Delina Ceca is a Public Health Specialist and Head of Primary Health Care at the Berat Local Unit of Health Care. As a regular participant in trainings supported by HAP and holder of an important position for the extension of the primary care reform, we discussed with her the importance of training family doctors and nurses for the prevention and management of non-communicable diseases, as well as the monitoring of the implementation of relevant protocols in their daily clinical practice.
Could you describe how the monitoring team of the Berat Local Unit of Healthcare (LUHC) is being trained to monitor the implementation of the protocols of non-communicable diseases (NCDs) by family doctors and nurses?
Our monitoring team has been trained and directly involved in all activities related to improving the management of NCDs in health centres, from their planning to their implementation and monitoring, to support family doctors and nurses in implementing the treatment protocols approved by the Ministry of Health and Social Protection (MoHSP). This is, of course, a continuous process, and the team is continually involved in training and preparatory activities to optimize this process.
Everything began initially with the training of the family medicine team for the implementation of protocols for the 5 NCDs. For this purpose, a Training of Trainers supported by HAP was conducted on the topic “Implementation of Treatment Protocols for Hypertension, Dyslipidemia, Diabetes, Asthma, and COPD (5 NCDs) in Primary Health Care,” in which three family doctors, two nurses, and one public health specialist from Berat LUHC participated. Subsequently, Berat LUHC organised and provided Training of Trainers for one family doctor and one family nurse from all 14 Health Centres (HCs) under its jurisdiction. With our support, they then established Peer Groups in the respective HCs to disseminate the knowledge gained during the training on the implementation of treatment protocols for the 5 NCDs to the rest of the family medicine team.
Meanwhile, HAP supported the training of our monitoring team for conducting visits to the HCs to monitor the implementation of these protocols by family doctors and nurses. These are what we call supportive monitoring visits because they aim to support and motivate the family medicine team to implement the 5 NCD protocols as accurately as possible.
Once these crucial trainings were completed for both the family medicine team and the monitoring team, it was time to conduct the monitoring visits. Us at Berat LUHC planned and conducted two such visits with direct support from HAP, after which we created a clear model of the monitoring process. From this point onward, our monitoring team has regularly conducted supportive monitoring visits at health centres regarding the implementation of the 5 NCD protocols.
How does this monitoring process differ from the previous one?
This monitoring process is supportive supervision aimed at improving the quality of primary care services, identifying and solving possible problems, and promoting high standards, teamwork, and better communication between the HCs and LUHC. This monitoring is equipped with all the necessary tools for implementation. The monitoring manual developed by HAP is a practical aid for conducting monitoring visits because it describes the supportive monitoring process step-by-step and with concrete examples. It also provides the tools/checklists for monitoring, including the notification templates for the HC to be monitored, the agenda, and the monitoring visit report.
All these make the monitoring visits easier to organise by LUHC and more concrete and beneficial for the health centres that receive this support regarding the implementation of the 5 NCD protocols.
What problems have you identified during the monitoring and how have you solved them?
One of the most common problems encountered during monitoring is the continuity of supplying family doctors and nurses with physical copies of clinical decision-making tools for new cases. These tools should be part of the patient’s record and need to be photocopied regularly for their daily use as needed. In some cases, we, as Berat LUHC, have assisted health centres with physical copies of tools that were lacking.
How do you think the monitoring visits will impact the quality of healthcare services offered to patients with chronic diseases?
After each monitoring visit, the health centre receives a report with instructions and recommendations regarding the deficiencies observed during the monitoring, along with realistic deadlines for their resolution. I believe this approach encourages and motivates HC teams to manage the 5 NCDs according to the treatment protocols approved by MoHSP, directly improving the quality of service for patients with chronic diseases. Monitoring also encourages family doctors and nurses to use clinical decision-making tools and, indirectly, to spend more time with the patient during consultations, whether in taking the anamnesis or in the objective assessment, as well as in advising and educating the patient or planning the next visit. This leads to better diagnosis and case management and makes referrals to specialists more rational, increasing trust in family doctors and nurses, which has been waning recently.
Have these monitoring activities affected the cooperation between LUHC and the dependent health centres? How?
The implementation of supportive monitoring has positively impacted our cooperation with health centres. We maintain continuous communication with them from the planning phase of the visit, when we agree on the date and agenda of the monitoring visit. This approach makes us more welcomed during the visit and makes the medical team more cooperative. The visit itself has helped us better understand the realities of primary care service, and the challenges, and difficulties faced by family doctors and nurses. Additionally, the concluding meeting of the monitoring visit has increased mutual understanding of existing problems, difficulties, and possible solutions. It should be noted that the monitoring visit report, which is sent to the health centre within ten days from the visit date, has elevated the official communication between LUHC and HCs to a higher professional level.
How long do you think it will take for the results of these primary healthcare reforms to become more visible?
I do not believe that time is the most important element; rather, finding and implementing system-level mechanisms to motivate doctors to manage NCDs according to the new protocols and to work as a team with family nurses is crucial. I think that the supportive monitoring process we are implementing is one of the mechanisms that encourage the use of protocols by primary care professionals.
What advice would you give to doctors and nurses after the monitoring visits you have conducted?
The only advice I would give is to spend more time with patients during consultations in the HC premises or during home visits. More time translates into better and more effective communication with patients, clinical decision-making based on the evidence produced by the relevant tools, and more appropriate advice for empowering the patient in managing their illness, which improves the patient’s quality of life.
What other support would you need to conduct the monitoring visits effectively?
HAP has provided exceptional support. Currently, I think it is very important to have periodic group meetings with all other local/regional/central health authorities, local government, or any other non-public institution in the framework of improving the entire monitoring process to provide health centres with the necessary support to fulfill the monitoring visit recommendations and to cope with the difficulties and deficiencies they have regarding the implementation of protocols, especially those related to physical infrastructure, equipment, staff shortages, etc.