Report prepared by Svetlana Rijicova, consultant, based on the results of a visit to Kazakhstan within a framework of a technical assistance project to the Government (стр. 2 )

· Directing/referring/connecting the client to different services (centers, cash benefits, searching for sponsors, center of employment, etc.) often depends on individual activity of a social worker and his/her motivation.

· Connection between the maternity and the polyclinic was established; it did not exist before.  It is necessary to strengthen this connection by establishing an information flow - from the polyclinic to the maternity and back, setting the type of information to be passed.  For example, assessment of the situation of the family / mother indicating a risk of the child's abandonment and performed preventive work. This is necessary in order to ensure that the psychologist from the maternity does not spend his/her limited time (3 days) to collect the information and uses his/her working time for direct work with the woman in labour.

The model of Demeu work on prevention and early detection of the risk of child abandonment may be qualifies as a well organised and functional service, providing a good basis for the improved approach to this problem. At the same time, the different parts of this report specifies the moments which can improve this model.

The recommendations:

· To consolidate the work of polyclinic on provision of the comprehensive services to the families for prevention, early detection of a risk of child abandonment, supporting the families with provision of specialized services: social, psychological, medical and legal counselling.

· To create a recourse center at Demy center  for the entire Astana providing methodological assistance to the social services workers and psychologists working in health care system that would along with participation in the development of educational materials assist in organizing and conducting the training courses for the social workers.

3.4.2 Karaganda - city level model

NGO "Family" has developed and piloted a protocol / algorithm of work for the prevention of child abandonment, as well a necessary working tools and procedures. These developments, at the very beginning of work and obtaining the first results, have been very important and well justified.

At the moment, the NGO members have also come to realize that they actually took over a part of responsibility of the social workers and psychologists of the institutions included into the preventive system for child abandonment, such as polyclinics, maternity hospital, and children’s homes. It turns out that they have developed a model parallel to a governmental model, taking over part of its functions.

At the moment, it is the time to institutionalise the developed protocol / algorithm so that a transfer of the experience to the social workers from state institutions is done in order to increase the responsibility of the state agencies to provide assistance to the families with risk of the child abandonment. Moreover, as the situation of the NGOs service providers is not stable and they may leave the service market, a risk may arise in the future for the sustainable operation of the developed protocol in the region.

In this regard, it is recommended that NGO "Family" revises the work protocol / algorithm developed by them based on their past experience (during conversation with NGO we have discussed the necessity of this process) and start the process of gradual exit from the implementation of the developed protocol / algorithm, transferring the developed methodology to the social workers and psychologists from the state health care facilities, according to their functional responsibilities.

In this regard, it is necessary to change the future role and functions of NGO "Family", taking into account their great experience and expertise.

Recommendations:

· To establish a Centre for methodological assistance of social workers and psychologists in the health care system for all Karaganda region with the responsibilities similar to the  Demeu centre.

· To institutionalize this Centre as the centre for methodological assistance under a regional health department.

· To entrust the Centre with functions for organization of the continuous training for social workers and psychologists on the basis of training needs analysis, identifying necessary resources available amongst universities and practitioners.

As a result of these revisions, a preventive system of child abandonment will operate and be guaranteed by the state thus, ensuring the institutional and financial sustainability of the developed models.

3.4.3 Semey city - city level model

The information collected during the visit allows formulating the following conclusions and recommendations for the start-up of the work in this place:

· Semey already has acquired an initial level of social work knowledge and experience which will allow them to implement the working protocol / algorithm at an accelerated rate than in the first pilot sites, while the experience of the first two pilot sites might be used as a valuable resource.

· The protocol / algorithm of work on the prevention of the child abandonment should be built in the Semey city within the state structure framework according to the one that is described in a typical protocol, which is proposed to be developed (see below).

· The polyclinic No12 can play a role as the Demeu center - as a polyclinic and Centre for methodological assistance.

3.5 The protocol of work

During the visit to Kazakhstan a practical modelling of the working protocols has been conducted with social workers in the pilot sites on the basis of their experience.  On the basis of the received information as well as analysing the developed protocols, it seems reasonable to develop a framework protocol in line with the Decree 907 of the Ministry of Health of the Republic of Kazakhstan. The framework protocol could be recommended to other regions for the implementation, having the possibility to make revisions, including details, in line with local specifics of the regions.

In line with this, it will be also necessary to improve the forms that are completed by the social workers in accordance with the Decree 907 and the piloting results, as well as to develop appropriate forms for the psychologists working in the health care system.

This will allow for the unification at the institutional level, of the algorithms and methodologies used by social workers and psychologists working in the health care system that can be farther transferred to other regions.

Comparative analysis of the protocols / algorithms of work shall allow making the following conclusions:

· Although the working protocols / algorithms in the 3 pilots seem different, there are many similarities: administrative responsibility - health care departments; institutions included in the work - polyclinics, maternity hospitals, children’s homes and other social services at the local level; the working methodology of the social workers - case management; partners of the interdepartmental cooperation etc.

· The differences are mainly related to the role of coordination, methodological support that is allocated to various institutions / organizations: NGO, Demeu Centre, the Polyclinic No 12. These institutions / organizations could be provided with a single status such as Centres for Methodological assistance /support for the social workers and psychologists working in the health care system. It may be necessary to develop regulations for these centers, which will have to carry out professional supervision and other methodological obligations.

· These centres should be institutionalized in a health care structure at a regional level.

· All of these arguments are in favour of the opportunity to unify the working protocol / algorithm on the prevention of the child abandonment used in the health care system by developing a framework protocol.

3.6 Data collection and monitoring

The data on provided social services in the health care system are collected at the local level by the person responsible for the social workers and psychologists in the regional health care department (Ust-Kamenogorsk, Karaganda).

For example, in Ust-Kamenogorsk region for 1 million 400 thousand of people there are 251 social workers and 40 psychologists working in the health care system. The coordinator of social workers and psychologists working in a regional health care department have some knowledge about the infant abandonment prevention work:  support for families / mothers with children with special needs, identification of cases of violence against children, cases of the children's abandonment, work with single mothers, early coverage of pregnant women.

At the same time, a report form used by the social workers includes quantitative data, which do not fully reflect all aspects of the social and psychological work they should perform. For example, the social workers submit the following quantitative indicators: the number of visits to the social worker, number of home visits, number of consultations, number of trained volunteers, number of children under 3 placed in the children’s homes, number of clubs, schools for mothers, etc. This type of information does not give an indication about the quality of the services provided, about the number of families who have received social support and as a result of this assistance has changed their situation as well as how many children have been prevented from abandonment, what is the success rate, etc..

According to the opinions of the Coordinator of social workers and psychologists there are no indicators to assess the quality of the work carried out by the social workers operating within the regional health care department. There are some indicators used to evaluate the work carried out to support the elderly and the disabled people. Even the Decree of 907 of the Ministry of Health of the Republic of Kazakhstan does not bring enough clarity on how the performance of the social workers and psychologists should be evaluated.

According to the opinion of the Coordinator of the social workers and psychologists in a regional health care department, the functions of the social worker and psychologist overlap a lot. This opinion was confirmed by the documentation filled in by the psychologists (in a free form) and reports provided by them. This situation is probably due to the lack of professional standards for social workers and psychologists working in the health care system.

The coordinator of social workers and psychologists in the regional health care department has indicated the necessity to establish a regional methodological centre, especially for the duration of the social protection system development, as there is a great need for methodical support and management. There are 251 new social workers employed in the region who do not yet fully understand the nature of social work and require methodological assistance and training.

Health Care Department of Karaganda, in addition to the quantitative indicators, which are collected in Ust-Kamenogorsk use the following quantitative indicators for monitoring of social services provisions: number of different population groups (adults, retired, deviant and neglected teenagers, people released from prison, people with special needs, homeless). Regarding children under 3 years of age – the only data collected is on the number of children with mental and physical disabilities. As in Ust - Kamenogorsk the qualitative indicators are completely lacking in Karaganda.  

Recommendations:

· To establish process and results indicators for collection of data on the social situation of families and children within the health care system.

· To identify indicators to assess the quality of services provided by social workers and psychologists in the health care system other than those used for the assessment of the medical personnel.

· To distinguish and separate the duties of the social worker and psychologist in the normative framework documents. At the same time, granting a freedom to the organizations and institutions to adapt the job descriptions to the working peculiarities of different institutions, approved by the Decree of the Director of the medical institution.

· To provide a methodological support to the social workers and psychologists working in the health care system on data collection and analysis.

3.7 Competence of social workers in the health care system

3.7.1 Official duties

Official job descriptions that guide the social workers in the health care system do not correspond to the work performed. They reflect only the work they do with the elderly and people with special needs oriented on the personnel with specialized secondary education; the focus is on identifying single elderly and disabled people. Families with children in difficult life situations are not covered. The job descriptions of the psychologists are typical and are not adapted to the type of institution they work for and the actually performed work.

Recommendation:

· To develop standard official Job Descriptions for the social workers working in the health care system;

· To develop a code of ethics for all social workers working in different departments;

· Each health care institution should develop the Job Descriptions for social workers reflecting the specifics of work with a certain group of clients;

· The same tasks should be undertaken to regulate the work of the psychologists working in the health care system.

3.7.2 The organization of social services.

At the local level the social – psychological - medical services are provided by doctors, nurses, social workers, psychologists (their number are defined by number of population). The social workers working in the health care system are not adequately provided with necessary the methodological framework and do not use indicators to assess the quality of the provided services. According to the interviewed government officials of the regional level, the job duties of the social workers and psychologists are not clearly differentiated and sometimes overlap. It should be noted that the health care department has an existing possibility to find and use financial resources (10% of the stimulating component) for the training of social workers and psychologists.

Social workers’ reporting form is built on the collection of quantitative data on the activities and measures carried out (the number of home visits, the number of psychological training) rather than on the number of families who have been supported and whose life situations have been improved. Thus,  the reporting forms do not reflect  the issues  of primary interest for the project: early coverage of pregnant women with early detection of the risk of infant abandonment, facilitation of the links between the  maternity unit with the polyclinic to ensure monitoring  of  the women  with a  risk of the child's abandonment, as well as of the collaboration with the children’s home for  the family preparation for future child's reintegration. It is necessary to assess the possibility of changing the focus of the social workers activity to cover issues of children and families, as well as including the above-mentioned indicators into a monitoring and evaluation system. The capacities of the coordinator of social workers at the regional level (in all pilots) also need to be consolidated.

3.7.3 The methodology of work for the social worker

Case management is used as a primary tool by the social workers working in the health care system; the case management tool is described in the Decree 907 of the Ministry of Health of the Republic of Kazakhstan.

The social workers are familiar with the contents of the Decree and they are making some efforts for its implementation. They have a good understanding of the main stages of work and have a general idea on content of the work at each stage. At the same time, it looks like the social workers put more focus on the assessment of the situation of the family and child and the development of a plan to support the family, although more often these plans are very general and do not contain a detailed list of activities required to carry out to support the family. At the same time, it looks like that there is no focus on implementation of the plan, with its regular review, tracking down the changes in the situation of the family and the child, the changes in the dynamics of the family situation. Thus, it is not clear when a decision to finalise the support is made, the dynamics and movement of clients in the social support system cannot be traced, with an understanding that there will always be a certain group of families who will need to be supported for a longer period (i. e. persons with special needs).

Thus, the social workers require further support to improve their performance and the quality of provided services.

Recommendations on the development of knowledge, skills and abilities for the social workers in order to:

· Use the criteria to make decisions to either begin  a  systemic work with the identified families with children in difficult life situations or to limit the interventions to a one-off support or providing information;

· Implement a comprehensive assessment of the family  situation  with a qualitative description of all aspects of the situation, determining the degree of risk (criteria for a low, medium and high risk), formulating the family problems and  making recommendations for further planning of the intervention;

· Develop the individual family support plan: identifying services necessary for this particular family,  as well as the need to involve different professionals  (who,  when and how) for preparation and implementation of the plan,  involvement of the family in  this process, etc.;

· Coordinate the process of implementation the individual family support plan. It is necessary to think over and determine the way of informing and involving different professionals in the development of the individual family support plan, as well as the way the stakeholders involved will be informed about the results of the work conducted by each professional, and how the review of the individual family support plans will be organised, etc. A special focus should be placed on the need to involve the beneficiaries in the development and implementation of the individual family support plan, setting up tasks for the family and motivating /encouraging the family to change its own situation;

· Close the case / finalise the work with the case. The social workers should know the criteria to base their decision to finalise the work with  the case and determine the level and  duration of the monitoring / tracking of the family;

· The social workers shall fill out the following forms, according to the Decree 907 of the Ministry of Health of the Republic of Kazakhstan: logbook of home visits, social passport of the family, the form for the assessment of the child needs in the family, the statistical card of the client, the family individual development plan. It is necessary to revise the forms in order to eliminate the repeats / duplication of information, such as general information about the family, assessment of the situation and even the family support plan, etc. thus increasing the efficiency of using the working time of the social worker.

3.7.4 Capacities for the prevention of infant abandonment

The social workers and psychologists do not yet have a clear idea of ​​what the preventive work of infant abandonment is. This requires the development of a model of the work to prevent the infant abandonment: who, when, how often and what kind of work should be performed. It also includes the development of methodological materials to assist professionals and conducting of appropriate training.

During the interviews with the social workers there have been identified some obstacles that affect the quality of the services provided, the assistance provided to families with risk of infant abandonment during the period from - 9 months to 3 years, i. e. in the pre-natal and post-natal periods when the risk of abandonment is the highest and the family is in a great need of support.

First of all, the performance of the social workers is evaluated using indicators set up for the medical personnel:

· Number of visits to the family. In this case the visits are strictly limited to two visits (not in all pilots) which are hardly sufficient to resolve difficult life situations. For more home visits, the social worker is punished with penalty points, which affect the amount of the salary.

· Number of people directed for screening. Social workers do not refuse to inform the public about the need for screening. The point is that both the social and medical workers chase higher figures; there is a trend that they assign to themselves quantitative indicators, as this affects their wages.

· Penalty points for an unreasonable call of an ambulance, hospitalization also limit the social workers from the opportunity to help the families in difficult life situations.

Evaluation of the social workers performance does not include the criteria that would motivate them to ensure a qualitatively assessment of the family and child situation, to make a qualitative family support plan ("it is not evaluated, not being asked for, and none needs it" - the statements of social workers). The work of the social worker is not being evaluated by number of prevented child abandonment cases, number of prevented placements of children in the children’s homes, number of families who have been supported to overcome difficult life situations, etc.

In other words,  identified obstacles, demotivate the social workers, disorient them and make them to undertake duties outside of their professional role (in this case medical). As a result, there is a distortion of the role and professional profile of the social worker in health care system.

3.7.5 Building professional capacities of the social workers working in the health care system

The need for capacity building has been reasoned above. What is critical is a form in which it should be. I recommend using professional supervision, as a method for building capacities. Professional supervision is a tool to provide methodological assistance to the social workers in order to mainly increase the quality of their work, to effectively organize their working time, and prevent professional burnout. Professional supervision is a tool to provide monitoring and quality control of the professional activity, as the supervisor from an administrative point of view ensures that the work of social workers is carried out in line with existing policies, guidelines, standards and examples of good practice. The main purpose of professional supervision is to improve the quality of service delivery, by providing opportunities for professional and personal growth of the employees, awareness of roles and responsibilities as well as organizational development.

Supervision is an effective tool stimulating the transfer of accumulated knowledge and skills into practice. The data of numerous studies have shown that for a practitioner is quite difficult to progress from accumulated knowledge and developed skills to their practical application and actions. Thus, professional supervision will complement the program of training scheduled by the project and provide a consolidating effect and facilitate a practical application of the competencies formed among the social workers.

Recommendations:

1. To develop a mechanism for professional supervision, adapted to the institutional structure and area of activity of  the  social workers working in the health care system, as well as considering  the socio-cultural characteristics;

2. To develop the methodology for professional supervision that shall include: consolidation of the work on case management, assistance in effective organization of working time of  the social worker, prevention  of professional burnout, as well as methods of organizing, conducting and documenting of the professional supervision sessions;

3. To identify professionals who will conduct professional supervision: coordinator of social workers from Demeu center, the social worker from the Polyclinic No 12 in Semey, in Karaganda it could be someone from NGO "Family". The Supervisor should be a social worker, preferably with an adequate education, work experience, showing the ability to work and motivated to share knowledge and experience. The supervisor, in the case when he has to cover a  region or  a big  city should be released from other work duties;

4. To train supervisors in the pilot sites and use them as trainers for other new regions (duration of competence);

5. To develop the methodological support materials for professional supervision.

3.7.6 Professional training of future social workers working in the health care system

During the visit, a meeting was organised at the University of Karaganda. The following conclusions and recommendations may be provided based on the information collected:

· The number of graduates (50 people graduated within 2 years, 120 people are studying now on different departments /courses), at the moment, cannot cover 100% of all positions of social workers in the region. This means that many people without social work qualifications will work in the system. This University is currently oriented more on training the students to work with elderly people and persons with special needs.

· For the time being, it is necessary to think over a system of professional skills development for social workers and psychologists working the health care system At the moment, the mechanism of professional development is as follows: the universities inform about the their courses and the  health department send students, using  10% from  promotional fund. At the same time there is no analysis of the training needs of social workers and the quality of offered courses is not assessed as well. 

· Social work professional training at the moment is quite theoretical. The University is trying to increase a practical aspect of training by using an elective component of training (elective subjects), involving practitioners to read elective subjects, organising practice placements in social services. However, this is insufficient to ensure that the professional training comply with the social work standards. The leading teachers who attended the meeting were not familiar with the methodology of case management, the mechanism of professional supervision, the case referral system, foster care and other important elements of social work, etc., that leads to the conclusion that the social work training lacks practical aspects of social work.

· It is necessary to identify the Universities / Colleges at the national level, which prepare or planning to start training social workers working in the health sector in order to ensure a compliance of professional training with the practical requirements and demands. Taking into account that at the moment the practice, i. e. the process of development of social services is ahead the process of the theoretical training improvement, the Universities require a support in obtaining the information on the progress achieved in the development of the social work support system provided for groups of the population.

· It is also recommended to invite the representatives of local Universities to the trainings organized by the Project on the topics related to various aspects of social protection, provide them with the methodological materials developed for their application in a professional training of future social workers.

4. General conclusions on the pilot sites

4.1. Demeu Center, Almaty

Social workers of the Demeu Centre and polyclinics included in the piloting of the working algorithm showed a pretty good level of knowledge of methodology of case management;  a cooperative relationship with the partner agencies on  prevention of the  child abandonment  (maternity, children's home) have been established. Social workers interact with medical personnel of the polyclinic in order to identify the families in difficult life situations. However, there is a need to improve certain aspects of their work.

The following is recommended in order to increase the efficiency of social workers’ activity:

· To use the mechanisms of professional supervision for improving the work with case management (for each stage of work, as well as for complex, typical and atypical cases). It is necessary to pay a particular attention to the formation of the ability to determine a level of risk (high, medium, low), prioritize the cases for support, develop and implement the individual family support, with its review and decision making to change the plan, or to finalise the work with the case.

· To improve the forms filled up by the social workers, the Client's files according to the standardized requirements and to unify the registers of clients and the work performed. 

· To improve the working protocol / algorithm at the moments of the women's movement to the maternity and back to the place of residence, setting the necessary level of flow of information, which should follow the client, in order to avoid duplication and gaps in work. The same requirements should also be met during placing the child to the children’s home and his/her reintegration with the family or placement in family-based alternative care.