Third week: a clearer picture of the assessment process

Halfways through the third week I’m happy to find that I’ve got a reasonable grip on the assessment process in Moldova’s elderly care. Findings emanate from formal documents, interviews with social assistants, care workers and their managers, as well as a sociology scholar, and, most importantly, several care-takers.

A brief summary:
When a person of age – a pensioner, basically – experiences difficulties in everyday life, they can turn to the local social care and ask for help. Initially, an assistance officer will evaluate their needs and gather the documentation required. This includes personal documents as well as medical certificates proving disabilities and, which makes Moldova very different from Sweden, a set of papers showing that the applicant lacks any form of close relative, who would otherwise be required by law to help their kid. That’s the portal paragraph in one of the documents photographed here.
When all due documents are in place, the assistance officer formulates a decision about providing help, and a schedule for its provision. The schedule, called a grafic, basically states at what days help will be provided, and what it will consist of. Formalities include registering data about the beneficiary in several different administrative systems, that appear to mean a lot of unnecessary job for the social secretary. The formal requirements – including a form with specific questions about living standard, disabilities, needs, and other personal data about the applicant – are stated in national law, which makes Moldova a different case from Sweden, where such a form (albeit a much more detailed one) is recommended, though not juridically enforced, by the National Social Board.

As soon as formalities are in place, a social worker will be assigned to start providing the help. After three months, an evaluation of the services is required by law, but in practice, this may take a lot longer, since the beneficiary is anyway free to make a phone call to the assistance officer at any moment, should the services not match expectations. Re-evaluations – including a visit to the beneficiary’s home – will then take place roughly once per year.

If the administrative process is not carried out according to the detailed regulation, the assistance officer will be held responsible. One of my informers has had their salary reduced twice because of formal mistakes. Considering the overwhelming amount of formal requirements involved in the assessment process, one may wonder if there is anyone who can actually perform this job to perfection.

From the beneficiaries’ point of view, the system seems to provide a set of security measures, aimed at preventing ignorance, poor quality care, or mistreatment. Apart from directing themselves to the care staff – which typically is one care giver specifically for one beneficiary – or to the assistance officer, a receiver of elderly care in Moldova may also address the local administration manager, or turn directly to the National Inspection of Social Care. Considering that a substantial part of the collective of beneficiaries may suffer from dementia – a majority, according to some informants – there seems to be quite a requirement for frequent check-ups. At the same time, informers are stating that the experts from the National Inspection tend to ask beneficiaries about data that they may have a hard time remembering, like on what day a certain service was provided. “They usually don’t even know what day it is”, said one care worker.

First impressions of Moldovan elderly care

During the second week of MFS I’ve had the great privilege of meeting the managers of elderly care in the central district of Moldovas capital, Chisinau. In a brief summary of what we’ve talked about, one may conclude a couple of crucial matters. Here are some of the highlights:
1 Moldovan elderly care mainly covers the need of people who don’t have a family, or whose families are unable of caring for them when they reach their old age. By law, family is obliged to care for their kin, and the assessment authority – the Directia Generala Asistenta Sociala si Sanatate, the administration for social assistance and health care – will duly investigate an applicant’s possibility to obtain help from their children or spouse. Hence, in this district, numbering about 100 000 inhabitants, a mere 300 are beneficiaries from elderly care, meaning 0,3% of the population receive elderly care. In Sweden, this figure is about ten times higher.
2 Once the assessment process has considered the applicant’s right to receive social help, a formal decision stating the amount of help admitted is issued. This amount may range from one to several hours a couple of days per week, and the help is delivered by a social worker which, as a general rule, will be the same person from day to day. In other words, a beneficiary of Moldovan elderly care will normally have to get aquainted with just one single person from the care provider. A Swedish home care receiver sees on average 15 different people per week.
3 The contents of the home care is decided upon by the care receiver and their social worker for each day. In this aspect, Moldovan elderly care differs widely from the Swedish one, where care provision is formulated in a set of interventions, scheduled in a detailed plan for each home care staff’s visit. Flexibility is minimal in Swedish home care, and appears to be rather wide in Moldova.
4 Public elderly care in Moldova takes place in the beneficiarie’s home. There are no publicly funded asylums, residential care homes or other units of that kind. Only those who can pay for residential care may recieve it. Regardless of how ill the care receiver is, help will only be provided in their home. In Sweden, approximately one out of five care receiver lives in a residential care home, and those that do, have been found to have explicitly severe disabilities or health conditions, motivating their move into a residential care unit.

During the upcoming week, my hope is to meet some of the social workers who provide care, and carry out at least one formal interview.

First week in Moldova

Dr Tatiana Gribincea and Glenn Möllergren

On Monday, October 5, I met my Moldovan mentor, Dr Tatiana Gribincea. Dr Gribincea is the leader of the department for social work at her university, the Free International University of Moldova. At our first meeting Dr Gribincea was running an online lecture for a class of students in social assistance, and I was kindly offered to share my research topic with them. The topic of the lecture was social work among old people, which is also my focus. Already on the next day, October 6, Dr Gribincea invited me to meet with social assistants, social workers and beneficiaries of elderly care in a village in the northern part of Moldova, Ochiul Alb. The experience from the visit to Ochiul Alb will be refered in an upcoming post.

MFS research project: Needs assessment in Moldovan elderly care

What happens when an old person in need of social care gets in touch with society’s institutions? What is the nature of the assessment interview, where the old person expresses their needs, and the assistance officer carries out an inquiry and decides upon provision of help?

These are the questions that originated a trip to Moldova in the autumn of 2021. As the research unfolds, this blog will report on some of the impressions. This, the first chapter, will provide a summary of the background and the setting of the scene for the eight following weeks.

1 The study
This research originated in a bachelor’s thesis in 2019 (Möllergren: Ålderism i riktlinjer för äldreomsorgen, link below) where care provision in Swedish elderly care was explored through an analysis of guideline documents from the municipal level. The main finding was that care provision is influenced by ageist prejudice about old peope. It is therefore much easier to receive help covering basic needs, like food, hygiene, security and home service, than to obtain support for “non-old-related” problems connected to psychical suffering, substance abuse, violence, and sexuality. The municipal guidelines explicitly state things like “going for a walk” as examples of what old persons are expected to need society’s help with. The crucial point is the assessment interview, where the assistance officer talks the applicant into accepting a certain set of care interventions, rather than openly listening to every expression of need that the old person might communicate. A “reversed assessment” evolves, where the care provision aligned with municipal guidelines replaces the actual needs, and the applicant is convinced to apply only for the type of care that the guidlines actually state.

But is this a purely Swedish phenomena? How would the assessment interview function in a less-ageist, less-guideline-oriented society? These reflections led to the establishment of a research plan for a master’s thesis in social work. As the MFS scholarship listed Moldova among eligible countries, this country became the location of choice. While Sweden has a decades-old tradition of manual-based assessment processes, this is a novelty in Moldova. And while the general Swedish perception of “old age” is among the most negative in the world, Moldovan culture is more appreciative.
The application for an MFS scholarship was handed in. A positive decision was concluded in the spring of 2021, but the Ministry of Foreign Affairs didn’t put Moldova off the corona restricted list until July 2021, meaning the research could take place only in the autumn of 2021.

2 The preparation
Initial discussions involving the mentor Linda Lill at MaU and the local Moldavian supervisor professor Tatiana Gribincea at the The Free International University of Moldova, ULIM, started out in the autumn of 2020. It was therefore possible to fast-forward the pracitalities once the scholarship was granted. In order to maximize flexibility during the research, I chose to use a car to get to Moldova. Departure date was September 29 from Malmö and the trip went through Poland and Ukraine entering Moldova in the north-west. The 1750 kilometers took four days to complete and today, October 3, I arrived in the capital of Moldova – Chisinau.

Chisinau is a city of 700 000 people, counting a number of universities as well as an array of economical, educational and political institutions. Official language is Moldovan, which is practically identical to Romanian, but broad layers of the population – especially in Chisinau – speak Russian. The territory currently known as the Republic of Moldova was under Russian and Soviet rule for the lion part of the last two centuries, and in Soviet time, russians were encouraged to relocate to Moldova. The country also has a significant Ukrainian minority as well as Roma and a number of smaller nationalities. Up until the Holocaust, it was also home to a large Jewish population, most of which was murdered by Romanian and German fascists.
After independence following the demise of the Soviet Union in 1991, Moldova has encountered a dramatic decline in living standards, resulting in migration to both Western Europe and Russia. Combined with a drastic decline in nativity, Moldova is, after 30 years of independence, a country that, to some estimates, has lost half its population while the remaining half is considerably older, compared to 1991. In other words, the present-day Moldovan state struggles with finding a way to support its increasingly larger old-age-population, with less working people around to contribute. The situation is challenging. As if this was not enough, a significant part of the contry’s territory is a de-facto independant state over which the central gouvernment exercises no control – Transnistria. It is a frozen conflict, where the Transnistrian leadership in its capital Tiraspol enjoys Russian support, meaning that Moldova is unable to win a military show-off. Lacking control over parts of its territory effectively blocks Moldova from entering the EU. In 2020/21 the Moldovan electorate, however, vote for a pro-EU, liberal leadership, throwing out the former communist gouvernment.

Since Moldova has primarily been ruled by pro-communists since 1991, it has defied the introduction of neo-liberal mechanisms that characterizes most Western states. At the same time, funding of welfare services is painfully insufficient. It therefore offers an interesting research environment for studies in social work, and the logic along which welfare services are provided – which brings us to the present moment, where this research is about to begin.

I’m looking forward to sharing findings along the way. I also welcome feedback and questions.

Glenn Möllergren, master student of social work at MaU