Outcomes of the Workshop at the Medicus Mundi Symposium 2017 with Manfred Zahorka, Swiss TPH, Monika Christofori-Khadka, SRC and Nicusor Fota, CRED Foundation
Challenges organising NCD care beyond the classic health system
Von Carole Küng
NCD care requires a more complex set of interventions, particularly when combined with multi-morbidity conditions, old age and additional social needs. The workshop discussed challenges and “people centred” examples as proposed by the World Health Assembly in 2016.
- NCD care requires a more complex set of interventions, particularly when combined with multi-morbidity conditions, old age and additional social needs
- Home-based care has the aim that sick, disabled or old people can stay as long at home as possible with a optimum quality of life. The “home care nurse” becomes the intermediary body between the health and the social care system. The home care team elaborates a diagnosis and then proposes and implements a care plan.
- In Romania, a voice has been given to local authorities, who have suddenly found themselves in a position of representing the community interest and acting towards finding solutions and create premises for service improvement; this has also been recognized at district level.
- On a policy level, the main challenges for patient-centered care result from a lack of adequate legislation, whereas there is clear interest at policy level.
- Africa can learn from experiences in organising HIV care and treatment and build up on those strong community based care systems that are in place.
- There is no universal solution for organising NCD care, however bringing services closer to people might be the valid approach for all settings, even though the models will vary within different contexts.
‘BP corner’ in Lugala hospital, Tanzania, where a Nurse Assistant checks every incoming patient for blood pressure, pulse, temp, body length & body weight. Photo: © SolidarMed
A bottom-up approach to building people centred services in rural communities in Romania
Nicusor Fota discussed widening access to health and social services through CRED Foundation’s bottom-up approach where people centred services are built in rural communities in Romania. The project is supported by the Swiss Government as part of its contribution to assisting the new EU member states. In Romania gaps in health status are resulting from vulnerable groups having limited access to basic health services. There is also an insufficient response to health and social systems with regards to the multi-dimensional needs of NCD’s.
The Romanian legislation is generous with its aim to ensure universal health coverage and protection of vulnerable groups, but there is a clear lack of policy as well as provider and user integration. Community nurses and social workers are working closely with local authorities as public employees, but family doctors are mainly contracted as private providers through the health insurance house. This governing structure results in very few collaborations between the individual social service providers and medical services on a community level. This project makes use of a bottom-up strategy to increase collaboration where locally developed functional models of integrated health and social services in remote communities respond to the needs of the local communities, especially disabled, teenagers, children and elderly. As well as the provision of commodities, long-term sustainable mechanisms are also put in place as well as tools for intervention which are developed. Local authorities were pre-selected, participated in capacity development and thereafter pilot projects were selected through requested proposals. Interim results included six social medical centres endorsed by the local authorities and two centres licensed by the Ministry of Labour, all providing integrated services and paving the way for further centres to follow. So far, collaborative work with family doctors has been developed in three communities, while five other communities have benefitted from preventive services, 100 vulnerable people have received homecare services and 20 vulnerable children have received educational supervision and food.
Challenges for the project included the disparity between the new models and parallel health and social legislations which were separately developed. Tools for planning and monitoring of the integrated activities were also missing. The definition of community centres is a recent one with no clear coordination. There are now clear opportunities for the developed models to become a basis for national scaling-up initiatives.
People centred care in Eastern Europe. Photo: © SRK
Challenges of home based care work with older people in Europe and CIS
Monika Christofori-Khadka presented examples of integrated patient centred care based on the Swiss Red Cross’ experience with home-based care work and older people in Europe and CIS (Commonwealth of Independent States). The objective is to care for sick, disabled, chronically ill and old people in their homes for as long as possible and with an optimum quality of life. General practitioners, policlinics, social workers and home care staff form one care team with a common goal: to improve the health and well-being of the client. Information is centralised and a functional up and down-referral system is developed within the public system. The “home care nurse” becomes the intermediary body between the health and the social care system. The home care team elaborates a diagnosis and then proposes and implements a care plan. Each development is discussed between the client and the care team so as to adapt the care-diagnosis and care-plan. On a policy level, the main challenges result from a lack of adequate legislation, whereas there is clear interest at policy level. Doctors are hesitant to co-operate due to fears of losing their authority and income. Further hindering factors are financial gaps and a lack of clarity about reimbursement. Main challenges of provider integration result from insufficient cooperation - with nurses not being recognized as care experts and lack of legislation for nurse-led services, as well as missing gerontologists and no joint trainings.
In many systems, people’s wish to stay at home is not recognized and therefore the relevance and necessity of homecare services is not understood.
The way forward: The need to build up a comprehensive supply system
During the workshops’ discussion, an important question was raised regarding how to prevent people falling through the net when they stay at home longer? A patient not being able to activate the necessary services is an important issue. In the case of the SRC example, the selection goes via the local General Practioner. Volunteers, neighbours and visiting people report back to the nurse, but without a 24-hour vigilance system. SRC is therefore looking into the possibility of using emergency buttons or similar. It is important for them to work together and split the tasks so as to become more present in local communities and improve data collection.
In reference to structural barriers the panellists were asked advice on how institutions could build up other integrated services. A costing study proved to be very relevant in the SRC approach. One therefore has to look at patient outcomes in order to evaluate cost-effectiveness. Especially when looking at different disease patterns,it becomes tricky to demonstrate. Studies assessing the changes in quality of life are also relevant in order to demonstrate impact on governments. It has also proved essential to bring all providers together in order to not duplicate services, especially doctors who have had to learn how nurses can add value. In Romania, a voice has been given to local authorities, who have suddenly found themselves in a position of representing the community interest and acting towards finding solutions and create premises for service improvement; this has also been recognized at district level.
Which way for Africa?
Workshop participants also discussed what Africa can learn from these experiences as it has a lot of experience in long-term care resulting from HIV. Strong community based care systems are in place and ready to be built upon. For example, HIV carers can receive training to learn how to take care of NCDs. In Lugala, SolidarMed has built on the capacity of HIV/AIDS for palliative care, counselling, follow-up of patients and monitoring. There is a huge experience to capitalise on with dozens of trained health workers. In Pakistan, secondary school students have been involved (trained for TB reach out). These young people have been a very important resource to develop.
In terms of using the HIV delivery systems for NCDs, the buzz word in Tanzania is ‘differentiated care’. This is not a public health nor a patient centred approach, but one that is somewhere in the middle. Important questions included “can we do visit spacing?”, “can we do drug delivery for a year?”, “how can we amend the scale from diagnosis to treatment so as to administer health effectively?”
Important insight: Bringing services closer to people
In conclusion, there is no universal solution for organising NCD care, however bringing services closer to people might be the valid approach for all settings, even though the models will vary within different contexts.
Carole Küng is the Executive Secretary of the Swiss Malaria Group. Email