The continuum of care through the health sector to reduce disabilities and vulnerabilities – from the maternity to home visiting at the household level. From 4th Child Protection Forum in Tajikistan, 2013.

1. Interesting country example: SERBIA
The 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 Jankovic
Institute of Public Health of Belgrade, Serbia

2. 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

3. 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, UNICEF
World Bank Report, 2012
National MDG Report, Government of the Republic of Serbia, 2006

4. 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

5. 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

6. 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 structure
Institute of
Public Health
“Halo Beba”
Phone
Counseling
Institutes
for
diagnostic
and
treatment

7. 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

8. 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

9. 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

10. 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

11. 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.

12. • 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)

13. Health care of newborn – PHC
– All children:
- Polyvalent patronage nursing services
- Child health care services
– Children with developmental risks:
- ECD Counseling unit

14. 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

15. 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

16. • 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

17. 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 service
ECD counseling unit Kindergarten
NGOs
SOCIAL INCLUSIONSOCIAL INCLUSION
• Project ‘Family as a center of child development’
(UNICEF, IPH Belgrade)
– Patronage nurses, social welfare, local government, NGOs
– Trainings, round tables, manual

18. 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.rswww.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

19. 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

20. 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

21. 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

22. 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)

23. Thank you
• Contact:
Svetlana Mladenovic Jankovic
Email: jankovic.svetlana@gmail.com