A project in Bosnia-Herzegovina and its Potential for NCD Control and Prevention
From Family Medicine to Community Nursing
Von Alexander Bischoff, Aldina Bukva-Mahmutovic, Greet Van Malderen and Emira Dropic
Bosnia-Herzegovina is, like other transition countries in Eastern Europe, engaged in health reform initiatives aimed at introducing primary health care centred on family medicine. Nurses and particularly community nurses have a pivotal role in this process. An SDC-funded project labelled Pro-Ses – Strengthening Nursing in Bosnia and Herzegovina – aims at providing care to all, especially by community nursing outreach to vulnerable groups. This is of relevance when it comes to reconfiguring primary care for the era of chronic and non-communicable diseases.
In all countries, high-income, middle-income and low-income alike, the sharp increase of chronic diseases is putting enormous pressure on health systems. The changing needs of the health care population combined with the necessity of cost containment have put the nurse workforce – by far the largest group of health professionals in any health system – in a pivotal role in every country’s health system. Scientific literature indicates that nurses are key to implement the patient-centred care model of the future (Bodenheimer, MacGregor, & Stothart, 2005). It is therefore crucial, that nursing competencies, organization and practice are such that they allow the profession to effectively contribute to a country’s health system.
Bosnia-Herzegovina is a case in point. Bosnia-Herzegovina (BiH) is, like other transition countries in Eastern Europe, engaged in health reform initiatives aimed at introducing primary health care centred on family medicine to enhance performance of their health systems (Atun, Kyratsis, Jelic, Rados-Malicbegovic, & Gurol-Urganci, 2007). For more than 15 years, the “FAMI”-project has been implementing Family Medicine (FM) in various regions in both entities of BiH, the Federation and Republika Srpska. “FAMI” is a foundation that originated thanks to the support of the University Hospitals of Geneva and the Swiss Development Cooperation (SDC).
During FM implementation, three issues emerged: the need to address control and prevention of non-communicable diseases (NCD), the importance of inter-professional collaboration and the crucial role of nurses in FM. In the following sections, we will comment on these three issues, thereby drawing on a survey that investigated how doctors and nurses perceived the development of FM.
Study objective: to examine how Bosnian doctors and nurses involved in FM evaluate
its on-going implementation, the management of chronic diseases common in primary
care settings, the division of curative, preventive, administrative and
training-related activities, the inter-professional collaboration, and how FM is
perceived by health workers and the general population.
Study design: quantitative cross-sectional survey, self-administered questionnaire
Study population: Nurses and doctors from health centres and dispensaries where FM was introduced.
Sampling frame: Two regions where FM was introduced were selected: Sarajevo region and Doboj region.
Sample: Nurses:n=508, 91% female, mean age 41. Doctors: n= 220, 71% female,
mean age 43
Doctors and nurses involved in FM are a largely female group: 9 out 10 nurses are
women, and 7 out 10 doctors are women. Nurses accounted for 70% of the health
professionals that were included in the survey. Most health professionals have
long professional experience and tend to stay at the same health facility.
In the past, the health professionals had attended both several inter-professional
courses (doctors 5 on average, nurses 3) and FM workshops (doctors 3, nurses 2).
Family medicine activities
How do doctors and nurses divide their time by the different activities, including curative activities, preventive activities, working in the community, administrative tasks and teaching activities? According to both doctors and nurses, the highest proportions of time are spent on curative working (56% among nurses, 58% among doctors). Administrative tasks are the second most frequent activities, especially for nurses (50%, vs. 29% among doctors), since they say they are busy during twice as much time with administration. Preventive activities take up a high proportion of the activities, especially among nurses (39%, vs. 23% among doctors). Working in the community is as frequent among nurses as the preventive activities (39%); there are, however, far lower proportions among doctors (15%). Teaching activities are frequent, even more (and even more surprisingly) among nurses (32%, vs. 15% among doctors).
With respect to inter-professional collaboration, a lot of satisfaction was noted, although more so by nurses than by doctors; this may well have to do with the fact that FM and Primary Health Care lend to nurses a role far more important than in traditional health care. Furthermore, respondents were prompted to rate “health care priorities”. It is interesting to see, that all of health care priorities concern the management of chronic conditions, the top four being (in this order): hypertension, chronic diseases in general, diabetes and cancer.
Furthermore, when asked of “what should in the future be improved in the health system”, respondents the following five topics most often:
1. Health staff hiring
2. Preventive medicine
3. Primary Health Care and FM
4. health promotion programmes
Future development of FM: The way to go towards Community Nursing
With respect to control and prevention of chronic diseases, the following recommendations can be formulated: In the future, doctors can (a) strengthen their FM team approach, and (b) pursue their change of attitudes by leaving behind the three traditional approaches which are specialist-centred, doctor-centred, and hospital-centred. Concurrently, nurses should (a) be able to work with more autonomy by improving multi-disciplinarity and inter-professional collaboration, (b) receive specific training on chronic disease management, and (c) strengthen their capacity in improving prevention and health promotion through community nursing.
In a global NCD policy book, a need at global level to “reconfigure primary care for the era of chronic and non-communicable diseases” was strongly advocated. Authors identified four levers to improve the functioning of primary care in the NCD era (Kruk, Knaul, & Nigenda, 2012):
- Integration of services (continuity, multidisciplinary approach, patient-level records)
- Innovation in service delivery (task-shifting, training to promote team-based care)
- Inclusion of communities (diagnosis and care of NCD to be provided at the point of care, concept of citizenship in healthcare
- Information and communication for better care (mobile phone technology in NCD care to promote information sharing and communicating health data in real time)
Interestingly, most, if not all, of these levers could be handled by community nurses. Articles like these and the findings of our survey made us realise that strengthening of nursing is urgently needed, and that it would be worthwhile investing in nursing, and in community nursing in particular. Therefore, out of the FAMI project emerged the ProSes project. ProSes stands for “Projekat jačanja sestrinstva u Bosni i Hercegovini“ (Strengthening Nursing in Bosnia and Herzegovina Project).
ProSes aims to make a sustainable contribution to better health outcomes in BiH by improving the quality and effectiveness of nursing services, in particular at primary health care level, and by increasing access to nursing services for vulnerable groups. Beneficiaries of the project are, first, the nursing workforce and associated health professionals, as well as, second, the health care service users, i.e. the general population, in particular vulnerable groups who presently have limited access to healthcare services.
ProSes uses a three-pronged approach: one component deals with nursing organisation, regulation and recognition, another one with formal university-level nurse education. The third component, especially relevant for control and prevention of non-communicable diseases at primary level, addresses community nursing and its outreach to vulnerable groups.
In order to achieve the outcomes of expansion of community nursing services and improved outreach to vulnerable groups, the project invests in the following activities: (a) the design of community nursing services which are congruent with international standards, address the prioritized needs of vulnerable groups in BiH and also fit local system characteristics. In order for the community nursing services to be optimally tailored to the specific needs, the project first carries out groundwork research which aims at identifying the vulnerable groups, the nature of their needs and the relevant system characteristics which impact the feasibility of services; (b) the adaptation of roles, training and curricula according to the community nursing services developed, and (c) the implementation and monitoring of these community nursing services in selected geographic areas, including piloting of financing schemes and development of a strategy for scaling up.
*Alexander Bischoff, technical expert for ProSes; lecturer at Institute of Nursing Science, University of Basel; nursing and public health advisor at Division of International and Humanitarian Medicine, Geneva University Hospitals; contact: firstname.lastname@example.org , email@example.com.
Aldina Bukva-Mahmutovic, component manager of ProSes, Fami Foundation, Sarajevo, Bosnia-Hercegovina; contact: firstname.lastname@example.org .
Greet Van Malderen, project manager of ProSes; Head of Administration, Institute of Nursing Science, Basel; contact: email@example.com.
Emira Dropic, project manager of ProSes, vice-director of Fami Foundation, Sarajevo/Doboj, Bosnia-Hercegovina; contact: firstname.lastname@example.org
Project implementation started in October 2012 and is now on-going till 2016. The project is funded by the Swiss Agency for Development and Cooperation (SDC).
- Atun, R. A., Kyratsis, I., Jelic, G., Rados-Malicbegovic, D., & Gurol-Urganci, I. (2007). Diffusion of complex health innovations--implementation of primary health care reforms in Bosnia and Herzegovina. Health Policy Plan, 22(1), 28-39.
- Bodenheimer, T., MacGregor, K., & Stothart, N. (2005). Nurses as leaders in chronic care. Bmj, 330 (7492), 612-613.
- Kruk, M., Knaul, F., & Nigenda, G. (2012). Reconfiguring primary care for the era of chronic and non-communicable diseases. In L. Galambos & J. Sturchio (Eds.), Addressing the Gaps in Global Policy and Research for Non-Communicable Diseases - Policy Briefs from the NCD Working Group. Baltimore: Johns Hopkins University.