Potentials for development of community based services in the transition from institutional care
Authors: Dr. Vito Flaker Vlado Krstovski Technical assistance support for the deinstitutionalisation process in social sector
EuropeAid/132633/C/SER/MULTI Specific contract number 2017/384095
A project implemented by the A.E.S.A. Consortium in partnership with Alternative Consulting CONTENTS
LIST OF ACRONYMS AND ABBREVIATIONS...... 5
Introduction...... 6
ASSESSMENT AND IDENTIFICATION OF POTENTIAL LOCATIONS FOR NEW COMMUNITY BASED SERVICES...... 7 1.1 Regional differences...... 8 1.2 Geographical variance of institutionalisation rate ...... 10 1.2.1 Factors of institutionalisation based on regional differences...... 13 1.3 Regional distribution of the services...... 14 1.4 Impact of transforming institutions...... 16 1.5 Interest for development on specific location...... 17 1.5.1 Brief profiles of potential locations...... 18 1.6 Conclusions and recommendations...... 21 1.6.1 Deinstitutionalisation framework propositions...... 21 1.6.2 Economic development rate ...... 22 1.6.3 Institutionalisation rate...... 23 1.6.4 Missing services...... 23 1.6.5 Transformation of institutions as a generator of the services...... 25 1.6.6 General recommendations for structuring development initiatives ...... 25 1.6.7 Recommendations regarding the specific projects and geographic locations...... 26
IDENTIFICATION OF POTENTIAL FUTURE COMMUNITY BASED CSO SOCIAL SERVICE PROVIDERS AND ASSESSMENT OF THEIR CAPACITY AND TRAINING NEEDS...... 28 2.1 Legal framework and background...... 28 2.2 Overview of the CSO service providers...... 29 2.3 Capacity of the CSO service providers ...... 34 2.4 Training needs...... 36 2.5 Conclusions ...... 36 2.6 Recommendations ...... 37
ESSENTIAL SUPPLIES AND WORKS FOR ADAPTATION AND MODERNISATION/REFURBISHMENT OF POTENTIAL LOCATIONS FOR NEW COMMUNITY BASED LIVING/HOUSING SERVICES, PLUS THE ESTIMATED COSTS WITH PARTICULAR ATTENTION TO THE ACCESS NEEDS FOR PERSONS WITH DISABILITIES...... 39 3.1 Overview...... 39 3.2 Options for resolving housing needs ...... 40 3.3 Social housing apartments provided by MoLSP...... 41 3.4 Overview of possible costs in securing accommodation in the resettlement process...... 42
RECOMMENDATIONS FOR DEVELOPMENT INITIATIVES...... 46
APPENDICES...... 49
5.1 Development indicators and Institutionalisation rate per region...... 50 5.2 Tentative allocation of funds by regions, locations and activities...... 51 Technical assistance support for the deinstitutionalisation process in social sector
Disclaimer
The content of this Report is the sole responsibility of the Contractor (AESA) and can in no way be taken to reflect the views of the European Union.
4 | Potentials for development of community based services in the transition from institutional care Technical assistance support for the deinstitutionalisation process in social sector
LIST OF ACRONYMS AND ABBREVIATIONS
AD adults under 65 CE Centre for counselling and advice CH children CO counselling service CRPD UN Convention on the Rights of Persons with Disabilities CSO Civil Society Organisations CSW Centres for Social Work DC Day centre EU European Union FC Foster care GE general: awareness raising, advocacy, education and information GH Group home HH Home help IPA Instrument for Pre-Accession Assistance IR Institutionatisation rate (number of residents in institutions per capita) MH Mental health MIHB Mothers’ and infants’ home Bitola MoLSP Ministry of Labour and Social Policy NGO Non-Governmental Organisation OA Old age adults OAH Old Age Home RI Residential Institution RIMH mental hospital TC tele-counselling UNICEF United Nations Children Fund
Potentials for development of community based services in the transition from institutional care | 5 Technical assistance support for the deinstitutionalisation process in social sector
INTRODUCTION
The following report has been developed under the EU funded project Technical Assistance support for the deinstitutionalisation in the social sector. This report provides a cumulative text of the outputs grouped around the second component of the project, notably:
- Output 2.1: Assessment and identification of potential locations for new community based services - Output 2.2: Identification of potential future community based CSO social service providers and assessment of their capacity and training needs - Output 2.3: Essential supplies and works for adaptation and modernisation/refurbishment
The data provided here have been collected following an extensive consultation with the institutional stakeholders, notably the Ministry of Labour and Social Policy, the residential institutions, the centres for social work, the CSO in the area of community based care, as well as through interviews and presentations with a group of municipality representatives, including mayors within a workshop held under the auspices of the project.
Each Output is presented in a separate chapter followed by brief recommendations for future development initiatives as currently discussed among the Ministry for Labour and Social Policy (MoLSP), service providers and the European Union Delegation to Skopje. It has to be noted that this report presents only suggestions and recommendations and that the decisions on the amount and type of support for the future development activities lies with the entire body of deinstitutionalisation (DI) stakeholders, namely the Ministry of Labour and Social Policy in coordination with the local municipal administration affected. In addition, it needs to be clear that this document does not present all the actions which need to be performed for the transition from institutional to community care – for this ‘The Deinstitutionalisation Strategy with the Action Plan’ and ‘the Common European Guidelines on the Transition from Institutional to Community Based Care’ have to be consulted.
6 | Potentials for development of community based services in the transition from institutional care Technical assistance support for the deinstitutionalisation process in social sector
ASSESSMENT AND IDENTIFICATION OF POTENTIAL LOCATIONS FOR NEW COMMUNITY BASED SERVICES
For the implementation of the National Strategy for Deinstitutionalisation, in addition to and in line with its Action Plan, it is important to identify locations and design mechanisms for how diverse actors will collaborate on and about the chosen locations in transforming the institutions and establishing a new response in the community; both – in the immediate environment of the residential institutions and in the locations further out from these foci of transformation. Hence, this document is more than just a mere selection of the locations, it is also laying out the logic and mechanism for the operative engagement of the resources and stakeholders, serving as guidelines for action as an important complement to the Action Plan itself. Along with other outputs of this component (i.e. Identification of potential future community based social service providers (output 2.2) and Report on essential supplies and works required for adaptation of potential locations for new services (output 2.3), it, as it is, sets the proposition for the projects supporting the deinstitutionalisation.
The selection of locations is based on a number of criteria. To provide diversity of experience and to address different issues in different circumstances, the analysis for selection was based on:
- regional diversity, - geographical variance of the institutionalisation rate, - the current presence or absence of services – i.e. distribution of services, - the vicinity and distance from the institutions in transformation, as well as their future activities after the transformation, and - local readiness and interest for such an effort.
Based on the propositions of the Strategy, and conclusions of the analysis, a general pattern of setting up local development activities is proposed, as well as specific recommendations for their prospective sites.
Potentials for development of community based services in the transition from institutional care | 7 Technical assistance support for the deinstitutionalisation process in social sector
1.1 REGIONAL DIFFERENCES
The beneficiary country is greatly diverse – in terms of culture and geography – and of rich history and tradition. Geographically it is divided into the Western, mountainous part, Central lowland part of Povardarje, and Eastern part consisting of plateaux and flat basins. There is no political and administrative regional division, the local government functions on the level of municipalities. There are, however, eight statistical regions used in this assessment.
Selected economic and development indicators show a great variety across the nation. The East region, for example, is performing consistently well on most of the indicators (except regarding GDP and gross earnings, which are just about the median average). Conversely, Polog and the Northeast regions are performing consistently under national average, but with exceptions. Polog has, in spite of low activity and employment rates, a high job vacancy and low unemployment rates, and earnings that are well above the national median average. In addition, a gender difference in salaries is favourable – just below national median. The Northeast region, which fares badly on most of the indicators, is on equal pay indicator, and together with the East they are the national champion. The Southwest region seems to be in the same class of less developed region, but is faring better than the other two on most of the indicators, and has a surprisingly low infant mortality rate.
The East region, Pelagonija and Skopje are regions that are more successful performers against the chosen indicators. There are indications of this ‘success’ being divided on different counts. Pelagonija is not performing so well on economic indicators (GDP, salaries), but extremely well on education and employment criteria.1 Skopje, on the other hand, is an anomalous and large entity2: economically the most successful, with a good educational structure, but with meagre employment opportunities (which in fact are ample but, due to good wages, so is the demand). The Vardar region, as a central one, is a region with GDP and employment just over the national average, but with lower salaries. Its centrality is also in relation to the education structure, where the region is leading in the segment of secondary education performance (on that account the Vardar region has a small proportion of the workforce with a low level of education, but also quite a low portion of highly educated persons).
The Southeast region has a mixture of development indicators values. It is a region of economic success, which shows also favourable results in employment, but with a low education level structure. Its economic success is probably attributed to agricultural development, where an educated workforce is not needed as much and which, even if the production is intensive, still in part sustains a system of traditional values.
1 Pelagonia used to be on the higher end of economic indicators but has dwindled, in this sense, over the past decade. It seems like this once prosperous region is degrading but still conserves more stable attributes of development, which in future may be a factor of recuperation or may be decreasing as well. 2 On some of the indicators, its volume dictates the national average.
8 | Potentials for development of community based services in the transition from institutional care Technical assistance support for the deinstitutionalisation process in social sector 12,98 17,35 14,72 10,36 17,12 12,96 10,91 21,21 13,85 16,03 ISCED 5 + 43,9 53,07 47,82 44,30 46,31 34,38 47,21 49,44 46,76 45,65 ISCED 3-4 33,95 34,83 41,38 45,34 36,57 52,66 41,87 29,36 38,98 38,32 Level of education in of education Level age population (%) working ISCED 0-2 6,08 5,22 4,38 4,59 7,12 3,59 4,82 6,93 5,02 5,42 Education Education Graduates Graduates (% of 20-24 population) 5 5 12 21 18 13 13 16 13 15 M-F (Gender) diff. 146 145 148 153 150 161 123 213 149 174 Hour, Hour, MKD Average gross gross Average earnings 1,68 1,60 1,59 1,77 1,97 1,72 0,76 1,42 1,64 1,52 Job Vacancy (%) Rate 21,6 16,4 33,0 14,1 19,0 16,4 42,2 22,3 20,3 23,7 Unemployment Unemployment rate 49,3 52,0 35,9 57,1 52,5 34,7 32,0 41,6 43,1 45,45 Employment Employment rate 62,8 62,3 53,5 66,5 64,9 47,2 55,4 53,5 56,5 58,85 Activity rate Activity rates of the population aged 15 years and over and over of the population aged 15 years Activity rates 291.516 253.656 212.913 315.717 260.855 121.824 164.161 386.876 269.996 GDP per capita (MKD) 257.255,5 7,10 7,90 11,9 13,20 10,40 15,60 14,10 12,00 11,50 11,00 Infant Infant mortality – performance above average; average; above – performance average; below – performance performance; – anomalous region; average – an Region Macedonia Vardar* East East Southwest Southwest Southeast* Southeast* Pelagonija* Pelagonija* Polog Polog Northeast Northeast Skopje** Skopje** median nation * region with heterogeneous indicators. indicators. heterogeneous with * region Table 1: Regional differences on selected development indicators on selected 1: Regionaldevelopment differences Table MakStat Source: Colour legend:
Potentials for development of community based services in the transition from institutional care | 9 Technical assistance support for the deinstitutionalisation process in social sector
The global picture is that there are two development axes across the country. A high development axis spanning from the South to the East of the country, and a low development one spanning from the Southwest to the Northeast, with Vardar as a central and average region in the middle. These differences can be attributed to various factors of a geographical, political and economic nature. The area along the low development axis coincides with three major elements: it is mainly a mountainous area with strong clanship mentality (except Northeast); there is a numerous Albanian minority (with lower educational level), and it lies on the borders of less developed, non-EU countries. On the other side, the area along the South-eastern axis is in a fertile part of the country, with ethnically homogenous population and on the borders of EU member states.
The consistency of the areas along the development axes outlined above is punctuated by the anomaly in pay (low difference in wages at the Eastern end of low development area and high difference in wages in the Southeast, which is contrary to the high development of this area). This indicates that economic and social development is only to a certain degree associated with changes in gender values. The differences are probably more emphasized in the cultural patterns than just in the economic ones. It also punctures the regional stereotypes on traditionalism of cultural patterns. Generally patriarchal mentality is considered to be stronger on the East and West sides, while North and South are seen to be more liberal. If we take out the Polog region, which generally is considered a poor community with dominant traditional values, the probability is that this still holds true, but the region has developed its own sustenance mechanisms resulting in a paradox of low employment and low unemployment rates simultaneously, and a relatively equal pay (difference at the national median).
1.2 GEOGRAPHICAL VARIANCE OF INSTITUTIONALISATION RATE
For the purposes of deinstitutionalisation, the geographic origin of residents is very important, since, in principle, residents should return to their home environment.3 This dimension of residents’ profile at statistical region level and at the level of territories covered by centres for social work is illustrated in the tables below.
Table 2: Regional distribution of geographic origin residents per 10.000 inhabitants4
No. Reg. Regions/ residents per 10.000 inhabitants adult children old age all institution
1 East 2,6 9,5 16,4 6,8
2 Northeast 0,4 5,4 35,1 5,8
3 Pelagonija 1,3 10,3 50,5 11,3
4 Polog 0,3 1,5 1,0 0,7
5 Skopje 0,9 3,9 10,5 3,2
6 Southeast 1,8 4,4 6,3 3,5
7 Southwest 0,8 2,2 6,3 2,0
3 This principle was not observed in previous wave of deinstitutionalisation. See the chapter below. 4 The IR is calculated on the basis of population in the age group. E.g., the high IR for the old age in Pelagonija means that there are 50,5 residents in all old age homes across the country per 10.000 inhabitants of Pelagonija region that are over 65 years old.
10 | Potentials for development of community based services in the transition from institutional care Technical assistance support for the deinstitutionalisation process in social sector
8 Vardar 2,0 6,2 15,3 5,4
0 R. Macedonia 1,1 4,7 17,0 4,3
Test of Homogeneity of Variances 0,334 0,167 *0,024 *0,028
ANOVA (analysis of variance) test 0,142 0,221 *0,017 *0,033
Source: Annual reports, questionnaire and Statistical Office data
Legend: – considerably above average; – considerably below average.
There is quite a variability in the distribution of the geographic origin of the residents. The Polog region has consistently much lower rate of institutionalisation than other regions, whereas Pelagonija has double the national rate for children and old age (but just a little above average for special institutions for adults). The Eastern region has higher rates for children and adults, and the Vardar region higher rates for adults. The Northeast region has a considerably lower rate of adult or special institutions, while considerably higher for old age institutions. Hypothetically, the differences could be attributed to:
a) vicinity of the institutions (e.g. Pelagonija has institutions for children and for old age, but there is no institution for adults; the Northeast has a big old age home but no other institutions); or b) regional cultural differences regarding institutionalisation (like strong traditional family ties and clan organisation of extended families, shame and fear of stigmatisation); or maybe c) some other structural moments (the East region has high rate of institutionalisation for children and adult institutions but there are no such institutions and the East region has a high emigration rate).
Polog and partially the Southwest region have consistently low rates, which could be attributed, with some probability, to migration as well as strong family traditions and extended families.
However, significant differences (*) of the institutionalisation rate are only between the old age home rates and the rate of all institutions. The picture is slightly different if we look at the differences between the geographic areas covered by centres for social work.
Table 3: Institutionalisation rate per 10.000 inhabitants by territory covered by centres for social work
Region CSW territory adult children old age all institution
East Probištip 1,3 12,7 0,0 3,3
East Berovo 1,7 28,0 9,9 7,9
East Kočani 2,5 4,9 21,1 6,7
East Delčevo 2,5 7,7 19,6 6,8
East Štip 2,7 6,0 13,2 5,7
East Vinica 4,6 15,0 30,3 11,3
Northeast Kratovo 0,0 14,0 43,9 9,6
Northeast Kumanovo 0,4 4,7 31,4 5,1
Northeast Kriva Palanka 0,4 7,2 48,8 8,9
Potentials for development of community based services in the transition from institutional care | 11 Technical assistance support for the deinstitutionalisation process in social sector
Pelagonija Resen 0,6 21,0 27,5 8,6
Pelagonija Kruševo 1,1 0,0 19,6 4,2
Pelagonija Bitola 1,1 13,9 75,6 15,6
Pelagonija Prilep 1,6 6,8 29,0 7,4
Pelagonija Demir Hisar 3,7 8,2 61,5 18,3
Polog Tetovo 0,0 0,7 0,6 0,2
Polog Gostivar 0,7 3,1 1,8 1,4
Skopje Skopje 0,9 3,9 10,5 3,2
Southeast Valandovo 0,8 4,7 17,6 4,2
Southeast Gevgelija 1,5 13,8 3,7 4,4
Southeast Strumica 1,9 2,1 6,4 3,2
Southeast Radoviš 2,1 2,9 4,9 3,4
Southwest Debar 0,0 3,3 0,0 0,7
Southwest Struga 0,3 2,2 1,5 0,9
Southwest Ohrid 0,4 1,9 4,6 1,4
Southwest Kičevo 1,6 2,2 7,5 2,8
Southwest Makedonski Brod 4,5 0,0 48,7 9,9
Vardar Veles 1,5 3,7 0,0 2,3
Vardar Kavadarci 1,6 10,0 28,6 7,7
Vardar Negotino 3,0 0,0 14,7 5,1
Vardar Sveti Nikole 3,5 14,3 34,5 11,4
R. Macedonia R. Macedonia 1,1 4,7 17,0 4,3
T-test *0,035 *0,043 0,330 *0,035
Source: Annual reports, questionnaire and Statistical Office data
Legend: – considerably above average; – considerably below average.
The differences in institutionalisation rates across the country are significant for aggregate institutionalisation rates for all institutions, special institutions for adults and children institutions, but are not significant for the old age homes. This is quite an opposite result to the significant differences of the regions where statistically significant difference was found with old age homes. The reason for a different significance is hard to explain and is probably purely computational (fewer extreme values and smaller variance inside regions for the institutionalisation rate to the old age home).
The table above adds to our speculation about the reasons for differentiation.5 The effect of the vicinity of an institution is even more obvious, as marked in Demir Hisar, Bitola and Negotino. The low rate in the Polog region
5 N.B. The speculative aspect of the discussion of the reason of geographic difference in institutionalisation rate are of course tentative. However, these are informed speculations, which can be important in further investigation, and to certain degree, in planning the activities in across the regions.
12 | Potentials for development of community based services in the transition from institutional care Technical assistance support for the deinstitutionalisation process in social sector can again be explained by the cultural attitude - sending someone away from home is perceived as a negative value, especially if they are sent to an institution. Nevertheless, the difference between the two regions covered by the centres for social work can be seen in this table, so as the fact that Tetovo has almost no institutionalisation, while rates for Gostivar are near the national average.
We can also see that a bigger part of the Southwest region has quite homogenously low institutionalisation rate, while the rates in Makedonski Brod exceed the regional profile and are well above average, except in respect of institutions for children. The case of Makedonski Brod, which has no children residing in institutions, but yet has an extremely high rate of adult institutionalisation, could be explained by the fact that there are many foster families in Makedonski Brod, but maybe not so many available for adults, therefore, the centre for social work may be inclined to refer adults to institutional care. This can be partially confirmed or seconded by the case of Kriva Palanka, where the centre for social work has taken out the residents of adult and children’s institutions and provided them with day care and fostering, while the institutionalisation rate for the old age homes is among the highest.
The East Region remains a riddle, most probably to be solved by cultural or structural social elements and impacts and their intraregional variations. In this region, the institutionalisation rate is consistently above average for children and adult special institutions, but relatively lower for the old age homes – mostly around average, but also at a zero value in Probištip. It looks like the region is oriented to care for old people at home, by family resources; however, it tends to be more readily and more hastily inclined to move adults and children into the institutions. This may be attributed to high rate of emigration, where emigrants can provide for their parents but cannot and do not want to leave their children and siblings to be looked after by their relatives—often their own parents in need of support themselves. There is a consistently high rate of institutionalisation in Vinica, which may also have some background in their micro-culture, maybe in the way that the centre for social work operates. The discrepancy between the old age rate and substantially high rate of institutionalisation for children in Probištip may also be attributed to that.
A more detailed statistical and graphic analysis may be found in the appendix 10. 2. of the Situation Analysis.
1.2.1 FACTORS OF INSTITUTIONALISATION BASED ON REGIONAL DIFFERENCES
To hint at the factors leading to the specific institutionalisation rates, we have performed a brief rank correlation test (Spearman’s ρ coefficient).6
Table 4: Rank correlation between the institutionalisation rate and selected development indicators in the beneficiary country regions
Special Children Old age homes All institutions
Infant mortality -0,64 -0,50 -0,31 -0,43
GDP 0,6 0,26 0,14 0,17
Activity rank 0,69 0,71 0,5 0,67
6 Table combining development indicators and institutionalisation rate in the appendix.
Potentials for development of community based services in the transition from institutional care | 13 Technical assistance support for the deinstitutionalisation process in social sector
Employment rate 0,79 0,55 0,24 0,45
Job vacancy 0,29 0,26 -0,02 0,17
Hour, MDK -0,26 -0,52 -0,55 -0,57
M-F (gender) -0,33 -0,67 -0,69 -0,69 diff.
Graduates 0,5 0,74 0,76 0,69
ISCED 5+ 0,29 0,24 0,24 0,19
Source: Annual reports, questionnaire and Statistical Office data
Legend: – very high (significant); – high; – medium; – low.
This set of correlations points to a probability that some development characteristics increase the institutionalisation rate in one type of institutions, while others have more impact on institutionalisation in another type. Employment rate seems to be a very important factor leading to institutionalisation, but is only moderately related to the institutionalization of children and has a low correlation to institutionalization in old age homes. Equal wages between the genders and the number of graduates, on the other hand, seem to be very important factors for understanding why more inhabitants from a given region have placed their relatives in children’s or old age homes. The activity of a population and the number of graduates in a region seem to be the most important factors determining institutionalisation rates and levels of admission with regard to any of the three types of institutions. Job vacancies and number of highly educated inhabitants seem not to be very much related to the institutionalisation rate, while GDP seems to contribute only to higher institutionalisation rate in special institutions.
All in all, the general picture is that the more developed regions have a higher institutionalisation rate. This is to be explained by the impact of the economic activity of the population, which prevents more people from taking care for their close ones, but it can also be attributed to the aspiration level and upward mobility in an area (number of graduates). For children and old people, the important thing to look at is the status of women who are usually the carers – if their salaries are lower, women lose less financially by caring for parents or children, while caring for adult progeny seems to be in weaker correlation with the difference in salary. In the latter case, economic indicators (GDP, employment) seem to have more relevance in admissions to special institutions, as well as the favourable health prospect of potential residents, while amount of the salary and its level is not so important in these cases (and continues to be of medium importance to other two types of institutions).
1.3 REGIONAL DISTRIBUTION OF THE SERVICES
In addition to the centres for social work, day centres are the most evenly distributed examples of community care service. However, there are only two day centres and two centres for social work in the Polog region, which is much less compared to other regions where there are typically six to eight such centres. Less than a typical number is also found in the Northeast region (four day centres). Group homes and foster care, i.e. residential facilities, are much more unevenly distributed. Group homes exist only in the Vardar and Skopje regions, Berovo group home in the Eastern region, and a mental health small residential facility in Gevgelija (hospital Negorci) in the Southeast. As identified above, there are two concentrations of foster carers, one in a circumscribed area
14 | Potentials for development of community based services in the transition from institutional care Technical assistance support for the deinstitutionalisation process in social sector
(however, divided between three regions – Pelagonija, Vardar and Southwest) and the other in Skopje. There are foster carers also in Kriva Palanka, as a result of early resettlements from Demir Kapija. CSOs operating in social care are also quite evenly distributed over the country, ranging from 35 in the East to 14 in the Southeast, with notably less in the Pelagonija region where there are only seven CSOs. There are counselling services of various types in every region, with a concentration (more than statistically expected) in Skopje. Home help, a nascent service has also begun in Skopje, but there are also registered individual providers in the East (Štip and Karbinci) and one in the Pelagonija region. Personal assistance has been briefly piloted, and in 2018 more substantial pilots are under way in seven municipalities (Bitola, Struga, Kumanovo, Negotino, Gostivar, Strumica and Skopje).
In conclusion, ambulatory services, with some exceptions, are quite evenly spread, while residential services are concentrated in very delineated areas. One of the main mid-term goals of transformation should therefore be that the latter are constituted in every region (one for adults and one for children) to enable residents to resettle or stay near their homes. In order to observe the principle of original environment, it is practical for these facilities to be heterogeneous. The crisis and respite services are not developed. They should be developed to serve the whole country while, if need arises, such services should be established in almost every region. In the long run, the group homes established in the first stage of implementation of the new deinstitutionalisation strategy, will be transformed, in the subsequent stages, into transitional services for crisis, respite and transitory accommodation (rehabilitation, and similar short-term activities).
Table 5: Regional distribution of community-based services
Region East Northeast Pelagonija Polog Skopje Southeast Southwest Vardar R Macedonia
Day centres + 8+1 4 4+3 2 14 6+2 7 6 51+6 clubs
No. users (DC) 70+14 77 59+46 35 184 64+34 63 85 637+94
No. staff (DC) 31+1 31 20+3 14 33 16+2 14 12 171+6
Group homes 1 0 0 0 8 1 0 5 15
No. users (GH) 9 0 0 0 88 NA 0 43 139+МH
No. staff (GH) 7 0 0 0 21 NA 0 14 42+МH
Residential 1 1 4 0 28 3 0 2 39 institutions
No. users (RI) 15 149 688 0 1256 89 0 240 2437
No. staff (RI) 7 41 134 0 NA NA 0 134 Nap (NA)
Foster care 0 1 3 0 2 0 1 1 8 organisers
No. users (FC) 0 10 125 0 Nap 0 29 42 206
Centres for 6а 3 5 2 1 4 5 4 30 social work
NGO 35 20 7 15 20 14 16 17 144
Home care 1 0 1 0 2 (281 0 0 0 4 u.)
Counselling 3 2 1 1 5+4 1 2 1 16+4
Population 176.262 176.169 230.004 320.826 624.585 173.545 219.740 152.571 2.073.702
Legend: – lack of services
Potentials for development of community based services in the transition from institutional care | 15 Technical assistance support for the deinstitutionalisation process in social sector
1.4 IMPACT OF TRANSFORMING INSTITUTIONS
The major source of formation of new services will be the transformation of the existing residential institutions. After the accomplished transformation, these institutions will have a changed and, generally, ‘double role’. They will be providers of services in the local community (where they are situated now); in addition, they will be the main coordinators of care and support activities for a designated user group or designated forms and methods of care for the whole country.
Table 6: Possible learning sites by division of topics7
Institution in Learning site and resource centre transformation
Demir Kapija Personal planning, intensive interaction, training support for accommodation of users with intense support needs, teamwork, mobile support, crisis and short term respite care support
Banja Bansko Rehabilitation, physiotherapy, independent living support for persons with physical disabilities, self and peer advocacy, personal assistance
Topansko Pole Production units, day centres, activities catalogue
MIH Bitola Early childhood protection and social intervention, adoption, early foster care, keyworkers.
11. Oktomvri Foster care and other alternatives for family care, children crisis centre
Ranka Milanović and Family empowerment, alternative community measures of children in conflict with law, family 25. Maj conferences
SOS Children village Quality standards and assurance
Poraka Negotino Housing, personal assistance
National Poraka Advocacy, legal capacity and supported decision making, family care, day centres and social clubs
OAH A (Prilep) Home help and telecare
OAH B Day care support in old age
OAH C Community care for dementia
OAH D Integration of health and social care services
The process of transformation will therefore entail double action: ‘spilling over’ into the immediate environment8 of an institution and assisting in the establishment of the services in a less immediate (further out) location in partnership with local actors.
7 This table is an attempt to present ideas for distribution of necessary innovation across the actors or stakeholder organisations. Naturally, this has to be reviewed and agreed. Some choices are just for illustration purpose and are coincidental but majority is done to fit the present purpose of an institution. Major CSOs are included since they will play important role in development and dissemination of new methods and forms of organisation. 8 As the institutions are now specialised to work with a certain user group there is a good chance that, after the resettlement, there will not be sufficient number of users of the category. This must be assessed in the local (and regional) needs assessment and should the transformation plan should be based on this assessment. However, in case this happens and to the degree there are two options, schematically speaking, either the institutions develops services for other user groups or it spreads its operation geographically. E.g. the staff in MIHB Bitola, who now works with infants and toddlers, might stay in Bitola after services are spread across the country, and start working as professional carers for e.g. adult users or they may move to another location.
16 | Potentials for development of community based services in the transition from institutional care Technical assistance support for the deinstitutionalisation process in social sector
1.5 INTEREST FOR DEVELOPMENT ON SPECIFIC LOCATION
On grounds of regional differences, geographic prevalence of institutionalisation rate, distribution of the existing services (so that the developed and underdeveloped regions, those with high institutionalisation rate and those with low, and with a need of development of services are represented), and with consideration of their vicinity to the transforming institutions, thirty-one municipalities were selected and invited to a workshop at the Demir Kapija Special Institution. The aim of the workshop was to present them with the process of deinstitutionalisation, and discuss, exchange and identify possible partners in the first stage of the development of new services.
Table 7: Municipalities invited to the ‘deinstitutionalisation’ workshop
invited municipalities Attended East region Vinica √ Berovo Delčevo Štip Northeast Kriva Palanka √ Kumanovo √ Lipkovo Pelagonija Bitola Prilep √ Polog Bogovinje √ Gostivar Tetovo Southeast Radoviš √ Strumica √ Gevgelija Novo Selo Skopje region City of Skopje Aerodrom Centar Čair Saraj Southwest region Debar Kičevo Makedonski Brod √ Ohrid Struga Vardar Demir Kapija √ Kavadarci √ Negotino √ Sveti Nikole Veles √
Potentials for development of community based services in the transition from institutional care | 17 Technical assistance support for the deinstitutionalisation process in social sector
Thirteen of the invited municipalities responded present and expressed willingness to participate in the deinstitutionalisation efforts. Three municipalities will be directly involved in transformation of Demir Kapija, and Strumica will be involved in the transformation of the Banja Bansko institution.9 This selection fits the selected parameters and represents a good mixture of adjacent and further municipalities, municipalities with capacities developed, and few with capacities yet to be developed, and they are sufficiently heterogeneous in terms of their inhabitants and institutionalization rate.
1.5.1 BRIEF PROFILES OF POTENTIAL LOCATIONS
Vinica is a municipality in the East region with 19.938 inhabitants (over 90 % Macedonians, some Roma and Turkish minority) and area of 432,67 km2 (density 46,08/km2). The town of Vinica has two primary schools and one secondary. The economy is mostly based on agriculture; the industry is textile and wood. There is a small public day centre (12 users), a day centre for old people (Istibanja) and a centre for social work. There are three NGOs registered in MoLSP from Vinica. Vinica has a considerable high overall institutionalisation rate, the highest for special institutions and the third highest for children.
Kriva Palanka is located in the Northeast region on the Bulgarian border. The town of Kriva Palanka has 14.558 inhabitants, and the whole municipality has almost 21.000 inhabitants in an area of 480,81 km² (density 27.81// km²). The ethnic structure is homogenous with some Roma and Serbian minority. The economy is based on the trans-border trade, agriculture and mining. The town has three elementary schools and a secondary school. In addition to a centre for social work, there is a day centre and six NGOs in the field of social care. It is also the only municipality, which has developed foster care outside its concentration zone (Manastirec, Makedonski Brod and Kruševo area). Kriva Palanka is noted for early attempt in deinstitutionalisation and has very low institutionalisation rate for residents in special institutions, while the rate of institutionalisation of children is above the national average, and for old age homes the rate is among the highest in the country.
Kumanovo is the third largest city in Macedonia and the municipality is the largest in the country with 105.484 inhabitants and area of 509,48 km² (density 207,04/km2). The ethnic composition is diverse, with 60 % Macedonians, 25 % Albanians and with substantial Serbian (8,6 %) and Roma (4,1 %) groups. It is well connected by road and railway communications, and quite near the airport. It has had many industries and is known for tobacco production. There is a grammar school and four vocational secondary schools in the municipality, offering various vocational education courses including mechanical, electronics, health, banking, economy, law and design courses. There are two day centres in Kumanovo, a centre for social services and an old age home. The institutionalisation rate in Kumanovo is not high; it is considerably below the average for special institutions, average for children and somewhat above the average for old people.
Prilep is a town in central Macedonia, at the north end of the Pelagonija region. It has 76.768 inhabitants, mostly in the city of Prilep, with an area of 1.194,44 km2 (density 64,27/km2). It is ethnically homogenous (92 % Macedonians) with a strong Roma minority. There are five secondary schools in the town, including vocational education in agriculture and veterinary science, economy, electronics and mechanics. Prilep is the seat of the Faculty of Economics of the St. Clement of Ohrid University, including studies in information and computer technology, agriculture and tobacco, mining and engineering, as well as postgraduate studies in robotics. It
9 It can be assumed that Bitola will be involved in the transformation of MIHB and later on in the transformation of the old age home. Gevgelija could be a partner in early development of the new services on the account of vicinity and existing capacities, Berovo on the account of past efforts and to complement the developed services, while Tetovo might be involved in connection with Bogovinje, which is under the jurisdiction of the Tetovo centre for social work, which in turn would need some restructuring.
18 | Potentials for development of community based services in the transition from institutional care Technical assistance support for the deinstitutionalisation process in social sector has a strong tobacco industry, as well as electronics and a quarry. In Prilep, there is a day centre, a social club and counselling centre for people with intellectual disabilities, a community mental health centre, an old age home and there are many foster carers. There are six NGOs (covering also some nearby municipalities). The institutionalisation rate in Prilep is a little above the average for all types of institutions.
Bogovinje is a small, rural municipality at the foothills of Šar Planina. There are 28.997 inhabitants in an area of 141,65 km² (density 204,71/km²). The majority of population is Albanian (95,2%) with small Turkish minority (4,1%). There are six primary schools in the municipality and two kindergarten groups in the small town of Bogovinje. Tetovo centre for social work is responsible for this municipality, which has no social services available on its own. In Tetovo, however, there is a day centre, centre for social services and a community mental health centre. There are ten social NGOs on the territory covered by the centre for social work Tetovo. The area is marked by extremely low institutionalisation rate for all institutions.
Radoviš is a municipality in the southeast of Macedonia, with area of 497,48 km2 and population of 28.244. The inhabitants are predominantly Macedonian with a strong Turkish minority (14.4%). There are two elementary schools, a secondary school and a faculty of electrical engineering. Mining and tobacco are the traditional base of the Radoviš economy, as well as agriculture. There is a day centre and a small private old age home (16 places). Institutionalisation rate in Radoviš is high for the special institutions and below the average for old age homes.
Strumica municipality has 54.676 inhabitants (density 170/km2), with majority of Macedonian population with substantial Turkish minority (6,5 %). The economic base is agriculture, and textile. There are four elementary schools in the town, three secondary schools, units of Goce Delčev University (economy, agriculture, education) and a private university (law, economy, security, sports management, communication technologies and languages). It has a day centre and a social club, and a counselling service for addiction. The institutionalisation rates are below the average, especially for children.
Makedonski Brod is a municipality in the Southwest region, however, not a typical one for the region. It has an area of 88,97 km2 and a population of 7.141 inhabitants (density 8,03/km2). Ethnically the inhabitants are great majority Macedonians with small Turkish minority. There is a primary and a secondary school in the municipality, as well as a kindergarten. There is a power station of Kozjak with an artificial lake. The economy is mainly agricultural. It is one of the centres of fostering and has two day centres – one for people with intellectual disabilities and one for old people (Samokov). It has zero institutionalisation rate for children and extremely high above the average for special institutions and old age homes.
Veles is a municipality in the north of the Vardar region with an area of 427,45 km2 and a population of 50.549 inhabitants (density 128,92/km2). Ethnically majority is Macedonian (84.9%), with Boshniak (4,4%), Albanian (4,2%) and Turkish (3.1%) minorities. Veles has seven primary and four secondary schools, including vocational education offering chemistry, technology, health, trade and economy, mechanics, electronics and catering courses. It is an industrial centre. There is a day centre and developed foster care. The institutionalisation rate is below the average, with no inhabitants placed in public old age homes.
Demir Kapija is a municipality in the south-east of the Vardar region with an area of 311,06 km2 and a population of 4.545 (density 15/km2). Ethnically it is quite homogenous with a substantial Turkish (7,6%) and a smaller Serbian (2,9%) minority. The economy mainly is agriculture, predominantly wine production. There is an elementary school and a nursery school in Demir Kapija. It is the seat of the largest institution for residents with disability providing many work places for the inhabitants of this and the neighbouring municipalities. There are, however, no other social services in the municipality.
Kavadarci is a municipality in the south of the Vardar region with an area of 992,44 km2 and population of 38.875 (density 39,04/km2). Ethnically it is a homogenous area, with small Roma (1,8%) and Turkish (0,4%) minorities.
Potentials for development of community based services in the transition from institutional care | 19 Technical assistance support for the deinstitutionalisation process in social sector
There are six primary and three secondary schools in this municipality, and a single public kindergarten with facilities dispersed through the municipality. The economy is mainly agriculture including wine production, as well as industry and mining. It has a day centre and a number of civil organisations in the area of social work. The institutionalisation rate is consistently above the average, for children markedly so.
Negotino is a municipality in the east of the Vardar region with an area of 132,9 km2 and population of 19.212 (density 45,05/km2). Ethnically majority is Macedonian (92,5%) with some Serbian (3,3%), Roma (2,4%) and Turkish (1,3%) minorities. There are three primary and a single secondary school in Negotino, as well as a kindergarten. Wine production is the main economic activity. The second largest back-up power plant in the country is located in this municipality. It is the seat of the largest complex of group homes covered by deinstitutionalisation run by a civil organisation. The institutionalisation rate is a bit above the average.
Bitola is a municipality in the south of the Pelagonija region with an area of 787,95 km2 and population of 105.644 (density 130/km2). Ethnically it is quite homogenous (Macedonians 88,71%) with Albanian (4,37%), Roma (2,74%), Turkish (1,69%), Vlach (1,33%), Serbian (0,57%) and Boshniak (0,02%) minorities. Its seat is the largest regional and administrative centre in the south of the country, with traditional international ties. Bitola is the seat of St Clement of Ohrid University with six of its faculties located there (technical, teaching, biotechnological, information and communication technologies, health and veterinary). There are also twelve primary schools, seven secondary schools including technical and music schools, as well as two public kindergartens with dispersed facilities. It has all amenities of a developed urban centre including a thriving cultural scene. The main power plant supplying the country with electricity is located in this municipality. There is also a large hydro-system for electricity production and water supply. The economy includes agriculture and forestry, food production and processing, textile, printing, metal and mining industries. Bitola has two public residential institutions – a home for infants without parents and an old age home; there are three day centres – one for children with intellectual disabilities, one for children with autism and a social club, and relatively strong support by the civil sector. The institutionalisation rate for adults is average and high above the average for children and old people.
Valandovo is a municipality in the west of the South-eastern region with an area of 331,4 km2 and population of 11.773 (density 35,88/km2). Ethnically majority is Macedonian (82,7%) with Turkish (11,2%) and Serbian (5,4%) minorities. There are two primary and a single secondary school, as well as a single public kindergarten. The dominant economic activity is agriculture, with great potential for tourism due to the Mediterranean climate and lack of polluting industries. There is day centre in this municipality and a local CSO. The institutionalisation rate is consistently on the national average level for all user groups.
Gevgelija is a municipality in the south west of the South-eastern region with an area of 317 km2 and population of 22.706 (density 47,55/ km2). Ethnically it is homogenous (Macedonian 96,8%), with small Serbian (1,6%) and Vlach (0,9%) minorities. It has four primary and a single secondary school as well as one public kindergarten. It has a thriving economy due to bordering the EU, including agriculture, tourism and service and leisure industries, resulting in the highest rate of employment in the country. It has a mental health institution (Negorci), two day centres for people with intellectual disability, a community mental health centre and a group home for ex-residents of the mental hospital. There are several civil sector organisations working in this area. The institutionalisation rate for adults is slightly above the national average, for children very high and for old age substantially below the average.
Skopje is the national capital and the largest economic and administrative centre. Administratively it is divided into ten municipalities including Aerodrom, Butel, Čair, Centar, Gazi Baba, Gjorče Petrov, Karpoš, Kisela Voda, Saraj, and Šuto Orizari with local governments independent from the Council of the City of Skopje and the Mayor of the City of Skopje. It is also the centre of the Skopje Statistical Region, with metropolitan area (including adjacent municipalities) of 1,854.00 km2 and a total population of 578,144 (Greater Skopje). The city itself has
20 | Potentials for development of community based services in the transition from institutional care Technical assistance support for the deinstitutionalisation process in social sector population of 506,926 (density 890/km2). Ethnically the majority of the population are Macedonians 66.7, and Albanians 20.4, with large communities of Roma 4.6, Serbs 2.8, Turks 1.7, Boshniaks 1.5 and Vlachs 0.5. All major national government institutions are located in Skopje. It is the seat of the first and oldest Ss Cyril and Methodius University and the University Clinical Hospital Mother Theresa. With regards to education, all municipalities have developed structure with primary and secondary schools (including vocational), as well as kindergartens. There are also special schools for persons with disabilities.
There are three institutions for children and another for people with disabilities one housing also adults. There are also 23 old age homes including one which is public, and there is a mental hospital in Bardovci. There are two clusters of group homes – one for children (SOS children village) and one for people with disabilities (Poraka Negotino). There are many (18) day centres for various groups of users, and attempts to provide home help. There are many counselling services provided by civil sector. On the whole, the provision in Skopje is most developed and presents an anomaly in the total picture – as a region in its size and other characteristic, but also in terms of services available, which are plenty but regarding the number of inhabitants not as developed as it would be needed.
1.6 CONCLUSIONS AND RECOMMENDATIONS
1.6.1 DEINSTITUTIONALISATION FRAMEWORK PROPOSITIONS
An important goal of the strategy is to bring services nearer to the people and make them more accessible and available. This means that the aim is to provide greater and more even dispersion of the services across the county. Missing services need to be developed locally, and accessibility and availability need to be enhanced by mobile services.
The even dispersion, availability and accessibility cannot be achieved at once. It takes time to develop services and build up experience and expertise. The Strategy foresees such a development starting fromfocal points of new service (or another activity) launch, which should subsequently grow in their momentum (like a snowball).
One of the driving forces to build momentum will be the institutions under transformation. They will guarantee the development of new services in the immediate environment of an institution. In order to secure even development and accessibility, efforts must be made to avoid merespilling over of the services into the neighbouring area, rather, to produce and stimulate new services and resettlement to further out locations10 in another municipality or region. The activities of establishing the community based services should be radiant, expanding from kernels of transformation (i.e. transforming institutions) toward more distant second-generation hubs (in another designated region), which in turn, will also serve as foci of further development of such services across the country in the subsequent stage.
Additional two aims of deinstitutionalisation are the decentralisation and pluralisation of services. This presupposes that the local government and the community should be involved, along with the local public (CSWs), the CSOs and
10 Distance here is meant as distance from existing institution. In the long run there should be services available everywhere. In the first period there will be new services generated in the immediate environment of an institution (e.g. around Demir Kapija) and in these selected municipalities (which are a good mix of diverse environments). These will serve as ‘seeds’ for the rest of the region and the country – in order to achieve a ‘perfect’ coverage in the long run (e.g. 6-10 years).
Potentials for development of community based services in the transition from institutional care | 21 Technical assistance support for the deinstitutionalisation process in social sector private service providers. Therefore, each local development coalition should also include the relevant stakeholders in addition to the institutions under transformation.
The intermediate structures, particularly the group homes11 and especially in the first stage, will be carrying the main group of resettlements. However, in designing the process and choosing the locations, attention must be given to the fact that the main challenge goes beyond intermediate structures and refers to the provision of personalised services and enabling people to live at home. This means that while developing intermediate structures, an organisational and personal vision must be maintained concerning each resettled resident of what the second step toward independent living will be. In addition, intermediate structures should be designed as transitional (in the case of group homes) or to be integrated into the community (day centres). This means that intermediary structures, as they are currently known, should be improved and upgraded.
The development of new services should respond to local and personal needs. Such a response needs to be formulated through personal and community service plans. The personal and community service plans, undertaken at the community level, should entail an assessment of needs undertaken with participation of stakeholders. Each new development should therefore involve a local (rapid) needs and response assessment.
An extremely important part of the future service landscape are also the new approaches and methods of working. In parallel with the development of new services, development actors (transforming institutions, CSOs and other service providers) themselves, should engage in their growth. Development projects or initiatives should therefore entail also introduction of new methods, training and their implementation and dissemination.
1.6.2 ECONOMIC DEVELOPMENT RATE
There are notable regional differences in the beneficiary country. Globally, the differences follow the geographic division of the country into a less developed, economically poorer mountainous part, stretching from the Southwest to the Northeast also comprising the Polog valley, and a more prosperous, developed or developing part, comprising the plateaux and basins in the Eastern region, as well as in the Southeast and the Pelagonija regions. The middle part of the country, the Povardarje or the Vardar region, is not only central, but also of average development. Also, the Skopje region on the North as an atypical (in size and structure) region (and metropolis), cannot be categorised univocally (or in simple terms).
The underdeveloped area (Southwest, Polog, Northeast) is mountainous, with significant Albanian population and bordering similarly underdeveloped non-EU countries, while the more prosperous area (East, Southeast and Pelagonija), in terms of economy and infrastructure, is situated on plateaux, nationally homogenous and at the border with EU countries.
It has to be noted that these inter-regional differences are not plain and consistent on all counts. In the regions that are less developed overall, there are some features that mark their performance as average or even above average (e.g. greater gender pay equality in Polog and Northeast, low infant mortality in the Southwest, low unemployment rate in Polog). Similarly, there are inconsistencies in the development rates in the more prosperous zone (e.g. Southeast as developing on the economic counts, but not so developed on more cultural counts (gender pay difference, level of education, infant mortality). It should be noted also that regional division is not completely
11 The definition of a ‘group home’ in terms of the deinstitutionalisation process, refers to an arrangement run by an organisation. The goal is to minimize collective arrangements run by organisations (or mark them as transitional) and stimulate independent living for e.g. former residents choosing to live together in their own will, sharing a flat or a house (living community)
22 | Potentials for development of community based services in the transition from institutional care Technical assistance support for the deinstitutionalisation process in social sector homogenous intra-regionally, with regions having notable differences between sub-regions and especially between urban and rural areas.
1.6.3 INSTITUTIONALISATION RATE
The rate of inhabitants per region institutionalised in various institutions varies greatly – from almost none (0,2 per 10.000 inhabitants) in Tetovo to 18,3 in Demir Hisar. The highest rate of institutionalised inhabitants is in the region of Pelagonija (11,3/ 10.000), with Eastern region also consistently above average, whereas the least rate of institutionalised inhabitants is in the Polog region with 0,7/ 10.000 inhabitants, and the Southwest with institutionalisation rate of 2,0 per 10.000 inhabitants. These pronounced differences are certainly, but in small part, due to the demographic distribution of the difficulties leading to institutionalisation (although there may be certain epidemiologic inter-regional variations), and are mostly consequences of the vicinity of the institution, cultural patterns and structural determinants of care.
The rate of institutionalisation reflects the activity of the workforce, as well as the upward mobility of the population. Gender inequality seems to contribute to low institutionalisation rates for children’s institutions and for old age homes, as does the level of economic development (GDP, employment) which contributes to a higher institutionalisation rate in special institutions.
There are considerable intraregional differences, in fact, the variance of institutionalisation rates for areas covered by a centre for social work are even more significant than on regional level. This points to micro determinants which have comparable, if not greater, impact than do more global ones, probably in terms of the culture and value system. Although overall the existence of community services does not have an impact on the institutionalisation rate, and in certain instances on the difference of institutionalisation rate of different groups of users, indicates that a local action or style of working of a particular centre for social worker could be the cause of such variations. For example, Kriva Palanka has no residents living in special institutions, but the level of institutionalisation is above the average for children and persons of old age; conversely Makedonski Brod has no children living in residential institutions, but it has extreme deviations for residents of special institutions and old age homes.
1.6.4 MISSING SERVICES
There are a sufficient number of centres of social work and day centres to warrant the provision of such services to be spread evenly across the country.12 They should, however, be improved in their function and style of working.
The existing community residential services – group homes and foster care – are concentrated in some areas and missing elsewhere. The medium term goal is that there should be at least one group home for adults and one for children located in each region after the second cycle of development of the process of deinstitutionalisation and upgrading of community based services (in 5-6 years). Similarly, there should be an organising agency of foster care in each region (including placement in families for adults).
12 Numerically there is a relative lack of day centres in the Polog region, and also – to a lesser degree, in the Northeast region. However, there should not be a mechanic translation of day centres into spots with a comparative lack of such facilities, but rather a careful assessment of needs, how should the ways of day care, but also of community and production inclusive activities be explored and put in place. Some centres, like the ones in the Polog and the Skopje regions may also need some input in terms of more professional staff and maybe some reorganisation.
Potentials for development of community based services in the transition from institutional care | 23 Technical assistance support for the deinstitutionalisation process in social sector
The greatest challenge in deinstitutionalisation is the transformation into personalised services – personal assistance, home care and personal care packages. These are presently only existing in the inception phase, these services are in need of groundwork to eventually become available and accessible across the country. Even though it could be presumed that massive resettlement in the first stage will be done through already tested and developed services (group homes and foster care), some of the resettlement from institutions could be done in a personalised manner, resulting in an independent mode of living. Existing group home and foster care capacities must be simultaneously relieved and transition to personalised, independent living arrangements secured.
Table 8: Minimal target of services for 2022 per regions13
Region East Northeast Pelagonija Polog Skopje Southeast Southwest Vardar R Macedonia Day centres 8+1 4 4+3 2 14 6+2 7 6 51+6 + clubs – existing Day centres upg14 2 Upg 4 upg Upg Upg upg upg+6? + clubs No. users 70+14 90 59+46 160 300 64+34 120 85 1038 (DC) Group homes 1 2 2 2 upg 1 2 upg upg+10 children upg 1 1 1 upg 1 1 upg upg+5 adults 1 1 1 1 upg Upg 1 upg upg+5 No. users 9 9 12 12 100 9 11 50 212 (GH) Foster care 1 Upg upg 1 upg 1 upg upg upg+3 organisers15 No. users 15 15 100 30 60 15 40 40 315 (FC) Centres for upg Upg upg upg upg Upg Upg upg upg social work NGO upg Upg +(7) upg upg Upg Upg upg upg Home care 1 1 1 1 1 1 1 1 8 No. users 70 70 90 130 250 70 90 60 830 (HC) Personal 1 1 1 1 1 1 1 1 8 assistance No. users 34 35 46 64 124 34 44 30 414 (PA) Personal 1 1 1 1 1 1 1 1 8 care packages No. users 34 35 46 64 124 34 44 30 414 (PCP) Population 176.262 176.169 230.004 320.826 624.585 173.545 219.740 152.571 2.073.702
Legend: – new services to be constructed1415
13 The figures in the table are of illustrative nature. They reflect mostly the population of the region, in some cases also existing development of the services. 14 Upgrading 15 Including care in another family for adults
24 | Potentials for development of community based services in the transition from institutional care Technical assistance support for the deinstitutionalisation process in social sector
1.6.5 TRANSFORMATION OF INSTITUTIONS AS A GENERATOR OF THE SERVICES
The missing services as outlined above will be generated in the process of transforming institutions and the institutions need to be part of this process. As most of the missing services lie outside the operating perimeter of institutions, there will be an imperative to involve other actors in the locality where services will be formed in joint effort by establishing adequate response. Thus, the institutions in transformation will not only relocate their residents, but also the knowledge and experience that they will gain in the process of transformation – i.e. the know-how (methods, organisation etc.) of how to accommodate, care and support them in the community setting.
1.6.6 GENERAL RECOMMENDATIONS FOR STRUCTURING DEVELOPMENT INITIATIVES
Any provision of resources to local service developments should consist of all the requirements posed by the deinstitutionalisation process as described in the National Strategy on Deinstitutionalisation 2018-2027. It is recommended that a number of projects or initiatives should be directly linked to the transformation of institutions, and a (smaller) number that would have a more general character.
The former should target an institution in transformation, support the transformation process in the institution and enable the resettlement, both to the immediate environment, as well as to less immediate (further out) locations, thus also providing development in the areas where there are no residential institutions.
To achieve this, proposals of projects submitted for funding by potential service providers who would enter into a development coalition with the state and municipal stakeholders (hereinafter termed ‘development coalition’) should consist of:
a) an institution in transformation, b) local authorities in nearby municipalities, c) local centre or centres for social work, d) a local authority from a distant municipality, e) a centre for social work responsible for the same municipality, f) a non-profit (generally NGO) social service provider.
Such development coalition basically consists of a transforming institution (or Body), a centre for social work and local authorities, which, in case the structure of any development project or initiative financially supported by Government is designed only locally, would be a four party coalition.
It is recommended that the activities that a project should comprise would be following:
1) needs and resources assessment in the immediate environment16 and an action plan of the response, 2) reformulated transformation plan according to the findings and the local plan,17 3) establishing services according to the plan (2-3 group homes, personal support services, alternative residential services, housing etc.). Entailing: a. recruiting new staff according to new job descriptions b. reorienting existing staff c. training and retraining of both existing and new staff d. acquiring premises for new services
16 E.g. in the radius of 50 km from the institution. 17 The transformation plans for individual institutions are currently under construction. The assessment results may change some of the planned activities.
Potentials for development of community based services in the transition from institutional care | 25 Technical assistance support for the deinstitutionalisation process in social sector
e. acquiring means to make the new, community based service provision possible (vehicles, IT, …) 4) needs and resources assessment on the second, further out location and an action plan for response, 5) establishing new services (typically a group home) on a further out location with input of local actors; entailing: a. clear vision and statement of the transitional nature of the establishment b. recruiting needed new staff according to new job descriptions c. providing training and mobile support from institution to the new structure d. acquiring premises for new services e. acquiring means of service provision (vehicles, IT, …) 6) Developing a designated method on both locations.18
1.6.7 RECOMMENDATIONS REGARDING THE SPECIFIC PROJECTS AND GEOGRAPHIC LOCATIONS
In the table below, the selected locations are paired with institutions under transformation and the types of services to be provided with the development initiatives.
Table 9: Recommendations for locations corresponding to institutional transformation19
Institution in Core Location Development of Day Home Personal Personal transformation (residential) other residential activities care assist care service services packs Demir Kapija Group home- Kumanovo xx x x xx children Group homes- Kumanovo Lipkovo adults Tetovo Prilep Banja Bansko Group home - M. Brod x x Xx x adults Topansko Pole Group home Vinica x Polog 2 – x X x -adults Bogovinje + 1 MIH Bitola Group home Pelagonija xx x (children in group homes) 11. Oktomvri Group home Radoviš xx x (children) Ranka Group home Tetovo xx x Milanović and (children in Southwest20 25. Maj group homes) OAH Bitola M. Brod x OAH Prilep x X Veles x
20
18 All transforming institutions are supposed to develop some new method of working (see the table above). These methods should be intensively practiced on both locations, so that the ‘twin’ location ‘seeds’ the method further on. 19 This table presents the twining of the RIs with the specified locations for development of the new services. This is a recommendation only. In order to achieve an even development some coordination will be necessary. 20 Municipality to be determined. Makedonski Brod was the only municipality from the region that participated in the informative workshop. But it does not meet the criteria since foster care is already (over) developed in the area.
26 | Potentials for development of community based services in the transition from institutional care Technical assistance support for the deinstitutionalisation process in social sector
To secure at least elementarily even distribution of residential facilities throughout the country there is a need for four children group homes and five group homes for adult residents. The Demir Kapija institution, as by far the largest one, would be expected to create four group homes in further out locations in addition to the ones in its immediate surroundings. One of them would be a group home for children, other three for adults. Proposed locations could be in Kumanovo (for adults and children), Vinica and Prilep. Topansko Pole would establish a group home in Tetovo, and Banja Bansko in Makedonski Brod. Other children group homes would be established in the Pelagonija region by MIH Bitola – probably a heterogeneous age group including infants (or a crisis centre for small children) and two other children group homes to be established by the three institutions now situated in Skopje (11. Oktomvri, Ranka Milanović and 25. Maj). These would be situated in Radoviš and Tetovo, as well as in one of the western municipalities of the Southwest region.21
All transforming institutions should start developing other forms of service provision (accommodation with care elements, i.e. other community services – but not residential institutions by any means, and not only group homes). For children, these could be done through enhancing and dispersing foster care, and for juveniles/young persons and adults, by developing various forms of support.
In the first three years of the transformation process, day activities, but not necessarily classic day-centres22, should be supplanted, if and where they are missing. There is a need for more coverage in the Northeast region, and more so in the Polog region’s mountain municipalities. Bogovinje is one of them which has expressed interest in development. The target in Northeast could be Lipkovo, where such a centre had secured the premises but did not take off. The initial local needs assessment could resolve the question of why this opportunity was not used, and design an alternative response to the need of activities and occupation.
Personalised services should be developed by most of the community care service providers who will be tasked to implement community care services aimed for adults, and coordinated care (personal care packages) also for children. Personal assistance should be developed also by special institutions, including some degree of personal assistance for children as well. Since the Deinstitutionalisation Strategy foresees some division of responsibilities for development, top down coordination and bottom up initiatives are expected – for e.g. designated special and intensive attention for the coordinated care may be with Demir Kapija, whereas personal assistance with Banja Bansko, and home help with Topansko Pole.
The old age homes as residential institutions will not be intensively subject to deinstitutionalisation during the first years of strategy implementation. However, there is a clear need for development of home help services for elderly persons. Such home help services could, as a possibility, be performed by the state old age homes of Bitola and Prilep, however also spilled over to locations in Veles and Makedonski Brod.
21 This municipality is not yet selected. However, the western part of this region was chosen because the eastern part (Makedonski Brod, Kičevo, Plasnica etc.) is atypical and has already ample residential care in the form of foster care. 22 Community centres, clubs and similar, or even production units (for e.g. small manufacturing, creative workshops), should be tried out in order to enrich the notion of day care and would probably be more suitable for the chosen locations. Yet this needs to be determined after a local needs assessment.
Potentials for development of community based services in the transition from institutional care | 27 Technical assistance support for the deinstitutionalisation process in social sector
IDENTIFICATION OF POTENTIAL FUTURE COMMUNITY BASED CSO SOCIAL SERVICE PROVIDERS AND ASSESSMENT OF THEIR CAPACITY AND TRAINING NEEDS
This report is focused on identification of active CSOs in the social sector to act as future community based social service providers, and on assessment of their capacity and training needs. The majority of information presented here was gathered during the work on the Situation Analysis and at meetings, workshops, focus groups, and direct communication of the project team with the CSO community.
The main finding demonstrates a number of CSO social service providers in the country that have significant experience in the deinstitutionalisation process and community based services, and that are willing and dedicated to further develop support services. Many of them are following the international and European trends in community based social service provision, bringing diverse approaches and quality to the process. Also, there is a considerable knowledge among the CSO community on the needed shift of the paradigm towards more personalised services, in light of the UN Convention on the Rights of Persons with Disabilities. However, their full potential is not sufficiently used because of the non-enabling environment and lack of support by the state, as elaborated below. Additionally, a shift towards more comprehensive knowledge and practice of the social model and human rights approach is needed, including in first place of the personalised services.
2.1 LEGAL FRAMEWORK AND BACKGROUND
With the introduction of the pluralisation principle and the decentralisation process in the social protection system, an important possibility was given to the CSO sector to become partner in providing social services for marginalised groups. The Social Protection Act provides legal framework for pluralism of the service provision and recognition of the associations of citizens that perform particular social protection activities in the field of:
28 | Potentials for development of community based services in the transition from institutional care Technical assistance support for the deinstitutionalisation process in social sector
− Social prevention – activities mainly focused on preventing social risks (as defined by the Social Protection Act); − Development and provision of social protection services for persons, families and groups of citizens at social risk; − Development and advancement of social protection; and − Development and advancement of voluntary work in the municipality.
The MoLSP maintains a register of citizens’ associations that perform social protection activities. Most of the CSO23 service providers have been registered under the expectation that the imminent further steps will lead to partnership with the state and financing of their services. However, other than undertaking the process of accreditation and approval through official registration process of CSO service providers as an act of recognition by the state, the CSOs have not been granted any meaningful support by the state. This regulative framework (and the registration process itself) is solely administrative and technical, but with no actual monitoring and support of the work undertaken by the State authorities of the CSOs. More importantly, the funding mechanism of services provided by the CSOs is not formulated and established properly, therefore lacks sustainability for the CSO services. The shift towards diverse service provision by the CSOs and towards local community service provision is hindered by the limited financing and missing measures of encouragement by the State. Currently, financing is project based and does not allow the minimal certainty in the future for service providers.
The process of decentralisation and the responsibilities in the social protection area (required by the 2002 Local Self-Government Act) provided possibilities for the municipalities to perform social protection activities and to act as services providers. The very important mechanism of delegating the social service delivery to private and CSO service providers, as an activity of public interest of local importance, is rarely used. There are some positive examples of cooperation of the municipalities with the CSOs, which could be multiplied around the country. Most of the day centres and social clubs for adults with intellectual disabilities were established in cooperation between CSOs and municipalities (RCPLIP – PORAKA with support of City of Skopje, Radoviš, Prilep, Bitola, Kumanovo, Struga etc., where municipalities usually provided facilities and some funding). Another example is the home help services for old people organised by Humanost in Skopje and the Red Cross in partnership with few municipalities in Skopje and elsewhere.
However, pluralism and the decentralisation remain underdeveloped since legal opportunities are not adequately implemented, leaving the service provision process to be mostly owned by the public authorities. Private service providers, both for profit and CSOs, are not sufficiently supported by the state and, currently, the only way for them to provide services is to seek project funding or donations from external donors.
2.2 OVERVIEW OF THE CSO SERVICE PROVIDERS
The CSO sector, mostly the parents’ associations of children or adults with intellectual disabilities, have been actively involved in the ongoing process of deinstitutionalisation. Activities have been mainly focused on prevention of institutionalisation and the creation of community-based support services. Faced with lack of support services at local level, these associations have begun with their own service provision since 2000, mainly supported by international donors. In this period, the Republic Centre for Support of Persons with Intellectual Disability (RCPLIP – PORAKA) with its local branches developed a network of day centres and social clubs for
23 There are 89 NGOs registered in the MoLSP Register. As a result of the lack of funding, some of them have closed their services, some of them do not exist anymore.
Potentials for development of community based services in the transition from institutional care | 29 Technical assistance support for the deinstitutionalisation process in social sector adolescents and adults with intellectual disabilities. Later, some associations of professionals, such as Solem and Open the Windows (‘Otvorete gi prozorcite’) started to provide services to people with disabilities. In the second wave of deinstitutionalisation, Poraka Negotino became the main provider contracted by the MoLSP to run the housing communities for people with intellectual disabilities who have been resettled from the institution in Demir Kapija. Recently few CSOs initiated provision of home help services for old people (Humanost, Hera and the Red Cross). For children the main CSO provider is the SOS Children’s Village.
30 | Potentials for development of community based services in the transition from institutional care Technical assistance support for the deinstitutionalisation process in social sector 6 Nap Nap Nap residents/ staff ratio staff residents/ Nap Nap Nap Nap Nap NAp NA 4,2 4 10 6 4,25 14 4,25 4,9 NA NA Nap 5 NAp NAp NAp n. staff NAp NAp NAp NAp NAp NAp NA 5 9 3,5 2,5 4 1 4 8 NA NA NAp 4 Nap Nap n. users Nap Nap Nap Nap Nap Nap Nap NA 21 39 35 15 17 14 17 39 NA NA Nap Prilep Strumica municipality Centar Šuto Orizari Šuto Centar and Centar Demir Kapija Orizari Šuto Kisela Voda Čair Vevčani Kumanovo Petrov Gjorče Aerodrom Centar Gevgelija Radoviš Struga Negotino Bitola Aerodrom Centar 3 AD AD age group AD/CH AD/CH AD/CH CH/AD AD/CH AD/CH CH OA AD AD AD AD AD AD AD AD CH CH AD/CH Persons with Persons disabilities intellectual d.) (intellectual with addiction Persons target group target groups vulnerable parents and children parents and children parents with Persons disabilities victims of family Roma children violence, victims of trafficking, violence family children vulnerable old people d. intellectual d. intellectual d. intellectual d. intellectual d. intellectual d. intellectual d. intellectual d. intellectual autism d. + autism intellectual victims of family victims of family violence 7 8 2 9 CO CO, CE CO type CO, CE CO CO CO, CE CO, CE, TC CO DC DC DC DC DC DC DC DC DC DC DC CO, CE, TC 1 13 10
12 11 Izbor Hera Institution or organisation Institution Svetlina Association of special Association educators Hera of of social workers Association Skopje Nadež na ženi grad Organizacija Skopje detstvo Za srekno of old people Day centre Naša Poraka Negotino Volkovo Poraka RCPLIP - PORAKA RCPLIP - PORAKA Majka Tereza RCPLIP - PORAKA Nova Poraka Negotino Poraka Explorer Polo Marko Lastovica Otvorena Porta Otvorena
Potentials for development of community based services in the transition from institutional care | 31 Technical assistance support for the deinstitutionalisation process in social sector 6 NA NA NA residents/ staff ratio staff residents/ 5,2 NAp NAp NAp NAp Nap Nap Nap Nap Nap NAp NAp NAp NAp NAp NAp NAp 6* 4 4,5 5 NA NA NA n. staff 12 NAp NAp NAp NAp 28 NAp NAp NAp NAp NAp 17 1 1 1 1 1 1 2* 9 8 4 15 NA NA NA n. users Nap NAp NAp NAp 191 NAp NAp NAp NAp NAp 90 14 16 8 22 15 19 12* 36 36 62 Šuto Orizari Šuto Čair Aerodrom municipality Čair Centar Gazibaba Saraj G. Skopje Veles Palanka Kriva Kicevo Debar Struga Aerodrom Štip Bitola Demir Hisar Prilep Gevgelija Strumica Ohrid Petrov Gjorče Negotino Radišani i Bardovci 3 CH CH CH age group OA OA OA OA NGO/LA NGO/LA NGO/LA NGO/LA NGO/LA NGO/LA OA AD AD AD AD AD AD AD AD AD CH street children street autism and d. autism target group target old people old people old people old people NGO/LA NGO/LA NGO/LA NGO/LA NGO/LA NGO/LA at home old people d. intellectual d. intellectual d. intellectual d. intellectual d. intellectual d. intellectual intellectual d. intellectual d. intellectual d. intellectual care without parental 2 DC DC DC type DC DC DC DC HH HH HH HH HH HH HH SC SC SC SC SC SC DC GH GH GH 1 14 Imago Plus mojot svet Vo Zraci Institution or organisation Institution na deteto Združenie za prava Red cross Red cross Red cross Red cross Red cross Red cross Red cross Red cross Red cross Red cross Humanost RCPLIP - PORAKA RCPLIP - PORAKA RCPLIP - PORAKA RCPLIP - PORAKA RCPLIP - PORAKA RCPLIP - PORAKA Poraka Negotino Poraka Negotino Poraka Makedonija Selo SOS Detsko
32 | Potentials for development of community based services in the transition from institutional care Technical assistance support for the deinstitutionalisation process in social sector 6 NAp NAp NAp NAp NAp NAp NAp NAp residents/ staff ratio staff residents/ 5 NAp NAp NAp NAp NAp NAp NAp NAp n. staff 4 NAp NAp NAp NAp NAp NAp NAp NAp n. users Kriva Palanka Kriva Veles Negotino Prilep Aerodrom Centar Centar Orizari Šuto municipality 3 OA OA OA OA CH AD/CH AD/ AD/CH age group old people old people old people old people children vulnerable HIV/AIDS, drug users, STD victims of Women, violence family violence family target group target 2 SC SC SC TC TC TC TC SC type 1 Red cross Red cross Red cross ,,Meǵaši,, of of social workers Association Skopje ,,SOŽM,, ,,Nadež Institution or organisation Institution Red cross
Potentials for development of community based services in the transition from institutional care | 33 Technical assistance support for the deinstitutionalisation process in social sector
The overview presented in the table above indicates that there are around 30 active CSOs, providing different types of services for different groups of people in need of support. Most of them provide services for people with intellectual disabilities (more than 20 day centres, including the social clubs). However, there is a lack of service provision by the CSOs both for children with disabilities, as well as for children without disabilities. The regional distribution is not even, as many of the services are concentrated in Skopje.
As presented in the Situation Analysis, there are three main service providers among the CSO community: SOS Children’s village, RCPLIP – PORAKA and Poraka Negotino, but also there are some other local CSOs that have been engaged in providing services. These CSOs are mainly delivering day care services. Looking deeper into this service provision, more can be found about the general position of the CSO services providers. There are 21 day centres run by CSOs (two jointly with local authorities). Most of them are intended for people with intellectual disabilities (16), some for people with autism (two and two mixed for people with autism and intellectual disabilities), one for old age people, and one for street children. For children there are five CSO day centres (all those intended for people with autism are facilities for children), and for adults the majority fourteen (14), or two thirds. These CSO-run day centres are not much different from what should be the main distinction to the public ones, regarding the age of their visitors. The more significant differences are that public day centres are better staffed, with secure (public) employment, whereas the staff in CSO sector maybe, to a certain degree and in spite of greater insecurity, more motivated and more adventurous and creative (what is important in more productive occupational activities). On a whole, the CSO day centres are more community oriented, with more activities outside, and more connected to the immediate community. Partly maybe because CSO day centres are situated in different kinds of buildings, while the public day centres prevail in official buildings; CSOs use more buildings of ‘civil’ kind, be it apartments or houses, or business premises. More so, the difference lies in the orientation of staff (there are significantly more social workers in, e.g. RCLIP - Poraka than in public day centres) and the ethos proper to CSOs, which means more pro-social and pro-right action.
2.3 CAPACITY OF THE CSO SERVICE PROVIDERS
Most of CSO providers provide collective advocacy (campaigns), counselling and project based services. Perhaps there is a lack of popular movement dimension, confusion on advocacy and provider role, and no mental health CSO. RCPLIP - PORAKA, Poraka Negotino, and SOS provide substantial amount of residential and day centre services. They, however, do not provide personal services. A number of CSOs based in Skopje who are vocal on disability, discrimination, and also care issues, are transiently engaged in piloting and establishing new responses. Project based financing, however, creates discontinuity and managerial approach to fundraising, so for this reason earmarked state funding should be required for CSOs.
It is hard to generalise about the capacity of CSO service providers in the country, as their development is connected with the overall legal and financial framework in favour of sustainability. As to the quality of work, CSO service providers are more flexible and quality oriented. The approaches are mainly contemporary; many are human rights based. As there are no regulatory mechanisms, including a lack of compulsory quality standards, some of the CSO are self-initiatively following the European quality frameworks.
In terms of capacity to implement innovative ideas, it can be argued that most of the CSOs are creative and innovative, but do not have the needed infrastructure, human resources and financial stability to pilot and later sustain their practices. The main providers (RCPLIP – PORAKA, Poraka Negotino and SOS) have built stable backgrounds in some parts of the service provision (day centres for adults, group homes for resettled users, alternative child care), but still their capacities are limited because of sustainability issues of their existing services.
34 | Potentials for development of community based services in the transition from institutional care Technical assistance support for the deinstitutionalisation process in social sector
The human resources are better positioned inside social CSOs, as the CSOs usually attract well educated and ambitious people willing to contribute and make the change. However, the insecurity of the employment for the staff is a major issue.
RCPLIP – PORAKA is one of the oldest associations in the country with well distributed network of local branches around the country. Also, it is one of the first service providers, which started with provision of day centres for adults with intellectual disability in Skopje in 2000. RCPLIP - PORAKA unites 3 day centres, 6 social clubs, and counselling services for parents in all municipalities with active local branches. RCPLIP - PORAKA is well connected and represented at European level through EASPD.
Poraka Negotino is the main provider of “organised living with support” services (group homes) created within the previous deinstitutionalisation effort 2000-2006. Poraka Negotino has been contracted by the MoLSP to organise and deliver these services to more than 80 service users that have been resettled from the Special Institute Demir Kapija in two locations – Volkovo near Skopje and Negotino. Poraka Negotino has gathered considerable experience in providing housing services for ex-residents of institutions.
National Association of persons with physical disability – Mobilnost is an umbrella association of local organisations of people with physical disability. In addition to advocacy as its core business, Mobilnost provides transport services, leisure and sport activities, counselling, and has been involved in the piloting of personal assistance within the EU funded project “Promoting Social Inclusion Services”.
Open the Windows, a CSO from Skopje has one of the most innovative practices in the region with their training centre on the use of accessible ICT and assistive technologies for people with disabilities. Open the Windows works to initiate and facilitate active inclusion of all people in the contemporary world through assistive technology.
Solem is a local CSO based in Skopje, currently working on development of social entrepreneurship activities for people with disabilities. Solem runs an occupational centre and has implemented several advocacy projects, such is the one on self-advocacy.
The Association of Special Educators in the last year has been involved in the preparation activities for resettlement of children from the Special Institute Demir Kapija, within a UNICEF funded project. The staff from the Association have been trained in intensive interaction methodology.
HERA - Health Education and Research Association, a CSOs based in Skopje, has established a social enterprise that provides home help services for old people. In addition, HERA provides health services to different marginalised groups, including counselling on sexual and reproductive rights of people with disabilities in partnership with RCPLIP – PORAKA.
Kreativa Istok and Lastovica are two CSOs from Skopje that have early childhood intervention centres, both established by a group of young professionals (special educators and speech therapists) that offer methodologies such as sensory integration, ABA method24 etc.
The Red Cross runs a network of service for old people, including day centres in Skopje, social clubs in four municipalities and home help services in five municipalities around the country.
Humanost, a Skopje based CSO, provides home help services for old people in one municipality in Skopje.
SOS Children’s village is the main private provider of alternative childcare in the country. It is a private institution registered to perform activities in the area of social prevention and protection with and without accommodation, including foster care within the institution. SOS also provide counselling centres for parents and children in Gazi
24 Applied Behaviour Analysis (mainly used for autism)
Potentials for development of community based services in the transition from institutional care | 35 Technical assistance support for the deinstitutionalisation process in social sector
Baba and in Šuto Orizari, a centre for support of foster families and development of children and four youth home units for organised living with support. SOS has significant knowledge and expertise in care provision for children, social service delivery mechanisms, social contracting and quality frameworks.
There are also smaller local CSO active in the social sector that have potential to enter the service provision process, if adequately supported and encouraged.
2.4 TRAINING NEEDS
The CSO service providers staff is probably, on average, more trained with more skills and knowledge needed for community provision than their counterparts in the public sector. Partly because their education profile, i.e. qualifications attained by staff, is higher than those working in the public sector and partly because they were more exposed to the training. However, there is still a need for training of the CSOs (some less, some more) on the basic principles, values, stages and implementation aspects of deinstitutionalisation, as well as in the new trends in service provision, based on the social model and human rights approach. New person-centred approaches and methodologies should be introduced in the services provided by the CSOs. The capacities of the CSO service providers could be strengthened by delivering the following [state accredited] training modules:
- Comprehensive module on deinstitutionalisation, human rights based approach and UNCRPD - Direct training on how to provide personalised services (home help, mobile support, community centres, housing cooperatives, models of shared ownership and participation in building, personal assistance etc.) - Training on methodologies of person centred care and methods (empowerment, strength perspective, the ethics, teamwork, personal planning, risk analysis, empowerment, shared and supported decision-making, recovery, crisis intervention, community support, mutual help groups, neighbourhood work, develop model of person centred care, risk taking, intensive interaction, care in physical disabilities, self and peer advocacy, community care for dementia, advocacy, legal capacity, family empowerment, alternative community measures of children in conflict with law, family conferences etc.) - Training on quality assurance of services, with focus on the service delivery process and user involvement in all stages of the process is needed.
Also, more general topics should be covered such as social economy, management of services and project cycle management, including financial management diverse types of service, entrepreneurship and innovation, community work and community action.
2.5 CONCLUSIONS
The deinstitutionalisation process must be guided by the Deinstitutionalisation Strategy and the Action Plan (2018- 2027). CSOs and CSO service providers have an important role to play in the deinstitutionalisation process. As advocacy organisations, CSOs have to contribute to the process and share the message that deinstitutionalisation needs to be effectively and efficiently performed as transition for institutionalised into community based care. On the side of the service provision, CSOs should be involved in all developments and be initiators of innovative projects, models and services for community living supported by the State and municipalities.
36 | Potentials for development of community based services in the transition from institutional care Technical assistance support for the deinstitutionalisation process in social sector
In the past, CSOs have failed to participate in the deinstitutionalisation process in a proper and sufficient manner, although the main CSO service providers provide substantial amount of day centres and group homes. The development of their network and diversity of services was limited, and their potential was not used adequately in terms of better coverage and more even distribution of their services. The reasons for this could be found in the lack of ‘enabling’ or otherwise favourable conditions. The dependence on international project funding and lack of support by the state has led to unsustainable future of the CSOs services. Their flexibility to provide community based services was also hampered by the lack of cooperation with the municipalities.
CSOs services are generally addressing the needs of the users well. The human rights based approach is accepted and promoted in the CSO service provision. The users’ involvement has been strongly developing in recent years. Also, the quality (if appropriately measured) of the CSO services will most probably be much higher compared to those provided by the public services. The proposed training modules (of accredited training programmes) could significantly strengthen the capacities of the CSOs and contribute for more quality oriented work with the users, on the basis of the persons-centred approach. Additionally, sharing of knowledge and expertise between the CSO and other stakeholders is a good possibility for capacity development.
Smaller CSO should be encouraged and their piloting efforts supported. The national umbrella associations (such as RCPLIP - PORAKA and Mobilnost Makedonija) should furthermore focus on capacity development of their local branches in order to be effectively involved in deinstitutionalisation activities.
2.6 RECOMMENDATIONS
For pluralisation, a real partnership is needed between the state and the CSO service providers. If they provide a public service, they need to have equal conditions. One of the basic recommendations is that changes are needed to the legal framework which will allow greater participation of the CSOs in the overall service provision process.
The new Social Protection Act should establish the new model of partnership with CSOs and introduce the regulatory mechanisms such as accreditation and licencing procedures, quality standards, state funding procedures, monitoring and evaluation of the social and community based services.
The legal framework for funding of the existing CSOs services should be allocated on an equal basis with the services delivered by the state. Also, the new innovative projects and pilot services of the CSO should be supported and encouraged. Services provided must be financed instead of providers en bloc. Project funding must be applied for innovative and development projects and not for continuous services of the CSOs. Assessed needs should be funded by means of concessions and/or direct funding of service users may be developed to suit this purpose.
Quality standards must focus on the service delivery process, including user involvement, methods, staff training, monitoring and evaluation, ethics, complaints procedures, etc. These requirements should be adequately addressed (added) in the new Social Protection Act and new rulebooks. A set of quality standards for each service should be developed. A step forward is needed to advance ‘personal’ planning and care management.
Another recommendation is that the CSO providers should widen their provision of services, in particular of personal services. Also, their membership (users and relatives as main stakeholders) should have a more important role in order to counter the approach of managerialism25. Incentives for users’ organisations and support to movements is needed and delineation between advocacy and service providers is also required.
25 Managerialism implies application of business management techniques to the running of organisations other than commercial businesses.
Potentials for development of community based services in the transition from institutional care | 37 Technical assistance support for the deinstitutionalisation process in social sector
In terms of participation of the CSO service providers in the future developments in the deinstitutionalisation process, it is advisable that all existing service providers should be included, regardless of the size, scope of work or services they provide. The main providers have more capacities and are more ready to take part in the deinstitutionalisation process; however, since smaller local CSOs are well connected with local communities, it would be very important to encourage and support the local CSOs to develop services.
The future role of the CSOs should be meaningful in terms of their contribution as service providers, but also in other development activities. CSOs should be included as partners and the state should use their potential, expertise, capacities and resources in a proper manner towards the development of services. CSOs should remain innovative and promote creative responses to the needs of users.
In the transformation of institutions, CSOs participation should be ensured in every partnership tasked to implement the deinstitutionalisation process. In communities near institutions, where leaders of the process would be the institutions themselves, the CSOs could be used to facilitate the connections with the communities, as well as to contribute with their human resources and work force in the new services. In further out communities, the CSOs should have a leading role in the development coalitions implementing the stages of the deinstitutionalisation process and should be responsible for the service provision.
38 | Potentials for development of community based services in the transition from institutional care Technical assistance support for the deinstitutionalisation process in social sector
ESSENTIAL SUPPLIES AND WORKS FOR ADAPTATION AND MODERNISATION/REFURBISHMENT OF POTENTIAL LOCATIONS FOR NEW COMMUNITY BASED LIVING/HOUSING SERVICES, PLUS THE ESTIMATED COSTS WITH PARTICULAR ATTENTION TO THE ACCESS NEEDS FOR PERSONS WITH DISABILITIES
3.1 OVERVIEW
As stated in the draft National Deinstitutionalisation Strategy 2018-2027, the practical and demonstrable vision of the future system is that there will be no more residential care institutions, that such institutions will undergo a transformation process with regard to their role in the sector, and ultimately that community support services and the community will supplant these institution-based living services. The preferred solution will be that people with support needs will live in their own homes – with community based service provision enabling them to stay at home or by creating new homes i.e. alternative community based supported accommodations, such as for residents resettling from institutions, people moving on from their parents, etc. There will be some small residential facilities (not more than six residents living in a housing unit) for short, medium and (a few) for long periods of accommodation.
For some residents and service users, an unresolved housing problem is a major issue contributing to their difficulties, increasing their dependence on others or even being the reason for the admission to an institution. The service providers of community services and also of institutional care have limited resources to provide decent housing and so, are left to their own devices. General public housing agencies provide housing to people in need. However, there are little or no priorities given to the ex-residents and other recipients of support and care services.
Housing was an obstacle to more efficient and effective resettlement in the past. Social housing should be provided in accordance with users’ needs. A pool of housing units should be available by and from the State but, in addition to the premises, it is important to observe other needs related to housing such as secure tenure, support in house maintenance and housework services, adapting the house for personal requirements, choice of co-residents or living alone, privacy and intimacy concerns, social life (visits), permanent address, need for temporary accommodation (transition, rehabilitation, respite, crisis), new forms of cohabitation (shared household, housing communities and cooperatives).
Potentials for development of community based services in the transition from institutional care | 39 Technical assistance support for the deinstitutionalisation process in social sector
Housing is one of the prerequisites for transition and needs special attention and concerted effort from housing and social services. To implement successfully the resettlements, a large number of housing units will be needed. A thorough assessment of housing needs of institutional residents and other (prospective) users of community services must be performed, and a special housing action plan constructed including a business model on how adequate, sustainable and affordable housing should be made accessible.
Moreover, the strategic orientation is that people with disabilities need ordinary housing (i.e. housing in the community). Creating congregated housing or ghettos must be avoided, including other circumstances that would segregate service users from the rest of the population. However, there are frequently physical and social adaptations of given premises that are required.
3.2 OPTIONS FOR RESOLVING HOUSING NEEDS
While the Strategy and the Action Plan foresee thorough analysis of the housing needs and resources, construction of a new model of housing for people with disabilities and other people in social difficulties requires short term solutions in the (re)inception of resettlements.
There are several options for resolving the housing needs of users during the initial, but intensive resettlement phase. One is the possibility for users to return to their home, if they own one. Another option is construction of new houses, if there is a possibility for it. Then, to buy existing houses or apartments and to renovate it according to needs. The rent of the houses or the apartments is probably the most viable answer at this stage, together with the mobilisation of the existing social housing apartments. There are also possibilities for donations, which have been known to occur in the past, either by individual donors (users’ relatives) or municipalities. There is also an option for partial donation, usually land, which typically, a municipality would donate for this purpose.
40 | Potentials for development of community based services in the transition from institutional care Technical assistance support for the deinstitutionalisation process in social sector
Whatever the agreed option for a particular resettlement, it should follow the basic principles of ordinary community housing (to be placed in the community, well connected to mainstream services, transport etc.). Users should be involved in all stages of the resettlement, including the preparation of their future home. Attention should be given to age appropriateness in service provision in general, and especially to accessibility issues of persons with disabilities. Freedom of choice should be allowed with regards to the furniture, wall colour, decorations etc., that will make the living arrangement personalised and as close to family and home atmosphere.
Also, whatever the MoLSP decisions on the provision of housing units, it will require a certain amount of work and finances to adapt and equip the houses or the apartments in order to meet the needs of the users.
Building new houses or apartments is the most expensive option in terms of parallel costs for starting new services (“hump and bump” costs, i.e. bridging costs for establishing new housing service). The price for construction starts from under 400 € per square meter in smaller towns, up to 1500 € in Skopje prestigious areas. For buying existing houses and apartments there are greater options, with prices starting from just under 200 € to over 1000 € on average. However, if there is a possibility for building or buying new housing units, it should be accepted, as it could be a more efficient investment in the long-run.
Renting a house or an apartment in a relatively good shape (ready for resettlement with minor adaptation) of app. 120 m2, would cost 150 € in the countryside and in smaller towns, all the way up to 1000 € in Skopje (Centar and Aerodrom); with median values of approximately 400 € in medium size towns. If a house is fully equipped with furniture and home appliances, cost could double.
If there is a need to renovate an existing house or apartment, the costs will depend mainly on the condition of the particular housing unit. However, an estimation can be made that it could go from 1.000 € for basic renovation for smaller units up to 10.000 € for extensive renovation and adaptation of larger units.
If the accessibility issues are in question, then the estimated price for overall renovation will be increased by 20 – 25% (for ramps, toilet adaptation, wider doors etc.). Otherwise, at locations where adaptation would not be possible, the accessibility could be easily provided with a requirement for ground floor apartments for users with reduced mobility.
3.3 SOCIAL HOUSING APARTMENTS PROVIDED BY MOLSP
MoLSP has provided 12 social housing apartments for resettlement of users. The size of the apartments varies from 40 to 70 m2. The MOLSP’s team of architects have done provisional estimations of the needed work and calculation of the needed costs. From the report provided, it could be concluded that the majority of the apartments need construction works and adaptation related to the accessibility needs of the users. Many of the apartments are in a bad condition, requiring substantial renovation, and few can be prepared with minimum budget.
The project team visited one of the apartments located in Gevgelija, in a social building in a settlement near the city centre. The building is not intended for socially disadvantaged groups, but for young married couples (with unsolved housing issues). The size of the two-bedroom apartment is 63 m2; it is on the first floor and in a really good condition. With minimum investment, it could be ready for living in a number of months. The MoLSP estimated the costs for renovation of this particular housing unit to 1.100 €, including wall painting, partial tile replacement, and electric installation and toilet repairs.
For purchase of all necessary equipment, including kitchen furniture and appliances, furniture for the living room, dining room and two bedrooms, it is estimated that the total cost will be 6.100 €.
Potentials for development of community based services in the transition from institutional care | 41 Technical assistance support for the deinstitutionalisation process in social sector
3.4 OVERVIEW OF POSSIBLE COSTS IN SECURING ACCOMMODATION IN THE RESETTLEMENT PROCESS
There are few possibilities in acquiring property needed for accommodation in the process of resettlement. Property may be bought, rented or donated. Returning to one’s own home (or remaining there) can be included, in terms of cost, in the latter category. There is a great possibility of other cost occurring. Renovation or refurbishment may be needed, sometimes just superficial and not extoling, just to make it habitable for a new dweller. Sometimes, when the property is in a bad condition, the cost of renovation may double. For some users also adaptation would be necessary to accommodate their impairment. In most cases, there will be a need for new fixtures and fittings, and usually also furniture and other necessities (linen, cutlery etc.). In the figure below, the costs are presented schematically.
Figure 1: Structure of possible cost of accommodation
42 | Potentials for development of community based services in the transition from institutional care Technical assistance support for the deinstitutionalisation process in social sector
Costs and a list of advantages and disadvantages are summarised in the table below.
Table 10: Typical cost and qualitative gains of different property acquisition
acquiring of price €/ m2 price €/ Advantages Disadvantages premises 120 m2 Purchase 160—1000 19.200— stability, property can additional cost may be 120.000 generate new property substantial Rent 1,29--8,68 1857,6— renovation usually no accumulation €/ m2 12.499,2 cheaper, costs incl. adaptation can be responsibility of landlord donation 0 0 obvious + the symbolic in some cases house or flat value renovation may be very expensive or administration complicated donation land 380--470 €/ 45.600— no cost for renovation time and effort + construction m2 56.400 and adaptation, only consuming furnishing and other equipment
Different acquisitions differ in their advantages. Buying premises is more expensive in the short-term period, but more rewarding in the long run. For speedy resettlement, rent or donation, including using existing property of national or local authorities is a better solution. However, purchasing property is a better option if there is an intention to create a stable and productive housing pool for socially vulnerable people. In purchasing the renovation, adaptation costs can be much higher than in other options. In renting property landlords may be inclined to bear the renovation, adaptation, and even fixtures and fittings costs, on the account of safe letting (by a public entity). Building new houses was quite popular in some countries in the process of deinstitutionalisation. For international donors it is a mark of contribution, and care organisation assume an active, visible role in the local economy. However, it is time consuming, delaying the resettlement, often on the account of bureaucratic hurdles and other administrative tasks needed for such a venture. The advantage is also that premises can be designed for the needs of the people who will live in them. This advantage is not so pronounced in case of transitional accommodation, in which occupants may change their characteristic over time. Returning to one’s own home and property may be similar with donations in terms of cost. Often, however, owned premises can be in a very bad condition since they may have been abandoned for some period, or sometimes the condition of the property may have contributed as a reason for admission to an institution. However, coming home is a value, and flat-mates can be hosted too.
In the next table the prices of rent and purchase per square meter in € and per 120 m2 in selected municipalities are presented. On the top there is a list of municipalities earmarked for the foci of development, followed by some Skopje municipalities, and some other towns that may be of interest. The prices vary to great extent, not only according to the peripherity or centrality, but also in comparable locations, and there are some obvious
Potentials for development of community based services in the transition from institutional care | 43 Technical assistance support for the deinstitutionalisation process in social sector irregularities (e.g. high price in Radoviš). This data cannot be considered of great validity. Nevertheless, they do provide an insight of what could the prices and property costs be in development projects.
Table 11: Property prices in selected municipalities (cadastre data)
Municipality purchase €/ m2 rent €/ m2 purchase 120 m2 rent 120 m2
Vinica 197 1,31 23.640 157,2
Kriva Palanka 412 2,75 49.440 330
Kumanovo 398 1,5 47.760 180
Prilep 401 5,07 48.120 608,4
Bogovinje 163 1,29 19.560 154,8
Radoviš 334 4,57 40.080 548,4
Strumica 522 1,66 62.640 199,2
Makedonski Brod 280 1,86 33.600 223,2
Veles 282 3,5 33.840 420
Demir Kapija 272 1,81 32.640 217,2
Kavadarci 386 2,80 46.320 336
Negotino 320 3 38.400 360
Bitola 614 4,10 73.680 492
Valandovo 172 1,14 20.640 136,8
Gevgelija 464 3,09 55.680 370,8
Skopje - Centar 957 8,16 114.840 979,2
Skopje – Aerodrom 956 8,68 114.720 1.041,6
Skopje - Chair 489 6,13 58.680 735,6
Skopje - Gazi Baba 555 2,65 66.600 318
Skopje - Karpoš 895 5,37 107.400 644,4
Skopje - Kisela Voda 736 2,37 88.320 284,4
Skopje - Butel 503 2,31 60.360 277,2
Ohrid 726 2,49 87.120 298,8
Gostivar 417 4,63 50.040 555,6
Debar 217 2,65 26.040 318
Kavadarci 386 2,8 46.320 336
Kičevo 367 2,89 44.040 346,8
Kočani 418 2,24 50.160 268,8
Struga 360 6,44 43.200 772,8
Tetovo 509 3,87 61.080 464,4
Štip 474 2,33 56.880 279,6
44 | Potentials for development of community based services in the transition from institutional care Technical assistance support for the deinstitutionalisation process in social sector
From a brief analysis at the possible cost, it can be concluded that costs of acquiring accommodation property will vary immensely. When resettling in the immediate environment, some institutions and their partners will be paying quite high costs (not only institutions in Skopje, but also in Strumica and Bitola), while Demir Kapija will face reasonable ‘deals’. Most of the targeted locations have reasonable prices of property, not exceeding far beyond 40.000 € for a house or a flat that could accommodate a group home.
In the development plans there should be a room for acquisition of property for independent living. This will be a more pressing need as the process advances. It has to be noted that independent living does not necessarily mean acquiring a bedsit or a one-bedroom flat. It can contain an extra room, to provide opportunities of sharing a flat with a helper or volunteer.
A strategic decision has to be made soon, probably after the completion of the foreseen housing needs assessment for a policy regarding handling properties. A business model must be constructed that would allow flexibility, create a housing pool of property and secure good governance and transparency, and at the same time allow users’ participation, shared ownership and inclusion in the community.
The design of other development initiatives has to encourage minimal spending on property, which can be motivated by letting the saved money be used for more services and community initiatives – this would motivate the local authorities to mobilise their real estate for housing resettled residents and other people in social difficulties.
The acquired property must be integrated in the community – a segregation of users, benefit claimants and other people at social risk must be avoided at all costs!
Potentials for development of community based services in the transition from institutional care | 45 Technical assistance support for the deinstitutionalisation process in social sector
RECOMMENDATIONS FOR DEVELOPMENT INITIATIVES
At the time of drafting this document, the technical assistance team of experts was aware of the plans for encouraging development initiatives for supporting and implementing the deinstitutionalisation process, including the support foreseen from the IPA II Programme.
Although at the drafting of this report the mechanism through which the deinstitutionalisation process is not fully developed awaiting the completion of the Action Plan and their adoption at the Government level, the team of experts recommends that the deinstitutionalisation development initiatives should be based on the above conclusions and recommendations. Available resources should be channelled towards designated providers and foreseen activities on the regional principle. The development funds could be indicatively used for the activities according to the breakdown below.
46 | Potentials for development of community based services in the transition from institutional care Technical assistance support for the deinstitutionalisation process in social sector
Figure 2: Breakdown of development initiatives funding use for specific activities
Main actions sustained by the development initiatives are targeting the residents of children homes and special institutions and users of social services in similar life contingencies (i.e. living in the community with similar needs for support). Most of the funding should be dedicated to direct service provision. Its efficiency, effectiveness and
Potentials for development of community based services in the transition from institutional care | 47 Technical assistance support for the deinstitutionalisation process in social sector relevance is, however, depending on a comprehensive needs assessment, good project management (including coordination of the participants) and good training.
In order to achieve balanced dispersion of new services, it is necessary to channel funds regionally. A tentative breakdown of the funding that would observe the regional distribution is suggested below.
Table 12: Indicative allocation of funds by geographical distribution
Statistical region Indicative allocation of funds East 150.000 Northeast 260.000 Pelagonija 165.000 Polog 250.000 Skopje 180.000 Southeast 185.000 Southwest 170.000 Vardar 340.000 Total 1.700.000
This reflects the size of the population in the regions and the need for new services. The exception is the Skopje region which already has a number of community services and also, given that access to funding tends to be more accessible to Skopje region as a metropolitan area, there is a lesser need for targeted funding for community based services than in other regions of the country. The second exception is the Vardar region which has benefited from a higher level of funding than other regions as the consequence of the transformation of the Demir Kapija institution.
To achieve the appropriate distribution of funding, strong support is required for informing and steering the potential applicants (municipalities, service providers) regarding opportunities for funding development initiatives by means of preparatory workshops and available consolations regarding both the form, as well as the content of the proposals and actions.
48 | Potentials for development of community based services in the transition from institutional care Technical assistance support for the deinstitutionalisation process in social sector
APPENDICES
Potentials for development of community based services in the transition from institutional care | 49 Technical assistance support for the deinstitutionalisation process in social sector 3,2 0,7 5,8 5,4 4,3 6,8 2,0 3,5 4,55 11,3 IR all 1,0 6,3 6,3 15,3 10,5 35,1 15,3 50,5 17,0 16,4 IR OAH 4,9 3,9 1,5 5,4 6,2 4,4 4,7 9,5 2,2 10,3 IR child 0,9 0,3 0,4 2,0 1,8 1,3 1,1 2,6 0,8 1,05 IR spec Institutionalisation rate Institutionalisation 13,85 21,21 12,96 10,91 12,98 10,36 17,12 16,03 17,35 14,72 ISCED 5 + 43,9 46,76 49,44 34,38 47,21 53,07 44,30 46,31 45,65 47,82 ISCED 3-4 38,98 29,36 52,66 41,87 33,95 45,34 36,57 38,32 34,83 41,38 level of education in of education level age population working ISCED 0-2 26 5,02 6,93 4,82 3,59 6,08 4,59 7,12 5,22 5,42 4,38 - educa tion - gradu ates 5 5 13 16 13 12 18 13 15 21 M-F (gen - der) diff. 149 123 213 161 146 145 153 150 174 148 hour, hour, MKD Average gross gross Average earnings 1,64 0,76 1,42 1,72 1,60 1,68 1,77 1,97 1,52 1,59 Job Vacancy Rate (%) 20,3 42,2 22,3 16,4 16,4 21,6 14,1 19,0 23,7 33,0 Unem - ployment rate 32,0 41,6 34,7 52,0 49,3 57,1 52,5 43,1 35,9 45,45 - Employ ment rate 55,4 53,5 47,2 62,3 62,8 66,5 64,9 56,5 53,5 58,85 Activity rates of the population aged 15 Activity rates and over years Activity rate 164.161 386.876 121.824 253.656 291.516 315.717 260.855 269.996 212.913 257.255,5 GDP per capita 5.1 DEVELOPMENT INDICATORS AND INSTITUTIONALISATION RATE PER REGION PER RATE INSTITUTIONALISATION AND INDICATORS DEVELOPMENT 5.1 7,10 11,9 7,90 11,50 14,10 12,00 15,60 13,20 10,40 11,00 Infant Infant mor - tality – performance above average; average; above – performance average; below – performance performance; – anomalous region. average – an Per 20-24 segment of population (in %) of population 20-24 segment Per median nation Northeast Northeast Skopje East East Polog Macedonia Vardar Southwest Southeast Pelagonija Region 26 Colour legend: legend: Colour 26
50 | Potentials for development of community based services in the transition from institutional care Technical assistance support for the deinstitutionalisation process in social sector
5.2 TENTATIVE ALLOCATION OF FUNDS BY REGIONS, LOCATIONS AND ACTIVITIES
Region location related institution activity total per activity region sum
East Vinica Topansko Pole adult GH 58.000
East Vinica? Demir Kapija coordinated 92.000 150.000 care
Northeast Kumanovo? Demir Kapija coordinated 92.000 care
Northeast Kumanovo Demir Kapija children GH 68.000
Northeast Kumanovo Demir Kapija adult GH 57.000
Northeast Lipkovo Demir Kapija day activities 43.000 260.000
Pelagonija Prilep Demir Kapija adult GH 57.000
Pelagonija Bitola? MIHB other RA 51.000
Pelagonija Bitola? MIHB children GH 57.000 165.000
Polog Tetovo Demir Kapija adult GH 58.000
Polog Tetovo RM + 25. Maj children GH 48.000
Polog Bogovinje + X? Topansko Pole day activities 86.000
Polog Bogovinje X community 58.000 250.000 action
Skopje Skopje NGO advocacy? 36.000
Skopje Skopje RM etc. crisis ac 94.000 children
Skopje Skopje RM + 25. Maj + 11 O other RA 50.000 180.000
Southeast Radoviš 11. Oktomvri children GH 57.200
Southeast Strumica? Banja Bansko PA 85.800
Southeast Strumica Banja Bansko adult GH 42.000 185.000
Southwest M. Brod Banja Bansko adult GH 44.000
Southwest M. Brod OAH Bitola home help 82.000
Southwest not known RM + 25. Maj children GH 44.000 170.000
Vardar Demir Kapija Demir Kapija other RA 49.000
Vardar Demir Kapija Demir Kapija adult GH (2?) 117.000
Vardar Demir Kapija Demir Kapija crisis ac 94.000
Vardar Veles OAH Prilep home help 80.000 340.000
Total 1.700.000 1.700.000
Potentials for development of community based services in the transition from institutional care | 51 Technical assistance support for the deinstitutionalisation process in social sector i Official name of the institution or organisation ii RI – residential institution (24h), RIMH – mental hospital, DC – day centre, GH –group home, CO – counselling service, TC – tele-counselling, CE – centre (mostly counselling and advice), HH – home help, GE – general: awareness raising, advocacy, education and information, FC – foster care. iii CH – children, AD – adults under 65, OA – old age adults, ND – not defined. iv In case of General NGOs just number of NGOs in a group of municipalities. In case of psychiatric hospital the number refers to an estimate of long-stay patients. v In case of foster care – number of families. vi In case of Centres for Social work the ratio is population per one worker; in case of foster care number of user in a family. vii Sexual and reproductive health, HIV, Roma, LGBTI, women viii Sexual and reproductive health, HIV, Roma, LGBTI, women ix Focus on family violence. x Fieldwork in Demir Kapija for 30 children by 15 staff. xi Education centre for Roma children. xii Shelter and crisis line for women. xiii Shelter and crisis line for victims of trafficking. xiv May not be in existence anymore. xv 28 users (cchildren) under 18, 36 users over 18.
52 | Potentials for development of community based services in the transition from institutional care Technical assistance support for the deinstitutionalisation process in social sector
Potentials for development of community based services in the transition from institutional care | 53 Technical assistance support for the deinstitutionalisation process in social sector Potentials for development of community based services from nstitutional care in the transition Potentials ●
THIS PROJECT IS FUNDED BY THE EUROPEAN UNION Technical assistance support for the deinstitutionalisation process in social sector Technical
THE CONTENT OF THIS REPORT IS THE SOLE RESPONSIBILITY OF THE CONTRACTOR (AESA) AND54 |CAN Potentials IN NO forWAY development BE TAKEN TOof community REFLECT THEbased VIEWS services OF in THE the transitionEUROPEAN from UNION. institutional care