Transcript Slajd 1

Primary Health Care in North East
Europe Countries
Arnoldas Jurgutis, PhD , assoc. prof., head,
Public Health Department Klaipeda University,
ITA, Primary Health Care Expert Group of the Northern
Dimension Partnership in Public Health and Social Wellbeing
EFPC Conference The Future of Primary Care in Europe
III Pisa 30-31 August 2010
Northern Dimension Partnership
Oslo Declaration of 27 October 2003 – ND Partnership in
Public Health and Social Wellbeeing (NDPHS) – four Expert
Groups till June 2010 (reorganisation is going-on):
 HIV/AIDS Expert Group
 SILWA Expert Group
 Prison Health Expert Group
 Primary Health Care Expert Group of the
NDPHS
• Lead country Sweden,
•Chair Dr. Goran Carlsson, Senior advisor
MoH&SA
Estonia
• Active participation:
Finland
Poland
Russia
Latvia
Sweden
Lithuania
Norway
Belarus
 Report: PHC in ND countries:
 http://www.ndphs.org/?database,view,paper,21%20
WHO European
Region
Objectives of presentation
To overview shortly the development of
Primary Health Care in North East Europe
Countries and to address recent challenges
Countries in focus - Belarus, Estonia, Latvia,
Lithuania, Russia (active East Europe
members in NDPHS network)
EFPC Conference The Future of Primary Care in Europe III Pisa 30-31 August 2010
Common past...
Semashko model of health care system
• very
centralized health care system with
hospitals leading health care
• primary care– a lowest chain in hierarchy
of health care system
• primary health care doctors trained
mainly in hospitals as specialists in
internal medicine, pediatrics, gynecology
etc.
• exaggerated role of narow specialists for
improvement of population health
•Law No.1000 on dispanserisation overproduction
of “specialoids”
EFPC Conference The Future of Primary Care in Europe III Pisa 30-31 August 2010
Common ideas since early 1990-ies
Strategies on Primary Care reforms:
Estonia - “National Development Program” 1991
Lithuania - “National Health Concept” 1991
Latvia - 1992 –MoW approved model of PHC based on
family doctors
Belarus 1998 MoH decree regarding the gradual transition
of the organization of primary care
Russia – started postgraduate training in 1992, main legal
requirements for new speciality in 2000
1990-ies - External drive and support
International support to PHC reforms:
 WB investment in East Europe and Central Asia –
200 mln US $
 EU PHARE, TACIS Projects
 USAID
 Swedish International Development Agency (SIDA),
through NGO Swedish East Europe Commitee (SEEC)
 Matra projects supported by the Dutch Ministry of
Foreign Affairs and implemented by NIVEL
 Support from FM associations (WONCA, Canadian FD
association)
 Other...
20 years – intensive reforms...
Introduction of new speciality of family doctors
training/accreditation system in all countries (residency
3years - Lith, Lat, Est, 2years - Russ, 6month - Bel)
Decentralisation – responsibility for municipalities for
PHC
Separated PHC and SC (in Estonia, Latvia, Lithuania
(partly)
Autonomy of PHC – FD - private (independed)
contractors (Est 100%, Lat, Lith 50%, political suport for
intruduction in Russia))
Free choice and listing to PHC institutions and FD,
Gatekeeping (Est, Latv, Lith, in some regions of Russia)
..
One step forward two steps back...
Lack of internal drive, political
intentions to step back since late
1990th, 2000
primary health reform - hot
political issue, possibility of
lobbying for “populistic” parties
Active reformists – kamikaze
experience
Estonia – success story of PHC reform
strong leadership of Tartu university,
FD association
practical approach to implementation,
careful change-management strategy
to avoid health reforms being
politicized too early in the process,
early investment in training to
establish a critical mass of best
model of health professionals
Atun RA, Menabde N, Saluvere K, Jesse M, Habicht J Introducing a complex health innovation--primary health
care reforms in Estonia (multimethods evaluation). Health Policy. 2006 Nov;79(1):79-91. Epub 2006 Jan 6.
Deviations from core Primary Care principles
How strong organisational PC features to
apply and nurture proper compentences in
primary care?
● First Contact
● Coordination, continuity
● Comprehensiveness
● Family orientation
● Community orientation
Different developments
Every country have good examples to
demonstrate
First Contact
Very ambitious goal for Semashko model countries
III
III
II
II
> 50 % health
problems
DI
I
DP
Semashko model
Over 50% direct contacts to
the specialists (out of all
encounters with physicians)
<20 % health
problems
FD
I
New model
FD – first contact with overall
health care system
First Contact – intentions to step back
Patients are looking for easier access to the specialists:
● More then half the respondents would be willing to pay higher patient
fees in order to have easier access to specialized care (TDRC study,
Latvia, HIT 2008)
Free access to any health care - constitutional right
(Belarus)
Strong political intensions to open free access to the
secondary health care specialists in Lithuanina, Latvia,
2008
Unequal competences and conditions of PHC physicians
to play a role of gatekeeper
●
●
●
●
GPs after 3 years residency
Retrained from district physicians
District physicians
Private independent contractors vs. policlinics
Coordination, continuity
1996-99 most intensive changes in Lith, Latv, Est,
● listing (free choice) to FD– coordinator of care
● with referal free choice of any specialist within country
Estonia:
● 90% of population new their FD and only 15% changed
during last year (Atun et all, 2006)
● recently advanced e-health technology used for shared pt
records
Belarus – 75 - 90% of patients indicated they would address
problem to their GP or therapist, before seeking help from spec
(WHO, NIVEL study 2009)
Projects aimed to foster teamwork in PHC (Lihuania 2000)
Specialists – keeping power in first line care
Often more political power,
including municipality boards
Suplier induced demand
Specialists’ driven privat
clinics in Lith
From FD gatekeeper to FD
gateopener
● Capitation payment for FD
services +fee for service for
consultations
Comprehensiveness
Increased scope of diagnostic and
treatment services if service
provided by FD (Jurgutis 2002, Atun 2006,
Jankauskiene 2007, Liseckiene 2009,)
In Belarus FD have a much more
comprehensive role when compare
with district interninst (WHO, NIVEL study
2009)
No significan changes in preventive & health educational
services in Lith (Liseckiene, 2009)
Less comrehensiveness if FD working in the same
premisses with secondary care specialists (Raila G, 2007)
Lack of incentives
Comprehensiveness and chronic diseases
Improtance of comprehensive family doctor’s care for patients
with several chronic diseases (high comorbidity):
Patients with high comorbidity who have registered with
family physicians more often visit their primary health care
physicians, and need specialist care less often, compared
to patients who registered with district physicians
● consistent finding for adults with several chronic conditions, including asthma,
diabetes, hypertension, and IHD
● similar finding for children with hypertension, but not for children with asthma
(Jurgutis A., Martinkenas A., Lemke K, Bumblys A., 2008)
Family orientation
Ideas on GPs for children
and GPs for adults (Bel,
Rus)
Better satisfaction with FD
care, no difference in
performance (Est)
Belarus – 70% FD serves
both children and adults
(Atun, 2006)
First visit to the child by family doctor and nurse in rural district of Klaipeda
region, Lithuania
Political lobying of pediatritians to get back responsibility
for primary care of children (Lat, Lith)
Community orientation
Community oriented primary
health care – limitted to some very
good examples could be found in
all East Europe countries
Lith case: Through team based
PC community interventions in
rural community succesfully
controled arterial hypertnesion
increased from 1,2% in1998 until
23, 6% in 2004 (Andriauskas, 2005)
Free choice of FD – lost defined
geografic area
Challenges to be addressed (1)
Unequal accesibility of proffesionals
with core FM competences
“Excuse” policy for district internist and district pediatritians (not
trained as family doctors):
● Estonia – the only country from former soviet which have only FD since
2005
● Lithuania – still 31% population served by district internist and pediatritians
● Belarus – only 15% of FD, mainly in rural areas
Russian Federation: Emphasised priority to Primary Health care
through National Programm “Zdorovie” :
● since 2006 plus 10 000 rub! per month to every PHC physician (average
drs salaries in 2006 about 8000)
● still equal policy FD, DI, DP,
Challenges to be adressed (2)
More responsibility and
competence for PHC nurse:
• managemnt of patients with
chronic conditions
• role in community health need
assesment
• leadership in primary health
care team
Teamwork and cooperation with
other sectors – social workers,
public health specialists,
schools etc.:
• to emphasize role of social
workers for chronic conditions
Latvia: Nurse assist doctor in consultancy
room. Also often case in Lith, Rus, Bel
Challenges to be adressed (3)
As reported by FD and nurses in NDPHS Workshop “Tomorrows role
of Family doctors and Nurses” (Baltic Conference of Family
Medicine, Piarnu, Estonia Sept 2009)
Unequal distribution of PHC practices – not attractive rural areas
Increasing workload – burnout , particular problem for solo practices
Lack of tools for patients empowerment, motivational counceling
Extended PHC team needed
More emphasis to patient centered, holistic care (informed patinets,
emigrants, needs to empower for selfcare)
Introduction of EB performance indicators
Internal quality assurance tools
Appropriate incentive payment scheems
Opportunities for for further PC development in North
East Europe
Recent years role of primary care was again reinforced
by national policy makers:
Financial shortcuts forced to rationalise health care
systems
Closing hospitals – needs for stronger care in the
community
Less patients’ complains and political tensions if strong
PC team
More internal drive and plans for ambitious PC reforms in
in East Europe Countries
Russia – plans for more efficient PHC
Kaliningrad oblast 1mln inh:
• trained 77 FD, working only 22
• stronger primary care –
expressed public need
• plans for FD – independed
contractors with Mandatory
Health Inssurance (MHIF)
• piloting new payment scheems
– FD partly fundholding
New Minister of Health of Kaliningrad oblast
Mr. V. E. Golikov observs privat FM practice
in Lithuania (August 2010, Klaipeda)
Belarus – rethinking primary health care
Strategy for HC development
2011 – 2015:
Residency of Family Medicine
up to 2-3 years (recently 6
month retraining)
Introduction of quality indicators
for PHC
New payment scheems for
PHC providers
Family doctor’ consultation in Family Medicine Center in Belarus
Opportunities through joint project
activities
Initiated by NDPHS EU BSR project IMPRIM –
“Improvement of public health by promotion of
equitably distributed high quality primary health care
systems”
13 organisations from 6 countries (Bel, Latv, Lith, Est,
Swe,Fin)
6 MoH as associate partners (Bel, Latv, Lith, Est, Swe,Fin)
3 years 2,6 mln Euro
Opportunities for Kaliningrad oblast to joint project activities
(SIDA funding)
www.oek.se/imprim
Conclusions
All North East contries since 1990-ies are in the process of
reform of their primary health care systems, still
implementation of PC principles varies between the
countries and within the countries
Estonia has experienced most ambitious reform and fully
introduced based on family medicine PHC model
Recent financial shortcuts forced to rationalise health care
systems and primary care is reinforced once again
It is now high time for commited national policy makers to
fortify genuine primary care in the East countries of the
Baltic Sea region
Thank you for your attention!