Serbia

Background information

Home visiting (HV) in Serbia is part of the basic package of universal primary health care (PHC) services and is entirely covered by the Health Insurance Fund (HIF) budget. HV is provided through the Patronage Nurse Service, which is delivered by the network of PHC facilities (dom zdravlja) which are well-distributed across the country. The main task of patronage nurses is to provide preventive home visits to certain population groups, improve family and parenting care of children and promote health education activities in a local community or health care facility.

Patronage nurses have an exclusive role among health care providers to link families with health services and other services in the community (e.g. social welfare, education, support groups, NGOs), according to family needs. One nurse is responsible for 5000 inhabitants and is expected to provide 7 visits per day. Target groups for home visiting are pregnant women, newborns and their mothers, infants, children aged 2 and 4, and elderly persons over 65 years of age.

The legal framework sets out the minimal number of visits to target groups: one for pregnant women, young children and the elderly; 2 for infants; and 5 for newborns and their mothers. In cases of certain risks (health or psychosocial) or if a family has additional needs, the number of visits can be increased.

Achievements and challenges

The Patronage Nurse Service was successful as they provided HV services that were more responsive to client needs. Outcome indicators for children showed improvement, especially for the Roma population who received more services from the project. In addition, improved parental knowledge and rearing practices have been reported.

The practices of patronage nurses related to early child development, in pilot sites supported by a UNICEF project, improved after intensive in-service trainings. Assessment tools were developed for various issues, including child development, maternal depression and parent-child interaction, and these were extensively utilized by patronage nurses during home visits in pilot sites.

Despite the success, several challenges were identified. It was difficult to cover the entire population as there were significantly fewer home visits provided to infants, pregnant women and young children compared to newborns. Additionally, data on the content and type of activities provided during the home visits were not systematically collected or monitored. The HV data was collected routinely at the national level; this was limited to process and output indicators without a sufficient level of disaggregation, and there was not enough evidence provided to allow for evidence-based planning.

The capacities, knowledge and skills of visiting nurses vary across districts, especially in the context of early child development. A risk identification checklist was introduced to enable the early detection of those in need of extensive services, but it was not yet widely utilized by nurses.

The shortage in the supply of patronage nurses at a number of PHC facilities is another structural barrier. Furthermore, complex paper-based administrative tasks are a significant burden for HV staff. Insufficient office space and a lack of transportation to some institutions lead to further inefficiencies in using time and resources. The absence of clear guidance on case management causes difficulties with coordination and referrals.

Gaps and needs for ECD

The development of evidence-based programmes, through a participatory approach based on the socio-ecological model and needs of families, can convince both political and technical leaders of the importance and potential impact of HV on ECD. Furthermore, the sustained engagement of all stakeholders, through the facilitation of national dialogue, high quality policy advice and technical assistance, allows for the improvement of existing HV programs or the initiation of new ones. Moreover, the availability of a sufficient number of well-trained home visitors with appropriate skills could be a significant factor for the success of ECD programs.

There is a need for strategic planning in scaling up good HV practices through a phased approach, in order to allow for the effective use of available institutional capacities and resources, and for implementation in accordance with expected goals. Additional needs are: the design and institutionalization of a quality improvement system, tools and processes for HV, including different types of supervision; development of inter-sectoral coordination mechanisms at different levels, especially at the local level; mapping available services and streamlining intersectoral referral and counter-referral pathways as well as an effective case management system; and the development of platforms for knowledge and experience sharing based on a synthesis of the evidence around effective ECD programs.