Interesting country example: SERBIAThe continuum of care through the health sector to reduce disabilities and vulnerabilities – from the maternity to home visiting at the household level

Dushanbe, August 1, 2013

Svetlana Mladenovic JankovicInstitute of Public Health of Belgrade, Serbia

Mother/Child health care system in Serbia

• Integrated model of publicly owned facilities• 3 levels of health care• MoH, Local Self-Government• Financing: Health Insurance Fund• Access to services

– Strengthening the role of paediatricians and gynaecologists in PHC: “dom zdravlja” (DZ)

– Moving from curative towards a preventive approach

– Developing and strengthenning home visiting services

Health status of women/children in Serbia

Indicator 2005 2010 MDG 2015

General population

Roma population in settlements

General population

Roma population in settlements

General population

Roma population in settlements

Infant mortality rate

8.0 25.0 6.7 14.0 4.5 12.0

Under 5 mortality rate

9.3 28.0 7.1 15.0 5.0 14.0

Exclusive breastfeeding under 6 months

14.9 18.0 13.7 9.1 30.0

Antenatal care, at least once

99.3 88.9 99.0 94.5 /

Skilled attendant at delivery

99.2 92.9 99.7 99.5 99.9

Early child development index

/ / 94.3 88.3 /

MICS 2005, 2010, UNICEFWorld Bank Report, 2012National MDG Report, Government of the Republic of Serbia, 2006

Enabling policies

• Comprehensive multisectoral policy towards children as an important component of Serbia’s development policy

• Instruments to mobilize all social partners to create conditions that are as favorable as possible for children’s development and social integration

• Instruments to identify and reach children from the most vulnerable populations, such as children with developmental difficulties and children from socially and culturally excluded populations

• Mechanisms to monitor the state of child rights and child welfare during this period of economic, social and political transition in Serbia

National program on health care of women, children and youth

• Goals• Objectives• Principles:

– Continuity– Equity– Accessibility– Human rights protection– Caring for vulnerable

groups – Participatory approach– Inter-sectoral cooperation – Quality of health care

services

• Implementation policies and guidelines– Activities– Content– Technologies– Team members– Data management

Hospital – maternity, neonatology

Counseling unit for

parenting

ECD Counseling

unit

Service for women health care

Service for child

health care

Patronage nurse service

Community services

Primary Health Care

Continuum care: Organizational structureInstitute of

Public Health “Halo Beba”

Phone Counseling

Institutes for

diagnostic and

treatment

Antenatal health care in primary level (1)

• Guidelines for PHC professionals– Standards and procedures – Health status control – Risk assessment– Criteria for referrals

• Team: Gynecologist, midwife, patronage nurse– Clinical and ultrasound checkups– Laboratory examinations– Health education

Antenatal health care in primary level (2)• Counseling unit for parenting:

– Group health education – Gynecologist, midwife, pediatrician, dentist, patronage

nurse, nutritionist– 7th – 9th months of pregnancy

• Preparation exercises for delivery

• Home visiting– Patronage nurse– Health education, risk assessment, reporting to

gynecologist

Perinatal care

• Guidelines for professionals:– Physiological delivery– General principles of care and treatment in

maternity wards• Team: Gynecologist, neonatologist, midwife• Baby-friendly (BF) and BF+ programs not fully

implemented

Health care of newborn – maternity hospital

• Guidelines for newborn care– Clinical care– Screening for metabolic disorders– Screening for visual or hearing disorders

• Discharge criteria/Early diagnosis/ Criteria for referral

Guidelines for communication with parents of newborns at risk (1)

• Training of professionals in maternity hospitals• Social model of counseling – partnership approach

with long-term impact on:– decision-making with regards to the needs of the child– the quality of cooperation between the parents and the

professionals– reduced risk of mother-child separation and institutional

placement– influencing the positive experience of raising one’s child

(relationship, nurturing, discipline practices)– expectations from the child.

• Objectives: – provide adequate information to parents– provide support– link family with available services in their community

• Team for counseling: pediatrician/neonatologist, head nurse, gynecologist, psychologist, social care associate, psychiatrist

• Phases: first counseling and support in maternity ward followed by counseling before discharge

• Notification of PHC services

Guideline for communication with parents of infants at risk (2)

Health care of newborn – PHC– All children:

- Polyvalent patronage nursing services- Child health care services

– Children with developmental risks:- ECD Counseling unit

Patronage nursing services• College-educated nurses• Preventive home visits• Health education in PHC or

community• Universal/enhanced

approach• Promotive care, prevention,

early intervention

• Since 2008: Roma health mediators

Target groups and number of visits

•pregnant women

1 or more )*

•women after delivery

5 or more )*

•newborns 5 or more )*

•infants 2 or more )*

•children in 2nd, 4th year

1or more )*

•the elderly 1or more )*

)* RISK OBSERVED

Home visiting objectives

• Promote family health• Assess family health, its functionality , the family’s living conditions,

and identify health and wellbeing-related risks of its members• Identify vulnerable populations and assess risk for neglect and abuse• Promote health of the children and stimulate early child

development• Promote responsible parenthood and positive relations between

parents and children• Connect the family with social and welfare services and other

services, according to family needs

• Family Data Set – Risk assessment (health, social, environmental)– Checklist of risks– Interview, observation, medical record data, health status control

• Method – Flexibility– Family needs– Family participation

• Activities– Health education– Health status monitoring– Skills training– Link family and local community services

(MoH, IPH Bgd,UNICEF, CPHA)

Guidelines for Home Visiting

Home visiting of high-risk families• Family monitoring• Evaluation of strengths • Priorities:

– Health control Early diagnosis of developmental difficulties and surveillance

– Skills training Early stimulation to promote development– Linking family with services in local community

PHC: pediatrician Social welfare serviceECD counseling unit Kindergarten

NGOsSOCIAL INCLUSIONSOCIAL INCLUSION

• Project ‘Family as a center of child development’ (UNICEF, IPH Belgrade)– Patronage nurses, social welfare, local government, NGOs– Trainings, round tables, manual

Phone Counseling for a Healthy Baby ‘Halo Beba’

• Aims: – to improve availability of information on child health and care to parents and family

members – to improve coordination of MCH services and continuity of care

• Since 2001• 24/7 concept• 46 patronage nurses + IPH• 900,000 received calls• 170,000 calls to families• Encompassed 170,000 mothers after delivery• 15,000 calls to pregnant women• 200,000 visits to www.halobeba.rs • 2,000 answers by email• Outcomes:

– visits to outpatient paediatric clinics and dom zdravlja have decreased by 10%– coverage of newborns and mothers with home visits has increased from 62% - 97%

• ‘HALO BABY ‘ as a NATIONAL BRAND

Child Health Care Services

• Team: Pediatrician and pediatric nurse– Preventive checkups– Control checkups– Health education– Home visit

• Referral to ECD Unit– Risk factors (biological, psychological, family, social)

• Referral to secondary and tertiary health care institutions– According to records from ECD Unit

• Monitoring of child health status and provision of health services• Risk assessment • Increase parental capacities for responsive parenting

ECD Counseling unit• Organizational unit (areas with more than 8500 children 0-6) • Team members:

– Pediatrician– Nurse– Psychologist– Speech therapist– Pedagogue educator– Social worker

• Early detection of disabilities/vulnerabilities• Needs and capacities assessment• Family support• Individual plan of intervention• Early stimulation• Referral to other health services and institutions for treatment• Referral to community services for family support• Pediatrician as a member of Committee on needs assessment for

educational, health and welfare support

Achievements of Serbia’s MCH services for young children

• Improvement of mother/child health status• Strong leadership• Decentralization in PHC• Accessibility of services• Improvement of professional capacities• Early detection • Referral system• Strong home visiting program• Strengthening of family capacities• Involvement of trained lay persons• Inter-sectoral cooperation• Social inclusion

Remaining challenges– Increase the number and coverage of counseling units for parenting in

PHC, primarily for vulnerable parents – PHC ECD unit: Organizational unit Functional team– Provide additional education of pediatricians in PHC on early detection

and intervention– Develop and implement the use of screening and assessment tools for

ECD– Fully institutionalize the BF+ standards– Update legislation on data management and reporting in health care

system– Improve data flow between services (particularly from PN to other

professionals within and outside health system)– Develop a data base of children with developmental difficulties – Strengthen partnership for health (local community involvement,

intersectoral coordination; civil society organizations involvement)

Thank you

• Contact: Svetlana Mladenovic JankovicEmail: jankovic.svetlana@gmail.com