assessment of the community nurse system in macedonia web viewif the existing mode of functioning of...

Community nursing assessment

with equity analysis in Macedonia

Final Report

Skopje, 2011

Community nursing assessment with equity analysis in Macedonia | Final Report

Table of contents

Executive Summary................................................................................................i1 Introduction......................................................................................................1

1.1 Background............................................................................................................11.2 Report design.........................................................................................................2

2 Assessment Methodology..................................................................................42.1 Quantitative data collection and analysis...............................................................4

2.1.1 Survey of Health care managers with Self-administered questionnaire (SA/HCM)......................................................................................................4

2.1.2 Survey of Patronage nurses with Self-administered questionnaire (SA/PN) 52.2 Qualitative data collection and analysis.................................................................5

2.2.1 Semi-structured interviews (SSI)..................................................................52.2.2 Focus group discussions (FG).......................................................................6

2.3 Facility assessment of 10 Health centers...............................................................82.4 Data analysis and triangulation..............................................................................9

2.4.1 Equity analysis..............................................................................................92.4.2 Challenges and Limitations of methodology and data................................102.4.3 Terminological explanations.......................................................................11

3 Main Findings.................................................................................................123.1 Human Resource development.............................................................................12

3.1.1 Human resource profile..............................................................................123.1.2 Professional growth needs..........................................................................153.1.3 Professional growth opportunities..............................................................18

3.2 Service coverage and utilization..........................................................................193.2.1 Supply side (existing coverage and utilization)..........................................193.2.2 Needs in community nurse services...........................................................22

3.3 Service quality preconditions/opportunities.........................................................253.3.1 Training opportunities................................................................................253.3.2 Technical means.........................................................................................273.3.3 Quality assurance.......................................................................................32

3.4 Service costs and resource requirements............................................................333.4.1 Current flow of funds and costs..................................................................333.4.2 Estimation of future resource requirements...............................................38

3.5 Feasibility of collaboration with other community services.................................394 Discussion.......................................................................................................44

4.1 Human resource profile........................................................................................444.2 Service coverage and utilization..........................................................................484.3 Service quality preconditions and opportunities..................................................504.4 Service costs and resource requirements............................................................524.5 Feasibility of collaboration with other community services.................................53

5 Conclusions and recommendations................................................................566 Annexes...........................................................................................................60

Annex A: Research questions by assessment domains and research subjects...........61Annex B: List of ZD with codes and respondents.......................................................63


Annex C: Response rate of PN to SA per Health center.............................................64Annex D: List of interviewees to semi-structured interviews by type of research......65Annex E: Functions and minimum required skill set..................................................67Annex F: Descriptions of in-service training courses of PN.......................................68Annex G: Projection of the needs for in-service training............................................69Annex H: Basic characteristics of a package of patronage services...........................70Annex I: Assessing the feasibility of including PN services demanded by

communities into the competence area of PN and matching it with practices reported by HCM.................................................................................................73

Annex J: Workload and resource requirement projections (modeling)......................74Annex K: Descriptive statistics charts and tables.......................................................79Annex L: Research instruments by research subjects, research methods and sample

type 99Annex M:Health care service utilization pathways (illustrative case)......................100Annex B: SA/HCM questionnaire..............................................................................103Annex C: SA/PN questionnaire.................................................................................111Annex D: SSI/HCM guide..........................................................................................117Annex E: SSI/AcExp guide........................................................................................119Annex F: SSI/HO guide.............................................................................................121Annex G: FG/PN guide..............................................................................................123Annex H: FG/Com guide............................................................................................125Annex I: FG/Doc guide.............................................................................................127Annex J: FA Guide (Part 1).......................................................................................129


Table of figuresFigure 1: Distribution of population per PN by Development Regions and Population

Residence......................................................................................................12Figure 2: Age scatter chart of patronage nurses (n=338)............................................12Figure 3: Age distribution of nurses by health centers (n=338)...................................13Figure 4: Inflow of new PN by years (n=325)...............................................................14Figure 5: “Turnover” of PN by the years of getting employed in the current ZD

(n=325)..........................................................................................................14Figure 6: Turnover of PN from 2006 to 2011 (as reported by ZD)................................15Figure 7: Number of nurses by level of highest education as per Health Center records

.......................................................................................................................15Figure 8: Professional training undertaken as self-reported by community nurses

(n=325)..........................................................................................................16Figure 9: Sources of funding for professional trainings (based on the information from

the last received training).............................................................................16Figure 10: Demanded (by communities) preventive services for which respondents

reported to have not attended training.........................................................17Figure 11: Demanded (by communities) curative services for which respondents

reported to have not attended training.........................................................17Figure 12: Trainings for which information was received but respondents cannot attend

for various reasons........................................................................................18Figure 13: Preventive and curative services provided by the community nursing system

(as reported by the Health Center, n=33).....................................................19Figure 14: Performance of ZD by the number of visits per PN in average (in 2010) as

reported PN...................................................................................................20Figure 15: Comparison of annual workload between PN and Domashna Poseta Nurse by

ZD (n=19) as reported by HCM.....................................................................21Figure 16: Comparison of daily workload of PN by ZD between reported by HCM and

PN..................................................................................................................21Figure 17: Services required by the community for which community nurses are not

authorized to provide (n=148).......................................................................22Figure 18: Higher (university and college) medical education for medical nurses in

Macedonia.....................................................................................................25Figure 19: Dedicated space per patronage nurse (as per reported dedicated space by

healthcare managers)....................................................................................27Figure 20: Use of transportation by type, as reported by patronage nurses in self-

administered questionnaire (n=287).............................................................29Figure 21: Basic minimum standard equipment per community nurse and pricing.......30Figure 22: Additional equipment for community nurse service (for additional services)

.......................................................................................................................31Figure 23: Comparison Financing of PN in 2009 and 2010 by Zd (in millions MKD) as

reported by HCM...........................................................................................35Figure 24: Comparison of the revenues for community nursing services to total

revenues by Health Center (2010 figures in MKD)........................................36Figure 25: Financing of the MoH Preventive Programs (PN component) by Years (in

MKD).............................................................................................................37Figure 26: Comparison of PN monthly salaries by development regions (in MKD, n=338)

.......................................................................................................................37Figure 27: Comparison of PN monthly salaries in 2010 by ZD (n=338).........................38Figure 28: Preventive goals of the primary healthcare (January-March 2010) (adapted

from Preventive Goals in PHC, HIF, 2010)....................................................39


Figure 29: Progress of privatization in PHC, per number of PHC providers signing contracts with HIF (2004-2008)....................................................................40

Figure 30: Description of ZD’s composition and its functional arrangements................42Figure 31: Requirements in PN by ZD............................................................................44Figure 32: Analysis of the flow of PN by work experience and ways of employment at ZD

(n=325)..........................................................................................................45Figure 33: Relationship between professional standards, in service training and

institutionalized Licensing & CME processes...............................................46Figure 34: Comparison between the population to PN ratio (coverage) and the workload

of PN per annum............................................................................................48Figure 35: Comparison of population to PN ratio and average visits per PN per year by

ZD (n=32, Year 2010 figures)........................................................................48Figure 36: Need (<0) in PN services by types (antanatal or postnatal) by ZD...............49Figure 37: Preconditions for PPS operations and quality assurance..............................51Figure 38: Description of Training costs by staffing levels approaches and types of

trainings........................................................................................................74Figure 39: Projection of investment costs.......................................................................75Figure 40: Projections of recurrent costs........................................................................76Figure 41: Workload projections.....................................................................................77Figure 42: Ranking of ZD by infant mortality rates (IMR 2009).....................................79Figure 43: Distribution of PN Ages (histogram)..............................................................80Figure 44: Population per PN and area per population distribution by ZD....................80Figure 45: Crosstab – Description of PN ways of employment (“origin”) and work

experience (n=325).......................................................................................81Figure 46: Age structure of PN by ZD.............................................................................81Figure 47: Staffing structure of ZD (n=33).....................................................................82Figure 48: Comparison of service performance between PN and Domashna Poseta (DP) -

2010...............................................................................................................83Figure 49: Needs for antenatal and postnanatal PN services.........................................83Figure 50: Inventory of vehicles in each health center (as reported in the self-

administered questionnaire for healthcare managers)..................................84Figure 51: Comparison of availability of asset (as reported by health centers) with

reported use (by community nurses).............................................................85Figure 52: Description of PN Monthly salaries by ZD as reported by HCM (in MKD)....86Figure 53: Comparison of the share of non-labor costs in total PN services costs:

estimated vs. reported by HCM (in MKD for 2010).......................................87Figure 54: Projection of financing of PN services by ZD.................................................88Figure 55: Composition of the basic benefit package financed by HIF in 2010..............89Figure 56: Description of ZD and administrative statistics.............................................90Figure 57: PN service delivery performance by ZD (as reported by HCM)....................91Figure 58: Performance indicators by ZD as reported by HCM and PN (2010)..............93Figure 59: Summary of findings of the facility assessment.............................................94Figure 60: Description of PN component of the MoH preventive health prgorams (2009-

2011)..............................................................................................................95Figure 61: ZD revenues and expenditurs (in thousands MKD) relatted to PN as reported

by HCM..........................................................................................................97


AcronymsCI Confidence Interval (95% if not indicated

otherwise)CME Continuous medical educationCN Community nurseCNS Community nursing systemCOM CommunityDP Domashna Poseta (Home visit/care teams)EC European CommissionFA Facility assessmentFG Focus group discussionGP General practice (practitioner)HCM Health care managers (directors of Health

Centers)HO Health officialsIEI International expert institutionIV/PE Intravenous/parenteral (administration)MANM Macedonian Nurses and Midwives

AssociationMCH Mother and child healthMKD Macedonian DinarMoH Ministry of HealthMS MicrosoftNEI National Expert InstitutionNGO Non-governmental (civil society)

organizationOHS Occupational health specialistsPA Preventive activitiesPHC Primary health carePLD Positive list of drugsPN Patronage nursePPS Polyvalent patronage serviceSA Self-administered [questionnaire]SAA The State Audit AgencySSI Semi-structures interviewsSTI Sexually transmitted infectionUNICEF

United Nations Children’s Fund

VAT Value added taxWHO World Health OrganizationZD Zdravstven Dom (Health Center)


AcknowledgmentsThe assessment of community nursing in Macedonia was conducted in

joint efforts of Curatio Consulting International Ltd, as International

Expert Institution and Centre for Regional Policy Research and

Cooperation “Studiorum” and Macedonian Association of Nurses and

Midwives (MANM) as National Expert Institutions. The research team

consisted of David Gzirishvili, Neda Milevska-Kostova, Velka Lukik,

Marina Pop-Lazarova, Marija Gulija, Kornelija Cipusheva and Vladimir

Nikov.

We would like to express our gratitude to the officials at the Ministry of

Health and the Health Insurance Fund for their support during the

process of data collection and preparation of this study, for technical and

policy-oriented input into the quality of the final version. This study would

also not have been possible without the cooperation from the staff of ZD,

especially the 33 directors and the 338 patronage nurses that provided

valuable information about the PPS. We also thank the local NGOs that

have helped organize discussions that informed the study about the voice

of the common citizens with respect to patronage nurses and community

services in general.

We also extend our gratitude to the other officials and professionals that

contributed with their experience, expertise and opinions, as well as to

the citizens that participated in the study and amply shared their

experiences and needs.


Executive SummaryBackground

Thi Community Nursing Assessment in Macedonia has been conducted with financial support from UNICEF, through the two-year cooperation agreement between UNICEF and the Ministry of Health of the Republic of Macedonia. The Ministry of Health intends to develop a plan for the strengthening of community nursing system in terms of service quality and coverage based on the assessment results.

The assessment was conducted in joint efforts of Curatio Consulting International Ltd, as International Expert Institution and Centre for Regional Policy Research and Cooperation “Studiorum” and Macedonian Association of Nurses and Midwives (MANM) as National Expert Institution.

The assessment was conducted in May-November 2011 and included a field research to collect qualitative and qualitative information in July-October and a series of consultations with key in-country stakeholders.

Main findingsThe assessment of community nursing in Macedonia was conducted with the intention to better understand how polyvalent patronage services have been functioning in a volatile environment and how to make it better – more efficient, sustainable and equitable respecting traditions of community services, building upon the best practices in the region and at the same time responding to challenges posed by the transition to public-private arrangements in health care in the country.

The main findings of the assessment in each area are as follows:

Human resource profile

o Aging PN, with no indication of the adequate supply of new generation PN in the labor market

o Very low mobility of PN on the labor market

o Significant disparities in the distribution of PN and staffing structure of ZD across ZD

o PN field seems to be a last resort for nurses for securing employment (in response to structural reforms in health care)

o Absence of formally recognized professional standards makes it difficult to assess needs in professional growth and relevance of the previous efforts

o Professional growth cannot be just a matter of planning and conducting trainings but should be an integral part of an institutionalized licensing and CME framework

Service coverage and utilization

o Volume and structure of PN services adjusted to population needs is extremely diverse across ZD

o Newborn related services are over utilized at the expense of pregnant in the majority of ZD

o Main barrier for balanced provision of antenatal and perinatal care is related to the lack of forma reliable communication channels between medical service providers

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Community nursing assessment with equity analysis in Macedonia | Final ReportExecutive Summary

Service quality preconditions and opportunities

o Understanding of quality of service provision as a concept is vague, is not perceived as a performance dimension and there is no practice either to assess or ensure quality of community nurse services

o Preconditions are not sufficiently met to ensure a minimum quality standards at the present

Service costs and resource requirements

o Financial and managerial accounting practices are weak

o Financing of PN does not provides incentives for higher performance and/or efficiency

o Increased financing of PN services creates a room to better recover non-labor related costs (including maintenance of assets and capital costs)

Feasibility of collaboration with other community services

o In terms of current workload there is a room to either expand patronage nursing services or establish functional collaboration with other community services

o Collaboration with other community services to be efficient and sustainable it requires PPS first to become streamlined

ConclusionIf the existing mode of functioning of PPS should be described in one word then “inertia” is the most appropriate definition. Although its importance together with other public preventive services is recognized at a high policy level, the recognition remains declarative unless PPS becomes structured and focused on the delivery of tangible benefits.

If PPS does not become structured and streamlined organizationally and functionally it is not feasible to either:

make an investment in PPS services (in terms of financial injections into its infrastructure or human resources), or

promote its collaboration with other community services

RecommendationsIn order to shape PPS organizationally and functionally as a prerequisite to any substantial investment and to streamline it step by step through the reform process the Ministry of Health has to apply the regulatory instruments that are fully under its auspices.

The Ministry of Health within its exclusive competence should introduce balanced regulation of patronage nurse services that includes:

1 Establishment of a regulatory framework:

1.1 Elaboration of professional standards, including:

1.1.1 Description of duties (scope of work)

1.1.2 Description of services (guidelines and/or protocols)

1.1.3 Description of qualification requirements (knowledge and skills)

Community nursing assessment with equity analysis in Macedonia | Final ReportExecutive Summary

1.2 Adoption of a regulation that sets clear rules to be followed by relevant actors

2 Enforcement of the regulation:

2.1 Elaboration of reporting and controlling mechanisms

2.2 Application of a punishment and/or rewards

2.3 Revision of professional standards (if needed)


1 Introduction

1.1 Background

The Government of the Republic of Macedonia embarked on the reform of mother and child health (MCH) services in the country.

The Ministry of Health (MoH) with technical support from UNICEF developed a proposal to support the implementation of a strategy for the improvement of MCH services. The project proposal was based on the evidence generated through a set of assessments conducted with UNICEF support:

Assessment of the National Immunization System

Assessment of the Quality of Perinatal Health Service and

Assessment of the Community Nursing System

The Government of the Kingdom of the Netherlands agreed to finance the MCH project allocating 6.3 million euro in addition to 11.3 million euro committed by the Government of Macedonia supporting efforts in the following areas:

3 Outreach services,

4 Improvement of infrastructure,

5 Replacement of outdated equipment and

6 Continuous professional development of health staff working in mother and child health services.

The country strategy (“Improving Maternal and Infant Health, Macedonian Safe Motherhood Strategy (SMS) 2011 - 2015”) pays special attention to the importance of patronage nursing system in postnatal care and targeting marginalized groups of population. It also “promotes a multidisciplinary and integrated approach to antenatal care with the active involvement of the patronage nursing system, the general practitioners and the primary care gynecologist”.

The MoH intends first to develop a plan for the strengthening of community nursing system in terms of service quality and coverage based on a thorough assessment of the community nursing system in the development phase of the MCH project. UNICEF country office agreed to provide a technical support to the MoH to conduct the assessment.

The Terms of Reference developed by UNICEF defined five domains of the assessment:

7 Human Resource development

8 Service coverage and utilization

9 Service quality preconditions/opportunities

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Community nursing assessment with equity analysis in Macedonia | Final Report6. Annexes10 Service costs and resource requirements

11 Feasibility of collaboration with other community services

Results of the assessment in each domain all together help to draw a framework of the future community nursing system including administrative and service provision arrangements (with possible integration into or collaboration with adjacent services), quality assurance mechanisms and resources (both human and financial).

The assessment was carried out by two expert institutions selected by UNICEF through competitive processes:

international - Curatio International Consulting Ltd), and

National – consortium formed by Centre for Regional Policy Research and Cooperation “Studiorum” (leading institution) and the Macedonian Nurses and Midwives Association.

The assessment was carried in 3 phases from May to November 2011:

12 The international expert institution (IEI) elaborated together with the selected national expert institution (NEI) the assessment design, field research plan and methodology in the 1st phase

13 The field research was conducted by NEI in July – October including data collection and processing with support from NEI in the 1nd phase

14 IEI together with NEI analyzed findings of the field research, carried out consultations with key in-country stakeholders and finalized the report in the last phase (November 2011).

1.2 Report design

The report was designed in such a way that allows a reader to familiarize separately with the description of facts (research results), analysis of the main findings and final conclusions and recommendations.

Section “2 Assessment Methodology” is devoted to the brief description of approaches and techniques used for the assessment including the field research and analysis. A more detailed description of the field research methods and instruments is available in a separate document “Field Research Plan and Methodology”.

Description of the results of the qualitative and quantitative research is presented in section “3 Main Findings”. The results are grouped under research subjects for each of five assessment domains. This section, as will be shown in the Methodology part, is structured to inform the assessment domains from various methodologies chosen, and thus provide a multi-angled view on each of the issues, from the perspective of providers (healthcare facilities and individual healthcare professionals), end users of the community nursing services, as well as key policy and decision makers in both healthcare and other sectors (academia, social services, etc.)

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Community nursing assessment with equity analysis in Macedonia | Final Report6. AnnexesThe descriptive part of the report is followed by the analysis of the main findings (section “4 Discussion”) the most important facts are picked up from the descriptive section and discussed for each research subject (i.e. “assessment domain”).

The final section (“5 Conclusions and recommendations”) reflects attempts of the assessment team to formulate conclusions and practical recommendations that can shape the interventions during the implementation of the country strategy for the improvement of MCH services in Macedonia, namely the plan for the strengthening of community nursing system in terms of service in terms of service quality and coverage.

Additional information that deemed helpful to get a better understanding of some technical aspects of the assessment is provided in annexes (section “6 Annexes”).

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2 Assessment Methodology

A mixed methods approach was used for informing different parts of the assessment. The quantitative methods were used to inform the first part of the assessment (system structure and performance, infrastructure and human resources inventory, and levels of services). The qualitative methods were used to further explore, understand and inform about the underlying causes of the quantitatively measured indicators, to identify needs and problems, as well as to find out the potentials for improvement and cooperation of the community nursing system with other sectors and services in a comprehensive and effective manner.

Considering diversity of the methods and thematic areas (research objects) a modular approach was used to design the research instruments. The matrix of research instruments by research subjects, research methods and sample type (see Annex L below) illustrates how different areas of the assessment were informed by corresponding modules of the tools. Each module is described in details below.

2.1 Quantitative data collection and analysis

2.1.1 Survey of Health care managers with Self-administered questionnaire (SA/HCM)

SampleThe sample of the survey of healthcare managers with self-administered questionnaire consists of managers of all 33 Health centers (ZD). The list of all health centers with names of directors is given further in the report (see Annex B below).

Administration of questionnaireThe self-administered questionnaire, accompanied with an explanatory letter of aims of the assessment and the purpose of the questionnaire, was sent via e-mail to the directors who were asked to fill it in, using the available resources and staff in their health center (economist, accountant, chief patronage nurse, etc.).

The response rate of this questionnaire is 100%. The data was collected via fax and regular mail within the deadline given, i.e. July 20, 2011.

However, as there were some questions that were not completed by the healthcare managers, the field surveyors have contacted each healthcare manager to obtain the missing data, by giving additional explanations to the question. The missing data rate is less than 1% of all questions in all self-assessment questionnaires collected. Due to the period of summer holidays, some of the directors could not be reached, and the still missing data (such as workload from Valandovo and Veles), is collected at the time of preparation of this draft-report, and will be reflected in the final version of the report.

Data entry and quality controlAfter data collection, qualified surveyors have checked the quality of the data and collected answers to questions that were omitted in the filled-in questionnaires.

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Community nursing assessment with equity analysis in Macedonia | Final Report6. Annexes

The data was entered in the specifically designed SA HCM Data Entry tool (developed on MS Excel platform by the IEI). For avoiding data encoding errors and possible data loss given the size of the data set, each questionnaire was encoded in separate file. Thereof, a special SA HCM Data collection tool was designed (on MS Excel platform by the IEI) to gather and systematize the data from each of the questionnaire files, and for analysis of the gathered data. Both tools are designed to allow checking data for consistency and integrity during the data entry and produce reports showing some quality aspects as well as completeness of the questionnaire.

2.1.2 Survey of Patronage nurses with Self-administered questionnaire (SA/PN)

SampleThe sample of the survey of patronage nurses with self-assessment questionnaire consists of the roster of all 338 patronage nurses, as recognized by the Health Insurance Fund (who is paying the patronage service package to Health centers as per employed patronage nurse). Information on the response rate of patronage nurses by each health center is provided in the report (see Annex C below).

Administration of questionnaireThe self-administered questionnaire, accompanied with an explanatory letter of aims of the assessment and the purpose of the questionnaire, was sent via e-mail to the directors who were asked to distribute to all patronage nurses in their health center and to return a printed copy to the research team.

The response rate to this questionnaire was 96.1% (325 of 338). The data was collected via regular mail by August 30, 2011.

Qualified surveyors have checked the data for completeness and quality. Where data was missing or was not completed correctly, the surveyors were calling each patronage nurse to obtain the missing answers, by giving additional explanations to the question. The missing data rate is less than 2% of all questions in all self-assessment questionnaires collected, and most of it was obtained through via telephone calls to the respondents.

Data entry and quality controlThe data quality check was conducted in two stages. Firstly, while collecting questionnaires, the surveyors have been checking whether the questionnaire is fully filled in or there were unclear issues for the respondent requiring assistance. Second completeness and quality check was performed during the data entry process, using the commands and logical filters, available within the software used.

The data from questionnaires was entered in a specially designed SA PN Date Entry tool (on a MS Excel platform). Given the size of the sample and of the dataset in particular, data from each questionnaire was encoded in separate Excel file. Thereof, a special SA PN Data collection tool was designed (on MS Excel platform by the IEI) to gather and systematize the data from each of the questionnaire files, and for analysis of the gathered data. Both tools are designed to allow checking data for consistency and integrity during the data entry and produce reports showing some quality aspects as well as completeness of the questionnaire.

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2.2 Qualitative data collection and analysis

The qualitative data gathering and analysis took place after the completion of the quantitative data collection and analysis, i.e. between October 14 and 28, 2011.

2.2.1 Semi-structured interviews (SSI)

For the semi-structured interviews, three categories of respondents were selected: (a) managers of healthcare centers (ZD), (b) academic staff and experts in the health and related fields, and (c) officials from the state institutions that work in the field of health and fields that have cross-cutting areas with health services in the community.

(1) Health care managers (SSI/HCM)The sample for semi-structured interviews with the managers (directors) of the healthcare centers was chosen based on the selection of the healthcare centers for Facility assessment (see below). The interviews were conducted with 9 managers of healthcare centers and with one main patronage nurse that was appointed by the director to speak on behalf of him (due to his absence at the time of interview). The list of respondents from this category is given in Annex D (below) of this Report.

The duration of each interview was between 45-60 minutes, and included discussion on issues that were related to the current challenges for the community nurses and future perspectives from the point of view of the director. The interviews were summarized in writing and the summaries were used for the thematic analysis of the findings.

(2) Academia/experts (SSI/Acad)The sample for semi-structured interviews with academic staff and experts was chosen based on the previous knowledge and experience of the research team, and in consultation with the IEI and with UNICEF. The list of respondents from this category is given in Annex D (below) of this Report.

The duration of each interview was between 40-45 minutes, and included discussion on issues related to the current setup of the community nurses and future vision for reforming this service from the point of view of the academia and experts. The interviews were summarized in writing and the summaries were used for the thematic analysis of the findings.

(3) Healthcare and other officials (SSI/HO)The sample for semi-structured interviews with healthcare and other officials from the state institutions was chosen based on previous knowledge and experience of the research team, but also in line with the objectives and expected outcomes of the research. The list of respondents from this category is given in Annex D (below) of this Report.

The duration of each interview was between 40-45 minutes, and included discussion on issues related to the current setup of the community nurses, and possibilities for cooperation with other segments of the social services, as well as future vision for reforming this service from the perspective of legislation, strategic and public policy objectives. The interviews were summarized in writing and the summaries were used for the thematic analysis of the findings.

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2.2.2 Focus group discussions (FG)

Another method for qualitative data gathering that was used was conducting focus group discussions to further analyze the findings and to obtain in-depth and richer data on the reasons and consequences for the current situation, on the practices and attitudes of the community nurse system, as well as on the demand and needs of the community with regard to this service. For this purpose, three types of respondents were targeted in focus groups: (a) community nurses, (b) physicians in primary healthcare, and (c) community, with main focus on the target population of the community nurses (pregnant women, mothers and newborns, elderly) and the vulnerable and marginalized groups (rural population, Roma communities, other minorities in rural and remote areas, etc.).

(1) Focus groups with community nurses (FG/PN)One focus group was organized with main or responsible patronage nurses from each healthcare center (a total of 38 main/responsible patronage nurses). The focus group took place in Skopje, on October 14, 2011, and was attended by 41 respondents from all healthcare centers (some were represented by two nurses, upon their own interest). The focus group discussion was audio-recorded, and the summary was prepared, based on the structure of the questionnaire guide, which was used in the thematic analysis of the findings and triangulation of the quantitative data and the qualitative data collected through other methods described herewith. The list of all respondents in this focus group is given in Annex to this Report.

Additionally, in three healthcare centers, small focus group-like discussions were conducted with the community nurses, after the facility assessment was performed (Veles, Tetovo, and Ohrid). Notes were taken during these discussions, and the notes were used for the thematic analysis of the findings.

(2) Focus groups with physicians in primary healthcare (FG/Doc)

In order to assess the viewpoints, opinions and willingness for cooperation with the community nurse by the primary healthcare physicians, which are working under concession primary healthcare model, three focus groups were conducted with gynecologists and pediatricians working in the primary healthcare, that have contract with the HIF (Tetovo, Bitola, Strumica). A total of 11 physicians were invited to the focus group, as per the list of HIF contracted gynecologists and pediatricians in each of the three cities. The attendance was: 9 physicians in Tetovo and 5 each in Bitola and Strumica. The lower attendance in Bitola and Strumica was as a result of impossibility of the physicians to leave the workplace due to higher number of patients after an extended weekend (for reasons of a national holiday). The list of physicians attending these focus groups is given in Annex to this Report.

The focus groups that were held in each of the three cities accordingly, took place during the qualitative data-gathering period (i.e. October 18, October 26 and October 27). The focus groups were audio-recorded and the summary of findings was prepared and used in the thematic analysis of the findings and for triangulation with the quantitative data and the qualitative data gathered through other qualitative methods.

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(3) Focus groups with community (FG/COM)A total of 9 focus groups with community, i.e. target population were held with community in: Bitola, Debar, Kochani, Ohrid, Prilep, Skopje-Shuto Orizari, Skopje-Novoselski pat, Shtip and Veles. The cities were selected based on the planning development regions division in the country, by selecting in each of the planning development regions, as well as bearing in mind the coverage of population by the respective health centers:

City Development region

Participants per FG/COM (invited 15

per FG)Bitola Pelagonia 8Debar West 14Kochani East 12Ohrid Southeast 15Prilep Pelagonia 9Skopje-Shuto Orizari Skopje region 15Skopje-Novoselski pat Skopje region 17Shtip East 15Veles Vardar 14

TOTAL 119

The participants for the focus groups were recruited through a local partner of the NEI, i.e. local NGO working in the field of healthcare or human rights in each of the selected cities. This was chosen as a method, in order to provide for impartiality in the selection of participants, towards providing objectivity in their personal accounts during the focus group discussions. Criteria for selection of participants were given to each local partner, and those included recruitment of up to 15 persons, as follows: 4-5 pregnant women, 4-5 mothers with newborn or infant, 4-5 elderly women, preferably women who had children before 2000 or 2005. Male population was excluded from the FG with communities, since the nature of the issues to be discussed were considered sensitive, and presence of men could endanger the richness of discussion and openness of personal accounts of the participants.

In each of the focus groups, the following categories were represented: pregnant women (at least 2 and up to 4 participants in each FG), mother with newborn and infant (at least 2 and up to 4 per FG), women that gave birth before 2000 or 2005, i.e. before the UNICEF project and before the introduction of concession model in primary care, accordingly (at least 2 per FG).

All FG were audio-recorded and summary of discussions were produced, in line with the questionnaire guide for FG/COM. The summaries and notes of discussion were used for further thematic analysis of the findings and for triangulation with the quantitative and quantitative data.

2.3 Facility assessment of 10 Health centers

In line with the proposed criteria for selection of 10 health centers for facility assessment, and based on the results of the quantitative data analysis, the following health centers are proposed for facility assessment:

Health center CriterionUrban/ Coverage Development Other (comments)

8


Health centerCriterion

rural rate regionBitola Mixed Underserved Pelagonia 11,111 population per

nurseDebar Urban Underserved South-western 7,120 population per

nurseKavadarci Mixed Over served Vardar PILOT health center for

the assessmentKochani Mixed Underserved Eastern 8,333 population per

nurseOhrid Mixed Underserved South-western 7,600 population per

nursePrilep Urban Underserved Pelagonia 7,647 population per

nurseRostushe Rural Over served Polog 4,640 population per

nurseShtip Mixed Underserved Eastern 4,857 population per

nurseGOOD PRACTICE example for organization model of community nurse system

Skopje Urban Underserved Skopje Special case due to complexity of organization and population size/area coverage

Strumica Mixed Underserved Southeastern 7,500 population per nurse

Tetovo Mixed Underserved Polog Reported low number of domashna poseta teams (patronage covering for the shortage?)

Veles Urban Underserved Vardar 7,600 population per nurseGOOD PRACTICE of cooperation of community nurses with primary healthcare physicians

The facility assessment was performed during the period of qualitative data collection, i.e. October 14-28, 2011, during which all facilities above were visited except for the Health Center Skopje, which was visited in November 2011. Facility assessment was performed by physical inspection of the health center infrastructure, with particular focus on the community nurse dedicated space and equipment, as well as procedures for maintenance and keeping of records, organization of work and flow of data. In each facility, an interview with the main or responsible community nurse was performed, and in some cases a focus group-like discussion was conducted with the present community nurses (see details under section “2.2.2(1) Focus groups with community nurses(FG/PN)” above)

2.4 Data analysis and triangulation

After the qualitative data was collected, it was processed using the thematic analysis approach. The triangulation of quantitative and qualitative data was performed, while at the same time consulting the relevant literature and reports from state (domestic) and

9

Community nursing assessment with equity analysis in Macedonia | Final Report6. Annexesforeign sources. The result of the analysis and triangulation is presented further in this report, under the main findings of the assessment that also includes an equity analysis of this preventive healthcare segment. Towards the end of the report, the conclusions and recommendations are proposed, presenting as well the human resource and infrastructure needs and financial projections, as well as the proposed models for reforming the community nurse system in the country, that are taking into consideration the possibilities for inter-sectoral (horizontal) and inter-governance (vertical) cooperation with social protection and other welfare segments in the society.

2.4.1 Equity analysis

Equity in health can be defined as the absence of systematic disparities in health (or in the major social determinants of health) between social groups who have different socio-economic status or levels of underlying social advantage/disadvantage.1 The very common definition (Whitehead) explains that health inequity concerns those differences in population health that can be traced to unequal economic and social conditions and are systemic and avoidable – and thus inherently unjust and unfair.2 Further, health inequities are defined as "avoidable inequalities that are unfair and unjust, where inequalities refer to differences in both health experience and status between countries, regions, socio-economic groups". Health equity implies a fair distribution of both the benefits and burdens of health services among groups and individuals.

However, the inequity should be distinguished from inequality;3 inequalities or disparities are differences in health status and health outcomes between groups independent of an assessment of fairness, while inequities are disparities that are strongly and systematically associated with certain social group characteristics such as level of wealth or education, whether one live in a city or rural area. Additionally, although equity in health and equity in healthcare are interrelated, the first refers to the outcomes of the health system and the latter to the process of provision of health services; this research is looking at both, from the perspective of the patronage nursing service in the community.

Equity in health can be assessed from horizontal/vertical, financial, human rights perspective. The most common way to measure equity is to assess the utilization of health services by using routine data of health care interventions (e.g. immunizations) by population groups categorized by the determinant that underlies the inequities (socio-economic status, geographical or urban/rural basis, gender, race, age, etc.) or to collect the data through a household survey on the target population.4

1 Braveman P, Gruskin S. (2003). Defining equity in health. Journal of Epidemiology & Community Health (57):254–8

2 Whitehead M. (1992). The concepts and principles of equity in health. International Journal of Health Services (22):429–445. (first published with the same title from: Copenhagen: World Health Organisation Regional Office for Europe, 1990 (EUR/ICP/RPD 414).)

3 Leon D. A. Walt G. and Gilson L. (2001). International perspectives on health inequalities and policy. BMJ (322):591-4.; Kawachi I. Subramanian S. V. and Almeida-Filho N. (2002). A glossary for health inequalities. Journal of Epidemiology and Community Health. (56):647-52.

4 O’Donnell et al (2008). Analyzing Health Equity Using Household Survey Data: A Guide to Techniques and Their Implementation, WBI Learning Resources Series; Washington: The World Bank.

10

Community nursing assessment with equity analysis in Macedonia | Final Report6. AnnexesHowever, there are other sources of non-routine data that can be used for equity in health analysis, such as the surveys and small-scale studies of the representative sample of healthcare facilities. As suggested by literature, the quantitative measurements are usually complemented with qualitative data for providing in-depth explanations of the inequities in terms of practices and behaviors of the systems or population groups. In this research, a non-routine data was collected through quantitative survey and qualitative data (focus group discussions and interviews), which were combined with available routine data on demographics, health outcomes and some socio-economic parameters.

The parameters used for stratification of data for equity analysis are: urban/rural principle; development regions and infant mortality.

2.4.2 Challenges and Limitations of methodology and data

When it comes to routine statistical data collection and processing by official institutions, the methodology for collecting the demographic and general health outcomes statistics is different from that of the healthcare services provision, on the level of service providers of interest to this study (i.e. health centers). Namely, the distribution and coverage by the health centers according to the old territorial division of 1976 (in 33 municipalities) is not aligned with the recent decentralization-initiated territorial division to 84 municipalities and the city of Skopje, with the boundaries of the new 85 local self-governments not coinciding with those of the old 33. Further, the Health Insurance Fund, inheriting the regional offices in the 30 major municipalities of the old territorial division, is presenting the data based on this division, which is again, not aligned to the official state statistics. Thus, in the sense of making the data comparable, some adjustments to the routine and secondary data sets had to be made, using the following assumptions: (1) boundaries of the 33 old municipalities coincide with the boundaries of the current 85 local self-governments; and (2) the data from the 30 regional offices of HIF represents the same population and area coverage as the 33 health centers, of which the data from 3 health centers where no HIF regional office is located are aggregated with the data of the health center where the HIF regional office recognizes that they belong (i.e. Pehchevo with Berovo, Rostushe with Gostivar and Vevchani with Struga).

With respect to the quantitative data, the major concern with the research instruments and chosen methods of self-assessment survey was that the complete data set could not be collected for reasons of personal characteristics, preferences and attitudes of the respondent. In order to minimize the data gaps, the data missing in the received questionnaires was amended by additional targeted telephone interviews with the respondents. The differences in the number of respondents answering particular question of interest are acknowledged wherever applicable.

With respect to qualitative data, the concern was not towards the completeness of the data, but rather to the richness of the gathered information, that included personal accounts on topics related to healthcare provision and equity but very indirectly connected to the community nursing, or to the question of particular interest to this

11

Community nursing assessment with equity analysis in Macedonia | Final Report6. Annexesstudy. Thus, not all data from the qualitative research was used, but some of the interesting findings are mentioned as potentials for future research.

Another challenge of the qualitative research was the selection of the sample for the community focus groups. As sample size calculations are not very commonly used in qualitative research,5 the theoretical saturation was used as criterion to define purposive sample, because ‘representativeness is not a prime requirement when the objective is to understand social processes’.6 However, as the prime target groups of research interest were marginalized groups, but not those that have been identified by the healthcare system, the approach taken was to recruit respondents through local civil society organizations and activists. The limitation hereof, is that, besides the criteria that were adhered to, the sampling for each focus group was based on the predominant mission of the local organization; in that sense, some marginalized groups were more analyzed than others, such as the Roma population, women and the rural population. Given the fact that most of the studies produced for the country quote these as the most vulnerable and at risk population groups, the research findings are validated from the community nursing practice point of view.

While interpreting findings of the SA survey it has to be considered that questionnaires were not anonymous and PNs may had a biased attitude toward reporting some figures although they were informed that the data provided by them would not be used for any administrative purposes.

2.4.3 Terminological explanations

Community nursing is widely used and internationally accepted term explaining a professional working with people and their families to help prevent disease, maintain health and treat any existing health problems; in many countries this service is recognized as to promote, support and maintain the patients' independence, safety and healthy lifestyle, at the same time as providing assistance to those that provide immediate care (to patient, newborn, etc.). However, in the organizational setup of the healthcare system in the country, historically the term patronage nurse has been adopted in use, and it has been recognized as part of the professional denomination of a particular type of nurse, that has the above named characteristics, vocational training and job description. Thus, for the purposes of this study, these terms will be used interchangeably as synonyms, having the meaning of a nurse working with people and their families in the community.

The type of healthcare facility that is explored here, i.e. the health center, in the national legislation and common language is recognized as “zdravstven dom”. The literal translation of this term in English is “health home”; however, for this study the term “health center” is used. Although health home is not used in this report, the references quoted are using it, thus it is annotated that these two terms refer to the same type of healthcare facility

5 Sandelowski, M., (1995), ‘Sample size in qualitative research’. Research in Nursing and Health, 18:179-183.

6 Mays, N. and Pope, C. (1995). “Qualitative Research: Rigour and Qualitative Research”. BMJ 311:109-12.

12


3 Main Findings

3.1 Human Resource development

3.1.1 Human resource profile

The community nursing system in the Republic of Macedonia is organized through patronage service units embedded into the structure of 33 Health centers (Zdravstven Dom). The population in the country is served by a total number of 338 community (patronage) nurses in 2010.

Figure 1: Distribution of population per PN by Development Regions and Population Residence

Distribution of PN by geographical areas in not even:

Figure 1 shows that the population to PN ratio for the country is approximately 6,000 that is higher than the recommended ratio (5000 population per PN). Only two development region (South-western) and Vardar demonstrate the distribution of PN closer to the desired level. All other development regions are understaffed, especially Eeastern, Pelagonia and Skopje, were the ratio of population per PN is above 6,000.

It is noteworthy that PN are better distributed in rural population (especially in South-western development region). As

expected, the ration for urban population is closer to the desired balance compared with mixed (urban + rural population). Figure 44 (below)

It total 4,339 persons were employed in these 33 ZD as of June 1 2011. There were 2,749 medical professionals (including health associates) that constituted 63% of the staff. Patronage nurses constituted one fifth of the total number of nurses (1,612) and 12% of the total medical professionals. Ratio of medical professionals to total staff varied between 49% (in Debar) and 73% (in Bitola), however the variation was bigger as regard to PN vs. all nurses: from 7% (in Pekhchevo) to 80% (in Berovo) – for details see Figure 47 (below in Annex K).

Figure 2: Age scatter chart of patronage nurses (n=338)

13 respondents identified themselves as a head of patronage unit. 35 respondents (9.5%) reported midwife as their professional background.

13

Mixed

Rural

Urban

Total

South-western

5,158 487 5,196 4,664

Vardar 5,151 5,151

North-eastern

5,236 5,236

Polog 5,908 4,309 4,628 5,336

South-eastern

5,789 4,924 5,357

Eastern 3,895 6,495 6,243

Pelagonia 11,626

6,715 7,004

Skopje 7,607 7,607

Grand Total 6,796 1,579

5,550 5,984


The average age of community nurses is 46.2 years (45.4-47.04)7, with age ranging between 26 and 62 years of age. All nurses are female. The scatter chart shows that most of the patronage nurses are within the age range of 40 to 60 years; only 52 are below the age of 40, and 4 are above age 60. About half of the pool of employed community nurses (151 above age 47) will be retired (at age 62) in the next 15 years, i.e. by 2025.

The distribution of PN by age (see Figure 43 below) was asymmetric with a long left tail (Skewness = -0.648, Std. Error of Skewness =0.135) and clustering more about the center of the distribution (Kurtoses=0.655).

As can be seen from Figure 3 below, the average age of community nurses by health center is around 50, whereas only two health centers have average age of nurses below 40 (Debar and Resen). The situation needs to be closely looked at in the health centers, which have small number of nurses and where the average age is close to or above 50 (Demir Hisar, Kratovo, Krushevo, Rostushe, Probishtip, and even Pehchevo with only one employed nurse above age 50).

The average work experience as per years of employment in the current institution is 19.6 years, with experience ranging from less than a year to 32 years of working experience in the community services.

7 95% confidence interval for the mean

14

20

22

24

26

28

30

32

34

36

38

40

Age

Community nursing assessment with equity analysis in Macedonia | Final Report6. AnnexesFigure 3: Age distribution of nurses by health centers (n=338)8

20

25

30

35

40

45

50

55

60

65

Age RangeSeries1Average Age

There were 35 nurses with total history of working as PN less than 4 years. At the same time, 23 PN reach the retirement age in 3 years.

In the last decade in average 10 newcomers to the community nursing were observed each years, except of year 2006 and 2007 when the inflow tripled (as shown on Error:Reference source not found Error: Reference source not found): in 2 years 72 persons joined patronage nurses, that is 41% of the total number of persons who has been employed as PN since 2010. The similar (but with less magnitude) sharp increase was observed in 1998-1998.

Only 78 (24%) reported that from the very beginning started work as PN. whereas also a substantial number of the respondents have spent more than 50% of their employment time in other posts before joining the community nursing services (196 have reported less than 20% of their total employment

time in the institution not in community nursing services). All of the surveyed community nurses have reported that they are on full-term employment with the institution, which covers all employment fringe benefits.

8 Facility codes are presented in Annex B below

15

Figure 4: Inflow of new PN by years (n=325)

18

32

39

33

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45

1975

1977

1978

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1980

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2011

Community nursing assessment with equity analysis in Macedonia | Final Report6. AnnexesSince 2010 only 22 persons has entered the labor market as PN, while remaining 87% of recruited PN worked in other area before being employed as PN. In 2006-2007 61 persons (out of 72 newcomers) moved to PN from other professional area.

Figure 5: “Turnover” of PN by the years of getting employed in the current ZD (n=325)

19721974

19761978

19801982

19841986

19881990

19931995

19971999

20012003

20052007

20100

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PN TransferredUpgraded to PNPN New

Year of employment at the current ZD

Only 27 of PN moved to the current place of employment from other institutions where they worked as PN. It means that only 8% of the current PN switched work place (not the profession) for last 20 years. For 131 PN the current institution is where they started their PN carrier. And 167, or 51% PN worked in the current instruction before becoming PN (labeled as “Upgraded to PN” on Figure 5 above).

Average age of the group “Upgraded to PN” was 46.23 (45.4-47.04), higher than of the group “Fresh PN” – 44.93 (43.49-46.37). The difference was statistically significant (with one-way ANOVA contrast test irrespective of equality of variances, p<0.05).

According to the managers ZD a net increase in PN after 2006 amounted to 101 persons. 17 PN have left the job for the same period (including retired 4 persons). It means that in total 118 persons (or 35% of the present cohort of PN!) at least have joined the PN pool in four and a half years.

Figure 6: Turnover of PN from 2006 to 2011 (as reported by ZD)2006 2007 2008 2009 2010 2011

PN by the end of the year 237 288 300 307 319 338 101PN Joined 59 15 11 14 19 118PN Left 0 8 3 4 2 09 17PN left as % of the total number

2.8% 1.0% 1.3% 0.6%

9 It is assumed that there was no outflow of PN in 2011

16

Community nursing assessment with equity analysis in Macedonia | Final Report6. AnnexesIt is noteworthy that average age of becoming PN was 33 years (mean and mode=33, n=325). However, average age of becoming nurse before 2005 was 29 years (n=205) while after 2005 it increased up to 40 years (n=120) (mean difference 11.6 years, p<0.001). If the average age of becoming PN is compared by the origin of employment, there is a statistically significant difference between the mean for the group “Upgraded to PN” (mean=37.1, p<0.05) and means for two other groups – “Fresh PN” and “PN transferred” (28.9 and 32.7 correspondingly). The age of becoming PN is higher among PN working in urban areas (35.5) vs. working in other areas (30.7) by 5 years (p<0.001).

The education level of community nurses has been assessed using the following categories: (i) secondary education, (ii) 3-year higher education (VSHS = “visha struchna sprema”), (iii) 4-year higher education (university degree, VSS = “visoka struchna sprema”) and (iv) postgraduate education. All of the education levels completed are reported to be in medical sciences, i.e. matching the required profile for community nurses.

Figure 7: Number of nurses by level of highest education as per Health Center recordsSecondary education

3-year higher education

(VSHS)

4-year higher education

(VSS)

Postgraduate

Unreported

Total

294 18 19 1 6 33887.0% 5.3% 5.6% 0.3% 1.8% 100.0%

Average time since graduation from the highest level of education is 25.2 years (period since graduation ranges from less than a year to 37 years).

3.1.2 Professional growth needs

The professional growth needs have been assessed through inquiry of the participants on one side about their last training attended (when the training was attended, topic and length of the training, etc.), and on the other – about the services and skills that they are asked about end users to perform, but are not in possession of. The questions about services and skills has been divided into (i) services and skills they do not have training for, and (ii) services and skills that they do not have official authorization to perform. In this section, only the first part will be assessed, whereas the second part is detailed elsewhere in this report.

Almost all community nurses stated that they received orientation training upon employment in the current institution; the training predominantly consisted of joint visits with senior staff during the first months of employment, and only few reported that they also received theoretical classes and printed guidelines. Exception to this practice, are 19 respondents who have either responded that they did not receive any orientation training or have not responded to the question at all. Cases of not obtaining orientation are sporadic, except to Health Centers in Makedonski Brod and Vinica, in both which 2 of the total 3 nurses (66.67%) responded that they have not received the orientation training upon employment.

17

Community nursing assessment with equity analysis in Macedonia | Final Report6. AnnexesIn respect to other professional training after graduation, respondents were asked to define the thematic areas in which they have received either theoretical knowledge or practical skills.

Figure 8: Professional training undertaken as self-reported by community nurses (n=325)

Thematic unit/issueTheoretical knowledge Practical skills

No. % of total No. % of total15 Newborn Care 251 77.23% 207 63.69%16 Nursing 254 78.15% 214 65.85%17 Medical documentation/records 221 68.00% 196 60.31%18 Communicable diseases 142 43.69% 74 22.77%19 TB 195 60.00% 81 24.92%20 Family violence 138 42.46% 49 15.08%21 Diseases of addiction 135 41.54% 57 17.54%22 Children with special needs 156 48.00% 65 20.00%23 Orthopedics 94 28.92% 46 14.15%24 Nutrition of a newborn 234 72.00% 131 40.31%25 Anti-rickets protection 169 52.00% 93 28.62%26 Anemia 125 38.46% 53 16.31%27 Standards/guidelines for operation 149 45.85% 99 30.46%

Of all respondents, 79 have reported that the last professional training they attended was more than 3 years ago (prior to 2008), and 223 responded that the last attended training was in 2010 or 2011. The funding for the training came from various sources, such as the institution of employment, the Ministry of Health/Health Insurance Fund and donors.

49 out 325 PN had no training since they entered the PN service or had trainings prior moving to PN services (assuming that these trainings in the past could not be relevant to PN).

Figure 9: Sources of funding for professional trainings (based on the information from the last received training)

Source of funding Number of respondents % of totalDonors* 171 52.62%MOH/HIF 73 22.46%Employing institution 44 13.54%Own funds 2 0.62%Unspecified 35 10.77%

TOTAL 325 100%* Under donor funding, respondents have specified one or more donors for the same training.

From the table above can be concluded that the donor-funded trainings are prevailing, of which largest portion has been attributed to UNICEF, the Global Fund, WHO and the government (or embassy) of the Netherlands.

Regarding the question whether there are services that the community served is requiring for which the respondents have not attended training, about 50% (161) have responded that there are no such services.

18

Community nursing assessment with equity analysis in Macedonia | Final Report6. AnnexesThe remaining 164 respondents have responded that there are services for which they are not qualified, and the services that they have listed are presented in the tables below

Figure 10: Demanded (by communities) preventive services for which respondents reported to have not attended training

Preventive service % of total*28 Treatment of painful breasts of nursing women (granuloma) 54.6729 Mental health advices 14.6730 Psychophysical exercises for pregnant women 12.0031 Cholesterol measurement 9.3332 Blood sugar measurement 5.3333 Care for the newborn (diapering, nursing, nutrition...) 1.3334 Exercises for children with special needs 1.3335 Blood pressure measurement 1.33*The percentage is calculated from those that responded that there are services that the community requires but they do not have training for (n=164)

Figure 11: Demanded (by communities) curative services for which respondents reported to have not attended training

Curative service % of total*36 Insulin therapy 28.3937 Lapisation of the umbilical cord 20.7638 Small surgical interventions 16.9539 Administration of IM therapy 14.4140 Administration of enema 6.7841 TB therapy (DOTS) 3.8142 Treatment of patients with communicable diseases 2.9743 Wound dressing and cleaning 2.5444 Treatment of drug users 2.5445 Administration of IV/PE therapy 0.4246 Post-hospital care (catheters, etc.) 0.42*The percentage is calculated from those that responded that there are services that the community requires but they do not have training for (n=164)

Focus group discussions revealed that the community served perceives the visits of patronage nurses as necessary not only for the mother and the newborn, but also for attending the other members of the family that have some health conditions, which can be assisted by the patronage nurse. Examples that were given are services of wound dressing, decubitus prevention, and advice for young people on sexual health. Some respondents confirmed that the patronage nurse was offering these services as well, whereas majority had not had such experience, but considered it necessary.

In the light of the reform of the preventive healthcare, many respondents were inclined to have the community nurse visit instead of visit to a doctor, when the issue was related to financial implications, i.e. necessity to make co-payments for a regular visit to a gynecologist as opposed to a free of charge visit by the community nurse. Additionally, the nurses visiting the home were seen as non-intrusive, but rather opposite: for some preventive services, like advising of young people about sexual health and

19

Community nursing assessment with equity analysis in Macedonia | Final Report6. Annexescontraceptives the women respondents have seen the visit of the patronage nurse as better option over the visit to a busy clinic with a waiting room full of patients.

3.1.3 Professional growth opportunities

In the quantitative analysis, the professional growth opportunities were assessed using the community nurses as the main source of information; they were asked (i) whether they are knowledgeable of any trainings that is offered for their profession, which they would like to attend; and (ii) if there are skills that they consider it would be valuable to obtain through training.

When asked if there are any trainings that they know of but cannot attend for any reason, 47% responded that there are such trainings, whereas the remaining 53% have not shown such knowledge. Such high percentage of persons not knowing of any training might imply that there is an obvious lack of information or delayed flow of information for training opportunities towards the community nurses.

Of those that have stated that there are trainings that they cannot attend for various reasons, the following trainings were listed:

Figure 12: Trainings for which information was received but respondents cannot attend for various reasons

Training % of total47 New methods and techniques of care/any training 24.3148 Psychophysical exercises for pregnant women 12.3949 Drug abuse 10.0950 Family violence 7.3451 Communicable diseases/STIs 5.5052 Congenital heart diseases 5.5053 Post-hospital care (wound dressing, catheter, etc.) 5.0554 Nursing and nutrition of a newborn 4.1355 Trainings for measuring blood glucose, lipids, bilirubin 4.1356 Care for newborn (umbilical cord, diapering, etc.) 3.6757 Orthopedics (hips exercises, flat feet) 3.6758 Administration of IV and IM therapy 3.6759 Children with special needs 2.7560 Care and nutrition of premature babies 2.75Other (rickets prevention, anemia, delivery at home, use of ECG/CTG equipment, etc.)

5.06

Main reasons for impossibility to attend the training for which information was received, as stated by the respondents were lack of information or information received too late (43.22%), financial reasons (37.73%) and big competition for limited number of seats (15.75%). Other reasons stated by less than 5% of respondents are personal reasons and inadequate level of education to attend the training.

In the focus group with all responsible PN from every health center and in the mini focus groups with PNs in selected health centers, the prevailing opinion is that training and CME is an urgent necessity (over supply of vehicle, for example), but that the lack of motivation for attendance is not solely on financial grounds; the nurses have again

20

Community nursing assessment with equity analysis in Macedonia | Final Report6. Annexesrepeated their battle for establishment of the nursing as profession that can stand on its own in the system and in the community per se. This, in their words means enactment of the law on nursing, in which, besides the rights and obligations, the accreditation system and CME requirements for licensing and re-licensing will be established.

The non-existence of the accreditation mechanism was confirmed in the interviews with officials from the education and vocational education institutions, who also confirmed that there is a need for such mechanism to be established, further informing that the patronage nurse is not recognized as separate profile in the health profession (whereby patronage nurse is seen as medical nurse with additional on-job training and skills for community nursing). In their view and in the view of the academics, the professional association of nurses as the most relevant actor in creating and implementing the system, and that the patronage nurse profile has to be introduced in the health profession, for such accreditation system to be valid and implementable within the healthcare system of the country.

3.2 Service coverage and utilization

3.2.1 Supply side (existing coverage and utilization)

The services provided by these community nurses, as listed by the Healthcare managers, are shown in Figure 13 below. Expectedly, all community-nursing units are predominantly oriented towards preventive services, with uniform feature to all being the provision of the care for the pregnant women, women after delivery and the newborn (making it the so-called bivalent patronage). The polyvalent concept is accepted by some health centers, by providing more preventive services (antenatal services 67%, school children 58% and care for elderly 61%) and some curative services (on average 15%) to the communities served.

Figure 13: Preventive and curative services provided by the community nursing system (as reported by the Health Center, n=33)

Type and name of service % of all HCPreventive services

Pregnant women and women after delivery 100%Newborn, infant and pre-school children (toddlers) 100%Women in reproductive period 67%Elderly persons 61%School children and adolescents 58%Families (or patients) under risk/with special needs (disabled) 27%

Personal hygiene (bathing, maintenance, etc.) 6%Curative services

CND patients 21%CVD patients 18%Chronic patients 15%Diabetics 15%Post-hospital care (wound dressing, catheters…) 12%Administration of IV and IM therapy 12%TB patients 6%

21

Community nursing assessment with equity analysis in Macedonia | Final Report6. AnnexesThe data reported by PN did not allow clearly distinguishing PN providing only monovalent, bivalent and/or polyvalent patronage services. Nevertheless, only 12 PN reported to perform monovalent services (visiting newborns), 7 PN did not report any services, and the remaining 306 PN provide at least bivalent patronage services. At the same time, out of 325 PN 51 reported that they deliver curative services (not related to TB and Diabetes), 44 PN reported the provision of curative services related to Diabetes and 15 PN said that they were providing TB related curative services. In total 62 PN (or 19% of the total PN cohort) had reported that they provided at least one type of curative services.

As reported by HCM, 333 PN performed 362 thousand visits in 2010 that amounts 1,087 visits per PN per year in average.

There is a significant variation of the number of average annual visits made by PN across 33 ZD as shown on Figure 14 below:

ZD in Prilep did not report any performance.

4 ZD (Struga, Vevchani, Kriva Palanka, Demir Hisar, Ohrid) demonstrated the performance below 500 visits per annum

3 ZD (Valandovo, Bitola and Debar) reported the performance above 2000 visits per annum

Figure 14: Performance of ZD by the number of visits per PN in average (in 2010) as reported PN

0

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All visits per annum per PNNational average

Only 19 ZD reported performance of Domashna Poseta (DP) and Figure 15 below shows comparison of the serviced provided by PN and Domashna Poseta in 2010 per nurse. It shows that in those 19 ZD there is no significant difference in the performance between PN and DP nurses – 1,127 vs. 1,062 per annum correspondingly. In some cases (e.g. Negotino, Skopje, Kumanovo and Struga) DP nurses were outperforming PN while in

22

Community nursing assessment with equity analysis in Macedonia | Final Report6. Annexesother ZD the ratio is in favor of PN (e.g. Debar, Bitola, Gostivar, Ohrid). Details of PN vis-à-vis DP nurse performance are presented in Figure 48 (below).

Figure 15: Comparison of annual workload between PN and Domashna Poseta Nurse by ZD (n=19) as reported by HCM

Struga

Vevchan

i

Kriva P

alanka

Demir H

isar

Ohrid

Strumica

Rostushe

Krushev

oVele

sRese

n

GostivarSko

pjeTet

ovo

Kavad

arci

Kumanovo

Gevgeli

ja

Negotino

Bitola

Debar

Averag

e0

5001000150020002500300035004000

Total visits per annum per PN Home visit per annum per DP Nurse

Performance of ZD by types of visits in 2010 (as reported by HCM) is shown in Figure57 (below): out of 362 thousands total visits 115.5 thousands were provided to newborns vs. 27.4 thousands provided to pregnant women. The ratio of postnatal/antenatal services is 4 to 1 while the both constitute 39% of the total performance (as reported by HCM).

Figure 16: Comparison of daily workload of PN by ZD between reported by HCM and PN

Prilep

Vevchan

i

Demir H

isar

Kratovo

Rostushe

Vinica

Kochani

Veles

Radovis

h

Gostivar

Tetovo

Kavad

arci

Delchevo

Gevgeli

ja

Sveti Niko

le

Valandovo

Debar

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

Average PN visits per day (as reported by HCM)

The average daily workload of PN is presented on Figure 16 (above): the daily workload reported by HCM (calculated by dividing the total number of PN visits by the number of PN and working days per year estimated at 223) ranges from less than 2 (e.g. in Struga,

23

Community nursing assessment with equity analysis in Macedonia | Final Report6. AnnexesVevchani and Kriva Palanka) to over 9 visits (as in Valandovo, Bitola and Debar). When PN asked about usual number visits per day, they presented slightly different pattern of workload with 6 visits per day mentioned by most of PN usually ranging from 5 – 8 but in some cases showing extremely low (2 visits per day in Strumica) or high workload (13 visits per day in Krushevo).

It is noteworthy that 75% of community nurses stated that they are asked to assist in other units , which are most often preventive services (immunization and systematic check-ups of school children), but also in the outpatient services, home visits, emergency unit, occupational health unit, gynecology, etc.

With regard to the re-assignment of the patronage nurses to other units, both nurses and healthcare managers have confirmed that this practice occurs on a non-regular basis, when there is a need for extra professional workforce on the preventive teams or in Domashna Poseta (home visit) teams. In some health centers, the nurses are given assignments every day by the nurse responsible for the patronage unit, and in some this is done on weekly basis. Managers in some health centers have claimed that such practice has been established as a result of facing lack of staff in the preventive teams (due to retirement or leave of service for preventive healthcare), but also as a result of the difficulty of providing permission for new employments from the central government.

On the other end, there are health centers in which the lack of patronage nurses (calculated based on the nurse-to-population ratio) is not allowing for this practice. However, in those centers, the managers have assigned more patronage nurses than the number of packages the HIF is paying them for, and the salary costs are covered from other funds (such as funds for other costs for patronage services or other funds of the Health center).

3.2.2 Needs in community nurse services

With regard to the issue of demand of services for which they do not have official authorization to provide, community nurses have different experiences; 54% say that there are no such services, and yet 46% have responded that they had faced such situations in the field. Among the services that are requested by the community for which the nurses are not authorized to perform, are both preventive and curative, as listed in the table below.

Figure 17: Services required by the community for which community nurses are not authorized to provide (n=148)

Type and name of service % of total who responded (n=148)

Preventive serviceBlood glucose level measurement 57.7Cholesterol measurement 14.1Smear/blood sample taking for laboratory examination 12.7Other person’s care (care for third person) 7.0Requirement for pediatric diagnosis 5.6Other 2.8

24

Community nursing assessment with equity analysis in Macedonia | Final Report6. AnnexesType and name of service % of total who

responded (n=148) Total 100.0

Curative serviceAdministration of IV/PE therapy 29.6Administration of IM therapy 21.7Wound dressing and cleaning 15.5Lapisation of umbilical cord (AgNO3 treatment?) 15.0Post-hospital care (catheter, etc.) 6.6Administration of proscribed therapy without presence of a doctor, in the home

4.0

Administration of therapy without diagnosis (or prescription) 3.1Diagnostics / prescribing 2.7Other 1.7

Total 100.0

The focus groups discussions yielded different opinions; some nurses consider that the extension of the service portfolio is good for the community but for upgrade of their profession as patronage nurse, whereas others have expressed mild reluctance towards extending the work beyond the preventive services, arguing that the extended package of services has to be well considered, as there are services (such as administration of antibiotics) for which in case of adverse effects the nurse cannot do much with the available equipment or consumables. The extension of the package has to be followed by appropriate training and provision of equipment and sufficient consumables that can enable the nurse to properly perform those new services.

The demand side for community nurse services was explored through focus group discussions with community in 9 cities with total number of 119 participants, as well as through interviews with representatives of civil society organizations that are working on service delivery level in marginalized and vulnerable communities. The list of cities and participants in both focus groups and interviews is given in Annex to this Report.

The respondents are generally satisfied with the quality of the current supply of the community nursing services, and only sporadic cases were reported of dissatisfaction or major disappointment. Mothers were satisfied with the structure of the visit, the advices and support/encouragement given. Most of the respondents were satisfied with the approach of the nurse, the questions nurse asked and the attitude towards the mother and the newborn. However, many of the mothers reported that the visit of the nurse was rather late (7 to 10 days after discharge from hospital), and they demanded that the visit occurs sooner, as the mothers, usually the primaparae feel left on their own after leaving the hospital care, and they need some practical advices. In cases when they needed support sooner than the patronage visit, they went to the PHC physician – pediatrician or gynecologist, which was a logical and recommended (by the PHC) step, but to some this was very difficult as they had to go out of the home (with the baby) and some of them even said they had to travel far.

This issue was also discussed with the community nurses, who reported that the root cause of such delay with visits is the channel for or the frequency of obtaining information about the deliveries. Namely, some health centers are located in the same

25

Community nursing assessment with equity analysis in Macedonia | Final Report6. Annexescomplex as the maternity (belonging to the hospital), so the data on the newly born is easily accessible, and usually taken personally by the community nurses that go and talk to the mothers; in other cases, this communication goes through provision of a list of deliveries in the past 30 days from the maternity to the community nurse unit. But, most difficult is the provision of a data for the deliveries occurring in a different city from the place of residence, and deliveries in private maternities (4 in Skopje, 1 in Bitola and 1 in Shtip).

On the service users end, many of the respondents have not received any information about the existence of patronage service and possibility of home visits from their doctor during their pregnancy or stay at the hospital; most of them had received such information from their relatives (mostly mother or mother in law), neighbors or friends. The same is the situation about the choosing of the pediatrician for the newborn; the information comes from experiences of the closest, or from own experience in case of second or subsequent childbirth. The community nurses are not providing such information, for multiple reasons, some related to not having comprehensive information on all pediatricians in the community (only personally acquired ones), others related to the issue of bias that nurses feel strongly about, as they do not like to be seen as protégés of ones over other pediatricians. PHC doctors also feel threatened by community nurses providing such information, as they think that the nurses can influence the choice of the mothers, thus shift the patients from one to another PHC doctor.

Regarding the visits of patronage nurses during pregnancy, the concrete conclusion could not be drawn; the experience in most of the focus groups was mixed, while at the same time the pregnancies from the recent time (in the past 10 years) there were no visits by community nurses. Many of the younger participants had no information that there is a possibility to be visited by a nurse, and they only expected to have an orientation on the pregnancy and motherhood within the maternity in their city.

This was also discussed with the community nurses, and in general, the coverage of pregnant women with community nurse visits is higher (nearly 100% in some places) in the smaller communities/towns, whereas the situation is lot different in the capital city of Skopje, that covers the population from 17 municipalities, and has 42 registered private primary gynecologist offices (not counting the private maternities), and where the patients choose the gynecologist on criteria other than the geographical location. In the case of this service too, the data flow is additionally aggravated by the primary gynecologists not having clear instruction or obligation to report the pregnancies to the community nurse service; some of them, as discussed in the focus groups, give the data on a collegial basis, and some refuse to give data protected under the laws of personal data and patients’ rights, fearing that it will bring them inconvenience for disclosing personal data of patients. Additionally, there is a reluctance to visit pregnant women, as there have been cases when the pregnancy was unwanted or still not disclosed to the family, and in such cases the community nurses found themselves and put the patient into inappropriate situation; thus, they stated that they avoid visiting pregnant women in the first trimester, suggesting that it would be appropriate to get the this information in addition to the information on the pregnancy.

26

Community nursing assessment with equity analysis in Macedonia | Final Report6. AnnexesFurther to this, the focus group discussions revealed that in many occasions, the pregnant women, especially from the socially marginalized communities, do not regularly go to a gynecologist, as there is a fee (co-payment) imposed to them, although there are four free of charge guaranteed visits to gynecologist during pregnancy. When asked about this fee, gynecologists said that the fees are imposed because the capitation provided by the HIF is not sufficient to cover for the equipment purchase and depreciation costs, the costs for the trainings for usage of the equipment, etc. Thus, they also considered that community nurses could be valuable asset in the system to make the visits to pregnant women and perform some basic services needed during pregnancy, such as measuring blood pressure, blood glucose, etc.

3.3 Service quality preconditions/opportunities

3.3.1 Training opportunities

Formal education for community nurses in Macedonia is organized on two levels: high school and higher (university and college) degree medical education. There are 14 high schools in 12 towns teaching secondary level medical education: Bitola, Gostivar, Kichevo, Kumanovo, Ohrid, Prilep, Shtip, Skopje, Strumica, Struga, Tetovo and Veles, offering education in Macedonian, Albanian and Turkish language.

Higher medical education for nurses is offered from 4 institutions (3 faculties of medicine and 1 medical college), all of which are offering 3-year degree programs that include both theoretical and practical coursework. Additionally, Faculty of Medicine at the University of Shtip offers a specialization in community nursing, which at the moment has 2 enrolled students.

Figure 18: Higher (university and college) medical education for medical nurses in Macedonia

School Duration No. of courses/no. of hours

Type of education Type of degree obtained

Minimum requirements

3 years 28 courses / 4600 hours

Theory at least 1/3Clinical practice at least 1/2

Graduated medical nurse

Skopje- Faculty of Medicine

3 years /6 semesters

35 courses /4205 hours

Applicable Graduated medical nurse (with final diploma work)

Tetovo- Faculty of Medicine

58 courses / 2400 hours

Bitola- Medical College


Shtip- Faculty of Medicine


Graduated medical nurse (without final diploma work)

27

Community nursing assessment with equity analysis in Macedonia | Final Report6. AnnexesAccording to the EU Directive 2005/36/EC on the recognition of professional qualifications,10 which adoption, transposition and implementation are among the criteria for EU accession, the clinical instruction for medical nurses (called general care nurses) and midwives shall take the form of supervised in-service training in hospital departments or other health services approved by the competent authorities or bodies. As part of this training, student midwives shall participate in the activities of the departments concerned in so far as those activities contribute to their training. They shall be taught the responsibilities involved in the activities of midwives. In 2010, Macedonia enacted a Law on recognition of professional qualifications,11 as one step towards transposition of this EU directive.

However, after graduation from each of the above levels, the nurses need to upgrade and update their theoretical knowledge and refresh practical skills in their field of expertise. Such continuous medical education (CME) for medical nurses is not proscribed as obligatory still, as there is no law on nursing and/or midwifery, that would regulate the licensing and re-licensing of the nurses, including the requirements of professional and continuous medical education.

Despite this fact, during the implementation of the previous UNICEF project on community nurses (in and around 2001), there have been attempts to refresh the community nurses’ knowledge and practical skills through organizing trainings in various areas, such as care for umbilical cord, breastfeeding and nursing, hygiene for the newborn, and more recently in other areas, such as mental health, family violence recognition, etc. However, all of these training opportunities are donor-driven and heavily depend on donor funding, which makes the CME for nurses a rather ad hoc and discontinuous process. In addition to this, the lack of regulation regarding the mandatory annual training is contributing towards the low degree of offerings of trainings for this profession.

In the quantitative survey, as well as in the in-depth discussions in focus groups, the community nurses have expressed the extreme need for trainings and update of their professional knowledge; this is especially the case with the nurses that have joined the community nurse service in the past 5 years (or since the reform of the primary healthcare), and that mostly have formal training received prior to the transfer to the community nursing unit or informal training and coaching from their colleagues upon admission to the service.

The matching of the training and skills is also a point that needs to be taken into consideration when hiring new community nurses. In one of the community focus groups and in the interview with the director of a service delivery NGO in Shuto Orizari, the lack of nurses was especially pointed, as there are merely 3 community nurses for a population roughly estimated at 40,000 persons. The demand for employment of nurses that speak Romani language was also expressed, and the director of the

10 EU Directive 2005/36/EC available at: <http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:2005:255:0022:0142:en:PDF>.

11 Law on recognition of professional qualifications, Official Gazette of the Republic of Macedonia no. 171/2010, available at: <http://www.slvesnik.com.mk/Issues/4612565AE44D754083A7000F9011D94A.pdf>.

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Community nursing assessment with equity analysis in Macedonia | Final Report6. AnnexesNGO said that there are graduated medical nurses that are unemployed, but speak the language and live in the community.

The Faculty of Medicine is providing education for patronage nurses, but through the profile of medical nurses (as we already have described in the medical education training section). There is no separate profile for patronage nurses, and the different skill that they need are obtained upon joining the institution where they will work as PN.

The formal medical training is provided by the medical faculties in the country on theoretical grounds. The practical skills which need to be provided to the future nurses in preventive/primary healthcare facilities is currently a problem, due to reform of primary healthcare and lack of capacities in the preventive healthcare. The nurses are receiving practical skills training as in-service training.

The Centre for vocational training also explained that there is no separate profile of patronage nurse within the healthcare profession (professions are defined with profiles and sub-profiles), and that the patronage nurses receive in-service training for additional skill that they require for working as PN.

In its Operational plan for active measures for employment 2011,12 the Government of Macedonia has determined that there is a lack of patronage nurses on the labor market, and the Centre for Vocational training was instructed to prepare training modules but for the patronage caretaker (neguvatelka) not patronage nurse. These courses could be attended by a person that graduated from elementary school, and the courses have lower educational level than the medical high school degree that is usually the minimum education for the patronage nurses in the country.

As the patronage nurse was identified as a deficient profession in the labor market, the Ministry of Labor and Social Policy (MLSP) has prepared two measures for the 2011 Operation plan that include training of patronage caretakers: training of deficient profiles and support to the employment for Roma. The two measures include training for other professional profiles, and the Operational Plan does not specify how many patronage caretakers were planned for training during 2011.

The modules for each of these vocational trainings are scheduled for a duration of 3 months theoretical and 1 month practical learning (practical part has to be completed in a service delivery institution, not at the training facility). The Medical High School of the City of Skopje has undertaken one cohort of 20 students for patronage caretakers that was successfully completed in September 2011.

Both measures are implemented in cooperation between MLSP, Employment Service Agency (ESA), and the Centre for Vocational Training and UNDP as donor. The first one has total planned budget of 9,996,000 MKD (approx. 230,000 USD) for training of 170 persons and it is implemented from the budget or ESA. The second one, targeting the Roma population, has a planned budget of 2,000,000 MKD (approx. 46,000 USD) for

12 Operation Plan for Active measures for employment, 2011. Ministry of Labour and Social Policy of the Republic of Macedonia. http://www.mtsp.gov.mk/?ItemID=BD66FCC3A7FBCB47AB9150CBFECD2C96

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Community nursing assessment with equity analysis in Macedonia | Final Report6. Annexestraining of 34 Roma persons. The budget for this activity is planned from the MLSP budget transfers to the ESA.

Many of the patronage nurses have expressed their desire to be more involved in the CME and trainings, but when asked what particular training they need, they are not expressing any distinct areas. Mainly quoted are: new techniques in nursing, medical records (if and when updated, for the time being, many of them have undergone the training when it was offered), and new and refreshing trainings on practical skills especially for the new patronage nurses.

3.3.2 Technical means

The technical means as quality precondition for community nursing services have been looked through the availability of spatial and infrastructural conditions, as well as in terms of equipment necessary for performing the services in the field. Almost all community nursing units within the 33 Health centers are organized as separate organizational units (29), with exception to 3 that are within another unit (Berovo, Delchevo and Radovish), and 1 that has not reported the status of their community nursing service (Kichevo).

With regard to the spatial and infrastructural conditions, almost all community nursing units have their own space (30), with exception to 3 that are sharing the space with another unit (Gevgelija, Kavadarci and Pehchevo). Among those that reported the size of the own space for the community nursing services, the space dedicated ranges from 16 m2 to 100 m2, on average being 40 m2 (this does not include the health centers in Debar, Kriva Palanka and Shtip that have reported to have own space for the community nursing services, but have not specified the dedicated surface).

Figure 19: Dedicated space per patronage nurse (as per reported dedicated space by healthcare managers)

Health center Number of Nurses

Dedicated space (m2)(as reported by HCM)

Dedicated space (m2)/nurse

Berovo 4 16.00 4.0Bitola 9 100 11.1Debar 5 0 0.0Delchevo 5 10 2.0Demir Hisar 2 12 6.0Gevgelija 8 0 0.0Gostivar 23 30 1.3Kavadarci 10 0 0.0Kichevo 11 16 1.5Kochani 6 30 5.0Kratovo 2 16 8.0Kriva Palanka 5 0 0.0Krushevo 2 15 7.5Kumanovo 26 80 3.1Makedonski Brod 3 48 16.0

30

Community nursing assessment with equity analysis in Macedonia | Final Report6. AnnexesHealth center Number of

NursesDedicated space (m2)(as reported by HCM)

Dedicated space (m2)/nurse

Negotino 6 26 4.3Ohrid 10 50 5.0Pehchevo 1 0 0.0Prilep 17 60 3.5Probishtip 2 20 10.0Radovish 6 100 16.7Resen 4 25 6.3Rostushe 2 16 8.0Shtip 7 50 7.1Skopje 76 65 0.9Struga 14 50 3.6Strumica 16 36 2.3Sveti Nikole 4 0 0.0Tetovo 32 55 1.7Valandovo 2 20 10.0Veles 10 40 4.0Vevchani 5 40 8.0Vinica 3 38 12.7

In the facility assessment of the 10 healthcare centers, the reported dedicated space was confirmed; however, in most of the health centers this space was not recently refurbished.

Basic office equipment was found to be in a very bad shape, given that most of the ZD had their patronage service equipped through donor assistance (UNICEF project of 2001). This refers to filing cabinets, desks, chairs and other office furniture. As for the office equipment, such as computers and printers, it was reported that the old ones have been recently replaced with new ones (one computer per PPS in each ZD), but those were not seen during FA visits, as they were not yet installed. In some ZD it was discovered that the furniture and equipment that was donated to PPS were used by other units.

Most of the drawers for keeping records were broken and not in use and alternatives for record keeping were noticed, such as cardboard boxes, on top of the drawer racks or within personal lockets of community nurses. In all healthcare centers the records were not kept locked, but was secured that the room is accessed only by the nurses, except in one case where the records were kept in the drawers in the corridor and in the room which is open to access by external personnel.

In some healthcare centers, the space for community nurses has been reduced due to the possibility for renting the space to the primary healthcare providers, which is an

income generating activity.

With regard to vehicles, only 21 of the Health Centers

31

Figure 20: Use of transportation by type, as reported by patronage nurses in self-administered questionnaire (n=287)


reported that there is a dedicated vehicle for the use by community nursing services; it is usually reported to be an off-road vehicle (4x4) or a passenger vehicle, most of which are over 10 years old (see tables below). All health centers that reported dedicated vehicles for the community nursing services have also reported that the vehicles are in use, but that the condition of the vehicles is not very good, often requiring repair. One health center reported that they often use bicycles (Gevgelija).

More than 80% of the community nurses have reported that they are using transport mean for their daily work, and 50% are using transport regularly or often. Among the offered answers, use of vehicle from the health center prevails (59%), but there is also a percentage of use of private vehicles (14%) for which reimbursement of costs has to be determined through the next stages of the research.

It was interesting to observe (see Figure 51 below) that some health centers did not report availability of transport, whereas the patronage nurses reported use of vehicle from the institution, leading to the conclusion that the patronage nurses are using vehicle that is not dedicated to the community nursing services (Debar, Kratovo, Krushevo, Ohrid, Radovish, Shtip, Valandovo). In all visited healthcare centers the vehicle that was donated to the community nurses in 2001 by the UNICEF project is currently being used by the healthcare manager, but those vehicles are also reported to be old and need frequent repair. In the case of Shtip, there is organized transportation for the community nurses, taking each of them to their community, and returning them at the end of the working hours back to the healthcare center. This is, however, still dependent on the availability of the vehicles and drivers, and the healthcare manager reported there is a need for a dedicated vehicle with a driver for the community nurse service.

When asked about transportation, many community nurses state that they prefer to have a driver-operated and maintained vehicle over the option for them to take care of the vehicle themselves. Several healthcare managers suggested that a 4x4 or a field vehicle is a better option for the community nurses, as often the most in need communities are in far and hard to reach places, with bad or no roads. Still, if they have to choose, the community nurses prefer to have training over a dedicated vehicle.

To collect standardized data on the available mobile equipment needed for delivering services in the field, the questionnaire for healthcare managers offered a list of equipment in which a quantity, year of production and condition of each item was required to be inventoried. Almost all healthcare managers responded that the standard but very basic tools are available, such as manometer with stethoscope, glucometer, cassette with tweezers, clamp and scissors, thermometer; all without exception confirmed the availability and regular usage of supplies (gauze, cotton, disinfectant) and protective gloves, as well as uniforms and shoes for the field work. Some health centers

32

Vehicle from institu-

tion58.54%

Private vehicle13.59%

Motorbike/bike

1.39%

Public transport26.48%

Community nursing assessment with equity analysis in Macedonia | Final Report6. Annexesin their inventory have mobile delivery set (Delchevo, Rostushe, Shtip, Vevchani), mobile incubator (Shtip, Delchevo), mobile ECG or CTG apparatus (Kumanovo, Shtip, Delchevo).

Likewise, from the community nurses’ point of view, the available equipment is not in good condition (72%), and insufficient for delivering good quality services to the community (95%). Among the equipment that can improve the quality of work, community nurses most often stated the following items: patronage bags with hygienic sets, set for personal protection, uniforms and walking shoes, mobile telephones, and vehicles. In focus groups, Bitola was pointed as good example, where the healthcare manager is regularly providing necessary consumables for the proper delivery of services (umbilical cord sets, sanitizing hand gel, gauze, protective gloves, etc.). The community nurses received a donation of glucometers and cholesterol meters but the consumables for these apparatus is expensive, thus they use it only in some occasions; however, the nurses from Bitola reported that the population sees them more seriously and with more confidence when they have a possibility to measure blood sugar, blood pressure or to perform other services that can be done with mobile equipment. A unanimous agreement exists that having proper equipment, will not only ease the monitoring of the condition of a pregnant woman at home, but also contributes towards the better appreciation of community nurse profession within the community.

The facility assessment also showed that the equipment is really scarce and in improper condition.

Thus, the following standard equipment that is required for functioning of community nurses was identified (basic and additional):

Figure 21: Basic minimum standard equipment per community nurse and pricingDescription Amount Price rangeGlucometer + 200 strips and 200 needles

1 per nurse = 15 EUR + VATconsumables: (15x4 + 200*0,4 EUR) + VAT

155 EUR + VAT

Manometer with stethoscope 1 per nurse 15 to 60 EUR + VAT

Thermometer 1 per nurse 2 EUR + VATConsumables (sterile gauze, cotton puffs, disinfectants, physiological solution)

Weekly supplies per nurse(per visit)

1-2 EUR per visit

Protective gloves Weekly supplies per nurse(1 pair per visit)

3-4 EUR

Protective apron Weekly supplies per nurse (1 apron per visit)

1 -5 EUR per piece

ID card (legitimation) 1 per nurse 1-2 EURUniform 1 set per nurse: garment +

shoes(Summer + winter type)

90-120 EUR per set

The uniform is currently available for nurses in only one healthcare center (Shtip), and there is no standardized ID card for presentation of community nurses during their visits in any healthcare center. The uniform in Sthip is a good practice example of initiative and creativeness of the main patronage nurse and healthcare center manager

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Community nursing assessment with equity analysis in Macedonia | Final Report6. Annexesseveral years ago, and it needs to be made a standard of the community nurse service; some of the respondents in the community focus groups disapproved a nurse visiting without an identification badge and uniform, and the community nurses share this opinion, adding that it is more appropriate to be dressed in working garments rather than own personal clothes that depict one’s taste, style, etc. It was suggested that an ID card and a uniform consisting of set of garments for summer and winter conditions and walking shoes be made available for each nurse, and in that way, besides providing a protective working garments, to also improve the image, recognizability and visibility of this profession among the population.

Figure 22: Additional equipment for community nurse service (for additional services)Description Units Price rangePatronage bag + Cassette with pincete, pean, scissors, scalpel (sterilizable)

1 per vehicle (not for carrying by a nurse) + 1 per patronage bag

184 EUR + VAT

Mobile delivery set including:Busch umbilical scissors, 16 cm long, angled

1 per vehicle1

248 EUR + VAT

Oechsner haemostatic forceps, straight, 14 cm long 2Gross-Maier sponge forceps, straight, 20 cm long 2Collin umbilical cord clamp, 9 cm long 2Stainless Steel solution bowl, capacity 6,0 liters 1Mixing bowl, stainless steel, 50mm x 116mm diameter 2Mobile incubatorHood with double Plexiglas walls for heat conservationDigital temperature display in the incubator and the skin of the newbornMicroprocessor controlDisplay of battery status and alarmTemperature control 22-38 degreesRelative humidity 50-70%Suitable for ground and air transportIncluded: mattress, belts, lamp, 12V batteryPossibility for operation (under full battery) 240 minutes and at least 200 cyclesCharging cable for use in a vehicleOxygen control 21-58% and O2 inlet socketDistilled water canisterTwo front doors and one hole with IRIS cover

1 per vehicle 13.500 EUR + VAT

Mobile ECG and ECG paper12 outlets, 1 channel to screen and 1 channel to paper. Standard: cable, 4 rods and 6 pumps, 20 rolls of ECG paper

1 per vehicle 290 EUR + VAT

Mobile CTG apparatus for pregnant women and gel 1 per vehicle 1.500 EUR +VATOxygen tank 0.5 L ; approx. 20 minutes treatment with refill possibility

1 per vehicle 200 EUR + VAT

Foetal Doppler gel 1 per vehicle 80 EUR + VATLight bag (for carrying by each nurse) 1 per nurse 15-25 EURScale 1 per nurse 20

Office equipment most usually consists of desktop computer and printer, but no Health center reported that they have internet connection. Landline is available to all

34

Community nursing assessment with equity analysis in Macedonia | Final Report6. Annexescommunity nursing units, and mobile phones are sporadically mentioned in the inventory (only by 5 Health centers, whereas most likely in other services community nurses are using private mobile phones for communication).

3.3.3 Quality assurance

According to the personal accounts of both community nurses and healthcare managers, there is a system of recording all visits performed by each nurse by type and number on a daily basis, and all healthcare centers to which facility assessment (FA) was performed maintain such records. However, there is no system to track the accuracy of the data provided in the records, as well as no system for quality assurance of the services provided. Thus far, according to community nurses, the system self-controls on the principles of their diligence and loyalty/devotedness to the profession; however they also note that such system is needed, for the reasons of fair and just valuation of the work and efforts of each nurse. In the focus groups with end-users some sporadic complaints were heard about the quality of the visit and of the advices provided by the visiting community nurse, mostly related to informality of the behavior of the nurse about other issues not related to the purpose of the visit, as well as to the differences in attitudes between the primary healthcare provider and the community nurse, mainly about the care for the newborn. Yet, much more were the comments that the nurses have been very helpful, providing support and encouragement to the mother, regarding breastfeeding, bathing, umbilical cord, etc. (further elaborated under training and technical equipment sections).

In some Healthcare centers (such as Skopje) the responsible nurses tried to introduce control via contacting the mother that was on schedule for visit that day, but they consider this method to be inappropriate. However, in smaller places (which is the case with most health centers), such method is also non-applicable due to the familiarity of the community nurses with the population and vice versa.

All healthcare managers that the team had spoken to think that the quality assurance is very important, but there have been no ideas yielded on how to establish this system. The only, so far, established method of monitoring the working hours of the community nurses is the necessity for each nurse to come to the healthcare center at the beginning of the working hours and to come back before the end of the shift, so that the working time is recorded. In the focus group with main and responsible community nurses from each healthcare center, this topic opened quite a vivid discussion, with argumentation that community nurse is a field profession, and returning to the premises of the healthcare center does not yield anything but a lot of stress on the side of nurses that they have to be back in time, and that the field work and the specificity of the target population (especially newborns) seldom allow for good planning of nurses’ time. (More on this is given under technical equipment section).

Many of the nurses have acknowledged the fact that after completing field work they are required to come back to the premises of the health center (except those that are located in separate units, such as the case of Tetovo and one nurse working in remote villages in Veles). There are several health centers that do not require this practice, but it seems that such practice is at the discretion of the director of the facility.

35

Community nursing assessment with equity analysis in Macedonia | Final Report6. AnnexesIn relation to reliance on the advice or support of other health professionals, community nurses were asked if they consult other healthcare professionals about some issues related to their field work; 99.7% responded that they do, of which nearly same percentage responded that they consult other healthcare professional often (49%) and sometimes (51%).

Additionally, if they need professional advice, all respondents stated that they refer to another healthcare professional, and the preferences for consultations is almost equally shared between colleague/peer (28.5%), main community nurse (25.5%), primary healthcare doctor (24.5%) and a specialist (21.5%). The qualitative research revealed that the advices sought are mainly for purpose of validation of own opinion or practice, which can be considered as informal way of refreshment of knowledge. However, the interesting emerging conclusion from such practice is that there are solid links to the primary healthcare providers in most health centers, although informal from the systemic point of view. Such links were established prior to the privatization of the primary healthcare, and have been maintained mainly as a result of personal connections and acquaintances.

3.4 Service costs and resource requirements

3.4.1 Current flow of funds and costs

(1) Financing mechanisms and practices

HIF provides financing to ZD for services under the basic benefit package as described schematically on Figure 55 (below).

The previous reports and analyses show that preventive and curative programs financed by the Central Budget and administered through the MOH budget, are formulated by the MOH, based mainly on two sources of information: 1) requested information about planning for the next year from the ZD and the information from reports received from the Institute of Mother and Child Health (IMCH), and on historical data, i.e. on previous years’ programs and reporting of the utilization of the services from those programs. It is noteworthy, that both sources of data are used as reference only, as the MOH is creating the programs based on the Strategic documents in the field, as well as on the overall budget projections for MOH by the government and the Ministry of Finance.

Once established, the budgets in the preventive and curative programs are executed based on contracts of MOH with the healthcare facilities from the public sector. In its 2010 report, the State Audit Agency has found out that the contracts concluded under the programs are not reflecting previous years’ unpaid obligations (that were not paid by the MOH from the Program), and these obligations are also not reflected in the accounts of the healthcare facilities as receivables.

HIF concludes contracts with the healthcare facilities (whether public or private) for purchase of healthcare services; likewise in the ZD are concluding contract with HIF, based on the offer that they send in advance in the current year for financing of the next year. The offer is translated into contract containing budget ceilings, divided into two main service categories: (1) preventive healthcare and emergency services with home

36

Community nursing assessment with equity analysis in Macedonia | Final Report6. Annexescare, and (2) specialistic-consultative services. Both categories of services are defined as packages of services (such as see Figure 55 below), for which the contact is stating the amount and modalities of payment. This new model of financing of the preventive healthcare and emergency with home care HIF introduced in 2010 defining packages by reference price per team, for 7 services types: emergency; home care; 24-hour health service; preventive dentistry; polyvalent patronage service (PPS); emergency dentistry; and systematic checkups, immunization and counseling.

However, it is noticeable, from the sample-contract that the packages for specialistic-consultative services are better defined in terms of conditions and indicators of performance, as well as specification of fixed and flexible percentage of the package, that indicates some performance-based payment for the services provided. On the other hand, the ones for the preventive and emergency services with home care do not have such specific determination in the contract, and clauses referring to these are much less in the revised sample-contract.

As explained, the contract between HIF and ZD specifies the budget ceilings that are paid based on invoice for implemented health services that the ZD delivers to the regional office of HIF. For the preventive packages, that includes the PN package, the reporting and invoice form consists of lump sum aggregated reporting for flat rate payment of the packages.

At the end of the year, if the invoiced amount is different than the contracted amount (either higher or lower), as per the contract provisions, both healthcare facility and the HIF will write-off the difference between the invoiced and contract-determined amount.

The package for PPS, as described by the HIF, consists of the following cost categories: (1) salary for the PN, based on the collective agreement for healthcare labor; (2) transportation costs; (3) consumables and medicines that are used by the PN; and (4) other utility costs. However, the exact cost breakdown could not be identified, as also in the contract the amount of the package is defined as: “groups of sets of healthcare services, presented as average of most commonly used services, in relation to the evidence-based medicine”.

The State Audit Agency (SAA) on annual basis is auditing particular institutions and other organizations that are using funding from the State budget. In the previous practice, the Annual reports of the SAA were showing details of the audits in every audited entity, whereas, this practice has changed from 2008 onwards, when only general opinions are given for some of the major institutions and organizations audited. In the 2007 annual report, the audit reports for ZD Skopje and HIF are presented, and the weaknesses of the ZD Skopje and HIF described are as follows:

ZD Skopje

Improperly kept and non-updated accounting books – ZD Skopje

Non-adherence to the accounting principle of cash/calculation accounting

Non-alignment of the recorded receivables/payables with the financial records of the clients/debtors

37

Community nursing assessment with equity analysis in Macedonia | Final Report6. Annexes HIF

Process of public procurement

Non-existence of written procedures for clear delineation of authorities and responsibilities

Improper recording of the changes in the balance sheet/balance statement

Payment of funds without basis, proper proof of purpose or sound documentation

Unrealized public procurements that were planned

Improper following of the established procedures

Since 2008, the SAA is providing a much more general view on the situation found in each of the audited entities. However, the situation described in these reports indicates that the contract-based service purchase of the HIF from public healthcare facilities has been paid more than the budget ceiling provided in the contract amount (Report 2008), based on which finding the HIF has enacted a decision on the criteria for determination of the budget of the healthcare facilities and procedures for monitoring of the concluded contracts (in 2009). SAA also recommended that the HIF makes payments to the HC based on the contracts and indicators described thereof. In the 2009 report, SAA has found that written procedures missing or not followed, and thus has recommended the HIF to establish those procedures, as well as to establish a sound and effective control mechanism in some segments of its performance, that will reduce or minimize the risk from incorrect payments to HC. In the 2010 report, SAA continues to notice that the established policies, procedures and activities are not providing rational justification that the goals of those entities will be achieved for which purposes SAA provides the recommendation that those procedures and activities are defined in a more structured and purposeful manner.

(2) Financial flows

The healthcare managers in the 33 health centers were asked to provide the data on the revenues and expenditures for the community nurses. The data that was received was followed up by the qualified surveyor to confirm accuracy and to collect the data that was not initially received. As stated by all healthcare managers, the financial records are not kept separately for patronage nurses. Summary of financial data reported by HCM is presented in Annex K(see Figure 61 “ZD revenues and expenditurs (inthousands MKD) relatted to PN as reported by HCM” below).

38

Community nursing assessment with equity analysis in Macedonia | Final Report6. AnnexesFigure 23: Comparison Financing of PN in 2009 and 2010 by Zd (in millions MKD) as

reported by HCM

0

5,000,000

10,000,000

15,000,000

20,000,000

25,000,000

30,000,000

Total 2009 Total 2010

Financing of ZD increased by 6% from 87.3 in 2009 to 92.8 million MKD in 2010 as reported by HCM (Figure 23 above). In some ZD financing of PN decreased substantially (by 74% in Probishtip, by 44% in Resen or by 29% in Kratovo) while in others a dramatic increase was observed (by 963% in Berovo, 663% in Kochani, 169% in Debar). Some HCM did not provide information on financing of PN services (e.g. Bitola, Kavadarci, Pehchevo).

The main sources of funding for the Health centers are: Ministry of Health (preventive programs), Health Insurance Fund (preventive services, specialistic-consultative packages and laboratory services) and own sources of revenues. The category of own sources of revenues consists of: fees for medical check-ups (mainly for driver’s license obligatory medical examination, systematic medical examinations under the Law of occupational health and safety), rent of excess space within the Health center (mainly renting to primary healthcare providers) and co-payment for services provided under the HIF basic benefit package. Some Health centers reported sporadic revenues from provision of mobile health units during organization of public events with mass gatherings.

Figure 24: Comparison of the revenues for community nursing services to total revenues by Health Center (2010 figures in MKD)

Health Center Total revenues13 Financing of community nursing14

PN financing share of total revenues (%)

Berovo 29,693,000 1,440,000 4.85Bitola 170,415,000 3,240,000 1.90Debar 17,396,000 1,800,000 10.35Delchevo 72,381,000 1,800,000 2.49Demir Hisar 25,387,000 720,000 2.84Gevgelija 38,480,000 2,880,000 7.48Gostivar 78,263,000 8,280,000 10.58

13 Source: Annual Report of Health Insurance Fund 2010 (HIF website: http://www.fzo.org.mk)14 Calculated as per paid package for community nursing services (30,000 MKD/nurse/month in

2010)

39

Community nursing assessment with equity analysis in Macedonia | Final Report6. AnnexesHealth Center Total revenues Financing of

community nursingPN financing share of

total revenues (%)Kavadarci 38,512,000 3,600,000 9.35Kichevo 36,409,000 3,960,000 10.88Kochani 42,538,000 2,160,000 5.08Kratovo 25,380,000 720,000 2.84Kriva Palanka 77,953,000 1,800,000 2.31Krushevo 22,308,000 720,000 3.23Kumanovo 93,123,000 9,360,000 10.05Makedonski Brod

21,581,000 1,080,000 5.00

Negotino 56,445,000 2,160,000 3.83Ohrid 63,660,000 3,600,000 5.66Pehchevo 18,491,000 360,000 1.95Prilep 136,885,000 6,120,000 4.47Probishtip 27,077,000 720,000 2.66Radovish 44,257,000 2,160,000 4.88Resen 59,320,000 1,440,000 2.43Rostushe 19,926,000 720,000 3.61Shtip 46,452,000 2,520,000 5.42Skopje 659,838,000 27,360,000 4.15Struga 40,377,000 5,040,000 12.48Strumica 61,700,000 5,760,000 9.34Sveti Nikole 40,434,000 1,440,000 3.56Tetovo 109,579,000 11,520,000 10.51Valandovo 33,419,000 720,000 2.15Veles 66,183,000 3,600,000 5.44Vevchani 37,716,000 1,800,000 4.77Vinica 34,241,000 1,080,000 3.15Total 2345819000 7200000 ** Expression is faulty

**

It is noteworthy that calculations of the financing of community nursing (from HIF presented on Figure 24 above) do not match with the figures reported by HCM (on Figure 61 below).

Figure 24 above that PN financing by HIF constituted in average 5.2% of the total revenues of the ZD. In several ZD (Struga, Shtip, Tetovo, Debar, Gostivar and Kumanovo) the share of financing of PN was more than 10% of the total revenues in opposite to less than 2% in Bitola and Perchevo.

Figure 25: Financing of the MoH Preventive Programs (PN component) by Years (in MKD)

Program components

2009’ 2010’ 2011’

Antenatal care 920,000Postnatal care 920,000Infants (patronage visits)

1,564,000

Families at risk 1,500,000

1,500,000

1,538,600

40

Community nursing assessment with equity analysis in Macedonia | Final Report6. AnnexesProgram components

2009’ 2010’ 2011’

Training 1,000,000

450,000 300,000

Total 5904000

450000 300000

Financing of the PN by the MoH has changed substantially for the last 3 years as shown on Figure 25 above: if in 2009 the MoH prevention program was financing non-labor costs of all services (4,906,009 MKD), from 2010 the financing of only one service (for families at risk) was maintained and the rest was absorbed by the financing of the patronage nurse package by HIF.

Institute for Mother and Child Health (IMCH) is responsible for providing technical support to the activities of the PN, realized as field visits for expert-methodological assessment of the polyvalent patronage services (in the 2011 Program for active healthcare to mothers and children, the 50 visits are budgeted with 5,000 MKD per visit, or total of 250,000 MKD, as co-financing for the ORIO grant from the Dutch government) This activity was not financed in the program of 2010 or in 2009. It is noteworthy that in the 2009 program it was also stated that the IMCH is responsible to participate in the preparation of the guidelines for performing PPS, and for field visits to PPS, but funding for these activities was not budgeted in the respective program.

(3) Salaries

Monthly salaries of PN are defined based on a collective agreement for the labor in health care (between the syndicate of health professionals and the MoH).

Figure 26: Comparison of PN monthly salaries by development regions (in MKD, n=338)

PN monthly salaries varied from 20,176 MKD to 40,921 MKD (equivalent to 460 – 930 US$) as shown on Figure 26.

The lowest average monthly salary was detected in Polog development region (25,772 MKD) vs. the highest average monthly salary in Eastern development region (28,008 MKD).

Country average PN monthly salary amounted to 27,012 MKD.

Figure 53 (below) shows the share of the non-labor related costs in the total financing of PN services: the share was estimated based on the figures reported by HCM as well as calculated by researchers (extracting salary costs from the revenues received by ZD from HIF under PN package financing). The figure shows that the share of no-labor costs was 10% in average ranging from as high as 20% in Rostushe to negative values -0.5% in Shtip (meaning that salaries expenditures were higher than all funds received from HIF for PN services). Calculations based on the HCM reported financial figures differ significantly – many HCM did not report non-labor expenditures at all and the

41

Development Regions

Average

Min Salary

Max of Salary

Polog 25,722 23,494 31,427South-eastern 26,449 24,296 29,238North-eastern 26,720 20,176 36,925Pelagonia 27,227 24,426 32,275South-western 27,417 23,961 40,370Skopje 27,430 24,148 38,033Vardar 27,459 24,222 38,180Eastern 28,008 23,651 40,921Country 27,012 20,176 40,921

Community nursing assessment with equity analysis in Macedonia | Final Report6. Annexescountry average share of non-labor expenditures amounted to 2.8% (vs. 10% estimated by researchers).

Figure 27: Comparison of PN monthly salaries in 2010 by ZD (n=338)

15,000

20,000

25,000

30,000

35,000

40,000

45,000

PN monthly salary range in ZD Series1

Average monthly Salary of PN

Monthly salary average by ZD varied from the lowest 24,000 in Rostushe to the highest in Shtip – 30,151 MKD. The largest variation in monthly salary was observed in Shtip, Ohrid, Kumanovo, Skopje and Kichevo ZD as shown on Figure 27 above.

3.4.2 Estimation of future resource requirements

Projections of PN service financing by HIF and MoH (see Figure 54 below) estimated 26% annual increase in 2012 (from 130.0 to 163.8 million MKD). If salary rates remain the same in 2012 then the share of non-labor related expenditures become 33% in 2013 (three times more than in 2010 and 4.5 fold increase in absolute terms from 12.4 million in 2010 to 53 million MKD in 2012).

A modeling tool has been used to estimate future resource requirements for the investments in human resources and infrastructure.

Costs of training were calculated based on the type of trainings (obligatory and optional), staffing level and investment approach (train all staff or only new staff and those that missed the specific training). Figure 38 (below) shows that total costs vary from 600,000 to 900,000 EURO.

A provisionary set of necessary equipment served as a basis to estimate the need for medical and office equipment, vehicles and additional medical equipment. Costs for renovation of space considered actual amount of space used by PN in ZD (as reported by HCM).

The results of projection are presented on Figure 39 (below): the total investment costs were estimated at 1.8 million EURO out of which 40% has to be allocated to human resources and the rest – to physical infrastructure and equipment.

42

Community nursing assessment with equity analysis in Macedonia | Final Report6. AnnexesIt has to be stressed that this projections are illustrative and actual investments costs can (and should) be revised after defining the professional standards first of all and elaboration of a HR strategy for patronage nurses. The modeling tool allows to link dynamically investment needs with the choices that shape functional and structural characteristics of PSS as well as more precise unit costs.

The same tool allowed the estimation of recurrent (running) direct costs for each ZD as shown on Figure 40 (below). The calculations are based on historical workload (total visits reported by PN and HCM) that defined the share of variable direct costs (consumables). The projection shows that salaries absorb approximately 77% of all direct costs and 16% are needed to cover costs of consumables.

If only HIF financing is considered (40,000 MKD per patronage preventive package), approximately 13% of the total revenues can contribute to the recovery of overhead (indirect) costs. The projections also show that the average direct cost of visit amounts to 400 MKD approximately (or 6.4 EURO). Again, the proposed projections are illustrative and the modeling tool allows to elaborate scenarios that differ by staffing level, workload rates and unit costs.

3.5 Feasibility of collaboration with other community services

For the purpose of this assessment community services refer to any health and social care related interventions provided by public entities directly to communities at the place of residence or education. Patronage nurse services are one of community nursing services delivered by Zdravstven Dom and it is important first to understand how Zdravstven Dom is positioned relatively to primary health care services that has undergone significant reform.

Briefly, the privatization of publicly-owned PHC which started in 2005, brought market rules into the healthcare sector in Macedonia; the PHC providers that have been working in the public sector as general practitioners (GPs), pediatricians, dentists, gynecologists, school medicine doctors and pharmacists15 have been obliged to open private PHC offices and sign a capitation-based contract with the HIF, for payment per registered patient.

In general, the contract includes two major payment categories: 70% of the capitation fee is transferred each month based on the number of registered patients. The remaining 30% of the capitation fee per registered patient is conditioned with fulfillment of the so-called preventive goals of the PHC (see Figure 28 below), which are defined each trimester: rational prescribing by limiting the number of prescriptions per registered patient (7%), rational referrals and sick-leaves (4%) and preventive services and early detection of malignancies and deformities in children (combined 19%) (HIF 2010). The preventive goals are planned at the beginning of each trimester (as per calendar year), implemented and reported.

15 Gjorgjev, D., Bacanovic, A., Cicevalieva, S., Sulevski, Z., Grosse-Tebbe, S. “The former Yugoslav Republic of Macedonia: Health system review”. Health Systems in Transition, 2006; 8(2):1–98.

43

Community nursing assessment with equity analysis in Macedonia | Final Report6. AnnexesFigure 28: Preventive goals of the primary healthcare (January-March 2010)

(adapted from Preventive Goals in PHC, HIF, 2010)Goal Description of activities Indicator % of

capitationApplicable to

A. General (for all PHC) (total: 11%)Prescriptions Rational use and rational

prescribing of medicines on the PLD

Number of prescriptions

7% All patients

Referrals Rational referral to higher levels of healthcare

Number of referrals

2% All patients

Sick-leaves Rational and justified referral for a sick leave

Number of sick-leave referrals

2% All patients

B. PHC for age groups 0-6 and 6-18 (19% in each group)Anemia PA for children age 0-6 Number of

reports5% For 12.5% of

age groupPreventive activities for children age 6-18

5% 1.875% of age group

Asthma PA for children age 0-6 Number of reports

4% For 2.5% of age group

Systematic check-up of newborn

PA for infants up to 30 days

Number of reports


Obesity PA for children age 0-18 Number of reports

6% 1.875% of the age group

Flatfoot problems

PA for children age 0-6 2% For 12.5% of age group

Spine deformities

PA for children age 6-18 Number of reports


Healtheducation

PA for children age 6-18 (in schools)

School-certified report

2% 1 lecture per 150 children in age group

C. PHC for age group >18 (total: 19%)Breast cancer PA for early detection Number of

reports3%

Prostate cancer PA for early detection Number of reports

2%

Cardiovascular diseases (CVD)

PA for early detection Number of reports

14%

Although not as a classical process of transfer of public goods into private ownership, the privatization process of the PHC has taken place between 2005 and 2008, with the biggest shift happening in 2005. As shown in Figure 3 the rapid increase of the total number of contracts has happened during 2005, although certain branches have made their major shift during other stages of the process. While doctors of general dentistry have moved to private practice mostly during 2005, the number of contracts with general practitioners (GPs) has doubled only in 2007.

44

Community nursing assessment with equity analysis in Macedonia | Final Report6. AnnexesFigure 29: Progress of privatization in PHC, per number of PHC providers signing

contracts with HIF (2004-2008)GP Gynecology Pediatrics School

Medicine

OHS Dentistry

Poly-clinics

Total

2004

387 45 31 1 3 12 72 551

2005

405 48 32 6 3 613 72 1179

2006

558 63 47 6 10 783 70 1537

2007

983 112 88 13 29 724 30 1979

2008

1040 118 85 13 28 857 35 2176

(Source: HIF Annual reports 2004, 2005, 2006, 2007 and 2008)

Health Center (Zdravstven Dom) is a public entity owned by the Ministry of Health. The manager (director) of Health Center is appointed by the Ministry of Health.

From a functional point of view health center consists of 6 units corresponding to 6 business processes (see Figure 30 below):

61 Domashna Poseta teams composed of a doctor and nurse

62 Preventive teams composed of a doctor and nurse

63 Patronage nurses (with a Patronage Nurse Coordinator)

64 Emergency services (with teams comprised of a doctor, nurse and driver)

65 Medical Board to expertise the health of insured (for a temporary disability) - SLC

66 Specialty-Consultative services led by a Head of the Unit and including a wide range of outpatient care offices run by the following specialists (and nurses) (Dermatologists, Neurologist, Mental health specialist, Ophthalmologist, Otolaryngologist, etc.)

67 Diagnostic unit including X-ray and Lab tests

All above-mentioned medical personnel are employees of the Health Center (thus working in public domain).

In addition to these functional units Health Center hosts private offices of General Practitioners (GPs) and Ob&Gy (Obstetrics and Gynecology) specialists with nurses.

Staff in each healthcare facility became difficult with respect to categorization of the staff.16 In similar way, the PPS staffing structure of future needs were not defined within this strategic document, so its destiny remained an issue at the discretion of the minister of health and was solved on a case by case basis on institutional level of each ZD. Namely, each ZD prepares an annual operations program for the next fiscal year,

16 Health Strategy of the Republic of Macedonia 2007-2020, available at: http://www.moh-hsmp.gov.mk/uploads/media/Zdravstvena_strategija_na_Republika_Makedonija_2020.pdf (in Macedonian).

45

http://www.moh-hsmp.gov.mk/uploads/media/Zdravstvena_strategija_na_Republika_Makedonija_2020.pdf

http://www.moh-hsmp.gov.mk/uploads/media/Zdravstvena_strategija_na_Republika_Makedonija_2020.pdf

Community nursing assessment with equity analysis in Macedonia | Final Report6. Annexeswhich also includes financial and human resource needs and projections. These programs have to be adopted by the Management Board of the ZD, and ultimately to be approved by the MOH. However, as there was no officially endorsed standard found for number of employed PN per population, the decision of the increase of staffing – in our case related to PN – is made upon discretion and strategic vision and knowledge of the MOH (this is also likely in relation with the approvals and decisions of the Ministry of Finance).

The organization and staffing structure of the polyvalent patronage service (PPS) is a responsibility of the MOH. However, the precise mechanism could not be understood in details. With the transformation of the primary healthcare (PHC) and the transformation of the 16 Medical centers into ZD and general hospitals (in the period 2004-2005), the staffing structure and determination of the

With regard to the PPS, the National health strategy mentions its importance, and also projects the vision for this service in the future; for improvement of healthcare services access and quality, MOH will encourage the cooperation between the PHC and the PPS, since PPS is envisaged in the following years to become strong partner to the PHC offices and the offices of family medicine (a healthcare segment currently being established within the health system, and it is envisaged to serve as basis of the future PHC system).

46

Community nursing assessment with equity analysis in Macedonia | Final Report6. AnnexesFigure 30: Description of ZD’s composition and its functional arrangements

In the strategic documents of the Ministry of Health, as previously described, the PPS is envisaged to become a strong partner to the PHC in the provision of comprehensive healthcare services. Further to this, the ruling party in the Government in its program has established a goal by April 2013, to improve the infrastructural and human resource situation in the ZD, by providing new equipment and new employments in the PPS, in

47

Community nursing assessment with equity analysis in Macedonia | Final Report6. Annexeswhich way the quality and accessibility of these services will be improved for the whole population in the country. According to this strategic programmatic document, PPS is defined as mobile healthcare provider delivering services in the home, for both preventive and curative purposes; document also stresses the focus on proper development and revitalization of PPS that inter alia includes coordination with all providers in the PHC, and efficient and mandatory cooperation between PHC (maticen lekar) and PPS. This strategic goal also envisages production of higher number of patronage nurses with university degree, as well as provision of additional vehicles for improvement of the access to the homes of everyone. PPS are also envisaged as extended hand of the family medicine doctors, especially for the follow-up of the medical conditions of patients, and will represent a key link between the healthcare system and the patients in their homes. In remote places, they will perform preventive medical check-ups and provide care for elderly and exhausted persons, families under social risk and follow-up of the chronically ill patients. For the sick patients, they will provide treatment and therapy, such as wound check-up, ampule therapy and care until full recovery of the patient.

48


4 Discussion

4.1 Human resource profile

Aging PN, with no indication of the adequate supply of new generation PN in the labor market

Very low mobility of PN on the labor market Significant disparities in the distribution of PN and staffing structure of ZD across

ZD PN field seems to be a last resort for nurses for securing employment (in response to

structural reforms in health care) Absence of formally recognized professional standards makes it difficult to assess

needs in professional growth and relevance of the previous efforts Professional growth cannot be just a matter of planning and conducting trainings

but should be an integral part of an institutionalized licensing and CME framework

There is a shortage of PN in the country: a simple computation of the need for PN (dividing the total population by 5,000) shows that 404 PN should be employed that is 66 persons more than the current number of PN 338.

However, if inequities in the distribution of PN by ZD are taken into account then the need for PN is even higher – 79 persons assuming that the deficit in some 12 ZD is not offset by the relatively moderate surplus of PN in other 8 ZD (22 persons). If so, the optimal size of the PN pool could be estimated at 417(=338+79).

Figure 31: Requirements in PN by ZDZD Name Presen

tOptima

lNew

68 Bitola 9 21 1269 Kochani 6 10 470 Krushevo 2 5 371 Kumanov

o 26 27 172 Ohrid 10 12 273 Probishti

p 2 3 174 Shtip 7 10 375 Skopje 76 116 4076 Strumica 16 19 377 Tetovo 32 38 678 Veles 10 13 379 Vinica 3 4 1Total 199 278 79

The study revealed not only unequal distribution of PN by ZD but also a wide range of disparities in the staffing structure of ZD. In average, PN constitute one fifth of all nurses in ZD. But in Kichevo (n=11), Debar (n=5), Delchevo (n=5) and Berovo (n=4) they constituted more than third of the nurses (and even all medical personnel!).

49

Community nursing assessment with equity analysis in Macedonia | Final Report6. AnnexesConsidering the fact that a) all ZD have similar functions and should perform duties in a uniform manner (with a slight variation in a service structure), b) have relatively small managerial autonomy and c) are mostly funded through central mechanisms (HIF and MoH), then it is hard to understand and explain the observed variations of staffing by PN, nurses, other health professionals and administrative personnel.

The age structure of PN cohort is another issue worth of discussion: 107 nurses (one third of the pool) will be retired in 15 years. As it is shown on Figure 46 (below), those ZD that are already understaffed would suffer more from the aging of PN (such as Bitola, Krushevo, Kumanovo, Shtip, Skopje, Tetovo and Veles), that is particularly true for Bitola, Kumanovo and Shtip where more than 15% of PN retires in 5 years.

PN labor market dynamics is also characterized with some interesting features:

a) A massive inflow of nurses in 2006 and 2007 (at a larger scale than the one observed in 1988-1989 years)

b) Low turnover and transfer rate from one to another ZD

c) High age of entering the market (33 years), with clear tendency of “aging” in last 5 years (40 years)

d) Migration of nurses from other fields to community nursing (at the age of 37 in average).

All these futures correspond more to the response on institutional changes in health care rather stabile labor market dynamics with a predictable entry of fresh human resource and natural maturity. Without a significant changes in the environment the PN labor market can regain “stabilization” similar to the one observed from 1993 to 2003 (see Figure 5 above).

50

Community nursing assessment with equity analysis in Macedonia | Final Report6. AnnexesFigure 32: Analysis of the flow of PN by work experience and ways of employment at ZD

(n=325)

As a result of the above mentioned tendencies the composition of PN by age and background is quite mixed as shown on Figure 32 above:

167, or more than the half of current PN worked before in the same ZD at a different position with a total length of service 24.7 years in average, becoming PN at the age of 37.1 (in average) and served as PN in average 10 years.

Another 131 PN become PN when they were employed in the current ZD as PN at the age of 29 (in average) having in average 21 years of work experience most of which was dedicated to community nursing (16 years in average):

A larger portion of this pool – 76 never worked before becoming PN – so patronage nursing is their only professional experience. Not surprisingly they entered the field at the young age (relatively) of 25 and are the most experienced sub-group (18.3 years of service as PN).

Remaining 55 persons from this pool had worked in other area first (presumably as nurses – the study did not explore in such details professional background) and later became PN at the age of 34 when were employed at the ZD as PN

The smallest pool of 27 PN joined the current ZD already as PN professionals presumably changing ZD – they had 14 years of working experience as PN (vs. 23.6 years of the total length of service). Only 2 of them worked all life as PN having the longest experience (24.5 years). These 2 PN together with the other 76 PN with work experience ONLY in PN form the core team of the most experienced 78 PN.

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Community nursing assessment with equity analysis in Macedonia | Final Report6. AnnexesThe study revealed that PN have undergone different types of in-service professional trainings. It was not possible to find any regulation that sets minimum skills set requirements for Patronage Nurses that either justify or explain appropriateness of the in-services trainings. Therefore, even if the attendance of 13 training courses reported by PN has been 100% it is not possible to conclude would it have been sufficient or not to meet (non-existent) professional standards.

Figure 33: Relationship between professional standards, in service training and institutionalized Licensing & CME processes

Figure 33 above shows a logical link between the content of professional standards (functions of PPS, duties, nursing and medical services and definition of required knowledge and skills) and content of in-service trainings. It is believed that PPS functions (as a basis for defining PN professional standards) are integral part of a broader framework of preventive care and that the professional standards are defined by the MoH (in cooperation with professional associations). Mandatory licensing is the only mechanism that assures PN’s compliance with the defined professional standards (therefore the dotted arrow refers to “Professional Standards” informing the licensing process). If the licensing is based on the collection of credit ours through CME, than the list of in-service training corresponding to the knowledge and skills requirements informs the CME processes. Finally, the “Description of Services” informs the content of PPS Package that is financed by HIF (for instance, by defining a volume of specific services, quantities and types of consumables, etc. as discussed in modeling of PPS resource requirements in section “3.4.2 Estimation of future resource requirements” above).

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Community nursing assessment with equity analysis in Macedonia | Final Report6. AnnexesIt should be stressed that at the present only the monetary value of the Package of PPS is clearly defined in the country – the content of remaining boxes (colored in blue) is not either clearly specified or formalized and the formal mechanisms of licensing and CME of PN are not existent at all.

If it is assumed that a) professional standards were set (in normative space) and b) reported trainings were clearly linked to those professional standards, then the low attendance rate revealed by the study, particularly related to acquiring practical skills, indicates that PN would hardly meet professional standards.

It is recognized that the professional standards (an in-service training requirements) have to be formulated and formalized within a broader context of PHC and preventive services, but it was needed to estimate existing gaps in knowledge and skills and project investments in professional human resources. For the purpose of this assessment a provisional description of PN functions and skills set was proposed (see Annex E below) with a corresponding description of PN service package (Annex H below) and the list of basic (obligatory) and facultative training courses (Annex F below) developed by the Macedonian Nurses and Midwives Association (MANM). The proposed functions, skills set requirement and training courses can serve as a basis for institutionalizing PN professional standards.

The study shows that without a formal continuous education system for PN it is hard to believe that either training courses are organized and financed in sustainable manner or used by PN as a requirement for their professional recognition. The fact that more than half of training courses (reported by PN) were financed by donors and only one third was initiated and sponsored by the health system (authorities or ZD) indicates that there is a little national ownership and alignment with the community needs.

There is a misconception among PN about services that fall under PN competences and should be delivered by PN if are either authorized or trained for these services (discussed in details in next section). Therefore, not all needs for professional growth as perceived by PN are relevant (vis-à-vis the professional standards proposed for this assessment).

Based on the reported attendance of trainings and the list of recommended in-service trainings the need for trainings was projected considering two pools of PN: the current one (338) and optimal (411). Results are presented in Annex G below. It was assumed that all the trainings reported by PN had been conducted in the recent years and do not require refreshment in next several years. The required capacity to deliver these trainings is discussed in section below (see “4.3 Service quality preconditions andopportunities”)

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4.2 Service coverage and utilization

Volume and structure of PN services adjusted to population needs is extremely diverse across ZD

Newborn related services are over utilized at the expense of pregnant in the majority of ZD

Main barrier for balanced provision of antenatal and perinatal care is related to the lack of forma reliable communication channels between medical service providers

The coverage of different geographical areas by PN was discussed in the previous section (in terms of distribution of human resources per population across different municipalities and/or development regions). In this section the focus the analysis is focused on assessing actual performance (volume and type of services delivered by PN) and demand for different type of services that fall within or outside of the PN area of competence.

Figure 34: Comparison between the population to PN ratio (coverage) and the workload of PN per annum

ZD grouped by Coverage Average coverage for the group

Average Workload per PN per annum

Very low 11,718 1,722Low 6,920 1,104Balanced 4,987 1,084High 4,131 1,256Very High 487 556

Country Average 6,042 1,128

An analysis of the quantitative findings shows that the significant variation of the workload (the number of visits performed per PN as reported by HCM) by ZD is hard to explain by any factor, including the level of coverage of population by PN (ratio of population to PN by ZD or development regions).

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Community nursing assessment with equity analysis in Macedonia | Final Report6. AnnexesFigure 35: Comparison of population to PN ratio and average visits per PN per year by

ZD (n=32, Year 2010 figures)

0

500

1000

1500

2000

2500

3000

0

2000

4000

6000

8000

10000

12000

14000Visit per PNCoverage

The Figure 34 above confirms there is less PN workload when coverage increases except the group of ZD with high coverage (between 2,250 and 4,500 population per PN) but still high workload (1,256 per PN). The further analysis of the coverage groups factoring the number of newborns (or pregnant women) per PN or birth rates could not explain the observed high workload vis-à-vis lower number of general population per PN in this particular coverage group (“High”).

It was assumed that PN were supposed to make 2 antenatal and 2 postnatal visits. When the actual number of services per pregnant or newborn was analyzed by ZD (as shown on Figure 36 below) its findings confirmed a common perception among PN and population that patronage services are targeting newborns more than pregnant women (except for Berovo and Kochani): the overprovision of postnatal services is combined with under-provision of antenatal services in most of ZD.

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Community nursing assessment with equity analysis in Macedonia | Final Report6. AnnexesFigure 36: Need (<0) in PN services by types (antanatal or postnatal) by ZD

-2

0

2

4

6

8

10

12

Visits per PregnantVisits per newborn

No difference was found in terms of workload or service structure between 19 ZD that reported the provision of Domashna Poseta services (home visits) and remaining 14 ZD without reporting DP services. It can indicate complete functional autonomy of these services when existence of one does not affect other and they run in independent parallel mode. It is noteworthy that the scales of both services were found to be almost equal. However, not reporting does not mean that DP does not exist in those 14 ZD. The findings does allow to conclude to what extent the collaboration between PN and DP services could ensure higher efficiency and quality though many believes it could benefit both services and communities ultimately.

The observed asymmetry is unlikely to be caused by unwillingness of PN to pay adequate attention to pregnant women. The study shows that the main barrier toward balanced (at least bivalent) patronage service provision is related to the lack of formalized communication between different medical service providers at the frontier of health care provision (namely PHC doctors and/or Ob&Gy specialists at maternity houses). Patronage nurses often are not aware timely about pregnancy in their catchment area, and if they are informed antenatal care starts with delay. The lack of communication channels affects the timeliness of postnatal care as well (though the volume of services is not affected similar to antenatal care). The need for existence of reliable, timely and quality communication channels is further discussed in next section (“4.5 Feasibility of collaboration with other community services”).

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4.3 Service quality preconditions and opportunities

Understanding of quality of service provision as a concept is vague, is not perceived as a performance dimension and there is no practice either to assess or ensure quality of community nurse services

Preconditions are not sufficiently met to ensure a minimum quality standards at the present

As it was discussed above (see Figure 33) there are no formal professional standards for patronage nurses that have to serve as a starting point for framing a quality concept. Though most of patronage nurses and health center managers were able to articulate quality in theoretical terms based on their personal perceptions and experience, it was obvious that even at the theoretical level this issue has never been elaborated internally (within institutions) or put on the agenda at the operational or policy levels. The package of patronage services that is commissioned by HIF does not contain any reference to quality aspects.

However the opinion is uniform among PN and HCM that quality of services should be defined and operationalized. Moreover, there are open to apply quality assurance mechanism although not surprisingly they have not come up with any feasible proposal for the introduction of quality in every day practice.

The practice of showing up in the office in the end of the working day is introduced for the purpose of establishment of a control system for the operation of the patronage nurses; however, the nurses feel that it is not an appropriate mechanism for control, as they are field workers and have to be in the field. The work they are performing often require that they stay longer in the home, or visit additional homes, if identified in the neighborhood of the visited mother and newborn. Additionally, return to the premises of the health center does not imply that they have completed their tasks for the day, and they are strongly opinionated that this practice should be replaced with another model of controlling the performance. Rather, it is only imposing additional costs (in time and travel expenses). When asked what system would be preferable, they did not have idea of a more optimal model.

On the other hand, directors are aware that this might not be the best option chosen, but it seemed fair in comparison to other services which are also working outside of the health center, such as Domashna Poseta and preventive teams, that also have to come back to the premises before the end of working hours.

Some directors have expressed their confidence in this project that it will ultimately propose a solution for a mechanism for control of workload and quality of services provided, as there have been cases of misuse of the position (field work) and misuse of equipment (vehicles) in the past, for private purposes. They also did not have a particular system in mind, but in essence, have felt that one is needed for improvement of the work of the patronage nurses, and for the betterment of the appearance of the patronage nursing profession in some communities.

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Community nursing assessment with equity analysis in Macedonia | Final Report6. AnnexesThe issue on travel expenses discussed in several of the mini focus groups with patronage nurses in the selected health centers was revolving around coverage of travel expenses of the patronage nurses. This was especially the case in areas where there is no public transportation and for the cases when the nurses have to come back to the premises towards the end of the working hours. Some of them have used alternative transportation (as public one is not available), such as commercial taxi transport, but have not been regularly or fully reimbursed for the costs. Regardless of the fact that the taxi transportation should not be the main transportation alternative, ad hoc incurred costs are difficult to be covered by the payment system of the health center, thus a unified (adjusted to the needs of a patronage service in particular area) system of payment for the transportation costs on monthly basis should be established.

Only in one health center the patronage nurses are receiving financial benefits for the use of mobile phones. Bearing in mind the nature of their work, the compensation of this costs should be taken into consideration; at the moment, most of them are readily providing their private mobile phone numbers to the clients, but are preferring to be called rather than to call someone in case of request of advice or additional home visit.

In terms of infrastructure, major preconditions for proper functioning of PPS have been looked at from infrastructural and functional points of view. It is obvious from the table below (see Figure 37), that critical preconditions for proper functioning are: sufficient and well-equipped space where files/records can be stored safely and cannot be accessed by external persons; means of communication and transport; appropriate and functioning medical equipment and proper supply of consumables; patronage health care record keeping practice; and adequate training and integration into continuous medical education.

In respect to the infrastructural and equipment preconditions for PPS, a standard should also be developed on the minimum dedicated space that needs to be provided for proper operation of the PPS, taking into consideration that most of the working hours they are in the field, but also the need for proper filing of records of visits performed and families/patients visited.

The study also identified that there was no assurance of a standard practice for maintenance of the valuable assets provided by donor assistance or through capital investment programs of the healthcare system, further discussed in the financial section of this study (“4.4 Service costs and resource requirements” below).

Figure 37: Preconditions for PPS operations and quality assuranceItem Criticality for

proper functioning

Desirability for quality of services

Space + facility Filing cabinet X Personal locket X Other office furniture (desks, chairs) XProfessional Identification attributes (e.g. uniform, ID badge)

X

Office equipment (computer, printer) X

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Community nursing assessment with equity analysis in Macedonia | Final Report6. AnnexesItem Criticality for

proper functioning

Desirability for quality of services

Communication and Transport Land telephone line (fixed telephony), mobile

telephone linesX

Internet X Vehicle or alternative transport solution XService-related equipment and commodities Medical equipment X Medical supplies and consumables X Filling and filing forms and medical records X Review of medical records XProfessional development Adequate training X Integration into the CME X

4.4 Service costs and resource requirements

Financial and managerial accounting practices are weak Financing of PN does not provides incentives for higher performance and/or

efficiency Increased financing of PN services creates a room to better recover non-labor related

costs (including maintenance of assets and capital costs)

The fact that 3 ZD (Bitola, Kavadarci and Pehchevo) were not able to provide information on revenues and another 13 ZD indicated only salaries as PN service related costs indicates that basic financial accounting or managerial accounting practices are quite weak. Expenditures on PN services in 2010 exceeded financing by 13.1 million MKD (14%) and 25 ZD reported negative balance between revenues and expenditures. It is not possible to assess if ZD with negative balance provided accurate financial information and if the figures are correct, how the deficit of financing was handled. This observation is also supported by the reports of the State Audit Agency.

Absence of standardized and reliable financial accounting and reporting practices in not surprising considering the following:

a) Though ZD are administratively subordinated to the Ministry of Health, as public entities do not feel they are accountable for their organizational performance and or financial sustainability, including regular preparation and submission of financial statements (with or without managerial reports) to the Ministry of Health

b) Existing financing practices do not link inputs (money) with actual work carried out by ZD. Moreover, ZD management or the Ministry of Health is only formally involved in defining financial flows from HIF to ZD but does not influence planning/budgeting decisions; historical costs of ZD are not used as an evidence to refine and/or negotiate the financing packages

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c) Though financing is input based, it is not clear to what extent the allocation of funds considers recovery of actual direct and, most importantly indirect costs.

Due to the absence of disaggregated and complete financial data it is not possible to estimate the structure of recurrent expenditures or capital expenses. Only labor costs were easily traceable that allowed calculating the non-labor related portion of the financing that presumably should be enough to cover other direct costs (including transportation, communication, consumables and maintenance of medical and other equipment) as well as indirect costs (so called “ZD overhead costs”). ZD in Skopje and Kumanovo (accounting for 30% of the total HIF financing of PN services in 2010) spent approximately 10% of their revenues for PN services on non-labor expenses while ZD in Tetovo (the second largest recipient of HIF funding for PN services) was able to allocate 18.5% of their revenues to cover non-labor costs. Though it is hard to justify based on actual cost calculations a non-labor share of the package should not be less than 20% of PN service revenues.

The recent increase in the value of preventive care package for PN from 30,000 to 40,000 MKD per month allows for allocation of more resources from the revenues to the recovery of non-labor costs. However, the increase in financing may signal to the syndicate of health professionals to negotiate higher remuneration for PN next year. If the syndicate succeeds (to increase salaries proportionally, or even by 25%) this 33% “zone” (of non-labor related revenues) will melt again leaving fewer resources necessary to finance operation. On the other hand, 33% “zone” does not guarantee that ZD managers will use these funds adequately on the maintenance of equipment or for the recovery of capital costs that are not recognized properly due to the absence of modern managerial/cost accounting practices.

In any case the disconnect between recognition and recovery of all costs at the ZD level, remuneration negotiation practices (and natural incentives of the syndicate) and methods of budgeting of ZD by HIF makes it unlikely that total financial requirements of ZD (related to PN services) will be met and financial sustainability will be secured.

The observed mode of financing does not create incentives to improve performance and/or efficiency. On the contrary, it may motivate ZD managers to hire young, inexperienced but cheaper labor to make higher gains from the flat amount paid by HIF.

Maintaining remuneration of PN at a competitive level is essential to secure necessary human resources, but a salary raise should not be done at the expense of neglecting other, no- labor costs. If the salary rates do not increase substantially next year the current balance of financing and labor costs create conducive “investment climate” in terms of enabling ZD to secure funds for the maintenance of assets and even capital costs recovery (though the latter is less likely to happen considering observed financial management practices of public entities).

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4.5 Feasibility of collaboration with other community services

In terms of current workload there is a room to either expand patronage nursing services or establish functional collaboration with other community services

Collaboration with other community services to be efficient and sustainable it requires PPS first to become streamlined

Collaboration with other community services cannot be perceived as a goal itself. It is rather means for attaining efficiency, access or quality related objectives at the policy or operational levels.

The patronage nursing system to engage in any long-term collaboration with other service delivery mainstreams (Domashna Poseta, PHC, TB services/DOTS, etc.) should obtain very clear structural and functional shape. Otherwise the possible collaboration may turn into dilution of the PN roles (at the best) or transformation into virtual services (existing just on paper but performing work for other service units within the ZD).

Calculations of the workload (using the cost modeling tool) showed (see Figure 41 below) that PN have more than 80% of their net working time free to provide other preventive or curative services in addition to total 4 obligatory visits to pregnant women and newborns.

Therefore, before discussing the feasibility of collaboration with other community services it seems more reasonable to explore existing opportunities for increasing efficiency or improving access to quality patronage nurses services.

In general, there are three ways to develop patronage nurse services (referred as to models below):

Status quo

No significant structural changes, just investment in human resources and quality related equipment.

Same status – improving efficiency and equity

In this proposed policy alternative, it is suggested to improve the efficiency and equity of the existing system, through:

Making HCM and PN accountable for the work performed (volume, quality)

Establishment of a clear-cut package of PN services (structure of package in terms of costs, volume of work to be performed, incentives for the HCM and PN)

Establishment of control mechanism for monitoring the performance (volume and quality)

For this model, advantage is that the HIF, and ultimately the tax payers will be able to detect and measure the cost of services, utilization and through feedback to adjust/remodel the package of services.

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Community nursing assessment with equity analysis in Macedonia | Final Report6. AnnexesPerceived disadvantages of this model are seen as increased motivation of HCM and PN to perform better without a control mechanism would promote over-reporting or misreporting for financial benefit;

Changing status

a) Closer to current model - “concession within the public system”

Although “concession” is not an adequate term, it is used to explain the proposed model. This is seen as a modification of the policy alternative explained under no. 2. The slight variation proposed is that the PN services would be established as a separate functioning unit within the ZD, that will mean that PN funding will be earmarked for use with PN services, and reported separately to the HIF thereof.

b) Different model – binding the PN with PHC

Another model that is proposed is a complete disaggregation of PN services from ZD, and placing them under the umbrella of the PHC. Compared with the previous two proposals this model is more controversial and deserves several advantages and disadvantages to be highlighted in more details as follows:

Advantages Disadvantages

PN service package includes services that are naturally connected to the PHC practice; communication with Ob/Gyn and pediatricians is essential for performing the preventive part of the package.

The concessionary fashion in which the PHC service is established at the moment, cannot offer sustainable and secure positioning of PN, for the reasons that the current PHC offices are established based on the availability of the PHC doctor, and not of the nurse. There are envisaged problems with the nurses that are already working within PHC, of their future employment after the retirement of the PHC doctor, in which cases these nurses will have to seek another job (most likely at the age of 40+)

PN can act as extended hand, as outreach of the pediatricians, per se, for the care of the newborn/infant in the home, for inspection of the socio-economic and physical living environment that is sometimes crucial for the detection of causes of health conditions in children.

There is no sufficient workload the one PN to work for a single PHC office. The time-sharing has to be applied, which is seen as obstacle, if the proper system is not established.

The common opinion among PHC is that the PN can assist the PHC as extended

The common opinion among PN is that they would not want to go under the

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Advantages Disadvantages

hand umbrella of the PHC, unless a job security clause is provided to them.

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5 Conclusions and recommendations

Conclusions

The assessment of community nursing in Macedonia was conducted with the intention to better understand how polyvalent patronage services have been functioning in a volatile environment and how to make it better – more efficient, sustainable and equitable respecting traditions of community services, building upon the best practices in the region and at the same time responding to challenges posed by the transition to public-private arrangements in health care in the country.

If the existing mode of functioning of PPS should be described in one word then “inertia” is the most appropriate definition. Although its importance together with other public preventive services is recognized at a high policy level, the recognition remains declarative unless PPS becomes structured and focused on the delivery of tangible benefits.

The current amorphous state of operation with a high degree of variation of resources and performance throughout the country makes irrelevant any discussion about efficiency, quality or equity of the provision of patronage nurse services. At the same time, the fact itself that PPS survives without a clear operational framework indicates that these services are demanded, valuable and represent a case of missed opportunities.

The findings of the assessment can be summarized in SWOT table as follows:

Strength Weakness

Services are demanded and valuable

Strong dedication among professionals

Long history of serving communities

Earmarked financing

Absence of professional standards

No incentives for quality and efficiency

Inadequate allocation of resources to recover non-labor costs

Financing and results are not linked

Poor coverage (understaffing) in some municipalities

Opportunities Threats

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Willingness of the government and partners to invest in PPS capacity

Efficient public-private partnerships

Feasibility of collaboration with other community level service delivery mainstreams

Fragmented service delivery and no formalized interaction between PN and other health professionals

Changes in policy (financing) may destabilize PN (as well as preventive care) landscape

If PPS does not become structured and streamlined organizationally and functionally it is not feasible to either:

make an investment in PPS services (in terms of financial injections into its infrastructure or human resources), or

promote its collaboration with other community services

Recommendations

As a precondition to any substantial investment the PPS should undergo structuring (or restructuring) through the application of regulatory instruments that are fully under the auspices of the Ministry of Health.

The Ministry of Health within its exclusive competence should introduce balanced regulation of patronage nurse services that includes:

80 Establishment of a regulatory framework:

80.1 Elaboration of professional standards, including:

80.1.1 Description of duties (scope of work)

80.1.2 Description of services (guidelines and/or protocols)

80.1.3 Description of qualification requirements (knowledge and skills)

80.2 Adoption of a regulation that sets clear rules to be followed by relevant actors

81 Enforcement of the regulation:

81.1 Elaboration of reporting and controlling mechanisms

81.2 Application of a punishment and/or rewards

81.3 Revision of professional standards (if needed)

How this can be done?

Step1 – “Professional Standards”:

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The current report contains some illustrative materials that can serve as a basis for the Ministry of Health to elaborate professional standards in close collaboration with the Association of Medical Nurses, Technicians and Midwives of the Republic of Macedonia. There is no need to come up with a perfect professional standards document – it is more important to initiate regulation of PPS with something simple and practical. The practical application will show how and in which way to advance the professional standards gradually. So it is more important not to miss the momentum – to start bringing PPS’s operation to some order rather spending time on the elaboration of sophisticated standards.

Step 2 – “Setting rules and administration mechanisms”:

As soon as the professional standards are agreed, the Ministry of Health defines:

rules to be followed by relevant actors

mechanisms to assess the compliance of ZD management and relevant medical professionals with these rules, including routine data reporting flows combined with on-site inspections

administrative (or plus financial) consequences of breaching the rules

capacity needed for the enforcement of the regulation

At this stage it would be important to carefully assess the complexity of the regulation to match it with needs and capacity for administration. It is better to start with a lighter rules making ZD and patronage nurses familiar with the requirements, helping them to perceive the regulation not as a mechanism for punishment, but a roadmap for making their job more productive and efficient.

MoH in collaboration with MANM has to adopt and impose the PN to maintain nursing documentation, which will show that the PN do not only perform simple services, but they also follow the overall nursing process in their performance (assessment, planning, intervention, evaluation of each case) and list of performed nursing interventions

Step 3 – “Investment Plan”:

In parallel or after the formalization of the regulatory framework the Ministry of Health can refine the investment plan, both in terms of strengthening the physical infrastructure as well as investing in human resources.

The present report provides some projections of the resources requirements for strengthening the capacity of patronage nurses through in-service trainings and upgrading physical infrastructure.

It is highly recommended not to allocate resources to in-service trainings without the introduction of a continuous medical/nursing education system (CME) for patronage nurses as a condition for licensing. The licensing with CME can be introduced at the previous stage (as a part of the regulatory package) or afterwards, as a separate stage.

While designing the requirements for in-service trainings the Ministry of Health has to assess the existing capacity for the delivery of trainings. The projections in this report can help the MoH to assess the need for investing in the training capacity before the CME is designed and introduced

As to the investment in physical infrastructure, it is highly recommended to apply a balanced approach without creating asymmetry at the institutional level (“positive

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discrimination”) by channeling resources to PN only and depriving other health care teams working shoulder to shoulder with PN under the same roof. In many cases the investment in vehicles or communication could be more rationale if the assets/equipment are shared in a formal and fair manner by medical teams serving communities.

Step 4 – “Human Resource Strategy”:

Along with the elaboration of the investment plan the Ministry of Health together with the Association of Medical Nurses, Technicians and Midwives of the Republic of Macedonia (and development partners) has to elaborate a long-term strategy for human resource mobilization and management in the area of community nursing. This strategy should define, inter alia, how the system fills in the existing gap (approximately 79 nurses), ensure maintenance of qualified professionals and their replacement related to aging the first of all or to other labor migration waves (similar to one observed in 2006-2007).

Step 5 – “Collaboration with other community services”

After defining the professional standards for PN it becomes easier to map duties of different medical teams vs. service needs and to identify areas for attaining higher efficiency and quality through collaborative efforts. The areas for collaboration can be explored into the following sequence:

formalization of the engagement of PN into the work of preventive teams (related to immunization)

sharing of functions for certain services between the PN and Domashna Poseta

Integration of some curative services related to long term outpatient care of patients with TB and diabetes

commissioning of PN services by private PHC providers

collaboration with social care service providers

It is highly recommended not to accelerate the collaboration processes artificially until the PN’s operation becomes structured, formalized and well recognized by other professional teams. Otherwise, the collaboration can be perceived as a “survival strategy” and may end up in assimilation of PN services instead of establishing fair, mutually beneficial working cooperation between equal players.

There is one area that can be addressed at an earlier stage (Step 1 and 2) – this is related to the formalization of communication channels between antenatal care doctors (PHC or Ob&Gy specialists) and patronage nurses. If the Ministry of Health within the regulatory framework imposes a rule (administratively or combined with financing mechanisms) that obliges private doctors to refer pregnant women timely and in a proper manner to patronage nurses it can dramatically improve coverage of communities with antenatal care provided by PN. In addition to restoring a balance between antenatal and newborn care, this step can further motivate PN and increase their trust in the reforms observing how effectively the government considered and responded to their concern shared during this assessment.

Other steps – “Financing of PN Package”

This step is not something that should happen in the end. After setting the professional standards, namely the detailed description of services and expected

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outcomes (as schematically shown on Figure 33 above), the platform is established to revisit the financing mechanism in cooperation with HIF by:

adjusting the package cost to the content and volume of PN services; the MoH should define the rule: either the package cost should be considered as a given, so the MoH sets a ceiling for collective negotiation of salary rates (e.g. as 80% of the package cost), or vice versa – the cost of package to be adjusted after the negotiation of salary rates in a way that wages do not absorb more than 80% of the package volume; and/or

Linking financing with results – switching to performance based financing (fully or partially), paying for outputs (for instance for a minimum number of visits as defined by the professional standards) rather than for staffing table of ZD.

Other steps – “Bridging services and results”

Irrespective of the introduction of performance based financing patronage nurse services should be associated clearly with at least one public health benefit and the outcome of their work should be measured and recognized. Even if there is no performance based financing of preventive times the benefit they produce is visible to everybody – immunization coverage. The same way, patronage nursing can be linked with breastfeeding or nutritional practices in the served communities (or with any similar public health benefit that can be attributed to the contribution patronage nurses make within their area of competence). Bridging preventive care and public health benefits brings more clarity at the policy level and justifies better the allocation of public resources to polyvalent patronage services by demonstrating its value for money.

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6 Annexes

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Annex A: Research questions by assessment domains and research subjects

Research Subjects Research Questions

82 Human resources – professional growth needs & opportunities

What is the most appropriate way to develop human resources in the community nursing system?

82.1 Human resource profile

What is the profile of professional resources in the community nursing system? Age and gender structure Educational/training background Distribution by geographic areas Turnover rates

82.2 Professional growth needs

What are the perceived needs for professional growth among practicing community nurses and related health care professionals What are the requirements set by

desired (envisaged) medical practice standards?

What are necessary skill sets enabling community nursing to perform well?

82.3 Professional growth opportunities

What educational services are available that can benefit community nurses in their professional growth? Is their capacity adequate? Are they accessible and/or affordable?

If educational services do not exist, which interventions are necessary to make them accessible and used in the foreseeable future?

83 Service coverage and utilization (including estimation of children/families being under-served)

Is there a gap in the scope and breadth of coverage17 of community nurse services?

17 Defined as the probability that an individual who needs a community nurse service intervention will obtain it

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83.1 Supply side (existing coverage and utilization)

What is availability of community nurse services by geographical areas?

What is actual utilization of community nurse services (by type of services, geographical areas, population groups, etc.)?

83.2 Needs in community nurse services

What are health care needs that fall under the competence of community nursing system? Which needs are not recognized? Which needs are recognized but not

covered adequately (in terms of volume of services or service content/quality)?

84 Quality of services (Assessing preconditions)

What is missing in ensuring desired quality of community nurse services?

84.1 Training opportunities What kind of on-job training (or other training means) can be institutionalized to ensure adherence to medical practice quality standards?

84.2 Technical means to deliver quality services

Which technical means (e.g. medical equipment, transportation, communication or other devices) are necessary for delivery of quality community nurse services: Are they available and used? Do they need upgrade or are they

missing and should be provided?

84.3 Quality assurance (existence and implementation of practice protocols/guidelines)

What are challenges and opportunities for the introduction of modern quality assurance mechanisms (at facility and national levels)?

85 Service costs and resource requirements

Could upgraded community nurse services be affordable and financially sustainable?

85.1 Current flow of funds and costs

What is a cost structure of current community nurse services?

To what extent are the costs covered? What are the main sources of funding the

community nurse system? How community nursing services are

financed?

71



85.2 Estimation of future resource requirements

How much resources are required to develop and sustain a modern community nurse system with 100% coverage?

How the total resource requirements can be met to address inequities both in current access and scope of services provided?

86 Feasibility of collaboration with other community services

What are the current trends in policy area toward unification of medical service delivery at the community level?

What are mid- and long-term opportunities for integrating community nurse services into other similar service delivery mechanisms (interfaces)? What are the expectations of different

level decision makers? What are the perceived benefits of or

concerns related to any type of collaboration with other community services?

72


Annex B: List of ZD with codes and respondents No. Health Center Director1 Berovo Kiril Nikolov2 Bitola Blagoja Radevski3 Gostivar Mensur Elezi4 Gevgelija Tomislav Petkov5 Debar Ilber Kokale6 Demir Hisar Sonja Talevska7 Delchevo Trajche Georgievski8 Kavadarci Ljupcho Janevski9 Kichevo Xhavid Balazhi10 Kochani Vancho Kocev11 Kratovo Nikolcho Gjorgiev12 Kriva Palanka Merima Zafirovska13 Krushevo Gjorgji Damchevski14 Kumanovo Miomir Pankovski15 Makedonski Brod Gordana Vojneska16 Negotino Blagorodna Bojadzieva17 Ohrid Mitko Dabeski18 Pehchevo Dragica Apostolova19 Prilep Ivan Tanevski20 Probishtip Jagoda Risteska21 Rostushe Shabre Nezirovski22 Resen Trajche Nichevski23 Radovish Lila Susinova24 Sv. Nikole Blagoj Panev25 Skopje Bojcho Janachkov26 Shtip Miodrag Milenkovikj27 Strumica Vasko Chaushevski28 Struga Vera Poposka29 Tetovo Besmalj Shefiti30 Valandovo Branisav Knezhevic31 Vevchani Boro Peshinovski32 Veles Tatjana Samarakova33 Vinica Martin Pavlov

73


Annex C: Response rate of PN to SA per Health centerRegion Zdravstven Dom Total

number of PN

Questionnaires received

% received

Skopje region Skopje 76 69 91%Vardar region Veles 10 10 100%

Negotino 6 6 100%Sveti Nikole 4 4 100%Kavadarci 10 10 100%

Polog region Gostivar 23 23 100%Rostushe* 2 3 150%Tetovo 32 32 100%

South-west region Ohrid 10 10 100%Vevchani 5 5 100%Struga 14 14 100%Debar 5 5 100%Kichevo 11 11 100%

Pelagonia region Bitola 9 7 78%Resen 4 4 100%Krushevo 2 2 100%Prilep 17 17 100%Demir Hisar 2 2 100%

North-east region Kratovo 2 2 100%Kriva Palanka 5 5 100%Kumanovo 26 26 100%

South-east region Radovish 6 6 100%Strumica** 16 12 75%Valandovo 2 1 50%Gevgelija 8 8 100%

East region Shtip 7 7 100%Probishtip 2 2 100%Kochani 6 6 100%Pehchevo 1 1 100%Berovo 4 4 100%Delchevo 5 5 100%Vinica 3 3 100%Makedonski Brod 3 3 100%Total 338 325 96.2%

* Rostushe has 3 PNs that work on the field (according to the manager), of which one is part-time PN and part-time social worker; the HIF pays only 2 patronage nurse packages.

** The 4 questionnaires that were not received are from the 4 PNs working in Novo Selo that were adhered to ZD Strumica after some changes in Novo Selo outpatient clinic (doctor was no longer available so they were absorbed by ZD Strumica).

74


Annex D: List of interviewees to semi-structured interviews by type of researchName Position InstitutionHealth Center Managers (SSI/HCM)87 Blagoja Radevski Director Zdravstven dom - Bitola88 Ilber Kokale Director Zdravstven dom - Debar89 Tanja Jordanova Main PN, on behalf of

the director Vancho Kocev

Zdravstven dom - Kochani

90 Mitko Dabeski Director Zdravstven dom - Ohrid91 Ivan Tanevski Director Zdravstven dom - Prilep92 Shabre Nezirovski Director Zdravstven dom - Rostushe93 Miodrag Milenkovikj Director Zdravstven dom - Shtip94 Vasko Chaushevski Director Zdravstven dom - Strumica95 Besmalj Shefiti Director Zdravstven dom - Tetovo96 Tatjana Samarakova Director Zdravstven dom – VelesHealth officials/other officials (SSI/HO)97 Jovanka Kostovska Head of Department Ministry of Health,

Department of Preventive Medicine

98 Nermina Fakovic Head of Unit, responsible for PN services

Ministry of Health, Department of Preventive Medicine

99 Suzana Manevska Head of Unit Ministry of Health, Department of Preventive Medicine

100Vlado Spiroski Head of Department Ministry of Health, Department of Primary Healthcare

101Maja Parnardzieva-Zmejkova

Director Health Insurance Fund of Macedonia

102Brankica Katushevska Head of Sector for planning and analysis

Health Insurance Fund of Macedonia

103Tatjana Lukanovska Chief of Department for Finances

Health Insurance Fund of Macedonia

104Ana Petrova Advisor to the Director Health Insurance Fund of Macedonia

105Tatjana Ristova-Dimova Director Institute for Social Activities, Ministry of Labour and Social Policy (Zavod za socijalni dejnosti, MTSP)

106Lidushka Vasilevska Advisor for vocational training and training in health profession

Centre for Vocational Training, under Government of the Republic of Macedonia

107Erol Ademov Head of Unit and Advisor for Relations between communities

Local Self-government of the Municipality of Sthip

Academia/experts/NGO representatives (SSI/Acad)108Prof. Sofia Glamochanin Pediatrician, Professor Faculty of Medicine,

University of Skopje109Prof. Bogdanovska Faculty of Medicine,

University of Skopje110Doncho Donev Professor Institute for Social

75

Community nursing assessment with equity analysis in Macedonia | Final Report6. AnnexesName Position Institution

Medicine, Faculty of Medicine, University of Skopje

111Sarita Jasharova President NGO LIL, Skopje (working on mother and child health in Roma communities in Skopje area)

112Nesime Salioska Director ROMA SOS, Prilep (working on reproductive health of Roma women in Prilep Roma settlement Trizla 2)

113Vera Zlateva President Women’s Association OZO Sveti Nikole (reproductive health)

114Ljatifa Shikoska Director Roma NGO UMBRELLA, Shuto Orizari (service delivery on access to health for Roma in Shuto Orizari)

76


Annex E: Functions and minimum required skill set

Main functions of patronage are defined as:

To promote health in the family and in the community

To participate in disease prevention

To make efforts to empower the community, the family and the patient

To accept authority and responsibility for her/his activities and decisions

In order to fulfill the main functions Patronage nurses should be able:

115 To work as a member of the PHC team maintaining professional ties with other members of the healthcare team in the community

116 To independently provide care to the patients in their home, especially mothers and newborns/children

117 To assess, plan, implement and evaluate the care for patients in their homes or in the community according to their physical, mental and cultural/ethnic needs from birth throughout their whole life

118 To make evidence-based decisions for care and health promotion, always when it is possible given the cultural and ethical principles and characteristics of the family and the community

119 To define health priorities together with the patients and the community and communicate it back to the health care system

120 To use epidemiological and statistical data for priority setting in healthcare that is being provided by the community nursing profession

121 To mobilize appropriate resources from the community in order to optimize the care for the patients

77


Annex F: Descriptions of in-service training courses of PN

Thematic unit/issue

Days Costs per unit in € (course for 20

pers)Amount Descripti

onBasic (obligatory) courses1. Care for newborn (care for umbilical cord, wrapping, etc.) 2 3,000 T/P2. Nursing 1 2,000 T/P3. Medical documentation/records 1 1,500 T/P4. Standards/guidelines for operation 2 3,000 T5. Orthopedics 2 3,000 T/P6. Nutrition of a newborn 1 1,500 T7. Children with special needs 1 1,500 T8. Communicable diseases 1 1500 T9. Ethical aspects of care and communication (with patients &

family) 1 1500 T

10. Care for pregnant women 2 3000 T/P

11. Postpartum care and complications 2 3000 T/PAdditional (optional) courses12. TB 0.5 1,000 T13. Family violence 1 1,500 T14. Diseases of addiction 0.5 1,000 T15. Congenital heart diseases16. Anti-rickets protection 0.5 1,000 T17. Anemia 1 1,500 T18. New methods and techniques of care (refreshment course) 1 2,000 T/P19. Trainings for measuring blood glucose, lipids, bilirubin 1 2,000 T/P20. Physchophysical exercises for pregnant women 1 2,000 T/P

21. Family violence 1 1,500 TAdditional courses (if curative care is admitted)Post-hospital care (wound dressing, catheter, administration of IV and IM therapy)

2 3,000 T/P

78


Annex G: Projection of the needs for in-service trainingTraining Courses Number

of PN that

attended

Number of PN that should

undergo training considering

Current pool

Ideal pool

Basic (obligatory) courses 207 131 2041. Care for newborn (care for umbilical cord, wrapping, etc.) 214 124 1972. Nursing 196 142 2153. Medical documentation/records 99 239 3124. Standards/guidelines for operation 46 292 3655. Orthopedics 131 207 2806. Nutrition of a newborn 65 273 3467. Children with special needs 74 264 3378. Communicable diseases 0 338 4119. Ethical aspects of care and communication (with patients

& family)0 338 411

10. Care for pregnant women 0 338 41111. Postpartum care and complications 0 0Additional (optional) courses 0 338 41112. TB 81 257 33013. Family violence 49 289 36214. Diseases of addiction 57 281 35415. Congenital heart diseases 0 338 41116. Anti-rickets protection 93 245 31817. Anemia 53 285 35818. New methods and techniques of care (refreshment

course)0 338 411

19. Trainings for measuring blood glucose, lipids, bilirubin 0 338 41120. Physchophysical exercises for pregnant women 0 338 41121. Family violence 0 338 411Additional courses (if curative care is admitted) 0 0Post-hospital care (wound dressing, catheter, administration of IV and IM therapy)

0 338 411

79


Annex H: Basic characteristics of a package of patronage services Type of service Duratio

n of visit

Average visits/year

Description of service Consumables required

Women in reproductive period, pregnant women, women after delivery, newborns, infants and school childrenVisit to woman in reproductive period

40 min 2 Inspection of socioeconomic conditions in the home

Detection of health conditions, risk factors, unhealthy lifestyles and risk behavior

Introduction of the women with the health rights regarding reproductive health (taking smears, PAP test, preventive breast examination)

Giving advice about prevention of malignant diseases and neoplasms

Examination of breasts and education about self examination

Control of mammography and PAP test (if available)

Giving advice on contraceptives Giving advice on early detection of

diseases and control of the bleeding amount in cases of gynecological interventions and diseases

Visit to pregnant woman

40 min 2 Inspection of socioeconomic conditions in the home of the pregnant woman

Detection of uncontrolled pregnancies and referring them to gynecologist for monitoring of the pregnancy – Informing the pregnant woman about the rights of health and social insurance

Motivation for attendance of predelivery education courses

Giving advices related to preparation of the pregnant woman for delivery and needed equipment/consumables for the newborn

Giving advices about hygiene and nutrition

Control of health status/condition of the pregnant woman – blood pressure measurement, blood count, with fast blood imaging set, urine test for albumen, glucose and bile colors,

Measuring height/weight Monitoring of fetal heartbeat with

portable CTG Advising on recognition of warning

clinical signs for immediate referring to a doctor

Control of administered therapy, and compliance with doctor’s advices in

- Laboratory testing sets, gel for portable CTG

80

Community nursing assessment with equity analysis in Macedonia | Final Report6. AnnexesType of service Duratio

n of visit

Average visits/year


risk and pathologic pregnanciesVisit to women after delivery and newborn

90 min 2 Inspection of socioeconomic conditions in the home of the newborn and the mother

Informing the mother about the rights of health and social insurance (maternity leave, package for newborn, third child policy, etc.)

Giving advices about hygiene and nutrition of the mother during newborn period

Examination of breasts and demo of the appropriate milking and position of the baby/breast for nursing

Care for the health of the mother after delivery – measurement of body temperature, inspection of episiotomy or the wound from cesarean section

Assessment of the amount of bleeding by appropriate methodology

Giving advice for contraceptives Assessment of mental health of the

mother for early detection of postpartum psychosis

Inspection and assessment of the health of the newborn by appropriate methodology for essential care in the home

Treatment of umbilical cord Demo of bathing the newborn Giving advice for the importance of

immunization and presentation of the immunization calendar

Demo of the preparation of baby formula (artificial milk) for the newborns that are not breastfed

Alcohol, gauze, hydrogen, umbilical cord set, protective gloves, set for wound dressing of episiotomy or cesarean section

Visit to Infant 30 3 Inspection of socioeconomic conditions in the home of the infant

Giving advice on the hygiene and nutrition of the infant (care, nutrition, development stimulation)

Control of regular administration of anti-rickets prophylactics

Control of the regularity of immunization in the infancy

Control of the BCG scar Early detection of signs of rickets Early detection of children born

under risk and children with special needs

Giving advice about psychosocial stimulation of the development in the home according to appropriate methodology

Visit to small 30 2 Inspection of socioeconomic

81

Community nursing assessment with equity analysis in Macedonia | Final Report6. AnnexesType of service Duratio

n of visit

Average visits/year


child and pre-school child

conditions in the home of the small child

Giving advice on the hygiene and nutrition of the infant (care, nutrition, development stimulation)

Control of regular administration of anti-rickets prophylactics

Control of the regularity of immunization in the infancy

Control of the BCG scar Early detection of signs of rickets Early detection of children born

under risk and children with special needs

Giving advice and training of the parents about psychosocial stimulation of the development in the home according to appropriate methodology

School children and adolescentsVisit to school child and adolescent (7-19 years)

30 min 1 Inspection of the hygiene, health and social environment in which the school child and adolescent lives and understanding the material situation, housing and other situation in the family;

Identification of school children and adolescents with malnutrition and health risks due to improper nutrition (measurement of weight and height, blood pressure)

Giving advices to parents and other members of the family about the importance of the balanced nutrition of the school child and adolescent; Identification of the school children and adolescents that do not attend school

Advising the parents and young people about the importance of the regular periodic control of health condition, dental examination and regular visit to dentist,

Introduction of adolescents and young people about the methods of contraception, especially advantages and disadvantages and advising on proper utilization

Prepared by the Association of Medical Nurses, Technicians and Midwives in Macedonia

82


Annex I: Assessing the feasibility of including PN services demanded by communities into the competence area of PN and matching it with practices reported by HCM

Feasibility of including in the area of PN competence

Existing practices (as reported by HCM)

Opinion of PNAuthorization is missing

Training is needed

Preventive ServicesTreatment of painful breasts of nursing women (granuloma)

Possible X

Mental health advices Possible XPsychophysical exercises for pregnant women

Included X

Cholesterol measurement Possible X XBlood sugar measurement Included X XCare for the newborn (diapering, nursing, nutrition...)

Included X

Exercises for children with special needs Not appropriate

X

Blood pressure measurement Included XSmear/Blood sample taking for laboratory Not

appropriateX

Medical check-up a child at home and diagnostics

Not appropriate

X

Curative

Insulin therapyNot appropriate (only to teach)

15% X

Lapisation of the umbilical cord Included X X

Small surgical interventions Not appropriate

X

Administration of IM therapy Not appropriate

12% X X

Administration of IV/PE therapy Not appropriate

X X

Administration of enema Not appropriate

X

TB therapy (DOTS) Possible 6% XApplication of treatment to patients with communicable diseases

Not appropriate

X

Wound dressing and cleaning Possible (post-partum)

(12%) X X

Post-hospital care (catheters, etc.) Not appropriate

X

Treatment of drug users Not appropriate

X

Administration of proscribed therapy without presence of a doctor, in the home

Not appropriate

X

Administration of therapy without diagnosis (or prescription)

Not appropriate

X

Diagnostics & prescribe Not appropriate

X

83

Community nursing assessment with equity analysis in Macedonia | Final Report6. AnnexesHome care

CND patients Not appropriate 21%

X

CVD patients Not appropriate 18%

X

Chronic patients Not appropriate 15%

X

84


Annex J: Workload and resource requirement projections (modeling)

Figure 38: Description of Training costs by staffing levels approaches and types of trainings

All Staff - Cur-rent

All Staff - Optimal

All Staff - Maximum

New Staff - Current

New Staff - Optimal

New Staff - Maximum

€ -

€ 100,000

€ 200,000

€ 300,000

€ 400,000

€ 500,000

€ 600,000

€ 700,000

€ 800,000

€ 900,000

€ 1,000,000 Obligatory Optional

85

Community nursing assessment with equity analysis in Macedonia | Final Report6. AnnexesFigure 39: Projection of investment costsItemHuman resources (trainings) 714,000€ 40%Infrastructure

Medical & Offi ce Equipment 388,024€ Vehicles 412,000€ Other equipment 136,566€ Space renovation 135,200€

Subtotal Infrastructure 1,071,790€ 60%

Total investment 1,785,790€

Investment Cost

40%

22%

23%

8% 7%Human resources(trainings)Medical & OfficeEquipmentVehicles

Other equipment

Space renovation

86

Community nursing assessment with equity analysis in Macedonia | Final Report6. AnnexesFigure 40: Projections of recurrent costs

RevenuesHIF 2,642,345€ Other

Total Revenues 2,642,345€

Recurrent CostsSalaries 1,784,460€ Consumables 362,061€ Transportation 81,120€ Mobile communication 81,120€

Total recurrent costs 2,308,761€

Excess of Revenues over recurrent Costs 333,584€ 13%

Average (direct cost) per visit 6.38€ MKD 392

Item

77%

16%

3%

4%

Salaries

Consumables

Transportation

Mobile communication

87


Figure 41: Workload projectionsZD Name Visits to

Newborns per year

Visits to Pregnant

Woman per year

Total time required to

conduct visits (in

min)

Net working time (min) available in year WorkloadCurrent staffing

Optimal Staffing

Maximum Staffing

Current staffing

Optimal Staffing

Maximum Staffing

Berovo 232 232 32,480 368,640 276,480 368,640 9% 12% 9%Bitola 2,126 2,126 297,640 829,440 1,935,360 1,935,360 36% 15% 15%Debar 662 662 92,680 460,800 460,800 460,800 20% 20% 20%Delchevo 456 456 63,840 460,800 460,800 460,800 14% 14% 14%Demir Hisar 126 126 17,640 184,320 184,320 184,320 10% 10% 10%Gevgelija 664 664 92,960 737,280 645,120 737,280 13% 14% 13%Gostivar 2,242 2,242 313,880 2,119,680 1,935,360 2,119,680 15% 16% 15%Kavadarci 862 862 120,680 921,600 829,440 921,600 13% 15% 13%Kichevo 964 964 134,960 1,013,760 1,013,760 1,013,760 13% 13% 13%Kochani 914 914 127,960 552,960 921,600 921,600 23% 14% 14%Kratovo 152 152 21,280 184,320 184,320 184,320 12% 12% 12%Kriva Palanka 566 566 79,240 460,800 460,800 460,800 17% 17% 17%Krushevo 644 644 90,160 184,320 460,800 460,800 49% 20% 20%Kumanovo 3,528 3,528 493,920 2,396,160 2,488,320 2,488,320 21% 20% 20%Makedonski Brod

250 250 35,000 276,480 184,320 276,480 13% 19% 13%

Negotino 468 468 65,520 552,960 460,800 552,960 12% 14% 12%Ohrid 1,184 1,184 165,760 921,600 1,105,920 1,105,920 18% 15% 15%Pehchevo 80 80 11,200 92,160 92,160 92,160 12% 12% 12%Prilep 1,832 1,832 256,480 1,566,720 1,566,720 1,566,720 16% 16% 16%Probishtip 272 272 38,080 184,320 276,480 276,480 21% 14% 14%Radovish 830 830 116,200 552,960 552,960 552,960 21% 21% 21%Resen 286 286 40,040 368,640 276,480 368,640 11% 14% 11%Rostushe 194 194 27,160 184,320 184,320 184,320 15% 15% 15%Shtip 1,198 1,198 167,720 645,120 921,600 921,600 26% 18% 18%Skopje 16,174 16,174 2,264,360 7,004,160 10,690,560 10,690,560 32% 21% 21%Struga 1,376 1,376 192,640 1,290,240 1,198,080 1,290,240 15% 16% 15%Strumica 2,312 2,312 323,680 1,474,560 1,751,040 1,751,040 22% 18% 18%

88

Community nursing assessment with equity analysis in Macedonia | Final Report6. AnnexesZD Name Visits to

Newborns per year

Visits to Pregnant

Woman per

Total time required to

conduct

Net working time (min) available in year WorkloadSveti Nikole 404 404 56,560 368,640 368,640 368,640 15% 15% 15%Tetovo 4,856 4,856 679,840 2,949,120 3,502,080 3,502,080 23% 19% 19%Valandovo 280 280 39,200 184,320 184,320 184,320 21% 21% 21%Veles 1,674 1,674 234,360 921,600 1,198,080 1,198,080 25% 20% 20%Vevchani 46 46 6,440 460,800 92,160 460,800 1% 7% 1%Vinica 392 392 54,880 276,480 368,640 368,640 20% 15% 15%

48,246 48,246 6,754,440 31,150,080 37,232,640 38,430,720 22% 18% 18%

89


Annex K: Descriptive statistics charts and tables

Figure 42: Ranking of ZD by infant mortality rates (IMR 2009)Code in Dataset

Name in English Name in Macedonian

Infant

Death

Newborn

IMR

Rank by IM

21 Radovish Радовиш 2 410 4.9 Low30 Sveti Nikole Свети Николе 1 198 5.1 Low35 Vinica Виница 1 196 5.1 Low6 Gevgelija Гевгелија 2 370 5.4 Low3 Debar Дебар 2 283 7.1 Low13 Krushevo Крушево 1 139 7.2 Low12 Kriva Palanka Крива Паланка 2 250 8.0 Low32 Valandovo Валандово 1 125 8.0 Low14 Kumanovo Куманово 14 1739 8.1 Low17 Ohrid Охрид 6 600 10.

0Average

31 Tetovo Тетово 25 2369 10.6

Average

29 Strumica Струмица 12 1113 10.8

Average

25 Skopje Скопје 88 7824 11.2

Average

9 Kichevo Кичево 5 437 11.4

Average

1 Berovo (and Pehchevo) Берово 2 167 12.0

Average

5 Demir Hisar Демир Хисар 1 81 12.3

Average

10 Kochani Кочани 6 470 12.8

Average

19 Prilep Прилеп 15 1168 12.8

Average

24 Shtip Штип 8 614 13.0

High

7 Gostivar (and Rostushe) Гостивар 17 1165 14.6

High

33 Veles Велес 12 813 14.8

High

4 Delchevo Делчево 3 201 14.9

High

28 Struga (and Vevchani) Струга 10 632 15.8

High

16 Negotino Неготино 4 249 16.1

High

2 Bitola Битола 19 1106 17.2

High

15 Makedonski Brod Македонски Брод

3 170 17.6

High

8 Kavadarci Кавадарци 8 433 18.5

High

20 Probishtip Пробиштип 3 152 19.7

High

90

Community nursing assessment with equity analysis in Macedonia | Final Report6. AnnexesCode in Dataset

Name in English Name in Macedonian

Infant

Death

Newborn

IMR

Rank by IM

22 Resen Ресен 3 133 22.6

High

11 Kratovo Кратово 2 77 26.0

High

Country totals 278 23684 11.7

Figure 43: Distribution of PN Ages (histogram)

91

Community nursing assessment with equity analysis in Macedonia | Final Report6. AnnexesFigure 44: Population per PN and area per population distribution by ZD

Vevchani

Makedonski

BrodRese

n

Rostush

eStru

ga

Demir Hisa

r

Kriva Palanka

Kichevo

Kratovo

Radovish

Pehchevo

TetovoOhrid

VelesSko

pje

Kochani

Bitola

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

0

100

200

300

400

500

600

700

Ratio Population per PN

Standard Ratio

Density

Popu

latio

n pe

r PN

Area

in sq

. km

. per

pop

ulati

on

Figure 45: Crosstab – Description of PN ways of employment (“origin”) and work experience (n=325)

Work Experience Total

Only PN ExperienceOther Background

Ways of employment at the ZD 76 55 131

% within Occurence in the current ZD 58.0% 42.0% 100.0%

% within Work Experience 97.4% 22.3% 40.3%

23.4% 16.9% 40.3%

PN Transferred 2 25 27



.6% 7.7% 8.3%

0 167 167

% within Occurence in the current ZD .0% 100.0% 100.0%

% within Work Experience .0% 67.6% 51.4%

.0% 51.4% 51.4%

78 247 325



24.0% 76.0% 100.0%

92

Community nursing assessment with equity analysis in Macedonia | Final Report6. AnnexesFigure 46: Age structure of PN by ZD

PN Age Groups<25 26-35 36-49 50-57 >58 Total

Berovo 0 .0% 0 .0% 2 50.0% 2 50.0% 0 .0% 4 100%Bitola 0 .0% 0 .0% 5 62.5% 2 25.0% 1 12.5% 8 100%Debar 0 .0% 2 66.7% 1 33.3% 0 .0% 0 .0% 3 100%Delchevo 0 .0% 0 .0% 4 80.0% 1 20.0% 0 .0% 5 100%Demi Hisar 0 .0% 0 .0% 1 50.0% 1 50.0% 0 .0% 2 100%Gevgelija 0 .0% 0 .0% 2 25.0% 6 75.0% 0 .0% 8 100%Gostivar 0 .0% 2 8.7% 12 52.2% 9 39.1% 0 .0% 23 100%Kavadarci 0 .0% 0 .0% 7 70.0% 3 30.0% 0 .0% 10 100%Klchevo 0 .0% 1 9.1% 6 54.5% 4 36.4% 0 .0% 11 100%Kochani 0 .0% 1 16.7% 5 83.3% 0 .0% 0 .0% 6 100%Kratovo 0 .0% 0 .0% 1 50.0% 1 50.0% 0 .0% 2 100%Kriva Palanka 1 20.0% 0 .0% 1 20.0% 3 60.0% 0 .0% 5 100%Krushevo 0 .0% 0 .0% 1 50.0% 1 50.0% 0 .0% 2 100%Kumanovo 0 .0% 1 4.5% 12 54.5% 5 22.7% 4 18.2% 22 100%Makedonski Brod

0 .0% 0 .0% 3 100.0% 0 .0% 0 .0% 3 100%

Negotino 0 .0% 0 .0% 5 83.3% 1 16.7% 0 .0% 6 100%Ohrid 0 .0% 0 .0% 8 80.0% 0 .0% 2 20.0% 10 100%Pehchevo 0 .0% 0 .0% 0 .0% 1 100.0% 0 .0% 1 100%Prilep 0 .0% 1 5.9% 11 64.7% 5 29.4% 0 .0% 17 100%Probishtip 0 .0% 0 .0% 1 50.0% 1 50.0% 0 .0% 2 100%Radovish 0 .0% 0 .0% 2 33.3% 4 66.7% 0 .0% 6 100%Resen 0 .0% 0 .0% 4 100.0% 0 .0% 0 .0% 4 100%Rostushe 0 .0% 0 .0% 1 33.3% 2 66.7% 0 .0% 3 100%Shtip 0 .0% 1 14.3% 4 57.1% 1 14.3% 1 14.3% 7 100%Skopje 1 1.3% 5 6.7% 48 64.0% 16 21.3% 5 6.7% 75 100%Struga 0 .0% 3 21.4% 5 35.7% 6 42.9% 0 .0% 14 100%Strumica 0 .0% 3 25.0% 8 66.7% 0 .0% 1 8.3% 12 100%Sv. Nikole 0 .0% 0 .0% 3 75.0% 1 25.0% 0 .0% 4 100%Tetovo 2 6.5% 5 16.1% 12 38.7% 11 35.5% 1 3.2% 31 100%Valandovo 0 .0% 0 .0% 1 100.0% 0 .0% 0 .0% 1 100%Veles 0 .0% 0 .0% 7 70.0% 3 30.0% 0 .0% 10 100%Vevchani 0 .0% 0 .0% 4 80.0% 1 20.0% 0 .0% 5 100%Vinica 0 .0% 0 .0% 2 66.7% 1 33.3% 0 .0% 3 100%Total 4 1.2% 25 7.7% 183 58.2% 92 38.3% 15 4.6 325 100%Shaded rows refer to ZD that are already understaffed with PN, and aging of PN is more dramatic than for other ZD

93

Community nursing assessment with equity analysis in Macedonia | Final Report6. AnnexesFigure 47: Staffing structure of ZD (n=33)

BerovoDelchevo

DebarKichevo

StrugaTetovo

GostivarKavadarci

KochaniKumanovo

StrumicaGevgelijaRadovishVevchani

ShtipOhridVeles

PrilepSkopje

RostusheMakedonski Brod

Sveti NikoleNegotino

VinicaKratovo

ProbishtipValandovoKrushevo

ResenKriva Palanka

Demir HisarBitola

Pehchevo

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

PN Other Nurses Health Associates Doctors Admin & Technical

Figure 48: Comparison of service performance between PN and Domashna Poseta (DP) - 2010

№ Name of ZD Q-ty PN Total PN Visits per

annum

Total visits

per annum per PN

Q-ty DP Nurses

DP Home

visits per Annum

Home visit per annum per DP Nurse

122 Bitola 8 16,726 2,091 8 5,090 636123 Debar 3 7,568 2,523 1 95 95124 Demir Hisar 2 890 445 1 559 559125 Gevgelija 8 10,894 1,362 1 1,594 1,594126 Gostivar 23 27,704 1,205 4 1,368 342127 Kavadarci 10 13,000 1,300 10 3,357 336

94

Community nursing assessment with equity analysis in Macedonia | Final Report6. Annexes№ Name of ZD Q-ty PN Total PN

Visits per annum

Total visits

per annum per PN

Q-ty DP Nurses

DP Home

visits per Annum

Home visit per annum per DP Nurse

128 Kriva Palanka 4 1,705 426 1 227 227129 Krushevo 2 2,217 1,109 2 2,316 1,158130 Kumanovo 27 35,551 1,317 7 16,489 2,356131 Negotino 4 7,222 1,806 2 7,433 3,717132 Ohrid 10 5,233 523 4 706 177133 Resen 4 4,777 1,194 4 2,598 650134 Rostushe 2 1,350 675 2 646 323135 Skopje 76 92,647 1,219 11 24,534 2,230136 Struga 14 3,351 239 5 5,701 1,140137 Strumica 16 9,698 606 8 5,264 658138 Tetovo 31 39,316 1,268 3 3,104 1,035139 Veles 10 11,400 1,140 16 18,734 1,171140 Vevchani 7 2,782 397 7 3,238 463

Total 261 294031 **Expressi

on isfaulty ** 97

103053 **Expressi

on isfaulty **

In remaining 13 ZD that did not report Domashna Poseta services, 72 PN performed 68,030 visits per annum, that is 995 visit per annum per PN

Figure 49: Needs for antenatal and postnanatal PN servicesName of ZD Antenat

al visitsPostnatal visits

Newborns

Visit per Pregnant Visit per newborn

Berovo 1,040 410 167 6.23 Overutilization 2.5 OverutilizationBitola 509 3,008 1106 0.46 Underutilization 2.7 OverutilizationDebar 390 969 283 1.38 Underutilization 3.4 OverutilizationDelchevo 301 924 201 1.50 Underutilization 4.6 OverutilizationDemir Hisar 92 80 81 1.14 Underutilization 1.0 Underutilizatio

nGevgelija 492 1,402 370 1.33 Underutilization 3.8 OverutilizationGostivar 1,646 4,729 1165 1.41 Underutilization 4.1 OverutilizationKavadarci 469 4,314 433 1.08 Underutilization 10.0 OverutilizationKichevo 1,014 2,379 437 2.32 Overutilization 5.4 OverutilizationKochani 3,706 2,897 470 7.89 Overutilization 6.2 OverutilizationKratovo 66 166 77 0.86 Underutilization 2.2 OverutilizationKriva Palanka 451 1,254 250 1.80 Underutilization 5.0 OverutilizationKrushevo 132 1,129 139 0.95 Underutilization 8.1 OverutilizationKumanovo 1,547 6,752 1739 0.89 Underutilization 3.9 OverutilizationMakedonski Brod

213 842 170 1.25 Underutilization 5.0 Overutilization

Negotino 170 887 249 0.68 Underutilization 3.6 OverutilizationOhrid 155 3,521 600 0.26 Underutilization 5.9 OverutilizationPrilep 1168Probishtip 201 282 152 1.32 Underutilization 1.9 Underutilizatio

nRadovish 382 2,660 410 0.93 Underutilization 6.5 OverutilizationResen 368 2,415 133 2.77 Overutilization 18.2 Overutilization

95

Community nursing assessment with equity analysis in Macedonia | Final Report6. AnnexesName of ZD Antenat

al visitsPostnatal visits

Newborns

Visit per Pregnant Visit per newborn

Shtip 570 3,472 614 0.93 Underutilization 5.7 OverutilizationSkopje 5,723 38,175 7824 0.73 Underutilization 4.9 OverutilizationStruga 813 3,900 632 1.29 Underutilization 6.2 OverutilizationStrumica 321 4,335 1113 0.29 Underutilization 3.9 OverutilizationSveti Nikole 314 530 198 1.59 Underutilization 2.7 OverutilizationTetovo 3,862 12,992 2369 1.63 Underutilization 5.5 OverutilizationValandovo 4,134 125 0.00 Underutilization 33.1 OverutilizationVeles 2,000 6,400 813 2.46 Overutilization 7.9 OverutilizationVinica 481 508 196 2.45 Overutilization 2.6 OverutilizationTotal 27,428 115,466 23,684 1.16 Underutilizatio

n4.9 Overutilizatio

n

Figure 50: Inventory of vehicles in each health center (as reported in the self-administered questionnaire for healthcare managers)

Health center

Field vehicles (4x4) Passenger vehicles OtherNumber

unitsyear of

productionNumber of units

year of production

no.of units

year of production

Berovo 0 0Bitola 0 1 1999Debar 1 1995 0Delchevo 1 1995 0Demir Hisar

1 1999 2 1995, 2000 vans - 2

1997

Gevgelija 0 0 bicycles

Gostivar 0 1 2000Kavadarci 0 2 2000Kichevo 0 0Kochani 0 0Kratovo 0 0Kriva Palanka

1 before 2000 (not known)

1 before 2000 (not known)

Krushevo 0 0Kumanovo 0 1 2000Makedonski Brod

1 1997 0

Negotino 0 1 before 2000 (not known)

Ohrid 0 0Pehchevo 1 before 2000

(not known)0 motorbike-1 not

nownPrilep 0 1 2001Probishtip 0 0Radovish 0 0Resen 1 1996 1 2009Rostushe 0 0 1 before 2000

(not known)Shtip 0 1 2001Skopje 0 0

96

Community nursing assessment with equity analysis in Macedonia | Final Report6. AnnexesHealth center

Field vehicles (4x4) Passenger vehicles OtherStruga 1 2007 0Strumica 0 1 2000Sveti Nikole

0 1 not known

Tetovo 0 0Valandovo 0 0Veles 0 1 2001Vevchani 0 1 1987Vinica 0 0

Figure 51: Comparison of availability of asset (as reported by health centers) with reported use (by community nurses)

Health center Reported by Health centers

Reported by community nurses

Availability of vehicle

Use of vehicles Most often used type

Berovo No Often Public transportBitola Yes Often Vehicle from institutionDebar No Often Vehicle from institutionDelchevo Yes Regularly Vehicle from institutionDemir Hisar Yes Often Vehicle from institutionGevgelija Yes (bicycles) Seldom Motorbike/bike; vehicle

from institution; private vehicle

Gostivar Yes Seldom to almost never

Vehicle from institution

Kavadarci Yes Often or seldom Vehicle from institutionKichevo No Often Vehicle from institutionKochani No Seldom Vehicle from institution or

private vehicleKratovo No Seldom Vehicle from institutionKriva Palanka Yes Regularly Vehicle from institutionKrushevo No Often Vehicle from institutionKumanovo Yes Seldom Vehicle from institution or

public transportMakedonski Brod Yes Seldom Vehicle from institutionNegotino Yes Often Vehicle from institutionOhrid No Seldom Vehicle from institutionPehchevo Yes Often Vehicle from institutionPrilep Yes Regularly to

oftenPrivate vehicle or public transport

Probishtip No Often Private vehicleRadovish No Almost never Vehicle from institutionResen Yes Seldom Vehicle from institutionRostushe Yes Regularly Vehicle from institutionShtip No Often Vehicle from institution or

private vehicleSkopje No Regularly Private vehicle or public

transportStruga Yes Regularly to Vehicle from institution

97

Community nursing assessment with equity analysis in Macedonia | Final Report6. AnnexesHealth center Reported by Health

centersReported by community nurses

oftenStrumica Yes Seldom Vehicle from institutionSveti Nikole Yes Seldom Vehicle from institutionTetovo No Seldom to almost

neverVehicle from institution or public transport

Valandovo No Regularly Vehicle from institutionVeles Yes Seldom to almost

neverVehicle from institution or private vehicle

Vevchani Yes Often or seldom Vehicle from institution or public transport

Vinica No Almost never Private vehicle

Figure 52: Description of PN Monthly salaries by ZD as reported by HCM (in MKD)Name of ZD Min

SalaryAverag

eMax of Salary

Rostushe 24,000 24,000 24,000Kratovo 24,880 24,880 24,880Tetovo 23,494 25,318 27,923Vevchani 24,077 25,543 27,451Strumica 24,296 25,587 27,916Vinica 23,651 25,631 27,073Kriva Palanka 23,845 25,775 27,101Resen 24,659 25,965 28,596Debar 24,850 26,233 28,637Berovo 25,440 26,334 27,096Prilep 24,426 26,373 27,980Struga 23,961 26,410 29,497Gostivar 24,115 26,435 31,427Probishtip 26,055 26,752 27,449Pehchevo 26,753 26,753 26,753Delchevo 25,073 26,758 27,776Valandovo 26,189 26,860 27,530Krushevo 25,705 26,903 28,101Makedonski Brod 25,490 26,971 29,714Kumanovo 20,176 27,043 36,925Sveti Nikole 26,008 27,103 29,342Kavadarci 24,222 27,217 31,040Veles 25,892 27,270 29,304Gevgelija 25,706 27,345 29,238Radovish 26,472 27,414 27,902Skopje 24,148 27,430 38,033Demir Hisar 27,520 27,520 27,520Kichevo 24,078 28,036 36,781Negotino 25,984 28,414 38,180Bitola 25,210 29,408 32,275

98

Community nursing assessment with equity analysis in Macedonia | Final Report6. AnnexesName of ZD Min

SalaryAverag

eMax of Salary

Ohrid 25,589 29,677 40,370Kochani 30,000 30,000 30,000Shtip 24,484 30,151 40,921

Figure 53: Comparison of the share of non-labor costs in total PN services costs: estimated vs. reported by HCM (in MKD for 2010)

Estimated Reported by HCMName of the ZD PN Salaries Finances for

other costsFinances for

other costs % of earmarked

funding (package)

PN Salaries Non-Labor expenditures

Non-labor expenditures

as % of the total

expenditures

Berovo 1,264,032 175,968 12.2 1,264,032 0 0.0Bitola 3,176,040 63,960 2.0 3,422,400 320,847 8.6Debar 1,573,968 226,032 12.6 741,268 18,000 2.4Delchevo 1,605,468 194,532 10.8 1,650,831 27,500 1.6Demir Hisar 660,480 59,520 8.3 688,339 0 0.0Gevgelija 2,625,120 254,880 8.9 1,685,624 0 0.0Gostivar 7,295,940 984,060 11.9 6,555,134 494,459 7.0Kavadarci 3,266,028 333,972 9.3 3,299,300 83,469 2.5Kichevo 3,700,764 259,236 6.5 2,824,228 112,965 3.8Kochani 2,160,000 0 0.0 1,580,000 10,000 0.6Kratovo 597,120 122,880 17.1 630,912 0 0.0Kriva Palanka 1,546,524 253,476 14.1 1,624,728 50,360 3.0Krushevo 645,672 74,328 10.3 664,659 140,000 17.4Kumanovo 8,437,440 922,560 9.9 9,134,770 70,000 0.8Makedonski Brod

970,956 109,04410.1

970,956 159,000 14.1

Negotino 2,045,772 114,228 5.3 1,517,440 15,435 1.0Ohrid 3,561,192 38,808 1.1 4,292,225 124,692 2.8Pehchevo 321,036 38,964 10.8 398,035 37,000 8.5Prilep 5,380,140 739,860 12.1 5,323,510 31,956 0.6Probishtip 642,048 77,952 10.8 675,055 40,000 5.6Radovish 1,973,772 186,228 8.6 1,980,545 0 0.0Resen 1,246,296 193,704 13.5 1,240,380 310,000 20.0Rostushe 576,000 144,000 20.0 576,000 115,400 16.7Shtip 2,532,672 -12,672 -0.5 2,689,644 125,176 4.4Skopje 24,687,192 2,672,808 9.8 26,795,472 55,984 0.2Struga 4,436,916 603,084 12.0 3,938,763 240,000 5.7Strumica 4,912,728 847,272 14.7 3,668,952 71,323 1.9Sveti Nikole 1,300,956 139,044 9.7 1,332,991 0 0.0Tetovo 9,722,124 1,797,876 15.6 8,649,844 324,677 3.6Valandovo 644,628 75,372 10.5 656,900 0 0.0Veles 3,272,424 327,576 9.1 0 0 0.0Vevchani 1,532,580 267,420 14.9 1,478,000 32,800 2.2Vinica 922,728 157,272 14.6 960,000 0 0.0

109,236,75 12,443,2 10.2 102,910,9 3,011,04 2.8

99


Estimated Reported by HCM6 44 37 3

Figure 54: Projection of financing of PN services by ZDName of ZD 2010 2011 2012Berovo 1,440,000 1,520,000 1,920,000Bitola 3,240,000 3,420,000 4,320,000Debar 1,800,000 1,900,000 2,400,000Delchevo 1,800,000 1,900,000 2,400,000Demir Hisar 720,000 760,000 960,000Gevgelija 2,880,000 3,040,000 3,840,000Gostivar 8,280,000 8,740,000 11,040,000Kavadarci 3,600,000 3,800,000 4,800,000Kichevo 3,960,000 4,180,000 5,280,000Kochani 2,160,000 2,280,000 2,880,000Kratovo 720,000 760,000 960,000Kriva Palanka 1,800,000 1,900,000 2,400,000Krushevo 720,000 760,000 960,000Kumanovo 9,360,000 9,880,000 12,480,000Makedonski Brod 1,080,000 1,140,000 1,440,000Negotino 2,160,000 2,280,000 2,880,000Ohrid 3,600,000 3,800,000 4,800,000Pehchevo 360,000 380,000 480,000Prilep 6,120,000 6,460,000 8,160,000Probishtip 720,000 760,000 960,000Radovish 2,160,000 2,280,000 2,880,000Resen 1,440,000 1,520,000 1,920,000Rostushe 720,000 760,000 960,000Shtip 2,520,000 2,660,000 3,360,000Skopje 27,360,000 28,880,000 36,480,000Struga 5,040,000 5,320,000 6,720,000Strumica 5,760,000 6,080,000 7,680,000Sveti Nikole 1,440,000 1,520,000 1,920,000Tetovo 11,520,000 12,160,000 15,360,000Valandovo 720,000 760,000 960,000Veles 3,600,000 3,800,000 4,800,000Vevchani 1,800,000 1,900,000 2,400,000Vinica 1,080,000 1,140,000 1,440,000

HIF Financing Subtotal 121,680,000 128,440,000

162,242,012

MoH Preventive programs 1,500,000 1,538,600 1,538,600

Total Financing123,180,000

129,978,600

163,780,612

Annual increase 6% 26%

Salaries 109,236,756 109,236,756 109,236,75

100

Community nursing assessment with equity analysis in Macedonia | Final Report6. AnnexesName of ZD 2010 2011 2012

6Non-labor costs 12,443,244 19,203,244 53,005,256

Share of non-labor costs 10% 15% 33%

Figure 55: Composition of the basic benefit package financed by HIF in 2010

ИМП1 Emergency CareПРЕ1 Home care / treatmentПРЕ2 Service on DutyПРЕ3 Systematic examination, vaccinations and counseling

101

Community nursing assessment with equity analysis in Macedonia | Final Report6. AnnexesПРЕ4 Preventive stomatologyПРЕ5 Urgent stomatologyПРЕ6 Patronage nursesПРЕ7 Medical board to expertise health of the insured

102


Figure 56: Description of ZD and administrative statisticsCode in

Dataset

ZD Name Residence type

Development region

Population size

Number of PN in ZD

Ratio Population

per PN

Status by coverage

Density(Population per sq. km)

Rank by Density

1 Berovo Urban Eastern 13,941 4 3,485 High 23 Very High2 Bitola Urban Pelagonia 105,644 9 11,738 Very Low 62 Average3 Debar Urban South-western 26,061 5 5,212 Balanced 98 Low4 Delchevo Urban Eastern 25,615 5 5,123 Balanced 42 High5 Demir Hisar Urban Pelagonia 9,497 2 4,749 Balanced 20 Very High6 Gevgelija Urban South-eastern 35,121 8 4,390 High 46 High7 Gostivar Urban Polog 106,441 23 4,628 Balanced 136 Low8 Kavadarci Urban Vardar 42,882 10 4,288 High 38 High9 Kichevo Mixed South-western 56,734 11 5,158 Balanced 68 Average10 Kochani Urban Eastern 48,846 6 8,141 Low 122 Low11 Kratovo Urban North-eastern 10,441 2 5,221 Balanced 28 Very High12 Kriva Palanka Urban North-eastern 24,964 5 4,993 Balanced 34 High13 Krushevo Mixed Pelagonia 23,252 2 11,626 Very Low 85 Low14 Kumanovo Urban North-eastern 137,382 26 5,284 Balanced 114 Low15 Makedonski

BrodMixed Eastern 11,686 3 3,895 High 12 Very High

16 Negotino Urban Vardar 23,757 6 3,960 High 32 High17 Ohrid Urban South-western 61,256 10 6,126 Low 59 High18 Pehchevo Urban Eastern 5,517 1 5,517 Low 27 Very High19 Prilep Urban Pelagonia 82,918 17 4,878 Balanced 30 High20 Probishtip Urban Eastern 16,193 2 8,097 Low 49 High21 Radovish Urban South-eastern 31,780 6 5,297 Balanced 33 High22 Resen Urban Pelagonia 16,825 4 4,206 High 23 Very High23 Rostushe Rural Polog 8,618 2 4,309 High 108 Low24 Shtip Urban Eastern 51,808 7 7,401 Low 60 Average25 Skopje Mixed Skopje 578,144 76 7,607 Low 311 Very Low28 Struga Urban South-western 63,376 14 4,527 Balanced 130 Low29 Strumica Mixed South-eastern 92,625 16 5,789 Low 84 Low30 Sveti Nikole Urban Vardar 21,355 4 5,339 Balanced 763 Very Low

103


Code in

Dataset

ZD Name Residence type

Development region

Population size

Number of PN in ZD

Ratio Population

per PN

Status by coverage

Density(Population per sq. km)

Rank by Density

31 Tetovo Mixed Polog 189,066 32 5,908 Low 175 Very Low32 Valandovo Urban South-eastern 11,890 2 5,945 Low 36 High33 Veles Urban Vardar 66,541 10 6,654 Low 43 High34 Vevchani Rural South-western 2,433 5 487 Very High 162 Very Low35 Vinica Urban Eastern 19,938 3 6,646 Low 60 AverageTotal 2022547 338

Figure 57: PN service delivery performance by ZD (as reported by HCM)№ Name of ZD Q-ty

PNHome

Visits - Antenat

al

Home Visits -

Postnatal

Total A&P

Home visits

Visits to Schools

All Other visits

Total Visits

Antenatal Home

visits per

annum per PN

Postnatal Home

visits per

annum per PN

A&P home visits

per annum

PN

Visits to schoold

per annum per PN

All visits

per annum per PN

1. Berovo 4 900 40 940 3,750 4,690 225 10 235 1,1732. Bitola 8 509 3,008 3,517 375 12,834 16,726 64 376 440 47 2,0913. Debar 3 390 969 1,359 1,363 4,846 7,568 130 323 453 454 2,5234. Delchevo 5 301 924 1,225 2 5,403 6,630 60 185 245 0 1,3265. Demir Hisar 2 92 80 172 718 890 46 40 86 4456. Gevgelija 8 492 1,402 1,894 9,000 10,894 62 175 237 1,3627. Gostivar 23 1,570 4,659 6,229 21,475 27,704 68 203 271 1,2058. Kavadarci 10 469 4,314 4,783 148 8,069 13,000 47 431 478 15 1,3009. Kichevo 10 1,014 2,379 3,393 9,456 12,849 101 238 339 1,28510. Kochani 6 3,706 2,897 6,603 0 6,603 618 483 1,101 1,10111. Kratovo 2 66 166 232 928 1,160 33 83 116 58012. Kriva Palanka 4 451 1,254 1,705 0 1,705 113 314 426 42613. Krushevo 2 132 1,129 1,261 243 713 2,217 66 565 631 122 1,10914. Kumanovo 27 1,547 6,752 8,299 10,701 16,551 35,551 57 250 307 396 1,31715. Makedonski Brod 3 213 842 1,055 3,478 4,533 71 281 352 1,51116. Negotino 4 170 887 1,057 6,165 7,222 43 222 264 1,806

104


№ Name of ZD Q-ty PN

Home Visits -

Antenatal

Home Visits -

Postnatal

Total A&P

Home visits

Visits to Schools

All Other visits

Total Visits

Antenatal Home

visits per

annum per PN

Postnatal Home

visits per

annum per PN

A&P home visits

per annum

PN

Visits to schoold

per annum per PN

All visits

per annum per PN

17. Ohrid 10 155 3,521 3,676 1,557 5,233 16 352 368 52318. Pehchevo 1 140 370 510 29 810 1,349 140 370 510 29 1,34919. Prilep 17 0 0 0 0 0 0 020. Probishtip 2 201 282 483 1,203 1,686 101 141 242 84321. Radovish 6 382 2,660 3,042 4,020 7,062 64 443 507 1,17722. Resen 4 368 2,415 2,783 205 1,789 4,777 92 604 696 51 1,19423. Rostushe 2 76 70 146 546 658 1,350 38 35 73 273 67524. Shtip 7 570 3,472 4,042 48 3,307 7,397 81 496 577 7 1,05725. Skopje 76 5,723 38,175 43,898 48,749 92,647 75 502 578 1,21926. Struga 14 538 2,813 3,351 0 3,351 38 201 239 23927. Strumica 16 321 4,335 4,656 5,042 9,698 20 271 291 60628. Sveti Nikole 4 314 530 844 6,348 7,192 79 133 211 1,79829. Tetovo 31 3,862 12,992 16,854 22,462 39,316 125 419 544 1,26830. Valandovo 2 4,134 4,134 0 4,134 0 2,067 2,067 2,06731. Veles 10 2,000 6,400 8,400 3,000 11,400 200 640 840 1,14032. Vevchani 7 275 1,087 1,362 1,420 2,782 39 155 195 39733. Vinica 3 481 508 989 1,756 2,745 160 169 330 915

Total 333 27,428 115,466 142,894 13,660 205,507 362,061 82 347 429 198 1,087

105


Figure 58: Performance indicators by ZD as reported by HCM and PN (2010)Reported by HCM (n=33) Reported by PN (n=325)

Name of ZD Antenatal home

visits per annum

Postnatal home

visits per annum

Visits to school

per annum

All visits per

annum per PN

Average visits per

day per PN

Number of

families

visited in last month

Number of visits made

in last month

Number of visits

per family

Average

visits per

month

Usual number of visits

you do per day

The highes

t numb

er visits

by PN per day

Optimal

duration of the

first visit to

newborn

Optimal

duration of a

repeated visit

to newbor

n

Optimal

duration of a

visit to pregna

nt

Berovo 225 10 1,173 5.3 79 139 7 12 60 40 60Bitola 64 376 47 2,091 9.4 72 110 1.5 120 6 19 60 30 30Debar 130 323 454 2,523 11.3 25 40 1.6 373 10 18 33 25 30Delchevo 60 185 0 1,326 5.9 50 108 2.2 109 6 9 57 36 35Demir Hisar 46 40 445 2.0 45 35 4 5 60 20 20Gevgelija 62 175 1,362 6.1 41 133 3.2 146 9 15 101 69 49Gostivar 68 203 1,205 5.4 49 132 2.7 126 6 7 59 33 37Kavadarci 47 431 15 1,300 5.8 84 130 1.6 128 6 10 80 51 70Kichevo 101 238 1,285 5.8 120 120 6 7 90 63 60Kochani 618 483 1,101 4.9 52 114 2.2 104 6 9 80 52 43Kratovo 33 83 580 2.6 85 90 5 12 90 60 60Kriva Palanka 113 314 426 1.9 120 166 6 9 63 38 36Krushevo 66 565 122 1,109 5.0 141 110 13 15 105 48 48Kumanovo 57 250 396 1,317 5.9 96 125 5 7 76 40 44Makedonski Brod

71 281 1,5116.8

46 134 8 14 55 27 37

Negotino 43 222 1,806 8.1 46 122 2.7 120 5 8 90 60 30Ohrid 16 352 523 2.3 55 162 3 5 98 75 60Pehchevo 140 370 29 1,349 6.0 64 152 8 11 90 60 30Prilep 0 0 0 0.0 88 116 1.3 116 6 6 48 34 32Probishtip 101 141 843 3.8 51 123 2.4 109 6 8 60 45 60Radovish 64 443 1,177 5.3 80 78 1.0 79 4 7 61 34 35Resen 92 604 51 1,194 5.4 44 117 6 7 40 20 30

106


Reported by HCM (n=33) Reported by PN (n=325)Rostushe 38 35 273 675 3.0 90 155 4 6 40 20 30Shtip 81 496 7 1,057 4.7 60 108 1.8 106 6 7 60 35 60Skopje 75 502 1,219 5.5 54 125 2.3 123 6 8 88 54 57Struga 38 201 239 1.1 36 99 2.8 119 6 8 65 31 62Strumica 20 271 606 2.7 44 116 2.6 118 2 3 110 65 60Sveti Nikole 79 133 1,798 8.1 52 136 6 8 79 55 56Tetovo 125 419 1,268 5.7 82 107 1.3 134 6 9 69 48 45Valandovo 0 2,067 2,067 9.3 103 180 8 19 60 30 30Veles 200 640 1,140 5.1 53 108 2.0 103 6 8 100 41 63Vevchani 39 155 397 1.8 61 116 6 12 60 40 32Vinica 160 169 915 4.1 65 120 6 10 60 30 60Total 82 347 198 1,087 4.9 55 109 2.0 126 6 8 76 46 49

Figure 59: Summary of findings of the facility assessmentHealth Center Bitola Debar Kochani Ohrid Prilep Rostush

eShtip Strumic

aTetovo Veles

General information1) Catchment area primarily: Urban Mixed Mixed Mixed Mixed Rural Mixed Mixed Mixed Urban2) Access to facility: Easy Easy Easy Difficult Easy Easy Easy Easy Easy Easy3) Road connections: Available Available Available Available Available Available Available Available Available Available4) Approx. Total space of the facility (м2)

5,500 164 3,100 1306* 5,070 5,039 6,750

5) Garage space Yes Yes Yes No Yes Yes Yes Yes Yes YesAmenities for Patronage Nurses6) Separate entrance for PN* Yes No Yes No Yes Yes Yes Yes Yes No7) Recognizable well marked entrance Yes Yes Yes No Yes Yes Yes Yes Yes No8) Accessibility of the entrance Easy Easy Easy Difficult Easy Difficult Easy Easy Easy Difficult9) Separate space for patronage service

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

10) Approx. space occupied by PN (м2)

100 15 30 26 16-18* 12 50 36 (20+16)

70 25-30

11) If shared with other service… Full time Full time

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Health Center Bitola Debar Kochani Ohrid Prilep Rostushe

Shtip Strumica

Tetovo Veles

12) Phone (land-)line shared Yes Yes No Yes No No No13) Office equipment shared No Yes Yes * No No No14) Conditions of the working space Good Acceptab

leAcceptable

Poor Acceptable

Acceptable

Good Good Acceptable

Poor

15) Need for major refurbishment No No No* Yes Yes No No No* Yes YesProcedures/ Record keeping18) Diary (Дневник) are updated Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes19) Family cards well organized Yes Yes Yes Yes Yes Yes Yes Yes Yes No*20) Notifications from Maternal houses available

* Yes Yes* Yes* Yes* Yes Yes Yes Yes

21) Documentation is stored properly Yes Yes Yes Yes Yes Yes Yes Yes Yes* No22) PN can be identified (badges, uniforms)

Yes No No No No No Yes Yes* Yes* No

23) Time sheets are filled in regularly No Yes Yes Yes Yes Yes Yes Yes Yes Yes24) Equipment is stored properly* Yes Yes Yes Yes Yes Yes Yes Yes Yes No

Figure 60: Description of PN component of the MoH preventive health prgorams (2009-2011)Item and description

2009 2010 2011Measures and goals (indicators) for whole program

Financially provided by program (in MKD)

Measures and goals (indicators) for whole program


Measures and goals (indicators) for whole program


Antenatal care

2 visits per pregnancy (total 52.000)

2300 uninsured pregnant x 2 = 4600 visits x 200 MKD

920,000

2 visits per pregnancy (total 52.000)

- 2 visits per pregnancy by PN and RHM (total 55.000)

-

Postnatal care

On average 2 visists per mother (total 75.000 visits) + 1 visit within 6

2300 mothers/newborn x 2 = 4600 visits x 200 MKD

920,000

On average 2 visits per mother (total 50.000 visits)

- On average 2 visits by PN and RHM per mother (total 55.000 visits)

-

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Item and description

2009 2010 2011weeks of delivery (total 25.000 visits)1 visit by doctor to newborns (no indicator of number of visits)* (not by PN)

no description of number of visits

- - -

Infants (patronage visits)

5 visits per infant (of which 2 as above when visiting the mother) and remaining 3 at the age: 4-6 mths, 7-9 mths and 12 mths.

2300 infants x 3 x 200 MKD

1,380,000

5 visits per infant (of which 2 as above when visiting the mother) and remaining 3 at the age: 4-6 mths, 7-9 mths and 12 mths.

- 5 visits per infant (of which 2 as above when visiting the mother) and remaining 3 at the age: 4-6 mths, 7-9 mths and 12 mths.

-


92,000

- -


92,000

- -

Families at risk

Visit to families at social risk

7500 visits x 200 MKD

1,500,000

Visit to families at social risk

7500 visits x 200 MKD

1,500,000

Visits to families with social risk

5217 families x 200 MKD

1,043,400

- - - Visits to Roma families by Roma Health Mediators (RHM)

1238 families x 2 visits x 200 MKD

495,200

Training Regional seminars for PPN for development of newborns, small children, adolescents and women in

10 workshops x 50000 MKD

500,000

Regional seminars for PPN for development of newborns, small children, adolescents and women in reproductive


300,000

Regional seminars for assessment of capacities of PPN and RHM (co-financing for ORIO project of the Dutch Government)

10 workshops x 300,000 MKD

3,000,000

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Item and description

2009 2010 2011reproductive period

period

Regional seminars for PPN for children born under risk, born at home


500,000

Regional seminars for PPN for children born under risk, born at home


150,000

- -

TOTAL for the above

5,904,000

1,950,000

4,538,600

TOTAL for the Program

32,700,00

0

14,000,000

20,000,000

Figure 61: ZD revenues and expenditurs (in thousands MKD) relatted to PN as reported by HCM2009 2010

Financing Expenditures Balance Financing Expenditures Balance

Name of ZD MoH HIF Total Salaries Med. Supp Other Total MoH HIF Total Salaries Med. Supp

Other Total

Berovo 42.7 35.0 77.7 1,264.0 0.0 0.0 1,264.0 -1,186.4 97.0 728.5 825.5 1,264.0 0.0 0.0 1,264.0 -1,167.0

Bitola 0.0 0.0 0.0 3,169.0 61.4 283.2 3,513.6 -3,513.6 0.0 0.0 0.0 3,422.4 58.5 262.3 3,743.2 -3,422.4

Debar 652.4 0.0 652.4 846.2 0.0 30.0 876.2 -223.8 181.8 1,573.0 1,754.8 741.3 0.0 18.0 759.3 -559.5

Delchevo 0.0 1,228.1 1,228.1 1,620.1 3.5 28.9 1,652.5 -424.5 0.0 1,311.9 1,311.9 1,650.8 3.2 24.3 1,678.3 -1,650.8

Demir Hisar 0.0 720.0 720.0 628.8 0.0 0.0 628.8 91.2 0.0 720.0 720.0 688.3 0.0 0.0 688.3 -688.3

Gevgelija 409.5 0.0 409.5 2,244.5 0.0 0.0 2,244.5 -1,835.0 543.6 0.0 543.6 1,685.6 0.0 0.0 1,685.6 -1,142.0

Gostivar 884.6 1,716.0 2,600.6 6,626.2 504.5 0.0 7,130.6 -4,530.0 449.3 4,287.5 4,736.8 6,555.1 494.5 0.0 7,049.6 -6,105.8

Kavadarci 0.0 0.0 0.0 3,337.8 125.4 0.0 3,463.2 -3,463.2 0.0 0.0 0.0 3,299.3 83.5 0.0 3,382.8 -3,299.3

Kichevo 317.7 1,025.4 1,343.0 2,819.1 41.5 111.0 2,971.7 -1,628.6 156.1 1,095.4 1,251.5 2,824.2 19.3 93.7 2,937.2 -2,668.1

Kochani 174.1 0.0 174.1 1,600.0 0.0 10.0 1,610.0 -1,435.9 24.4 1,304.6 1,329.0 1,580.0 0.0 10.0 1,590.0 -1,555.6

Kratovo 42.0 338.7 380.7 597.4 0.0 0.0 597.4 -216.7 14.0 256.5 270.5 630.9 0.0 0.0 630.9 -616.9

Kriva Palanka 347.3 0.0 347.3 1,532.9 6.3 60.0 1,599.2 -1,251.9 324.7 0.0 324.7 1,624.7 0.4 50.0 1,675.1 -1,300.1

Krushevo 471.9 0.0 471.9 657.3 10.0 160.0 827.3 -355.5 179.2 0.0 179.2 664.7 10.0 130.0 804.7 -485.4

Kumanovo 729.9 9,134.8 9,864.7 8,672.8 0.0 75.0 8,747.8 1,116.9 444.0 8,672.8 9,116.7 9,134.8 0.0 70.0 9,204.8 -8,690.8

Makedonski Brod 216.1 971.0 1,187.0 971.0 24.0 140.0 1,135.0 52.1 151.3 971.0 1,122.3 971.0 24.0 135.0 1,130.0 -819.6

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2009 2010

Negotino 131.0 0.0 131.0 1,430.7 34.8 0.0 1,465.5 -1,334.5 130.9 0.0 130.9 1,517.4 15.4 0.0 1,532.9 -1,386.6

Ohrid 384.7 4,292.2 4,676.9 4,140.9 16.8 133.0 4,290.7 386.2 112.4 4,140.9 4,253.2 4,292.2 26.2 98.5 4,416.9 -4,179.9

Pehchevo 0.0 0.0 0.0 324.5 2.0 35.0 361.5 -361.5 0.0 0.0 0.0 398.0 2.0 35.0 435.0 -398.0

Prilep 445.2 2,965.9 3,411.0 5,350.0 4.6 41.7 5,396.4 -1,985.3 128.3 3,305.5 3,433.7 5,323.5 6.0 26.0 5,355.5 -5,195.3

Probishtip 325.9 0.0 325.9 644.8 10.0 33.0 687.8 -362.0 84.7 0.0 84.7 675.1 10.0 30.0 715.1 -590.3

Radovish 63.2 900.4 963.6 1,982.7 0.0 0.0 1,982.7 -1,019.1 0.0 976.6 976.6 1,980.5 0.0 0.0 1,980.5 -1,980.5

Resen 1,733.0 1,550.0 3,283.0 1,223.7 10.0 300.0 1,533.7 1,749.3 290.0 1,550.0 1,840.0 1,240.4 10.0 300.0 1,550.4 -950.4

Rostushe 0.0 660.0 660.0 576.0 65.0 50.4 691.4 -31.4 0.0 660.0 660.0 576.0 65.0 50.4 691.4 -576.0

Shtip 215.5 3,175.5 3,391.0 2,564.0 20.3 34.2 2,618.4 772.6 273.7 4,586.0 4,859.7 2,689.6 48.0 77.2 2,814.8 -2,415.9

Skopje 0.0 26,795.5 26,795.5 25,106.0 5.7 69.9 25,181.6 1,613.9 0.0 25,106.0 25,106.0 26,795.5 9.1 46.9 26,851.5 -26,795.5

Struga 425.0 3,938.8 4,363.8 3,540.8 120.0 120.0 3,780.8 582.9 194.0 3,540.8 3,734.9 3,938.8 120.0 120.0 4,178.8 -3,744.7

Strumica 0.0 3,740.3 3,740.3 4,083.4 0.4 61.8 4,145.6 -405.4 0.0 4,145.6 4,145.6 3,669.0 1.2 70.1 3,740.3 -3,669.0

Sveti Nikole 25.0 875.4 900.4 1,310.1 0.0 0.0 1,310.1 -409.8 25.0 881.3 906.3 1,333.0 0.0 0.0 1,333.0 -1,308.0

Tetovo 1,484.0 8,732.0 10,216.1 9,378.4 6.4 205.7 9,590.6 625.5 1,886.2 11,780.0 13,666.1 8,649.8 6.8 317.9 8,974.5 -6,763.7

Valandovo 156.6 488.0 644.6 669.9 0.0 0.0 669.9 -25.3 62.3 582.3 644.6 656.9 0.0 0.0 656.9 -594.6

Veles 234.3 2,356.4 2,590.7 3,266.7 0.0 10.0 3,276.7 -686.1 327.0 2,200.4 2,543.4 0.0 0.0 0.0 0.0 327.0

Vevchani 151.0 1,532.6 1,683.6 1,532.0 32.0 12.0 1,576.0 107.6 716.5 1,532.6 2,249.1 1,478.0 25.0 7.8 1,510.8 -761.5

Vinica 80.0 0.0 80.0 972.0 0.0 0.0 972.0 -892.0 70.0 0.0 70.0 960.0 0.0 0.0 960.0 -890.0

Total 10,142.3 77,171.8 87,314.1 104,683.9 1,104.6 2,004.9 107,793.3 -20,479.2 6,866.5 85,909.0 92,791.5 102,910.9 1,038.0 1,973.1 105,922.0 -96,044.5

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Annex L: Research instruments by research subjects, research methods and sample type

Research subjectsDesk research

Facility assessmentFA

Semi-Structured interviewsSSI

Focus groupsFG

Self-administeredSA

HCM AC & Exp HO PN Com HCM PN

1) Human resources1.1 Human resource profile DR/-1.1 SA/HCM-1.1

1.2 Professional growth needs X SSI/HCM-

1.2 SSI/Exp-1.2 FG/PN-1.2 SA/PN-1.2

1.3 Professional growth opportunities DR/-1.3 SSI/HCM-

1.3 FG/PN-1.3

2) Service coverage and utilization

2.1 Supply side (existing coverage and utilization) DR/-2.1 SA/HCM-2.1

2.2 Needs in community nurse services X FG/PN-2.2 FG/Com-2.2 SA/PN-2.2

3) Quality of services (Assessing preconditions)

3.1 Training opportunities SSI/HCM-3.1 SSI/AC-3.1

3.2 Technical means DR/-3.2 FA/-3.2 SSI/HCM-3.2 FG/PN-3.2 SA/HCM-3.2

3.3 Quality assurance X SSI/HCM-3.3

4) Service costs and resource requirements

4.1 Current flow of funds and costs DR-4.1 FA/-4.1 SSI/HCM-

4.1 SA/HCM-4.1

4.2 Estimation of future resource requirements

5) Feasibility of collaboration X SSI/HCM-5 SSI/Exp-5 SSI/HO-5 FG/PN-5

HCM Health Center managers

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AC Academia (teaching and research institutions)Exp Experts (public health, health care administration)HO Health officials (Ministry of Health, Health Insurance Fund, others…)CN Community NursesCom Community

113

Annex M: Health care service utilization pathways (illustrative case)

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Community nursing assessment with equity analysis in Macedonia | Final Report6. AnnexesA 28 years old pregnant woman (20th week) under TB treatment (DOTs) gets fever (39°) and suffers from severe dyspepsia at 22:30 Saturday (see Error: Reference source notfound Error: Reference source not found).

From the very beginning there are two alternative pathways:

1b – call a doctor/nurse on duty at the PHC doctor’s office, or

1a – call emergency.

Each pathway steps are discussed separately below.

Calling emergency – 1aStep 1Emergency team assess the situation, provides necessary interventions if needed and either:

a) Offers to stay at home and refer to PHC doctors at the earliest convenience (see step 2 of the pawthway “Calling a doctor on duty – 1b”), or

b) Offers hospitalization. The patient, in turn, may:

a. Agree to be hospitalized – pathway 2a

b. Refuse and decide stay at home – pathway 2b

Pathway 2a – hospitalizationIt is assumed that patient recovers in the hospital and is discharged. PHC doctor might be notified to follow up the case (“3d”).

Pathway 2b – refusing hospitalizationIf the patient requires medical care but refuses hospitalization the emergency team informs “Domasna Poseta” team to provide follow up medical services. The team of “Domasna Poseta” can respond only on Monday, that is 2 days after the onset of health problem.

The team can assess the patient’s condition and advise either to visit the PHC whenever she can physically afford it or to continue home care. The team cannot prescribe drugs and can only provide some medications from a kit (e.g. antipyretics).

Calling a doctor on duty – 1bStep 1Calling a doctor on duty may end up by:

a) Getting advise on managing fever and other symptoms (in case some drugs are on hand) and visit the GP office at the earliest convenience (go to Step 2)

b) Getting advise to call emergency immediately or if the situation does not get better despite of following the doctor’s advice. In such a case the next steps are discussed under 1a (calling emergency).

Step 2It is assumed that the patient is capable (physically) and willing to make an office visit to PHC office.

The office visit may be enough to “close the case” or the patient can be referred to any of the following services:

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“3a+” – Diagnostic services

“3b+” – Specialists

“3c+” - Pharmacy

The patient may move several times between the diagnostic services or specialists and GPs.

Finally, the patient can be referred by the PHC doctor to hospital – “3d”.

Analysis

It is unclear whether three health professionals are informed and/or engaged in this case:

1? – TB doctor and nurse (the health problem was related to TB or not regardless). There is higher probability of their engagement in case of 1b pathway if the GP decided that the health problem is related to the underlying TB and the patient should be referred to TB specialized clinic (“3e?” arrow).

2? – Patronage nurse – there is no formal procedure ensuring that the patronage nurse is informed about the case. There is some probability the patronage nurse to learn about the case if the pathway ends at “2b”.

3? – Ob&Gy specialist: if the case follows pathway 1a it is unlikely the Ob&Gy specialist to get informed about the case unless the patients makes a planned visit to the PHC office.

Considering the time of health problem occurrence (Saturday 22:30) it is most likely the case to follow the pathway “1a”. It entails that the case is managed either in inefficient way (high costs of inpatient care instead of solving the health problem using outpatient services via PHC) or may pose a threat to health outcomes if the patient refuses hospitalization and gets medical services provided by the team of “Domasna Poseta” (with no ability to refer the patient to specialists or prescribe proper treatment).

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Annex N: SA/HCM questionnaire

1) Please fill in general information about the Health House….

1.1 Name of the institution

1.2 Location (District) of the institution

1.3 Contact person’s name

1.4 Contact person’s position

1.5 Contact details - telephone

1.6 Contact details – email

2) Please list municipalities the HC provides services to:

3) What is coverage area (approx. in km2)?

4) What is estimated size of the Total population in coverage area

117

Community nursing assessment with equity analysis in Macedonia | Final Report6. Annexes5) Please indicate number of positions and actual employees as of June 1st

2011:Planned / positions Actual employed

5.1 All Doctors

5.2 All Nurses and Midwives

5.3 Only Patronage Nurses

5.4 Health associates (biochemist, psychologist, etc)

5.5 Technical staff

5.6 Administrative staff

5.7 TOTAL

6) Please provide a copy of the organization chart if available.

Number of services (annual level) – patronage service

7) Please provide details on the workload of patronage nurses and actual number of patronage nurses employed in last 5 years

Years2006 2007 2008 2009 2010

7.1 Number of Patronage Nurses that performed the visits

Home visits including7.2 Antenatal

7.3 Postnatal

7.4 Other….

7.5 Other…

7.6 Other…

7.7 Visits to other places (e.g. schools)

118

Community nursing assessment with equity analysis in Macedonia | Final Report6. Annexes8) Please provide details on the workload of Domasna Poseta – home visits they

made in each year and actual number of Domasna Poseta team (doctor+nurse) employed in last 5 years

Years2006 2007 2008 2009 2010

8.1 Number of Domasna Poseta Doctors

8.2 Number of Domasna Poseta Nurses

8.3 Number of home visits

Information on organization of Polyvalent Patronage Services (PPS)

9) How is PPS organized? (Please check only ONE answer)

9.1 As separate unit 9.2 Within other unit

9.3 Undefined

10) What are spatial conditions for PPS?(Please check only ONE answer)

10.1 Has own space _____m2

10.2 Shared space 10.3 No space at all

11) Are other professionals working in PPS?

11.1 YES 11.2 NO

12) If YES, please list professionals working in PPS:

13) What is the time coverage of PPS?(Please check only ONE answer)

13.1 8 hours 13.2 12 hours 13.3 24 hours

14) Please list which preventive/curative services are provided in PPS:Preventive Curative

119

Community nursing assessment with equity analysis in Macedonia | Final Report6. Annexes15) Please indicate number of patronage nurses employed in your HCI as of

June 2011:

15.1 Full employment (staff member):

15.2 Contract basis

16) Please indicate how many PPS nurses have retired or left:Years

2007 2008 2009 2010

16.1 Number of PPS Nurses retired

16.2 Number of PPS nurses left

17) When leaving PPS the main reason are:(Please check as many answers as needed)

17.1 Firing 17.2 Other

17.3 Transfer 17.4 Other

17.5 Private reasons 17.6 Other

18) If some patronage nurse positions are vacant, how do you provide services to the population that is not covered?

19) Are patronage nurses in other services?

19.1 YES 19.2 NO

20) If Yes, are they in other services…

20.1 Regularly

20.2 From time to time

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Personal information on patronage nurses:

21) Please list all patronage nurses that are currently employed in your institution (as of June 2011).Name Year of

birthYear of graduation from highest level

Type and level of highest education Year of employment in your institution

Gross Salary (Per month)

SSS Visha VSS Postgrad









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Technical means and equipment for patronage nurses

22) Please provide information on the equipment/technical means used in PPS.:In column “Working Condition” CIRCLE 1, 2 or 3

In column “Used” CIRCLE 1, 2 or 3

1 = not working or needs major repair2 = working but minor repair is needed3 = working

1 = not used2 = irregularly used3 = regularly used

Category Item Name Quantity Year of production

Working Condition(1, 2, 3)*

Used:(1,2,3)**

1. Patronage bag Cassette with tweezers, pean clamp, scissors that can be sterilized

1 2 3 1 2 3

Mobile delivery set 1 2 3 1 2 3

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Used:(1,2,3)**

Glycometer 1 2 3 1 2 3Manometer with stethoscope 1 2 3 1 2 3Supplies: gauze, cotton, disinfectant YES NOProtective gloves 1 2 3 1 2 3

Protective apron 1 2 3 1 2 3

Thermometer 1 2 3 1 2 3

One mobile incubator 1 2 3 1 2 3

ECG apparatus (mobile) 1 2 3 1 2 3

Mobile CTG apparatus for pregnant women 1 2 3 1 2 3

Legitimation card YES NOUniform and shoes 1 2 3 1 2 3

2. Transportation field vehicles (4x4) 1 2 3 1 2 3

passenger vehicles 1 2 3 1 2 3

bicycles 1 2 3 1 2 3

bus 1 2 3 1 2 3

motorbikes 1 2 3 1 2 3

van or other bigger vehicle 1 2 3 1 2 3

3. Communication land line (telephone/fax)mobile phoneinternet YES NO

4. Office equipment desktop computer 1 2 3 1 2 3

laptop computer 1 2 3 1 2 3

printer 1 2 3 1 2 3

other: 1 2 3 1 2 3

5. Other 1 2 3 1 2 31 2 3 1 2 31 2 3 1 2 3

123




Used:(1,2,3)**

1 2 3 1 2 3

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Financial Information – REVENUES

23) Do you have separate accounting/coding for patronage services?

23.1 YES 23.2 NO

24) How much funding did you receive for patronage services from each of the following sources:

2010 2009

MOH = ____________________ MKD

HIF = _____________________ MKD

Donations = _________________ MKD

MOH = ____________________ MKD

HIF = _____________________ MKD

Donations = _________________ MKD

25) Sources of own funding – which are the sources of own revenues?

25.1 MoH (preventive programs) 25.2 Physical check-ups (lek.uverenija) and other such services

25.3 Co-payments 25.4 Rent from management of business space

25.5 Other ___________________________

25.6 Other _____________________________

26) Please provide a copy of the last report to MOH | Month/year of the Report ___________

27) Please provide a copy of the last report to HIF | Month/year of the Report ___________

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Financial Information - EXPENDITURES

28) What were the total expenditures of your HCI on PPS:

2010 Comment

Salaries = ____________________ MKD

Medical Supplies = ______________ MKD

Other = ______________________ MKD

For “other” please specify:

2009 Comment

Salaries = ____________________ MKD

Medical Supplies = ______________ MKD

Other = ______________________ MKD

For “other” please specify:

Salaries = include the salaries for patronage nursesMedical supplies = supplies of medicines, gauze, disinfectants and other consumables used by patronage nursesOther = any costs that are not listed above – please specify what is included under “other”

126


Annex O: SA/PN questionnaire

1) Please provide general information about the respondent

28.1 Name of the institution

28.2 Location (District) of the institution

28.3 Respondent’s name

28.4 Respondent’s year of birth

28.5 Respondent’s position

28.6 Contact details - telephone

28.7 Contact details – email

29) What is population in catchment area?

30) Coverage area is (please check only one answer):

30.1 Mostly urban 30.2 Mostly rural 30.3 Mixed

31) What is your educational background:Years Institution / place of education Degree obtainedFrom To

SSS VSHS VSS Postgrad




32) Can you please specify professional trainings you have undertaken?Thematic unit/issue Year Theoretical

knowledgePractical skills

127


32.1 Care for newborn (care for umbilical cord, wrapping, etc)

32.2 Nursing

32.3 Medical documentation/records

32.4 Communicable diseases

32.5 TB

32.6 Family violence

32.7 Diseases of addiction

32.8 Children with special needs

32.9 Orthopaedics (phimosis)

32.10 Nutrition of a newborn

32.11 Antirickets protection

32.12 Anaemias

32.13 Standards/guidelines for operation

33) Please give us details about your professional experience (in years):

33.1 Total number of work experience

33.2 Total number of work experience as PN

33.3 Number of years in current institution

34) Current employment is:34.1 full 34.2 contract-based

Please answer as accurate as possible questions on your workload

35) How many families/visits did you make in the last month you were fully in work (with no sick leaves, vacation days, etc):

35.1 Families

35.2 Visits

36) Most often how many visits you do per day:

37) What the highest number visits you made per day last year?

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Community nursing assessment with equity analysis in Macedonia | Final Report6. Annexes38) Can you please describe how your work is distributed in terms of type of

patronage service:

38.1 Preventive - Pregnant:

38.2 Preventive - New-borns:

38.3 Preventive – Other:………………………………………….……….

38.4 Preventive – Other:………………………………………………….

38.5 Curative – TB

38.6 Curative – Diabetes

38.7 Curative – Other…………………………………………………..

38.8 Other……………………………………………………………………

38.9 Other……………………………………………………………………

39) How many visits do you make in average per month?

40) How many times you use transport per month?

40.1 Regularly (every day)

40.2 Often (several times a week)

40.3 Seldom (few times during month)

40.4 As usually never (go to question 42).

41) What is the transportation you use mainly? (please check only ONE, the most appropriate)

41.1 Vehicle (from institution)

41.2 Vehicle (personal)

41.3 Bicycle/motorcycle

41.4 Public transportation (bus, van)

42) Are there services that your community requires that you do not have attended training for?

42.1 Yes, they are

42.2 No

43) If there are such services, can you please list some of them:Preventive Curative

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Community nursing assessment with equity analysis in Macedonia | Final Report6. Annexes44) Are there services that your community requires that you do not have

authorization to provide?44.1 Yes, they are

44.2 No

45) If there are such services, can you please list some of them:Preventive Curative

46) In which of these languages can you communicate?

46.1 Macedonian

46.2 Romani

46.3 Serbian/Bosnian

46.4 Albanian 46.5 Turkish

46.6 Other…………………………

47) How often do you consult with other HC professional about some issues in the fieldwork?

47.1 Often 47.2 Sometimes 47.3 Never

48) In case you need professional advice, do you know who you can refer to?

48.1 Yes 48.2 No 48.3 Cannot answer

49) If you know who to refer to, please name them:

49.1 Colleague 49.2 PHC doctor 49.3 Other …………………………

49.4 Specialist 49.5 Main PN 49.6 Other …………………………

50) How long is usually your visit in to a home (in minutes)?:

50.1 Visit to newborn (first visit)

50.2 Visit to newborn (repeated visit)

50.3 Visit to pregnant woman

51) Do you sometimes assist in other units?

51.1 YES 51.2 NO

52) If YES, please list units you assist:

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53) How long should in your opinion take a usual visit in a home (in minutes)?:

53.1 Visit to newborn (first visit)

53.2 Visit to newborn (repeated visit)

53.3 Visit to pregnant woman

54) Which languages are spoken in your community?

54.1 Macedonian 54.2 Romani 54.3 Serbian/Bosnian

54.4 Albanian 54.5 Turkish 54.6 Other…………………………

Training and professional needs

55) Please tell us about the LAST training….

55.1 Year of your last training

55.2 Duration of the training (in days)

55.3 Who paid for the training

(Indicate only ONE, main sponsor)

55.4 Myself 55.5 Donor 55.6 Other

55.7 Employer Which: Which:

55.8 MoH/HIF

56) Did you receive orientation training when you were employed in current institution?

56.1 YES 56.2 NO

57) If YES, what this training consisted of? (Check as many responses as needed)

57.1 Joint visits with senior staff

57.2 Receiving classes and printed guidelines for work

58) Are there skills that you need for serving your community better?

58.1 YES 58.2 NO

59) IF yes, please list them:Preventive Curative

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60) Is there any training that you know of but cannot attend (because of some reasons)?

60.1 YES 60.2 NO

61) If YES, please list them:

62) If YES, what are main reasons you cannot attend these trainings? (check as many as needed)

62.1 Financial

62.2 Personal

62.3 Inadequate level of education

62.4 Big competition for participation

62.5 Lack of information/ information not timely

62.6 Other _______________________________

Equipment needs

63) Is the available equipment in good condition?

63.1 YES 63.2 NO

64) Is available equipment sufficient?

64.1 YES 64.2 NO

65) What equipment would improve you work if it can be obtained?141 142143 144145 146147 148

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Annex P: SSI/HCM guide

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1. IntroductionThe interviewer gives background information about the project, the objectives, and expected outcomes and how the interviewee can contribute towards these objectives/outcomes.

The interviewer (with switched-on Dictaphone) asks for permission to voice-record the interview, and also explains the procedure for interview data validation with the interviewee.

2. Human resources – professional growth needs and opportunities What is the educational profile of the patronage nurses in your institution?

What is the age structure of the patronage nurses? If the age structure is older, do you have a strategy how to attract, employ and train younger persons?

Do you have the right to hire/fire patronage nurses, if you are not satisfied with their performance? Explain.

How do you measure their performance? Are there standardized guidelines/rules/forms?

Do you offer/provide training opportunities to patronage nurses? Do you offer/provide funding for attending trainings organized by other institutions?

What in your opinion is mostly needed to patronage nurses (education-wise, training-wise, accreditation, regulation, etc)?

3. Service coverage and utilization What range of services are provided by the patronage nurses (monovalent:

mother and children, polyvalent, other). How is this related/linked to the HIF patronage package (in financial terms)?

Do you have enough patronage nurses to cover the population under your healthcare centre? If not, WHY?

Is the population in your coverage area demanding other types of services that are currently not provided (curative, palliative, etc)?

Are there observations from your side that some of the activities that are now within scope of work of the home visit (Domashna poseta) which also has a doctor in the team, should be more resource efficient to be performed by patronage nurse?

4. Service costs What is your opinion about the financial resources dedicated to patronage

nurses (fro HIF and MOH): are they sufficient, or only partially sufficient? What should be provided more (e.g. equipment, uniforms for all nurses in the country, vehicles, higher salaries, more funding for medical supplies).

5. Feasibility of collaboration with other community services Is there in your coverage area de facto/de jure exiting a formal communication

channel for referral from patronage nurse to social worker and vice versa when a respective problem is identified? Explain the communication channel

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(formal, informal, and details).

If we assume that the main principle for the country should be that the “family is in the center of the services”, what, in your view is the IDEAL model of cooperation and communication between the institutions and individuals to provide a highest possible level of service to the families in Macedonia?

Do you have established collaboration with other institutions in the community (social services centers, kindergartens, schools, police, homes for elderly, Red Cross, NGOs, etc).

Explain what are the collaboration practices you have. Are there some formal/legal links missing for these collaborations? Are there sufficient funds to cover the collaboration? Is the jurisdiction of the collaboration covered (who is responsible for each part of the service/cooperation).

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Annex Q: SSI/AcExp guide

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2. Human resources – professional growth needs and opportunities What are currently the possibilities for education and training for the patronage

nurses? Were there more opportunities in the past? If yes, why were they decreased? Is there a plan to increase the number of opportunities in the future?

Given that the patronage nurse is working on her own in the field (without supervision from a medical doctor), is there a system for accreditation of the patronage nurse skills and knowledge? If not, WHY?

Is there a defined legislation regarding the skills and competences that patronage nurses should have to work? Are her duties and rights fairly and explicitly written somewhere?

If there is no defined legislation on skills and competences, which in your opinion are the most important skills and competences that patronage nurse should have (medical, social, communication, psychology, etc.)

If there is no accreditation system, what should be the optimal model for establishing such accreditation system?

What are the additional adaptations to patronage nurse education that could increase their professional ability to provide services that will answer to the demands of the population?

Are there identified and perceived needs for improving the existing formal training curricula (regular schooling, continuous medical education, accreditation, etc.).

3. Quality of services To your knowledge, what are the exiting mechanisms for quality assurance and

professional audit of the work of patronage nurses?

Are there existing protocols/guidelines for standardized nursing care of patronage services?

If there are no standardized protocols, what in your opinion are the cutting edge guidelines and protocols in this area (from which country, school, etc), that can be adjusted to and implemented in Macedonian context, in order to standardize the nursing care in patronage services?

4. Feasibility of collaboration with other community services In your opinion, is it feasible to have a polyvalent patronage nurse? Explain and

describe.

In your opinion, is it possible to expect cooperation between the patronage and other community services? If not, WHY? How can this be overcome? Do you

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know of a good model from other countries? Please explain.

In your opinion, how should the patronage nurse profile be shaped to respond to the polyvalent and other service expectations from a one person?

5. Vision of collaboration with other community services If we assume that the main principle for the country should be that the “family is

in the center of the services”, what, in your view is the IDEAL model of cooperation and communication between the institutions and individuals to provide a highest possible level of service to the families in Macedonia?

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Annex R: SSI/HO guide

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2. General questions – about primary and preventive healthcare (for HO only) What were the ideas for reforming the preventive services when the primary

healthcare was transformed into concession model provision of services?

Explain about the ideas for reforming the preventive care.

Which are the reasons that these reforming ideas have not been pursued? (What was/is the back-up plan…)

Is there a political will to put this issue back on the agenda? If no, WHY? If yes, please explain.

Who are the key players that can forward the process of reforming the preventive healthcare?

Do you think there is a missing link in the communication of main actors (MoH, HIF, PHC, other?)

Is every institution fulfilling their roles in the system? If not, do you think there are compensatory mechanisms and which re they? Are they sufficient? If not, WHY?

3. General questions – about patronage services (for HO only) How is patronage service positioned in the system as of now? Is this the vision of

the country? If not, explain.

What are the mechanisms for quality assurance of the work of patronage nurses? What are the reporting mechanisms and control feedback?

Are there direct links and communication between HIF and MOH regarding the work of the patronage nurses (i.e. exchange of information about number of visits, quality of work, availability of technical means, etc).

If there were no direct communication links, what in your opinion would be a good model of communication? Which data should be exchanged/controlled? Who should have control over the quality of the care provided?

4. Human resources in patronage services (for HO only) What are currently the possibilities for education and training for the patronage

nurses? Were there more opportunities in the past? If yes, why were they decreased? Is there a plan to increase the number of opportunities in the future?

Given that the patronage nurse is working on her own in the field (without supervision from a medical doctor), is there a system for accreditation of the patronage nurse skills and knowledge? If not, WHY?

Is there a defined legislation regarding the skills and competences that

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patronage nurses should have to work? Are her duties and rights fairly and explicitly written somewhere?

If there is no accreditation system, what should be the optimal model for establishing such accreditation system?

5. Vision for reforming the preventive healthcare/patronage services What, in your opinion, is the vision of the country for the preventive healthcare

and patronage services?

What are the models that have been taken into consideration for reforming preventive/patronage services? Are there any role-model countries? Which ones and what are the reasons?

In the role-model countries, what is the approach towards inter-sectoral cooperation of patronage nurses with other sectors (social work, education, internal affairs, etc.).

6. Current inter-sectoral cooperation Are there any strategic documents that are looking into the preventive health

services as part of a larger system of providing comprehensive social and health services to the family, and especially marginalized groups?

Are these documents available? (who prepared them, can a copy be obtained). Explain the status of these documents (are they implemented? If not, why and what is the vision).

What is the authorization of the social worker with regard to health issues (family violence, drug users, etc).

Is there e facto/de jure exiting a formal communication channel for referral from patronage nurse to social worker and vice versa when a respective problem is identified? Explain reasons.

Who takes the responsibility for the cases, if there is no formal channel for transfer of cases?

Are Roma Health Mediators part of the social worker scheme, or they are more envisaged as part of the patronage nursing profession?

7. Vision for inter-sectoral cooperation If we assume that the main principle for the country should be that the “family is

in the center of the services”, what, in your view is the IDEAL model of cooperation and communication between the institutions and individuals to provide a highest possible level of service to the families in Macedonia?

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Annex S: FG/PN guide

142


0. EntryThe moderator and co-moderator introduce themselves; introduce the project and the purpose of the focus group. Moderator asks (with turned-on Dictaphone) if everyone agrees the focus group to be audio-recorded, for the purposes of comprehensiveness of data collection and analysis. If no one has objection, the recorder stays on.

If anyone has objection, the recorder is turned off, and a note-keeper is assigned to fully hand-record all discussion points.

1. Introductory and warm-up questions: How long is your experience in the patronage service? (to be considered that

some might not have been patronage before)

Do you have any experience in other services (domashna poseta, hospital nursing, emergency services, etc)? Please explain.

Are you satisfied with the working and financial conditions at your workplace? WHY? Give examples.

2. About the practice before and after:A) Experience before the privatization/concessioning:

What was your experience of cooperation with GPs before the concessioning of the primary healthcare (PHC)? Please give examples how the communication was happening (for a newborn, pregnant woman).

Were there established formal mechanisms for cooperation? If not, WHY? Were there informal channels of communication with GPs? Please explain.

What was the way of communication and cooperation with GPs? Were you satisfied from the results of that communication? WHY?

Were you receiving feedback from GPs about follow-up of patients? Explain and give examples.

B) Experience after the privatization/concessioning: Do you have any communication with the GPs now? If not, WHY?

Do you think that there is any cooperation between private PHC and patronage nurses? If not, WHY?

Is this different from before privatization? Is it better or worse? In what ways? Give examples.

Do you think that this cooperation is important and beneficial? WHY? Or if it is not important, WHY?

In your opinion, what are the main reasons for the lack of this cooperation? Is it related to privatization itself? In what way? Give examples.

C) New patronage service package Do you feel any changes in your daily work after the change of the payment

system by HIF (introducing patronage package)? Explain and give examples.

Do you have better financial conditions (incentives) after the change of payment system bu HIF (patronage package)? Please give examples.

Do you think that this is a better model of payment? If not WHY? If yes, can it be

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further improved? HOW? Please give your opinion.

3. About the origins of the fragmentation of the primary/preventive care services:

Who do you think is responsible for the problems of lack of communication and cooperation between PHC and patronage services? WHY?

In your opinion, what are the main reasons for these problems (professional, financial, organizational)? WHY? Please give examples.

Regarding the communications with GPs and other services do you feel/think that current setting is better or worse for the patients? WHY?

4. Possibilities for future development of the system: If you can give a solution to this, what should be done to re-establish connections

between preventive and primary healthcare? WHY?

Are there any professional issues that might be obstacle to introduce this model? What are those (training, authorization, etc), and WHY?

Are there other issues (financial, spatial, human resources, etc) that might need to be addressed as precondition? What are those and WHY?

In your opinion, do you think that patronage services should be reformed as separate public entity or be given under concession (as GPs)? Please explain.

5. Closing remarks and conclusions: Are there other issues that you would like to raise? Please explain.

The moderator gives summarized conclusions of the discussion, to gain common agreement and refresh memory of any issues that were not raised. Participants are again invited if anyone wants to give additional comments before close-up.

The moderator thanks the participants and explains the further procedures with the data from focus groups, i.e. giving feedback to participants (until what date a final report can be shared, or if they will again be invited to comment/discuss/participate in the process).

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Annex T: FG/Com guide

145




1. Introductory and warm-up questions: How long are you living in your community? (informal discussion about number

of children, number of family members in the household, level of education, etc.)

Do you have health insurance (ID documents in some communities)?

Do you live near/far from the healthcare facility (healthcare center, hospital, outpatient service, etc). How do you go to healthcare facility? Is this difficult/convenient?

Do you have any experience with home-delivered services (domashna poseta, patronage nurses emergency services)? Please explain and give examples.

Is this convenient or better service can be provided in hospital setting (with equipment, etc).

2. About the experience with patronage nurses:A) For persons having experience with patronage nurses:

Have you ever (and roughly how many times) had a visit by a patronage nurse in your home? If not, WHY?

Is this the persons you know (from before, or from talks)? Are you comfortable about that?

When was this? For what purpose the patronage nurse visited your home (newborn, pregnant woman, elderly child, other)? Was she helpful (for the purpose)? Was she helpful with anything else (social services, ID cards, etc)? Examples.

How long has she stayed? Was she polite and helpful? Did she answer all your doubts and questions? Has she given you further instructions what to do? Has she left her contacts to you (in case you need her)? Please explain. (collect opinions as to whether they recall it as good and trustful experience).

Have you ever contacted patronage nurse after her visit? What was it for? Nurse came or not? Give example.

B) For persons without experience with patronage nurses: Do you have any knowledge about patronage nurses (neighbor, family member,

friend)? What was their experience? (retelling examples as recollection for general perception of the patronage nurses)

Do you know that the patronage nurses can visit your home even if you are not registered, insured and free of charge (with no payments)? (collect general understanding and reactions to this question).

3. About the experience with primary healthcare (GPs, domashna poseta):

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Community nursing assessment with equity analysis in Macedonia | Final Report6. AnnexesA) Experience with GPs

Do you have GP (and pediatrician for the child, gynecologist for woman)? How often do you go to your GP? For what purposes (sick child, immunization, infection, pregnancy, etc.)?

Is it easy to get to him (waiting time, distance from home, etc)? (get general discussion on the availability of the GPs for preventive services)

Has your GP ever given a recommendation to the domashna poseta or patronage nurse to come and visit you? Did they come? Did they know why they came or you had to explain all over again the situation? Please describe.

B) Domashna poseta Do you have any experience with domashna poseta? Give example.

Have they arrived fast/slow, was the service satisfactory? WHY?

What happened afterwards? (referrals, repeated visits, visit by patronage nurse, etc). Explain and give examples.

4. About other services community needs (and future development): Was there any service that you asked from the patronage nurse that she said she

cannot provide? Which one and WHY?

What happened afterwards? Did you have to go to the GP/hospital for the service? Explain.

Did patronage nurse ever gave you advice on other things, e.g. where to go for social benefits, how to apply for health insurance with Employment agency, etc? Was this helpful? Please give details.

Do you wish patronage nurse to come more often to your home, or it is sufficient as it is? WHY?

Do you think that patronage nurse should be acquaintance with your GP and talk to her/him from time to time? WHY? Explain what might be benefits or issues.




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Annex U: FG/Doc guide

148




1. Introductory and warm-up questions: How long is your experience in the healthcare practice? (to be considered that

some of doctors have previous practice as GPs and then got specialization)

How long have you been practicing in the public practice before concessioning of PHC?

In which specialization (pediatrician, school medicine, occupational medicine, gynecologist…)? Please explain.

Are you happy with the current financial and working conditions? WHY? Please explain.

2. About the practice before and after:A) Experience before the privatization/concessioning:

When you were in public practice, did you cooperate with partronage nurses? If not, WHY? What was your experience from that cooperation?

Were there established formal mechanisms for cooperation? If not, WHY? Were there informal channels of communication with patronage nurses? Please explain.

What was the way of communication and cooperation with patronage nurses? Was it effective? WHY?

How was patronage service assisting you in your work at that time? How was the patronage service assisting in discovery and identification of pregnant women/newborns born at home, unvaccinated children? Were you receiving feedback from patronage service about your patients? Explain and give examples.

B) Experience after the privatization/concessioning: Do you have any communication with the patronage nurses now? If not, WHY?

Do you think that there is any cooperation between private PHC and patronage nurses? If not, WHY?

Is this different from before privatization? Is it better or worse? In what ways? Give examples.

Do you think that this cooperation is important and beneficial? WHY? Or if it is not important, WHY?

- In your opinion, what is the main reason for the lack of this cooperation? Is it related to privatization itself? In what way? Give examples.

3. About the origins of the fragmentation of the primary/preventive care

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services: Who do you think is responsible for the problems of lack of communication and

cooperation between PHC and patronage services? WHY?

Do you as professionals have contact with that institution/person? And, if you can with whom will you start a dialogue on the issue of cooperation/communication between PHC and patronage? WHY?

in your opinion, what are the main reasons for these problems (professional, financial, organizational)? WHY? Please give examples.

Regarding the communications with patronage and other services (including other GPs) do you feel/think that this you are better off/worse off after the concessioning of the primary health care? WHY?

4. Possibilities for future development of the system: If you can give a solution to this, what is the best model to re-connect the two

segments (primary and preventive)? WHY?

Are there any professional issues that might be obstacle to introduce this model? What are those, and WHY?

Are there other issues (financial, spatial, human resources, etc) that might need to be addressed as precondition? What are those and WHY?

Who, in your opinion, can best address these issues? Can your GP community do something? Please explain.

In your model, who should take the steps and activities to start this re-connection? WHY?




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Annex V: FA Guide (Part 1)

General information

66) Catchment area primarily: Rural Urban Mixed

67) Access to facility: Easy Difficult

68) Road connections: Available absent

69) Approx. Total space of the facility

q.m.

70) Garage space Yes No

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Community nursing assessment with equity analysis in Macedonia | Final Report6. AnnexesAmenities for Patronage Nurses

71) Separate entrance for PN Yes No

72) Recognizable well marked entrance

Yes No

73) Accessibility of the entrance Easy Difficult

74) Separate space for patronage service

Yes No

75) Approx. space occupied by PN q.m.

76) If shared with other service… Full time Part time

77) Phone (land-)line shared Yes No

78) Office equipment shared Yes No

79) Conditions of the working space

Good Acceptable

Poor

80) Need for major refurbishment Yes No

81) IF yes, please describe

82) Overall impression on the patronage service and treatment of the service/nurses in the facility (are they appreciated, treated as secondary personnel, etc).

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Community nursing assessment with equity analysis in Macedonia | Final Report6. AnnexesProcedures/ Record keeping

83) Diary (Дневник) are updated Yes No

84) Family cards well organized Yes No

85) Notifications from Maternal houses available

Yes No

86) Documentation is stored properly Yes No

87) PN can be identified (budges, uniforms)

Yes No

88) Time sheets are filled in regularly Yes No

89) Equipment is stored properly Yes No

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