Igor veljkovic Role of Patronage Nursing System INICEF by y486F4V

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									     ACCESS TO HEALTH CARE

ROLE OF PATRONAGE NURSING SYSTEM

         IGOR VELJKOVIK, UNICEF
DEFINITION - “GATEKEEPER OF THE HEALTH SYSTEM“

Patronage Nursing System provides its services outside the
health institutions and reaches out to communities to
deliver both preventative and curative health care

Essential services:
• Pregnant women and women after delivery
• Newborn, infant and pre-school children

Additional services:
• Elderly persons and chronic patients
• Families under risk/with special needs (disabled)
• School children and adolescents
                                SWOT Overview
Strengths                                    Weaknesses
 Strong dedication among professionals       Requires new professional standards and
 Long history of serving communities          job description
 Recognisability of patronage services in    Financing and results to be linked and
  the community (e.g. Roma)                    measurable (performance indicators)
 Earmarked financing                         Unequal coverage (understaffing) &
 Good network of health facilities            workload (performance) in municipalities

Opportunities                                Threats

 Willingness of the government and           No formalized interaction between
  partners to invest in patronage services     patronage nurses and other health
 Possibility of collaboration with other      professionals at primary health care
  community social services (Roma             Changes in health policy (financing)
  health mediators)
                                Services delivered
  • Most are bivalent patronage services, and only some
    deliver polyvalent services or curative services

Type and name of service                                                    % Health
                                                                            Centers
Essential preventive services

    Pregnant women and women after delivery                                            100%
    Newborn, infant and pre-school children (toddlers)                                 100%
Additional preventive services

    Women in reproductive period                                                       67%
    Elderly persons                                                                    61%
    School children and adolescents                                                    58%
    Families (or patients) under risk/with special needs (disabled)                    27%
Curative services

    Chronic and TB patients, diabetics, post-hospital care, IV/IM therapy          6-21%
             Coverage and utilization (national)

• There is imbalanced/inequitable service coverage and
  utilization across country (by Health Centers)

3000


         All visits per annum per PN   National average
2500



2000



1500



1000



 500



   0
                   Coverage and utilization (Roma)
• More balanced across municipalities with Roma community:
  optimization required and potential of joint work between
  patronage nurses and Roma health mediators (1)
3000



2500
        All visits per annum per PN   National average



2000



1500



1000



500



   0
 Coverage and utilization – essential services (national)
• Overutilization of postnatal services at the expense of antenatal
  services
• Underperformance of antenatal services due to no formalized
  interaction between patronage nurses and primary healthcare
  physicians (gynecologists)

14.0
             Visit per pregnant
12.0         Visit per newborn
             Standard number of visits (for both categories)
10.0


 8.0


 6.0


 4.0


 2.0


 0.0
       Coverage and utilization – essential services (Roma)

 • Underperformance of antenatal services in some
   municipalities – potential of joint work between
   patronage nurses and Roma health mediators (2)
14.0
              Visit per pregnant
12.0          Visit per newborn

              Standard number of visits (for both categories)
10.0


 8.0


 6.0


 4.0


 2.0


 0.0
      Supply and demand of Romani speaking community nurses
                 (self-reported language knowledge)

      • Demand to alleviate language barrier - potential of joint work
        between patronage nurses and Roma health mediators (3)
 3

                Availability of Romani speaking nurses   Needed nurses per Roma population
2.5


 2


1.5


 1


0.5


 0




*Skopje is excluded as it is reviewed as separate case with different complexity
**The demand is calculated based on % Roma in coverage areas of each Health Center
(population above 500)
     Satisfaction of services
• Focus Group Discussions with Roma community
    Focus group discussions (FGDs) with
 pregnant women and mothers of newborn
• Overall FGDs findings:           Focus group      Structure of
- PN are very well known and       discussions      participants
  accepted in the community
                                   Bitola           Mixed

BUT:                               Prilep           Mixed
- Very inhomogeneous picture       Skopje –         Roma only
  on national level, as well as    Shuto Orizari
  among Roma community, with       Skopje –         Roma only
  different experiences, quality   Novoselski pat
  of services, range and
  frequency of services            Shtip            Mixed
  FGDs findings – Roma communities (1)

• Patronage Nurses (PN) are very well known
  and accepted in the community
  – “…for my first child the patronage nurse came
    stayed long time, explained to me everything
    well…” (FG in Bitola, October 2011)
  – “…our patronage nurse knows all of us, and comes
    to every newborn in time, as she knows all families
    and all pregnant women…we feel as she is part of
    the family…” (FG in Skopje – Novoselski pat,
    October 2011)
  FGDs findings – Roma communities (2)
• Very inhomogeneous picture with experiences,
  dependent on attitude towards health services (Roma)
  and on the experience and attitude towards Roma (PN)
  - “…the nurse that came had a long list of women she had to
    visit…she could not stay too long, she is busy with visiting
    others….” (FG in Prilep, October 2011)
  - “…if it was not for the nurse, I almost lost my baby, it had
    fever for many days, I didn’t know what to do…” (FG
    Skopje-Novoselski pat, October 2011)
  - “…no nurse has ever visited me, I didn’t know there is such
    thing…I go to a doctor if I have any problem with my
    baby…” (FG Skopje – Shuto Orizari, October 2011)
   FGDs findings – Roma communities (3)
• Infrastructure and equipment affect quality of and
  access to services
   – “…there are no roads here, and nurses don’t know street
     numbers, and they cannot find us…” (FG Skopje – Shuto
     Orizari, October 2011)
   – “…the nurse visited me and told me the baby needed the
     [umbilical] cord cleaned, but she did not have any
     medicines, so my husband ran to the pharmacy to buy
     what was needed…” (FG Shtip, October 2011)
   – “…the nurse visited me and my baby many times, even if
     she is in the neighborhood for another baby, she stops to
     say ‘hello’…” (FG Skopje – Novoselski pat, October 2011)
FGDs with primary healthcare physicians

• General finding:
   – Patronage nurses are essential link of the community with
     the healthcare system:
       “…some of my patients live in very poor conditions and
   they have repetitive illnesses that I cannot find out causes
   to…if the patronage nurse visits them, she can determine the
   social and environmental causes in the home, such as mold,
   poor ventilation, no sanitation, etc…” (pediatrician, FG in
   Strumica, October 2011)
       “…families gladly accept the visit of the patronage nurse,
   but sometimes they are scared if doctor wants to visit, due to
   the white coat phenomena…” (pediatrician, FG Tetovo,
   October 2011)
- Health promotion & protection    - Identification of families at
                                   medical-social risk
- Refer to physician & guide for
regular check-ups                  - Alleviates language & cultural
                                   barriers
- Monitor treatment
recommended by the physician       - Assists in health promotion




- Facilitate   access to health    - Identify & assess family social
insurance                          risk & needs

- Facilitate access to labor       - Facilitate access to social
market                             assistance & education system

- Prevent and management of        - Keep register of families at
domestic violence                  medical-social risk
 Points for Discussion:


• How to ensure good cooperation and referral among
  community services - social; health; Roma health mediators

• How to ensure services are tailored to community needs
  more adult care and/or mother and child health care

• Reasons for lack of access – demand side (community) and
  supply side (health system)

• Sources of sustainable financing – central and/or local
  government

								
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