policy framework necessary for the implementation of some
interventions, such as the below-listed Youth Law, youth Strategy and a budgeted Plan of Action
for 2009, national strategies and programmes in the area of health and economic empowerment
of young people. The Government covers with free health insurance children and youth up to 18
years. With support from international donors, youth-friendly services were piloted and VCT
centers were opened and their financing was taken over by the HIF. In addition the legal
framework mentioned earlier, several mechanisms of youth empowerment and participation have
been developed in the whole country. Specific achievements are listed below:
13
1. Youth Law, Youth Strategy for years 2009-2013 and Budgeted Plan of Action for year
2009
2. National Policy on Health, national strategies and programmes
3. Initiation of National Health Accounts reform
4. Existence of national strategy and national programmes that address healthy lifestyles,
HIV and STIs, Reproductive Health, Mental Health
5. Free Health Insurance coverage for children up to 18 and for students
6. Development of 12 youth-friendly clinics covered by HIF
7. Development of a network of 35 VCT centers covered by HIF
8. Establishment of 82 Youth Resource Centers, Youth Media network, Local Youth
Councils, Peer educators network
6. Remaining gaps in the area of adolescent health and development services
1. The national statistics collect a significant amount of routine indicators; however they do
not usually provide disaggregation by age groups, gender and geographic distribution.
Routine statistics from Transdniester region are not available.
2. Health policies are well-defined, have youth-specific activities, but have insufficient
budget support and implementing mechanisms. The budget allocations cover only
partially the stated activities.
3. National programme budget allocations are difficult to monitor, especially when there are
multiple sources of funding and multi-sectoral programmes that involve several
ministries.
4. When there are sufficient budget allocations, they are usually oriented towards human
resources and infrastructure maintenance, and lack operational budgets necessary for the
implementation of activities, especially preventive activities. The prevention and health
promotion activities are severely under-funded. In the first half of 2009 HIF has allocated
only 0.1% of its budget to reimbursement of these activities.
5. As a rule, national policies do not identify most at-risk subpopulations of adolescents in
which the implementation of activities will have the most impact.
6. The poor results of knowledge and practices assessment in youth regarding reproductive
health and substance misuse show a continuing need of effective life skills and health
education in schools. At present, it is not clear what the coverage and the quality of the
life-skills based education in schools are, since there is no qualitative or quantitative
monitoring system.
7. Access to youth friendly services (YFC) is geographically limited, since there are only 12
clinics in cities and towns and they do not have outreach programmes to most-at-risk
adolescents, such as rural youth, youth from incomplete and poor families or without
parental supervision, youth practicing high-risk behaviors etc, which are most in need of
the services. In addition, YFCs need to enter an accreditation and quality monitoring
system.
8. Health and development services are not adapted to the needs of young people.
Adolescents have an overly positive opinion about their health and lifestyles, which leads
to a lack of active health-seeking behavior, therefore there is a need of specific
communication skills of personnel, confidentiality and counseling, vulnerability
assessment and active referral systems, in order to help them identify their own needs and
solve their problems.
9. Health prevention and treatment services are not integrated and adolescents need to go to
different places to receive different services, which eventually leads them to not
accessing these services.
10. The unemployment rate in youth continues to be high and there are no services helping
youth, especially rural youth, in planning their continuation of studies beyond schools
based on a vocational assessment and market demand. There is a discrepancy between
the supply of types of young specialists graduating from universities and the market
14
demand, which leads to youth working in fields outside their specialty or youth
migration.
11. Leisure activities are lacking and most adolescents spend time at home or in activities
that do not contribute to their development. Although youth services are available in all
districts, they are often outdated and do not correspond to youth needs.
12. Although successful participation models have been piloted, there is a lack of legal
mechanisms that prevent local authorities from involving adolescents in solving their
problems at local level. Young people themselves do not feel empowered and do not seek
actively involvement due to a lack of tradition of youth participation, therefore this
behavior should be encouraged by the state.
7. Recommendations
I. Statistics and evidence
1. To disaggregate national statistics by age, gender, ethnic group, some other social criteria
(e.g. poverty) and geographic distribution, in line with international recommendations,
including in Transdniestrian region
2. For non-routine surveys, to expand the age of young people starting with age of 10 (as
opposed to age of 15, as it is the current practice).
3. Where data is missing, to conduct detailed studies on problems affecting youth (including
suicide, reproductive health, mental health, injury, school environment, specific
vulnerable subpopulations of youth, Transdniestrian region) for evidence-based
programmeming
II. Legal and policy framework
1. To develop legal mechanisms for public sector to contract NGOs to provide youthfriendly services
2. To develop a legal framework that would request local public authorities to involve
youth in decision-making and participation at local levels
3. To include some mechanism for child participation at school in the new Code on
Education
III. Development and expansion of services
1. To provide financial coverage and implementing mechanisms to existing national
programmes, especially for prevention and health promotion activities and to develop a
specific injury prevention programme
2. To develop implementation mechanisms for prevention and health promotion activities
through contracting out services to NGOs and through financial reimbursement
mechanisms by HIF.
3. To introduce personal, social and health education course in schools as a mandatory
course and to monitor its effectiveness and quality.
4. To expand geographic access to youth-friendly services, especially in rural areas, and for
the most vulnerable ones (including in Transdniestrian region).
5. To develop and implement accreditation and quality monitoring systems for YFS and to
increase the capacity of these centers to outreach the vulnerable groups of adolescents
and expand the range of preventive services.
6. To develop special programmes addressing parenting skills of care-givers
7. To introduce vocational assessment and orientation, and livelihood training in schools,
especially in rural areas and to expand participation of youth to the national programme
of economic empowerment of youth
8. Train service providers in contact with young people (Youth workers/social workers in
the communities, especially in rural areas, health workers in educational institutions)
15
9. To develop specialized services for MARA (e.g. harm reduction programme, drug or
alcohol rehabilitation services etc)
10. To work with the media to promote healthy lifestyle
16
ADOLESCENT HEALTH
General health
The adolescence period is usually marked by a good health status. In fact, children aged more
than 10 years use significantly less health services compared to early childhood period. Women
start using health services more intensively when they get into the reproductive age, while young
men tend to address to health care only when they have specific health problems.
The surveys conducted in Moldova confirm this common knowledge. A total of 78% of
Moldovan youth aged 15-24 perceived their own health status as good or excellent (Figure
1). Youth in the South and Transdniestrian region had a better self-perception of their health,
where 17-20% of youth considered themselves perfectly healthy, compared to an average 8-11%
in the Central and Northern regions of Moldova.4 (Figure 2)
Figure 1. Self-perceived health status, youth aged 15-24
years, Republic of Moldova 2008
3.2%
2.5%
2.8%
22.2%
18.7%
Figure 2. Geographic distribution of youth aged 15-24
years who consider their health status excellent (în %)
100%
90%
14.3%
80%
70%
60%
50%
64.7%
64.1%
63.6%
40%
30%
20%
10%
17.5%
14.2%
11.5%
0%
Boys
Girls
Excellent
Good
Average
Total
Poor
Very poor
At the same time, when we look at the data extracted from the national statistics, the results are
not as optimistic. The data from the routine health statistics collected through yearly preventive
medical checkups in school children shows that around 10% of school-age youth are identified
yearly with health problems with eyesight, posture and even physical retardation, with
large disparities between rural and urban settings in physical development of people aged
0-18 years5 (Figure 3). This only is data collected by routine prophylactic checkups of general
physical condition that does not include hospital or clinic attendance. The national statistics offer
general morbidity data only for the age group 0-17 years and 18 and older, so they do not allow
to breakdown by age (0-5 years, 6-10 years, 10-18 years), to see the age-based differences in
access to services. Only in year 2008, a total of 423,246 episodes of illness in children aged 0-17
years, equivalent to 5,405.5 episodes of illness per 10,000 children, were registered.6
17
Figure 3. Results of prophylactic exams in children 0-18 years, new cases in 1,000 examined children
30
24.8
25
Detection rate
21.4
20.5 20.5
20
15
Cities
Rayons
14.5
11.2
11.1
10
7.6
5.7
3.6
5
7
6.3
7.2
7.4
10.4
10
9
8.5
8.4
6.8
2.3 2.6 1.6 2.4
0
`2007
`2008
Physical
retardation
`2007
`2008
Low eyesight
`2007
`2008
Low Hearing
`2007
`2008
Speech
disorders
`2007
`2008
Scoliosis
`2007
`2008
Posture
problem s
The health services available to youth are generally oriented towards diagnosis and treatment of
episodes of illness and usually lack a system of vulnerability assessment in adolescents entering
into a health care setting. In addition, the health and preventive services do not outreach to most
vulnerable groups of adolescents. Another problem is that when adolescents do enter the health
system, there is a lack of an established referral system to other services in the community
(prevention and healthy life style promotion, social services etc).
18
Substance use in youth
As elsewhere reported in the world, Moldovan youth experience exposure to use of various
substances that harm their health, but they use alcohol and injecting drugs in higher
proportions than their peers in the European countries. In comparison to the European
Union (EU) countries, the national prevention efforts to decrease the use of tobacco, alcohol and
drugs are modest and not efficient. This translates into high prevalence of use of tobacco, alcohol
and injecting drugs and a low awareness that this is a problem that can affect the life, health and
the development of adolescents and lead to premature morbidity and shorter life expectancy.
Tobacco
Smoking remains a major contributor to the gap in mortality and healthy life expectancy between
the most and least advantaged. According to the tobacco control database, years lost from death
by smoking range from 12 - 20 years, and up to 21% of deaths are attributed to smoking. In the
WHO European Region smoking prevalence is estimated at around 28.6% with a large gender
difference - males account for 40% and females 18.2%. Among young people aged 15 years,
the prevalence of weekly smoking is on average 24%.7 In addition to the known established
effects on health (reduced lung capacity, increased heart rate, worse physical performance,
increased doctor visits), teens who smoke are three times more likely than nonsmokers to use
alcohol, eight times more likely to use marijuana, and 22 times more likely to use cocaine.
Smoking is associated with a host of other risky behaviors, such as fighting and engaging in
unprotected sex.8
The prevalence of smoking among youth (15-24 year olds) in Moldova was quite high.
According to the Youth Knowledge Attitudes and Practices (KAP) 2008 survey, some 22.8%
were smoking and another 17.3% have smoked in the past, thus 40.1% of respondents had
exposure to smoking in their lifetime (Figure 4).9 More boys than girls had a lifetime
smoking history. Boys are heavier smokers compared to girls. Among boys 42.2% (15-19
years) smoke 5 to 10 cigarettes per day, and 41.8% (20-24 years) smoke 10-20 cigarettes a day.
Girls in both age groups (57.1% in 15-19 year-old and 51.4% in 20-24 year-olds) smoke 5 to 10
cigarettes a day. No significant changes were reported between smoking prevalence in 2006 and
2008. Recent data suggest that half of young people started smoking before the age of 10
years.10 Another survey showed that 72.1% of girls and 66.3% of boys considered smoking an
important issue in their community.11
Figure 4. Substance use in youth aged 15-24 years, comparison years 2006 and 2008, in %
70.0%
61.3%
60.0%
53.9%
50.0%
40.0%
30.0%
23.5%
22.8%
20.0%
10.0%
2.9%
2.3%
0.0%
Present smoking
Alcohol use in the past 30 days
`2006
Cannabis use in 12 months
`2008
A survey conducted in school adolescents of age 13-15 years showed that 39% have smoked
cigarettes in their lifetime and 11.3% smoked cigarettes at the time of interview, a slight
19
decrease from year 2004 (Figure 5). At the same, 90% of respondents consider smoking
should be banned in public places. Approximately 80% adolescents have seen anti-tobacco
messages, at the same time another 60% of them have seen commercial banners promoting
cigarettes and another half have seen those commercials in newspapers and magazines,
demonstrating exposure to contradictory messages.12
Figure 5. Prevalence of lifetime and present smoking in school adolescents aged 13-15 years, comparison 2004
and 2008, Republic of Moldova, in %
64.4
70
57.7
60
50
41.7
39.2
40
30
20
23
24.3
22.7
18.5
13.7
11.3
6
10
5.6
0
total
boys
girls
total
`2004
boys
girls
`2008
Lifetim e sm oking
Sm oke at present
The same survey revealed that the majority school-aged adolescents buy their cigarettes in shops
and vending locations and have not been refused by the sellers because of age. The exposure
to passive smoking continues to be high both at school, at home, and in the public places,
where more than 70% of adolescents are exposed to passive smoking. At the same time three
quarters (74% boys and 77% girls) stated that they have been told about the consequences of
smoking in the past year and the majority 83% would like to quit smoking.13
Tobacco control programmes
In 2007 the Parliament of the Republic of Moldova has approved the Law on Framework
Convention on Tobacco Control. It bans the direct publicity of tobacco products in all public
places, TV and radio, leaving it possible only at selling points; it bans smoking in public places,
including schools, regulates labeling and warning messages, it bans selling cigarettes to minors.
Yet, the enforcement mechanisms are not working properly for banning selling cigarettes to
minors and exposure to passive smoking in public places.
Moldova has one the lowest prices to cigarettes in Europe and this is demonstrated to be the
most important factor for adolescent’s access to cigarettes. A tax increase on cigarettes is the
single most effective strategy in determining people to quit smoking or prevent from
starting smoking14. A 70% increase in cigarette price could prevent up to a quarter of smokerelated deaths worldwide.15 Increase in taxes would benefit both the government and the health
of the young generation.
In addition, the survey showed that Moldova does not have a multilaterally developed
antismoking programme, there are no sufficient informational materials on tobacco and smoking
cessation programmes are virtually lacking, especially for young people.16
20
Alcohol
Young people are more vulnerable to suffering physical, emotional and social harm from their
own or other peoples' drinking. There are strong links between high-risk drinking, violence,
unsafe sexual behaviors, traffic and other accidents, permanent disabilities and death. The health,
social and economic costs of alcohol-related problems among young people impose a substantial
burden on society.17
High-risk drinking is defined is defined as those situations that may involve but not be limited to:
binge drinking (commonly defined as five or more drinks on any one occasion); underage
drinking; drinking and driving; situations when one’s condition is already impaired by another
cause, such as depression or emotional stress; and combining alcohol and medications, such as
tranquilizers, sedatives, and antihistamines18. In 2008, of Moldovan youth with aged 15-24
years, 81.8% consumed alcoholic drinks, with higher proportions in boys, compared to girls.
Binge drinking was reported by more than half of respondents, as 58.7% had six glasses of wine
or more or its equivalent in strong drinks per one occasion.19
At the same time, another survey showed that youth do not perceive alcohol consumption
as a problem. Only 54.4% of girls and 47.1% of boys (42.7% of respondents in Transdniestrian
region) consider excessive alcohol consumption to be an issue in their community. Compared to
perceptions about smoking, less respondents perceived alcohol consumption as a problem.20 The
consultations with youth also revealed that adolescent perceive as bigger problems tobacco and
drugs, compared to alcohol, which demonstrates an overall low awareness about the negative
consequences of alcohol in youth and a cultural acceptance of high alcohol consumption in the
Republic of Moldova, including by teenagers.
Drug use and drug-related problems
The transition from adolescence to young adulthood is a crucial period in which experimentation
with illicit drugs in many cases begins. Drugs may have strong appeal to young people who are
beginning their struggle for independence as they search for identity. Drug abuse continues to
emerge as a strategy to cope with problems of unemployment, neglect, violence and sexual
abuse. Marginalized youth are particularly susceptible to the enticement of drugs21.
Moldova is a country where drugs, such as cannabis and poppy are being cultivated,
produced, and consumed. Our analysis shows that while the use of milder drugs, such as
cannabis and methamphetamines in Moldova is lower than in EU countries, the prevalence
of injection drugs is high compared to other European countries (Figure 6). The European
average lifetime prevalence1 of cannabis use among 15-24 year olds is 30.7%22, while in
Moldova it is 3.4% in 15-24 year old group.23 The same is valid for the use of synthetic drugs,
such as amphetamines. While ecstasy use in Europe is 5.6% lifetime prevalence among 15-34
year olds24, it is 1.3% in 15-34 year olds for ecstasy in Moldova 25.
Lifetime prevalence stands for any use of a specific drug during one’s lifetime, regardless of other characteristics
(quantityt, frequency etc).
1
21
Figure 6. Cannabis and ecstasy lifetime use, comparison between Moldova and EU countries, 2008
35%
30.7%
30%
25%
20%
15%
10%
5.6%
3.4%
5%
1.3%
0%
Cannabis lifetim e use, 15-24 years
EU countries
Ecstasy lifetim e use, 15-34 years
Moldova
Injecting drug users are among those at highest risk of experiencing health problems from their
drug use, such as blood-borne infections (e.g. HIV/AIDS, hepatitis) or drug induced deaths. The
youth in Moldova experiences a higher prevalence of injecting drugs than youth in EU
countries. While some EU countries report a prevalence of annual opioid drug use (usually
equivalent to injecting drugs) between 0.1% to 0.6% population (15-64 years), 26 the general
population survey in Moldova report a 0.5% opioid lifetime prevalence in the population of 1564 years, and a lifetime prevalence of 1.0% in the subset population of 15-24 years.27 No
comparison is available for prevalence of opioid use in youth aged 15-25 years in the European
countries (Figure 7).
Figure 7. Prevalence on opioid drug use, comparison between Moldova and European countries, year 2007
1.20%
1.00%
1.00%
0.80%
0.60%
0.40%
0.50%
0.1 -0.6%
0.20%
0.00%
15-64 years, European average
15-64 years, Moldova
15-24 years, Moldova
As of January 1, 2008, on the right bank of the Dniester River, 7,720 people were officially
registered as drug users in the Republican Narcology Dispensary database. During 2007,
there were 917 newly registered cases of drug use, representing a decrease compared to year
22
2006 (1,030 newly registered cases of drug use)28. Most cases are registered among those aged
between 18 and 35 years. At the same time, the harm reduction projects count a cumulative
number of 12,632 injecting drug users benefiting from Harm Reduction projects by the end
of March 2009.29 No breakdown by age group is available.
According to the national statistics, at the beginning of 2009 there were only 9 adolescents with
clinically attested addiction to any type of drugs and 152 adolescent drug users in the age
group 0-18 years.30 Yet, the sample of a survey conducted in adolescents injecting drugs in
three cities recruited in four months a total number of 193 injecting drug users with age
comprised between 12 and 18 years.31
If we attempt to make an estimation of absolute numbers of cannabis users, and opiate drug users
based on the Youth KAP 2008 study mentioned above, around 8,000 youth have used opioids in
their lifetime and around 23,000 youth have used cannabis in their lifetime in the age group 1524 year olds.2 This shows an underreporting in the official registry of Narcology Dispensary.
The reasons for underreporting are procedural. The “officially registered” cases are entered into
the Narcology Dispensary database only if the person was referred by police or assessed by a
narcologist. Anonymous treatment cases are not entered into the database.32
According to one survey, the general youth have had relatively small exposure to drug users:
16.65% think there are rare cases of drug use and 35.6% do not know anyone who uses drugs.
Therefore, they consider drug use being a smaller issue compared to smoking and alcohol
excessive consumption, only 30.0% of girls and 26.5% of boys perceive drug use being an
important issue in their community. There is a difference in urban youth and rural youth, less
than half of rural youth know anyone who uses drugs, compared to 86% in urban settings.
In Transdniestrian region 93.5% of young people know anyone who uses drugs and 76.3%
think drug use is an issue to their community. 33
The injecting drug use is associated with high risks for health of drug users. A recent survey
conducted in Balti, Chisinau and Tiraspol among young drug users with ages between 12 and 24
years old showed that while the majority used sterile syringes (93.7% at last injection and 83.6%
consistently), the proportion of indirect sharing3 is very high. Indirect sharing of injection
equipment within the last month was reported by 85.3% respondents, and decreases with age
(100% in the 12-14 year-olds, compared to 81% in 20-24 year-olds). The respondents from the
Tiraspol sample are more likely to practice indirect sharing (93.3%) compared to those from the
right bank of the Dniester River (79.8% in Balti and 83.3% in Chisinau).34 By comparison,
beneficiaries of harm reduction services have a prevalence of 55% indirect sharing.
Another survey has documented the effect of risks associated to drug use on transmission of
blood-borne infections.35 The prevalence of Hepatitis C among drug users beneficiaries of
Harm Reduction projects was reported to be 42.7%, HIV 21.0%, chronic carriage of
Hepatitis B at 6.8% and syphilis at 12.1% (Figure 8). At the same time, while the prevalence
2
Estimation method: according to the National Bureau of Statistics, there are 680455 people with age between 15
and 24 years registered in Moldova in 2008. These numbers are multiplied by 1.2% for opiate users and 3.4% for
cannabis users. The limitations for this estimation method are very small numbers of drug users in the population,
which might introduce bias. More data sources are necessary for more exact estimations. This is just an operational
exercise to show a difference between the national statistic and general population or youth population surveys and
should not be quoted as an estimation number for Republic of Moldova. No official estimated of the number of
drug users are available in Moldova at the time of report writing.
3
Indirect sharing stands for front/back loading drug solution in a syringe and/or drawing up drug solution from a
common jar and/or drawing up drug solution from a common syringe and/or use of preloaded syringes and/or use of
common filter
23
of HIV and Hepatitis C is much higher in the adult drug users, the younger drug users that are in
harm reduction programmes still have much higher prevalence of all infections compared to any
other youth groups. The explanation is that while most drug users in the HR programmes do
not share needles and syringes and have access to clean needles, they still practice indirect
sharing and unsafe sexual practices and this is responsible for the high level of
transmission.
Figure 8. Prevalence of HIV, Hepatitis B and C and Syphilis in Injecting Drug Users, beneficiaries of Harm
Reduction Projects, 2007
60.0%
49.1%
50.0%
42.7%
40.0%
30.0%
26.3%
25.7%
21.0%
20.0%
13.2%
9.6%
10.0%
4.2%
7.1%
11.2% 12.1%
6.8%
0.0%
HIV
Hepatitis B
less than 25 years
Hepatitis C
25 years and m ore
Syphilis
total
Services available to drug users
Harm Reduction
Harm Reduction (HR) programmes are available in Moldova starting with year 2000, with a
geographic expansion since year 2003. However, starting with year 2007, the number of IDUs
who newly entered HR programmes decreased (924 IDUs in 2006 and 463 IDUs in 2007). The
number of syringes distributed decreased as well, by 12.8% in 2007. Altogether, at the end of
2007, needle exchange services were offered in 21 administrative territories (with extensions to
rural areas) and in 6 penitentiary institutions. During the same period a decrease by one third in
the budget allocation to HR services has been registered, due to the end of Global Fund round
II and the World Bank grants.36 As of end of March 2009, a cumulative number of 12,632
injecting drug users have ever accessed HR services.37 In the period 2007-2009 a continued
decreased volume of services was provided: less syringes and condoms were distributed, while
additional range of counseling services previously available to harm reduction clients have been
cut due to financial constraints. Given that HIV transmission in IDUs is presently linked to
indirect sharing and high-risk sexual behaviors, these cuts will likely translate in higher HIV/STI
transmission rates in the future.
Another problem is that low proportions of adolescents injecting drugs access HR services.
The MARA survey showed that only 12.9% of IDUs aged 15-17 years accessed syringe
exchange programmes in comparison with 30% of IDUs aged 18-24 years.38 Most likely,
adolescent IDUs are at even greater risk of HIV and STI transmission.
Drug treatment and rehabilitation
24
A quality drug treatment programme offers a wide range of treatment options, including
detoxification, maintenance treatment, long-term rehabilitation, psychological and social
interventions, self-support groups, relapse prevention strategies etc. Yet, the main service
offered by the national health care system is detoxification The offer does not differ in the
private sector of the health care system compared to the public one; detoxification is mainly
provided, with no additional treatment modalities. In 2007, there was an increase in the number
in the number of newly detoxified patients in the Republic of Moldova (right bank of the
Dniester River) (336 patients in 2007 and 308 patients in 2006). As for methadone substitution
treatment programme, the number of newly enrolled drug users increased sharply from 39
patients in 2006 to 222 patients in 2007.39
Rehabilitation services for IDUs are underdeveloped for the adult population and especially for
young people below the age of 18. The few existing services are offered the National Center for
Narcology and a few NGOs. The number of beneficiaries is limited. During 2006 –2008, NDR
and the NGO “Your Choice” have assisted about 200 people, while an additional 100 people
where assisted by the NGO “New Life”. There were 280 people enrolled in the 12 Steps
Programme.40
Gaps
There are no national comprehensive anti-tobacco programmes targeting youth. Although
the Framework Convention on Tobacco has been approved, the implementation and enforcement
lags behind. In addition, the tobacco prevention lacks the single most effective measure in
reducing smoking adolescents – significant increase in cigarette price. Although the majority
of adolescents would like to quit smoking, smoking-cessation programmes are practically
inexistent. School education regarding tobacco prevention is of an unknown quality and
effectiveness, given that life-skills based curricula is not monitored and evaluated.
There are no national alcohol prevention and consumption reduction programmes in
youth. There is a module on alcohol prevention within the life-skills based course, but the
implementation of this course is sporadic and not monitored to measure effectiveness and
quality.
There are no official estimations of the number of injecting drug users available in the
Republic of Moldova, thus it is difficult to assess the needs of a population of unknown size.
The official statistics cannot be used as proxy, as they significantly underreport the total number
of drug users. Harm Reduction services have registered higher numbers of drug users accessing
their services, but it is still unclear what coverage they have in the country.
Comprehensive national drug prevention programmes are not available in Moldova. There
is a lack of consistent and school-based drug prevention programmes, such as drug prevention
module included in life-skills curriculum. The existing harm reduction programmes have no
“breaking-the-cycle” interventions, aiming at encouraging older IDUs not to initiate younger
ones into injecting drug use, and they are not complemented with drug use prevention
interventions. Existing services should examine ways of extending their HIV prevention services
and drug abuse prevention programmes to cover younger cohorts.
Although there is an extensive network of harm reduction services in the country, the
range of services they provide is limited due to shrinking financing in the past years. Even
though direct syringe sharing is not common, about a half of clients of harm reduction services
still report indirect sharing and unsafe sex practices, that still might be leading to transmission of
blood-borne pathogens such as HIV, Hepatitis B, C and Syphilis. Another survey showed
25
significant differences in risk behaviors associated to drug use of teenagers outside harm
reduction projects, therefore there is a need of finding ways to outreach to the youngest and
short-experienced injectors.
Limited treatment options are available to drug users in both public and private sectors,
detoxification being the most important service. Long term rehab programmes or other treatment
options are limited and have a very small number of clients accessing them, making it difficult
for Moldovan drug users to abstain from using drugs for long periods of time. The number of
clients on methadone substitution treatment is still very limited.
Recommendations
1. To implement a comprehensive tobacco control programme that would address some
specific measures absent from the current legislation, such as significant tax increase on
cigarettes, development of smoking cessation programmes, and more effective education
programme regarding prevention of starting smoking.
2. To develop implementing mechanisms for existing regulations regarding tobacco control
3. To develop alcohol consumption reduction programme targeting youth and integrate in
existing healthy lifestyle promotion activities
4. To review and implement tobacco and alcohol prevention in the life-based skills
curriculum
5. To estimate the total number of injecting drug users, including adolescents and assess
coverage with services
6. To assess drug initiation practices, in order to develop tailored drug prevention and
“Break the Cycle” programmes
7. To increase the range of harm reduction services, including targeting indirect sharing and
safer sex practices
8. To increase coverage with harm reduction services, particularly by outreaching to the
youngest drug users and those with short injecting experiences.
9. To increase the number of treatment options for young people, including long-term
rehabilitation
10. To increase coverage and quality of with methadone substitution treatment for young
people
11. To develop support groups at the community level for young people who abuse alcohol,
tobacco and drugs
12. To strengthen the capacities of schools, colleges and universities and preventive medicine
institutions in promoting healthy lifestyles and preventing substance use in adolescents
26
Reproductive Health and Youth
Sexually Transmitted Infections
The incidence of sexually transmitted infections (STI) in Moldova is very high, compared
to other European region countries. In 2006, it was 186.8 to 100,000 in 15-19 year-olds (202.6
in boys and 170.5 in girls), compared to 119.6 to 100,000 in the total population. This situates
Moldova in the second place in the European region after the Russian Federation (Figure 9) 41.
The KAP survey conducted in 2008 showed that although most adolescents have heard about
STIs, less than half of them (47.8%) could name at least one STI symptom, without any
significant change compared to the 2006 KAP survey (48.0%).42
Figure 9. Incidence of syphilis and gonorheea, youth aged 15-19 years, year 2006
209.7
Russian Federation
186.8
Moldova
165.4
Belarus
Ukraine
Estonia
Bulgaria
Kyrgyzstan
Kazakhstan
Azerbaijan
Czech Republic
Latvia
Hungary
Armenia
Georgia
Tajikistan
Uzbekistan
Turkmenistan
Slovakia
Bosnia and Herzegovina
Croatia
Slovenia
Poland
Serbia
91.8
61.8
59.0
46.7
37.0
23.4
21.5
20.1
19.0
16.9
14.6
12.8
11.1
10.7
6.9
2.2
2.1
1.7
1.2
0.6
HIV
The HIV incidence in youth aged 15-24 years is increasing, with an incidence of 14.34 in 2007
compared to 13.32 in 2006. At the same time, the main mode of transmission in 2008 was
through sexual intercourse (72.1%) and sharing injecting equipment is accountable only
for 26.2% of new cases. The prevalence is increasing among pregnant women from 0.1% in
2005 compared to 0.23% in 2007.43 However, since all the statistics are based on reported cases
and that the main entry point for testing is through during pregnancy, these data have to be
considered with caution.
There were 155 new HIV cases in the age group 15-24 years in 2006, accounting for 24.2% of
the total number of new cases.44 Youth is primarily affected, 46% of new cases in 2008 being
among young people under 30 years of age. In 2008 adolescents aged 15 to 19 years
accounted for 2.22% of the cases on the right bank and 2.04% in Transdniester region.45
The knowledge about HIV, stigma and discrimination levels and HIV testing behaviors have
been assessed in 15-24 year olds in 2006 and 2008. The integrated HIV knowledge indicator
has significantly increased from 26.0% in 2006 to 40.8% in 2008, while the voluntary HIV
testing has remained low at 6% and the tolerant attitudes towards PLWH to an alarmingly
low 10% (Figure 10)46.
27
Figure 10. Main indicators of knowledge and sexual behaviors in youth aged 15-24 years, comparison years 2006
and 2008
75%
71%
80%
70%
64%
60%
50%
52%
48%48%
41%
`2007
40%
30%
`2008
26%
16%
10%
20%
5% 6%
10%
8% 10%
0%
HIV
know ledge
HIV testing
Tolerant
attitudes
tow rds
PLWH
Know ledge
about
condom s
Know ledge
of at least
one
sym tpom of
STI
Multiple
sexual
partners
Condom
use at last
sex w ith
occasional
partner
The pre- and post-training assessment conducted in school children in seven raions that took part
in peer-to-peer HIV prevention activities in 2008 shows a baseline 12% of school children aged
15-18 years having correct HIV knowledge about modes of transmission and protection means,
which indicates that rural school youth has an even lower baseline level of HIV knowledge,
compared to general youth aged 15-24 years.47
Sexual behavior
The initiation to sex in Moldova usually happens at around age of 16 years and about a
quarter of adolescents start sexual activities before age of 18 years. The percent of young
women that did not have sex before 19 remained stable in the past 17 years. The DHS 2005
showed that 21% of women 15-19 years have ever had sex48, compared to 22% in 199749..
According to the Youth KAP 2005 survey, 22.8% of youth aged 10-24 years have ever had sex
and the average age of sexual onset was 16.350. The mean age at first sexual contact in 2008 was
16.6 years in the total sample and 19 years in the sample of youth that was never married, nor
living in a partnership (for boys 17 years, for girls 20 years), a year less than in the KAP
conducted in 2006. A quarter of the sample (26.9%) had sex before 18 years and 13.3% of the
total sample who had sex, had sex before 15 years. 51
At the same time, while the proportion of those entering prematurely into sexual relations is
relatively small, the sex practices they enter are not always safe. Some 15.24% of the
sample had non-permanent sexual partners in the year previous to 2008 survey, and 17.7%
of the never married/no partnership category had two or more sexual partners in the past
year. Boys (33.7%) were ten times more likely to have multiple sexual partners compared to
girls (3.4%). A total of 10% of the sample reported having had commercial sex in the past
year. 52
Condom use
In 2008 some 62.7% of youth that have had sexual relations reported condom use at their
first sexual contact53, compared to 45.6% of youth in 2005(Table 1).54 In 2008, 53.6% of
youth 15-24 years reported condom use at last intercourse (67.1% of boys and 35.8% girls).
28
The younger ones (15-19 years) reported using condoms at last sex in 70.6% cases, compared to
41.1% of 20-24 year-olds. Condom use varies by partner type. It was much more frequently used
with permanent (not in a current partnership), occasional or commercial sex workers compared
to married/live-in partners. At the same time consistent condom use during the past year was
reported by less than half of respondents with all types of partners. Of special note is that less
than half of young people use condoms consistently with commercial sex workers.55
Table 1. Proportion of condom use at last sex and consistent condom use in the last 12 months, 15-24 years,
Republic of Moldva 2008, in %
Spouse/ live-in
partner
Permanent, not
living together
Occasional
Commercial
20.4
59.8
78.5
62.5
3.8
27.2
45.6
43.8
Condom use at last
sexual intercourse
Consistent condom use
in the past 12 months
Sexual and physical violence
According to Youth KAP 2005, around 5% of youth 15-24 years have reported sex initiation
through forced sex.56 According to 1997 reproductive health survey, a total of 4.4% of women
have reported sexual abuse in their lifetime.57 In general, a total of 27% of women have reported
physical violence since age 15 (14% for women aged 15-19 and 22% for age 20-24 years) and
6% experienced spousal sexual violence58. This shows an insufficiency of negotiation skills in
sexual relations.
Adolescent Pregnancies and Contraception
Teen pregnancies and low age at first birth in women represent a health risk for both the mother
and the baby, and limit the opportunities for young mothers for personal development and
education and their autonomy in their future life. Moldova ranks first among SEE, CEE and
CIS regions regarding the lowest reported average age at first birth (22.5), although it has
been increasing in the past 10 years. Moldova also has a high age-specific birth rate in the age
group 15-19 years, constituting 28.7 per 1,000 live births (Figure 11). 59
29
Figure 11. Age-standardized birth rate, 15-19 year old group, Republic of Moldova, 2006, per 1,000 livebirths
33.0
35.0
28.7
30.0
22.1
25.0
20.0
21.5
16.1
15.0
10.0
5.0
0.0
CEE
SEE
Moldova
Caucasus
Central Asia
According to the KAP survey 2005, around 5% of sexually active youth aged 10-24 years
have had experience with pregnancy, with only 7.1% of pregnancies ending with birth. For
the majority (89%) of those that had experience with pregnancy this was an unwanted
pregnancy. The girls aged 15-18 years were three times more likely to end the first pregnancy
with birth (46%), compared to 19-24 year-old girls (14.6%).60 According to the DHS study,
66.1% and respectively 63.7% of pregnancies end up with an abortion in the groups less than 19
years old and 20-24 years old.61 The national statistics register yearly around 10% of officially
registered abortions or a total number of 1,349 in 2007 performed in girls aged 15-19 years.62
This data seems to be realistic, given the DHS 2005 findings that the abortion rates increase
rapidly after the age of 19 (8 per 1,000 women in the age group 15-19 years, compared to 56 per
1,000 women in the age group 20-24) (Figure 12).63 This is also consistent with the average age
of sexual initiation, which is more than 18 years in girls, according to Youth KAP 2008.
Figure 12. Age-specific Abortion Rate, (in 1,000 women), DHS, 2005
59
56
54
35
9
8
15-19
1
20-24
25-29
30-34
35-39
40-44
45-49
At the same time, the high proportion of unwanted pregnancies shows a lack of knowledge and
practice about contraception. In fact, according to DHS in 2005, the best known options are
condoms and traditional methods. Around 70% of 20-24 year olds have used any contraception
method in the past, but early withdrawal was reported as the most frequent method and condom
was used by 43.6% of girls aged 20-24 years.64
30
Access to youth friendly services
A total of 12 youth-friendly clinics are available in the Republic of Moldova, of them one
each in Chisinau and Balti and in 10 raions. This is one of the few services in health where
multidisciplinary teams offer services. The offered services are OB/GYN consultations, STI
counseling and management, urologist, psychologist or psychiatrist, social worker, internal
medicine specialist services. Informational activities are oriented towards reproductive health,
mental health, personal skills and communication, violence prevention, healthy lifestyle,
prevention of HIV, TB and Hepatitis, healthy nutrition, and children rights. In 2006 and 2007,
some 70,000 youth benefit yearly from the services of these clinics. An average 35% of them
access confidential STI counseling, diagnostics and treatment services. Although this is by far
the most required service, the clinics do not have the necessary STI diagnostic and treatment
capacity. This is critically important especially for around 10,000 socially vulnerable clients,
who cannot afford paying for STI services by themselves. Starting in 2008, the services of these
clinics are reimbursed by the NHIF. The year of 2008 was a transitional one, when youthfriendly services started to be financed by the national health insurance fund; therefore the first
half of the year was marked by an erratic activity of all the centers. In 2008 only some 47,000
youth have accessed services, of which 16,000 were clients that accessed medical,
psychological and social services and 27,000 were beneficiaries of informational activities and
the rest accessed phone hotlines.65
The limited budgets available cover in practical terms only human resources costs, nothing being
earmarked for activities per se. Health services lack the approach of vulnerability assessment of
adolescents which would contribute to early identification of potential risk behaviors among
adolescents and referral to appropriate services. In addition, there are no outreach programmes
oriented towards most vulnerable and at risk adolescents. While the quality of services, the legal
framework and the sustainability were enhanced in the past few years, the number of YFHS
centres has not increased. A major effort will be required to cover the whole territory as initially
planned.
Voluntary counseling and testing for HIV and Hepatitis B and C is available starting with
year 2008 in each raion. There is a network of 35 VCT centers throughout the country, the VCT
services are reimbursed by the NHIF. While HIV testing is available free of charge for the client,
testing for Hepatitis is a paid service. A total of 19,423 people benefited from pre-test
counseling in 2008, of them 1.4% (or 279 persons) of age less than 15 years and 3.6% (or
701 young people) aged 15-18 years, which clearly indicates an underutilization of VCT
services by young people66.
Health and life skills education
Although many policies, such as the Law on HIV, the National Health Policy and some national
programmes, stipulate the necessity of introducing the health education course and life education
course as a mandatory part of the curricula, after only a period of two months of mandatory
course being introduced in 2005, the life skill based education course was made optional in
schools. As an alternative to the two above-mentioned courses, some schools have adopted the
course of civic education. However, experience and data from other countries show that health
and life skill based education play an important role in providing young people with knowledge
and skills.
To date, there is no situation analysis as to how many schools teach any of the three courses and
the information on life skills and health education in schools is fragmented. It is also not clear
how many school children and students have been trained through these three courses. There is
no monitoring and evaluation system in place to assess baseline and final level of
knowledge.
31
Gaps










Knowledge about safer sex behaviors continue to be low among adolescents, and
most importantly behaviours themselves continue to be unsafe, translating into
teenager unwanted pregnancies and high STI incidence.
Life skill based education and health education are not compulsory, and when they are
taught their effectiveness is not monitored or evaluated..
Routine statistics do not provide data disaggregated by gender and age groups (1014, 15-19, 20-24 years).
Most interventions focus on equipping adolescents with theoretical knowledge on HIV,
and not on developing their skills to effectively recognise and avoid risk behaviours
leading to HIV: substance misuse and unprotected sex.
The coverage with youth-friendly services is insufficient: only 10 districts out of 35
have geographic access. Even where the youth-friendly are available the range of services
remains limited, especially for STI testing and treatment, especially for the most
vulnerable youth from rural areas that do not have health insurance (after age of 18
years). In addition, they do not outreach to most vulnerable and at risk adolescents,
but rather are facility-based services and lack the proper incentives to do the outreach
efforts.
Even though youth friendly services have the unique opportunity to address multilaterally
the problems of adolescents by multidisciplinary teams, they lack the proper tools to
assess adolescents’ vulnerability.
The access to modern contraception (especially condoms) continues to be limited for
youth. Only some socially vulnerable categories receive modern contraceptive methods
through youth-friendly clinics and where there are no such clinics, the access to free
contraceptives is limited.
HIV counseling and testing among adolescents continues to be low. While there are
no set standards as to what proportion should test for HIV, the uptake of the number of
clients linked to opening the network of VCT centers in 2007 and 2008 did not translate
yet into an increase of the proportion of youth taking an HIV test. This might be an
indication that adolescents are not a target group that is normally referred by service
providers to HIV testing
HIV tolerant attitudes continue to be very low, despite the efforts to decrease stigma
towards living with HIV through public campaigns, Dance for Life and Social Theater
initiatives. The mass communication strategies aim mostly an increase in information,
rather than a change in behavior. In addition, they need to be complemented by consistent
education in schools and communication for better impact and BCC efforts at community
level.
To date, there is no accreditation system for services provided outside the public
system that would enable the government with a mechanism of quality assessment
and quality assurance of these services. The existence of an accreditation system
should then be followed by the development of a contracting mechanism for the NGO
sector providing health prevention services to populations that usually are outside the
reach of the public system
Recommendations



To disaggregate routinely collected data by age and gender
To conduct repeated surveys on reproductive health in youth every 3-5 years, in order to
be able to observe and monitor trends over time
To introduce life-skills based education curricula in schools as a mandatory course
32


To introduce quality standards for youth-friendly services, accreditation and proper
financial allocations for the activity of youth-friendly services.
To increase geographic access to youth-friendly services, the outreach to most vulnerable
youth, as well as expand the range of services, such as STI diagnostic and treatment and
contraception services, free condoms programmes.
33
Mental Health
Mental health and well-being are fundamental to quality of life, enabling people to experience
life as meaningful and to be creative and active citizens. Mental health is an essential component
of social cohesion, productivity and stability in the living environment, contributing to social
capital and economic development in societies.67 Mental ill health accounts for almost 20% of
the burden of disease in the European Region and mental health problems affect one in four
people at some time in life. Nine of the ten countries with the highest rates of suicide in the
world are in the European Region.68
National statistics
According to the WHO Health For All Database, Moldova has high prevalence of mental
health disorders in the total population, compared to both new EU countries and the CIS
region (Figure 12). The prevalence is almost twice higher than in the CIS and EU countries and
is on an increasing trend.69 One explanation for this difference could be that Moldova, as other
CIS countries, uses ICD 10 classification, while the European countries use DCM 4
classification, so there might be incorrect to compare Moldova with other countries. Some
experts have concerns regarding over-diagnosis problems in the case of mental retardation, and
misdiagnosing some psychological and social issues related to conflict situations as psychiatric
disorders. Yet, this needs to be further investigated by technical experts in the area.
Figure 13. Prevalence of mental disorders total population, comparison of Moldova with new EU and CIS
countries, years 2004-2007, in %
4.5
4
3.93
4.01
4.12
4.15
3
2.73
2.96
2.9
2.91
2.8
2.78
3.5
3
2.5
2.74
2
1.5
1
0.5
0
`2004
`2005
Republic of Moldova
`2006
EU members since 2004 or 2007
`2007
CIS
The incidence of mental disorders in people aged 0-18 years constituted 496.1 to 100,000 total
population aged 0-18 years in year 2007 and 455.8 in year 2008, while the prevalence was 2,404
in year 2007 and 2,443 in year 2008. Most disorders are of non-psychotic nature, such as
depression, neurosis and were accountable for 77% of all new cases in 2008 (Figure 14).70 It is
of note that starting with year 2003 the statistics are not collected separately for adolescents and
all data is collected for the age group 0-18 years old.
34
Figure 14. Structure of mental disorders new cases in 2008, Republic of Moldova, age 0-18 years
11.1, 2%
126.7, 21%
455.8, 77%
Non-psychotic disorders
Mental retardation
Psychotic disorders
The main factors conducive to mental disorders in children and adolescents are conflicts in
the family, family separation and parent migration, and conflicts at school. In this context, it
is important to introduce mental health education in schools and high schools, with an increase in
the counseling services in schools and at community level, in order to increase the level of
adolescent and child adaptation and skills to face social and family difficulties.
Mental services for children and adolescents in Moldova
According to statistical data, there were 26 active pediatric psychiatric offices in the Republic of
Moldova at the beginning of year 2007, including six within the children’s outpatient services of
the Republican Psychiatric Hospital. In 18 out of 35 raions there were no child psychiatrists. To
fill the gap, the Psychiatry Department of the Medical University has trained 8 rayon
psychiatrists, but the shortfall is still critical.71 There are three community centers (Chisinau,
Balti and Ungheni) that have multidisciplinary teams that include psychiatrists, psychotherapists,
speech specialists and ergotrheparists, but the coverage and quality of services has not been
assessed. The General Practioners (GPs) in Moldova play an important role in identifying and
referring to specialized services, but they do not have a role in diagnosing most common mental
disorders or the severe enduring mental disorders.72
Most adolescents with mental health disorders receive treatment on an outpatient basis.
Some are treated in inpatient facilities (Psychiatric Hospitals in Chisinau and Balti), day care
facility, with a capacity of 25 beds, located at the National Center of Psycho-neurology in
Chisinau.
Unfortunately, the multi-sectoral coordination between education and health systems is not
established in terms of data collection or referral systems.73 Thus, the children that address to
school or other psychologists are not captured in the national statistics presented above. In fact,
the referral system between the two systems is not established by any regulation and in reality
does not exist.
35
Suicide
Worldwide the suicide rates in young population are increasing. The rate of suicides increased
more rapidly in men compared to women.74 Moldova is a high suicide rate country, with more
than 13 suicide per 100,000 people75(Figure 15). In Moldova the suicide rates have been
relatively constant in the past 25 years (1981-2006) at around 20 per 100,000 annually, the rate
in men being 30 and in women around 10. Most suicides take place in the adult age groups (35 to
74 years) and in men. 76
Figure 15. Map of suicide rates, general population, year 2007
The average suicide rate among the group age 15-19 years was on a decreasing trend in the
period 1998-2002 (Figure 16) .77 However figures are different depending on the method of
collection and who collects the data. Therefore statistics are not very reliable.
Figure 16. Suicide rate for population aged 15-19 (per 100,000 relevant population), Moldova,
12
11.3
10.1
10
9
8
7.4
6.7
6
6.1
5.7
5.1
4
4.1
3.6
2
0
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
At the same time, the number of suicides in the age group 0-18 years has increased sharply again
in 2008, compared to 2007. More girls have been registered to commit suicide attempts,
compared to boys. Most suicide attempts are by intentional poisoning or strangulation (Figure
17).78
36
Figure 17. Number of suicide attempts in the age group 0-18 years, Republic of Moldova, years 2007-2008,
absolute numbers
40
37
35
30
24
25
20
2007
18
2008
16
13
15
9
10
7
12
8
8
4
5
0
3
0
0
Total
Girls
Boys
Strangulation
Intentional
poisoning
Falls from
height
Body lesions
Gaps
1. The current statistics rely on routinely collected data based on passive reporting of the
number of registered cases. There is insufficient information regarding the burden,
distribution, structure and underlying causes of mental disorders in adolescents in the
Republic of Moldova. The difference in classifications used by European countries and
Republic of Moldova poses additional difficulties in assessing the burden of mental
disorders in the population.
2. The mental health services are fragmented within specialized care (diagnosis, treatment,
rehabilitation) and there is no continuity of care with the primary care system. Within
psychiatric system there is a shortage of staff, especially in rural areas, and this shortage
is even more pronounced in providing care to children and adolescents.
3. Referral systems between psychological counseling system and psychiatric systems do
not exist and the psychologists do not have a monitoring system to collect routine
statistics on the number of clients and type of problems they address with.
4. The current monitoring system is designed to register new and existent cases, but is not
oriented to evaluate mental care outcomes and performance indicators for the mental
health system.
5. The current mental health system is still oriented towards clinical management of mental
health disorders in specialized institutions, be it psychiatric hospital or special institutions
for children, rather than long-term community programmes to help family and
community reintegration.
6. National mental health and suicide prevention programmes are limited.
7. Community services exist only in several locations and their coverage with services is
limited. They are mostly relying on external donor support and once this support is
ending, sustainability of these programmes is at risk.
8. Suicide statistics are not accurate and there are discrepancies between data collected by
various agencies.
37
Recommendations
1. To conduct a qualitative and quantitative assessment of the distribution and underlying
causes of mental disorders in adolescents in Moldova
2. To improve the monitoring system registering suicide attempts and mortality in health
and MIA systems
3. As part of the general health and life-skills curriculum, to include a module on coping
with stress
4. To develop a national mental health and suicide prevention plan that would be focused on
developing community-based service and group support, rather than mostly psychiatric
care.
5. To improve the early identification and referral of young people with mental problems
6. To expand access to community services for reintegration and deinstitutionalization for
children and adolescents.
7. To develop a model of service provision that would ensure the continuity of care in both
primary and specialized services
8. To improve the quality of specialized care available to adolescents and expand the range
of clinical and rehabilitation services available geographically
9. To expand the focus of the mental health monitoring system from inputs and processes to
outcome and impact measurement, e.g. number of cured case, number of reintegrated
youth in community.
38
Injuries and intoxications
Injuries are the leading cause of death in children aged 5–19 years in the WHO European
Region, and send many millions of children to hospitals or emergency departments, possibly
leading to lifelong disabilities. Injuries thus pose a huge drain on the resources of not only health
systems but also society at large. The leading causes of unintentional injury are road traffic
accidents, drowning, poisonings, thermal injuries and falls. The burden falls
disproportionately on the most disadvantaged children and on the countries undergoing
the greatest socio-economic change. Death rates from unintentional injuries among
children vary by as much as nine times by socioeconomic stratum. The death rates vary by
age, where highest rates for unintentional injuries are registered in children up to 1 year
and in teenage boys.79 This needs to be taken into account when designing preventive activities.
Although injuries are a leading cause of the burden of disease and seriously drain health and
societal resources, they have not been a high-priority area of action in most countries.80
There is extensive evidence that child injuries show some of the steepest social gradients in
mortality. Poverty is linked to high rates of injuries in many ways: supervision may be
difficult in families headed by one parent or where parents have conflicting demands on their
time and no adequate child-care facilities; fast traffic, lack of safe play areas, crowded homes
with unsafe structures; poor families cannot afford safety equipment, such as child car restraints,
smoke alarms or bicycle helmets81. Very often they are not aware or do not have the necessary
information to take simple preventive measures. European research shows that childhood injury
is strongly associated with poverty, single parenthood, low maternal education, low maternal age
at birth, poor housing, large family size and parental alcohol use and drug abuse.82
According to the European Detailed Mortality database, in year 2006 Moldova was the top 4th
country from the European region, with an age-standardized mortality rate due to external
causes of death for the total population of 109.03, compared to 55.09 in Romania or 40.88 in
Austria.83 In fact, Moldova ranked 3rd in average standardized rate for all unintentional injuries
in children aged 0-19 years in the period 2003-2005. In specific causes, Moldova ranked 4th in
mortality due to drowning, 5th in mortality due to poisoning and to thermal injuries84.
In the past five years the incidence of trauma and intoxications among 0-18 year olds is
around 5,000 (per 100,000 population), with an absolute number of 41,077 cases in 2008
(Table 2)85. Unfortunately, the morbidity and mortality statistics are not disaggregated by
detailed age groups; hence, all the statistics for youth presented below are for the age group 0-18
years old.
Table 2. General incidence of trauma and intoxication cases in children (0-18 years), Republic of Moldova, years
2004-2008
Year
2004
2005
2006
2007
2008
Number of registered cases
% of the total number
Absolute number
of cases (all population)
44,828
28.1
39,427
27.2
39,211
28.5
37,101
28.2
41,077
27.2
Reported to 100,000
population 0-18 year
old)
5,100.5
4,658.7
4,815.3
4,738.2
5,129.8
By far, most cases of trauma occur at home, around 37,000 cases, annually, thus parental
supervision is a critical point for interventions (Table 3). It is also alarming that around 1,600
39
cases of trauma occur in schools, which calls for better supervision at schools. Of note is that on
average there are 130 cases of trauma related to work in youth at the beginning of their activity
mostly in agriculture, which shows a lack of protection at workplace and a lack of safety
training.86
Table 3. Places of trauma occurrence in children aged 0-18 years, Republic of Moldova, years 2004-2008
Year
Work
Road
accidents
Street
School
Sports
Home
Other
Total
2004
2005
2006
2007
2008
0.3%
0.4%
0.4%
0.4%
0.0%
1.7%
4.1%
1.8%
1.7%
1.2%
6.9%
10.8%
6.2%
6.8%
4.4%
3.6%
3.2%
4.3%
6.5%
3.4%
2.5%
2.6%
2.7%
2.9%
1.8%
81.0%
72.9%
74.2%
77.9%
86.5%
4.0%
6.1%
10.5%
3.8%
2.6%
43,478
40,078
39,896
31,905
46,957
In the past five years, 226 children have died of drowning. The majority of cases were registered
in rural settings, where unsupervised children go to swim in local lakes (Table 4). This situation
could be easily prevented without major costs, by enforcing safer surroundings around lakes.
While on average 17 children die yearly due to unintentional poisoning, most of death due to
poisonings are intentional (suicides), mostly occurring in rural areas.
Table 4. Mortality due to drowning and poisoning, absolute numbers, 0-18 years, Republic of Moldova, 20042008
Year
2004
2005
2006
2007
2008
Drowning
urban
rural
11
25
11
33
11
41
22
29
12
31
Unintentional
poisoning
urban
rural
6
17
10
7
7
12
10
7
5
13
Intentional
poisoning
urban
rural
28
41
18
41
17
29
16
38
23
42
Gaps
The data that is available at this point from the routine statistics related to child injuries is
sufficient to understand the burden of the disease, but it does not allow to analyze in detail the
circumstances under which injuries occur, or the subpopulations of children more at risk
for injuries. Research related to causes and risk factors leading to high injury rates is not
available. It appears that while injuries put the highest burden on the health system and are the
leading cause of death in children and adolescents, there are no specific national injury
preventing programmes, and little is done to provide for safe environments for children and
teenagers and for better parenting skills.
40
Recommendations

To capture better data disaggregated by age groups (0-5, 6-9, 10-18, 19-24), as well as
data on circumstances and activities surrounding an injury, as well as socio-economic
determinants, including gender, essential to understanding which are essential to
understanding exposure and risk and to developing comprehensive responses.

To develop an inter-sectoral specific policy and plan to prevent and control injuries.

To implement specific preventive actions that prevent and control injuries based on the
findings of the conducted research. These actions will need to be of legislative and
regulatory nature, in order to modify the environment surrounding children and teenagers
and include a strong behavior change component for better education and skills of parents
and care givers, as well as capacity building efforts on the supply side (trauma and poison
control centers, better trauma management in health care settings etc.).

To implement trauma prevention module as part of life-skills based education in schools,
to address personal safety in children and adolescents.
41
ADOLESCENT DEVELOPMENT
School environment
Adolescents spend a significant amount of their time in schools, therefore the school
environment influences the general adolescent health and development. The further analysis
focuses on the existing data regarding school conditions (state of the facilities, water and
sanitation, and heating), as well as the effects on adolescent health.
An analysis of the state of the 1,534 school facilities shows that the vast majority of them have
been built before 1990, around 60% of buildings are older than 30 years and 41% need capital
refurbishments. 87 This hinders the capacity to organize the educational process according to new
educational requirements, as well as the capacity to increase the access of children with
disabilities to come to general schools.
All the schools from Chisinau and Balti and only 61% of schools in other areas have access to
pipe water and sanitation.88 The quality of the water is not nationally monitored or assessed on a
regular basis, but the experts consider that the quality of water is variable. A quality assessment
of the 181 rural schools that have autonomous water systems from ground waters shows that
36% of them are not in conformity with quality standards. There is no national system to
monitor the access to different sources of water in schools (piped water, underground water, etc).
A proportion of 29% of schools do not have proper heating systems, this having significant
consequences on the health and education of school children in the cold period of the year. The
annual assessments of hygiene conditions in schools in the years 2004-2008 have shown that in
16% of school microclimate requirements are not met and in 20% of schools the heating systems
were temporarily out of order.89
A proportion of 49% of primary schools, 64% of gymnasiums, 90.2% of general schools and
94.3% of lyceums have a medical office within schools. 90 This indicates a decreased access of
access to medical and public health services in schools located in rural areas where most of
primary schools and gymnasiums are located.
In addition to the conditions of the facilities, there is limited data regarding the effects of the
educational process on the health of school children. The State Sanitary-Epidemiologic Service
has assessed the educational process in 2009 in 1377 educational facilities and the preliminary
results show that the overall educational process overburdens the children in all grades. In some
schools the breaks between classes last only 5 minutes, and 7% of schools continue to work in
two shifts.91
All the above-mentioned problems affect the health of the school children. The multi-annual
evaluation of the health status in school children shows a significant increase in most health
conditions in school compared to pre-school children, such as posture problems, eye conditions,
cardio-vascular, endocrine, digestive, bone and muscles, nutrition and metabolism, neurological
and some other conditions. Chronic morbidity is also high in children with the following
ranking: respiratory problems (30.9 per 1,000), eyesight (9.3 per 10,000), digestive system
conditions (8.8 per 1,000) and neurological conditions (7.7 per 1,000).92
In conclusion, data regarding the conditions in schools and the effects of the educational process
on the health and development on adolescents is limited and requires further investigation. From
the existing data, it appears that many schools do not offer proper hygiene and safe environments
to school children and do not offer access to children with special needs. In addition, the school
curriculum overburdens the children and requires reshaping. This finding is corroborated by the
consultations with youth presented in case box 1. All these shortcomings affect negatively the
42
adolescent health and contribute to development of various health conditions and an increased
chronic morbidity.
Text box 1. Consultations with young people regarding the quality of education in schools
Adolescents mentioned that the school programme overburdens them and children are not able to
correspond to the requirements. The system is based on memorizing and reproducing information
provided in the manuals, which is very boring. The curriculum is too academic and overwhelmed with
unnecessary information; it is not oriented to developing skills.
“The content of the school curriculum is more complicated compared to other countries. There,
several disciplines are mandatory, and the other are optional and the adolescent has the choice. Our
society wants to develop multilaterally developed persons and not a person who is well trained in one
area, as it is in other countries”
Boy, 15 years, Hincesti
“Our school programme does not allow personal choice and provide a big quantity of information
that cannot be memorized. The manuals often change and contain a lot of unnecessary information”.
Girl, 16 years, Hincesti
Family environment
The consultations with vulnerable youth in Balti and Tiraspol have shown that most adolescents
see family situation as their biggest problem. It is either lack of parental supervision (due to
migration, divorce, substance abuse) and poverty, that result in children receiving insufficient
attention, affection and supervision from their parents, as well to conflict situations with parents
and sometimes family-based violence and abuse. This primary problem usually leads to other
types of problems: dropping out or lack of interest in school, communication problems
with peers and other adults, unhealthy behaviors: substance abuse and unsafe sexual
behavior, conflict with law, lack of interest and motivation to participate in community life
or access services. In the following pages several factors affecting the family situation and
adolescent behavior will be reviewed, such as family-based violence, poverty and migration.
Child violence and abuse
The desk review of existent studies revealed an insufficiency in parenting skills. Many parents
use abusive methods to educate their children or limit the opportunities of their children to
socialize by forcing them to do housework or farm-work, especially in rural areas and for the
poorest children.
A national survey of children and their parents has assessed the prevalence of different forms of
violence in families and schools, as well as differentiation between various forms of abuse and
discipline. The findings were that a third of children in Moldovan families report to be subject to
emotional abuse, 10% experience family neglect, a quarter of children report to be beaten when
they disobey parents, and 30% of mothers report using slapping for discipline and compliance of
their child Also, a third of children reported to be verbally abused by teachers at schools and
24% of children feel discriminated by teachers93.
Family neglect: 10% of general sample are hungry because there is no sufficient food in the
house, 10% consider they are neglected and not taken care of.
43
Emotional abuse: 30% of children say parents control every movement, 20% are subject to
verbal violence, 10% of parents recognize emotional abuse, 30% are not supported by parents in
their endeavors, 42% of children feel they are not up to parent’s expectations
Physical abuse: 25% children are beaten when they disobey their parents, but only 7% of
parents recognize to do so. Only 5% of parents seeing another parent beating his child would
report to police. Boys are beaten more often.
Forced labor: 40% of children state they are forced to do housework after school and do not
have time to play or have friends, or homework, and only 20% of parents (30% rural) recognize
to do so.
Sexual abuse: 10% of children have seen pornographic movies with adults, 10% report that
they know of children who have been sexually abused or molested, 5% of parents know
about cases of sexual abuse on children
Discipline over abuse: More than three quarters parents state they use explaining as method of
child education. Mothers use slapping more often (30%) than fathers (10%). For youth 11-14
years olds criticizing is used by 16% of parents and the menace to deprive of goods are
frequently used. For 15-18 year-olds criticizing is the generally used method for behavior
correction and 10% of parents interdict hobbies, seeing friends of buying certain goods for a
certain period of time.
School abuse: 30% are verbally abused by teachers, and 40% of parents know such cases, 20%
know teachers that menace they will beat the child. 10% of parents know teachers who have
sexually abuse, molested children. 24% of children feel discriminated by teachers, especially
those from poor families. The youth consultations have shown that discrimination by teachers
leads to poor academic results and increase in drop out and dropping out schools in adolescents.
Poverty
Poverty in itself affects the development of children and adolescents in many ways. On one
hand, it affects their access to good diet, and health services, as well as opportunities for
education, leisure and participation; on the other hand it influences the family in which the
adolescents live, by sending parents away to find work or by determining parents to neglect
children in favor of struggling to cover basic needs. Some parents might not cope with the
continuing stress to provide for a living and could start abusing alcohol and have other behaviors
that affect the relationship with their adolescent children.
Unemployment alone does not provide a full explanation for poverty. As one source has
noted, 68% of poor households still have at least one person employed, suggesting that wages are
generally below subsistence levels. Volunteer work is not popular among young. One possible
explanation that volunteerism on any sustained basis is difficult for most because they need to
devote their attention to generating income. 94
In the rural region, the poverty rate began to rise in 2004. While poverty continued to decline
in urban areas over 2003-2005, the poverty rate in rural areas, where 63% of the population lives,
increased from 35.7% in 2003 to 42.5% in 2005, underscoring the impetus for out-migration to
generate family income95. Child poverty is an acute problem as two thirds of poor households
have children. Moreover, it is estimated that one fifth of children live in absolute poverty. 96
According to the rural youth survey, 38% of respondents indicated that the income level of
their household is “enough only for basic needs” (26%) or “not enough for even basic
needs” in 12% of cases (Figure 18). The problem of rural poverty relates primarily to stagnant
or falling prices for agricultural commodities at a time when the cost of farm inputs – including
diesel and labor – has been increasing and a stalled land reform process.97
44
Figure 18. Perception about household livelihood, rural youth, 15-30 years, year 2008
5=4%
1=12%
4=23%
1 Not enough to meet basic needs
2 Enough only for basic needs
3 Enough for decent life but no
expensive goods
2=26%
4 If we save money we can buy
expensive goods
5 We have everything we need
3=35%
Massive remittances from family members working abroad enable those left in Moldova to
survive. Since the level of remittances has been decreasing in the past year, this will increase the
number of families living at or below subsistence level. The potential effects of economic crisis
on adolescent development could be increased unemployment, school drop out, additional
migration, increasing the number of institutionalized children, increase in the rates of substance
abuse, increase in levels of violence and delinquency, and increase of child labor prevalence.
Employment
The transition from school to work is another problem for youth in Moldova. The
unemployment rate is much higher in the youth compared to the total population, and in
young females compared to males. Only 27% are employed, despite representing a higher
proportion of the economically active population (Figure 19)98. Some survey shows that only
25% of rural youth report that they are engaged in some form of work, 5% working on their own
land and 3% running their own business. Twenty percent (20%) report themselves to be
unemployed. 99
Figure 19. Unemployment rate, comparison of 16-24 years group and total population, year 2007, in %
18
16
14
12
10
8
6
4
2
0
16.6
16.4
13.4
11.7
8.4
5.4
4.5
2.6
females
males
Urban
Total unemployment rate
females
males
Rural
unemployment rate youth 16-24 years
45
A significant number of youth enter the market without having the necessary skills. In
addition, the youth, especially rural youth, does not have sufficient information in choosing their
future career path; there is a lack of vocational counseling. There are several entrances of youth
to the job market: at the age of 16 years after gymnasium studies, this being the most
unfavorable, since they are minors and lack any skills. Yet, yearly about 10,000 youth of this
category enter the labor market. Another group enters labor market after completion of one-year
programme professional schools at 17 years, when they have some skills, around 5,000 annually.
The next group is the graduates of three-year programme professional schools, they have a basic
qualification and the age of 19 years, so they are in a better position. Also, at the age of 19 years,
youth that graduate lyceal studies can enter the labor market, but they are usually ill equipped
with skills and usually continue to university studies. The next entrances are after college and
university graduation and these usually do not pose difficulties for employment. The biggest
disadvantage of the last two is that there is a discrepancy between the demand and supply in
terms of qualifications and professions. Usually the enrollment plan of the universities is not
linked to the real demand on the job market and the result is an excess of graduates in
some professions and a deficit in others.100
There is a direct relationship between educational level of youth and the desire to emigrate
for work. The level of remuneration and the lack of jobs are the most frequently invoked factors.
In fact, when youth talk about lack of job openings, they usually refer not to lack of jobs in
general, but to jobs that would meet their expectations in terms of salary. Another interesting fact
is the opinions of youth about the expected salary, which according to a survey, equals to an
average 3,689 MDL, which is only 46% more than the average salary of 2,530 MDL registered
in 2008101.
In conclusion, there is a disproportional high unemployment rate in youth, compared to the
general population. The high unemployment rate among youth cannot be explained totally by a
lack of jobs, but more likely by disconnect between the expectations of youth towards
remuneration and a low level of offered salary. The fact that there are many vacant positions
that are not filled for long times confirm this hypothesis. In addition, there is a discrepancy
between the enrolment plan by specialties in universities and the actual demand on the job
market, showing inefficiencies in the transition from education to labor. Entrepreneurship
continues to be a limited option, only 3% of youth engaging in such activities and the national
programme of economic empowerment is very much needed.
Migration
Estimates of the number of migrants
There is extensive evidence and awareness about the phenomenon of population migration.
While official data has placed emigration at 309,000 migrants, some unofficial data indicate that
that number is between 600,000 and 1,000,000.102 In its National Development Strategy (NDS)
for 2008-2011, the Government of Moldova estimates that 21.1% of the total active working
population (15 years and older) left the country in 2006 in search for a job abroad, of which
40.3% were aged between 20-29 years. More than 75% of Moldova’s outbound migrants are 2140 years old.103 Fifty-five percent (55%) of respondents noted that at least one member of the
household had migrated for economic purposes within the past five years (62% of these migrants
were males and 38% females), and that for 71%, migration is a regular activity. 104
According to the Census 2004 data, of the total migrants, 30.4% were people with age of 1024 years.105 A survey of young people aged 15-29 carried out by the National Bureau of
Statistics in 2005 found that nearly one fifth (18%) of young people registered in surveyed
46
households were already abroad either working or looking for work. According to a survey, 7%
of rural youth respondents indicated that they, themselves, had traveled away from their village
to work or study over the past 12 months.106 Approximately 70% of young people who had a
job in Moldova reported that they would go abroad for work if they had the opportunity.
Of these, 36% said they would only be interested in a job in keeping with their qualifications, but
38%t said they would also accept a job they were overqualified for, and 26% said they would
accept any kind of job.107
Those who are leaving tend to be well educated. According to the Moldovan census, 76% of
international migrants had at least secondary school education and 26%, higher education. 108
Moldova is losing many of its brightest and most productive young people to other countries.
Estimates of the number of children left behind
Different studies estimate that up to half of children living in rural areas have one or two
parents abroad. A survey conducted in the schools of the northern part of Moldova has found
that nearly 50% of the children in village schools had at least one parent working in Europe 109. A
World Bank report quotes a study which found that 50% of children in rural schools may have
one or both parents working abroad110. Survey results indicate that 30% of the rural youth
reported that there is no father within the household at any time, and 18% report that there is no
mother present at any time. Where a father is reported to be part of the household, 18% of these
were reported to have been absent from the household for various periods of time. 111Another
report provides the rough figure of 20,000 Moldovan children left by both migrating parents 112.
Effects of migration on youth left behind
Remittances from family members working abroad often enable children to have better
consumer opportunities than their peers. Most of them live in better conditions, like repaired
and fully equipped houses. They have financial resources which allow them “to pay without any
difficulty all the school fees”, to buy expensive clothes and pay for entertainment.113 In addition,
those receiving remittances from abroad have much more opportunity to visit clubs, bars and
discos, and are often able to purchase vehicles, computers, and other things that the poorer youth
cannot. At the same time remittances also have the effect of increasing inequalities,
particularly among rural youth.114
Many youth receiving remittance funds have the desire to leave the country. A survey
showed they are more inclined to view legal employment in Moldova as highly uncompetitive
and undesirable, and migration as much more desirable. Remittance recipient youth who were
interviewed were the ones who most often expressed no interest in remaining in their villages or
even in Moldova, let alone in investing in any kind of business. Indeed, their parents are often
reported to be working abroad in order to send their children away to university and get the
family away from the village. 115
Children’s perception regarding social problems that can affect them
A qualitative study revealed that children with parents abroad mentioned the urgent need for
them to develop certain personal abilities in order to cope with possible difficulties of adult life,
in particular independence in the decision-making process, self-confidence, time management
and control of emotions.116
Psycho-emotional health. The psychological effects on the children left behind have been
documented by a study based on case-studies of children that accessed psychological counseling.
For the age 12-18 years, the following consequences were documented: antisocial behavior;
school failure; truancy; vagrancy; addictive behavior (addiction to Internet, gambling); drug
47
and/or alcohol use; early sexual life; depressive and anxious states; difficult relationship
between brothers/sisters. 117
Migrant’s youth are more prone to various risks associated to lack of parental supervision.
While being economically relatively advantaged, at the same time adolescents are largely
unsupervised and may engage in unhealthy activities and become involved in crime, etc. 118 In a
qualitative study, caregivers of children thought that, as a rule, children left in their care are not
more vulnerable than other children. For most survey participants, migrants’ children constitute a
group of children for whom “there is a strong probability of risk”.119 Risks associated to the lack
of parental supervision are the following:
 The loss of interest in school and a decrease in academic performance that results in
quitting school
 Deprivation of parental care is considered as a risk factor for children’s health. Some of
their illnesses can become chronic because they “do not solicit medical assistance when
they need it”.
 Higher likelihood that children with at least one parent working abroad commit offences
 Vulnerability to drug abuse
 Lack of opportunities to pursue education and find easily a job
 Risks associated to family relations. In the opinion of many adults, the development of
relationships within families with at least one member working abroad proves that in the
nearest future “there will be a generation gap”
 Human trafficking and labour exploitation
In conclusion, the effect of parent migration has also been established by a number of studies.
Up to half of rural youth leaves in a family with one or both parents away. Besides the obvious
advantage to have a better financial situation compared to their peers, the lack of parental
supervision leads to increased vulnerability. Some risks include dropping out school, earlier
sexual initiation, addictive behaviors, such as drinking and smoking, gambling, internet games,
and psycho-emotional and adaptation problems. Economic crisis will affect further family
situation by bringing back migrant parents that have lost their connection to the children and
since unemployment rate will increase, this will probably have a negative effect on family
relations as well.
Leisure and Access to Basic Social Services
Another problem area is what youth does in their leisure time outside school or work. A study
has shown that most rural youth spend time at home or visit friends or just hang around
parks or bars and cafes, and much lower proportions are engaged in some developing
activities. In fact, there is a documented discrepancy between the opportunities that urban youth
have compared to rural youth in accessing internet, going for sports or dance classes. A survey
shows that rural youth does housework more than any other activities necessary for youth
development (Figure 20). 120
48
Figure 20. Leisure time, geographic distribution, youth 15-24 years, 2008
90%
To listen to m usic
80%
70%
To do housew ork
60%
To w atch TV
50%
To go out w ith friends
40%
To navigate on Internet
30%
Reading
20%
Go to disco/bar/café
10%
Go for sports
0%
Rural
Urban
Transdniester region
To paint/knit
Go to a dance class
Righ bank of Nistru
Another survey documents further the disparity between rural and urban youth. One of the
main issues reported by rural youth is the lack of recreational and social activities to engage
them during their spare time. Some 91% of the rural youth report that “staying at home” is what
they usually do during their free time, “daily” or “most days of the week. Discos and bars are the
most used facilities by youths (85% of the youths participate in this activity). Other youth
facilities/activities reported to be available to youth included the following: Football (95% said
this is available in their community); Basketball /volleyball (54%); Café (57%); Discos/clubs
(85%); Computer Centre (45%), Cinema (12%); Youth Media Centre (10%). Thirty-two
percent (32%) of youth participate in activities at Culture Houses, but only 10% of rural
youth were aware and 5% accessed new services, such as youth resource centers, youth
organizations operating various youth activities such as HV/AIDS and health education, family
planning, helping with disabilities.121
While most youth know that education and health are available in their locality, the access to
other services, such as leisure activities, is much more limited, even when it is available. One
important point to note is that using services of bars and cafes compete with health care and all
the other services are used very little (Figure 21)122.
The same survey showed that among those that had health problems in the past year, only half
have accessed medical services. The main reason was patient procrastination (57.6%), but
another third mentioned provider-side problems: distrust in medical personnel (27.7%), lack of
money (28.8%) and fear about confidentiality break (13.1%)123
49
Figure 21. Access to services in the past year, youth 10-24 years, Republic of Moldova, year 2005
39.3%
Internet café
52.7%
75.8%
Café, bar
17.2%
Youth Center
33.9%
11.8%
Public bath
35.9%
46.9%
Sports, dance classes
19.0%
Creativity Center
77.1%
48.9%
54.4%
Culture house
Psycho-social counseling
3.2%
Fam ily planning
3.7%
92.1%
78.2%
24.5%
28.5%
73.2%
Health services
Education institution
Available
100.0%
99.1%
100.0%
Used
Participation and Empowerment
Participation of youth to community life allows them to develop a spirit of belonging to their
community and regions. In addition, this helps them to improve their socializing skills and avoid
loneliness and isolation. It also has the benefit to empower and improve decision-making skills
of youth.
Unfortunately in Moldova there is a lack of tradition of participating in the community life. In
addition, poverty often means that families give priority to survival and do not have time or
money for leisure activities. Youth have been asked if they would be willing to participate in
solving their community problems and while a third said that they are not willing, 42.4% said
they cannot participate. Reasons showed that they do not know how to participate and there is
nobody to organize such activities in their community (Table 5).
Table 5. Willingness to participate in community life, youth aged 15-24 years, 2008
Is willing to participate
Does not wish to participate
Is not able to participate
Lack of time
Does not know how to get
involved
It is not possible
There is nobody to organize
Too little
Noone has asked
His opinion is ignored
There is no point
Other
No answer
Total
16%
33%
42%
16%
12%
3%
3%
3%
2%
1%
1%
1%
9%
100%
50
Communities, especially rural ones, offer children very few activities in which they can get
involved. And the existing ones do not meet children’s needs and interests. Children consider
those activities as interesting and useful that are organized and managed by themselves. For
example, children and young people would like to establish a successful relationship with the
town halls within the framework of developed projects. But the local administration is not
always receptive to children’s problems and ideas.124
In the period 1999-2003, UNICEF has provided support to new models of youth participation
that involved a total of 7,000 youth in the following forms: youth parliament, local youth
councils, youth act, youth initiative groups, youth media project, peer education and social
theaters. Some 500,000 youth in Moldova have benefited from these activities throughout the
project life (Table 6).125 The participatory evaluation has shown that young people have greatly
improved their confidence in being agents of change in their communities and improved their
own life skills, independence and acceptance of difference. Unfortunately, at the end of the
programme not all of these initiatives were taken over by local authorities, because of a lack of
implementation mechanism and financial support required, although they were recommended
and included in the Youth Strategy for years 2003-2008 and 2009-2013.
Table 6. Results of participation programmes implemented by UNICEF in the years 1999-2003
Young people involved in
UNICEF supported
participation projects in
Moldova
Directly
involved people
Beneficiaries
of youth
group
activities
Localities
involved
Children's Parliament
682
75,432
682
Local Youth Councils
2,588
160,384
198
Youth Act
Small Grants for Youth
Initiative Groups
1,284
38,827
46
297
20,020
148
635
47,480
94
1,508
137,255
64
81
38,511
130
Youth Media Projects
Peer Educatos in Prevention of
HIV and STIs
Social Theaters
Recommendations
1. A behavior change effort in changing parental culture about child education and
supervision needs to be implemented at the national level. This BCC effort should focus
51
on changing current child discipline methods and decreasing family-based violence, as
well as increasing supervision and positive parenting skills.
2. The education of a new generation of parents should be taken into consideration, by
including a parenting module in life-skills based curriculum in schools
3. Since many adolescents live in incomplete families without both parents due to
migration, the government should develop strategies in improving supervision and
education skills of the current care givers. The social system needs to address the needs
of these families and children by providing community-based social services,
emphasizing the right of children to be raised in a family environment.
4. To introduce vocational assessment and orientation, and livelihood training in schools,
especially in rural areas and to expand participation of youth to the national programme
of economic empowerment of youth. To provide incentives for young graduates of
universities to seek employment in Moldova.
5. To improve the quality of youth development services available in raions, by planning
and developing them in accordance with youth needs and with a strong youth
participation.
6. To develop legal mechanisms that would require local authorities to involve adolescents
in solving their problems at local level
52
YOUTH POLICIES AND BUDGETING
National Policies related to Youth Health and Development
Law on Youth
The law was developed in 1999 and were recommended for amendments in 2008. It defines
youth in Moldova is defined as the group with age comprised between 15 and 30 years, as
opposed to Council of Europe definition of age 15-25 years and UN definition of 15-24 years. It
stipulates basic rights of youth and sets a minimum of 3% of national and local budgets to be
spent of youth activities yearly, as well as develop special funds for youth activities.126
Youth Strategy for years 2009-2013 and Plan of Action (PoA) for year 2009
The PoA for 2009 includes budgeted activities related to (1) increase in access to education (with
a focus on increasing the number of scholarships, decreasing youth migration, increased support
to young researchers and youth with excellence in academic performance; (2) promoting healthy
lifestyles (tobacco prevention and safer sex activities, quality standards for youth-friendly
clinics, encouragins sports activities); (3) ensuring economic opportunities for youth(economic
empowerment programme, job fair, social and vocational support to young unemployed people)
and (4) youth participation (small grants to the development of local youth councils, encouraging
volunteer activities, support to one-day events dedicated to youth activities in various areas).
National Programme of Economic Empowerment of Youth, 2008-2010
Its main objective is to encourage entrepreneurship activities of youth from rural areas. The main
results in 2008 are that 3,245 youth received business consultations, 262 youth were trained in
entrepreneurship and 181 private businesses were opened by youth for a total amount of 52 mln
MDL, and the amount is a 60% credit from Moldovan banks at 11.8% annual rate. For year 2009
58 mln MDL were budgeted and another 60 mln MDL are budgeted for the year 2010.127
The National Health Policy comprise a few areas that relate to adolescent health issues: health
promotion and disease prevention, health of the young generation, a better environment for better
health, healthy diet and increased physical activity, a society free of tobacco, alcohol and drugs,
life free of violence and trauma, improvement of mental health. The progress report on the
Implementation of Health Policy does not breakdown activities related to adolescents in the
above-mentioned areas, except for the component The Health of the Young Generation. The
document reports that in the year 2008 the following has been accomplished in this
component128:
 The MoH has approved the registry of additional services for children, school children
and students in educational settings that include prevention services, health services and
health education;
 MoH approved a Plan of Action for Strengthening the Health and Healthy Lifestyles of
school children and students in educational institutions for years 2009-2011, which
include activities to promote healthy lifestyle, improving physical and psycho-emotional
health;
 Three Reproductive Health Centers and 40 Reproductive Health Offices operate in the
country. Free contraceptives were donated. As a target group is listed youth with age 1524 years.
 Youth-friendly services: “Neovita” informational outreach campaigns on healthy
lifestyles and substance abuse prevention
 Opening of the Rehabilitation Center for Physically Challenged Children with a capacity
to offer services to around 2,500 children yearly.
53
National Strategy on Reproductive Health
This national policy has been approved by the government in 2005, but it does not stipulate a
timeline. The strategy has a separate goal to improve the reproductive health of adolescents and
youth with the following objectives: adolescent education for developing responsible and healthy
sexual behavior; ensuring free access to youth friendly health services; decreasing the abortion
rate and the incidence of STIs. Other components that also include youth-related activities are
family planning, risk-free maternity, STI management, abortion services, prevention and
management of sterility, prevention and management of violence and sexual abuse, prevention of
human trafficking, early detection of breast and cervical cancer. It stipulates as outcomes: at least
80% of schools will implement sexual education course, a level of 80% youth having correct
knowledge about reproductive health, each district will have youth-friendly health services,
reduction of abortion rate among adolescents by 30% and reduction of syphilis incidence in
adolescents by 20%.129
Policy and legislation in Mental Health
In 2007, Moldova has developed and adopted a National Programme for years 2007-2011, which
provides direction for achieving reductions in morbidity, mortality and incapacity from mental
disorders and for gaining increases in the accessibility and efficiency of psychiatric assistance
and family integration.130 It has a specific goal related to children and adolescents of priority
development of community services for children, youth and elderly. In addition, it stipulates the
necessity to open psychiatry offices with psychiatrists for children, opening 50 positions for
psychologists-psychotherapists and 50 positions of social assistants, and 50 positions of nurses.
It also stipulates the necessity to conduct a baseline study to evaluate the causes underlying the
mental disorders, the prevalence of various mental disorders and the mental health needs of the
general population.131 Although it has been planned for 2007, it was not conducted so far.
In addition, the latest law regarding mental health was amended in 2008 and it covers topics that
were missing in the previous law such as areas as access to care in community settings, legal
rights of family members of mental health service users, competency or capacity issues for
people living with mental illness, accreditation of professionals, accreditation of facilities and
mechanisms to implement provisions of mental health legislation.
National Programme on Preventing HIV and STIs for years 2006-2010
This national programme has set as the second priority to build the capacity and expand the
information, education and communication services for the large public, youth and vulnerable
groups in HIV/STI prevention and as the fourth priority the extension of prevention efforts in
vulnerable groups (mostly of age 15-30 years). It sets as a priority the introduction of the
mandatory course on life skills for schools and universities, with the annual goal to reach
560,000 school children and students starting with year 2005. It also sets as priorities the
development of the Strategic HIV/STI Communication Framework for years 2005-2010, access
to free HIV counseling and testing services for pregnant women and youth aged 15-24 years, and
the access of vulnerable groups to harm reduction services, to maintain the level of HIV
prevalence at 40%.132
National Programme to Promote Healthy Lifestyles
Among objectives it stipulates: improving and introducing modern health education for youth
and children, in order to consolidate life skills and disease prevention, education to prevent
traffic accidents, home and work-related injuries and education to provide first help in case of
injuries; prevention activities related to socially-determined diseases (HIV, STIs, TB, excessive
alcohol use, drug use). As tasks specific to youth are listed the development and implementation
of curriculum of mandatory health education course in grades 1-12 and the implementation of
the WHO concept of integrating Moldovan schools in the European Network Health Promoting
Schools.133
54
Gaps
 Most problematic areas in adolescent health discussed in the situation analysis are
included in national policies, such as reproductive health issues, lifestyle behaviors
(substance use, HIV, STIs) and mental health. Only injury prevention and management is
not reflected sufficiently in the national policies.

National programme budget allocations are difficult to monitor, especially when there are
multiple sources of funding and multi-sectoral programmes that involve several
ministries.

When there are sufficient budget allocations, they are usually oriented towards human
resources and infrastructure maintenance, and lack operational budgets necessary for the
implementation of activities, especially preventive activities.

As a rule, national policies do not identify most at-risk subpopulations of adolescents in
which the implementation of activities will have the most impact and “bang for the
buck”.

It is very difficult to assess the level of implementation of these programmes, which,
except for the National AIDS Programme, lack yearly or midterm review mechanisms
and qualitative and quantitative monitoring systems in place. In addition, they lack
transparency in accounting for the results per target groups.
55
Health Expenditures and Budget Flows
The main source of funding in the health sector is by far the Health Insurance Fund (HIF), that
was accountable for 83% of health budget in 2008, followed by the central budget (10% in
2008), the contributions of local public authorities, special funds and grants, credits and external
sources of funding being accountable for only 7% of the total budget in health. The main types
of expenditures are: 60% for hospital costs, 35% for primary care, outpatient care and emergency
care 6%, and costly investigations and compensated drugs below 2%. The main beneficiaries of
health services are people ensured through employment (24%), people with disabilities and a
retired people. While children and student youth account for 40.3% of insured people, they
use only 13.3% of health services (Figure 22). 134 While this is the basic principle of social
solidarity that is the cornerstone of mandatory health insurance, the underutilization of treatment
services by youth should be used as advocacy to HIF to reallocate some of the saved resources to
cost-effective preventive services to youth, that would not only the delay the onset of diseases in
this generation later on but would bring significant societal cost-savings.
Figure 22. The distribution of insurance holders and use of services by population categories, Republic fo
Moldova, year 2008
36%
26%
24%
20%
14%
13%
11%
9%
ur
a
nc
e
ho
ld
er
s
nt
w
om
en
pl
e
pe
o
d
In
di
vi
du
a
et
ir e
un
e
ly
R
m
pl
oy
ed
s
tie
ci
al
O
ffi
w
i th
Pe
op
le
at
io
n
di
s
ab
i li
st
ud
e
ch
i ld
ed
uc
d
iz
e
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ec
ia
l
ts
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ud
en
nt
s
re
n
ts
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ho
ol
er
si
ty
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ud
en
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ho
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es
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oy
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1%
li
ns
1%
1% 1%
2%
0%
2%
2%
eg
na
1%
5%
4%
Pr
2%
Hold insurance
Access services
Central Budget
The public budget that is administered by the MoH is mainly dedicated to administrative
spending necessary for the MoH and some republican institutions in its subordination, of which
44% go to human resources, capital investments and equipment (28%), while procurement of
services and goods is around 28%.135
In reference to the national programmes related to youth described above, the MoH covers only
psychotropic drugs in the mental health programme (a total of 6.7 mln MDL spent in year 2008
and 15.2 mln MDL approved for year 2009), and HIV tests (9.35 mln MDL spent in year 2008
and 10.35 mln MDL approved for year 2009).136
The national programmes can be categorized as (1) system strengthening, (2) treatment oriented,
(3) prevention oriented and (4) reducing risks to health. The analysis of the national health
56
programmes shows that most programmes are oriented to system strengthening and treatment,
while prevention and risks account for only 23% (Figure 23). At the same time, within the
prevention and risk reduction programmes, most spending is dedicated to human resources (more
than 95%) and the rest to capital investment.137
Figure 23. Budgetary priorities of national health programmes for years 2008-2010
Prevention
18%
Treatm ent
23%
Health risk reduction
5%
System
strenghthening
54%
The HIF allocated in 2009 only 0.1% of its fund to preventive services, which is very low level of funding
that should be investigated further in detail regarding the obstacles of increasing the allocation to
prevention and health promotion services.138 Some of these inefficiencies related to health promotion
and prevention activities could be explained by lacking mechanisms to provide preventive
services to youth, especially for most vulnerable adolescents. While there is the system of
preventive medicine centers, they are usually oriented towards case finding and reporting, rather
than modern prevention activities related to behavior change communication, mass
communication and COMBI strategies, At the same time, in the past 15 years a network of
NGOs have developed that could access these vulnerable adolescents. Therefore, there needs to
be developed a contracting mechanism of NGOs to provide services to most vulnerable, as well
as mechanisms to assess the quality of and accredit the services provided by NGOs.
Effects of financial crisis on national spending for health
In April 2009, as a consequence of economic crisis and the decrease of funds in the central
budget, the Ministry of Finance requested the MoH to cut its budget by 20%. The MoH
suggested differential budget cuts, with higher cuts for national programmes (35%), 33% for
preventive medicine, blood transfusion services, forensic medicine and rehabilitation services
and for medical education (29%). The only cut pertinent to national programmes that stipulate
activities for youth are for the National Programme for HIV/STI prevention at a total of 1.39 mln
MDL. In addition, they have suggested a 20% budget cut for children rehabilitation centers, TB
rehabilitation center, residential institution for children of small age and the National Center of
Reproductive Health and Medical Genetics.139
The financial report made by HIF to the Government for the first seven months of 2009 shows a
reduction in the total amount of contributions at 90.1% from the foreseen funds and a reduction
of transfers from the central budget at 87.1% from the planned amount. Only in July 2009, the
reductions were more significant: 75.4% of the planned contributions and 65.9% from planned
transfers from the state budget.140 This indicates to a significant reduction of contributions and
central budget transfers in the past month and is a sign that the economic crisis only starts to hit
the health system.
57
Gaps

Although school children and students represent 40% of the total insured population in
Moldova they use only 13% of health services. Some of these savings should be
reoriented towards funding of health promotion and preventive activities.

The budget allocations usually do not cover fully the necessary activities and the national
health budget is usually oriented towards hospital and primary care services, rather than
preventive and health promotion activities. The preventive services are most costeffective and significant allocation to these services would translate in lower morbidity
and prevalence of risk factors, which would bring significant cost savings in the future.

There are currently no financing and accreditation mechanisms in place that would allow
contracting out youth services to NGOs, in order to fill the gap in implementing
preventive activities among youth.

The economic crisis affects the central budget, and starting with mid 2009 a 20% budget
cut for children rehabilitation services and 33% cuts for the national programmes will be
implemented. HIF has already reduced revenues by 25% in July, which will soon
translate into a need of prioritizing the current system and the development and
expansion of new services will be highly questionable. There is a need of feasibility
studies, in order to prioritize services based on their cost-effectiveness.
58
Donor Mapping
International donor agencies that work in Moldova were asked to fill in a short form regarding
the programs that target youth. A total of 14 agencies were contacted: UN Agencies, such as
IOM, ILO, UNFPA, UNDP, the World Bank, WHO, and other donor agencies, such as
Delegation of European Union, Every Child Moldova, DFID, SIDA, Soros Foundation-Moldova,
Social Investment Fund, SDC, and TACIS. A total of 10 donors have provided information about
19 projects in the area of youth health and development. The projects cover the following areas:
1. Youth Health
 WHO – mid term evaluation of the reproductive health strategy, 115,000 USD for 20102011
 Soros Foundation-Moldova, Harm Reduction Projects, est. 1 mln USD for 2010-2011
 SDC’s Regionalization of the Pediatric Emergency and Intensive Care Services in
Moldova (including injury prevention program), 4,9 mln SF for years 2008-2010
 SDC’s Community Services for Parental Education and Support to Young Families.
Piloting and Promotion, 200,000 CHF, 2008-2010
2. Human Trafficking prevention and protection and child labor
 IOM: 3 projects with a total amount of 113,600 USD, years 2006-2009
 ILO: 255,830USD, years 2003-2009
3. Reintegration of children from boarding schools and other residential institutions and
opportunities for children from vulnerable families and street children
 IOM, Hope is a waking dream – a decent life for young women in Moldova, 360,000
USD, 2006-2009,
 IOM, Reconstruction and opening of the Centre for Street Children “Speranta” (“Hope”)
in Cahul, 38000 Euro, 2008-2009
 UNDP’s Better Opportunities for Women and Youth, 4,2 mln USD, 2004-2009
 Every Child Moldova, The Reorganisation of the Cahul Residential School, Support care
givers in the Raion of Cahul, 2008-2009
4. Prevention of child abandonment,
 Every Child Moldova Prevention of child abandonment at birth in Chisinau and Ungheni,
2008-2009 and Family Counseling Centre Tiraspol, 2005-2009
5. Capacity building and policy development
 World Bank’s Italian Grant for Strengthening National and Local Capacities for Youth
Strategy Implementation, 244,904 Euro, 2007-2009
 EU Delegation Youth in Action, years 2007-2013
 Every Child Moldova, Set up of the Children’s Advisory Board of EveryChild in
Tiraspol
6. Juvenile Justice: SDC Reform of the Juvenile Justice System in Moldova with a budget of
appr. 1 mln USD for years 2007-2012
Detailed information on donor mapping is presented in attachment 1.
59
CONSULTATIONS WITH ADOLESCENTS
With the purpose to bring the opinions of the adolescents themselves in this situation analysis,
adolescents were consulted regarding the problems that they personally face and those that their
adolescent peers are confronted with.
Methods:
The data collection tool was specifically designed for this exercise. It addressed the following
areas:
 Personal problems
 Problems of peers in their communities
 Personal and family empowerment to solve the identified problems
 Leisure time
 School
 Access to services
 Vulnerable children
Participatory techniques were used, namely:
(1) VIPP cards to identify personal problems and adolescent problems,
(2) Voting to prioritize problems from a predetermined list
(3) Focus group discussion regarding empowerment, feedback about school, leisure and
participation, access to services and vulnerable adolescents
Four workshops were conducted, of which two on the right bank of Nistru (Balti and summer
camp in Hincesti) and two in the Transdniestrian region (Tiraspol and summer camp) with a total
of 41 participants (18 girls, 23 boys).
Table 1. Distribution of participants of focus groups
Date
13.07.09
Place
Summer camp,
nearby Tiraspol
Type
General youth
13.07.09
Correctional school
“Makarenko”, Tiraspol
Juvenile delinquents
15.07.09
Balti city
17.07.09
Hincesti
Vulnerable
adolescents (various
factors of
vulnerability)
Recruited as peereducators
Participants
3 boys, 6 girls,
ages between 13 years and 21
years
9 boys
ages between 11 and 14 years
6 boys, 6 girls
Ages between 12 and 18 years
5 boys, 6 girls
Ages between 14 and 18 years
Each workshop was 1.5 - 2 hours long. Audio recording was performed in Hincesti and summer
camp near Tiraspol, while in Balti the participants refused to be recorded and in the correctional
school in Tiraspol the administration did not allow recording. In the latter cases, the transcripts
were made based on written notes.
Results
The workshop participants were asked to name three main problems that affect them and their
peers in their communities. In all groups at the beginning there was a reservation to name
problems that affect adolescents personally, and it took some effort to concentrate on issues
affecting their lives and development. For adolescents it was much easier to name problems
60
affecting other adolescents. Still, this exercise extracted a wider range of issues than
professionals in health, education and social services identified as main problems.
The self-identified problems by youth could be grouped in several categories:
Family: Communication problems with parents and migration
Most adolescents from vulnerable groups have mentioned that they feel neglected in their
families, parents do not pay enough attention to them and do not spend time with them, do not
trust them and they never listen to them. In addition, family violence emerged as a problem of
interaction with parents, both verbal and physical violence.
The adolescents left behind by migrating parents feel alone and they lack parental attention,
education, they do not have anyone to share their feelings with or to supervise them. When they
leave, many parents lose the emotional bond with their children and when the parents return, the
relationships become complicated and change irreversibly. Many adolescents feel offended that
they have not been consulted about parent’s decision to leave the country. In the absence of
parental supervision many adolescents become more responsible, but others become more
susceptible to high-risk behaviors.
School
Many youth have mentioned school being an issue, in terms of the quality of education, and the
opportunities to continue studies beyond school. In addition, they mentioned that teachers pay
attention only to “good” children and are not concerned about what happens to those that do not
fare well in class. In addition, teachers have a discriminatory attitude towards those from poor
families or families that cannot offer financial support to class funds and are neglected while in
class or subject to verbal abuse. Mostly boys and adolescents from vulnerable groups mentioned
this differential attitude as a disincentive and a demotivating factor to attend school and,
although many are enrolled, they just do not go to classes.
Leisure time
Most adolescents mentioned very limited opportunities of spending leisure time and limited
extracurricular activities that could develop additional skills. They have linked the lack of
activities of leisure time with substance abuse and delinquency.
Substance abuse
Most respondents in all groups mentioned smoking and drinking affecting them personally. Girls
have mentioned smoking being an issue for them and boys mentioned both smoking and
drinking. All have mentioned that although they would not want to do this, they feel under
pressure to start and continue smoking and drinking because of peer pressure and group culture.
The vulnerable adolescents start young – at age of 5-7 years for boys in correctional school for
smoking and 10-12 years for drinking and the general groups mentioned the age of 10-15 as
starting smoking and drinking. As causes to start and continue substance use are mentioned lack
of parental supervision, lack of alternative activities, wide accessibility to cigarettes and alcohol
products, peer pressure, following the model of parent behavior. The consequences are increased
violent behavior, worsening of academic performance, strained relationships with parents,
teachers and peers.
Discrimination
The vulnerable and poor adolescents feel discriminated against because of social and financial
status both by peers and teachers. Especially youth in Balti identified that poor economic status
affects their social integration and acceptance.
61
Juvenile delinquency
This issue emerged in discussion with participants from the correctional school and Balti. Most
boys in correctional school thought this was their biggest problem, that they are institutionalized
there and they thought they got in there mostly because of the type of friends they hang out with
and lack of parental attention that lead them to quit school, spend time with computer games and
gambling, which lead then to stealing.
Geographic placement of their community
Geographic placement emerged as a separate issue for rural youth interviewed in the summer
camp in Hincesti, in that rural youth has fewer opportunities in education, leisure, and skills
development compared to their urban peers.
Prioritizing problems
When asked to prioritize problems personally affecting them, the following six main problems
emerged in decreasing order:
 Substance abuse
 Communication with parents
 General health status
 Leisure and extracurricular activities
 School and continuation of studies
 Employment opportunities
 Juvenile delinquency (was mentioned frequently as a problem in Hincesti and Balti, but
was not included in the list in Transdniestrian region)
Table 2. Main problems personally affecting the focus group participants
No
Type of problem
Balti
Hincesti Tiraspol Tiraspol
Total
summer correctional
camp
school
1 General health
2 Communication with
parents and teachers
3 Communication with peers
4 Leisure and extracurricular
activities
2
3
3
4
2
4
7
5
14
16
2
2
0
3
0
4
4
4
6
13
5 Employment opportunities
6 School and continuation of
studies beyond school
7 Access to youth-friendly
services
8 Economic situation and living
conditions
2
1
2
6
5
0
3
5
12
12
1
1
2
0
4
1
3
0
5
9
9 Nutrition and diet
10 Sexual relationships and
sexual education
1
2
0
2
1
1
5
0
7
5
11 Migration and family
separation
12 Family violence
4
3
2
0
9
4
4
0
0
8
62
13 Substance use (tobacco,
alcohol, drugs)
14 Farm and household labor in
free time
15 Environment issues (water,
air, sanitation)
5
9
4
2
20
1
1
0
3
5
0
3
4
2
9
16 Adolescent delinquency
17 Other problems
7
2
3
N/A
1
N/A
0
9
4
When asked to prioritize problems that affect in general adolescents in their community, the
distribution was somewhat different, as follows:
 Communication with parents and teachers
 Substance abuse
 Sexual relationships and sexual education
 Leisure and extracurricular activities
 School and continuation of studies
It is of note that a completely new problem emerged regarding sexual relationships and
education compared to personal problems, which is a sign of discomfort expressing this as a
personal problem, but nevertheless high on their priority list when anonymity was provided (not
them personally, but youth in general). When the moderator tried to discuss more on this topic,
there was an obvious discomfort to contribute to the general discussion, an indication that
discussing sex matters is a taboo for adolescents. Some respondents have mentioned that they did
not receive sex education in school and that the biology topic on reproductive organs is usually
given as homework.
Table 3. Main problems affecting adolescents in general
No
Type of problem
Balti
Hincesti Tiraspol Tiraspol Total
summer corr.
camp
school
1 General health status
2 Communication with parents
and teachers
3 Communication with peers
4 Leisure and extracurricular
activities
5 Employment opportunities
6 School and continuation of
studies beyond school
2
3
5
7
4
5
0
9
11
24
2
2
1
3
1
3
5
8
9
16
2
1
3
8
5
1
1
4
11
14
7 Access to youth-friendly
services
8 Economic situation and living
conditions
1
2
2
0
5
1
3
1
4
9
1
2
0
5
0
4
1
6
2
17
4
4
3
1
12
4
5
1
1
11
9 Nutrition and diet
10 Sexual relationships and
sexual education
11 Migration and family
separation
12 Family violence
63
13 Substance use (tobacco,
alcohol, drugs)
14 Farm and household labor in
free time
5
4
5
4
18
1
0
3
1
5
15 Environment issues (water, air,
sanitation)
0
1
0
1
2
16 Adolescent delinquency
17 Other problems
7
4
N/A
1
N/A
4
11
5*
*In correctional school other problems included computer games, gambling in casinos and slot machines
Empowerment and Participation
Most adolescents felt they could not solve their problems by themselves, but their parents could
help them to solve some. For family-related problems, friends are the ones they could share their
problems with. Adolescents could not identify services outside their family and their immediate
network that could help them solve their problems. The vulnerable adolescents felt they or their
families are not empowered to change their situation.
Adolescents mentioned that they would like to participate in the life of their communities, but
they do not know how. Boys mentioned more frequently that they are not interested in such
activities. In Tiraspol girls mentioned as participation forms cleaning the environment around
their homes or public spaces, but usually not because of their will, but also taking part in some
community activities that target institutionalized and orphan children. Adolescents thought that
school councils are not functional form of school participation and their opinions are not taken
into account, usually all the decisions being made by the headmaster and teachers.
Education system
All the respondents from Balti, Hincesti or summer camp Tiraspol were not happy with the
educational system. Most mentioned teachers have differential attitudes to children, engaging
and focusing on the best children and living without attention the average ones and especially
those that do not have a good academic performance. In addition, they use abusive methods to
discipline especially those from vulnerable families. It is worth noting that boys from
correctional school were all happy with everything about the schools and thought that they
themselves were the only problem. Grading was also mentioned as a problem, in that it is
subjective and it is in direct relationship to giving bribes, despite all the efforts to eliminate
corruption from the schooling system.
Regarding teaching methods they mentioned that the system is based on memorizing and
reproducing information provided in the manuals, which is very boring. The curriculum is
too academic and overwhelmed with unnecessary information; it is not oriented to
developing skills. They felt the quality of some manuals was bad, and that besides manuals there
are no alternative reading materials.
Teacher’s differential attitude, abusive and discriminatory methods, boring classes and
peer pressure and stigmatization were mentioned as causes to dropping out, as opposed to
factors mentioned by teachers in other contexts (working with parents, lack of clothes and
school supplies or lack of parental support). 4
Access to community services
4
See mid-term evaluation report on leadership area on education
64
The community services are limited or non-existent in rural areas. Most respondents from urban
areas are aware about community centers for youth and children, but they usually are not high on
their agenda, because of incomplete coverage or outdated activities and elderly staff (e.g.,
knitting classes). Boys are mostly interested in going for sports and the access is limited
financially for some sports, such as soccer or tennis, while others are free of charge and
available: greco-roman fight, athletics, but less appealing. Some activities supported by Catholic
Church are accessible to adolescents.
Some adolescent heard about social workers, but most participants do not know personally them
or think that they are intended for providing food and financial aid for vulnerable families. Even
adolescents form vulnerable families did not know about social workers and their work.
School psychologists are not popular among adolescents, they feel that this more a formal
position and in case school psychologist does offer services, they usually perform psychological
tests, for example, to assess leaders in class, but do not offer counseling or vocational
assessment. Moreover, only several would go to a counseling session to a school psychologist.
Vulnerable adolescents
Finally, participants were asked to identify who is most vulnerable in their community. An
interesting observation was that adolescents from vulnerable groups mentioned a wider range of
vulnerability factors, but the leading ones related to family situation. The adolescents from
general population mentioned more frequently adolescents with disabilities and special needs. A
full list of all vulnerability factors mentioned by participants is listed below:
1. Abandoned Adolescents
2. Children without parental care
3. Children without parental love and affection
4. Children from incomplete families
5. Children with migrant parents
6. Children left in the care of grandparents
7. Adolescents from families with many children
8. Adolescents from families where the father loses all his money in gambling
9. Those that rely on parents good financial status and children from rich families
10. Adolescents whose parents do not care about school
11. Adolescents from families where parents are drug users
12. Adolescents from families where parents sell their children
13. Adolescents from families where parents force them to commercial sex
14. Adolescents where they dominate their parents in their families
15. Violent families
16. Homeless, beggars, those that run away from their families
17. Unemployed
18. Poor
19. Hungry
20. Disabled children
21. Orphaned and institutionalized children
22. Adolescents living with HIV
23. Adolescents with bad academic performance
24. Adolescents that do not attend school and work to make for a living
25. Roma adolescents
26. Adolescents that drink and smoke
27. Adolescents whose parents drink and smoke
28. Adolescents without belief in God
29. Those that lack self-esteem and self-confidence
30. Those that only think about present
65
31. Those that destroy nature
32. Those that self-affirm themselves among their peers
33. Adolescents with ages between 11 and 16 years
66
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