Volume 2: Primary Health Care: Service Delivery

Loading...

PRIMARY HEALTH CARE: SERVICE DELIVERY

Volume 2

Acknowledgements Oxford Policy Management would like to thank all the individuals, too numerous to name, associated with the programme, Georgian and international. The documents contained in these volumes are the result of several years of collaboration between government officials, development partners, and other contractors. It is our hope that they have already contributed to the development of better health outcomes in Georgia. We also hope that these volumes can contribute in the future to further improvements in health outcomes in Georgia and other countries. It should be emphasised that the views expressed in these volumes cannot be attributed to the Government of Georgia, or the UK Department for International Development.

i

Primary Health Care: Service Delivery – Volume 2

List of volumes 1. Introduction to Primary Health Care in Georgia 2. Primary Health Care – Service Delivery 3. Public Health, Health Promotion, Public Relations 4. Health Policy Systems 5. Health Financing and Purchasing 6. Management Systems 7. Ministry of Labour, Health, and Social Affairs (MoLHSA) Systems – Organisational Development

ii

Table of contents Acknowledgements.......................................................................................................................... i List of volumes................................................................................................................................ ii List of tables and figures ................................................................................................................ vi Glossary ........................................................................................................................................ ix Abbreviations ................................................................................................................................ xv Introduction to reforms and OPM ................................................................................................ xviii 1

PHC Service Delivery.......................................................................................................... 1

2

1.1 Introduction.............................................................................................................. 2 Briefing Note No. 8: The Evolution of Primary Health Care in Western Europe ................... 7

3

2.1 Introduction.............................................................................................................. 8 2.2 The roots of European PHC..................................................................................... 8 2.3 Challenges in European health care ........................................................................ 9 2.4 The role and contribution of PHC to health .............................................................. 9 2.5 Conclusions ........................................................................................................... 10 2.6 References ............................................................................................................ 11 Briefing Note 10: Workforce Composition and Roles in European Primary Health Care .... 13

4

3.1 Introduction............................................................................................................ 14 3.2 Workforce composition .......................................................................................... 14 3.3 General practitioners ............................................................................................. 14 3.4 Nurses ................................................................................................................... 15 3.5 Pharmacists........................................................................................................... 15 3.6 PHC managers and other professionals ................................................................ 15 3.7 Roles and interactions ........................................................................................... 16 3.8 Team working in PHC ............................................................................................ 16 3.9 References ............................................................................................................ 17 Primary Care: Western European Best Practice of Institutional Involvement and Responsibilities in Human Resource Policy....................................................................... 19 4.1 4.2 4.3 4.4 4.5

5

Introduction............................................................................................................ 20 Understanding PHC in the European Union........................................................... 20 Providers of services in PHC delivery in different EU countries.............................. 25 Different actors for different interests in PHC in the EU; Models of best practice ... 30 How doctors and non-physician professionals are paid in the EU. The implications of different methods (and the use of incentives to correct it) .................................. 48 4.6 Conclusions ........................................................................................................... 56 4.7 References ............................................................................................................ 58 Identifying the Critical Steps Undergone by European Countries to Setup the Foundations of a Primary Health Care System in Conditions of Resource Constraint............................ 61 5.1 5.2

Introduction............................................................................................................ 62 Greece................................................................................................................... 63

iii

Primary Health Care: Service Delivery – Volume 2

6

5.3 Italy........................................................................................................................ 67 5.4 Portugal ................................................................................................................. 73 5.5 Spain ..................................................................................................................... 78 5.6 Conclusions ........................................................................................................... 85 5.7 References ............................................................................................................ 88 Master Plan for Retraining PHC Doctors and Nurses in Georgia ....................................... 91

7

Executive summary ........................................................................................................... 92 6.1 Purpose ................................................................................................................. 92 6.2 Rationale ............................................................................................................... 93 6.3 Objectives.............................................................................................................. 95 6.4 Core strategies ...................................................................................................... 95 6.5 Governance of the training..................................................................................... 99 6.6 Purchasing training services ................................................................................ 102 6.7 Management arrangements and implementation plan.......................................... 105 Report on Review of Training Programmes for Doctors and Nurses in Family Medicine . 123

8

7.1 Introduction and summary of proposals ............................................................... 124 7.2 Curricular content and design in the current programmes.................................... 127 7.3 Teaching and learning ......................................................................................... 138 7.4 Training resources ............................................................................................... 140 7.5 Assessment and licensing ................................................................................... 142 7.6 Student selection, support, career guidance and continuing education ................ 145 7.7 Key findings ......................................................................................................... 147 7.8 The future ............................................................................................................ 153 7.9 List of recommendations...................................................................................... 155 Review of the Road Map for PHC Reform in Georgia from the Perspective of Pharmaceuticals and Drug Benefit Scheme for Primary Health Care in Georgia ............. 159 8.1 8.2

9

Introduction.......................................................................................................... 160 Review of the road map for primary health care reform in Georgia from the perspective of pharmaceuticals............................................................................ 160 8.3 Drug benefit scheme for primary health care in Georgia ...................................... 164 Health Services in the Reformed Village Ambulatory Clinics ........................................... 187 9.1 9.2 9.3 9.4

Introduction.......................................................................................................... 188 The Georgian context 2005 ................................................................................. 188 Strategic intent of the proposed short term measures .......................................... 194 References .......................................................................................................... 205

Annex 6.1

Illustration of new mode of delivery...................................................................... 107

Annex 6.2

Costing of new modes of delivery ........................................................................ 109

Annex 6.3

Criteria and procedures for selection of trainees .................................................. 111

Annex 6.4

Content of capability statements for provider organisations ................................. 114

Annex 6.5

Contract specification for family medicine training................................................ 116

iv

Annex 6.6

Role and membership of the family medicine advisory board............................... 119

Annex 7.1

List of contacts..................................................................................................... 158

Annex 8.1

Primary care funding 2003/4 and pharmaceuticals .............................................. 179

Annex 8.2

An example: Mother and child care...................................................................... 182

Annex 8.3

Financial overview of a drug benefits program (cost-sharing) .............................. 183

Annex 9.1

Proposed timing for determining optimum preventative services for short term reform .................................................................................................................. 207

Annex 9.2

Scoring the benefits of the preventative services options for immediate reform ... 208

v

Primary Health Care: Service Delivery – Volume 2

List of tables and figures Table 6.1

Timescale .............................................................................................................. 93

Table 6.2

Cost ....................................................................................................................... 94

Table 6.3

Re-training of GPs ................................................................................................. 99

Table 6.4

Re-training of GPNs............................................................................................. 100

Table 6.5

Doctors training purchasing plan.......................................................................... 102

Table 6.6

Nurses training purchasing plan........................................................................... 103

Table 6.7

Midwife training purchasing plan.......................................................................... 103

Table 6.8

Based on the assumptions the total expenditure on training per se (not including QA, etc) ............................................................................................................... 104

Table 6.9

Financial plan ...................................................................................................... 106

Table 6.10

Possible division of the curricula into three elements ........................................... 107

Table 6.11

Doctor and nurse re-training resource cost elements and volumes...................... 109

Table 7.1

Comparison of curricular elements....................................................................... 132

Table 7.2

Responsibility for areas of quality management – Doctors................................... 151

Table 7.3

Responsibility for areas of quality management – Nurses.................................... 152

Table 8.1

PHC situation as characterized in the MOLHSA roadmap and its parallel regarding pharmaceuticals................................................................................................... 161

Table 8.2

Pharmaceuticals and the management of the roadmap ....................................... 162

Table 8.3

Proposal regarding immediate action................................................................... 163

Table 8.4

Proposal of critical steps to achieve substantial progress .................................... 164

Table 8.5

proposal of PHC pharmaceutical services in Georgia .......................................... 169

Table 8.6

Drug based model – an example ......................................................................... 173

Table 8.7

Population group based model – an example ...................................................... 174

Table 8.8

Family Medicine model – examples ..................................................................... 175

Table 8.9

Drug use management mechanisms in Tbilisi ...................................................... 177

Table 8.10

Health financing programs and drug coverage..................................................... 179

Table 8.11

Cost categories of required drugs for adults and children .................................... 180

Table 8.12

Summary of conclusions...................................................................................... 181

Table 8.13

Drug requirements for adults per 1000 population based on standard treatment guidelines ............................................................................................................ 182

Table 8.14 Drug scheme with and without Public Funds contribution (catchment area 100,000 pop.) ............................................................................................................................ 183 Table 8.15

Financial overview drug cost-sharing program (Family based package) .............. 185

Figure 6.1

vi

Proposed mode of training delivery and clinical rotations for one cohort group of FM Doctors on the retraining programme ................................... 107

Figure 6.2 Figure 8.1 Figure 9.1 Figure 9.2 Figure 9.3 Figure 9.4 Figure 9.5 Figure 9.6 Figure 9.7 Figure 9.8 Figure 9.9 Figure 9.10

Proposed Mode of Training Delivery and Clinical Rotations for One Cohort Group of FM Nurses on the retraining programme ................................... 108 Presentation of primary care services and related pharmaceutical benefits.... ..................................................................................................... 170 Infant deaths per 1000 live births............................................................. 189 Components of infant mortality in Georgia ............................................... 189 Infant mortality ......................................................................................... 189 070101 Neonatal deaths per 1000 live births........................................... 189 Maternal mortality per 100,000 live births ................................................ 189 Children <14 morbidity per 100,000 children............................................ 190 Incidence of infectious and Parasitic diseases per 100,000 population .... 190 TB incidence per 100,000 Georgia and other countries ........................... 191 Number of PHC consultations per patient per year, Georgia, 1990-2002 . 191 Average number of visits per patient per year in different countries ......... 192

vii

Glossary Ambulatory care – medical care given on an outpatient basis. ‘Ambulatory’ in this case literally refers to people who are able to walk out of hospital. Basic Benefits Package – The package of health services financed through the State Budget, including emergency, primary and some secondary care services. Continuing Medical Education (CME) – an ethical and moral obligation to maintain and upgrade knowledge and skill after postgraduate training and during one’s entire career. In some European countries (such as Belgium and Italy) it has become a legal obligation. Disability Adjusted Life Years (DALY) – is a measure for the overall "burden of disease." It is designed to quantify the impact of premature death and disability on a population by combining them into a single, comparable measure. In so doing, mortality and morbidity are combined into a single, common metric. Effectiveness – The extent to which a specific intervention, procedure, regimen of service…does what it is intended to do for a defined population. The extent to which objectives are achieved (WHO, 2000d). Efficiency – refers to obtaining the best possible value for the resources used (Alban & Christiansen, 1995). Technical efficiency means producing the maximum possible sustained output from a given set of inputs. Allocative efficiency is when resources are allocated in such a way that any change to the amounts or types of outputs currently being produced (which might make someone better off) would make someone worse off (World Bank, 2000). Allocative efficiency requires that an economy provides its members with the amounts and types of goods and services that they most prefer. Allocative efficiency is sometimes called “Pareto efficiency.” Equity – Principle of being fair to all, with reference to a defined and recognised set of values. There are two kinds of equity: Horizontal equity is the principle that says that those who are in identical or similar circumstances should pay similar amounts in taxes (or contributions) and should receive similar amounts in benefits; vertical equity is the principle that says that those who are in different circumstances with respect to a characteristic of concern for equity should, correspondingly, be treated differently, e.g., those with greater economic capacity to pay more; those with greater need should receive more. Family Medicine – the medical specialty which provides continuing, comprehensive health care for the individual and family. It is a specialty in breadth that integrates the biological, clinical and behavioural sciences. The scope of family medicine encompasses all ages, sexes, each organ system and every disease entity. (1986) (2005) Feldsher – senior nurse in Soviet “Semashko” health care system (see ‘Semashko’). General Profile Hospitals – provisional name given to moderately sized hospitals providing a range of general clinical specialties within fairly ready access of the population. Health benefit – In health economics, a health benefit is one which is recognised as providing a gain in terms of reduced costs or increased health. Health care systems – A formal structure for a defined population, whose finance, management, scope and content is defined by law and regulations. It provides for services to be delivered to

ix

Primary Health Care: Service Delivery – Volume 2

people to contribute to their health, and delivered in defined settings such as homes, educational institutions, workplaces, public places, communities, hospitals and clinics. Health Management Information System – systems for planning, organizing, analysing and controlling the data and information, including both computer–based and manual systems. Health Needs Assessment – a formal, systematic attempt to determine and close important gaps between current outcomes and desired health outcomes, and the placing of those gaps in priority order for closure. Needs assessments should be used to guide health policy and programme development. It provides information on which to base health funding allocations. Health Insurance – term generally used to describe a form of insurance that pays for medical expenses. It is sometimes used more broadly to include insurance covering disability or long-term nursing or custodial care needs. Insurance may be provided through a government-sponsored social insurance programme, or from private insurance companies. It may be purchased on a group basis (e.g. by a firm to cover its employees) or purchased by individual consumers. In each case, the covered groups or individuals pay premiums or taxes to help protect themselves from high or unexpected healthcare expenses. Similar benefits paying for medical expenses may also be provided through social welfare programs funded by the government. Health policy – A formal statement or procedure within institutions (notably the government) which defines priorities and the parameters for action in response to health needs, available resources and other political pressures. Health Policy Analysis – the process of assessing and choosing between spending and resource alternatives that affect the health care system, public health system, or the health of the general public. Health policy analysis involves several steps: identifying or framing a problem; identifying who is affected (stakeholders); identifying and comparing the potential impact of different options for dealing with the problem; choosing among the options; implementing the chosen option(s); and evaluating the impact. The stakeholders can include government, private healthcare providers (e.g. hospitals, health plans, and office-based clinicians), industry groups (e.g., pharmaceutical, biotechnology, and medical device manufacturers), professional associations, industry and trade associations, advocacy groups, and consumers. Health Promotion – The planned and managed process of encouraging and assisting improvement in the health of a population as distinct from the provision of health care services. Health promotion is the science and art of helping people change their lifestyle to move toward a state of optimal health. Optimal health is defined as a balance of physical, emotional, social, spiritual, and intellectual health. Lifestyle change can be facilitated through a combination of efforts to enhance awareness, change behaviour and create environments that support good health practices. Health systems – The people, institutions and resources, arranged together in accordance with established policies, to improve the health of the population they serve, while responding to people’s legitimate expectations and protecting them against the cost of ill-health through a variety of activities whose primary intent is to improve health. Health technology assessment – Comprehensive evaluation and assessment of existing and emerging medical technologies including pharmaceuticals, procedures, services, devices and equipment in regard to their medical, economic, social and ethical effects.

x

Joint Stock Company – A private company which has some features of a corporation and some features of a partnership. The company sells fully transferable stock, but all shareholders have unlimited liability. Management Systems – the framework of processes and procedures used to ensure that an organisation can fulfil all tasks required to achieve its objectives. MoLHSA – Ministry of Labour, Health, and Social Affairs of Georgia, created following the merger of two ministries – the Ministry of Health and the Ministry of Labour and Social Welfare in 1999. Currently the MoLHSA has the following responsibilities: planning and determining health priorities; developing and implementing national health care policy; drafting healthcare laws and enacting regulations subsequent to primary legislation; ensuring supervision of health-related law enforcement; developing and overseeing the implementation of public health programs; advocating for adequate resource allocation for the healthcare programs from the state budget; and regulating healthcare professions, health facilities and pharmaceutical market. Multi-Profile Hospital – provisional name given to hospital providing Sub-specialty clinical services. Out of pocket Payment – describes ways of paying for services (in this case health). Forms of out of pocket payment include: -

-

Direct payment: payment for the goods or services that are not covered by the insurance or state finding; Cost sharing: a prevision of health insurance or third party payment that requires the individual who is covered to pay part of the cost of health care received. Often referred as formal cost sharing or user charge. Cost-sharing could be direct or indirect. Informal payments: unofficial payments for goods or services that should be fully funded from pooled revenue.

Primary Health Care – health care that is provided by a health care professional in the first contact of a patient with the health care system. In Georgia, since 2006, Primary Health Care (PHC) is defined as a non-hospital health care. It means that all services provided by general practitioners and specialists in out-patient clinics are considered as a PHC. Private Health Insurance – Private health insurance schemes are provided by private companies and are based on voluntary contribution by individuals or by individuals and their employers jointly. There is usually a wide range of private insurance schemes varying in the type of conditions or services covered. Payroll tax – A tax paid by the employer on the basis of its payroll. Polyclinic – A type of health provider that provides ambulatory health care for more than one specialty of services. Premium – A flat-rate payment for voluntary insurance. Private health care sector – Involves the transfer of ownership and government functions from public to private bodies, which may consist of voluntary organisations and for-profit and not-forprofit private organisations. The degree of government regulation is variable.

xi

Primary Health Care: Service Delivery – Volume 2

Public Health – The science and art of promoting health, preventing disease, and prolonging life through the organised efforts of society. The field of medicine and hygiene dealing with the prevention of disease and the promotion of health by government agencies. Purchaser – A health care body which assesses the needs of a defined population and buys services to meet those needs from providers. Purchasing Power Parity – the rates of currency conversion that equalise purchasing power across the full range of goods and services contained in total expenditure and Gross Domestic Product of a country. Quality of medical care – The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. Quality assessment – Planned and systematic collection and analysis of data about a service, usually focused on service content and delivery specifications and client outcomes. Quality improvement – Ongoing response to quality assessment data about a service in ways that improve the process by which services are provided to clients. Rayon – territorial unit, or district. There are 68 rayons in Georgia. Rayon Health Corporation – The Health Care Services Act, elaborated by the MoLHSA in 2006, proposed that that the corporations be established in Georgia to provide public health services in hospitals (Hospital Corporations or HC) and primary health care/ local health services (Rayon Health Corporations or RHC). These corporations had to be independent, non-for profit organizations owned by the State and governed by Supervisory Boards. Regulation – setting forth mandatory rules that are enforced by a state agency. According to the broader definition, it incorporates all efforts by the state agencies to steer the economy. Semashko model – Health care model, functional in the Soviet system, based on complete State financing of all types of health care services for the entire population of the country. SUSIF – State United Social Insurance Fund. SUSIF was set up in 2003 following the merger of the State Medical Insurance Company and the state pension fund, as an independent agency acting under the control of MoLHSA. SUSIF became a key social insurance institution in charge of financing pensions, social security benefits, unemployment and state health programmes. State Ambulatory Programme – The state programme for the entire population of Georgia, providing PHC (ambulatory and policlinic) services, paid through the State budget. The service includes consultations with PHC providers, defined specialists at out-patient level, and defined sets of laboratory and diagnostic services. Tbilisi State Medical University – Tbilisi State Medical University is the largest Medical University in Caucasus region [Georgia, Armenia and Azerbaijan]. Running for more than 80 years, this university currently educates 5000 students using 1200 Professors. Under-the-table payments – Informal, unofficial payments which are usually prohibited in order to have one’s wishes/demands/needs fulfilled in a timely manner or to a larger extent than by following the official rules and regulations.

xii

Universal Health Insurance – A national plan providing health insurance or services to all citizens, or to all residents. Universal package – A set of services paid through the State budget for all citizens of the country. Utilization – The number of health services used by a population, often expressed per 1000 persons per month or year. Voluntary health insurance (VHI) – Health insurance which is taken up and paid for at the discretion of individuals (whether directly or via their employers).

xiii

Abbreviations BBP

Basic Benefit Package

BIOMED

Biomedicine and Health Programme (EU)

CCEE

Countries of Central and Eastern Europe

CIS

Commonwealth of Independent States

CME

Continuing Medical Education

CSEC

Central and South Eastern European Countries

DFID

Department for International Development (UK)

DRA

Drug Requirements Analysis

EPI

Epidemiology

EU

European Union

EURACT

European Academy of Teachers in General Practice

EURO

European Regional Office (WHO)

FM

Family Medicine

FMAB

Family Medicine Advisory Board

FMC

Family Medicine Clinic

FMTCs

Family Medicine Training Centres

FMTP

Family Medicine Training Programme

FPs

Family Practitioners

FTE

Full Time Equivalent

GDP

Gross Domestic Product

GEL

Georgian Lari

GFMA

Georgian Family Medicine Association

GNA

Georgian Nurses Association

GPs

General Practitioners

GPNs

General Practice Nurses

GPP

Georgia Pain Physicians

xv

Primary Health Care: Service Delivery – Volume 2

HEI

Higher Education Institution

HIF

Health Insurance Fund

HMO

Health Maintenance Organisations

HR

Human Resources

HS

Health Services

IKA

Industrial Workers’ Social Security (Greece)

JSC

Joint Stock Company

MCQ

Multiple Choice Question

MEQ

Modified Essay Question

MeSH

Medical Subject Headings

MOE

Ministry of Education

MOJ

Ministry of Justice

NIH

National Institute of Health

NIHSA

National Institute of Health and Social Affairs

NIVEL

Dutch Institute of General Practice

OECD

Organisation for Economic Cooperation and Development

OGA

Agricultural Workers’ Social Security (Greece)

OPM

Oxford Policy Management

OSCE

Objective Structure Clinical Examination

PC

Primary Care

PHC

Primary Health Care

QA

Quality Assurance

RIU

Reform Implementation Unit

SMA

State Medical Academy

SMIC

State Medical Insurance Company

SOE

Mandatory Sickness Fund (Spain)

STG

Standard Treatment Guidelines

xvi

TACIS

EU programme

TB

Tuberculosis

TSMU

Tbilisi State Medical University

UEMO

European Union of General Practitioners

UK

United Kingdom

USA

United States of America

WG

Working Group

WHO

World Health Organisation

WHR

World Health Report

WICC

WONCA International Classification Committee

WONCA

World Organisation of National Colleges and Academies of General Practitioners / Family Physicians

xvii

Primary Health Care: Service Delivery – Volume 2

Introduction to reforms and OPM This brief introduction is present in every volume of the Primary Health Care (PHC) Reform Support Programme. It aims to analyse the health care system reforms undertaken by the Government of Georgia (GoG) in the period of 2003-2007 in parallel with the implementation of Department for International Development (DfID) Georgian PHC reform support programme, executed by the Oxford Policy Management (OPM). The main emphasis is on capturing the health policy changes affecting the nature and volume of OPM’s work.

Georgian health care reforms September 2003 – Summer 2005 In 2003, without having elaborated a comprehensive health care reform plan, the GoG concentrated on PHC reform, supported by three major donors – DFID, the World Bank and the European Union. Aid support for this five year period amounted USD 40 million. Two big projects started in 2003 – the World Bank supported a PHC programme implemented by the World Bank Health Policy Unit, and DFID supported a PHC reform support programme, implemented by Oxford Policy Management. The Ministry of Labour, Health, and Social Affairs (MoLHSA), in which these projects were housed, had limited technical capabilities. As a result, it was not able to formulate specific objectives for the aid programmes, and instead expected them to work in a proactive manner. Consequently, until the end of 2003, projects worked on inception phases, assessing local context and re-formulating their goals and objectives to boost possible outcomes. After coming to power in the Rose Revolution of 2003, the new government pledged to undertake health care reform, aiming at securing the social welfare and good health of entire population of Georgia. However, despite this political declaration, the new government did not speed up the process of decision making on health care reform strategy development and implementation. The MoLHSA was a passive listener to the proposals coming from different aid partners, being partially involved in the discussions of elaborated technical products. The major challenge of the 2003-2004 period was that a high number of donors and contractors were competing with each other, while supporting the Ministry in the same area of PHC, and operating in a completely uncoordinated environment because of the low capacity of the MoLHSA to lead the process. OPM programme The central goal of the DFID supported PHC reform programme was to enhance the MoLHSA’s capacity to develop and manage the PHC sector. Originally the programme was structured in five work streams, including ‘Support to the PHC Coordination Board and Management Committee’, ‘Support to heath care financing and policy’; ‘Support to Human Resource development for PHC’; ‘Support to the development of Health Management Information systems’, and ‘Support to Health Information Education and Communication System (IEC) based activities’. From the beginning, OPM has been working closely with the PHC Coordination Board and its Management Committee in the MoLHSA to strengthen the Board’s leadership role in designing and implementing PHC reforms. An early objective of the PHC Board was to develop a PHC reform implementation plan, integrating DFID, World Bank and European Commission support to the MoLHSA, and leading to a harmonisation of donor and government efforts. However, this

xviii

harmonisation was not achieved, partly due to wrong arrangements for the PHC coordination, which was situated outside the Ministry and had only de jure, rather than de facto power; and partly due to low capacity in the PHC management committee. Within one year, the MoLHSA dissolved the PHC Coordination Board and its Management Committee. Responsibility for PHC reform coordination was given to the Director of National Institute of Health. In the first few months, OPM conducted an assessment of the existing context to structure the programme according to the needs of the government. Initial reviews have been transformed into the reports from early 2004, covering the fields of PHC Policy development; harmonisation of partners; an assessment of PHC roles and functions in Georgia; an institutional map of agencies involved in human resources and service delivery in Georgia; notes on the Evolution of Primary Health Care in Western Europe as well as on European Primary Health Care Policy processes, stakeholders and actors; Resource allocation; Budget structure and budget management for Health Care. According to the request of the Ministry, large technical documents prepared by OPM were also transformed into briefing notes for wider dissemination.

Summer 2005 – January 2006 Aside from healthcare, the new government concentrated sharply on social sector reforms from the very beginning, with the aim of allocating the State social subsidies more effectively to those in need. A “Targeted Social Assistance Scheme” was developed and implemented in 2004-2006, identifying and ranking 1/3 of the population of Georgia according to the social status. 1/4 of the population were defined as recipients of different types of social allowances. In parallel, the government wanted to develop adequate capacity in the MoLHSA to steward the Social and Health sectors. They approached aid partners, including OPM, to support the Ministry in reorganisation, with the purpose of defining the structure and functions of the “contemporary Ministry of Labour, Health and Social Affairs”, emphasising the need for transforming both social and health segments. OPM programme In summer 2005 the top management of the OPM programme changed. The new leader restructured the programme according to the government’s new requirements in key three areas of work: 1. Effective implementation of the new PHC system; 2. Building capacity in key Ministries and associated structures; 3. Support to policy development. Programme resources began to concentrate on supporting the MoLHSA in Organisational development. Together with Co-reform, the USAID contractor, OPM started work on the overall Ministry Charter, proposing its functions and structure. At the same time, at the request of the MoLHSA and with the approval of DFID, OPM put huge emphasis on the organisational development of the Labour and Social affairs segment. Documents were prepared in the period of autumn 2005-January 2006 on the following areas: assessment reports on current regulatory function at the MoLHSA, and assessments of the Social Policy functions and the organisational structure of the MoLHSA; an organisational assessment of Labour and Employment Policy Department; an Organisational Assessment for Labour Inspection; Charters and sub-charters of the Department of Labour and Social Security, Social Integration and Care Division, Pensions and Social Assistance Division, and Labour Divisions of the MoLHSA; an assessment report on the organisation of Targeted Social Assistance (TSA); organisational requirements for a New Flat Rate

xix

Primary Health Care: Service Delivery – Volume 2

Pension System; and an assessment of the agencies responsible for the TSA and pensions administration. At the same time, OPM was intensively working with the Ministry on PHC policy, PHC financing, HR development and organisational design issues, trying to convince the government of the necessity of elaborating the PHC Road Map and overall strategy for health care system development. The documents produced in this period cover wide spectrum of the areas, including the “Stewardship and regulation of health services”; “The Road Map for Primary Health Care Reform”; “Ambulatory Services in Villages”; “Drug Benefit Scheme for Primary Health Care in Georgia”; “Review of the Road Map for Primary Health Care Reform in Georgia from the perspective of pharmaceuticals and Drug Benefit Scheme for Primary Health Care in Georgia”; First draft on the HMIS strategy; Technical Notes on “Delivering better public health services in Georgia”; State Health Budget structure, and “Planning human resources for health in Georgia”; “PR strategy for MOLHSA”. Most importantly, at OPM’s initiative, and with the participation of Coreform, the MoLHSA prepared a first strategic paper “Main directions in Health”, outlining the goal and main objectives for health system development. Finally, the MoLHSA approved the Road Map for PHC prepared by OPM.

January 2006 – October 2006 In January 2006, the Prime Minister requested the MoLHSA to initiate the transparent and coordinated process for the elaboration of the health sector development strategy with the involvement of all key stakeholders within a four month period. The first deputy minister was put in charge of the assignment. The National Institute of Health team was leading technical work for the development of the strategy, which would consist of three parts: service delivery, health system organisational design and health care financing sections. The strategy paper was worked out through the painful but useful process of controversial discussions and debates. The document proposed the development of the health care system based on public ownership, improved public administration and a separation of functions between the different health actors. It envisioned the MoLHSA in the role of a steward with enhanced regulatory and supervision functions. It called for an accelerated role for strategic purchasing through the establishment of strong public health purchaser. The paper also described the service provision in the public sector run through Rayon Health Corporations (RHC) in Primary Health Care and Hospital Corporations (HC) in Secondary and Tertiary Care, as publicly owned non-profit organisations subject to private law; and the strategy gave multiple roles to the private sector in service provision, under proper regulation. It proposed the production of human resources by reforming undergraduate and post-graduate training of both doctors and nurses; and called for the development of health service management capacity through intensive training to run the newly created Corporations through modern managerial criteria. The paper was submitted to the Prime Minister on June 6, 2006. However, the top government did not approve the paper. The new instruction to the MoLHSA was to elaborate in more detail the separate segments of the strategic document, concentrating on the development of the PHC master plan, the Hospital development master plan, the Health Human Resource development strategy; and the Health care financing strategy. At that time, the government did not make clear that the reason for the objection to the proposed health care development strategy was rejection of the idea of publicly owned, purchased and provided health care services. As a result, all the following assignments were conducted based on an (incorrect) understanding that the government was looking for better proposals for public health care system development.

xx

In parallel, the MoLHSA, with extensive support from all three donors, was working on finalisation of PHC Master Plan. The goal of PHC development should have been to guarantee universal accessibility to, and efficient utilisation of, basic health services. The plan included upgrading the competences of primary care staff and the rehabilitation of PHC infrastructure countrywide. The plan also involved discussing the development of adequate management and supervision structures for PHC management, together with development of health information systems. In parallel to the Policy work, the government requested aid partners to concentrate on PHC human resource development. OPM was asked to revisit the budget to re-allocate funds for the retraining of PHC doctors and nurses, as well as PHC and Health System managers. OPM programme OPM was extensively involved in the elaboration of the Health Care Strategy Document. OPM supported the Ministry in setting up the process and gave significant input into the content of the paper. Numerous discussion notes and back up documents worked out in January-May 2006 are testament to this. Although several stakeholders were involved in the strategy elaboration process, the main weight of technical expertise came from OPM and Co-reform. These two organisations brought different perspectives of the heath system development. OPM supported the continental model of Health systems, favouring social values as equity, fairness to financing, accessibility and affordability. Coreform, on the other hand, promoted a more US health care model, with Health Maintenance Organisations, primary and hospital service delivery by the same institution, and a private-public mix for health care financing. This partner controversy was reflected in the final strategic paper, which incorporated several options in each section for the health system development. After June 2006, OPM received new assignments from the Ministry, which asked OPM to elaborate more on the PHC Master plan modification, namely to define the structure and functions of PHC Rayon Health corporations and MoLHSA regional branches; to prepare background materials for Hospital Master plan development, work on Human resource development and health care financing strategies. In response, within five months OPM produced a number of significant technical documents, including the “Governance of the health system in Georgia; Role, organisation and operations of the Regional MoLHSA”; “Governance and Management of Medical Facilities;” “Managing Health Systems in the Public sector;” “Georgian PHC Reform: Management Evaluation Systems;” “Health Management Information Systems Technical Strategy”; “Planning Human Resources for Health in Georgia”; “Prototype Hospitals Planning Philosophy;” “An Outline Service Delivery Model for Hospital Services in the Reformed Health System” “Report on staffing norm development for hospital services in Georgia, Final Draft”; and “ OPM NIHSA Hospital Cost Model”. In summer 2007, OPM was requested to work on the development of the Public Health System for the MoLHSA. In response to MoLHSA’s request, OPM elaborated four memos on Public Health Systems development, covering the proposals for the needed Public Health structure and capacity in the MoLHSA and subordinated agencies; and revision of State public health programs. “Health promotion and Disease prevention strategy” was also finalised in cooperation with the Public Health Department and National Centre for Disease Control staff. Health promotion Guidelines were prepared and provided to the Ministry. In parallel, at the government’s request, OPM revisited the programme budget to allocate funds for the development and prevision of Health Care Management Programme and for the re-training of PHC doctors and nurses.

xxi

Primary Health Care: Service Delivery – Volume 2

Re-training of the PHC personnel was undertaken using the curricula and the programme prepared by the first DFID supported health project in 2001-2002. OPM produced following documents for the Management training programme: “Health Service Management Training programme Introduction”; and “Health Service Management Training programme Curricula”; followed by a number of quality materials for all three modules of the training. According to Georgian regulation requirements, the Management training programme was accredited by the MoLHSA. OPM made plans for accreditation of the programme by international accreditation agency “the Institute of Leadership and Management.”

November 2006 – end of 2007 In autumn 2006, the State Minister in charge of Public reforms was requested by the Prime Minister to lead the elaboration of new Health Reform Strategy. The Prime Minister was assigned as the head of Governmental committee for health and social reforms, in charge of decisions about the health policy. The governmental team was requested to prepare an alternative version of the reform, based on the following principles: -

Almost full privatisation of health service provision; Radical changes in State Health resource allocation to the benefit of socially vulnerable; Involvement of private insurance in health service purchasing; Significant simplification of governmental regulations.

The new arrangements for health policy elaboration and decision-making virtually excluded active participation by donors and contractors. Most of the work fell to the MoLHSA staff to work on daily assignments coming from the State Minister. International and local experts were requested to revise the elaborated technical work to fit with the government’s new vision of a private sector based health care system. Most of the aid agencies, including OPM, preferred therefore to select a single niche in the PHC reform process, more or less independent of the government’s decisions on health system design, and concentrate on it. With the agreement of the government and DFID, OPM identified ‘Health Care Management training’ as a desirable output that could be produced before the end of the programme. The Ministry also requested that some of the OPM programme resources should be allocated to modular trainings for PHC personnel. In addition, OPM found it necessary to build a PHC networking capacity in Georgia in the context of global privatisation of primary and secondary care facilities. In summer 2007, the Ministry asked OPM to conduct a Health Needs Assessment. This would be used as a basis for the revision of benefit package covered by the State health programmes, and the development of health insurance packages to be purchased through the State funding. OPM programme OPM has concentrated on Health Management Training programme development and provision. In fact, almost all local and senior international staff were involved in the processes of preparing and delivering training. In 18 months, seven groups of twenty-five people have been re-trained, composed of PHC, Hospital and Health Systems Managers. By mid 2007, OPM Management Training programme became a brand, famous among health care managers all over Georgia. In recognition of the OPM programme’s success, MoLHSA allocated funds from the 2007 budget to finance the health management training for 200 managers in addition to those trained by OPM, using OPM developed curricula and materials. The fact that MoLHSA took over the training

xxii

provided a guarantee for the sustainability of OPM’s product, as several local academic and training institutions got involved in the delivery of the Management programme. In parallel, OPM has been working intensively on modular trainings for the re-trained GPs and nurses in three regions – Ajara, Kakheti and Imereti. These efforts were highly appreciated by the PHC providers, who requested an extension of the trainings to other regions. In total, about 250 individuals will be re-trained through the modular trainings by summer, 2008. From December 2007, OPM initiated activities for building the capacity of PHC medical personnel to network in regions. As mentioned above, this initiative was particularly important as the government declared a plan to privatise PHC facilities countrywide in 2008. This privatisation would mean that instead of existing Rayon policlinic/ambulatory unions in most of the regions in Georgia, there will be individual PHC providers in villages, rayon centres and cities. PHC personnel will therefore need some form of networking capability in order to derive sufficient power and the ability to speak with a joint voice to the MoLHSA and private health purchasers. OPM intends to prolong these activities until the end of the programme. By the end 2007, OPM finalised the work on health human resource strategy, producing the papers on “Planning of the Medical Workforce in Georgia;” “Workforce estimation model for Kakheti region”; “Workforce Model Presentation”. Finally, in agreement with the Ministry, OPM intends to conduct the Health Needs Assessment from March, 2008. Field work will be completed within one month. OPM will provide the Report of the assessment to the MoLHSA by June 2008. In the current context, this assignment also gains particular importance, because the government intends to revisit the insurance package purchased by private health insurance companies through the State health service programme for the population below the poverty line. In parallel, the MoLHSA intends to modify the health care services covered by other State Health programmes for the entire population of Georgia and some specific groups of target beneficiaries. Health Needs Assessments results would provide a sound background for evidence-based decision making by the MoLHSA.

xxiii

PHC Service Delivery

1

PHC Service Delivery Orvill Adams

February 2007

1

Primary Health Care: Service Delivery – Volume 2

1.1

Introduction

Primary health care (PHC) reform is complex, requiring political support and commitment and must be accompanied by information for the users of services so that they will have confidence in the new system. These are some of the key messages that are contained in this volume on PHC Service Delivery. The volume consists of eight documents: 1. Briefing Note 8: The Evolution of Primary Health Care in Western Europe 2. Briefing Note 10: Workforce Composition and Roles in European Primary Health Care 3. Western European best practice of institutional involvement and responsibilities in Human Resource policy 4. Primary Health Care: The Case of the Mediterranean Countries 5. Master Plan for Retraining PHC Doctors and Nurses in Georgia 6. Report on Review of Training Programs for Doctors and Nurses in Family Medicine 7. Drug Scheme and PHC in Georgia 8. Health Services in the Reformed Village Clinics Documents 1 to 4 present evidence and lessons from different primary health care systems in Europe. Documents 5 to 8 present a set of options and suggest actions that can be taken in Georgia to improve primary health care. Reforms can fail because of a large number of factors. Reviewing the experiences of other countries can assist policy makers and planners to better understand critical factors such as the method of financing, the ways that systems are organised, investments in the system and the roles and functions of different stakeholders. The governance and the management of the dynamics and interaction between different factors will contribute to the degree of success of a PHC system. A central lesson of the first four documents is that the country context is a critical factor in the reform of any health care system. Therefore, reforms cannot be copies of other systems but they can be informed by their experiences. Primary Health Care was announced as a policy direction by the Government of Georgia and steps had been taken by the Ministry of Labour, Health and Social Affairs (MoLHSA), to realize the policy through the retraining of appropriate health care workers (family doctors and nurses), and through plans to refurbish health centres and to put in place legislation and regulations to support the development of a PHC system. As in other health care systems engaged in PHC reform, the concept was not well understood and, therefore, not well supported by key stakeholders in the country. The Government was supported in the reform process by a number of donors and their respective contactors. The World Bank, The European Union, USAID, WHO and DFID were the principal partners of the Government in this reform. These first four documents were designed to inform the policy debate and enable critical discussion and decision making.

1.1.1

Briefing Note 8: The evolution of primary health care in Western Europe

This Briefing Note contributes to the debate by making a number of key points: • •

2

There is no single right model of PHC; PHC continues to evolve in Western Europe along several different lines and continues to change in the face of old and emerging challenges.

PHC Service Delivery

Health systems, and subsystems such as PHC, are shaped by national histories, linked to economics, politics, culture and beliefs. They have evolved from different starting points in the countries of Western Europe. At different times workers and/ or employers have pressured for improved access to health services. The three main policy actors are identified as governments, insurers, and health professionals. In Western Europe consumers are beginning to play an increasing important role in the policy process.

1.1.2

Briefing Note 10: Workforce composition and roles in European primary health care

This Briefing Note discusses the different categories of health workers involved in PHC in Europe. It shows that there is wide variation across countries in the number of general practitioners (GPs), and nurses per capita. The Note also suggests that team work is beneficial to the quality of health services and provides some evidence. The experiences in Europe show that the range of PHC providers can include: pharmacists, dentists, managers, social workers and therapists of different kinds. An expanded concept of PHC from personal services provided only by nurses and doctors to other disciplines is advanced in this Note. This is a challenge for Georgia with its highly specialised medical workforce. Not only is retraining of narrowly trained specialists necessary to reform the PHC system but attitudes regarding the involvement of multidisciplinary teams also require change.

1.1.3

Western European best practice of institutional involvement and responsibilities in human resource policy

This document provides a more complete analysis of who is involved in the organisation of health services across European countries. It reviews and outlines the roles and functions of different stakeholders in the various systems. The paper places PHC in the larger health system and discusses the challenges that are faced by countries. It argues that PHC has been used as a strategy to ameliorate the pressures of demographic changes (aging populations), increasing population mobility, health inequalities, growing social exclusion, increasing costly diagnostic and therapeutic technologies. This is coupled with rising public demand and expectations. These are challenges faced by Georgia. The paper tells us that countries adopt PHC systems because they can be less costly and can allow for the coordination and management of chronic conditions which are rapidly gaining prominence as a burden of disease. Different schemes of governance are presented and the power relations between the central and local governments discussed.

1.1.4

Primary health care: The case of the Mediterranean countries

This document complements the previous three while focussing on Greece, Italy, Portugal, and Spain. These countries, it is argued, did not have the same resource base as the larger Western European countries and, therefore, during their PHC development faced a set of issues that are closer to that of Georgia. Issues faced by these countries include: lack of political commitment and continuity; PHC providers have low respect and relatively low earnings among other providers; curative services dominate; public perception that the quality of PHC services are low. In a number of these countries the private sector is a significant player. It is argued in the paper that for success of PHC systems the following conditions are required: • • • •

A broad consensus among political parties and continuity of the PHC policy direction; Consumers must have confidence and credibility in the public system; Decentralisation should be evolutionary; Support of the medical professions;

3

Primary Health Care: Service Delivery – Volume 2



Well equipped PHC centres and appropriately paid staff.

These four documents while not exhaustive in their description or analysis of PHC in Europe provided policy makers and other stakeholders in Georgia with increased knowledge of the strengths and weaknesses of different models of PHC. The second set of Documents, 5, 6, 7, and 8 addresses specific issues related to the setting up PHC in Georgia.

1.1.5

Drug scheme and PHC in Georgia

The document ‘Drug Scheme and PHC in Georgia’ presents the current drug system in the country and argues the importance of ensuring that the drug scheme be developed to support PHC. The paper suggests that access to PHC services in Georgia is dependent on the availability and affordability of pharmaceuticals. Financing and delivery options are presented to realize the Road Map for Primary Health Care Reform. Short term options to support 100 refurbished health centres are outlined and longer term options for the development of PHC discussed. Clear policy decisions are required in the areas of coverage (list of drugs, services and target groups in the population), cost sharing, and definition of benefits and the management of the scheme. Documents 5 and 6 are concerned with the training of PHC doctors and nurses. The Donors provided support to the training which was delivered primarily by five approved family practice centres and the State Medical University. The trainers and the training curriculum were in part developed during the first DFID supported Primary Health Care Programme. The training capacity was primarily limited to the aforementioned providers. The Government of Georgia made a decision to significantly increase the number of trained PHC providers, 1800 family doctors and 1800 family nurse and 600 community midwives between 2007 and 2011.

1.1.6

Master plan for retraining PHC doctors and nurses in Georgia

Document 5, ‘Master Plan for Retraining PHC Doctors and Nurses in Georgia’, sets out a detailed plan and presents options for increasing throughput of trainees while increasing the quality of the training. The plan proposes a scheme that is more cost effective and separates functions among the stakeholders. The paper suggests that for successful implementation the following factors are important; governance, human resource planning, curricula development, student selection and support, quality assessment and licensing and assessment of trainees.

1.1.7

Report on review of training programs for doctors and nurses in family medicine

Document 6 ‘Report on Review of Training Programs for Doctors and Nurses in Family Medicine’ was a detailed review of the training process and the curricula. This review provided valuable input into the previously discussed Document 5 above. Five steps are suggested for the retraining content and process. The steps are: 1. 2. 3. 4. 5.

4

clarify assessment processes initial review of curricula round table conference among stakeholders build capacity of stakeholders involved in the training process, and full review of curricula and assessment procedures.

PHC Service Delivery

The review presents a set of detailed recommendations that will provide the Ministry of Labour Health and Social Affairs with actions that can be taken to improve training for PHC providers. The final document, ‘Health Services in the Reformed Village Clinics’, presents options for the reform of 100 rural Primary Health Care Centres. The proposal describes the type of services to be delivered at the clinics, curative and preventive. The functions of the doctors and nurses are suggested and their relationship with the work of the public providers outlined. The paper suggests that a manager/developer function be developed to support the establishment of 100 centres. The proposal provided the MoLHSA with a plan that could be debated with policy makers and other stakeholders. The eight papers in this volume provided the MoLHSA with a sound basis for the making policy and operational decisions to support the development of a reformed PHC system for Georgia.

5

The Evolution of Primary Health Care in Western Europe

2

Briefing Note No. 8: The Evolution of Primary Health Care in Western Europe Antonio Duran

October 2004

7

Primary Health Care: Service Delivery – Volume 2

2.1

Introduction

Primary Health Care (PHC) has evolved in Western Europe along several different lines and continues to change in the face of new challenges. Surprisingly, it has been the subject of very little research (Olesen 2003). Most studies of PHC effectiveness have been conducted in the USA where PHC is almost non-existent, and general practice itself is under threat. The dearth of studies in Europe means that there is insufficient evidence on which to base sound health care policy for Georgia. This note describes the origins of primary health care in Western European countries and its contribution to the quality of care, health system costs and health outcomes.

2.2

The roots of European PHC

Health systems have their foundations in national histories and are linked to economics politics, cultures and beliefs. As a result, the structure of PHC in European countries has been greatly influenced by its roots. For several centuries “general practitioners” (GPs) in Europe have provided care to workers and to various professional groups, generally on a fee for service basis. Early on, some city councils paid general practitioners’ salaries to provide care for the poor and for hospital patients, pilgrims, the terminally ill or people affected by specific diseases, such as leprosy. During the 19th century, workers began to organise themselves into clubs to save and to share the costs of healthcare. As labour unions developed they put pressure on employers to finance “sickness funds”. By the end of the 19th and start of the 20th centuries, thousands of sickness funds, clubs and worker groups existed in Europe. As societies evolved, these collective arrangements for funding and providing PHC gave way to larger organisational arrangements so that, today, three main policy actors have an interest in PHC to varying degrees across European governments, insurers, and health professionals. General practice was, and still is, popular amongst European policy-makers. For example, it became a common feature of German sickness funds from 1860, of the Spanish “Instituto Nacional de Previsión” from 1908, of the Dutch mandatory “sickfund system” in 1942 and of the British National Health Service from 1948. The Dawson Report of 1920 first distinguished between concepts of “primary” and “secondary” care in the United Kingdom. It argued for a bottom-up or population-based approach to health service organisation, the allocation of resources, the generation of essential records and statistics and the training of health personnel for both environmental and personal health services. It set out a future vision of PHC being delivered from health centres close to the population. More recent developments in some countries include the development of group PHC practices, where PHC physicians, sometimes with different professional interests, work together, so expanding the range of services on offer; and the increased use of nurse practitioners and paramedical specialist staff. Another innovation, introduced in a number of countries was to assign the role of `gate-keeper’ to PHC practitioners. In these countries, patients cannot access secondary or specialist care, except in an emergency, unless they are `referred’ by a PHC physician. Although health systems are the products of history and, as a result, may be different from each other, there is general agreement that four levels of care are needed in order to ensure a rational use of resources:

8

The Evolution of Primary Health Care in Western Europe

• • • •

Self-care (personal and familial); Primary professional care (general practitioners, nurses, others); Secondary care (generally inpatient care); and, Specialist care.

Within each European health system somewhat different decisions have been made about what function each level should perform, how each level should operate and how each level should relate to the others, for both acute and chronic conditions. These roles and functions determine the resources allocated to each, their organisation and the education, training and supervision each level requires.

2.3

Challenges in European health care

Health systems in Europe now face enormous challenges: ageing populations, increasing population mobility, growing social exclusion and health inequalities, expensive new techniques and rising public demands and expectations. The overall effect has been rapidly rising costs and increasing constraints on public funding. Policy makers now have to make sharper public spending choices involving better defined priorities, if resources are to be rationed on the basis of “value for money” criteria and allocated equitably. Demographic, social, economic and technical changes have also had complex and off-setting consequences at the provider level: These include the increasing rates of chronic (long-term) conditions and “co-morbidity” (patients with several medical conditions) due to ageing, the increasing effectiveness of medical care, an increasing recognition that illnesses may have multiple causes and an awareness of the dangers of medical interventions. These have created additional demands on health services and on the coordination between service providers and health care delivery levels. In many cases coordination mechanisms have not developed rapidly enough to facilitate the flexible involvement of health care services and providers at different levels or to cope with the demand for cost-effective long-term care arrangements (Rico et al 2003). Two possible solutions are being explored to improve coordination between different levels of care: • •

2.4

transferring coordination power to general practitioners, as in recent UK NHS reforms, where Primary Care Trusts purchase a significant amount of secondary and specialist care for their patients; and, expanding or merging organisational units to form multi-level health organisations in order to internalise service coordination functions.

The role and contribution of PHC to health

In almost all developed countries (especially the USA), and despite a general lack of evidence to support it, specialist care has expanded more rapidly than PHC. As a result, medical practice has become increasingly hospital-centred and dominated by specialists. However, a PHC system centred on general practice has the potential to improve the cost-effectiveness, coordination and responsiveness of care, while at the same time improving equity. PHC requires less medical technology, the workforce is cheaper and there is less capital expenditure than in hospitals. It also has the potential to improve coordination between services and is better placed to manage chronic conditions (and co-morbidity) and to reverse the impact of economic and social inequity on health.

9

Primary Health Care: Service Delivery – Volume 2

A 1991 study comparing ten countries (including seven in Europe) found a close relationship between the expenditure on primary care, the overall ranking of 12 public health indicators and the satisfaction/cost ratio (people’s satisfaction with their health care system divided by the per capita cost of the health care system) (Starfield 1991). Another study in 2001(Engström et al 2001) found that increased access to PHC physicians contributed to better public health and a decline in the use of personal health services, leading to lower health care costs (or at least reductions in the rate of cost increase); that GPs could provide the same quality of care as specialists for many conditions, often at a lower cost; and that the way in which PHC is organised has a significant impact on outcomes. Outcomes were found to be best when funding was on a capitation basis, where GPs practiced in groups, where there was personal continuity and where PHC physicians were generalists. In other words, for common medical conditions and interventions, GPs were able to obtain similar health outcomes as specialists at lower cost. In summary, the financing, organisation and delivery of PHC have significant impacts on health outcomes. This was demonstrated by an analysis of the association between the strength of national PHC systems and health outcomes in 18 economically similar countries between 1970 and 1998. The study showed that PHC-oriented health systems were associated with improved health outcomes. However, the degree to which PHC features in European health systems varies. The UK, Denmark and Spain had the strongest PHC orientation in 1995, whilst Germany, Switzerland and France had the lowest (Macinko et al 2003). Those countries with the weakest PHC have generally not made much progress in PHC organisation and practice, despite having the most potential to benefit from improvements. It should be noted that, although France has not emphasized the importance of PHC to the extent of other European countries, the French health system was ranked number one in the World Health Report 2000 (WHO 2000). However, in 2004, reforms were introduced to give greater emphasis to PHC and to define new roles for general practitioners.

2.5

Conclusions

There is strong presumptive evidence that PHC is a cost effective way of delivering `first contact’ healthcare and that it has important advantages over secondary and specialist services: • • • •

its lower costs and use of capital make it more cost-effective for the treatment of many common conditions; its gate-keeping functions reduce unnecessary consultations at the secondary and specialist levels; it can deliver continuity of care more easily, particularly for chronic conditions; it can be located closer to communities giving consumers easier access to services and providers greater knowledge of local problems and conditions.

Whilst the studies discussed above suggest positive relationships between strong PHC and better health outcomes, there are few evaluations available to guide policy towards the most effective ways in which to organise PHC services. Despite this the history of PHC developments in Western Europe raises issues of relevance to Georgia: •

10

PHC funding in Western Europe developed from a fee-for-service basis, through smallscale collective funding arrangements to the involvement of the state in some countries and of insurers in others. Given Georgia’s limited means, it may not be easy to `leap-frog’ these stages of development.

The Evolution of Primary Health Care in Western Europe



PHC in Western Europe developed from sole practitioners to groups of PHC practitioners offering an increased range of services. The largest PHC practices, mainly to be found in cities, have some of the characteristics of polyclinics. This may be a cost-effective model for delivering one-stop services in areas with high population density. However, as emphasized here, the empirical evidence for the advantages of one organisational model over another is sadly incomplete.

This note is based on a longer paper prepared for the programme by Juan Gérvas (2004) Primary Care: Western European best practice of institutional involvement and responsibilities in Human Resource policy.

2.6

References

Engström, S., M. Foldevi and L. Borgquist, (2001), ‘Is general practice effective? A systematic literature review’, Scandinavian Journal of Primary Health Care, 19:131-144. Macinko, J., B. Starfield and L. Shi, (2003), ‘The contribution of primary care systems to health outcomes within Organization for Economic Cooperation and Development (OECD) countries, 1970-1998’, Health Services Research, 38:831-865. Olesen, F., (2003), ‘A framework for clinical general practice and for research and teaching in the discipline’, Family Practice, 20:318-323. Rico, A., R. B. Saltman and W. G. Boerma, (2003), ‘Organizational restructuring in European health systems: the role of primary care’, Social Policy and Administration, 37:592-608. Starfield, B., (1991), ‘Primary care and health: A cross-national comparison’, Journal of the American Medical Association, 266:2268-2271. Starfield, B., (1998), Primary care: Balancing health needs, services, and technology. OUP, New York. WHO, (2000), The World Health Report, 2000, Health Systems: Improving Performance. World Health Organisation, Geneva.

11

Workforce Composition and Roles in European Primary Health Care

3

Briefing Note 10: Workforce Composition and Roles in European Primary Health Care Antonio Duran

October 2004

13

Primary Health Care: Service Delivery – Volume 2

3.1

Introduction

Healthcare is a labour-intensive service sector. Workers’ remuneration is its largest single budget item and a health system’s workforce is vital to its effectiveness. Its skills and the way they are combined affect its cost effectiveness. Until recently, doctors dominated the PHC health workforce in Europe. However, in recent years more diverse PHC teams have been formed in most European countries so that the skills of general practitioners (GPs) are being increasingly complemented by those of nurses, pharmacists, managers, auxiliaries and other professionals. Each brings professional skills and training to providing a broad range of PHC services. Despite many PHC reforms in Europe since the early 1990s, there is very little information available on which to base comparisons between countries of the cost-effectiveness of different combinations of skills in PHC delivery (Boerma 2003). The Organisation for Economic Cooperation and Development (OECD) Health Data 2003 (OECD 2003) refers mainly to 2001 and focuses on expenditure rather than outcomes, as do most international studies. This briefing note describes the characteristics and responsibilities of the main categories of PHC workers, the way in which their roles are changing, their interactions in practice and the potential for team working.

3.2

Workforce composition

The number of health professionals per 1,000 people varies widely in Europe, from 46.9 in Finland to just 13.3 in Portugal. The UK, France, Germany and the Netherlands average around 30. The number of general practitioners and nurses per 1,000 people also varies significantly: from 1.7 GPs in Finland to around 0.5 in the Netherlands, Portugal and Switzerland; and 14.9 nurses in Finland to 3.8 per 1,000 in Portugal (OECD 2003). In 1999, GPs were usually a minority amongst active physicians, ranging from 18 percent in Portugal to 53 percent in Finland. Increases in the number of GPs have generally been in line with population growth, whilst the ratio of nurses to population has tended to increase slightly.

3.3

General practitioners

In most European countries the role of the general practitioner is to provide “comprehensive care to every individual seeking medical care irrespective of age, sex or illness” in the context of his or her family, community and culture; to promote health, prevent disease and provide palliative care and cure for medical conditions (Bentzen 2003). GPs are usually the first point of contact between patients and the health system. They make initial decisions about the diagnosis and management of illnesses and over 90 percent of problems are dealt with entirely at the PHC level. In many, but not all European countries, GP’s complement the skills of other medical specialists by acting as “gatekeepers” to minimise unnecessary contact between patients and specialists, whilst referring patients who genuinely need specialist care to the appropriate specialist. A Europe-wide analysis in 2003 showed that GPs in western countries cared for a wider range of conditions than those in post-communist countries. In all countries GPs working in rural provided more comprehensive services than those working in urban areas (Boerma 2003).

14

Workforce Composition and Roles in European Primary Health Care

3.4

Nurses

The role of the PHC nurse has changed substantially in Europe over the last 20 years. A nurse’s main responsibility is to assist and care for individuals and groups (families and communities) in varying states of health: that is, care which relates to health as well as illness and which stretches from conception to death. Nurses promote and maintain health, care for the sick and provide rehabilitation. Although the number of nurses in Europe has increased slightly, comparing the proportion of nurses directly involved in PHC in different countries is difficult because the definition of a qualified nurse varies and their responsibilities in different countries are very wide. The term “nurse” can refer to those both qualified and unqualified. A qualified nurse is a professional who has completed a programme of nursing education and is authorised to provide nursing care for patients (Bentzen 2003). At one end of the spectrum “nurse practitioners” (e.g. in Spain, Sweden and the UK) are trained to function as practitioners in their own right, undertaking much of the work traditionally regarded as that of a physician (e.g. prescription of medicines). Auxiliary nurses, on the other hand, mainly assist in less technical work. But just as the nurse’s role has changed in relation to doctors, so the role of auxiliaries has changed in relation to qualified nurses. The perception of nurses as low-status staff with little training is changing, although at faster rates in some countries than others. Nurses in Finland, Portugal, Spain, UK and Sweden work as members of PHC teams. In other countries (e.g. Denmark, Italy and the UK) nurses also have “preventative” roles as health visitors and public health nurses. Community (district) nurses who provide care in neighbourhood clinics or in patients’ own homes are common in the Scandinavian countries, France and Italy.

3.5

Pharmacists

Professionally trained and licensed PHC pharmacists practice in various settings, mostly in retail pharmacies but also in group PHC practices, community pharmacies and health centres (e.g. Sweden).Their role is changing from being providers of drugs prescribed by doctors to being pharmaceutical care providers. Four areas are critical for the future of pharmacy: the management of prescribed medicines; management of long-term conditions; management of ailments; and the promotion and support of healthy lifestyles (Edmunds and Calnan 2001). Pharmaceutical care is particularly strong in the Netherlands, Spain and the UK.

3.6

PHC managers and other professionals

The emergence of PHC managers is relatively new in Europe. It was linked with the growth of group PHC practices being run like small firms. Now, increasingly practice managers are the business managers for the PHC team. They deal with strategy, management systems, negotiation with suppliers, team working, organisational development, economics and finance. In some countries (e.g. Spain) managers are usually physicians; whilst in others (e.g. the UK) they are often professional managers. Administrative staff and receptionists are critical to the care process (e.g. organising doctors’ workloads, and providing support). Other professionals such as social workers, dentists, physiotherapists and occupational therapists can also be part of a PHC organisation, for instance as in Spain, the UK and Sweden.

15

Primary Health Care: Service Delivery – Volume 2

Outside official health systems there are a range of other practitioners. During recent decades public interest in acupuncture, homeopathy, osteopathy and other types of alternative or complementary medicine has increased considerably whilst the traditional antipathy between the established medical profession and other practitioners has declined. In France and Germany, homeopathic prescriptions are covered by public sickness funds.

3.7

Roles and interactions

The roles of PHC personnel have changed over time. PHC professionals in many European countries are currently under pressure to take on new roles and functions in the delivery of care. The re-definition of roles and functions can occur in three ways: • • •

Supplementary functions (increasing the efficiency of another professional by taking on some of their tasks, but usually under their direction); Substitute functions (providing services that have been provided by other professionals); and, Complementary functions (doing things that other professionals do not do at all, do poorly or do reluctantly) (Starfield 1998).

The re-definition of responsibilities may change the structure and management of a health system and can result in conflicts. For example, PHC nurses used to receive less training, had less responsibility and, as a result, received less pay than doctors. However, the increasing use of nurse practitioners, which has been associated with high levels of patient satisfaction and high quality care, is now challenging the relevance of undergraduate education for physicians. Continuity of care requires that members of the PHC team must work together in a coordinated way. However, in many systems poor liaison and suspicion between professional groups remain. The evolution of roles tends to foster this suspicion. For example, in Ireland, the UK and Italy there can be problems of poor liaison between community nursing (e.g. district nurses, health visitors) and GPs. There have also been tension between PHC physicians, traditionally the team leaders, and managers. However, each have much to offer the other in improving PHC efficiency (e.g. using electronic data bases in decision-making, as in Denmark and the UK). Forums such as the European Association of Public Health and the European Association of Health Economics are important for achieving this. The Spanish Primary Care Network (a scientific association of GPs and community pharmacists) is also an example of different professionals cooperating effectively. Good coordination is also necessary between different levels of care (e.g. hospitals and PHC; health care and social services). The Dutch “trans-mural care” is an example of a bottom-up approach being used to facilitate coordination between traditionally separate sub-sectors (Linden et al 2001). In particular, as patients get older, the boundaries between health care and social services are becoming increasingly unclear in terms of funding and of continuity of care (e.g. in the Netherlands, UK, Spain). This increases the need for good cooperation between PHC staff and social workers.

3.8

Team working in PHC

At the start of the 20th century most PHC physicians in Europe worked alone. In the UK the Dawson Report of 1920 established the concept of health centres where a group of PHC providers would work together. An early, although relatively short-lived, example was the Peckham Pioneer Health Centre in London in 1935 (first established as a health club in 1926). Other services based

16

Workforce Composition and Roles in European Primary Health Care

on similar ideas include the Pholela Health Centre in South Africa and the 1950s project of the Montefiore Group in New York. The World Health Organisation (WHO) began to support both PHC and public health centres in the 1970s. Finland was the first country to implement the health centre concept nationally, in 1972. Solo practice is still common in countries where GPs are self-employed (e.g. Austria, Denmark, France, urban Greece, Germany, Ireland, Italy, and the Netherlands). However, GPs increasingly share their practices and facilities or work as employees of health centres owned by health insurance funds or the government (e.g. rural Greece, Finland, Spain, Portugal, Sweden). Working in teams enables patients to call on a wider range of skills than those possessed by an individual working in a solo practice. Where there is shared decision-making and management of patients, results should improve. However, little is known about the cost effectiveness of teamwork in PHC. Research has shown that efficient teamwork is less likely in groups of more than 12 members. In Finland, Portugal and Spain, for example, health centres can often have over 25 professionals and some have over 100 staff. It may be that the shift from solo to group practice has gone too far. This note is based on a longer paper prepared for the programme by Juan Gérvas (2004) Primary Care: Western European best practice of institutional involvement and responsibilities in Human Resource policy.

3.9

References

Bentzen, N., (ed.), (2003), WONCA dictionary of general/ family practice. Laegeforeningens Forlag, Copenhagen. Boerma, W. G., (2003), ‘Profiles of general practice in Europe. An international study of variation in the tasks of general practitioners’, Doctoral Thesis. NIVEL, Utrecht. Edmunds, J. and M. W. Calnan, (2001), ‘The re-professionalisation of community pharmacy? An exploration of attitudes to extended roles for community pharmacist amongst pharmacists and general practitioners in the United Kingdom’, Social Science and Medicine, 53:943-955. Horrocks, S., E. Anderson and C. Salisbury, (2002), ‘Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors’, British Medical Journal, 324;819-823. Kernick, D. and A. Scott, (2002), ‘Economic approaches to doctor/nurse skill mix: problems, pitfalls, and partial solutions’, British Journal of General Practice, 52:42-46. Linden, B. A. V., C. Spreeuwenberg and A. J. P. Schrijvers, (2001), ‘Integration of care in the Netherlands: the development of trans-mural care since 1994’, Health Policy, 55:111-120. OECD, (2003), OECD Health Data 2003: A comparative analysis of 30 countries. CD ROM and user’s guide. OECD, Paris. Starfield, B., (1998), Primary care: Balancing health needs, services, and technology. OUP, New York.

17

Western European Best Practice of Institutional Involvement and Responsibilities in HR Policy

4

Primary Care: Western European Best Practice of Institutional Involvement and Responsibilities in Human Resource Policy Juan Gérvas

February 2007

19

Primary Health Care: Service Delivery – Volume 2

4.1

Introduction

It is known that the political and economic dimensions of health systems shape the governance and organisation of service delivery in general and of primary health care (PHC) services in Europe in particular. It is clear that the position of PHC and general practice1 is stronger in some countries than in others. The strength of a country’s PHC depends of the balance of health policy power of different actors, mainly governments, insurers, and professionals. This paper has been commissioned by Oxford Policy Management Ltd for DfID in the context of the Georgia Health Sector Reform Programme - CNTR 02 4201, Primary Health Care, for the Human Resources Policies Work Stream. This paper will review the role of different actors and in its interactions in countries of the European Union (EU) where general practice is strong. The reasons why PHC has a key role in the organisation of the national health services will also be explored. The objective is to identify the major components of a modern institutional map for the professions of general practitioners, nurses, managers and other professionals as seen in European PHC. The three questions this paper intends to answer are: • • •

who (and why) is involved in the organisation and delivery of PHC services and what are their respective roles; how they use their formal or informal policy power?, what services are provided, by whom, using what resources in PHC?; are there intercountries differences, and why?, how PHC relates to the wider health care system, what methods have empirically proved to be effective in improving the coordination role of PHC?

Given the policy nature of this paper, historical questions, such as the role of international agencies, and national social organisations, will also be considered. This document is not an academic research paper. Some explicit major characteristics of it are: a) it is an applied analysis of different ways of organising PHC, as a response to the intellectual challenge of understanding and translating into practice best practice models, focus on its scientific base b) it has a teaching style, by means of extensive use of examples and a case study (more studies are included in a parallel document), and c) it has a neutral approach to any policy initiative.

4.2

Understanding PHC in the European Union

4.2.1

Health and health services

There is too little research into PHC in all countries, compared with other fields of medicine (Olesen 2003). Ignorance and illusions abound. In 2003, the WHO has insisted that a basic feature of a health care system based on primary care is to “continuously assess and strive to improve performance” (Jong-wook 2003). In Europe, the WHO Ljubljana Charter emphasized the same principles, with emphasis on PHC (WHO 1996).

1

In Europe, family medicine is synonymous with general practice and the latter term is used in the remainder of this paper since is the term used in the countries included in this analysis. The same applies to general practitioner versus family physician.

20

Western European Best Practice of Institutional Involvement and Responsibilities in HR Policy

Research has shown that the greatest factors influencing the health of any population are national wealth and its distribution. In fact, the interrelationships between health and social class in particular have been extensively studied in Europe. Health and ill health are not equally distributed. For the sake of conceptual clarity is it worth emphasizing that health systems cannot “create” health but rather improve or optimise it and prevent avoidable a) suffering, b) morbidity and c) mortality. Also, health is not a “human right” (if so, morbidity and mortality should be “inhuman and illegal”)2. Another key influential determinant of health is the genetic structure (the other determinants recognised by the seminal Lalonde Report in Canada in 1976, namely social and physical environment, individual behaviour and health services, are superimposed on the genetic structure) (Starfield 1998). It is also known that health services are not “artificial” structures that can easily be set up or dismantled at will by the policy makers of the day, as they are inextricably involved in the economics and politics of society. Each national health system is rooted in national history, which is linked with political and cultural philosophies and beliefs. In fact, the roots of Primary Health Care and General Practice in Europe explain its present configuration. From Middle Age, workers in Europe have had some kind of “general practitioners” who took care of the different professional groups (workers and their dependents) and were paid a monthly fixed amount per capita. At that time City councils also organised with general practitioners, paid by salary, the care of the poor and the care provided in hospitals (mainly places for pilgrims and terminal patients, or people affected by specific diseases, such as leprosy). During the 19th century workers began to organise labour unions, and under their pressures business leaders realised that it was in their own self-interest to develop “sickness funds” (later on Bismarck would pioneer a sickness funds national plan). At the end of the 19th century and beginning of the 20th, Europe had thousands of those sickness funds, clubs and worker groups, organisations which somehow could be seen as today Health Maintenance Organisations (HMO) in the USA. In short, in Europe general practice was, and still is, popular amongst policy makers and the population. For example, general practice became a common feature in the German sickness funds from 1860, in the Spanish “Instituto Nacional de Previsión” from 1908, in the Dutch mandatory “sickfund system” in 1942, and in the British National Health Service from 1948. Historically, the three main collective policy actors, governments, insurers and professionals, have supported PHC. Almost 60 years before the WHO Alma Ata Declaration, in 1920, the landmark Dawson Report in the United Kingdom introduced the concepts of “primary” and “secondary” care, setting out the future concept of health centres3 and PHC. With a clarity and specificity unequalled since, the report argued the case for the bottom-up or population based approach to health services organisation, the allocation of resources, the generation of essential records and statistics and the training of health personnel for both environment and personal health services. The Dawson report stressed that the elements of a logical system should be suitable, correlated and available to all. Health systems are thus historical products and thus are different from each other. But in a way all health systems can be considered to have to face similar basic needs and requirements. There is wide consensus that in order to ensure a rational use of resources there have to be four levels of care:

2

There is continuous confusion between “health as a human right” and “the right to health care”. Health centers, however, could be state owned (Greece, Finland, Portugal, Spain, Sweden), or owned by the general practitioners (Denmark, Ireland, Italy, the Netherlands, the UK).

3

21

Primary Health Care: Service Delivery – Volume 2

• • • •

self care (personal and familiar), primary professional care (general practitioners, nurses, others), specialist care, and super-specialist care.

Each health system then has to decide how each level should operate and how each should relate to others, for acute and chronic conditions. Each level has to have its own understandable roles supported by resources, organisation, education/ training and supervision. For example, collective disease prevention, as it is the case with immunization, could be organised separately from PHC, as in Finland, Italy, and the Netherlands. It is also well known that health services in areas where social and economic disadvantage is intense need more resources. Health systems in Europe face enormous challenges: demographic changes (emigration and immigration, aging of the population), increasing population mobility, health inequalities, growing social exclusion, costly new diagnostic and therapeutic techniques, and rising public demands and expectations. As a result, public spending is always under tight constraints. Health care is expensive and has to be paid for. Also, in Western Europe, and linked to the above, a major change has been the growing prevalence of chronic conditions and co-morbidity4 resulting from the ageing of populations and the improving efficacy of medical care. The increasing recognition of the multiple causes of illness, the predominance of co-morbidity and the dangers of medical interventions all challenge the biological model of “one disease at a time” and the model of health services with poor coordination between service providers and health care delivery levels. The coordinative capacity of many health care systems is inadequate to enable the flexible involvement of various health care services and providers, and to cope with demand for different long-term care arrangements (Rico et al 2003). As a consequence, policy makers have to make explicit choices in spending public money, which involves defining priorities, equitably allocating resources, rationing and placing concerns with value for money high on the agenda. Possible solutions to increase such coordinative capacity within the health service institutions are: • •

transferring coordination power to general practitioners, and expanding or merging organisational units as health centres (or hospitals) in order to internalise actions that were previously inter-unit.

A coherent PHC, with general practice as its integrative core, has the potential to improve costeffectiveness of care as well as coordination and responsiveness, while at the same time reducing the adverse effect on health of lack of equity. Nevertheless, the truth is that in almost all developed countries, with the USA in a leading position, specialist care has expanded much more than PHC, without any scientific base justifying such an expansion. The rapid growth of the health services techno-structure has almost irrevocably altered the course of medical practice, making it increasingly hospital-centred and dominated by specialists. Apparently, PHC is cheap, as it requires less expensive technologies, workforce and capital expenditure than hospitals. But, as noted, some kind of PHC has always existed in Western Europe, to the point that we cannot even consider the experience of developed European countries without general practice. The critical question: “is PHC cost effective in Europe?” cannot 4

Co-morbidity is the norm in people with an illness. That is, more people have multiple diagnoses that can be accounted for by random distribution in the population. Although there is increasing morbidity with increasing age, the extent of comorbidity in children is much greater than expected at random than in the case in older people.

22

Western European Best Practice of Institutional Involvement and Responsibilities in HR Policy

therefore be answered in full because there is no control group. Of course, much of what is provided in hospitals and by specialists is also unproven (and expensive). The only point raised here is that if health care reforms should include emphasis on PHC, as recommended by the WHO Ljubljana Charter (WHO 1996), then policy goals must be clearly articulated and the knowledge base informing efficient delivery of care must be improved. In short, no country can now escape the conflict between increasing demands and costs of health care and what people can afford. A coherent PHC could be the choice not only because it is apparently cheap (the cost), but because of its potential for coordinating and managing chronic conditions (and co-morbidity) and its impact in reversing the effect on health of economic and social lack of equity.

4.2.2

The contribution of PHC to quality of care, health system costs, and health outcomes in Europe

Paradoxically enough, most studies about the effectiveness of PHC have been conducted in the USA, where PHC almost does not exist, and general practice itself is under threat. As an illustration, general practice is considered in the USA just as family medicine and even “general practice” as well as “general practitioners” are not MeSH terms in MEDLINE, which is an expression of the low scientific and social value of general practice in the USA. But the results from studies of the commercialised health care system in the USA may not be easily generalised to Europe. In the USA costs are easier to find than in Europe in the form of claims from doctors and hospitals to health insurance organisations. The shortage of studies of European health systems implies that health care policy, to a great extent, is acting without knowing (Engström et al 2001). In short, is PHC in Europe taken for granted? In a pioneering study, in 1991, comparing 10 countries, seven European, (Australia, Belgium, Canada, Denmark, Finland, Germany (former Federal Republic), the Netherlands, Sweden, the UK, and the USA (fee for service, private practice sector)), a close association was found between the ranking of primary care, the overall ranking of 12 public health indicators, and the satisfaction/cost ratio (the inhabitants’ satisfaction with their health care system divided by the per capita cost of the health care system of that country) (Starfield 1991). Also, an analysis to assess the effectiveness of general practitioners in PHC, in 2001, found evidence that 1) increased access to physicians working in PHC contributes both to better public health as measured by different health parameters and to less consumption of medical care, leading to lower costs in the health care system (at least, to slowing the growth rate in health care costs), 2) compared to other specialists, general practitioners can take care of many diseases with the same quality, and often lower cost, and 3) the way in which PHC is organised has a great impact on outcomes, and those effects are enhanced by reimbursement by capitation, group practice, personal continuity, and having generalists as PHC physicians. In other words, general practitioners are generally able to obtain similar health outcomes as those obtained by other specialists in the case of frequent conditions or interventions that allow them to see enough patients per year to acquire and maintain the necessary skills directly (Engström et al 2001). The financing, organisation, and delivery of PHC appear to have significant impacts on health outcomes at the national level, as all cause specific – and several categories of cause specific premature – mortality proved to be sensitive to PHC (e.g., asthma, pneumonia and cardiovascular disease). A time series analysis was performed in 2003, of the association between national PHC systems and health outcomes, from 1970 to 1998, in 18 countries [Australia, Belgium, Canada, Denmark, Finland, France, Germany, Greece, Italy, Japan, the Netherlands, Norway, Portugal, Spain, Sweden, Switzerland, the UK, and the USA] (Mazinko et al 2003). Those countries were chosen based on the availability of data and economic similarities among them. The study

23

Primary Health Care: Service Delivery – Volume 2

demonstrated that strong PCH oriented health systems were associated with improved population health. But not all European countries have a strong PHC orientation. Ordered by practice score (maximum, the best, 20) they rank, in 1995 (the latest date): • • • • • • • • • • • • • •

the UK (19), Denmark (18), Spain (16.5), the Netherlands (15), Italy (14), Finland (14), Norway (13) Sweden (11). Portugal (7), Belgium (4), Greece (4), Germany (3), Switzerland (2.5) France (2).

In fact, the two later are under the USA practice score of primary care, 35. It is noteworthy that countries with the weakest PHC, and therefore those with the most potential to benefit from improvements have, in general, not made much progress in improving PHC structure and practice. However, it must be noted that the French health system was ranked number 1 by the WHO in 2000 (WHO 2000). This obviously shows either that the WHO’s WHR2000 criteria did not value PHC, or that chronic deficit incurred to obtain its performance had been not noticed until 2004, when pressures to change French health system gave emphasis to PHC and a new quasi gatekeeping role to general practitioners. In short, PHC in Europe should not be taken for granted. In Europe a few countries have strong PHC (Denmark, the Netherlands, Spain and the UK). Strong PHC is associated with a similar quality of care to that provided by specialists, better population health outcomes, and lower costs in health care systems (or at least, a slower growth rate of health care costs). In many wealthy European countries PHC is not a euphemism for cheap and low quality care (second rate health services for poor people) but an organisation for answering population needs. But it is clear that European studies evaluating how to most effectively organise PHC are far too few. 4.2.2.1

Summary

The health of a population is mainly determined by wealth and its distribution. Strong PHC in Europe has been shown to be associated with better health outcomes, and to some extent to reduce the adverse effects of lack of equity, which is consistent with the postulated benefits of primary care. General practitioners, in comparisons with other specialists, take care of many diseases without loss of quality, and often at lower cost. Emphasis on PHC has been partially successful in at least slowing the growth rate of health care costs. Expectations about the beneficial role of PHC in improving the health of the population may be plausible, as suggested by the association between strong PHC and better health outcomes, but there is no firm evidence base to support this. If PHC is to make a more effective contribution to reducing health inequalities, 5

Primary care practice score in 1995 was 13 for Australia, 11.5 for Canada and 7.5 for Japan.

24

Western European Best Practice of Institutional Involvement and Responsibilities in HR Policy

it needs to be more aware of the nature and scale of social and economic disadvantage at both geographical and individual levels.

4.3

Providers of services in PHC delivery in different EU countries

4.3.1

European differences in PHC workforce

As seen above, despite the presence of universal health insurance in all European countries, there are marked differences in emphasis in PHC and its organisation. Indeed, heath care is still largely a national affair in the European Union. Then, differences in the tasks and activities of PHC professionals, as general practitioners, do not only exist between individual physicians, but also between countries. Sources of variation between countries lay in the features of the respective health system, such as their specific financing and regulation modes. As in other sectors, when countries of central and eastern Europe look to the West for models of PHC organisation, provision, and financing, they face no easy choices. But the fact is that whichever models these countries have chosen, all have decided to move towards a health care structure with a firm base of primary care, including general practitioners playing a more or less central role, and a simultaneous reduction of the hospital sector. It is astonishing how little information is available for comparison of PHC in different European countries, even at descriptive level (Boerma 2003). Information from one of the best databanks, the OECD Health Data 2003 (Organisation for Economic Cooperation and Development) refers mainly to 2001 and focuses on expenditure, not outcomes (OECD 2003). In fact, international studies on expenditure abound, but research on the effects and mechanisms of health care provision to the population is scarce and handicapped by lack of data. According to OECD Health Data 2003, • • •

health professionals’ density per 1,000 inhabitants varies from 46.9 in Finland to 13.3 in Portugal (32.1 in the U.K., 30.9 in France, 30.4 in Germany, 28 in the Netherlands, and 17.1 in Spain), general practitioners’ density varies from 1.7 in Finland to 0.5 in Switzerland (1.6 in France, 1.4 in Austria, 1.1 in Germany, 0.6 in the UK, and 0.5 in the Netherlands and Portugal), and nurses’ density varies from 14.9 in Finland to 3.8 in Portugal (14.8 in Ireland, 12.8 in the Netherlands, 9.7 in Germany and 9 in the UK).

In the European Union general practitioners are a minority amongst active physicians, ranging from 18% in Portugal to 53% in Finland, in 1999. Their total number has increased, but only in parallel to the increase of the population. Available data on the supply of physicians suggest that the composition of the workforce has not kept pace with specific technical aspects of the development in delivery of care. Concerning nurses, the ratio has tended to increase slightly. What staff is involved in PHC delivery in Europe? We might regard as “core” European PHC workers the following: a) general practitioners, b) nurses, c) pharmacists, d) managers e) auxiliaries and f) other professionals. Such professions do show the classic traits required for a cooperative coordination mechanism to work effectively, such as a common socialisation process (training), high salience of reputation and shared value systems (deontology). Each will be briefly assessed in the next section.

25

Primary Health Care: Service Delivery – Volume 2

4.3.2

General practitioners in Europe

According to WONCA Dictionary of general/family practice, a general practitioner (family doctor, family physician) is a specialist physician trained in the principles of the discipline (Bentzen 2003). A general practitioner is “a personal doctor, primarily responsible for the provision of comprehensive care to every individual seeking medical care irrespective of age, sex and illness” (this emphasis on responding to medical care- seeking is linked to the so called ‘Osler paradigm’). The general practitioner cares for individuals in the context of their family, their community and their culture, always respecting the autonomy of the patient. S/He recognises the professional responsibility to the community. General practitioners exercise their professional role by promoting health, preventing disease and providing cure, care and palliation (Bentzen 2003). General practitioners accept the responsibility for making an initial decision on every problem with which a patient presents, and more than 90% of problems are dealt with entirely within general practice. General practitioners and specialists have complementary ways of thinking. Using epidemiological concepts, general practitioners have very high negative predictive value (they know very well who is healthy) and specialists have very high positive predictive value (they know very well who is ill, when working with populations who have high prevalence of disease). So the natural way of organising health services (in order to increase the efficiency and quality of medical care) is to use general practitioners as a “barrier” to keep healthy patients away of the unnecessary contact with specialists, and to refer the “filtered” population which higher prevalence of disease to specialists. The diagnostic task of specialists consists of reducing uncertainty, exploring possibility and marginalising error. The diagnostic task of general practitioners, as a way of contrast, is to accept uncertainty, to explore probability and to marginalise danger (Sweeney 1994). First access should be only to general practitioners with enough knowledge and skills to answer directly almost 95% of the demands, thus referring around 6% of the patients to specialists, because probably they have infrequent diseases, or they need costly diagnostic and therapeutic procedures. An analysis of the general practitioners’ tasks profiles in Europe, in 2003, shows a consistent contrast between post-communist and western countries (Boerma 2003). In western countries general practitioners have more comprehensive services profiles, particularly regarding the first contact with health problems and the provision of medico-technical procedures. In all countries, there is a contrast between rural and urban areas; in rural areas the profile of services is more comprehensive. General practitioners have longer working weeks in countries where they are selfemployed (Austria, Denmark, France, Germany, Ireland, Italy, the Netherlands, the UK and others) (Boerma 2003). Paediatricians have the role of general practitioners in countries like Italy and Spain, where they care for population under 14 years in the public health system.

4.3.3

Nurses in Europe

The primary responsibility of nurses is to assist individuals and groups (families and communities) to optimise function within varying states of health. This means that the discipline is involved in caring functions which relate to health as well as illness and which stretch from conception to death. Nursing is concerned with maintaining and promoting health, caring for the sick and providing rehabilitation. A nurse is thus a professional who has completed a programme of nursing education and is qualified and authorised to provide nursing care for patients (Bentzen 2003). The term “nurse” includes both qualified and unqualified nurses, the latter describing a wide range of professionals who assist doctors and help patients. Moreover, even the definition of a “qualified” nurse differs between European countries, where the range of activities and responsibilities of

26

Western European Best Practice of Institutional Involvement and Responsibilities in HR Policy

PHC nurses is very wide. At one end of the spectrum (“nurse practitioners”) they have been trained to function as practitioners in their own right, taking over much of the work traditionally regarded as that of the physician (even prescription rights), as in Spain, in Sweden and the UK. Auxiliary nurses in Europe are devoted mainly to assisting fully trained nurses in less technical work, such as bed bathing patients at home. But just as the nurse’s role has changed in relation to the doctor, so the auxiliary’s role has changed in relation to the nurse. Nurses are members of health teams (public health centres) in countries like Finland, Portugal, Spain and Sweden. Nurses involved in prevention are common in Europe, as health visitors and public health nurses, as in Denmark, Italy and the UK. The midwife has a fairly clearly defined role related to the delivery of birth. However, it has become progressively more related to ante and postnatal care than with the actual supervision of deliveries (yet, for example, in the Netherlands home deliveries are still not uncommon and most of them are attended by an independent midwife6). Community nurses, or district nurses, are common in Scandinavian countries and in France and Italy; they provide care for patients in neighbourhood clinics or in their own homes. Although the number of nurses has tended to increase slightly in Europe, there is a serious problem of inter-country comparability due to different definitions of nursing. It is not exactly known what proportion of these nurses is directly involved in PHC. The perception of nurses as low-status staff requiring minimal training is beginning to moderate, though the process of changing attitudes is very slow and widely uneven among European countries.

4.3.4

Pharmacists in Europe

A pharmacist is a professional licensed to practise pharmacy. PHC pharmacists practise in various settings including community pharmacies, and health centres (as in Sweden). PHC pharmacists are moving from being providers of drugs prescribed by doctors to pharmaceutical care providers, pharmaceutical care being a patient-centred, outcomes- oriented pharmacy practice. The four main areas considered critical for the future of pharmacy are: 1) the management of prescribed medicines, 2) the management of long-term conditions, 3) the management of ailments and 4) the promotion and support of healthy lifestyles (Edmunds and Calnan 2001). Pharmaceutical care is stronger in the Netherlands, Spain and the UK than in the rest of Europe.

4.3.5

PHC Managers in Europe

The PHC manager is a professional who is responsible for conducting or directing PHC organisations. Managers could be mostly physicians, as in Spain, or professionals in their own field (from business schools), as in the UK. Managers may be specialists in finance, marketing or human resources, but many more PHC managers are generalist doctors. Managers think first about organisations and deal with leadership, strategy, systems, negotiation, team working, organisational development, economics and finance. Managers could also include in their management teams pharmacists devoted to promoting the rational use of drugs in PHC. PHC Management development is in many ways in its infancy.

6

According to the scientific evidence, the outcome of ante and postnatal care, and normal pregnancy is better under care by midwives and general practitioners than by obstetricians

27

Primary Health Care: Service Delivery – Volume 2

4.3.6

Other PHC professionals in Europe

Administrative staff, the receptionist and other professionals are important in PHC daily practice, as they care for critical components in the process of care (booking and repeat prescriptions, as examples). Other professionals as dentists, social workers, physiotherapists and occupational therapists could be part of the PHC organisation, as in Spain and Sweden. Outside of the official health care system a variety of unorthodox healers flourish and during the last decades there has been a considerable increase in public interest in acupuncture, homeopathy, osteopathy and other types of fringe medicine (alternative or complementary) in Europe. Borders are erased when, for example in France and Germany, homeopathic prescriptions are covered by public sickness funds.

4.3.7

Inter-professional interactions in daily practice

As already explained, currently the PHC team members are under steady pressure to take on new roles and functions in the delivery of care. New roles mean conflict and re-definition of responsibilities. There are three types of functions for that re-definition: 1. supplementary functions (extending the efficiency of other professionals by assuming some of the tasks usually under the direction of that professional), 2. substitute functions (providing services that are often provided by other professionals), and 3. complementary functions (doing things that other professionals do not do at all, do poorly or do reluctantly) (Starfield 1998). Until today, nurses in PHC have received less training, accepted less responsibility, and dealt with less uncertainty (and as a result, they have received less remuneration) than doctors. Increasing availability of nurse practitioners, with high level of patient satisfaction and high quality care, is even challenging the relevance and balance of existing undergraduate education for the physicians (Horrocks et al 2002; Kernick and Scott 2002). Poor liaison exists between community nursing (district nurses, health visitors, etc.) and general practitioners, as it is recognised to be the case in Ireland, Italy and the UK. The auxiliary is not so much assisting the nurse, but deciding to whom she needs to refer and what she can do by herself. While community pharmacy is developing strategies to enhance its professional status, those strategies are not so much aimed at usurping the general practitioners’ role as they are a bid for survival, especially on the part of the rank and file. General practitioners and pharmacists can cooperate in imaginative ways, even in the fields of continuing education and research, as is the case in the Spanish Primary Care Network (a scientific association of general practitioners and community pharmacists). But frequently, general practitioners may fear that in the privately financed, commercially focused environment of a community pharmacy, a pharmacist may not be able to resist the temptation to act, may be unconsciously, in their own interests. Privacy is also cited as a potential barrier. Research in Europe has shown that pharmacists are able to avoid such moral hazards, and that when deciding where to seek advise and from whom, patients make a series of trade offs (while holding very firm views about who does what and why with regards to their care) (Edmunds and Calnan 2001).

28

Western European Best Practice of Institutional Involvement and Responsibilities in HR Policy

About general practitioners and managers, a constructive dialogue has to replace mutual suspicion. They are learning from each other in daily practice (use of electronic databases in decision-making, for example, as in Denmark, the UK, and other countries) and particularly from forums such as the European Association of Public Health and the European Association of Health Economics. Also, the boundaries between health care and social services are becoming blurred, so that services such as homes for the elderly and family care are currently included in health care. This forces cooperation between PHC workers and social workers, as in the Netherlands, Spain, the UK, and other countries. When coordination between levels of care and services (e.g., hospitals and PHC, health care and social services) occurs, it is usually as a result of network interactions operating within public hierarchies and across boundaries. Coordination requires enough stability and a common set of professional values. An example is the “trans-mural care” Dutch experience, where a bottom-up facilitating approach was chosen to stimulate development of coordination between traditionally separate sectors (Linden et al 2001). The traditional antipathy between the established medical profession and other healers seems to be declining.

4.3.8

Teamwork

A team is a group of people brought together to work towards a common purpose. At the beginning of the 20th century PHC in Europe was characterised by solo practice. In the early years of the 21st century, solo practice is still common in Europe in countries where general practitioners are self employed, as Austria, Denmark, France, Greece (urban areas), Germany, Ireland, Italy, the Netherlands, and others. But general practitioners increasingly share their practices and facilities (group practice, as in the UK) or work as public employees in health centres owned by the health insurance funds or by the government (as in rural Greece, Finland, Portugal, Spain, Sweden and others). The already mentioned Dawson Report set up the concept of health centre. One of the early examples was that of the relatively short-lived Peckham Pioneer Health Centre in London in 1935 (first established as a health club in 1926). Mention must be made among services based in similar ideas of the Pholela Health Centre in South Africa and the project carried out in the 1950s by the Montefiore Group in New York. WHO started to support both PHC and public health centres in the 1970s, with the Finnish reform as first national example in 1972. In practice, teamwork could be an ideal rather than a feasible reality as most health centres, in Finland, Portugal and Spain for example, have more than 25 professionals (even some health centres have more than 100 staff!). Research has shown that teamwork is highly unlikely with more than 12 members. All teams are groups but not all groups are teams. Inter-professional collaboration is difficult to attain via hierarchical mechanisms only. Without collaboration, task profiles expanded by decree are not easy to implement either. Teamwork is becoming increasingly important to patients because it enables them to call on a range of skills which is wider than those any one individual may have. Where there is shared decision-making and management of patients, results improve. The disadvantages of teamwork lay in problems of communications, confidentiality and either competition or duplication of services by different members of the team. Little is known about the scientific base of teamwork in PHC and about its cost effectiveness. Team members need to be more aware of management as a

29

Primary Health Care: Service Delivery – Volume 2

discipline in its own right and of the need for valid criteria of effectiveness to be developed and monitored. 4.3.8.1

Summary

Little information is available for comparison of PHC in different European countries even at a descriptive level. This lack of information is particularly remarkable in the light of the health care reforms that have occurred since the early 1990s, many of which have affected primary care. We know little about the impact of different modalities of practice organisation and workforce distribution. Core professionals in European PHC are general practitioners, nurses, pharmacists, managers and others. Roles are changing with implies conflict and reorganisation of responsibilities. Although teamwork is seem as desirable, its scientific base and cost effectiveness is not well known.

4.4

Different actors for different interests in PHC in the EU; Models of best practice

4.4.1

PHC policy in Europe: similar actors, different interactions (and solutions)

The categories of social actors in PHC policy in Europe are invariably: 1. the patients (or their families and associations), consumers of services and population (in a broader sense, society), 2. the providers of services and institutions as health centres and hospital (those directly contacted by patients, those available via first contact providers and others, as future providers) and their associations, 3. teaching and research institutions, 4. the health industry (consultancy, pharmaceutical and technological industries), 5. the financers or insurers of health care, and 6. government authorities (international, national, regional and local). Informal policy power is in hands of the main collective actors: government authorities, insurers and professionals. The main sources of informal policy power are: 1. ownership and financial resources, 2. knowledge and information resources, and 3. social and political support (Rico et al 2003). Formal policy power lies in turn in the hands of government authorities. Differences between PHC in Europe do not lie in the types of actors, but in the way they relate to each other (Gervas et al 1994). Collective actors, endowed with informal policy power, can exert pressures upon the political process (e.g., lobbing for private entrepreneurship), and exercise formal influence (for example, joint decision-making among physicians and insurers). As a result, policy shifts may: 1. modify the rules of the interactions (external rules imposed by the government upon other actors), and-or 2. allocate and redistribute resources.

30

Western European Best Practice of Institutional Involvement and Responsibilities in HR Policy

The dynamic interactions between the actors relate to: • • • • • •

the provision of services to patients and populations, the movements and referrals between each level of providers, patients’ payment of insurance premiums, or taxes, providers’ ways of payment, scientific and policy knowledge (as reports and guidelines) and regulation by government.

Little is known about the way the PHC actors interact with each other (Rico et al 2003; Boerma 2003; Gervas et al 1994). As a proxy, we can measure the success of the interactions at country and international levels as reflected in outcomes such as the cost of the health systems and the health outcomes produced (Mazinko et al 2003). The impact on the adverse effects of lack of equity on health is also critical. Accomplishing the European public health policy objective of ensuring that everyone has access to the necessary health care while keeping expenses affordable whatever the income has proved very difficult (Maynard and Bloor 1995). Again, the problem for governments and societies, as demonstrated by experience in recent decades, is that demand for health care is rising inexorably. In fact, the supply of health care actually fuels further demand. Worse, demand is not equivalent to need. Also, it is worth noting that organisations do not start in real life from a clean slate from which ideal choices can be made. Health systems are not easy to change, since they only develop within a framework which they have inherited, building on what has gone before. Often, organisations are true memorials to old problems, institutional residues that reflect the historical processes through which problems have been tackled. Historically, the dominant interest group included the professional monopolisers, the physicians, whose control of medical knowledge both explains and reinforces the dominance of the disease model of illness. Although numerically small, as compared for example to nurses, their definitions of health and illness tend to dominate health policy and service provision. The fact is that actors with better social reputation (e.g., hospitals versus health centres, or specialists versus general practitioners), and organised interests (for example, specialists supported by pharmaceutical and technological industries) do enjoy more informal policy power, which might not always lead to efficient coordination solutions. The dynamic policy process ends with a health services structure and function which reflects how rules are established and modified and how resources are allocated and redistributed (Rico et al 2003). Policy making being a dynamic process, there is no real end to it, and changes in formal and informal policy power (due to changes in the distribution of resources and social and political support) lead to reforms. Reforms aimed to empower PHC may: • • •

increase the power of general practitioners over other levels (pro-coordinating reforms, as introducing gate-keeping or purchasing rights), broaden the profile (the service portfolio) of general practitioners and other primary care providers, and induce concurrent changes in PHC organisational resources and control systems (necessary for promoting a major role for PHC) (Rico et al 2003).

31

Primary Health Care: Service Delivery – Volume 2

4.4.2

Models of best practice

General practice is a well-recognised medical specialty in Europe, with postgraduate training now obligatory in the EU, ranging in practice from 3 years (as in Spain) to 6 years (as in Finland). But it is clear that the position of PHC (and general practice) is stronger in some countries than in others (Starfield 1991; Mazinko et al 2003; Boerma 2003; Gervas et al 1994; Boerma et al 1993). The strength of a country’s PHC system depends of its actors and their interactions. In some countries, there is a negative circle of low social esteem, poor education, low self respect, poor earnings, scarce research and heavy competition with the more glamorous specialists and hospital-based medicine (Boerma et al 1993). Countries that have broken this vicious circle, like Denmark, the Netherlands, and the UK (and to a lesser extent Spain) have strong professional organisations which elbowed its way into the universities and finally achieved postgraduate training courses, which became mandatory for the profession of general practitioner (before the EU issued the corresponding legislation). The above mentioned 4 countries are very different. Perhaps the most interesting case is the Netherlands, because of its success compared to Belgium, France and Germany, also wealthy countries with a “Bismarck” health system model (a social security system, funded from proportional premiums earmarked for health care). Generally speaking, governments in countries with Bismarckian systems have played a more hands-off, reactive role, with the two other main actors (professionals and insurers) dominating the policy process (Rico et al 2003). Governments share in fact their formal policy power with sick-funds (public insurers). In these countries, organisational networks follow neo-corporatist schemes, based in joint decision-making by stateinsurers and professionals (with specialists as key actors), whereas (with the exception of the Netherlands) they have a weak general practice. The status of general practice is better in countries with national health services (“Beveridge systems”), such as Denmark, Spain and the UK. In national health services funding is through taxation and services are largely provided in kind by the state, but general practitioners may be contracted and work in private practice, as in Denmark and the UK. In these countries State authorities have the monopoly of formal policy power and they are pro-active, establishing targeted interventions by external rules and allocating and distributing resources (Rico et al 2003; Boerma 2003). Insurers play almost no role (financing is public, albeit private insurance is a profitable business) and professionals are powerful lay actors. The example of Spain is very interesting, being a country with a Beveridge system only from the 1980s which has achieved reasonable success compared with other Mediterranean countries, such as Greece and Portugal. General practice forms the solid base of these 4 European countries’ health care system. It is aided by protective measures, like: • •

limiting direct access to specialist care and providing the general practitioners with the role of gate-keeper (external rules imposed by the state), and allocating enough financial and material resources (even ownership of health centres in Denmark, the Netherlands and the UK) (Rico et al 2003; Boerma 2003; Gervas et al 1994).

Gate-keeping is perhaps the most important example of mechanisms through which hierarchical coordination power over other levels of care is delegated to general practitioners. The capitation way of payment, associated with the patient list, has proved important for general practitioners to maintain their role of gate-keepers to specialised care in Denmark, the Netherlands, Spain, and the UK (though Spanish general practitioners are salaried, with only around 10% of the total amount per capita) (Sweeney 1994; Gervas et al 1994).

32

Western European Best Practice of Institutional Involvement and Responsibilities in HR Policy

In Denmark and the Netherlands, the application of the general principle of gate keeping differs in practice, according of the type of health insurance. For the publicly insured (97% and 60% of the population, respectively, with an income below a certain annual level) this requirement is absolute. The privately insured patients may access specialists directly (Gervas et al 1994; Boerma et al 1993). Gate-keeping gives general practitioners a de facto monopoly over patients’ flows into secondary level, with the exception of emergency care. In practice, gate-keeping has improved neither communication nor cooperation between general practitioners and specialists, because administrative rules have dominated the referral process, at least until the pro-coordination reforms of the 1990s. Being mainly a formal process, gate-keeping does not accomplish its full power, and cooperation and redistribution of functions and resources across the interface of levels of care remain in its infancy. Denmark, the Netherlands and the UK can be considered examples of best practice for the design and implementation of pro-cooperation reforms in an attempt to further transfer power and tasks to the general practitioners (Rico et al 2003). Comprehensive, strong inter-organisational networks have emerged as a result. Having strong general practitioners’ associations, empowered with informal policy power before the 1990s, has made PHC professionals the natural coalition partner of governmental authorities in pro-coordination reforms, thus facilitating policy change and granting implementation. General practitioners associations in these 4 countries have strong informal policy power because of: • • • • • •

their professional autonomy, and status of independent contractors and ownership of premises (not in Spain), their monopoly of first contact (gate-keeping), which has allowed the creation of multidisciplinary groups and expanded task profile, their knowledge production (research in PHC) and information control (development and implementation of classifications, dictionaries and electronic medical records), their impact on national health outcomes and on health care system cost control, their contribution to reversing the impact of social inequity on health, and the population satisfaction levels they have achieved.

By contrast, general practitioners’ associations are weak and enjoy almost no informal power in other countries with national heath systems as Finland, Greece, Portugal (patient list, gatekeeping, salary payment) and Sweden. The same happens in countries with Bismarckian systems, as Austria, Belgium, France, Germany, Ireland (patient list, capitation and gate keeping role for lower social class), in Luxembourg and Switzerland or in transitional countries (ex-communist), such as Bulgaria, Croatia, Hungary and Poland. In countries with a Bismarckian system, general practitioners have the ownership of provision, are private entrepreneurs, but no gate-keeping role, and they share the financing scheme with ambulatory specialists, in a context of heavy competition (specialists control more than 50% of the first contact market) (Boerma 2003). Consequently, it can be said that the balance of relative informal policy power of general practitioners versus specialist does not help in establishing procoordination policies or in broadening the PHC portfolio. In countries with national health systems and salaried general practitioners, doctors do not enjoy ownership of health centres and have low social esteem (they are frequently skipped by the median and upper classes which go directly to visit private specialists). In transitional countries, even the lower class prefer specialist care (Rico et al 2003).

33

Primary Health Care: Service Delivery – Volume 2

4.4.3

Actors and interactions in Dutch PHC: A case study7

The position of general practice in the Netherlands at the beginning of the 20th century was very difficult. General practitioners were at the bottom of the medical hierarchy, entrepreneurs who offered little medicine beyond support, or even union employees who signed ‘absence from work’ permits. Two factors complicated the situation around World War II: •



In 1942 the government decided to introduce a new sickness fund system, which was already initiated before the war. The consequence was that about 70% of the population (wage earners with a limited income) became members of a compulsory system and each came to be on the list of a general practitioner, who had gate-keeper role. Without financial barriers, after a short time, overall medical consumption rose to the level of upper classes before the war. The second factor which influenced the position of general practice was the rapid development of specialist medicine. This was the result of scientific and technical progress, but in the Netherlands the sickness fund system stimulated hospital medicine in an indirect way as the costs of specialist care were not limited. The remuneration of specialists was a fee-for-service system, while general practitioners were paid by capitation fees.

The tension created by the increase of general practitioners’ workload was relieved by the general practitioners referring patients to specialists, who accepted them with pleasure, because they were paid fees for their service. Universities were not limited in their acceptance of new medical students. Many of the young physicians wanted to become specialists, and so there were almost no limitations on the education of future specialists. In 1956 the Dutch College of General Practitioners was started and in 1965 a National Institute for General Practice was set up. The first chair in general practice was created in 1966 in the University of Utrecht. In the same year, the remuneration of general practitioners, after a deep conflict between trade unions (National Association of General Practitioners) and professional associations with the government, was increased by 50%. In that year, also, the government published a White Paper on the organisation of health care, in which general practice was given an important role. Nevertheless, further development of Dutch general practice was very slow and it took almost two decades to transform and fully develop it (Es 1987). Crossing the border between PHC and hospital care proved even more difficult. Integration of PHC and hospital services has been the subject of health policy in the Netherlands from the 1990s -the already mentioned “trans-mural care”- (Linden et al 2001), following the Biesheuvel Report. The proposed introduction of additional fees for general practitioners for extra services on top of their capitation rates was never implemented. In 2004 trans-mural care is a research activity and a daily reality which involves more hospital and home care providers than general practitioners.

4.4.4

Policy analysis of the Dutch PHC case study

This case study summarised the role and interactions of the main actors in the system and the use of informal and formal policy power.

7

Italics are interactions

34

Western European Best Practice of Institutional Involvement and Responsibilities in HR Policy

In health policy terms, World War II had powerful consequences for population, politicians, and professionals. As showed, even with a targeted and well selected policy that induced desired changes, it took decades to transform the health system and fully develop PHC (re-accreditation, performance monitoring, quality assessment, guidelines, peer audit, research, etc). It must be noted how it was necessary to increase, at least initially, the amount of resources (financial, material, human and knowledge). To be successful, the transfer of power and tasks should be tightly coupled with parallel shifts in accountability and resources. As seen in the Netherlands case, policies can be aimed at • •

modifying the rules of the game, as in the 1940s (e.g., setting up a new sickness fund system, with patient list, gate-keeping and capitation method of payment to general practitioners), and allocating and redistributing resources among actors (e.g. increased financial resources in PHC, in 1966 and the trans-mural care initiative in the late 1990s).

The centre of gravity of policy shifted because the post-war climate, which allowed the exercise of formal influence (setting up a compulsory insurance system and giving a gate-keeping role to general practitioners). This later on had in turn two main feedback effects: • •

more institutional changes in regulation and legislation, in terms of empowering general practice and promoting pro-coordination reforms (trans-mural care) and a modification of the socio-political structures via resource shifts induced by public authorities (forced by the strike in 1965, or by policy knowledge, as was the case with the above-mentioned White Paper and Biesheuvel Report).

The “trans-mural care” reform had a bottom-up facilitating approach (again, participation has been entirely voluntary), which was successful. However, it needed to be followed by top-down measures to insure adequate evaluation and encourage wide-spread implementation, since it was not easy to cross boundaries between professionals who work independently as general practitioners, community nurses, specialists and others, in hospital, nursing homes, health centres and community settings. Improved continuity and integration of care were the most prominent goals for participation, but the lack of financial incentives and support might explain the different participation figures in 2001 (98% of all hospitals, 75% of home care organisations, 22% of nursing homes, 21% of general practice settings, 18% of health insurers and 12% of patient organisations). Attention should be paid in the Dutch case to the main actors: • • • • • •

patients and population (individual, unions), providers (general practitioners, specialists, medical students, hospitals, home care providers, College of General Practitioners, National Association of General Practitioners), teaching and research institutions (University of Utrecht and others, National Institute for General Practice), the health industry (new technology for specialists and hospital), insurers (sickness fund), and government (national, in this case).

35

Primary Health Care: Service Delivery – Volume 2

There were many interactions which explain the policy dynamics: • • • • • •

4.4.5

provision of services to patients and populations (medical consumption, patient list), the movements and referrals between levels (gate keeping, trans-mural care) patients’ payment (free access), providers’ payment modalities (capitation, fee-for-service) scientific and policy knowledge (White Paper, Biesheuvel Report), and regulation by government (compulsory insurance, monopoly of first-contact)

Governments

The ultimate responsibility for health care (the formal policy power) lies with the government. The driving force in publicly-operated health systems in particular is normative in character, seeking to extend coverage and services on grounds of social justice and moral obligation. However, the direct involvement of governments in the health system may be diverse. Two extreme strategies are at one end comprehensive funding and provision by the State (the case in former USSR and elsewhere) and a policy of minimum State intervention (the case in the USA, and elsewhere) at the other. Intermediate strategies are a) national health systems, or Beveridge systems in which funding is through taxation and the State is substantially involved, and b) State harmonization of arrangements developed among interest group in society, as trade unions, as in the Bismarck system (the case of France, Germany, Ireland, the Netherlands, Switzerland, and others) (Boerma 2003). In general, as already mentioned, a Bismarck system can be considered as rather reactive in terms of State authorities’ involvement, whereas the Beveridge system requires more pro-active government interventions (Rico et al 2003). There are many variants within the above scheme. Some countries with a national health system, such as Portugal and Spain, have salaried general practitioners and a patient list, while other countries like Denmark, Italy and the UK have, private self-employed general practitioners with contractual link with the system and paid by capitation and allowances (Gervas et al 1994). Moreover, the main orientation of the entire health system may change with times, as shown by the French case, evolving from a medium State intervention in the 20th century to a strong government involvement, as the system bankruptcy approached in 2004. Spain is also an example of evolution, from a heavy central government intervention in the 1980s to a regional, almost federal responsibility, in 2003. In all cases, governments face many critical decisions. The obvious initial one is whether to answer a health problem only with measures that entail the provision of services by the health system, or to look for an answer outside the health system proper. If the answer is the former, policies can be aimed at: • •

modifying the rules and agreements inside the system, and/or re-allocating and redistributing resources among actors.

Setting and crossing the boundaries between hospital and PHC, and between health care and social services (home care is a good example) is particularly important (but again, too little is

36

Western European Best Practice of Institutional Involvement and Responsibilities in HR Policy

known about the relative cost effectiveness of providing care in different settings and by professionals with different types of training) (Maynard and Bloor 1995; Davies 2004). Governments may promote a strong PHC in different ways, such as expanded pro-coordination experiments (for example, fund-holding in the UK, trans-mural care in the Netherlands), or expanded task profiles (minor surgery in Spain) but their success always depends on receiving professional support from strong general practitioners’ associations. Gate-keeping as a procoordination measure in France and Germany, for example, was blocked in the turn of the 20th century by the powerful professional opposition of specialists’ associations (and insurers’ associations with support of the health industry), and supported only by relatively weak associations of general practitioners. A similar approach had been successfully introduced in Belgium in 2004 on a voluntary basis. The scheme allows patients to select a “preferred” general practitioner, who has the patient’s electronic medical record and who may order referrals to specialists with a lower share of the cost for the patient (and a better payment for the specialist). Countries with weak general practice will have problems adopting international best practice, as redistribution of informal and formal policy power will raise opposition from socio-political actors, and thus reduce the likelihood or scope of institutional change. This is the case in France, Germany and Greece, for example (Rico et al 2003). Politicians thus can be a force for change but also an obstacle to change, because they may choose different options according to: • • •

different political visions (right and left), different points of view in the central and regional and local governments, and different sensibilities to lobbing activities (insurers, professionals, industry, patients’ associations, international agencies, and others).

There is not a common European health care policy (Mckee 2001). Even the new European Constitution, 2004, says nothing about a common approach to the topic. In western Europe there are 4 dominant schemes of governance of PHC, reflecting different balances of power between central and regional/local governments: • • • •

decentralised governance within a Beveridge system (Denmark, Finland, Italy, Norway, Spain and Sweden), centralised governance within a Beveridge system (Greece, Iceland, Portugal and the UK), decentralised governance between a Bismarck system (Austria, Belgium, Germany, the Netherlands and Switzerland), and centralised governance within a Bismarck system (France and Luxembourg) (Rico et al 2003).

Institutions matter because they translate socio-political actors’ informal policy power into formal political power. That is, institutions embody: • •

modifications of the institutional framework (regulation, legislation, rules), and changes in allocating and redistributing resources (financial, manpower, equipment and knowledge). When target decisions by governments of countries with cooperative networks (e.g. Denmark, the Netherlands and the UK) meet relatively autonomous group practice of general practitioners, a “positive circle” is fulfilled. The public power can play an important role in removing obstacles for networks to achieve efficient system coordination, by means of financial mechanisms, decision-

37

Primary Health Care: Service Delivery – Volume 2

making rules and production and dissemination of knowledge. It is important to note here that competition can be an obstacle, because it inhibits cooperation. Decision-making responsibility may be formally vested in elected politicians at the national level (France, Portugal, the UK), national and regional levels (Denmark, Norway, Spain, Sweden) or national and municipal levels (Finland), while day-to-day operating authority is delegated by these politicians to a corps of career administrators and planners (Abel-Smith et al 1995; Saltman and Figueras 1997). Until 1998 national governments and insurance funds had believed that they had the right to decide whether they would pay for non-urgent treatment carried out abroad. That year, two rulings by the European Court of Justice had wider implications as relevant precedents. So in fact, a European healthcare policy is emerging, developed by the European Court (Mckee 2001).

4.4.6

Insurers

Insurers or financers have a narrower point of view, as they do not consider actions outside the health system. Insurers are intermediary representatives of payers and potential patients. They have a strong interest in keeping up to date in scientific and policy development (introduction of new technologies, Evidence Based Medicine, guidelines, new organisation arrangements, effectiveness of incentives, and so on). As explained, public insurers (sickness funds) have a particularly important policy role in countries with Bismarck systems, with strong informal and formal policy power (Boerma 2003; Saltman and Figueras 1997). Private insurers do not enjoy such strong informal and formal policy power but are becoming more and more powerful in Europe, as the example of the UK demonstrates. Only in Switzerland do private insurance premiums and out-of-pocket payment combined exceed 50 per cent of total health expenses. The role of private insurance also varies across countries in Europe. In some countries (e.g., Ireland and the Netherlands), private insurance is geared to providing cover for persons (the better-off) without comprehensive public coverage. In others (e.g., Italy, Portugal, Spain and the UK), private insurance provides supplementary cover (double coverage, looking for more comfort and avoiding waiting lists) to persons who are already entitled to comprehensive public cover. In other countries still (e.g., Denmark and France), private insurance covers against public sector co-payments levied on prescription medicines, dental care, etc. Public and private health insurance and service delivery organisations in Europe, both for-profit and non-profit are rather traditional. Mixed forms of private insurance and service delivery, such as the USAdeveloped Health Maintenance Organisations (HMO), have not found their niche in Europe (Erdmann and Wilson 2001). All insurers’ interactions with professionals are concerned with defining: • •

which patients or services should receive priority, and to what extent it pays off to invest a given amount of resources on one patient rather than on another one.

Insurers contract insurees (usually workers) and define their practice profile through more or less explicit contractual clauses. The critical question is, as always, the interface between them and service providers. The clustering of unrelated diagnosis (i.e., co-morbidity) in patients, its impact on costs and outcomes, and the need for coordination suggests the usefulness of exploring new interfaces between PHC and secondary care. There is therefore a continuous interest in redefining the boundaries between primary and secondary care, with the aim of shifting selected services

38

Western European Best Practice of Institutional Involvement and Responsibilities in HR Policy

traditionally provided in the acute and chronic hospital to less resource-intensive primary and community based alternatives. An example of the above is the successful primary-secondary substitution in the field of emergency care. The Swedish Adel reform, in the 1990s, involved a decentralisation of coordination power over hospitals to the municipal community sector (from hospital care to nursing home) which decreased acute beds in hospitals and increased chronic beds in nursing homes. The payment mechanisms could control general practitioners’ behaviour, but the scientific base on which to recommend any specific remuneration or incentive scheme is rather weak. Insurers and financers usually have a biological orientation to the health and disease phenomena, which fits more with specialists than with general practitioners. Thus when sickness funds play an important policy role (as in the Bismarckian systems): • •

spending in high technologies is easier than in small or low technology (in part this bias probably explains why health services research is underdeveloped worldwide), and the usual way of payment is fee-for-service.

With patients, insurers’ interactions are aimed at defining: • •

which services will be covered (the well known basic packages of health services), and to what extent cost-sharing will be established.

As rationing is usually necessary, an explicit choice should be made about rules on waiting lists, for example. In Europe service coverage is more comprehensive in Germany and Switzerland. Self-help groups, and other groups, could exercise strong lobby action. Transexion (change of sex) is a peculiar example that deserves to be mentioned, as it is included in the basic package of the public health system in Andalusia (Spain). All European countries have used cost-sharing to reduce demand to some extent, but the role played by cost-sharing compared with total health expenditures has been modest, except in France and Portugal. In summary, insurers may have an important influence on priorities through their decision on levels of reimbursement and coverage of services.

4.4.7

The health industry

The health industry is among the most important influences on the organisation and delivery of health care in any country. The health industry is part of the economic world (and so is the health system, although few physicians notice it). The influence of the health industry is both bottom-up and top-down, that is, from government to population and from patients and professionals to politics. One example of top-down interaction is the widespread interest in proposing HMO8 - like solutions to Europe, as in Switzerland and the UK (Erdmann and Wilson 2001) [by the way, a rather strange interest, it must be said, since HMOs have not yet solved the problems in their country of origin, the USA, and their superiority as insurance and service delivery structures lack definitive scientific base]. By contrast, governments are confronted by medical professionals groups in relation to the application by the latter of new technologies, e.g. aggressive treatment of infertility, before those technologies had been evaluated as to their necessity, effectiveness and efficiency. The demand from patients may also hasten the introduction of a technology which has not yet been evaluated. 8

HMOs as any alternative introduce new problems. For example, adverse selection, undertreatment of poor and chronically ill patients, uneasiness in taking financial responsibility for the elderly, etc.

39

Primary Health Care: Service Delivery – Volume 2

Of course, the value of the health industry as an innovator is enormous. Innovation is relevant not only for diagnosis and treatment, but also for organisation of care, for finding out the precise location at which the care should be delivered (hospital, health centres, home), as well as in other fields, such as comfort and privacy (single rooms in nursing homes) and information for policymaking or research (a good example is the promotion of electronic medical records in general practice in Belgium). In general, the absence of an explicitly defined research strategy and limited government funding for research means that the industry (consultancy, pharmaceutical and medical equipment) will become the major force in directing research and in developing and disseminating initiatives, as for example, Evidence Based Medicine. Also, doctors, and to a lesser extent pharmacists and nurses, may establish strong relationships with the health industry because of promotional and continuing medical education activities. More recently, the industry has shown a broader approach, seeking to influence political decisions on the structure of health care systems in ways that will benefit its own interest (Abel-Smith et al 1995).

4.4.8

Teaching and research institutions

In 1963, the first chair in general practice in the world was established in Edinburgh, Scotland (the UK). The second one was established in Utrecht, the Netherlands, in 1966. In general, universities have been very important in PHC development, but there is a sharp contrast in Mediterranean countries (Portugal has chairs of general practices from the 1980s whereas Spain has had its first chair in 2002 in Barcelona, a “Novartis” chair of general practice). However, Portugal has a very weak PHC and Spain has a strong one. Professors are usually general practitioners who do not leave their clinical duties. Numerus clausus (restricting entrance to Medical School by means of quotas) is considered by most to be essential, as it allows the control of vocational training in coordination with workforce planning by central government. As already explained, more physicians and more hospitals do not necessarily mean more health in developed countries (not infrequently the opposite is true!). It is not the quantity but the quality (general practitioners versus specialists and their geographical distribution) that matters. In any case, a lack of numerus clausus is linked to medical unemployment, as was the case in Spain, with a peak of 22% in 1999 (this high rate of medical unemployment was in part relieved by “exporting” general practitioners to Portugal, the UK, and Sweden in the 2000s). Again, we lack scientific knowledge about the optimal proportion of general practitioners and specialists9 but empirical data show a consistent positive relation between the availability of general practitioners and population health levels (Starfield 1998; Engström et al 2001). How many general practitioners per inhabitants then? We do not know the right answer. Evidence suggest that perhaps the right figures lay in between 500 (very isolated rural areas) and 3,000 inhabitants per general practitioner. Some universities in Denmark, Finland, the Netherlands, Portugal, the UK and others have advanced a PHC-oriented teaching policy in their schools of medicine. The general world movement is expressed by the slogan “from ward to office, from acute to chronic, from disease to problem solving orientation”. That means: early and permanent contact and integration of the 9

When the data become available, it will possible to calculate the appropriate proportion of general practitioners and specialists, instead of relying on demand-oriented projections that reflect the current state of practice rather than rational planning.

40

Western European Best Practice of Institutional Involvement and Responsibilities in HR Policy

students in PHC, a focus in management of chronic patients with co-morbidity, and teaching from a clinical, not disease description, point of view. Nursing schools are in general more PHC-oriented than Medical schools. Even schools of pharmacy are introducing PHC, as in Spain. Organisation of vocational training varies. In the Netherlands, for example, the responsibility for vocational training is with university departments of general practice. In Spain vocational training is under the control of the Health Ministry and hospitals still play an important role in how doctors are trained. In practice, (too) many aspects of continuing medical education depend on the pharmaceutical industry in some countries (the idea of a “free lunch” is very common). The role of universities, public institutes, insurers and professional associations varies. In general (rhetoric aside), continuing medical education usually has a rather weak value and low scientific base. Mandatory re-accreditation in general practice will soon be in place in Europe. It already exists in some countries, as the Netherlands (every five years) or Spain (on a voluntary basis). Research institutes, either independent or part of the universities, have proven their value in developing PHC in Europe, and mention must be made of Portugal, the Scandinavian countries, the UK and the Netherlands. For example, the Dutch Institute of General Practice (NIVEL) has been giving support since the 1960s to research programmes promoted by the College of General Practitioners, and has continues its activities from then on. A similar role is played in the UK by the Nuffield Provincial Hospital Trust, which supported, for example, Collings to prepare his seminal report in 1949. In Spain, the “Fondo de Investigaciones Sanitarias”, [Health Research Fund], has funded hundreds of studies and researchers in PHC, from 1982 onwards. In Italy, mention needs to be made of the Mario Negro Institute of Milan. Research is a source of informal policy power (i.e., it increases the knowledge and information resources, as well as social and political support) and it has added strong support to self respect and social esteem of general practitioners. Research has proved a valuable way to understand the role of general practice in the health system and in society at large. In fact, to improve the relationship between general practitioners and specialists (and to facilitate pro-coordination reforms), general practice needs a much stronger scientific development of its specific knowledge and experience. This specificity can only be discovered when general practitioners are confident in their own value and identity (which in turn helps to break the negative cycle of poor general practice). PHC research is well developed in Belgium, Denmark, Finland, the Netherlands, Norway, Spain, Sweden and the UK. In 1958, members of the (now Royal) College of General Practitioners in the UK demonstrated that almost half the problems brought to general practitioners could not be assigned a “diagnosis”, at least during the initial encounter with the patient, with the available rubrics of the International Classification of Diseases, Injuries and Causes of Death, then in force. The WONCA International Classification Committee (WICC) has followed such pioneering work. The most recent products of the WICC, to help in understanding PHC and research, are the International Classification of Primary Care (2nd version), in 1998, and the WONCA Dictionary of General/Family Practice, in 2003 (Bentzen 2003). There are European Associations of general practitioners with an interest in research (e.g. European General Practice Research Network, founded in 1970) and in promoting better teaching activities (European Academy of Teachers in General Practice, founded in 1992). Some EU programs, as COMAC-HSR, AIM, DELTA, BIOMED, and others, have had crucial importance in promoting research and interchange of PHC professionals in Europe.

41

Primary Health Care: Service Delivery – Volume 2

Schools of public health might have a critical influence on PHC development. This was, and is, the case in Portugal (School of Public Health of Lisbon) and Spain (School of Public Health of Granada and Madrid). Finally in this account, leadership indeed matters. A few “reports” have captured an essential vision of health, health services, or general practice. Examples in the UK are the Collings (general practice) and Black (health inequalities) Reports. In Canada, the Lalonde Report. In the world, the Alma Ata Declaration. In Sweden, the Crossroad Project. In Spain, the “Sociología de los ambulatorios” [Report on the sociology of ambulatory care] and the Abril Report. In the Netherlands, the Biesheuvel, Dekker and Dunning Reports. As a matter of contrast, Evidence Based Medicine has a strong biological bias, and low proven external validity. Its impact in PHC is not known, as it is focused on the model of “one disease” (and thus nothing is said about co-morbidity) and pharmaceutical products. Guidelines may indeed help in very specific problems, and there is an important European development of the area.

4.4.9

The service providers

As already indicated, general practitioners have a central role in PHC in Europe. This professional group is one of the main collective actors in health care, enjoying informal policy power attached to their source of knowledge resources, and valuable social support. The above described Dutch case study demonstrates the important role of their organisations. There are strong associations of general practitioners that support pro-coordination reforms, or reforms that broaden the PHC portfolio. The first professional association of general practitioners in Europe was founded in 1952, the (English) College of General Practitioners (from 1967 designated “Royal”). Some Associations concentrate their activities around mostly scientific and ethical areas while others are engaged in defending their members in the more mundane issues of working conditions and the like. Associations with quasi-trade union activities can have crucial informal policy power, as shown by the role of the Union Européenne des Médicine Omnipracticien (UEMO, European Union of General Practitioners). As early as 1970 the UEMO set forth guidelines for a vocational training programme for general practice of at least two years, including a minimum training period of six months in a general practice setting. In 1984 the Commission of the European Community adopted these guidelines in a draft proposal published the same year to the Council, as to a specific programme of vocational training in general practice. In 1986 the European Community accepted the draft. This single decision, mandatory vocational training in general practice in Europe, may be the key step to conserve and improve the role of general practitioners in PHC. As explained above, governments and insurers may aid general practice with protective measures, like limiting direct access to specialist care and providing the general practitioner with the role of gate-keeper or co-ordinator. Again, gate keeping saves money and can become popular as it is the case in Denmark, Iceland, Ireland, Italy, the Netherlands, Norway, Portugal, Spain, and the UK (Gervas et al 1994). Gate-keeping as an arrangement has sound scientific bases in that: • •

it acts as a filter of morbidity and for the selection of patients who might probably need specialist care (thus increasing the probability of a proper balance regarding the aggressive test used by specialists), and it is an effective way of controlling cost.

Even countries like Austria and Germany, with no gate-keeping, try to reduce patients’ shopping around from one doctor to another by means of a health insurance voucher system (each insured

42

Western European Best Practice of Institutional Involvement and Responsibilities in HR Policy

is entitled to one voucher per period of three months which enables the patient to visit only one general practitioner). However, the evidence on whether gate-keeping is better than other arrangements in terms of efficiency and coordination is limited (Engström et al 2001; Gervas et al 1994). Gate-keeping establishes a monopoly over patient entry flows into secondary care and is very frequently associated with patient lists, as in Denmark, Ireland (lower income), Italy, the Netherlands, Portugal, Spain and the UK. Specialists often see only the cost-control role of the filter, and sometimes gain support to this thinking, as in France and Germany. Gate-keeping and patient lists favour in theory the population orientation of PHC as general practitioners may contact at the end of a defined period those persons who have not shown up around the surgery when they were expected to do so according to their health status or risks. This should in principle make it easier to reverse the “inverse care law” (“people who need more health care receive less of it”), first formulated in the 1970s in the UK by Julian Tudor Hart, and which is more evident in more market-oriented health systems (Hart 1988). There seems to be some relationship between gate keeping and better health care outcomes, such as costs, population satisfaction and health status of the population (Gervas et al 1994). Task profiles in general practice in Europe are not homogeneous. Those differences in general practitioners’ task profiles can be statistically explained by individual characteristics of general practitioners (gender, age, training), the organisation of practice (teamwork, available equipment), the setting (urban, rural, practice population, availability of hospital facilities) and features of the health care system (remuneration, gate keeping role, patient list) (Boerma 2003). In Europe there is common interest in expanded task profiles covering poorly evaluated experiences as outreach clinics, integration of community nurses, provision/coordination of hospital emergency care, and others. For example, in the late 1990s, almost 10% of Danish general practitioners spent a few hours per month as advisors and coordinators of the interface between hospital care and PHC services. Experimentation with expanded task profiles has led to some degree of duplication. Although the development of doctor/nurse skill mix has historically occurred ahead of evidence of effectiveness, there is a developing literature to suggest that, in some areas, substituting nurses for general practitioners gives equal or better health outcomes, with high level of patient satisfaction and high quality care (Horrocks et al 2002; Kernick and Scott 2002). Teamwork might help in mutual understanding and new compromises. Several research groups and institutes for nursing research in Europe have been operating since the 1970s, but new understanding and knowledge of the nursing process has not resulted in any policy shift as the concerned professional group lack resources of informal policy power (mainly ownership and social and political support). Once more, the fact that nurses and other nonphysician professionals have weak informal policy power reveals the importance of social trust and reputation. Pharmaceutical care has scientific plausibility to improve health outcomes, but until now such has not been proved yet. Answers to questions around health centres, their workforce, the size and composition of health teams, target population definition, and many other issues, often lack a scientific basis, and are answered by governments and insurers in a knowledge vacuum (Engström et al 2001; WHO 2000; Boerma 2003; Gervas et al 1994; Maynard and Bloor 1995; Davies 2004).

43

Primary Health Care: Service Delivery – Volume 2

There are serious signals that doctors in PHC may be in a process of declining morale. A key factor seems to be a change in the psychological compact between the profession, employers, patients and society so that the job is now different from what doctors expected. A danger has been identified that consumer demands for increased access to specialists, coupled with an industrial transformation of the health sector (HMO-like) plus commercial incentives for hospitals to induce demand for their services, might well undermine the current trend towards PHC.

4.4.10

Patients and their families and associations; Consumers; Population

Patients are increasingly active consumers and they demand and are encouraged to expect enhanced services, including extended hours and rapid access (Abel-Smith et al 1995). Gain in life expectancy and quality of life seem to have raised expectations of a life without illness and disease (or even promises of no-death, in view of the advances in genetics!). Very interestingly, research proves that better health services do not necessarily mean better perception of health (this has been formulated as “the paradox of health”, in which healthier populations of wealthier nations declare more perceived morbidity than poor populations with bad health outcomes in underdeveloped countries). The truth is that patients do not seem to care about the precise organisation of health services, but rather about having their problems solved as soon as possible (and note that resolution of a health problem in many cases means assessment, not diagnosis and treatment). Thus if a general practitioner efficiently solves the tasks of consultation for most common health problems, general practice will be accepted as a permanent component of the health system, even with a gatekeeping role. By the same token, when general practice is weak, with low social esteem, poor education, lack of research, low self respect and poor earnings, general practitioners lose the competition with specialists, and patients prefer direct and frequent access to specialist care (as found in Austria, Belgium, France, Germany and Switzerland). Upper classes seem to prefer specialists to general practitioners. Seeing a specialist is not a random affair, nor is it associated with differences in the frequency of illness in different populations. On the contrary, research shows that specialists’ visiting rates are directly associated with social class: the higher the social class, the greater the rates of seeing specialists (even in most European countries where rates of seeing general practitioners are inversely related to social class) and even though rates of illness are inversely related to social class (Dooslaer et al 2002). In 2002, a study about equity in the use of physician visits in OECD countries demonstrated that after standardisation for need across the income distribution, significant horizontal inequity in total physicians’ visits emerges only in Austria, Greece and Portugal (and the USA). However, disaggregating by general practitioner and specialist visits reveals a net effect from quite diverging patterns in the type of doctor consulted by income level: in all countries (except Luxembourg) the rich see a medical specialist more often than expected on the basis of their health needs, while the use of general practitioner visit is fairly closely related to need. In several countries, the visits to general practitioners are even distributed in a somewhat pro-poor way (as in Belgium and Spain). The degree of pro-rich distribution of use of specialists is much larger in Ireland and Portugal (Dooslaer et al 2002). There is no solid research about the reasons why upper class people uses more specialist service, but the following ideas have been forwarded as hypotheses: • •

44

a more biological orientation on the side of the patient, which would fit with specialists’ orientation, wrong understanding of the use of technology in health care,

Western European Best Practice of Institutional Involvement and Responsibilities in HR Policy

• • •

path dependence of the historical development of general practice in association with workers’ unions, gate-keeping as a threat to individual autonomy, and strong development of Osler’s paradigm in specialists’ professional behaviour

As repeatedly suggested in this paper, understanding this policy question is crucial not to lose one important source of informal policy power: social and political support. Patients’ autonomy to select a general practitioner is nowadays the rule in most countries, including those with gate keeping arrangements as Denmark, Ireland, Italy, the Netherlands, and the UK. This right has been extended in Spain and Sweden. How can the public be involved in the development of health policies? Experience shows that achieving this is not easy in practice. Three main approaches have been tried: • • •

the representative democratic process (European, national, regional and local elections), organised interest groups, and direct involvement of individual citizens in the health care spheres. Denmark could be an example of management of health services by local governments.

The Netherlands is an example of consumer groups’ involvement. And the UK, in turn, can be considered a model of public direct consultation (Abel-Smith et al 1995). There are a multiplicity of self-groups and organisations which provide mutual education and support for people suffering from specific conditions. Such conditions usually are, for obvious reasons, chronic and linked to a substantial degree of disability and suffering, such as diabetes, alcoholism, epilepsy or psoriasis. These groups can raise considerable attention and amounts of money, and lobby for quicker development of specific services. On the other hand, and from a population point of view, the success of such self-groups and organisations could raise concerns about inequalities in health and health care. Greece, Italy, Portugal, Spain and the UK show the lowest levels of expressed public satisfaction with their health care system while Denmark shows the highest level of satisfaction (Blendon et al 1991; Mossialos 1997). How can public health activities and PHC be matched? Public health addresses specific problems, such as food and environmental questions, and PHC can help in targeting the population who use those services. In hypertension, for example, a case finding activity may be more productive than a population approach. But there is no scientific basis for prescribing a specific type of cooperation between public health and PHC. 4.4.10.1 Summary PHC Actors in European health systems are the same everywhere, but its interactions are very different. Patients, providers, teaching institutions, the health industry, financers or insurers, and governments cooperate to promote health and to avoid morbidity and mortality (in other words, to avoid suffering and to prolong the life span). Europe provides many examples of successful health actors’ interactions, mainly gate-keeping and patient list. Experimentation as a way of improvement is common around expanded task profiles for general practitioners and other workers, and procoordination activities with specialist care. But many key questions in health services research have no scientific answers yet, so decisions are taken in a vacuum knowledge. Changes in the

45

Primary Health Care: Service Delivery – Volume 2

expected role of physicians and in the expectations of the population about medical possibilities seem to be eroding the morale of general practitioners.

4.4.11

The role of international models and organisations

Socio-political structures, such as governments, endowed with formal policy power, can introduce policy changes in their health care systems. Evidence suggests that exogenous factors (ideology, political considerations) have played an important role in health systems reforms development. The Bismarck system of Germany, for example, has been very attractive for Eastern European countries, with support form the World Bank and other international agencies10. The Beveridge system of the Nordic countries, in turn, influenced the creation of the national health systems in the Mediterranean countries in the 1970s and 1980s. In this context, WHO and WONCA have promoted PHC and general practice only with a limited knowledge base. Exogenous factors have thus played an important role in health system reform and development all over the world. One key influence is the transfer of models and ideas across national boundaries. In some cases, the legitimacy of reform policies has been eroded when those reforms have been perceived as imposed from the outside. As a result, those reforms have encountered greater difficulty in implementation. Yet many national governments obtain credibility and social support through international agencies and organisations, which support them with new ideas. In 1974 the Lalonde Report on the health of the Canadian was the first government report to acknowledge that a biomedical health care system is not the only option for improving health. Also, PHC as defined in 1978 by the Alma Ata Declaration of the World Health Organisation was a wider concept than general practice/family medicine, requiring that doctors in this field look again at their traditional role (Jong-wook 2003), following the Lalonde approach. However, it does not challenge the need for doctors, nurses and other staff whose remit is providing a broad range of services, who are readily accessible and who provide continuity of care. A specific problem with the WHO approach is that in many countries PHC is a part of the health system where needs, utilisation and effectiveness are poorly defined but boldly asserted, and uncritically advocated by international organisations (Maynard and Bloor 1995). In 1996, the Ljubljana Charter on Reforming Health Care addressed health care reforms in the specific context of Europe (WHO 1996). The (then) 49 Member States of WHO’s European Region approved a Charter which underlines the fundamental principle that the objective of health care reforms should be to improve people’s health, not to contain costs. Within the European context, according to the Ljubljana Charter, “reforms, with primary health care as a philosophy, should ensure that health services protect and promote health, improve the quality of life, prevent and treat diseases, rehabilitate patients and care for the suffering and terminally ill. They should reinforce joint decision-making by the patient and care provider and promote the comprehensiveness and continuity of care within their specific cultural environments”. In other words, health systems need to be: • • • • 10

driven by values, targeted on health, centred on people, focused on quality,

I will no consider the role of World Bank and the General Agreement on Trade in Services (World Trade Organisation) because their negligible impact on Western Europe’s health policy, until now.

46

Western European Best Practice of Institutional Involvement and Responsibilities in HR Policy

• •

based on sound financing and oriented towards PHC (WHO 1996).

However, WHO still promotes PHC with a rather low scientific base, promoting Finland as the reference national model (“best practice”). But the Finish PHC system is a very rigid and hierarchical one, with a network of public health centres staffed with salaried public employees, and no personal doctor. WHO promotes PHC, and the popularity of PHC seems to be spreading. However, as is the case with other elements of health care delivery, its scientific base, in terms of the cost effectiveness of competing interventions, is poor. Its efficiency, in particular, should not be accepted uncritically. Note that PHC is seen as a philosophy and that its role covers almost everything. Many of the interventions PHC promotes have no knowledge base. But population, policy makers and providers’ groups accept PHC reform where much is promised but little can be demonstrated to be cost-effective. WONCA is in turn the World Organisation of Family Doctors / General Practitioners (former World Organisation of National Colleges and Academies of General Practitioners / Family Physicians). The objectives of WONCA are: • • • •

to promote and monitor high standards of general practice through education and research, to foster communication and understanding among general practitioners, to represent the academic and research activities of general practitioners to other world organisations, and to stimulate the development of the educational and research organisations of general practitioners.

There is no problem of compatibility with the WHO in WONCA’s special concern with research and education. But WONCA has promoted, and still promotes, a kind of doctor whose main task is to respond to the complaints of individual patients (the so-called Osler’s paradigm). This model fits better with general practitioners as independent entrepreneurs working in a fee-for-service system than as public employees working in publicly owned health centres. WONCA promotes general practice, but general practitioners should understand that to be consistent with science, PHC must serve the whole population according to their needs rather than be merely available to individual demanders or purchasers of care (irrespective of whether these are state subsidised demanders or buyers of a freely marketed commodity). 4.4.11.1 Summary The European population thinks that some kind of national insurance should distribute the financial risks of disease, handicap and other health problems, and contribute to keeping expenses affordable irrespective of the income. European health services also have a long history of general practice as primary care, so WHO’s and WONCA’s emphasis on PHC fits with the perceptions and interests of population, insurers, providers groups and policy makers. However, a) as is the case with other health care arrangements, the science base of PHC in terms of the cost-effectiveness of competing interventions is poor, b) many of the interventions in the general practitioner daily practice have no knowledge base, c) PHC is seen more as a philosophy than as an answer to health needs, and d) general practitioners are still educated and work according to Osler’s paradigm, with their main task to respond to the complaints of individual patients.

47

Primary Health Care: Service Delivery – Volume 2

4.5

How doctors and non-physician professionals are paid in the EU. The implications of different methods (and the use of incentives to correct it)

4.5.1

On paying the health professional of PHC

It is well known that the method of paying health professionals must be distinguished from the method by which funds for meeting the cost of health services are raised. Both are part of the financing function, but the payment methods belong to the so-called “resource allocation” whereas the latter belongs to the “revenue raising” sub-function. Both elements share a common background, as the way of payment is associated with a whole series of values involving autonomy, quality, attitudes to solidarity and efficiency, as well as other important attributes of professional services. Methods of paying doctors also have an enormous importance for the way PHC institutions relate to each other. Few questions in the organisation of medical care have provoked such heated controversy over the years as the method of paying health professionals for their services. Capitation, salary and fee-for-service are the main methods of remunerating general practitioners11. In European PHC, countries with “Beveridge systems” are associated to salary and capitation payments, while in countries with “Bismarck systems” fee-for-service prevails (with the notable exception of Ireland and the Netherlands, where general practitioners are paid by capitation). Most countries have mixed systems of physicians’ payment, but countries with a predominant fee-forservice system almost never mix payment methods. Changes in the way of paying general practitioners in the lasts decades have occurred against a background of surprisingly little empirical evidence about the effects of different forms of remuneration on general practitioners’ behaviour, on the costs of care, and on the welfare of patients (31-36). Needless to say, without such evidence, those changes are unlikely to be compatible with the desired efficiency and equity goals of European health systems. In a few countries (e.g. Spain and the UK) general practitioners are better paid than specialists. In Norway, systematic efforts have been recently made to narrow the income gap between general practitioners and specialists. Medium total earnings per year for senior doctors are quite different in European countries, from €120,000 in the UK to €36,000 in Spain, in 2001. The above-mentioned three main methods of remunerating general practitioners are hypothesised to provide very different incentives (Roemer 1963; Gosden et al 2001). Under capitation, the general practitioner receives income in the form of a payment for each registered patient; capitation is supposed to encourage income-maximising physicians to keep costs below the per capita fee. A salaried general practitioner, as a way of contrast, receives a salary, usually in a monthly basis, for a specific number of hours per year; under salary payment the incentive is supposed to operate in the sense of minimising personal costs (such as effort). Fee for services, finally, means that general practitioners are given a fee for each item or unit of care they provide, such as consultations, immunisations and prescription; as a payment linking remuneration to health care output, the incentive is supposed to be to maximise output (quantity of items of care). When physicians fully respond to these incentives, salaries and capitation payment may result in under-treatment, and fee-for-service in over-treatment.

11

Little is known of the effects of remunerating health professionals other than general practitioners on the costs and outcomes of care. In the remainder of this section the focus will be on general practitioners.

48

Western European Best Practice of Institutional Involvement and Responsibilities in HR Policy

Under capitation and salary payment, general practitioners know in advance the amount of payment they will anyway receive before any care is provided (prospective payment). Under feefor-service, the amount of payment is known after care has been provided (retrospective payment). Payment systems therefore do influence job choice decisions and the recruitment and retention of general practitioners. For example, the variability of income under salary is lower than under capitation and fee-for-service. So in areas where income is expected to vary greatly (or to be too low), general practitioners may be more likely to accept employment in salaried post in underserved areas (inner city, rural). The available evidence suggests that general practitioners paid by fee-for-service provide a higher quality of primary care services compared with capitation and salary general practitioners. Capitation seems in turn to be associated with better population health, and with better control of the total health care budget. But the studies about whether the remuneration system resulted in changes in health outcomes are not conclusive. There are no studies about differences in access to care between the three payment methods by population subgroups according to level of need either. Evidence suggests that the overall satisfaction of patients with salaried general practitioners do not differ from those with doctors paid by fee-for-service. Overall, the evidence of the impact of payment systems is not robust enough to be used and applied in every policy context. This general lack of empirical research means: • •

that policy makers have very little guidance with respect to the design of payment systems, and that the frequently found strong opinions about the relative merits of the different payment systems are to a great extent ideology-led nonsense (Gosden et al 2001; Delnoij et al 2000).

Politics, and even economics, assume that the ways of payment have an impact on the general practitioners’ behaviour. There is empirical evidence, however, that a strong system of ethics may dilute, or completely remove, the economic incentives inbuilt in some payment systems for physicians to provide costly diagnostic and therapeutic services merely to increase their income (Gosden et al 2001; Scott and Hall 1995).

4.5.2

Capitation

Medieval guilds and later fraternal orders and health clubs of workers paid physicians by a capitation system (i.e., so much per year for each member, who would then be attended if someone would become ill). The capitation system thus stipulates the person served, rather than the medical act (per capita) as the unit of remuneration. In the 1910s in the UK, under the British National Health Insurance, local communities were asked to decide their own choice of method of payment; many soon changed from fee-for-service to capitation as the latter was found to be much less troublesome. Theory has it that under the capitation system: • •

doctors may make excessive referrals, the method induces a preventive point of view in the general practitioners, since he earns no more if illness occurs and s/he has to treat it,

49

Primary Health Care: Service Delivery – Volume 2

• • • • •

administrative procedures are simpler, the volume of services rendered is immaterial, and the general practitioner’s income is dependent on the proportion of patients who choose to be on his list (thus, it is the population rather than the physician that ultimately determines professional incomes), among physicians, capitation serves as a kind of buffer against sharp competition, a list establishes some kind of implicit relationships not only with users but also with nonusers (which gives an opportunity to reverse the inverse care law, by pro-active contacts with non-users), and because capitation is linked to a patient list with a cap, it is associated to a more even geographical distribution of general practitioners.

The general practitioner has the economic inducement of wanting to keep a maximum number of persons in his list, and patients’ dissatisfaction can reduce this number if they leave to register with another general practitioner. European countries regulate the maximum number of persons on GPs’ lists in different ways. In the Netherlands, general practitioners receive from the sick funds the full tariff for 1,600 publicly insured patients on their list, and a lower tariff for those exceeding this number, up to a maximum. General practitioners may select low-risk patients, or actively discourage high-risk patients, but in many countries, e.g. Spain, the fee is adjusted upwards by social deprivation, age (0-1, and > 65 years), and geographical isolation. General practitioners’ capitation payments are not to be confused with capitation payments made to health care organisations as HMO in the USA and Switzerland, and former fund-holders in the UK. The fact that there is some sort of capitation contract between an insurer and an HMO does not mean that the physicians are remunerated in the same way. Capitation is the way of payment (always in the context of a mixed system, as it was explained) in Denmark, Ireland (low class), Italy, the Netherlands, Spain (around 10% of total earnings), and the UK. In the Nordic countries Finland, Norway and Sweden there is an experimental Personal Doctor Program going on, which pays on per capita bases. Also in Belgium a capitation system to pay general practitioners of the Maison Médicales has been developed on an experimental basis. General practitioners are self-employed (independent contractors) in all capitation countries, except in Spain (Gervas et al 1994). Capitation means patient list and gate keeping. The aim of gate keeping, as repeatedly explained, is more concerned with efficiency by avoiding un-necessary and expensive specialist treatment, whereas the aim of patient registration is more concerned with enhancing continuity of care and general practitioners’ responsibility for their patients’ files. Capitation might be used to pay nurses also, as demonstrated by the case of Spain, where nurses have a specific variable financial incentive according to the total number of patients in the lists of the health centre. Capitation is associated with strong primary care score and with improved population health. In the above mentioned comparison of 18 wealthy OECD countries, UK, Denmark, Spain and the Netherlands are rated as the best (Mazinko et al 2003).

50

Western European Best Practice of Institutional Involvement and Responsibilities in HR Policy

4.5.3

Salary

The Greek city-states, as well as mediaeval cities, paid salaries to designated general practitioners for taking care of the poor. Physicians attached to feudal manors and to armies (public or private) also received salaries. The salary method is essentially a payment to the doctor for his/her time, regardless of the number of units of service provided or of the number of persons whose health is supervised. A salary method is invariably associated with some form of organised framework of medical practice, as health centres in PHC. An organisation of this kind means some group-discipline and control of autonomy. Most salaried general practitioners have a community responsibility, or at least they have a defined geographical area. Theory has it that under salary payment the inducement to optimal performance is lodged in the organised framework surrounding the physician, rather than in the financial mechanism per se. It is the judgment of the pairs, more than of patients, that counts. At the same time, however, physicians might minimise personal cost (as effort) by: • • • •

selecting low risk patients, writing prescriptions, making referrals, and shortening consultation time.

Some patients might receive superficial attention and inadequate care just because a financial incentive toward maximum service is lacking. The salary system, when the salary is relatively low, might create incentives for informal payment (“black money”, “under the table payment”) to secure quicker and improved access to some desired services. But it is important to note also that a salaried PHC permits the professionals to undertake postgraduate studies periodically. At the same time, the young professional can be supervised by more experienced colleagues and can be adjusted to the level of his/her capacity. These factors contribute to advancing the quality of care. As for its administrative implications, the salary system is manifestly simpler than any other. Geographical distribution of professionals is usually a matter of more or less central planning. General practitioners are paid by salary in European countries where the State has a dominant and comprehensive role in the health system, both in funding and providing services. The main examples are Finland, Greece (rural general practitioners in health centres), Iceland, Norway (as city employees), Portugal, Spain and Sweden. The salary payment method is compatible with patient list and gate keeping as in Iceland, Portugal and Spain. Salary is more beset with controversy than any other way of payment. Many professionals see it as “socialised medicine”, as part of the “Semashko system” in place in communist countries for decades, tainted with low quality care and poor working conditions. But physicians are salaried in medical schools, hospitals, and teaching medical centres which offer excellent quality of medical care in Western Europe and elsewhere. This clearly shows that it is not the salary form per se, but the organised framework of regulation and incentives surrounding the physician what matters.

51

Primary Health Care: Service Delivery – Volume 2

4.5.4

Fee-for-service

After the industrial revolution and while the rise of the bourgeoisie and the cities was taking place, physicians broke their attachment with feudal manors and occupational guilds and set up shops as private entrepreneurs. They thus offered their professional services to anyone who could buy them, and for each service they charged a fee. In doing so, the fee-for-service system became firmly rooted in the capitalist society, at least for the treatment of patients at home or in the physician’s office. Theory has it that under fee-for-service payment, there is an incentive to deliver more care in order to inflate the output. This can lead to supplier induced demand (excessive and unnecessary diagnosis and treatment), where the patient receives more care than they would have chosen if they had the required knowledge. Physicians might induce demand when • • • •

there is scientific uncertainty, physicians have low workloads, competition is increasing, and fees decrease its monetary value.

Induced demand could lead to excessive referral and “trafficking in patients” when kickbacks exit, but the common problem is a referral rate that is too low, when physicians do not want to “lose” patients. The fee-for-service method of paying for medical care is associated with greater freedom and autonomy for the doctor. But autonomy might disappear (for good or bad) with any way of payment, even fee-for-service, as the USA industrial model of general practice demonstrates. In HMOs, doctors act within a clear management framework and management control is exercised over a whole range of care. Procedures are codified; standards are set in relation to criteria for hospital admission and the use of ambulance services; and protocols and guidelines are devised for the management of common disorders such as hypertension. Styles of communication, with patients and colleagues may be monitored. Fee-for-service fits with Osler’s paradigm of seeing the physicians’ main task to respond to the complaint of individual patients. There is no implicit relationship with non-users, or with population. General practitioners tend to provide more services themselves and consequently have more patient contacts and longer working days. The practice will be organised, staffed and equipped in such a way as to cope with the range and complexity of services, which implies more use of technology. Fee-for-service is associated with weak informal policy power of general practitioners, low primary care score (see ranking above) and not improved population health in correspondence; in a comparison of 18 wealthy OECD countries, Germany, Switzerland and France were the worse (Mazinko et al 2003). The fee often depends on the type of service, and is stipulated in a published fee-schedule. Given its inflationary character, fees may have a relative value: • •

52

pro-rating general practitioners’ bills (more items of the same service, less value), and capping the global budget and giving in the fee-schedule a number of “units” to each fee (at the end of the period considered, the unit means a monetary value according to total number of units), as in Germany.

Western European Best Practice of Institutional Involvement and Responsibilities in HR Policy

But this relative value system makes fee-for-service administratively even more cumbersome (and expensive). No doubt, fee-for-service is popular among physicians under the claim that it fosters a good personal relationship between the doctor and the patient (one may be surprised that physicians should so often claim these interpersonal advantages for the fee-for-system, as if to imply that attitudes toward patients would be less considerate if they were not enforced by an earmarked fee!). General practitioners are paid fee-for-service in European countries with a “Bismarck system”, as Austria, Belgium, France, Germany, Ireland (middle and upper classes), Luxembourg, and Switzerland. As already explained, general practitioners do not have gate keeping roles in those countries, and patients can go directly to visit specialists (sometimes with costly cost-sharing when patients bypass general practice, as for example in Belgium, from 2004). Fee-for-service does create incentives for uneven distribution of general practitioners, as physicians are reluctant to establish themselves in areas of low population density. In a public reimbursement model (a fee-for-service system where patients pay directly doctors according to the services rendered) the fees are later on reimbursed by the health system, often with cost-sharing. Countries with a public reimbursement model are Andorra, Belgium, France, and Luxembourg. Under fee-for-service payment in a public reimbursement model physicians are paid in cash and “doctors follow [rich] patients”. For example, in France approximately one third of all doctors practise in the Paris region, another third in the Côte d’Ázur-Provence, while the rest of the country contains the remaining third (Gervas et al 1994).

4.5.5

Incentives

“Most policy changes in the area of payment systems are inadequately informed by research. Future changes in general practitioners’ payment systems need to be rigorously evaluated” is the systematic conclusion of all revisions of this topic, from 1963 to 2004 (Roemer 1963; Gosden et al 2001; Delnoij et al 2000; Scott and Hall 1995; Arrowsmith et al 2001; Smith 2004). The studies reviewed, experimental and observational, did not evaluate the effects of remuneration on: • • • • • • • • •

patients’ health outcomes (errors and adverse effects included), population health (avoidable morbidity and mortality), access to care by population sub-groups differentiated by their level of need (inverse care law), geographical distribution of general practitioners, administrative cost, doctor satisfaction, informal payments (“black money”, “under the table”), “trafficking in patients” (kickbacks), and over and under diagnosis and treatment.

From a policy perspective, therefore, the main point to note regarding the literature is that it is not possible to make conclusive recommendations about the optimal remuneration system for general practitioners. As indicated above, fee-for-service seems to result in a higher quantity of services of PHC, compared with capitation, but the evidence of the impact on the quantity of secondary care

53

Primary Health Care: Service Delivery – Volume 2

services is mixed. Fee-for-service results in more patients visits, greater continuity of care, higher compliance with recommended number of visits, but lower satisfaction with access to a physician compared with salary payment. The evidence of the impact of target payment is also inconclusive. Target payment is a form of feefor-service for which the general practitioner is remunerated if s/he reaches a certain target level of service in a defined population. The objective is to control cost and to promote certain important services, as immunization, cervical smear and so on, in specific population sub-groups (Arrowsmith et al 2001; Smith 2004). This is also the problem with the performance-related payments in health care which have been widely extended within the British public sector (in the last 15-20 years), the Irish, Spanish and others health systems in the last decades. Performance-related payment has been introduced for a variety of reasons, such as: • • • • • • • •

to provide incentives to general practitioners (use of protocols and guidelines, to promote interventions of proven efficacy, prescription of generics, control of pharmaceutical cost, to increase home visiting, etc.), to improve access, to motivate staff, to enhance staff recruitment and retention, to signal a change in organisational culture, to control staff costs, to reduce the power of trade unions, and to reinforce staff development policies.

But most of the evidence on performance related pay points to it having, at most, only a very modest beneficial impact (Arrowsmith et al 2001; Smith 2004). Efforts resulting in some success include making agreements on yearly objectives with the whole team (Spanish health centres) and rewarding them in relation to goal achievement. The way is paved to introduce “outcome” incentives in the future, that is, to promote clinical activities which avoid “avoidable health outcomes” such as: • •

ambulatory care sensitive conditions (potentially avoidable hospitalisations), and/or avoidable deaths (as, for example, death by tetanus or pneumonia).

Some incentives may have mixed effects. For example, in 1993, a scheme to provide incentives to general practitioners to contain the cost of their prescription to publicly funded patients (low class, capitation) was introduced in Ireland (Walley et al 2001). General practitioners were allowed to keep half of any under spending for projects benefiting their patients while the remainder of the saving went to the health authority for PHC development. There were no penalties for overspending the indicative budget. A survey in late 1990s demonstrated that general practitioners supported the scheme, pharmacists opposed it, and patients were unaware of the scheme but seemed to have suffered no harm as a result. This aspect has never been fully addressed in any study about the impact of incentives for doctors around prescribing. In fact, evidence suggests that the results of purely financially focused incentives may be perverse to good patient care. There is anecdotal evidence of some success with the use of incentives. In 1964, in the UK, specific payment for group practice, for improvement of premises, and for ancillary staff led to dramatic changes in British general practice which produced the structure of primary care that exits today (Hart 1988). In Norway, general practitioners who were remunerated under a system that

54

Western European Best Practice of Institutional Involvement and Responsibilities in HR Policy

gave them €30 for home visits were more likely to do routine home visits than other doctors who were paid €6 for such a visit. However, in this example it was not clear whether patients gained much from increased home visiting. Part of the differences found in observational studies on the impact of payment mechanisms and incentives could be due to a selection effect, as salaried physicians prefer shorter working hours and prefer to work less intensively. Physician payment systems affect the trade-off between leisure-time and work. Female and younger general practitioners value family life and leisure-time more highly than the rest. This was the case, for example, in Norway, in 1990, where there were two main types of general practitioners: local government employees remunerated by salary and independent contractors mostly paid by fee-for-service. In this case, the change from salary to feefor-service would increase service production by 20-40%. At the same time, working part-time, or salaried, could be an incentive to some general practitioners. Only where there are health centres or group practices it is possible to use group incentives. In Spain there are group incentives in health centres for the whole team (global and per professional groups), to spread over more than just a general practitioner the risks associated with costs control (including prescription costs), and to encourage mutual monitoring among physicians and nurses. In such a setting, this monitoring is effective because professionals have better information about each other’s practice patterns than health managers do. Privatisation of PHC in Croatia (general practitioners changed from salary payment and public employees status to capitation payment and independent contractors status) was associated with accessibility improvements (appointments at precise times, scheduled visits by telephone, telephone advice outside working hours) (Hebrang et al 2003). However, we know nothing about the access by population sub-group, or the impact on patients’ health of those changes. Incentives can also have a professional character. For example, in Portugal where there are many “obstacles” to be overcome from the bottom to the top of the ladder, and few rewards, a scheme exists which provides professional incentives as a career. In Portugal and Spain, the most popular incentive used by managers has been the opportunity for professionals to take part in important management decisions and health service planning. Finally, there is also some experience with punitive approaches to incentives (“negative incentives”). In Germany, a scheme that penalised doctors for overspending a national drug budget resulted in a decrease in drug costs by 25% but it may have resulted in an increase in hospital admissions and referrals. In France, punitive incentives have been designed against prescribing outside recommended guidelines. While most of the examination of the guidelines has looked at compliance and there is provision to examining their clinical effects, the results of the study have not yet been reported. Incentives may be also used to promote self-care because self-care (personal and familiar) is the basic level of care. For example, financial support for families caring for a chronically ill patient at home (home care) is provided in Germany. 4.5.5.1

Summary

Little is known of the effects on the costs and outcomes of care of different modes of remunerating general practitioners. The studies reviewed did not evaluate the effects of remuneration on patients’ health status and were characterised by the omission of major confounding variables. This makes it impossible to generalise results to other settings. Sadly enough, however, most ongoing policy changes in the area of payment systems are inadequately informed by research.

55

Primary Health Care: Service Delivery – Volume 2

The three main methods of remunerating (capitation, salary and fee-for-service) are hypothesised to provide general practitioners with very different incentives.

4.6

Conclusions

There are no best models ready to be copied in the field of PHC. The (limited) European best models of PHC analysed in this text might help in understanding basic questions, such as the difficulties in breaking the negative circle of weak general practice, and the importance of gate keeping. But there is not enough information “to sell” any package of health policy rules which ends in a “perfect” PHC system. Each country should follow its way, according to its history, culture, wealth and socio-political circumstances. The review of the European experience allows us to suggest that: 1. In the EU, PHC is the base of the health care services. But the science base of PHC is poor, in terms of the cost-effectiveness evidence of competing alternatives. 2. General practitioners are key professionals in PHC, with better reputation and strong policy power compared with others professionals. Nurses, managers, pharmacists and other nonphysician professionals have weak informal policy power, which shows the importance of trust and reputation. 3. Little is known about the impact of different ways of practice organisation, different ways of payment, and different workforce arrangements. General practitioners need a minimum workload to maintain knowledge and skills. In some areas, substituting nurses for general practitioners has shown to produce equal or better health outcomes. 4. General practitioners, in comparison with other specialists, take care of many diseases without loss of quality, and often at lower cost. The very high negative predictive value of general practitioners gives scientific justification to gate-keeping (as it allows the “filtration” of the population who contact specialists). Specialists in turn have very high positive predictive value when working in conditions of high prevalence of disease. 5. Informal policy power is in the hands of six main collective actors or stakeholders: government authorities, insurers, professionals, patients, teaching and research institutions, and the health industry. The main sources of informal policy power are: ownership and financial resources, knowledge and information resources, and social and political support. Actors’ interactions might change health policy in two ways: by modifying the rules of interactions and by allocating and redistributing resources. 6. There are four EU countries where general practice is strong and have a positive circle of high social esteem, enough earnings, high self-respect, good education and research, and cooperation with specialists: in alphabetical order, Denmark, the Netherlands, Spain and the UK. In spite of many other considerations (see below, point 11), I have considered these countries as best practice models. 7. Governments in the above four countries have been pro-active for decades, supporting PHC with rules and resources. They promote general practice in eight main ways: a) limiting access to specialist care and providing general practitioners with the role of gatekeepers, b) promoting pro-coordination reforms to emphasise basic characteristics of PHC, such as coordination, continuity and comprehensiveness, c) allocating enough financial and material resources, which gives PHC professionals the opportunity to answer more common problems as chronic diseases and co-morbidity (and solving more than 90% of total patients health problems entirely within PHC), d) establishing capitation as the way of payment (plus allowances and target incentives) and patient list as an opportunity to work with the community, e) promoting reforms aimed at broadening the PHC portfolio, f) shifting the balance to promote decentralisation decisions and professional networking, g)

56

Western European Best Practice of Institutional Involvement and Responsibilities in HR Policy

establishing numerus clausus and mandatory vocational training, and h) promoting the production and dissemination of knowledge. 8. Associations of general practitioners in Europe are well established and have supported governments initiatives (in some cases have forced it) thinking not only in professionals and earnings improvement, but in the health of the population. Gate keeping is a monopoly with cannot survive without efficient services of high scientific, technical and human quality in general practice. General practitioners must therefore accept the responsibility for making the initial decision on every problem with which a patient presents him or herself. Having the same or better earnings than specialists demands scientific development of the knowledge and experience which are specific for general practice. 9. General practitioners’ associations in the above mentioned four countries have strong informal policy power and high salience of reputation for twelve main reasons: a) professional autonomy, b) scientific answer in daily practice to the challenge of having the monopoly of first contact, c) multidisciplinary groups, d) expanded task policy, e) knowledge production (research), f) information control (with the use of low and high technology), g) impact in controlling national health costs, h) contribution to reverse the inverse care law, i) satisfaction of the population, j) lobbing not only for earnings issues (deontology), k) promoting local self-coordination steered by general practitioners through network-like arrangements and l) developing a system of continuing medical education and promoting re-accreditation. 10. Research is a source of informal policy power, as it increases the knowledge and information resources. In countries with best practice models, general practice research is well developed, with support of universities and research institutes. National and international organisations, public and private, have helped in research activities through funding and production of basic tools, such as classifications. 11. The four countries with strong PHC and which can be considered best practice models have important problems. In general, there is poor coordination with hospitals and the social sector, and underdeveloped answers to the co-morbidity challenge. There are also specific problems, as very weak relationships between community care and general practice in the Netherlands and the UK, or the fact that paediatricians work as general practitioners for those under 14 years in Spain, among others. The UK is in fact involved again with major reform proposals which intend to foster efficiency in PHC by means of “constructive discomfort” (Maynard 2004). 12. General practice is pro-poor health care in many European countries. European upper classes seem to prefer specialists’ care (rich people see a specialist more often than expected on the basis of health need). Specialists care is pro-rich, particularly in Ireland and Portugal. Not much is known about the reasons behind this social behaviour but understanding the question is critical not to lose one important source of informal policy power: social and political support. Again, there are no best models ready to be copied in the field of PHC. Having said that, common sense indicates that it is better to consider the example of countries which have solved most of their basic problems and have a socially strong PHC, than considering countries which have a weak PHC (except for learning the consequences of wrong decisions). The above 12 conclusions draw a map in which general practitioners are central to PHC, and PHC is central to developing a balanced health system. Governments and professional associations might contribute to a strong PHC system in different ways, with support from universities and research institutes, insurers, patients and the health industry. However, it must be stressed again that not enough is known about many critical questions in developing PHC.

57

Primary Health Care: Service Delivery – Volume 2

This leads us to conclude that final decisions in any country should not follow a simple recipe from anywhere. It is up to the main actors and stakeholders to make their decisions with extreme care.

4.7

References

Abel-Smith B, Figueras J, Holland W, McKee M, and Mossialos E., (1995), Choices in health policy. An agenda for the European Union. Aldershot: Dartmouth. Arrowsmith J, French S, Gilman M, and Richardson R., (2001), ‘Performance-related pay in health care’, J Health Serv Res 6: 114-119 Bentzen, N. (ed.), (2003), WONCA dictionary of general / family practice. Copenhagen: Laegeforeningens Forlag. Blendon RJ, Donelan K, Jovell AJ, Pellisé L, and Costas-Lombardía E., (1991), ‘Spain’s citizens assess their health care system’, Health Affairs 216-228 Boerma WGW, Jong FAJM, and Mulder PH., (1993), Health care and general practice across Europe. Utrecht: NIVEL. Boerma, WGW., (2003), ‘Profiles of general practice in Europe. An international study of variation in the tasks of general practitioners’, Doctoral Thesis. Utrecht: NIVEL. Davies C., (2004), ‘Regulating the health care workforce: next steps for research’, J Health Serv Res 9: SI 55-61 Delnoij D, Merode GV, Paulus A, and Groenewegen P., (2000), ‘Does general practitioner gatekeeping curb health care expenditure?’, J Health Serv Research 5: 22-26 Dooslaer EV, Koolman X, and Puffer F., (2002), ‘Equity in the use of physician visits in the OECD countries: has equal treatment for equal need been achieved?’, in Measuring up: improving health system performance in OECD countries. Paris; OECD. Pp 222-248 Edmunds J, and Calnan MW. (2001), ‘The re-professionalisation of community pharmacy?. An exploration of attitudes to extended roles for community pharmacist amongst pharmacists and general practitioners in the United Kingdom’, Soc Sc Med 53: 943-955 Engström S, Foldevi M, and Borgquist L., (2001), ‘Is general practice effective? A systematic literature review’, Scand J Prim Health Care 19:131-144 Erdmann Y, and Wilson R., (2001), ‘Managed care: a view from Europe’, Ann Rev Public Health 22: 273-291 Es JCV., (1987), ‘General practice in the Netherlands’, in The construction of a new curriculum of vocational training for general practice in the Netherlands. Utrecht: CHG. Pp. 3-10 Gervas J, Pérez Fernández M, and Starfield B., (1994), ‘Primary care, financing and gatekeeping in Western Europe’, Fam Pract 11: 307-311 Gosden T, Forland F, Kristiansen IS, Sutton M, Leese B, Giuffrida A, Sergison M et al., (2001), ‘Impact of payment method on behaviour of primary care physicians: a systematic review’, J Health Serv Research 6: 44-55

58

Western European Best Practice of Institutional Involvement and Responsibilities in HR Policy

Hart JT., (1988), A new kind of doctor. The general practitioner’s part in the health of the community. London; Merlin Press. Hebrang A, Henigsberg N, Erdeljic V, Foro S, Vidjak V, Grga A et al., (2003), ‘Privatization in the health care system of Croatia: effects on general practice accessibility’, Health Policy Plann 18: 421-428 Horrocks S, Anderson E, and Salisbury C., (2002), ‘Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors’, BMJ 324: 819-823 Jong-wook, L., (2003), ‘Global health improvement and WHO: shaping the future’, Lancet 362:2083-2088. Kernick D, and Scott A., (2002), ‘Economic approaches to doctor/nurse skill mix: problems, pitfalls, and partial solutions’, Br J Gen Pract 52: 42-46 Linden BAV, Spreeuwenberg C, and Schrijvers AJP., (2001), ‘Integration of care in the Netherlands: the development of trans-mural care since 1994’, Health Policy 55: 111-120 Maynard A, and Bloor K., (1995), ‘Primary care and health care reform: the need to reflect before reforming’, Health Policy 31: 171-181 Maynard A., (2004), ‘Using markets to ensure “constructive discomfort” in English primary care’, HSJ (in press). Mazinko J, Starfield B, and Shi L., (2003), ‘The contribution of primary care systems to health outcomes within Organisation for Economic Cooperation and Development (OECD) countries, 1970-1998’, HSR 38: 831-865 McKee M., (2001), ‘Is a European health care policy emerging?’, BMJ 323:248 Mossialos E., (1997), ‘Citizens’ views on health care systems in the 15 members states of the European Union’, Health Economics 6: 109-116 OECD, (2003), OECD Health Data 2003. A comparative analysis of 30 countries. CD ROM and user’s guide. Paris: OECD. Olesen, F., (2003), ‘A framework for clinical general practice and for research and teaching in the discipline’, Fam Pract 20:318-323 Rico A, Saltman RB, and Boerma WB., (2003), ‘Organisational restructuring in European health systems: the role of primary care’, Social Policy Administr 37:592-608 Roemer MI., (1963), ‘On paying the doctor and the implications of different methods’, J Health Human Behavior 3: 4-14 Saltman RB, and Figueras J (eds.), (1997), European health care reform. Analysis of current strategies. Copenhagen: WHO Europe. Scott A, and Hall J., (1995), ‘Evaluating the effect of GP remuneration: problems and prospects’, Health Policy 31: 183-195

59

Primary Health Care: Service Delivery – Volume 2

Smith PC., (2004), ‘Incentives for quality: the challenges for research and policy’, J Health Serv Res 9: 65-66 Starfield B., (1991), ‘Primary care and health. A cross-national comparison’, JAMA 266: 2268-2271 Starfield B., (1998), Primary care. Balancing health needs, services, and technology. New York: OUP. Sweeney B., (1994), ‘The referral system’, BMJ 309: 1180-1181 Walley T, Murphy MB, Codd M, Johnston Z, and Quirke T., (2001), ‘Effects of a monetary incentive on primary care prescribing in Ireland’, Eur J Gen Pract 7: 92-98 WHO, (1996), ‘The Ljubljana Charter on reforming health care’, BMJ 312:1664-1665 WHO, (2000), World Health Report 2000. Health systems: improving performance. Geneva: WHO.

60

Critical Steps Undergone by European Countries to Setup the Foundations of a PHC System

5

Identifying the Critical Steps Undergone by European Countries to Setup the Foundations of a Primary Health Care System in Conditions of Resource Constraint The case of the Mediterranean countries Juan Gérvas

February 2007

61

Primary Health Care: Service Delivery – Volume 2

5.1

Introduction

When countries of central and eastern Europe (CCEE) confronted the changes associated with what has been described as “the Berlin Wall fall”, they clearly looked to the West for models. Germany, for example, is one of the richest countries of the world (and culturally and geographically very close to many Eastern European countries), so its way of living and its economy was seen as an ideal reference. It is clear that their move towards social insurance systems and their wish to raise traditionally very low levels of remuneration to providers, together with other factors, have made the German health system very attractive. However, when it comes to issues of organisation, provision and financing of PHC, wealthy countries might not be the best example. The German PHC system in particular is not considered a model by other countries of western Europe. German PHC is in fact very weak, and the whole system costs too much, even for a rich country (Gérvas et al 1994; Mazinko et al 2003). Experience has supported those fears. For example, the move in the 1990s of the Czech Republic to adopt key features of the German point system, with free access to specialists and fee-forservice payment in ambulatory care (before the development of adequate information systems, and before the establishment of a process of negotiating fees) proved catastrophic, with loss of expenditure control, huge cost inflation and serious social problems within a few months of initiating the new system (Saltman and Figueras 1997). The adoption of the German system shows the strong informal policy power of Czech professionals at that time, supported by external agencies, as the World Bank and others. It shows also the weak formal and informal policy power of the government authorities (more or less brilliantly supported by the WHO) but almost void of financial, knowledge and social resources. Another document by this Consultant (this volume, document 2.4) has made the point that there is not enough research basis to speak about best practice models in PHC in Europe. In more limited sense, however, there is consensus that western Europe includes a few countries that can be considered good PHC practice models. Denmark, the Netherlands and the UK have broken the typical PHC negative circle of low social esteem, poor earning, and heavy competition with specialists. Spain is close to these countries in 2004 after its PHC was successfully reformed in the 1980s. At that time, Spain was not a rich country. In the 1970s it came out of a hard dictatorship and democracy returned. The reform of PHC began in the 1980s, following the political program of the Socialist party in power from 1982 to 1996. Much can be learned by analysing Spain as a benchmark, and comparing it with other Mediterranean countries (Greece, Italy, and Portugal) [in alphabetical order], that have been less successful in developing a solid PHC. All four belong to the European Community (now the EU), and Spain, Portugal and Greece were (and are) included in the group of less affluent developed countries (Gené et al 1996). As it is the case now with CCEE, external influence also played an important role at that time in the health system reforms in the Mediterranean countries. The creation of the national health services in Greece, Italy, Portugal and Spain was influenced in particular by the British and Nordic national health systems, and by the WHO policy of emphasising PHC and Health for All (Figueras et al 1994). Later on, membership of the European Union forced them to control the national budget, according to the Maastricht Treaty in 1994, and to act according the new “Euro” financial discipline in 1998. Public finance, which includes compulsory health insurance contributions, remains the main way to fund access to health care in these four Mediterranean countries, and its role was extended with

62

Critical Steps Undergone by European Countries to Setup the Foundations of a PHC System

the moves towards ensuring universal coverage. The worsening economic climate in the world during the late 1970s and the 1980s (the “oil crisis”) exacerbated the difficulties of the reform. It therefore looks fair to compare and learn from their successes and failures in reforming PHC when Georgia is going through a rather similar process of change. This review will identify the main steps developed by politicians and professionals in creating a PHC system in the 1970s and 1980s in the above mentioned four Mediterranean countries. The objective of this paper is to understand why Spain has finally succeeded in the 2000s whereas the others have not.

5.2

Greece

5.2.1

PHC in Greece as a case study

The democratic Greek Constitution of 1952 was reformed and approved in 1975, at the end of the “Colonels” dictatorship (which lasted from 1967 to 1974 and followed the track of a previous fascist government before World War II). The Greek Constitution states that all citizens have an equal right to health care. In addition it refers to the responsibility of the State to “care for the health of the citizens and to take special measures for the protection of the young, the elderly, the handicapped and the indigent”. In 1981 Greece became a member of the former European Community. With 10 million, the population is unevenly distributed over the country as more than 30% of it lives in Athens. In 1991, the Greek Gross Domestic Product (GDP) per capita was $16,137 (at purchasing power parities) (OECD 2003). In 1983 the then Socialist government passed a law on the introduction of a National Health System, with great political support, thus challenging the existing social security-based health care financing. The reform followed many of the Doxianes Plan recommendations issued in 1980. The National Health System Act was an attempt to create a more comprehensive public scheme (until then public coverage was 88%, and a public PHC system almost did not exist) as well as to increase control of the private sector. It was a definitive step to change the financing of its health care from a Bismarck system to a tax-financed Beveridge system (Tragakes and Plyzos 1996). Greece faced great obstacles in such an endeavour, because it had to transform a health system which comprised different private health insurance providers to one with public health services providers in a time of adverse economic situation (as already mentioned, the “oil crisis” was having at the time a very negative impact on the global economy). At the end of 1983, a Ministerial Committee for Health Policy was established under the chairmanship of the Prime Minister. Its main task was to coordinate all health-related agencies in formulating and implementing a common health policy. As a consequence, the Ministry of Health and Social Security was reorganised in 1985 as the main agency responsible for the administration, organisation and provision of health services. Under the Minister there were two Deputy Minister, one of them responsible for Social Insurance, and the other for Health and Welfare Services. In a hierarchical order, immediately below the Minister was the Central Health Council, established in 1982, and consisting of 24 members who were representatives of physicians, pharmacists, and nurses associations, medical schools, trade unions, civil servant associations, and urban (industrial workers, IKA) as well as rural (agricultural workers, OGA) insurance associations (sick-funds). There was a strong opposition from professionals and sickness funds which could at least slow the reform process. The Council was invested with many tasks and responsibilities, such as:

63

Primary Health Care: Service Delivery – Volume 2

• • • • •

planning and defining the aims and policy directions, formulating a national policy in the health sector, submitting proposals to the Minister, monitoring the planning process, and proposing corrective measures whenever necessary, and coordinating and controlling the regional health councils and advising on the allocation of economic resources between regions.

The Council set up a committee on “Primary Care Organisation and manpower planning of the primary health centres”. This committee’s mandate was aimed at: • • • • •

achieving full time employment of doctors in the public health system, thus diminishing simultaneous attachments to both public and private practice, developing a national network of health centres with teamwork and salary system, following WHO recommendations (Alma Ata Declaration, and Health For All objectives), promoting general practice as to balance the trend towards specialisation, introducing a pro-coordination reform (general practitioners as gatekeepers), and training PHC medical and nursing staff.

General practice did not exist, and hospital out-patient care included services provided by paediatricians, internists, obstetricians, and other specialists (Boerma et al 1993). In 1991 and 1992, the reform was corrected with comparatively increased emphasis in private provision of health care, and the introduction of cost-sharing (Matgasanis 1991; Katrougalos 1996). Because of the Maastricht Treaty stipulations, a new Socialist government appointed in 1994 an international committee to make an independent review of the Greek health system and suggest how to increase efficiency and equity. The central recommendation of this committee was to establish PHC with self-employed general practitioners and capitation system. It highlighted the need for introducing emphasis on general practice in medical schools, and for developing programmes for the training of managers, public health doctors and general practitioners. Also, a Medical Council should be established to police the ethical standards of the medical profession and stamp out illicit payment of every kind to doctors (OECD 1994). Most of these provisions were never implemented because delays and a subsequent change of government stopped the implementation process. Instead, a new correction again increased private provision in the late 1990s and early 2000s, emphasizing patient freedom of choice and private initiative. After more than 20 years, despite improvement (for example, public coverage reached 100% from 1985 onwards), the Greek health care system still has many features of former days: 1. the government has only been successful in developing health centres in rural areas. Those health centres are run by the national health system and the sickness funds, and are staffed by salaried doctors and nurses. The health care budget has not been sufficient to fund the necessary development of facilities and the plan was never fully implemented, 2. the publicly funded insurance funds (IKA and OGA cover around 75% of the population, and there are numerous small funds) are also suppliers mainly by contract of self-employed physicians on fee-for-service payment bases, 3. there are notable differences in the services and coverage provided by the many health insurance funds,

64

Critical Steps Undergone by European Countries to Setup the Foundations of a PHC System

4. the state supplies free of charge health care mainly through a network of hospitals in urban areas and health centres in rural areas; the private sector, however, is still important, and of increasing importance in service delivery, 5. physicians work frequently in public hospitals or health centres in the morning (salaried) and in private clinics in the afternoon (fee-for-service payment), 6. there is an oversupply of physicians (mainly specialists) and hospital beds (although rather declining), 7. there is a severe shortage of nursing personnel, 8. “black money”, “under the table payments” and tipping practices are common, as there are hidden extras frequently both to private and public general practitioners and specialists, 9. in 2001, almost 45% of total health expenditure was private ($665 out of a total of $1,511 per capita [for comparative purposes, it must be noted that according to OECD Health Data 2003, the average private health spending in the 22 OECD European countries (including Czech Republic, Hungary, Poland, and Slovakia) was 25%, $505 out of $2,049] (OECD 2003), 10. Greece join Austria and Portugal (and the USA) in being the only countries of the OECD where total visits to physicians appear not to be distributed according to need, although lower income groups use general practitioners significantly more often than higher income groups. Adjusting by region reduces the degree of inequity in Greece, suggesting that the income-related inequities in specialists use are, at least in part, associated with regional differences in access to such care (Dooslaer et al 2002), 11. the gate keeping role of general practitioners does not exist in practice (it is just a formal role) (Boerma et al 1993), and only rural general practitioners have patient lists, 12. paediatricians work in health centres as (some kind of) general practitioners for children, 13. after medical graduation one year of practice in PHC in rural areas is compulsory (but many physicians feel the countryside experience of general practice as almost a punishment before entering specialist training) (Boerma et al 1993), 14. in 1995, the practice primary score of Greece was 4 (the best score being 20), one of the lowest in Europe (but still better than Germany, 3, Switzerland, 2.5, and France, 2). It is important to note that the score has not changed over time (it was 4 in 1975 and again in 1985) (Mazinko et al 2003), 15. there clearly is an overuse of medication and diagnostic tests, 16. in 1996, 24% of the Greek population was very dissatisfied with the way the health care is run (the second highest rejection rate, after the Italian population) (Mossialos 1997). The situation has not improved over time (in 2003, total satisfaction was 4, in a scale from 0 to 10) (INRA 2004), and 17. the Greek Association of General Practitioners is powerful, but devotes its power mainly to union tasks; as a consequence, research and knowledge production in general practice are underdeveloped.

5.2.2

Policy analysis of the Greek PHC case

This case study shows the struggle of formal policy power (mainly the socialist government of the 1980s and 1990s) to develop PHC and a Beveridge health system with almost no control of any source of informal policy power. In fact, insurers and professional associations usually have more informal power than governments. The existing Greek health system was and still is fragmented and with no decentralisation at all. Yet at the same time, there is a plethora of social and private insurance plans, and public and private providers, especially in urban areas. The 15 regions have almost neither health policy nor

65

Primary Health Care: Service Delivery – Volume 2

decision-making power. As in Portugal (see below), Greek governance of PHC is centralised within a national health system (Tragakes and Plyzos 1996; Boerma et al 1993; Matgasanis 1991; Katrougalos 1996). History might have the key to explaining the weak position of a democratic party in the government. Greece has had frequent turbulent times until 1974, with a fascist administration before World War II and a hard dictatorship from 1967 until 1974. A national social security system (IKA) was established in 1934 for industrial workers with coverage of around one third of the population. This IKA developed its own health care infrastructures for its insured population. Staffed with a number of specialists, they provided free at the point of use care to fund members. The three more important collective stakeholders (government authorities, insurers and professionals) have played their role and used their power in changing such a health system without general practice, from a Bismarck system to a Beveridge one based in PHC. There was strong opposition of the professionals and insurers. Doctors used their influence to block badly needed reforms, probably to preserve a system that gives them financial abundant illegal incomes (tipping practices). The socialist government utilised its formal policy power, and the Constitution, to launch the reform with the National Health System Act. However, it never had enough financial and ownership resources, so health centres were a reality only in rural areas, and the health care budget has never been sufficient to fund the required development of facilities and workforce. The State authorities lack also strong knowledge and information resources, as their main source in this regards was the external informal policy power of WHO [Alma Ata Declaration, Health for All, and the Finnish health care system as best practice model]. But knowledge and information resources are more important in Greece than elsewhere. The social support was strong in the beginning of the reform, in 1983, because of the perception of social inequities, but became very weak with every new government of a different political sign, as usually happens after experiencing a dictatorship (societies are typically left morally and ethically handicapped for decades). Insurers and professionals had important formal policy power in the Central Health Council in the 1980s. Having a Bismarck system at that time meant that their networking allowed them to develop neo-corporatist schemes, based in joint decision-making by the State, insurers and professionals. Moreover, insurers had the ownership and financial power. The Social Security budget is always bigger than any other budget in the country. In the 1980s, the existence of one Deputy Minister of their own in charge of Social Security, with more power than the Deputy Minister of Health and Welfare, made the day-to-day management rather difficult (later on, Social Security was moved again back in the Ministry of Labour). Not surprisingly, workers and trade unions supported in the Central Health Council and everywhere “their” own sickness funds (IKA; OGA, and the small ones, as well as their organisation and role in health care supply). Workers of the banking sector and other powerful business had, and still have, better services and coverage. As a consequence, and as explained above, Greece has still a health system with many of the Bismarck model features; in 2000, almost 50% of total health care was social insurance-financed. Also, without previous experience of general practice, PHC development in Greece was rather weak. Patients had had personal experience in using specialists as some sort of general practitioners. The health system was and is hospital driven. There is a lack of properly trained PHC management, medical and nursing personnel. And to make it worse, the few general practitioners

66

Critical Steps Undergone by European Countries to Setup the Foundations of a PHC System

worked in competition with ambulatory specialists for patients’ first contact. Thus the procoordination reform, the gate keeping system, was only a formal, administratively hierarchical decision, never a functional change. The referral system was considered a failure in the whole country (Tragakes and Plyzos 1996; Boerma et al 1993; OECD 1994). General practitioners have at least succeeded in giving more care to poor people, but income related inequities in specialist care use means that urban areas have an oversupply of specialists who give, probably, unnecessary care to the rich. Public opinion of public services in Greece is very low, as a result of shortages and long waiting time (in a country with oversupply of doctors!). There are also serious deficiencies in the public health service infrastructure. As these deficiencies result in public provision of a limited range of services, the public health sector is very weak. Many Greeks, dissatisfied with publicly provided PHC, have turned to the private sector. Public insurance funds increasingly also contract out private providers for services not offered by the public system. Low credibility of the public system often induces many patients to seek a second opinion, mainly from private doctors. That is why 45% of total expenditures are private, against 25% in European OECD countries, reflecting a very weak public health sector. To make it worse, total health spending as a percent of GDP in 2001 was 9.4 (higher than Portugal, Italy and Spain, with 9.2, 8.4 and 7.5 respectively) (OECD 2003). Overall, general practitioners lacked in Greece social trust and were never able to break the already mentioned negative circle of low self respect, poor education, poor earnings, scarce research and heavy competition with specialists and hospitals. PHC has always been underfunded, and under-developed. Research was almost non-existent, and only a few universities, such as the University of Crete, give emphasis to PHC. 20 years after the start of the reform, two indicators clearly show the power of professionals, and long-lasting ethical problems: 1) the persistence of all sorts of informal payments and 2) the official objective of fulltime public employment of physicians (working only in the public sector and not privately as well) has not yet been achieved.

5.3

Italy

5.3.1

PHC in Italy as a case-study

Italy has a population of 60 million, and it is a member of the European Union from its early foundation as European Community. It is one of the wealthier countries of the world, with a GDP per capita, in 2001, of $26,345. The Italian Constitution (1948) was approved after World War II, abolishing the Constitution of the fascist government before the war. The new Constitution defined an administrative organisation of Italy in 20 regions, with 5 of them having a special status because historical and linguistics reasons (Friuli-Venecia Giulia, Sardinia, Sicily, Trentino Alto Adige, and Valle d’Aosta). The devolution of power to the regions has been an evolving process, and a very important one from the point of view of the health system reform. It began in the immediate post-war years, languished until 1971, and accelerated from the late 1980s, with the regions being transformed from what were essentially administrative apparatuses into real political entities (Gérvas et al 1994; Boerma et al 1993; Donatini et al 2001).(Ferrera 1996; Ferrera 1997). After the constitutional amendments approved in 2001, Italy can now be regarded as a quasi federal State.

67

Primary Health Care: Service Delivery – Volume 2

In 1958, an independent Ministry of Health was established for the first time. The objectives advocated by WHO in the 1970s were adopted by Italy in terms of ensuring ideal health conditions and providing the necessary services to each citizen. At that time, sickness funds with their direct relationship with doctors (through a fee-for-service payment system) had made health expenses almost impossible to manage, and new payments had to be increased. The national debt thus increased as the State attempted to aid insurers. With a coalition of parties which included the then powerful Communist Party, a National Health Service was created in 1978 (Act 833) with the objectives of • • •

transforming a Bismarck system into a Beveridge one, giving PHC a central position in the system, and improving access to the whole population (universal coverage, from 95% in 1975 to 100% in 1980).

The 1978 reform was a success regarding the abolition of the sickness funds, because of the existing division of professionals’ associations and the low prestige of those sickness funds. In theory, the latest instalment of the State debt towards any insurer was to be paid in 1984-1985 (Degan 1986). However, the intention to change the health system from mainly insurance funding to general taxation funding took decades, as in 1999 workers and employers contribution was still 44% of the total public health cost (the remaining 46% came from public national taxation, as well as from local and regional taxation). The health care law that in 1978 set up the Italian National Health Service was initially conditioned by the primary need to control health expenditures while reaching very broad objectives, in line with WHO positions. Initially, measures were designed to: • • •

• • • • • •

68

limit expenditures and control costs, reorganise the hospital network in areas where there was an exaggerated number of beds (one of the main characteristics of the Italian health care sector is a strong hospital structure), regulate the workforce market, decreasing the number of physicians (although not the variety: the Italian system was and still is based on developing specialised services and professionals for each health problem), and increasing the number of nurses (i.e. correcting the existing very low nurse/doctor ratio), improve and established family planning centres, develop mother and child health local centres, transfer power to regions and local authorities, and allow local health units (20,000 to 50,000 inhabitants), the daily management of health services and the contract of services through their elected committees, provide care through hospitals, polyclinics, and engaged self employed paediatricians and general practitioners (who would be paid by capitation payment plus allowances, and would be given a gate keeping role), improve public coverage (from 95% to 100% of the population).

Critical Steps Undergone by European Countries to Setup the Foundations of a PHC System

The truth was that the sudden implementation of this reform increased the fiscal deficit, year after year. In 1995, the Maastricht Treaty made it necessary to review the reform in order to solve the chronic deficit and increase efficiency and equity. Doctors were allowed only one job in the National Health System. In fact, simultaneous private and public work was forbidden since 1978, but many physicians have been working both as general practitioners (with small patient lists) and as hospital doctors paid part-time salaries. General managers then replaced the elected committees which used to run local health units (their number was reduced from 650 to 250, serving populations from 100,000 to 250,000). Capitation fees, which varied depending on the patient’s age, were allowed to be supplemented with fees for about 20 services up to a maximum of 25% of capitation income. In 1999, a new reform introduced new financial incentives in PHC with the objectives of • • • •

decreasing referral rates, strengthening group practice, broadening the portfolio (for example, allowances for the delivery of care to specific patient as home care for chronically ill), and promoting better integration with social services.

The history of the National Health Service can also be seen as an ongoing attempt to come to grips with the financial implications of expanding regional autonomy. Arrangements for financing the system were for many years characterised by a form of skewed fiscal federalism. Regions enjoyed considerable discretionary power in the expenditure side of the budget but had virtually no responsibility on the revenue side. Lacking any significant own-source revenues, the regions could not be obliged to finance their deficits. Faced with this situation, the different central governments felt obliged to resort to more or less veiled forms of under-financing. Central-regional relationships have always been conflict ridden, with a negative effect on the health system performance and low public satisfaction with the provision of care. The situation remained stalled until the early 1990s, when a process of transferring revenue sources to the regions was launched (with an explicit mechanism limiting the financial obligation of the central government for health care). The Bassanini reform gave real power to regions, which were given freedom to spend as much as they wished to, but were obliged to guarantee a nationally uniform entitlement to all residents (“essential level of care”, “basic package”, an agreement between central and regional central governments, in addition to negotiating overall spending levels). A peculiar feature of the Italian political life worth noting here is that governments are usually granted only a short life, with more than 50 of them in 50 years. And indeed changes mean different political options and priorities. For example, implementation of the established plan for fiscal federalism in the national health system was blocked after the election of the Berlusconi government in the early 2001. In any case, unable to live within the spending limits inherent in the current negotiated funding levels, regions are applying patients’ co-payments and are de-listing services, and these practices vary form region from region. Setting regional caps to health expenditures can not resolve all problems, if they are not supported by up-to-date data on the movement of patients between regions. In Italy, where there is a permanent contrast between the rich industrialised north and the poor agrarian south, simply allotting more money to the south will not necessarily attract well-qualified workforce nor will it stop patients going north in search of health care. In addition, northern regions such as Lombardia and Bolzano are financially autonomous (in 2000, respectively, 81% and 82% of the health budget

69

Primary Health Care: Service Delivery – Volume 2

came from regional taxation), in contrast with southern regions as Calabria and Campania (where the equivalent figures were 24% and 28%, respectively) (Reviglio 2000). After more than 25 years of reform, Italy now has a Beveridge-type of health system, its deficit is under reasonable control, private health spending is around 25% of total health cost ($546 out of $2,212 per capita) (OECD 2003), decentralisation is a reality as regions have more power than ever, and general practice has been established with a solid performance (the Italian primary care system had a score of 14 in the above-mentioned ranking, as it includes home visiting, medical records, etc.) (Mazinko et al 2003; Boerma et al 1993; Boerma 2003; Donatini et al 2001). Yet the system still has some problems because the health system reform and PHC are not fully developed, as follows: •

• • • • • •

• •

• •

70

doctors’ unemployment is a chronic problem, and many general practitioners have a very small patients list. In Italy, the optimum doctor to population ratio is considered to be one general practitioner per 1,000 patients (maximum 1,500 for full-time general practitioners). Part-time doctors, with a maximum of 500 patients, need supplementary sources of income, there is direct access without referral to many specialists, as obstetricians, gynaecologists and ophthalmologists, and poor coordination between PHC and public specialists (mainly paid by fee-for-service, in policlinics and out-patient services), paediatricians work in general practice as general practitioners for those under the age of 14, nurses work in community teams, with only slight coordination with general practice, receptionists and other staff personal are almost not existing in private premises, were general practitioners work mainly single handed, community care (mainly devoted to preventive activities) is independent of general practice, having its own community teams. This means that general practitioners have mainly a personal care curative approach (in line with Osler’s paradigm), in 1990, 40 % of the Italian population thought that “the health care system has so much wrong that we need to completely rebuild it” (highest per cent rejection rate in an international study, the Blendon report) (Blendon et al 1990). After the revision of the reform, in 1995, things seem to be going better (but again in 1996 a similar survey found 26% of Italians to be very dissatisfied with their health care system, the highest rejection rate in Europe) (Boerma 2003). In 2003 public satisfaction (in a scale from 0 to 10) was 4, the same score as in Greece, which is below the European average but much better in Italy than in 1990 (INRA 2004), hospital beds are still in excess, as is the case with the proportion of health personnel working in hospitals, in 2001, no inequity in access to general practitioners was found, but the use of specialists showed a profile favouring the higher income users (Dooslaer et al 2002). Private insurance seems to be one of the factors contributing to this differential use. There are also systematic regional differences in specialists’ utilisation, in favour of northern regions, there seems to be a clear overuse of medicaments (in 2001, Italian pharmaceutical expenditure as a percentage of total health cost was 127 relative to the average 100 (17.6% of the total) in European OECD countries) (OECD 2003), and there are few associations of general practitioners. Moreover, those associations devote their power mainly to professional and financial questions rather than to promote research or innovation. The Mario Negri Institute (Milan) has contributed to general practice development in Italy more than many universities.

Critical Steps Undergone by European Countries to Setup the Foundations of a PHC System

5.3.2

Policy analysis of the Italian PHC case

The Italian case highlights the relevance of two practical difficulties when implementing a formal health system policy: 1. the lack of political continuity, which precludes policy proposals from being properly implemented. For example, many aims of the original 1978 reform where in the 1980s either not implemented or rapidly reversed by the new political coalition in power. And 2. the serious consequences of power imbalances and, within that context, of the fact that one of the main collective actors, the government authorities, proved unable to fulfil a critical obligation of its mandate, in this case controlling health expenditure. As usual, social insurance revenues were earmarked. But before the 1978 reform, the costs of the health care system were out of control because decision-making was based in a regulatory scheme with essentially only two actors – insurers and professionals – as in any Bismarckian system with a very weak central government (50 governments in 50 years!). The government tried to change that, but was unable to succeed fully (Donatini et al 2001). In a way, therefore, the history of the health system reform in Italy is the history of a struggle between central national government and the autonomous regional governments in a country with great differences in regional wealth. Again, Italy has had chronic uncontrolled health deficit for more than half a century, and the aim of controlling costs was driving most of the proposed reforms (Reviglio 2000). In 1978, the central government, using its formal policy power (and with the external support of ideas coming from WHO and the British experience), changed the health system for it to become a Beveridge one, giving PHC a central role and abolishing sickness funds (yet the government resisted WHO’s advice to establish health centres along the model in Finland, in view of the Italian culture of doctors as private entrepreneurs who had been contracting with sickness funds, and the very evidence of the British national health system, where doctors are independent contractors). The pro-coordination reform introduced gate keeping, capitation and patient lists. The 1978 reform portfolio broke general practice in two: paediatricians for children up to 14 years, and quasi-general practitioners for the rest of the population. Both kinds of doctors had, and have, strong biological orientation. Also, PHC was split in the Italian reform design into curative services (dominated by general practice, in which group practice does not exist as most physicians work in solo practices, with almost no other staff) and community services (dominated by nursing) (Boerma et al 1993; Boerma 2003; Donatini et al 2001). The consequences of these two artificial separations (population according to age, and services according to settings) have been weak cooperation between professionals and the ensuing lack of public satisfaction. In 1995 and 1999, the clinical portfolio was broadened, but simultaneously supplementary fees for specific services had to be introduced. Gate keeping was and still is weakly enforced in practice, as referral is not necessary for many specialists, and in many cases it is only a hierarchical, administratively formal measure (Boerma 2003; 22,). This is so because a strong hospital structure remains a leading characteristic of the Italian health system. The reform could not fully attain its objectives because of the informal health policy power of professionals, and the local importance of hospitals for communities (as explained, local health units coordinate PHC with hospitals, and contract hospital services). In 1995, the updating of the reform shifted the power from local units to regions, and, in order to improve management, general

71

Primary Health Care: Service Delivery – Volume 2

managers replaced the elected committees in charge of local health units (which in turn merged to look for more power in contracting). But this had no specific impact on promoting PHC. Before the Bassanini reform, central government had: • • •

the source of financial power (taxation) but without any realistic possibility to cap the health budget, weak knowledge and information power, and very weak social support.

The regions enjoyed discretionary power on the expenditure side of the budget but lacked any significant power to raise revenues from their own sources, which created a serious accountability problem. After the State took over the role of the old sickness funds, and in view of the cost explosion, the fiscal federalism has entailed new threats to PHC because regions are de-listing services and applying generalised patient co-payments. Co-payments decrease access to health services (some diagnostic and specialist services require 100% co-payments and some medicaments a 50% co-payment). They also favour the use of private specialists. As a consequence of all the above, the considerable inter-regional heterogeneity in service provision that had always existed, has tended to increase over time in the form of distinct regional health services in the 2000s. These differences in wealth and service provision, by the way, might explain differences in the use of specialists. The reform has also proved unable to control the number of physicians and the severe shortage of nursing personnel. Instead of addressing the roots of the oversupply problem, a small patient list in general practice, to be supplemented by a part-time job in a public or private setting, as hospitals, was presented as a solution to medical unemployment. Although some of the most dramatic elements were attenuated during the modification of the reform, in 1995, problems remain. Many doctors not only have two jobs but resent their poor earnings, as shown by the recent scandal with illegal payments from pharmaceutical industry (Glaxo-Wellcome) to more than 4,000 physicians in 2004 (Carpenter 2004). In more technical terms, it is important to note that small patient lists generate the important professional disadvantage that general practitioners will not see the various presentation of disease with enough frequency. Practitioners may therefore have difficulties to maintain their skills in diagnosing and treating emergencies in dealing with rarer clinical case presentations, and in getting experience in handling common chronic illnesses. As explained above, public dissatisfaction with the health care systems is noteworthy in Italy, which has the worst score in comparative international surveys in the 1990s (though improving slightly in the early 2000s) (INRA 2004; Blendon et al 1990). Dissatisfaction might well be the consequence of poor system performance linked to permanent inter-governmental conflicts. The finding of the highest public dissatisfaction in the country with the highest number of physicians per capita is also highly revealing. Unemployment, small lists, low clinical quality, part-time hospital or private work, and weak gate keeping role seem to fuel in Italy the vicious circle of low social esteem, poor earnings, scarce research, low self respect and (in some cases) corruption in general practice.

72

Critical Steps Undergone by European Countries to Setup the Foundations of a PHC System

Finally, the peculiarly segmented rigidity of the Italian system, based on developing specialised services and professionals for almost each health problem, has precluded it from coping efficiently with the new health needs of the population.

5.4

Portugal

5.4.1

PHC in Portugal as a case-study

With a population of a bit less than 11 million, Portugal is a member of the former European Community (now EU) since 1986. In 2001, Portugal GDP per capita was $17,560. In general, Portugal’s level of income inequality is amongst the highest in Europe (together with that of the UK). After a particularly hard fascist dictatorship of more than 40 years, which ended in 1974, the new democratic Constitution in Portugal (1976) established the right to the access of all citizens to “health promoting commodities”, of which health care is but one. In the late 1970s, population health indicators in Portugal were the worst amongst the western European countries and the government had strong social and political support for introducing reforms aimed at improving public services (Gené et al 1996). Portugal (as the other Mediterranean countries presented in this paper) thus took a decided step to broaden the coverage of medical services and change its health care system financing from a predominantly social insurance base to a tax financed national health service (INRA 2004; Bentes et al 2004; Guibentif 1997). Public coverage of health services was only 60% of the population in 1975. The National Health Service Law of 1979 stated that “access to the national health service is guaranteed for all citizens, independently of their income or social status” and public coverage became 100% in 1980. The private health sector has always had an important role in Portugal. During the 1980s (when the first steps in shifting from a social insurance model to a tax-financed model were taking place), the country saw a continuous rise in the share of private health care expenditures. Years after the reform was launched, evidence shows that although the national health system claims to be universal, a number of occupational insurance schemes which tend to cover the better-off socioeconomic groups remain in place (Pereira et al 1993). Implementation of the reform was difficult because the international economic crisis of the 1970s, and the opposition of the professionals (trade unions and medical colleges), and of the sickness funds. The persisting importance of the private sector is highlighted by the fact that after 25 years, the Portuguese health system relies heavily in private funding and provision for more than a quarter of the population. In 2001 private health spending was 31% of total health care costs ($500 out of the $1,613 per capita) (OECD 2003). The health system has three financial sources: taxation (half the total), social insurance and private money (almost 40% of the total). Approximately, 10% of the population is covered by private insurance, mainly through group insurance provided by employers. In 2001, the index of private health expenses as a percentage of GDP was 143 compared with the European OECD average of 100 (2.03%), only below Switzerland and Greece, with a 236 and 202 respectively (OECD 2003). Thus Portugal is now roughly midway between the predominantly taxfinanced countries (e.g. Spain) and the predominantly privately financed bloc of countries (e.g. the USA). A decisive factor in explaining the above may be that in the 1980s, with a change of the party in the government (from 1985 to 1995), public employees’ sickness funds were privatised in parallel with the privatisation of many public enterprises. Ever since, civil servants with private insurance coverage are refunded and face substantial cost-sharing. In 1990, 1992 and 1993, new reforms were introduced aimed at increasing the efficiency of the system and decreasing public

73

Primary Health Care: Service Delivery – Volume 2

expenditures. The trend has always been towards privatisation, with an increased role for costsharing and private insurance (tax deductible) (Bentes et al 2004). Shared private and public work for doctors has been promoted. In 1995, another change in the political sign of government, coupled with the evidence of limited resources in the private sector, slowed down the implementation of the privatisation reform and introduced some innovations in PHC (e.g., capitation, performance incentives and the Alpha Project promoting professional cooperatives) (Bentes et al 2004). Yet later on, legislation was not fully implemented and the latest change of government (again, of a different political ideology from the previous one) reversed the entire direction of the reform, in this case under the influence of the Maastricht Treaty and new “Euro” discipline. Portuguese health care reform thus seems like a pendulum, but the private sector has always managed to remain at its centre. As in Greece, Portuguese governance of PHC is centralised within a national health system. There are five regions in terms of planning, but decentralisation of formal policy power, even when it was high in the political agenda, was never successful (Bentes et al 2004; Guibentif 1997; Pereira et al 1993). In 1946, the first social security law was passed in Portugal, and before the early 1970s there was a “social security PHC”. The national PHC Directorate was reorganised in 1971 and again 1984, on both occasions following general WHO health policy recommendations and under advice from other countries. The following landmarks were important in developing general practice in Portugal: •

• •

a Norwegian-Portuguese collaboration, funded by the Norwegian Agency for International Development, helped in 1977 to establish the Institute de Clínica Geral do Hospital de San Antonio in Porto [Institute of General Practice of northern Portugal], and helped to implement general practice in the district of Vila Real, a British-Portuguese cooperation in 1979 which strongly influenced decision-makers through a seminal workshop on the future of PHC and through a study tour and its report, and the National School of Public Health of Lisbon, which supported necessary early academic and research activities (Jordao 1995).

In 1980 general practice became a medical specialty and three years later the Institute of General Practice of Southern Portugal was set up. Portugal has an advanced PHC-oriented undergraduate teaching policy. Vocational training (three years) has been mandatory from the early 1980s. In 1987 the new chair of General Practice (and Community Care) in the University of Lisbon started its operation within a common project with WONCA and WHO. Before the 1978 reform, curative care was provided in social security medical clinics by physicians who worked part-time (two hours), while health centres were only involved in preventive care. A network of health centres was then developed in 1979. In the new health centres the above two functions were integrated; PHC teams are now responsible for addressing all health problems of the population in a limited geographical area. Professionals are public employees, paid by salary. General practitioners have a gate keeping role and a patient list. PHC is therefore based in a well developed network of health centres, staffed with multidisciplinary teams (mainly general

74

Critical Steps Undergone by European Countries to Setup the Foundations of a PHC System

practitioners, nurses and dentists), with a broad portfolio (from IUD and other contraception methods to antenatal, paediatric and community care) (Boerma et al 1993; Boerma 2003). However, many problems remain in the Portuguese PHC: 1. Portugal has increased the proportion of GDP allocated to health services during the last decades, but PHC has been always under-funded. The proportion of the public health expenditure allocated to PHC has even fallen in relative terms. 2. General practitioners order many of the prescriptions and diagnostic tests on the advice of specialists. In fact, specialists do not order tests directly in hospitals or private practice, in order to avoid increasing the expenses attributable to them. 3. Health centres are not properly equipped for carrying out quality diagnostic services, and for these procedures patients are usually referred to private settings. The relationship with private diagnostic centres (X-ray, laboratory and others) is settled by contracts, the socalled “conventions”. Clinical diagnostic tests are overused. 4. The above means a perennial under-utilisation of equipment in public premises, either because of shortages in the supply of human resources, or laxity in administrative controls of providers who work simultaneously for the national health system and for the private sector. 5. Doctors and nurses tend to work for the national health service in the morning and in private practice in the afternoon (although for general practitioners having additional private practice is becoming less usual). 6. There is a severe shortage of PHC personnel (both general practitioners and nurses). Portugal has in fact had to “import” Spanish general practitioners and African nurses (from former Portuguese colonies). 7. The gate-keeping role of general practitioners is very weak. Formally, secondary care is only accessible after referral, but since people show a strong preference for hospital care, they very frequently use the hospital emergency departments as backdoor entry points (Boerma et al 1993; Abel-smith et al 1995). 8. A rigid PHC appointment system decreases access to acute care and increases emergency use. General practitioners and nurses devote most of their time to controlling chronic patients and to scheduled preventive care (antenatal care, immunisations, family planning, and screening programs). First contact with the usual provider of care is difficult in practice (25% of patients wait more than 8 days for consultation with their general practitioner). Continuity of care and comprehensive care are almost restricted to chronic patients. 9. Portuguese health centres are huge in size and personnel, with an average of 80 professionals per health centre. In those circumstances, “health teamwork” is mainly just an ideal. 10. In 1995, the primary care score of Portugal in the above mentioned international study is only 7 (compared to a maximum of 20), which is well below the average. Worse still, changes in scores over time have been negligible (Portugal scored 6 in 1975, and 7 in 1985) (Mazinko et al 2003). 11. There seems to be serious medicament overuse (in 2001, the index of pharmaceutical expenditures as a percentage of total cost was 130, in relation to the European OECD countries’ average of 100 (17.58% of the total)) (OECD 2003), 12. The population seems not to be happy with the current state of affairs. In 1996, 22% of the Portuguese population was very dissatisfied with the way health care was being run (Mossialos 1997). In 2003, global satisfaction with the health system in Portugal was the

75

Primary Health Care: Service Delivery – Volume 2

lowest in Europe (3.3 in a scale from 0 to 10), worse even than in Hungary and Poland (INRA 2004), 13. In Portugal the degree of “excess use” of specialist visits compared to their health needs by higher income groups is much larger than in other European countries (Dooslaer et al 2002). 14. The powerful association of general practitioners has played an important role in supporting innovation in PHC but the results have only been mediocre due to their relatively low power compared with that of other stakeholders. Its scientific journal is not included in Index Medicus. In summary, and at the risk of oversimplifying, Portuguese public PHC is still weak and plays almost a complementary role to the private health sector. This often puts the public interest in the shadow of the private one. In many ways, PHC in Portugal is almost an invisible structure, eroded by low social esteem in a land of private provision and financing.

5.4.2

Policy analysis of the Portuguese PHC case

The Portuguese case-study mainly shows the difficulties of developing a PHC-led national health service in a country where, • •

ideology-led reforms are often incompletely implemented, due to managerial limitations, resistance to change and political discontinuity. Legislation is not seen as a tool, but as an end; and many services rely on private health care suppliers who are not successfully brought on board by policy makers (as explained, private provision has always played an important role in the delivery of health care in Portugal; the majority of specialist consultations take place in the private sector) (Boerma et al 1993; Boerma 2003; Bentes et al 2004; Guibentif 1997; Pereira et al 1993).

Portuguese society and governments have encountered insurmountable difficulties in building up a universal, free at the point of use, PHC-led national health service. Public and professional dissatisfaction with health care has not gathered enough informal policy power to re-build a national health system in full. Political instability (indeed linked with the handicaps in consensusbuilding inherited from a fascist dictatorship) did not provide fertile ground for such a titanic endeavour. The reform was never completed due to an absence of clear objectives and continuous changes in politics and polities. In 1979, the reform had strong social support but strong opposition from professionals and insurers. After a few years, people became disappointed with democracy (which could not respond to excessive expectations), so the reform was changed (1985 to 1995) (Abel-smith et al 1995; Bentes et al 2004; Guibentif 1997). And re-changed again (1995, 1999) because of the influence of the Maastricht Treaty and the new discipline from the Euro. In that context, external policy powers gave only slight support, as the British and Norwegian models were seen as strange and the knowledge base provided by WHO and WONCA was too much ideology-led. The history of the Portuguese reform is also the history of the struggle to transform a health system (from Bismarck into Beveridge) in a situation of extreme resource constraint, when private service provision played an important role. The private health sector has always been central in any turn of the reform process, and there is still too much overlap with the public health system (Bentes et al 2004; Guibentif 1997; Pereira et al 1993).

76

Critical Steps Undergone by European Countries to Setup the Foundations of a PHC System

The current combination of health system fragmentation and the lack of decentralisation (there are 5 regions with very limited decision-making power) has also proved deadly. There are many subsystems and schemes for which membership is based on professional or occupational activities parallel to the national health service (for example, for civil servants and some large companies’ staff). Public schemes thus coexist with a number of occupational non-voluntary insurance schemes which tend to cover the better-off socio-economic groups (Boerma et al 1993). There is a tendency towards decentralisation in the 2000s, but the governance of PHC is currently very centralised and regions have not been given sufficient room to develop innovative approaches within clearly set objectives. A plan to decentralise such controls in the middle of the 1990s failed. Changes in the 1990s tried to improve satisfaction both of consumers and public health professionals, but they did not change the perception that higher quality services are provided by the private sector, particularly in high technology environments. Conventions (contracts with the private sector to provide specific services) are very common, and swallow a high proportion of total public health expenditures (Abel-smith et al 1995; Guibentif 1997; Pereira et al 1993). The national health service is dominant in the provision of hospital stays and general practitioner as well as child care. But it plays a minor role in specialist and dental consultation, as well in diagnostic services. The truth is that private insurance is much less widespread in Portugal than in other European countries (again, private provision is covered through public insurance). Yet in Portugal (as in Ireland) the degree of pro-rich distribution of use of specialist care is much larger than in other European countries. The role of cost-sharing in Portugal is also worth mentioning. The high out-of-pocket expenditures reflect the strength of the insurance funds but there is also evidence that national health service users face flat-rate co-payments for consultations and diagnostic tests as well, and pay in particular a large and rising proportion of the cost of drugs. A plan in the 1990s to vary the level of cost-sharing by income group could not be implemented, allegedly because of administrative difficulties. As already explained, a particular Portuguese problem is the increasing use of hospital emergency services. It is both an indicator of the strong preference for specialist care, and a way to bypass hospital waiting lists and the rigid appointment system in PHC (Boerma et al 1993; Abel-smith et al 1995). The PHC system is commanded by professionals and has little sensibility to patients’ demands and needs. Portuguese PHC is weak (and will remain weak unless big changes are introduced) because of its complementary role to private provision of care for diagnostic and specialist services. Lack of public diagnostic facilities has paved the way to a perverse use of PHC. On top of that, understaffed health centres with a rigid appointment system restrict first-contact for acute care and increase the use of hospitals’ emergency services, thus forming a vicious circle in which PHC is neither easily accessible nor a real entry point to the system. The sad reality is illustrated by the strong population preference for specialist care and private provision of many services. However well intended in its original design, the reform has never been properly implemented and PHC has lost much of its legitimacy.

77

Primary Health Care: Service Delivery – Volume 2

5.5

Spain

5.5.1

PHC in Spain as a case-study

Spain has a population of 40 million. It has been a member of the European Union (then the European Community) since 1986. Between 1960 and 1980 (and again from 1998 to present), Spain was one of the fastest growing economies among the developed countries. In 2001, per capita GDP in Spain was $21,294, and health spending as percentage of GDP was 7.5% (OECD 2003). After a hard fascist dictatorship of almost 40 years which ended in 1975, the new democratic Constitution was approved in 1978 and a semi-federal state was set up. The Spanish people’s rights to health care and health protection are explicitly recognised in the Constitution. In 1977, one of the first initiatives of the newly democratic elected government was to create a Ministry of Health (“and Social Security”). Until then, most health care resources, and the delivery of humanitarian health care services, were managed by the Social Security, within the Ministry of Labour (and public health services and care of the very poor were in turn under the Ministry of the Interior and local authorities) (Saturno and Saltman 1988). The Spanish Social Security was a powerful quasi-autonomous public entity which at that time jointly managed the budget of medical care, cash benefits (pensions, unemployment, sickness leave payments, etc) and social services (elderly, handicapped, etc). In 1981 the Minister of Health was renamed as Minister of Health and Consumer Affairs, and Social Security lost its health budget while coming back to be a part of the Ministry of Labour. In 1981, the failure of an attempted military coup d’état led to a strong social and political reaction against anything reminiscent of dictatorship. Following the political programme of the Socialists in power from 1982 to 1996, Spain began a wide programme of social reforms. A General Health Law (National Health Care Act), passed in 1986, started the health system reform and regulated the national health system (Saturno and Saltman 1988; Rodríguez et al 2000; Gillén 1996). The health system reform had five main explicit objectives: •







78

extending universal coverage, from 90% in 1980 to 99% in 1990 (those not covered were the richest segments of the population, such as self-employed lawyers and others). By 1995 universal coverage was practically completed (99.5%), although enrolment kept its original link to labour status and social security (Minister of Labour) until the present moment, instead of being done straight through the Ministry of Health and Consumer Affairs. providing the basis for the transfer of the management of the public health system from the central government to the seventeen autonomous communities recognised by the new Constitution. Decision making was immediately transferred to four of them (Andalusia, Basque Country, Catalonia and Navarra) of which two had in fact started to enjoy that right before 1986. The whole decentralisation process took more than a decade and finished only in 2002. establishing a process for integrating other public health institutions in the national health system (e.g., general and psychiatric hospitals, maternal institutes and other health services for the poor operated by provincial councils). Teaching hospitals were attached to medical schools. The military was left with its own, separate health system. providing support for the establishment of a nationwide network of primary care health centres, following the Finnish model promoted by WHO, and;

Critical Steps Undergone by European Countries to Setup the Foundations of a PHC System



changing the financing basis of the national health system. Until 1989, social security contributions represented about 75% of total public health financing, while transfers from tax revenues made up to the rest. In 1989 a formal transition from a public insurance-based model to a tax-based national health service model was launched and by the beginning of the 1990s, the proportion had been inverted. In 1999, public health care was solely (100%) funded through general taxes (Rodríguez et al 2000).

This has to be seen in a historical perspective. Since the beginning of the 20th century, Spanish employers and employees had developed hundreds of small sickness funds, very popular capitation-like, prospective payment arrangements (“igualas”) by which a flat monthly stipend was given to doctors or insurers according to the number of members of the family in exchange for the right to receive care in due time. The scheme became regulated by the Instituto Nacional de Previsión. Before the Civil War (1936-1939), the National Parliament discussed a new law to develop a national sickness fund. This law was never passed because of the military coup d’état. After the Civil War, the fascist government established in 1942 a national mandatory sickness fund (SOE), primarily intended to provide curative services to industrial workers and their dependants, and financed through social security contributions (Saturno and Saltman 1988; Rico 2000). Compulsory enrolment was gradually extended to other types of workers so that public coverage increased steadily throughout the years (54% of the population in 1960, 81% in 1975). The SOE surpluses were used mainly to subsidise other government industrial institutions. In time, the SOE’s provision of solely curative services and its structural isolation from other health institutions came to be seen as important flaws in its organisation. Nevertheless, the SOE experience forged in Spain an irreversible social agreement that access to health care is a right of the whole society, and one strongly valued by the population. The Spanish population learnt to value having a general practitioner, a fully equipped hospital network, and good continuity of freely provided care at the point of use (it has since become clear that any policies aimed at increasing financial obligations of the user when receiving the services are very unlikely to succeed) (Saturno and Saltman 1988; Rodríguez et al 2000). Medical care was provided through a network of public clinics (primary care settings and specialist ambulatorios) supplemented by hospitals (Rico 2000). While almost all doctors practiced in social security facilities, quite a number of them had double jobs (one in the public system and another one in the private sector). In the 1960s and 1970s, as the economy improved, thousands of hospital beds were built up by and for the SOE. Most of them were in large, sophisticated and fully equipped modern hospitals. Public hospitals are generally well regarded by the population (private hospitals are less well equipped, both in terms of high technology and personnel than the public ones) (Saturno and Saltman 1988; Rodríguez et al 2000). The public hospital network was supplemented in the 1980s and 1990s by hundreds of health centres built up in rural and urban areas (the first primary health care centres were established in 1984, before the National Health Care Act). In the 2000s, public hospitals account for almost 75% of all hospital beds. Health expenditure absorbed 7.4% of GDP in 1997 (a percentage which was 31% higher than the 5.6% that it represented in 1980). The average annual growth of health care expenses in Spain between 1991 and 2001 has been 3.2% (OECD 2003; Rodríguez et al 2000). Health professionals (with the exception of ambulatory specialists and general practitioners) were, and still are, salaried public employees. Ambulatory specialists and general practitioners working for the SOE were paid under a pseudo-capitation system in which the item of payment was the

79

Primary Health Care: Service Delivery – Volume 2

“social card”, which grouped the worker and his/her dependants. General practitioners were paid according to the number of social cards in their list, and had to devote two hours to office work and “the necessary time” for home visiting. They also had a gate-keeper role in relation to an identified group of specialists of a designated hospital to which each of them was linked for referrals. The system was, and is, very rigid, strictly pyramidal. Spaniards are allowed to select their general practitioner and paediatrician within certain geographical limitations (Saturno and Saltman 1988; Rico 2000). The main characteristics of the Spanish PHC reform launched in the 1980s were: 1. Organisation and planning according to districts with populations of between approximately 40,000 and 250,000, which included sectors of between approximately 5,000 and 25,000 people. Each sector has one health care centre, staffed with general practitioners (one per 2,000 people), paediatricians (one per 1,000 children), nurses (one per doctor) and a variable number of midwives, social workers and ancillary staff. The health centre is explicitly requested to be the main management unit coordinating curative, treatment, preventive and promotion, as well as community care activities. 2. Full time employment (doctors were requested to shift from 18 hours per week in the old clinics to 40 hours per week in the new health centres); however, physicians could retain the privilege to practice privately after their public service obligations. 3. Paediatricians (who had been so far caring of those under the age of 7) expanded their remit to include children under the age of 14. 4. Health professionals were integrated in “primary care teams” with broader portfolios of curative and preventive activities (teaching and research activities are, respectively, explicitly and implicitly included). Nurses work on their own, mainly taking care of chronic patients, home visiting and preventive activities following guidelines provided by the health centre. For daily clinical work, the “minimum team” is a doctor and a nurse who take care of a defined population (a patient list). 5. Salaried doctors (general practitioners and paediatricians), with a capitation surplus according to the size of their personal patient list, have a gate-keeper role. Nurses are salaried and receive an allowance in proportion of the total population served by the health centre. 6. Improved earnings for PHC professionals, at least in parallel with the earnings of hospital staff. 7. A construction programme of new health centres (purposefully built, fully equipped) to provide quality PHC. In 1978, Family and Community Medicine was legally recognised as a postgraduate specialism in general medicine, with an appropriate vocational training. However, training was mostly provided by the government outside the universities, and the first chair of general practice was established (in Barcelona) only in 2002 (a “Novartis” chair). The Association of Family Physicians supported the PHC reform, and has always shown a strong commitment to promote prevention and research activities, with a scientific journal included in Index Medicus (Gené et al 1996). After the initial changes, the Spanish health system reform has undergone frequent adjustments mostly addressing organisational issues (as first recommended by the Abril Report, published in 1991) which have invariably followed a supply-side approach aimed at keeping costs within reach (Abel-smith et al 1995; Rodríguez et al 2000). Regional allocation of resources is mainly based on population and has not worked particularly well in controlling the health budget. The accumulated health system debt has had to be recognised and specifically funded on several occasions.

80

Critical Steps Undergone by European Countries to Setup the Foundations of a PHC System

The Maastricht Treaty and the new “Euro” financial discipline forced some changes in the reform, to improve macro and micro-efficiency, and to improve patient satisfaction. In any case, the solution has been a deepening of fiscal decentralisation. However, even in 2004, after the full decentralisation of planning, management and budgeting, there is concern that the health budget is systematically transcended. From 1994, PHC teams have a performance annual payment according to some process indicators (e.g., percentage of diabetic patients with a normal level of blood haemoglobin A1c) and control of pharmaceutical expenditures (medicaments absorb more than 20% of total public health expenditure; in spite of efforts to reduce expenditures on pharmaceuticals, success has been rather scarce). The objectives of this collective incentive have been formulated as 1. 2. 3. 4. 5.

extending the portfolio of PHC (for example, antenatal care), increasing inter-professional cooperation, improving the quality and controlling the costs of prescriptions, implementing a quality assurance program, and reinforcing the role of the general practitioner as gatekeeper (Gené et al 1996).

Since 1995 also there is an explicit definition of the package of benefits covered by the public sector. Excluded services are psychoanalysis, surgery to change sex (which has recently been included in Andalusia), spa treatments and elective aesthetic surgery. Exclusions in practice also include institutional mental care, dental services for adults and some prostheses, such as spectacles. The only existing cost-sharing in Spain is for medications, for which the average patient has to pay around 40% of the cost, except for life-saving products (for example, insulin). Pensioners and their dependants are excluded from paying (Saturno and Saltman 1988; Rodríguez et al 2000; Gillén 1996; Rico 2000). Around 11% of the population has double insurance coverage, frequently using public coverage for hospitalisation and private insurance for specialist consultations. The private sector is important, but the size of the market has remained stable over the past decades (which clearly contrasts with the situation in other Mediterranean countries). A recent policy promoting collective private insurance through employers (by considering the corresponding contributions as income-exempt for the wage earner and deductible expenses for the employer) has been issued but its consequences have not yet been evaluated (Rodríguez et al 2000). In addition, public employees and their dependants (almost two million in total) have a special insurance scheme. It is a voucher system through which the public employer (national and local governments) pays a non-risk adjusted capitation payment to the private insurance plan of the civil servant’s choice. The option can be exercised on an annual basis. Around 90% of public employees currently opt for private coverage. Human resources planning also received attention during the reform. There has historically been a severe shortage of nursing personnel which refers mainly to hospital (PHC nurses are better paid and have more professional autonomy) combined with an oversupply of doctors. A nationwide numerus clausus for new medical students was made mandatory in 1979. In 1983, more than 10,000 new physicians graduated, the highest figure in the history of the country. In fact, and as already mentioned, in the 2000s Spain is “exporting” general practitioners and pharmacists to European countries like Portugal, Sweden and the UK. Specialists initially resisted the reform but as changes in hospital care were never immediate or deep, their resistance soon decayed.

81

Primary Health Care: Service Delivery – Volume 2

Overall, after 25 years of reform, things have improved substantially. The primary care system score in the above mentioned ranking was 11 in 1975 and 1985 but jumped to 16.5 in 1995 (ranking after the UK and Denmark) (Mazinko et al 2003). In 1991, the PHC reform was still in transition, and 28% of the population replied to the Blendon Report that “our health system has so much wrong with it that it needs to be completely rebuilt” (Blendon et al 1991). In 1996, however, only 8.2 % of the population was “very dissatisfied with the way health care runs” (Mossialos 1997). In 2003, the health care system obtained 5.4 points (in a scale from 0 to 10) in an international customer satisfaction survey (INRA 2004). In summary, population coverage is now de facto 100%. In PHC, electronic medical records are almost universal. Research is well developed in PHC, supported by general practitioners associations and funded by national and regional agencies. Total health care budget has increased to 7.4% of GDP, and although Spain lacks a definitive model of health system financing, due to the complex balances between the centre and the autonomous regions, health care expenses are under much more control. Private spending is 29% of the total health spending ($457 out of $1,600 per capita) (OECD 2003). Nevertheless, the Spanish PHC still confronts some serious problems: 1. The total PHC budget has increased, but the percentage of health spending given to PHC remains constant (around 16%), which raises doubts about the priority given to PHC versus other care modalities. 2. The referral system is weak and frequently the gate-keeper function is mostly a formal role. The health system is in many ways driven by specialists. Coordination between levels is difficult or non-existent. 3. The rigidity of the referral system (general practitioners cannot select neither the specialist, nor the hospital), coupled with long waiting lists for specialist care, constitute a powerful incentive for patients to leave the public system and obtain direct access to specialists through additional insurance or direct payment. 4. Satisfaction with PHC is comparatively low, and there is a danger of developing a two tier system (public PHC for the elderly, the poor and immigrants, and private insurance for the better-off). 5. Although additional private practice is unusual for general practitioners (except in Catalonia, with a historically important private sector), it is quite frequent for paediatricians and specialists. 6. Paediatricians work in general practice as general practitioners for those under the age of 14, and there are pressures to increase the age to 18, which goes against the role of general practitioners as responsible for the care of the person throughout his/her life span. 7. Efforts to reduce pharmaceutical expenditures have not succeeded. Medications are responsible for an unduly high fraction (more than 20%) of total public health expenditures. Worse, there is not only a problem of quantity, but also of the quality of those expenditures (Puig-Junoy 2004). 8. Implementation of the reform has been very uneven (Andalusia finished it first; Catalonia more than a decade later), which raises problems in terms of equity and comparative coverage. 9. PHC lacks in Spain flexibility as the design and implementation of health centres follow a rigid model, with no clear adaptation to the social environment or to population health needs. There is an average of 23 professionals per health centre, which makes the “health workteam” extremely difficult in practice. 10. The collective performance incentive has clearly introduced a new culture of quality assurance. However, its impact on patients’ health status has never been evaluated.

82

Critical Steps Undergone by European Countries to Setup the Foundations of a PHC System

11. The amount of purely bureaucratic work general practitioners have to perform, particularly single-item prescriptions and work related to weekly sick-leave certification of workers is rather abusive. 12. New electronic medical records may facilitate many aspects of PHC. But they also present an opportunity to build up a huge medical database, which places in danger the doctorpatient relationship because of problems of confidentiality (Gervas 2003). 13. The PHC philosophy was extremely dogmatic and rigid in the 1970s and 1980s, because of the combined influence of the Finnish and Cuban models in Spain. There was, and still often is, a continuous confusion between clinical care, community care and public health work, which has frustrated many expectations. 14. While the distribution of use of general practitioners’ services is somewhat pro-poor, as in the other Mediterranean countries the rich see a medical specialist more often than would be predicted on the basis of their health needs. 15. Intra-professional conflicts remain among general practitioners. “Old” (median age, 40 years in 1986) general practitioners had serious difficulties in participating in PHC reform, as the new Family Medicine and Community speciality (and the new association) emerged under the leadership of younger general practitioners. 16. From the 1980s onwards, there have been three associations of Spanish general practitioners (family physicians, rural doctors and general practitioners) with only started to cooperate in the 2000s. 17. Finally, some doctors are suffering from declining morale. The health care system is changing with no answer to specific professional expectations. In particular areas, the reform has created considerable uncertainty. Doctors have less scope for clinical autonomy as they are largely concerned with efficiency matters (for example, control of the pharmaceutical expenditures). Bureaucratic work in daily clinical activities means a heavy load.

5.5.2

Policy analysis of the Spanish PHC case

The case-study of the Spanish reform shows the success in reforming a health system when: • • • • •

the population (or at least, substantial segments of it) strongly supports the reform, the reform profits from the previous system, without major disruptions, the reform is not implemented at once, but through a step by step process, there is a political agreement among parties that ensures reform continuity, and, professional associations become the most relevant political actors regarding PHC in a reform process characterised by mainly bottom-up policy making.

After years of fascist dictatorship, Spanish society has been able to provide the talent and energy required to reform many essential institutions while keeping the much-valued free universal provision of health care (which later on, in the 2000s, was offered to even illegal immigrants without any administrative barrier) (Saturno and Saltman 1988; Rodríguez et al 2000; Gillén 1996; Rico 2000). Health care reform has thus enjoyed strong formal policy power and political continuity. The Spanish transition from dictatorship to democracy was paved by agreements and consensus about critical questions, as what should be the future of the health system. In fact, none of the three major political parties that have governed Spain in the last 25 years has showed willingness to change the key positive characteristics of the old SOE. Of course, in 1986, after 40 years of evolution, its original structure and organisation needed improvement (e.g. through the integration

83

Primary Health Care: Service Delivery – Volume 2

of curative and preventive care). The PHC reform was thus seen as a “natural” development of the previous social security system, which provided care directly, free at the point of use, in their own premises, and had general practitioners, capitation, gate-keeping and patient lists. External policy power has also been important. Finland and Sweden played the role of best models, WHO provided the philosophy of Alma Ata, and Cuba was seen a mirror for emphasising public health. The USA model of Family Medicine was another ingredient of the peculiar recipe that has been implemented. Universal coverage was not difficult to attain (as already explained, pre-reform SOE covered 90% of the population). However, some privileges remain in access to private care for public employees and their dependants (almost two million people) (Rodríguez et al 2000). Their voucher system decreases the credibility of the public health care sector. The credibility of publicly funded PHC is also threatened by the fact that around 11% of the population (around four million) have double coverage (public plus private voluntary insurance). This phenomenon is more frequent in big cities, in the region of Catalonia, and among high class and professional groups. People with double coverage use the private sector for direct access to specialists and for hospitalisations linked to minor health problems (for example, normal delivery). At the same time, they use their public coverage for hospitalisations requiring highly and expensive qualified interventions. Double coverage often results in shifting high cost medical care to the public sector. In terms of service delivery, Spain offers an example of how with more financial and material resources, PHC reform can achieve success. Physicians have changed to a new time schedule, of 40 hours per week in the new health centres (from 35 in 2003) and have increased their earnings. A powerful incentive for leaving private practice was introduced. The salary system has decreased income uncertainty while the capitation surplus (around 10% of total earnings) allows the retention of patient lists. Capitation fees are directly related to the practice population (age, social indicators, geographical dispersion, etc.). Because of such a mix of salary and capitation payment, the geographical distribution of professionals is very even in Spain. Rural practice has distinctive characteristics but it is not actively rejected by PHC professionals. Research in PHC was, and still is, a source of informal policy power for Spanish general practitioners. Research has added strong elements of support to raise the self respect and social esteem of general practitioners. National (FIS) and regional agencies have extensively funded research in PHC, and some public health schools (in Madrid and Granada) have provided critical help in theoretical aspects. In Spain, general practitioners have managed to break the already mentioned negative cycle of low social esteem, poor education, low self respect, poor earnings and heavy competition with specialist and hospital care. Overall, again, the system has managed to change from a system based on social security to a system based on tax funding without too much difficulty, because of the existence of only one national mandatory sickness fund under political control. The decentralisation process (which took almost 15 years) is proving to be more difficult. As in Italy, Spanish governance for the health system was centralised within a national health system and the transfer of services to regions is full of complexities (Rico 2000). Coordination between regions is poor; there is an Inter-regional Committee which provides a forum for policy making and planning, and a Coordination Law has been approved in 2003, but both give only very general rules on how to proceed. PHC professionals’ earnings have been increased to the level of hospital specialists and nurses. However, this has not been enough to encourage the best medical graduates to apply for the new Family Medicine specialty.

84

Critical Steps Undergone by European Countries to Setup the Foundations of a PHC System

There has also been a problem that nurses have been drained from hospitals at a time of severe shortage of nursing personnel. Nurses have no proper vocational training in PHC other than midwifery. Also, there are no clear official programmes for training district or health centre managers; they have typically been general practitioners with special interests in management and political support. Pro-coordination reforms kept the gate-keeping role of general practitioners, but have not succeeded in improving continuity across levels of care. Coordination is also poor with social services (but including social workers in the health teams has proved to provide valuable links on many occasions). Hospital emergencies are increasingly used because long waiting lists and the dissatisfaction with the lack of resolution power of the PHC system. Reforms aimed to broadening the profile of PHC were more successful, and preventive activities, minor surgery and others are currently included in the service portfolio (Boerma 2003). Many specialists still have double appointments, public in the morning and private in the afternoon. The potential conflicts of interests might damage performance in the public health system. Budget constraints in the 2000s have limited, and will continue to limit, health care expenditures. The chronic deficit is under control, and financial decentralisation may help in the future. Openly promarket policies are only a theoretical exercise in Spain so far. However, there is no definite agenda to increase the efficiency of the health system.

5.6

Conclusions

As argued in the document on the PHC institutional map, there are no best models ready to be copied in reforming PHC. For countries of central and eastern Europe that have lived for decades during a communist system, the German model of health system might be attractive. But much can be learned from analysing the experience of European countries which reformed their PHC during the 1970s and 1980s. The “oil crisis” had a negative impact on the global economic situation of all of them and most only had limited financial resources available for reforming their health care systems in a context of high public expectations. In contrast with other Mediterranean countries, like Greece, Italy and Portugal, Spain has been relatively successful in reforming its PHC. Still, the Spanish model should not be considered a blueprint but just another case to consider and study. Why did Spain succeed? There are many reasons, as seen in the policy analyses above: 1. There was a previous structure, a national mandatory sickness fund which did not needed to be re-built, but only reformed. The roots of the system dated back to the beginning of the 20th century, and the principles of this fund have historical support, starting in the Middle Ages (general practitioners paid by capitation, gate-keeper role, and patient lists). 2. During the transition from dictatorship to democracy (1975 to 1979) there was a broad consensus among the political parties which also applied to health system reform. 3. The reform has had political continuity, and none of the three major political parties that have governed Spain in the last 25 years has advocated any change of the foundational principles of the health system, which in turn were highly valued by the population. 4. Spaniards seem to consider as an irreversible social arrangement, built up along the whole 20th century, that access to care is a fundamental right of the population.

85

Primary Health Care: Service Delivery – Volume 2

5. The Spanish population values having a public health system which offers care from general practitioners, fully equipped hospitals and free provision of care in public premises. 6. The reform was not immediate, but a step by step process. The General Health Law, issued in 1986 and passed in 1989, was a tool in a long period of changes which expanded over more than 15 years. 7. The Spanish health care system appears to be efficient in macroeconomic terms. Measures taken to improve micro-efficiency have had a supply-side approach and are organisational in nature (as opposed to demand-driven and politically conflicting). The only existing cost-sharing is for medications (pensioners and dependants are excluded, as some life-saving products). 8. Decentralisation has been managed as an evolutionary process, which started before the reform, in 1981 (in Catalonia) and ended only in 2003. Regions have played an important role in the reform process. 9. The system is 100% funded through taxation. 10. General practitioners’ patient lists (of between 1,700 and 2,000 patients) have forced even geographical distribution of doctors. With no financial barriers, the use of general practitioners is somewhat pro-poor. 11. Sufficient salaries combined with various other incentives have resulted in PHC working full-time in well-equipped public health centres, with no private appointments. 12. Coordinated health teams provide curative and preventive care, and integrate medical and community care activities. PHC is a point of entry, easily accessible. 13. General practitioners’ associations supported the PHC reform. 14. Research is a well established activity in Spanish general practice, which has added strong support to the self respect and social esteem of general practitioners. National and regional agencies have actively funded research in PHC. As a consequence of the successful reform in Spain, • • •

the primary care system score jumped from 11 points in 1975 and 1985, to 16.5 in 1995; in 2001, health spending as a percent of GDP is 7.5% (where the OECD average is 8.1%). Total health care spending is $1,600 per capita, at purchasing power parity ($457, 29%, represent private health expenditure); and general population satisfaction is currently higher than ever before in the country (in 2003, 5.4 in a scale from 0 to 10).

Needless to insist, the Spanish situation is far from ideal, as commented in the case study, and problems abound. Problems include the existence of the “voucher model” for public servants and dependants, the role of paediatricians in general practice, control of pharmaceutical expenditures, coordination between levels and across services, population dissatisfaction which ends in double coverage, and doctors’ declining morale. But experience gives reasons to believe that answers to the relevant questions might be found in the continuing process of adaptation to a dynamic social reality. By contrast, in other Mediterranean countries: 1. Previous health structures were either re-built (in Italy and Portugal), or remained almost unchanged (in Greece). There were also long histories of fee-for-service systems, with no patient lists, no gate keeping and even no general practitioners (as in Greece). 2. In those countries there was no consensus among political parties regarding the reform.

86

Critical Steps Undergone by European Countries to Setup the Foundations of a PHC System

3. Reform continuity was not present in Greece, Italy or Portugal. Frequently, laws concerning healthcare were passed but never fully implemented, and were even sometimes reversed according to the political party in power. 4. Health care reforms in Greece, Italy and Portugal might be seen as highly normative, instead of as instruments for policy development. The Spanish case shows that legislation is not just an end, but a powerful tool. 5. All European populations agree in general that access to care should be considered as a fundamental right of the population. But in practice, collective actors as sickness funds in Greece and Portugal and specialists in all three countries may manage to de-rail the reforms (while managing to have their own “access to [good] care”). 6. In Greece, Italy and Portugal the public health system has low credibility and private practice has higher prestige, to a higher degree than in Spain. The population does not value general practitioners, and people prefer specialist care even in emergency hospital services. 7. In contrast with Spain, which has used supply-driven initiatives, the measures taken to improve micro-efficiency have had a demand-side approach in Greece, Italy and Portugal. As a consequence, substantial cost-sharing is frequent. 8. Greece is centralised but the level of decentralisation in Italy is, in some way, similar to that in Spain. But contrary to Spain, where regions have been in the lead in moving towards a PHC based system, regions have played no role in the health reform in Greece or Italy. 9. Whereas Spain has moved in the sense of simplifying the sources of funding for healthcare (through taxes), healthcare financing in Greece, Italy and Portugal is based on a complex mix of taxation and social insurance revenues. 10. It is important to adjust organisational issues in line with high level design issues. Patient lists, for example, are too small in Italy. In Greece, there is a lack of properly trained personnel in PHC. Portugal does not pay enough attention to diagnostic services in public PHC. 11. Double appointments (private and public) are much more frequent in Greece, Italy and Portugal than in Spain. In Greece, tipping practices are the rule. The Greek and Portuguese PHC reforms have been under-funded from their very starts. 12. PHC offers curative and preventive care in rural Greece and in Portugal. In Italy there is almost no coordination between general practice and community care. In Portugal the PHC appointment system is very strict, and primary care is not an easy point of entry. 13. Greek and Italian general practitioners’ associations do not support the reform, 14. PHC-related research is poor in Greece and Italy. In Portugal general practitioners are increasingly undertaking research. As a consequence of the relative failure of the reforms, •



Primary care system scores have not changed at all in Greece in 20 years (4 points in 1975, 1985 and 1995); have almost not changed in Portugal (6 points in 1975, and 7 in 1985 and 1995), and have improved by almost 50% in Italy (10.5 points in 1975, 13.5 in 1985 and 14 in 1995). Thus, in a general comparison of PHC in the three countries Italy would come first, then Portugal and then Greece (with the worst score). In 2001, health spending as percentage of GDP was 9.4% in Greece, 9.2% in Italy and 8.4% in Italy (interestingly enough, all of them above Spain). In per capita dollars of health care spending at purchasing power parities, the figures were $2,212 (Italy), $1,613 (Portugal) and $1,511 (Greece) compared with $1,600 in Spain. Private health spending was 45% of total health care expenditures in Greece, 31% in Portugal, and 25% in Italy (compared to 29% in Spain).

87

Primary Health Care: Service Delivery – Volume 2



Population general satisfaction in 2003 is very low in Portugal (3.3, in a scale from 0 to 10), below Greece (Gené et al 1996) and Italy (Gené et al 1996).

The above conclusions, in any case, should be considered with caution. Beyond the stated fact that there are no best models in PHC, there are also well documented difficulties in obtaining reliable comparative data. This paper has only given a broad overview of the health systems in four European Mediterranean countries (Greece, Italy, Portugal and Spain), by describing in detail some of the reforms that have taken place in the 1970s and 1980s, and their impact on the actual systems’ performance.

5.7

References

Abel-Smith, B., Figueras, J., Holland, W., McKee, M., and Mossialos, E., (1995), Choices in health policy. An agenda for the European Union. Aldershot: Dartmouth. Bentes, M., Dias, C.M., Sekellarides, C., and Bankauskaite, V., (2004), Health care in transition. Portugal 2004. Copenhagen: WHO EURO (on behalf of the European Observatory on Health Systems and Policies) Blendon, R.J., Donelan, K., Jovell, A., Pellisé, L., and Costas-Lombardía, E., (1991), ‘Spain’s citizens assess their health care system.’ Health Affairs10:216-228 Blendon, R.J., Leitman, K., Morrison, I., and Donelan, K., (1990), ‘Satisfaction with health systems in ten nations.’ Health Affairs 9:185-192 Boerma, W.C.W., (2003), Profiles of general practice in Europe. Utrecht: NIVEL [Doctoral Thesis]. Boerma, W.G.W., Jong, F.A.J.M., and Mulder, P.H., (1993), Health care and general practice across Europe. Utrecht: NIVEL Carpenter, G., (2004), ‘Italian doctors face charges over GSK incentive scheme.’ Lancet 363:1873 Degan, C., (1986) ‘Newest development in the Italian health care system.’ In Virgo JM (ed). Restructuring health policy: an international challenge. Edwardsville: IHEMI. Donatini, A., Rico, A., D’Ambrosio, M.G., LoScalzo, A., Orzella, L. et al., (2001), Health care in transition. Italy 2001. Copenhagen: WHO Europe (on behalf of the European Observatory on Health Systems and Policies). Dooslaer, E., Koolman, X., and Puffer, F., (2002), ‘Equity in the use of physician visits in OECD countries: has equal treatment for equal need been achieved?’ In OECD, Measuring up: improving health system performance in OECD countries. Paris: OECD, pgs. 222-248 Ferrera M., (1996), ‘The “southern model” of welfare in social Europe.’ J Eur Social Policy 6:17-37 Ferrera, M., (1997), ‘The uncertainty prospects of Italy’s welfare state.’ West Eur Politics 20:231249 Figueras, J., Mossialos, E., McKee, M., and Sassi, F., (1994), ‘Health care systems in southern Europe: is there a Mediterranean paradigm?’, Int J Health Sci 5: 135-146.

88

Critical Steps Undergone by European Countries to Setup the Foundations of a PHC System

Gené, J., Goicoechea, J., Sadana, R., Cricelli, C., Mercuris, B., Paccagnella, B. et al., (1996), ‘Primary health care in southern European countries: an analysis of cross-national experiences’, in Goicoechea, J., (ed.), Primary health care reforms. Copenhagen: WHO Europe. Pp 38-74. Gérvas J, Pérez Fernández M, and Starfield B., (1994), ‘Primary care, financing and gate keeping in western Europe’, Fam Pract 11:307-317 Gervas J., (2003) Sacred secret broken. Threats to the confidentiality of medical records. The case of Osabide, the centralised data base of Osakidetza (Basque Health Service) in Spain. Available at www.wbcispclub.be/tension/ssb.html Gillén AM., (1996), ‘Citizenship and social policy in democratic Spain: the reformulation of the francoist welfare state’, South Eur Soc Politics 1:253-271 Guibentif P., (1997), ‘The transformation of the Portuguese social security system’, In Rhodes M. (ed), Southern European welfare states. Between crisis and reform. London: Frank Cass INRA, (2004), European Coordination Office. European Social Survey. Brussels: INRA Jordao, J.G., (2004), A medicina geral e familiar. Lisboa: Faculdade de Medicina [Doctoral Thesis] Katrougalos, G., (1996), ‘The South European welfare model: the Greek welfare State in search of an identity’, J Eur Social Policy 6:39-60 Matgasanis, M., (1991), ‘Is health insurance in Greece in need of reform?’, Health Policy Plann 6:271-281 Mazinko, J., Starfield, B., and Shi, L., (2003), ‘The contribution of primary care systems to health outcomes within Organisation for Economic Development (OECD) countries, 1970-1998’, HSR 38:831-865 Mossialos, E., (1997), ‘Citizens’ views on health care systems in the 15 members States of the European Union’, Health Economics 6:109-116 Organisation for Economic Cooperation and Development, (2003), OECD Health Data 2003. A comparative analysis of 30 countries. CD ROM and user’s guide. Paris: OECD. Organisation for Economic Cooperation and Development, (1994), The reform of health systems: a review of seventeen OECD countries. Paris: OECD. Pereira, D. (ed), (1992), ‘The European study of referrals from primary to secondary care’, Occasional Paper 56, London: Royal College of General Practitioners. Pereira, J., and Pinto, C.G., (1993), ‘Portugal’, In Dooslaer, E.V., Wagstaff, A., and Rutten, F., Equity in the finance and delivery of health care. An international perspective. Oxford: OUP, pgs. 181-200 Puig-Junoy, J., (2004), ‘Incentives and pharmaceutical reimbursement reforms in Spain’, Health Policy 67:149-165 Reviglio, F., (2000), Health care and its financing in Italy: issues and reform options. Washington: IMF

89

Primary Health Care: Service Delivery – Volume 2

Rico, A., (2000), Health care in transition. Spain 2000. Copenhagen: WHO Europe (on behalf of the European Observatory on Health Systems and Policies) Rodríguez, M., Scheffler, R.M., and Agnew, J.D., (2000), ‘An update on Spain’s health care system: is it time for managed competition?’, Health Policy 51:109-131 Saltman, R.B., and Figueras, J. (eds), (1997), European health care. Analysis of current strategies. Copenhagen: WHO Europe Saturno, P., (1998), ‘Spain’, in Saltman, R.B. (ed) The international handbook of health care systems. New York: Greenwood Press, pgs. 267-284 Tragakes, E., and Plyzos, N., (1996), Health care in transition. Greece 1996. Copenhagen: WHO Europe (on behalf of the European Observatory on Health Systems and Policies).

90

Master Plan for Retraining PHC Doctors and Nurses in Georgia

6

Master Plan for Retraining PHC Doctors and Nurses in Georgia Antonio Duran and Mike Esau

November 2006

91

Primary Health Care: Service Delivery – Volume 2

Executive summary This document provides the Ministry of Labour, Health & Social Affairs (MOLHSA) with a realistic set of strategies and overall plan for the retraining of key staff for the implementation of primary health care. While recognising the pioneering work undertaken in the last five years in retraining practitioners, there are timescale, quality and cost problems that now make a new approach compulsory if the needed 4,000 new PHC doctors and nurses are to be produced in time, with the required quality levels and within the available resources. The paper outlines the modes in which such training will be provided and sets out clear roles and responsibilities for those organisations to be involved in this programme. Training doctors and nurses will be strongly coordinated with other Primary Health Care Reforms (construction, equipment, reform of PHC organisations and financing, etc). During 4 years (20072010 included) PHC staff training will be considered as a special project. The Government has mobilised earmarked funds to this end and will invite partners to pool resources. Training will be purchased by the MoLHSA from accredited providers with whom contracts with clear specifications (staffing, programme, quality of materials, etc.) will be signed. As much as possible, training delivery will be decentralised to regions. The Government is ready to invest in Regional Training Facilities. While eligible candidates will be allowed to fund their own training, participation in the training programme with public funding will require nomination by regional MoLHSA. Selection will take place through a national assessment process. The quality of the training will be closely supervised, including an independent examination. The necessary institutional arrangements will be articulated to make the above possible. Family Medicine medical and nursing specialists will be trained under the leadership of a Family Medicine Advisory Board articulated around the Regulation Department of the MoLHSA. Management of the process (including planning and purchasing of services) will take place under the leadership of the Health Investment Agency. After the 4 years of the special project, this training will be handed over to the regular institutions in charge of pre- and post-graduate training Finally, a number of specific management decisions are proposed in the text with the corresponding milestones for implementation.

6.1

Purpose

The purpose of this document is to provide the Ministry of Labour, Health & Social Affairs (MOLHSA) with a realistic set of strategies and overall plan for the retraining of key staff for the implementation of primary health care based on family medicine models. It sets out clear roles and responsibilities for those organisations to be involved in this programme. The document covers the training of Family Doctors and Family Nurses. A revised version of this document will include detailed proposals for Midwifery training. These will be included when MOLHSA has developed a strategy for better maternity services. For the time being only numbers and approximations of costs are included.

92

Master Plan for Retraining PHC Doctors and Nurses in Georgia

6.2

Rationale

This document recognises the pioneering work that has been undertaken over the last five years in the retraining of primary health care practitioners. However, if the government is to achieve a transformation in health care service during the next four years different strategies are required. The key problems in continuing down the current path can be grouped in 3 main blocks: timescale, cost and quality.

6.2.1

Timescale

Despite the efforts of the government and partners over the past 5 years only 12% of the retraining requirements have been met. The table below, consistent with the World Bank and EC Master Planning exercises, seems however to be inconsistent with the need to train equal numbers of doctors and nurses and it probably underestimates the need for midwives. It is clear in any case that the pace of retraining has to increase.

Table 6.1

Timescale

Region Adjara Imereti Guria Racha-Lechkhumi Samagrelo (inc Poti) Samtskhe-Javakheti Kvemo-Kartli Mtskheta-Mtianeti Shida Kartli Kakheti Tbilisi Osetia Zone Totals

Rayons

6 12 3 4 8 6 6 5 6 7 5 2 70

Nos Requiring Masterplan Nos Nos. completed reRetraining from Jan required for Re-training training by Jan 2007 2007 Drs. Nrs MdWs Drs. Nrs MdWs Drs. Nrs MdW 196 203 27 70 75 126 128 27 353 381 30 87 74 266 307 30 72 63 26 15 0 57 63 26 25 24 30 0 0 25 24 30 208 165 74 0 0 208 165 74 107 94 34 0 0 107 94 34 190 63 26 0 0 190 63 26 60 57 16 29 30 31 27 16 147 140 23 26 7 121 133 23 263 263 120 127 143 136 0 647 647 124 30 523 617 0 0 0 2268 2100 286 471 343 0 1797 1757 286

Total All Clinical Professions 6.2.2

4654

814

3840

Cost

As shown in the table below, the current training is delivered at an average cost per trainee of GEL 6,078 for doctors and GEL 5,130 for nurse retraining.

93

Primary Health Care: Service Delivery – Volume 2

Table 6.2

Cost Cost per Trainee GEL

Donor

Training Cost

Per Diem

Total

World Bank PHC Dev. Project: Doctor

3140

2700

5840

EU Kakheti PHC Dev. Project : Doctor

3616

2700

6316

World Bank PHC Dev. Project: Nurse

2724

2250

4974

EU Kakheti PHC Dev. Project : Nurse

3035

2250

5285

To retrain the additional 3,840 primary care clinical staff required by the Government from 2007 by continuing the current approach would cost more than GEL 21 m. The major cost drivers of the current training are the low FM Trainer ratios (training is delivered to cohort groups of a maximum size of 6) and the per diem payments to trainees for Tbilisi based training for the duration of the re-training process.

6.2.3

Quality

The evaluations of the current training undertaken by John James (HLSP/EU Feb 2006) and Carl Whitehouse (OPM/DfID October 2005) have highlighted the following shortcomings in the quality of the re-training process for doctors and nurses: • • • • • • • • • • •

94

The theoretical education loading is too intensive since there is no break from theoretical/classroom teaching and no time for reflection or application in the intensive 6 month delivery (clinical practice sessions are interspersed between classroom sessions); Clinical skills training is generic based upon the availability of patients (clinical material) and not tailored to the specific needs of trainees; The lack of patients available within the Family Medicine Training Centre with many of the specific conditions covered in the curriculum; Different FMTCs have different types of patients historically derived from their original status as adult or child polyclinics; Insufficient breadth of coverage in clinical experience to all clinical aspects of Family Medicine. Trainees tended to be assigned to the same single FM trainer/ practitioner throughout the 6 months with no rotation; The unwillingness of patients to deal directly with “rural” trainee doctors rather than their own Tbilisi doctor; Organisational difficulties around arranging appropriate rotations with clinicians; The programme content is heavily influenced by the needs of urban patients with little emphasis on the specific needs of FM practitioners working in rural and more isolated locations in Georgia; There is no external monitoring of the assessment of skills and broader competencies within the training programmes; There are insufficient resources for trainers to receive support and develop their teaching skills; There is no co-ordination to ensure that personnel, skills and facilities are used to the greatest advantage. Individual organisations should take responsibility for specific areas of development and quality management in which they are best qualified;

Master Plan for Retraining PHC Doctors and Nurses in Georgia

• • • •

6.3

No formal arrangements are in place to approve training centres in terms of capacity and level of facilities and the quality of teaching; The TSMU and other schools providing undergraduate medical education are not involved in the curricular planning process; There is no authoritative and independent organisation responsible for assessing the standard of training facilities and approving them. There is no system of continuing professional development and mentoring for students returning to regions.

Objectives

The re-training process aims to achieve the following objectives: General objective: •

To retrain up to 1800 family doctors, 1800 family nurses, and 600 community midwives during the 4-year period 2007 to 2011.

Specific objectives: •

• • •

6.4

To improve the capability of professional staff in delivering effective PHC services. In other words, to make staff teams of one doctor and one nurse working in PHC clinics competent to deal with the range of health problems presented to them by any person in their catchment area regardless of age or gender. To maximize the utilization of all potential resource availability in Georgia and enable all the actors in the healthcare human resource generation market to participate in the development of this function; To train those staff in sufficient time to be able to offer the new services when the centres are refurbished; To add value to previous investments in PHC human resource generation and contribute to future human resource institutional development.

Core strategies

In order to increase significantly the throughput in numbers and quality of trainees and make the whole retraining scheme more cost- effective (so that the above objectives can be met) the key changes proposed are:

6.4.1

Function separation

The institutional map of agencies involved in the re-training will include clear separation of the functions of regulation and quality assurance; purchasing; and service delivery with the aim of encouraging specialization, transparency and accountability.

6.4.2

Achievement of retraining within a fixed time period

By 2011 the training of family medicine doctors, nurses, and midwives will be wholly integrated into the normal arrangements for undergraduate, postgraduate, and continuing education. Up until then, this special programme will be undertaken over four years and achieve the aim of ensuring the availability of one family medicine doctor and one family medicine nurse per 2000 population; and one trained midwife per 5000 population.

95

Primary Health Care: Service Delivery – Volume 2

6.4.3

Coordination with other primary health care reforms

The Reform Implementation Unit within the MoLHSA will ensure in liaison with Regional Departments that there is a coordination of activities, and, particularly, that the upgrading of facilities and the availability of trained staff is synchronised.

6.4.4

Improved provision of training

In order to overcome the limitations identified in the previous section, training will now be organized differently: • • • •

Encouraging an increase in the number of trainees per group where the teaching methodology allows; Putting more emphasis on organization of clinical practice; Gradually shifting the training concentration from Tbilisi to regions Supporting the development of additional training resources.

The training programme will have four components: • • • •

Principles of family medicine practice Practical exposure to the organisation of family medicine Clinical teaching Clinical experience

The way to increase throughput and reduce costs is by dividing the curricula into two primary elements: •

a “group teaching” element which in turn can be subdivided into - clinical content (“Pedagogical Element 1”) and - non clinical content (“Pedagogical Element 2”), and



the supervised clinical experience component, with additional elements of multidisciplinary group work and tutorials (“Pedagogical Element 3”).

Pedagogical “element 1” (group-teaching non-clinical education and training) can be delivered to large groups of up to 24 trainees; “Element 2” (clinical education and training) can be delivered to groups of up-to 12 trainees; Element 3 (supervised clinical practice) should be delivered to groups of no more than 3 trainees. Annex A illustrates the duration of these 3 elements, the possible mode of delivery of this approach and the locations of each element of the re-training for the Doctors and Nurses curricula.

6.4.5

Decentralisation and Modes of Training Delivery

Moving away from the Tbilisi-based model for non-Tbilisi trainees is precondition to save costs and get services training closer to where they are needed. The majority of training will thus be undertaken outside Tbilisi in the Regions and increasing responsibilities will be given to the Regional Departments of MoLHSA in the planning and regulation of the training programme. The “taught” elements of the training programme (elements 1 & 2 above) will be delivered by qualified Family Medicine Doctors or General Practice nurses who have undertaken an approved Trainers Programme and have a minimum experience of 6 months as trainers. As a matter of

96

Master Plan for Retraining PHC Doctors and Nurses in Georgia

contrast, the practical skills element of the programme (3 above) need to be delivered by Family Medicine Doctors and /or GP nurses who have completed either the Trainers programme or a 3day Clinical Supervisors Training Programme. The trainer resource numbers required for decentralising without eroding quality are: • • • • • •

2 FTE (Full time equivalent) FM Doctors Trainers for 6-weeks central training 2 FM Trainers for 6-weeks nurses central training 4 FTE FM Doctor trainers for 18-weeks regional training 4 FTE Doctor Clinical Supervisors in the regionally approved clinics for 9 weeks 4 FTE Nurse Trainers for 14-weeks regional training 4 FTE Nurse Clinical Supervisors in the Rayon approved clinics for 4 weeks

Based on this some training delivery modes can be defined as following: •



Mode 1 assumes provision of non-clinical education and training at Tbilisi FMTC and 8 trainers (4 GP +4 GPN) travelling to regions for the delivery of clinical education and clinical practice teaching. During the clinical practice teaching, Tbilisi trainers will be supported by 4 regional clinical supervisors. Mode 2 assumes provision of all 3 elements of the course at the regional FMTC. It is a completely devolved training to centres in the regions with no travelling trainer requirements or per diem payments.

These modes have been costed in Annex B.

6.4.6

Ensuring availability of trainers

Effective decentralisation of training will depend on the availability of trainers in all Regions. Whilst this might be achieved through market pressures on training providers this cannot be assumed. Therefore, for three years there will be a centrally funded Training of Trainers Programme with an emphasis on the least served Regions. The emphasis in 2007 will be put on Semegrelo and Tbilisi.

6.4.7

Requirement for government investment in training facilities

Establishment of Regional training should not be constrained by the lack of appropriate facilities. However, it would be inappropriate for structures to be established for a limited life programme. Therefore, MOLHSA should ensure that in each Region, and collocated with the Regional Referral Hospital there is a Centre For Continuing Professional Development available for use by this programme as well as others.

6.4.8

Quality assurance

MOLHSA will put in place and resource an independent mechanism to ensure that training is of the required standard. This will include the establishment of standards and criteria for training providers, family practice placements, clinical placements, and examination arrangements.

6.4.9

Independent examination

MOLHSA will put in place and resource arrangements for independent assessment of the competence of trainees.

97

Primary Health Care: Service Delivery – Volume 2

6.4.10

Purchasing of training

A key MoLHSA role will be the effective purchasing of training. It will not get involved in operational matters related to the provision of training. A special unit will be established within MoLHSA with sufficient resources to undertake the detailed planning and procurement of training for a period of four years. Training will be procured through the use of contract mechanisms and open competition amongst accredited training providers. Whilst Annex B illustrates how the training could be delivered in a decentralised way and provides the basis for contract pricing, it is up to providers to deliver the programme in accordance with the contract specifications, which will set the required standards. Contracts will be of sufficient specificity to ensure that the quantitative and qualitative objectives of the government are achieved but of sufficient flexibility to allow innovation by providers.

6.4.11

Realistic resource assumptions

The total costs of the re-training during the period 2007 to 2010 (included) have been calculated (see below). It is assumed that government / partner funds for the family medicine retraining programme will be of around GEL 12M. It is also assumed that in Tbilisi there will be a significant number of practitioners prepared to meet the full or part cost of retraining.

6.4.12

Pooling of Government and partner resources

Government Funds will be the main form of funding of retraining (the government has already earmarked GEL 2M for 2007). Partners will be invited to supplement available government funds. Where partner funds cannot be formally pooled, funds should still be administered through the same government mechanisms.

6.4.13

Allocation of resources

Resources for Training will be allocated to: • • • • • •

6.4.14

Quality Assurance (3-5%) Independent Selection and Assessment (10-12%) Training of Trainers (1-2%) Training Procurement Function (1-2%) Costs of Training (75-80%) Continuing Professional Development (3-5%)

Selection to the programme

There will be two stages in the selection process. • •

Stage One – nomination to be made by an employing organisation and MOLHSA Regional Department, or by self nomination. Stage Two – selection through a national assessment process. Selection to the scheme will infer eligibility to be trained.

As indicated in 4.13 above the national assessment process will require appropriate resourcing.

98

Master Plan for Retraining PHC Doctors and Nurses in Georgia

6.4.15

Entry to the programme and contractual obligations

MOLHSA Regional Departments will be informed annually of their quota for national purchasing of training places. They will also be informed of the list of eligible candidates, i.e. those persons who meet the criteria, from within their Region and in consultation with Rayon Health Corporations they will nominate candidates for the programme. In doing so, they will take particular account of the need for retrained staff to be available in rehabilitated facilities. The candidates may or may not be selected later on. Arrangements for continuation of salary and contractual requirement for service post-training will be a matter for agreement between the trainee and an employing organisation. Eligible candidates not placed may seek entry to training on a self-paying basis.

6.5

Governance of the training

6.5.1

Transitional nature of retraining; Institutional arrangements

Retraining of doctors and nurses gives them the possibility to obtain the license in new specialty (Family Medicine) related to their prior specialisation. The normal mechanism for supplying appropriately trained doctors in Georgia is through the Higher Medical Education system which has three levels: undergraduate, postgraduate and continuous medical education. Under the current legislation the Ministry of Education (MoE) is in charge of regulation of undergraduate and postgraduate medical education, whereas the Ministry of Labour, Health & Social Affairs (MoLHSA) is responsible for continuous medical education and professional development. Training of the PHC staff will be considered as Professional Development during the 4 years of the special training programme given the need to produce “new” health workers in sufficient numbers to respond to the requirements of the new PHC model. It will thus be run by the MoLHSA in close collaborating with the MoE. As indicated, in the long term high medical education institutions designated by MoE (in consultation with MoLHSA) should have relevant resources and management systems to perform family doctor post graduate professional education. In order to have the same arrangement available for general practice nurses and for midwives the government should undertake active steps in the reforming of nurse education system in Georgia. The tables below illustrate the key features of the institutional arrangements that should be in place by 2011 or earlier for the routine preparation of family medicine medical and nursing specialists. They also show the interim arrangements that need to be put in place immediately to provide an adequate institutional arrangement for the governance of the four-year retraining programme.

Table 6.3

Re-training of GPs

Re-training of GPs

2011

Interim

Human resource planning

MoLHSA

MoLHSA

Components of an overall quality framework

Curricula development & revising

Higher Medical Schools/MoE

Quality assessment and Licensing (including assessment of trainees)

MoLHSA Professional associations

Student selection and support

Ed.

Advisory Board/MoLHSA MoLHSA Independent external assessor MoLHSA

99

Primary Health Care: Service Delivery – Volume 2

Table 6.4

Re-training of GPNs

Re-training of GPNs

2011

Interim

Human resource planning

MoLHSA

MoLHSA

Components of an overall quality framework

Curricula development & revising

Nursing schools/MoE

Advisory Board/MoLHSA

Quality assessment and Licensing (including assessment of trainees)

MoLHSA Professional associations

MoLHSA Independent external assessor

Student selection and support

6.5.2

MoLHSA

Human resource planning and management

To accomplish the goals and objectives of the national health policy doctors, nurses, and other staff must be produced in such a way that the investment in their production, whether privately funded or state subsidized, is used as effectively as possible. A key role of MoLHSA is therefore to regulate the number of clinical professionals through proper planning exercises. The planning function will permanently remain under the Ministry in close collaboration with the Ministry of Education. In the future this function should be undertaken by a Human Resource Development Unit to be created within MoLHSA. As indicated, during the transitional period MoLHSA will provide overall management of the rapid and large scale retraining programme of Family Medicine practitioners. It will ensure that: • •

The outputs of the re-training are planned to be completed on schedule with the other elements of the reform agenda (particularly, as indicated, to coordinate with the pattern of rehabilitation of medical facilities); Donor support for the re-training is coordinated so that the resources are targeted towards achieving the reform of the health system of Georgia.

MoLHSA will implement this function through its Reform Implementation Unit, in charge of the coordination and implementation of agreed reform strategies. The RIU will have one person designated as a coordinator of the re-training process.

6.5.3

Curricula development & revising

In the long-term higher medical institutions will be in charge of developing the training curricula for undergraduate and postgraduate education. MoE will retain the responsibility for accreditation of the teaching programme and this function will be executed by the designated structure (like Post Graduate and Continuous Education Board). MoLHSA will encourage the development of CME courses in different specialties by professional associations and other organisations and will be responsible for the accreditation of those programmes developed. However, during the transitional period any revisions to the re-training curricula of GPs and GPNs (approved in May 2005) will be subject to MoLHSA approval. The MoLHSA will be supported on curricula issues by an Advisory Board (see below). Preparation of teaching plans and associated materials is and will remain the responsibility of the training providers. They may be assisted in this through the provision to them of materials already

100

Master Plan for Retraining PHC Doctors and Nurses in Georgia

developed and judged adequate by the Advisory Board. This arrangement will apply to the regular training but also “Training of Trainers” courses and one week “Clinical Supervisors” courses. A clear legal basis for the education of nurses and midwives will also be established. This will follow the same pattern as that for doctors with the respective responsibilities of the MoLHSA and MOE. Prior to this the responsibility for oversight of nurse education and training will be undertaken by MOLHSA.

6.5.4

Student selection and support

The applicants will be short listed based on criteria developed by the Advisory Board and approved by MoLHSA (see Annex C). The selection process will be comprised of written test and interview prepared and carried out with support from the Advisory Board. It is then responsibility of the training provider to organize the programme in the most effective way and to prepare the trainees for independent assessment within 12 months of the commencement of training. Training providers will be obliged: • • • • • •

6.5.5

To cover the whole content of the curriculum To ensure adequate clinical practice with accredited centres and specialists To ensure adequate exposure to the organisation of family medicine practice To undertake the training with competent trainers and in appropriate facilities To make use of high quality training materials To be fully transparent in all their work, comply with standards, and be open to financial and professional audit

Quality assessment and licensing

The Government through the MoLHSA is responsible, on behalf of society, for ensuring that those licensed to carry out certain tasks have acquired the requisite competency. MoLHSA itself, with professional advice (“State Licensing Board”), determines what competencies are appropriate for licensing and then licensing -including revalidation of licenses- requires assessment against the core competencies. MoLHSA will permanently execute this core function through its Licensing and Regulation Department. The licensing exams are organized by the State Licensing Board. In the future, with the establishment of Medical Chambers MoLHSA will have independent and authoritative sources of professional advice on these matters.

6.5.6

Assessment of Trainees

Current organization of the re-training process obliges students to complete a mid term and final four–part summative assessment consisting of: • • • •

a knowledge-based (MCQ) examination; a written case-based examination (termed a MEQ – Modified Essay Question); a project; and an oral examination which may be carried out as a role-played patient interview.

These assessments will include the involvement of independent / international assessors. The Advisory Board will be responsible for the development of mid term and final assessment tests. Tests will be approved by MoLHSA.

101

Primary Health Care: Service Delivery – Volume 2

Newly qualified family practitioners will have formal support from a named mentor for a period of one year after qualification and thereafter will become part of the continuing professional development scheme. Mentors will be accredited by the Advisory Board which will also advise on the content and standards for continuing professional development. The RIU will then ensure the there is no delay in setting up the licensing exam.

6.6

Purchasing training services

6.6.1

Purchasing plan

As indicated, MoLHSA will undertake the purchasing of re-training delivery from different training providers (public and private) through open competitive tendering along the standards established by the Advisory Board. The tendering process and contract management will be undertaken by a Purchasing Unit accountable to a Deputy Minister. This Purchasing Unit will work based on the purchasing plan below, which has been built upon the following assumptions: • • • • •

Priority is given to the poorest areas of the country and the pilot Regions Need to allow time for build-up of trainer capacity in some Regions Training matching numbers of doctors and nurses as far as possible Matching physical rehabilitations as far as possible Public purchasing of training places and self-funded training (anticipated in Tbilisi and perhaps in other major urban centres) are included.

Table 6.5

Doctors training purchasing plan

Region

2007

2008

2009

Adjara

48

48

30

Imereti

48

48

72

Guria Racha-Lechkhumi Samagrelo / Poti

24

Samtskhe-Javakheti Kvemo-Kartli

24

Mtskheta-Mtianeti

2010

Total 126

98

266

57

57

25

25

48

48

88

208

50

24

48

35

107

48

48

70

190

30 48

30

Shida Kartli

24

49

121

Kakheti

48

8

47

Tbilisi

96

96

144

187

523

312

463

511

535

1821

143

Osetia Zone Total

102

Master Plan for Retraining PHC Doctors and Nurses in Georgia

Table 6.6

Nurses training purchasing plan

Region

2007

2008

2009

Adjara

48

48

30

Imereti

48

48

72

25

25

48

48

88

208

24

48

35

107

48

48

70

190

Guria Racha-Lechkhumi Samagrelo / Poti

24

Samtskhe-Javakheti Kvemo-Kartli

24

Mtskheta-Mtianeti

2010

Total 126

98

266

57

57 50

30

30

Shida Kartli

24

48

49

121

Kakheti

48

48

47

143

Tbilisi

96

96

144

187

523

312

463

511

535

1821

2010

Total

Osetia Zone Total

Table 6.7

Midwife training purchasing plan

Region

2007

2008

2009

Adjara

13

14

27

Imereti

15

15

30

Guria Racha-Lechkhumi Samagrelo / Poti

24

Samtskhe-Javakheti Kvemo-Kartli

26

26

15

15

30

24

26

74

17

17

34

26

26

Mtskheta-Mtianeti

16

Shida Kartli

10

13

88

98

16 23

Kakheti Tbilisi Osetia Zone Total

6.6.2

100

286

Pricing

It is assumed that all training in 2007 will be in accordance with the Mode 1 (central with travel) and will be priced at: Doctors

4800

Nurses

3840

Midwives

3840

103

Primary Health Care: Service Delivery – Volume 2

It is assumed that all training in 2008 and 2010 will be Mode 2 (fully regional devolved) and will be priced at: Doctors

2400

Nurses

1800

Midwives

1800

It should be noted that providers will be invited to prepare tenders from the outset based on both modes. Trainees resident in Tbilisi will only be charged on the basis of Mode 2 prices. Based on the assumptions above the total expenditure on training per se (not including QA, etc) will be:

Table 6.8 Based on the assumptions the total expenditure on training per se (not including QA, etc) Category

2007

2008

2009

2010

Total

Doctor

1497600

1111200

1226400

1284000

5119200

Nurse

198080

833400

919800

963000

3914280

158400

176400

180000

514800

2695680

2103000

2322600

2427000

9548280

Midwife Total

6.6.3

Contracting strategy

In January 2007 organisations will be invited to submit Capability Statements for the provision of retraining. This call will be repeated in January 2008. Organisations will indicate their capability to provide training according to Modes 1, and 2. Where at present they do not have the capability to provide in a particular mode they will provide a plan as to how this capability will be developed. Annex D illustrates the type of information that will be required in a Capability Statement. This will be reviewed by the Advisory Committee. Organisations meeting the minimum requirements of capability will be eligible to submit proposals for the provision of training. Invitations to provide training will be by Discipline / by Region / by Year. For example “Invitation to provide training for family doctors in Adjara in 2007”. Organisations will be eligible to submit multiple proposals but where they do so it will be necessary for them to demonstrate capability to meet the volume of training indicated. Contract prices will be fixed and therefore the proposals will be judged on the basis of ability to meet the requirements and standards in the specification. Annex E illustrates the main content of the contract specification. Invitations will be issued: • • •

104

in February 2007 for 2007 contracts, in October 2007 for 2008 contracts, and subsequently in October of each year.

Master Plan for Retraining PHC Doctors and Nurses in Georgia

6.6.4

Contract monitoring

Training Providers will be obliged to establish internal quality assurance arrangements and these will be subject to both pre-arranged and random audits by the MoLHSA Purchasing Unit. Reports will be provided to the Purchasing Unit in a format to be described in the contract. Supervisory visits will be made to all aspects of training by teams including a member of the Advisory Board, the Purchasing Unit, and the Regional MoLHSA.

6.7

Management arrangements and implementation plan

The implementation of this Master Plan will require detailed activity planning with critical support being provided by the Reform Implementation Unit. This section includes key decisions and milestones, particularly for 2007.

6.7.1

Establishment of structures

To achieve the effective governance of the retraining process without conflicts of interest a Family Medicine Advisory Board needs to be established by Ministerial Decree. The Advisory Board will be the prime source of professional advice and will support independence in the selection of trainees. The roles and membership of this Board are described in Annex F. The Ministry will also establish a Retraining Purchasing Unit. This will function either within the Health Investment Agency or preferably under the direct supervision of the Deputy Minister responsible for Human Resource Development. In the meantime, this Unit could be staffed by secondment from Ministry Departments.

6.7.2

Decisions

The following Ministerial decisions and associated instruments of promulgation will be required: • • • • • •

Approval to this Master Plan. Establishment of Advisory Board and appointment of members. Approval of the Financial Plan for 2007 to 2011 and Budget for 2007. Approval of the inclusion of Centres for Continuing Professional Development in the Investment Plan. Approval to the creation of a Purchasing Unit and assignment to a Deputy Minister. Approval to the delegated functions in retraining of Regional MoLHSA Departments.

It is anticipated that these decisions will be made by end of November 2006.

6.7.3

Milestones

Partner Participation. Those partners with an interest and mandate for supporting this Master Plan will be invited in December 2006 to indicate their formal support for participation in the programme and to indicate the means by which their funds can be utilised in accordance with the overall Master Plan. Regional Participation. In January 2007 Heads of MoLHSA Regional Departments will be invited to a special meeting to discuss their role in the retraining programme.

105

Primary Health Care: Service Delivery – Volume 2

Briefing of Providers and Call for Capability Statements. In December 2006 all current and potential training providers will be invited to a briefing on the Master Plan and provided with detailed information about the tendering process and contractual arrangements. Establishment of Structures. The Training Purchasing Unit will be established in December 2006. Initial meetings of the Advisory Board to agree its work plan for 2007 will be held in January 2007. Planning. Numbers and regions for the retraining programme for 2007 will be confirmed in early January 2007 Training of Trainers. In December 2006 invitations will be made to provider organisations to undertake the training of trainers programme for 2007. Nominations and applications for the programme focusing on the appropriate Regions will be sought in January 2007. The programme will be undertaken in March and April 2007. Recruitment of Trainees. Nominations and personal applications for the 2007 retraining programme will be invited in mid-January 2007. Selection will be undertaken during February and March 2007. Purchasing Arrangements. Contract Specifications will be completed by December 2006. Capability Statements will be called for and received during January 2007. Providers will be invited to tender in February 2007 and contracts will be agreed from March 2007.

6.7.4

Financial plan

The overall financial plan is in the table below.

Table 6.9

Financial plan

Item

2007

2008

2009

2010

Total

Quality Assurance / Advisory Board

100000

100000

100000

100000

400000

Selection and Assessment

300000

300000

300000

300000

1200000

Training of Trainers and Supervisors

50000

50000

50000

Purchasing Costs

50000

50000

50000

50000

200000

2695680

2103000

2322600

2427000

9548280

100000

100000

100000

100000

400000

3295680

2703000

2922600

2977000

11898280

Training Contracts Continuing Professional Development Total

106

150000

Master Plan for Retraining PHC Doctors and Nurses in Georgia

Annex 6.1

Illustration of new mode of delivery

The table below illustrates the possible division of the curricula into three elements:

Table 6.10

Possible division of the curricula into three elements

No

Pedagogical Elements

Doctors Hours

Nurses Hours

1

Element 1 of non-clinical education and training

206 hours + 40 hours Project (6 weeks)

210 hours + 15 hours Project Work (6 weeks )

2

Element 2 of clinical education

334 hours + 24 hours tutorial (9.5 weeks)

325 hours + 45 hours Project Work (10 weeks)

3

Element 3 of clinical practice

336 hours (8.5 weeks)

160 hours (4 weeks )

Total

940 hours (24 weeks)

755 hours (20 weeks )

Source FM Doctors and GP Nurses Curricula MoLHSA May 2005

Figure 6.1 Proposed mode of training delivery and clinical rotations for one cohort group of FM Doctors on the retraining programme 2 Weeks

9 Weeks Clinical Training

2 Weeks

2 Weeks

9 Weeks Clinical Training

2 Weeks

Total Training Period 26 weeks Element 1

Element 2

Element 3

Regional Clinical Teaching Venue 1 Cohort

12

Central Training Venue Nonclinical Cohort

24

Regional Clinical Teaching Venue 2 Cohort

12

Approved Rayon Clinic Cohort 3 Approved Rayon Clinic Cohort 3 Approved Rayon Clinic Cohort 3 Approved Rayon Clinic Cohort 3

Approved Rayon Clinic Cohort 3 Approved Rayon Clinic Cohort 3 Approved Rayon Clinic Cohort 3 Approved Rayon Clinic Cohort 3

Element 1

Element 2

Element 3

Regional Clinical Teaching Venue 1 Cohort

12

Central Training Venue Non Clinical Cohort

24

Regional Clinical Teaching Venue 2 Cohort

12

Approved Rayon Clinic Cohort 3 Approved Rayon Clinic Cohort 3 Approved Rayon Clinic Cohort 3 Approved Rayon Clinic Cohort 3

Approved Rayon Clinic Cohort 3 Approved Rayon Clinic Cohort 3 Approved Rayon Clinic Cohort 3 Approved Rayon Clinic Cohort 3

Element 1

Central Training Venue Non Cliniical Cohort

24

107

Primary Health Care: Service Delivery – Volume 2

Figure 6.2 Proposed Mode of Training Delivery and Clinical Rotations for One Cohort Group of FM Nurses on the retraining programme 2 Weeks

7 Weeks Clinical Training

2 Weeks

2 Weeks

7 Weeks Clinical Training

2 Weeks

Total Training Period 22 weeks Element 1

Element 2

Element 3

Regional Clinical Teaching Venue 1 Cohort

12

Central Training Venue Nonclinical Cohort

24

Regional Clinical Teaching Venue 2 Cohort

12

Approved Rayon Clinic Cohort 3 Approved Rayon Clinic Cohort 3 Approved Rayon Clinic Cohort 3 Approved Rayon Clinic Cohort 3

Approved Rayon Clinic Cohort 3 Approved Rayon Clinic Cohort 3 Approved Rayon Clinic Cohort 3 Approved Rayon Clinic Cohort 3

Element 1

Element 2

Element 3

Regional Clinical Teaching Venue 1 Cohort

12

Central Training Venue Non Clinical Cohort

24

Regional Clinical Teaching Venue 2 Cohort

12

Approved Rayon Clinic Cohort 3 Approved Rayon Clinic Cohort 3 Approved Rayon Clinic Cohort 3 Approved Rayon Clinic Cohort 3

Approved Rayon Clinic Cohort 3 Approved Rayon Clinic Cohort 3 Approved Rayon Clinic Cohort 3 Approved Rayon Clinic Cohort 3

Element 1

Central Training Venue Non Cliniical Cohort

24

The cohort sub groups might be organised as follows: up-to 4 subgroups obtaining placements in approved clinics with adult patients with chronic diseases etc. and the other 4 sub groups’ clinical placements in approved centres with maternal health patients and children.

108

Master Plan for Retraining PHC Doctors and Nurses in Georgia

Annex 6.2 Table 6.11

Costing of new modes of delivery Doctor and nurse re-training resource cost elements and volumes

Training costs Per Cohort Group

Unit Cost per week

No

No weeks

Doctors Cohort

Mode 1 Central Travel

Mode 2 Fully Devolved

GEL

GEL

FM Trainers Salary Central Teaching

420

2

6

5040

5040

Room Hire

120

1

6

720

720

25

1

6

150

150

FM Trainers Salary Regional Teaching

420

4

18

30240

30240

Per diems the Regional Trainers

350

4

18

25200

Transport costs per Regional Trainer

60

4

18

4320

FM Salary Supervisors

50

4

10

2000

2000

Room Hire

60

2

18

2160

2160

Light and heat

25

2

18

900

900

120

24

6

17280

Light and heat

Per diem for Trainees(Tbilisi Central Training) Total Costs Trainers and Rooms Printing Costs (per trainee)

100

24

Total Direct Cost per Cohort Direct Cost per Trainee Doctor

24

88010

41210

2400

2400

90410

43610

3767

1817

Nurses Cohort FM Trainers Central Teaching

420

2

6

5040

5040

Room Hire

120

1

6

720

720

25

1

6

150

150

FM Trainers Regional Teaching

420

4

14

23520

23520

Per diems the Regional Trainers

Light and heat

350

4

14

19600

Transport costs per Regional Trainer

60

4

14

3360

GP Nurse Supervisors

50

4

4

800

800

Room Hire

60

2

14

1680

1680

Light and heat

25

2

14

700

700

120

24

6

17280

50

24

Per diem for Trainees(Tbilisi Central Training) Total Costs Trainers and Rooms Printing Costs (per trainee) Total Direct Cost per Cohort Direct Cost per Trainee Nurse

24

72850

32610

1200

1200

74050

33810

3085

1409

109

Primary Health Care: Service Delivery – Volume 2

Overhead Costs Training Delivery Organisation

Per 6 Months

Support Staff

2200

Offices Expenses

2000

Contribution to Premises (excluding room hire above)

1500

Total

5700

No Trainees per 6 months

48

Overhead cost per trainee

119

119

Total Training Cost per Trainee Doctor

GEL

3886

1936

Total Training Cost per Trainee Nurse

GEL

3204

1528

Tbilisi Travel Model

Wholly Regional Model

FM Doctor

3886

1936

GP Nurse

3204

1528

Cost per Team

7090

3463

Total Training Cost in Gel per Trainee

110

Master Plan for Retraining PHC Doctors and Nurses in Georgia

Annex 6.3

Criteria and procedures for selection of trainees

Criteria and Procedures for Selection of Trainees The applicants to the training programme will be short listed based on criteria developed by the Advisory Board and approved by MoLHSA. Next is the set of preliminary criteria and procedures to be reviewed by the Advisory Board. Step 1. The National Roster of Nominated Candidates As explained in the core document, the training process from 2007 onwards will be run with a single, national roster including all candidates (as proposed by health care provider organizations/ PHC Rayon Corporations). In order to be in that list, however, the current legislation (MoLHSA Order 129/O, of 13th May 2005, recently ratified as order 252/m of 18th September 2006) states that candidates should have had to meet a number of criteria for selection, as follows: Criterion 1: Medical speciality of origin The list of candidates for re-training can only include certain professionals. The doctors who are allowed to undergo training in Family Medicine have to have been licensed previously to practice in one of the following related medical specialities: • • • • • • •

Internal diseases Paediatrics Gastroenterology Nephrology Pulmonology Rheumatology Cardiology

Therefore, service providing organisations can only forward their pre-selected staff from the specialities above. In comparative terms, none of the above professions has any preference over any of the others when selecting professionals for re-training. The pre-condition of having another speciality obviously does not apply to nurses. In recent years, however, one of the main criteria for qualifying for retraining as a GPN has been working in the facility that was going to be re-built. This may have discouraged hospital nurses from applying to re-training, when in reality no legal obstacle precluded them from doing so. Criterion 2: Working experience Both doctors and nurses are requested to have at least 2 years of working experience. In the case of doctors, such experience could have been gained in any of the above specialities in isolation or combined, i.e. one year in each of two of the above specialities. Criterion 3: Age limit Unless exceptionally authorised by the Minister of Health, doctors and nurses above 55 years of age will not be admitted to re-training. Below that age, no gradient applies (that is, neither a young doctor will have preference compared to a more senior doctor, nor the other way around).

111

Primary Health Care: Service Delivery – Volume 2

Criterion 4: Commitment to work at the designated medical facility at least for 2 years The final criterion for selection is the willingness to work in the designated medical facility which presented the candidacy of the professional, for a minimum of two years after completion of the retraining, subject to satisfactory performance during that period. The ongoing employment is a matter of bilateral agreement between the professional and the employing health care facility, based on performance. Health care provider organizations/ PHC Rayon Corporations will send their request to the Regional MoLHSA offices, which will ensure that such lists are integrated at the national level. Step 2. Short-listing by Regional MoLHSA Out of the above lists of candidates nominated by health care provider organizations/ PHC Rayon Corporations, Regional MoLHSA offices will short-list candidates for interview according to the numbers allotted to that Region in the national GP and GPN training programmes. The reasons for selecting the successful short listed candidates must be documented by the Regional Director of MoLHSA and placed on file in the central HR Department of MoLHSA. The short-list for the region for each training round will be published in the premises of the Regional MoLHSA. The dossier of each short-listed candidate will consists of the following documentation: • • • • • •

Copy of the State Certificate; Curriculum Vitae A document justifying that the applicant has not less then 2 years experience of work in the related specialty to family medicine; Written consent from the applicant that he/she will work at the designated medical facility at least for 2 years. Evidence of being within the age limit of 55 years. Recommendation from the Regional Health Authority as member of the short-list;

Step 3: Panel interview and tests. Short-listed candidates will then undergo an interview and a number of tests with a panel appointed by MoLHSA to be responsible for the selection of candidates for the re-training process of GPs and GPNs. According to the current Norm, the composition of the interviewing panel is as follows: • • • • • • • • •

112

2 Deputy ministers; Head of the Health Department; 2 Representatives from the Health Department; Head of the Sector Regulation Department; Representative from the Sector Regulation Department; Director of the NIHSA; 1 GP; 1GPN; FM Faculty Head;

Master Plan for Retraining PHC Doctors and Nurses in Georgia



Director of the regional MoLHSA (the Region concerned)

The norms to be developed by the FM Advisory Board may change the above composition. Applicants will be selected based on a written test and an interview, as follows: 1. Written test on clinical knowledge and skills. Participants will undergo a written test of their clinical knowledge and skills. The test will be designed in such a way as to assess whether the candidate meets the minimum requirements in the field of medicine (or nursing). 2. Interview on attitudes towards Family Medicine/ Family Nursing Applicants will be assessed based on their understanding of the PHC reform concepts, their attitude towards Family Medicine principles, their understanding of their own roles and responsibilities in the new system; and their willingness to participate in the re-training process; The MoLHSA will request the FMAB to operationalise both the written test and the individual interview. Step 4: Publication of results of the selection process At the end of the process, the MoLHSA will publish the list of the approved/selected candidates for training, with indication of where and when the training will take place. From then on, trainees will be under the guidance of the training delivery institutions

113

Primary Health Care: Service Delivery – Volume 2

Annex 6.4 Content of capability statements for provider organisations Content of Capability Statements for Provider Organisations 1. Concept Any organisation which wishes to contract with the Government to provide re-training for GPs and GPNs in the context of the 4-year special training programme must be able to demonstrate that it has the capability to deliver training outcomes. In other words, the prospective contractor must show the authority responsible for selecting training institutions that of those trainees who commence the course a high proportion will complete the program with a high level of the desired knowledge, skills and competence in the context of the volume of training indicated. 2. Types of issues to be addressed There are two categories of matters to be addressed. -

Firstly, matters of fact where failure to meet them will simply preclude the respondent from being awarded a contract (“threshold issues”) Second, areas designed to demonstrate an existing capacity to deliver high quality training and a given approach to, or philosophy of, training. These are more subjective and are intended to show the selection authority high likelihood in delivering high quality graduates to the Georgian primary health care system (“capacity demonstration issues”).

3. Threshold Issues The respondent to the tender must demonstrate that it has the essential means to provide the training -that is, the respondent has to; -

be licensed by the relevant Georgian institution (in this case, MoLHSA) to provide medical training; have guaranteed access to premises which meet the requirements of the type of training envisaged by the tender (plenary sessions, working groups, practical clinical work, etc) have guaranteed access to the range of equipment necessary for the type and volume of training envisaged by the tender (clinical, audio-visual, office, computing, etc) have sufficient insurance to cover claims of injury or similar to trainees or instructors and to replace furniture or equipment during the program

4. Capacity Demonstration Issues The respondent to the tender must also provide as much evidence as possible to allow the selection authority to asses its ability to deliver the quantity and quality of training required. As a minimum the following issues must be addressed, -

-

114

Previous Successes – including information as to training programs previously conducted with evidence of high quality outputs. In other words, the respondent should demonstrate the ability to teach to the desired level; Business Revenues and Budget Management – details of budget and realised performance in previous contracts for training during the last 3 to 5 years;

Master Plan for Retraining PHC Doctors and Nurses in Georgia

-

-

-

-

-

-

Testimonials – documents from previous clients (preferably institutional and not connected to the respondent) as to satisfaction with previous programs; Quality Assurance – details of the processes which have been and/or will be implemented in order to continuously monitor that the teaching quality is likely to deliver the necessary results. This should include whether the institution has been accredited by a recognised organisation which assesses quality of output as well as details of methods of ongoing assessment of trainees; Financial Viability – independently certified financial information which shows that the respondent has the financial means to fulfil its obligations under the proposed contract till completion without recourse to the Government for assistance; Teaching Staff – full details of the qualifications and experience of all staff proposed for the program together with details of the means the respondent will use to ensure that the necessary staff are available for the full term of the project; Assessment of Teaching Staff - provide a description of the means used to ensure that teaching staff maintain their professional knowledge and proper teaching techniques; Training Methods – description of the teaching methods and optimum class sizes preferred by the respondent and why those methods are preferred plus an explanation of how the preferred methods will apply to the program. In case the tender would request the use of specific methods, evidence should be provided of adherence to those methods; Teaching materials – details of what teaching materials, if any, will be prepared and produced by the respondent. In case the tender would request the preparation of specific materials, evidence should be provided of the capacity to produce those materials in the right amounts and with the right quality; Evidence of Ethical Behaviour - with particular focus on the approach to student complaints, emerging concerns of the authority responsible for contract management and the provision of feedback to students;

The FM AB will devise a composite index for weighing the different items above in a transparent manner. Such index will be published before every round of contracting. With time, as the overall quality of the training improves, capacity demonstration issues may become threshold issues (e.g. being accredited by a recognised organisation which assesses quality of output may shift from the second to the first category).

115

Primary Health Care: Service Delivery – Volume 2

Annex 6.5

Contract specification for family medicine training

Contract Specifications for Family Medicine Training The contract for the delivery of training between MoLHSA and training delivery organisations meeting the requirements of capability should address the following issues, 1. Identify date and location, etc. 2.

Provide context - Set out that the contract reflects the Government’s wish to re-train GPs and GPNs under the approved (by the relevant educational authorities) programs

3. Identify the parties to the contract – the licensed training organisation and the MoLHSA as the agency of Government which will be responsible for the re-training program 4. Make a statement of the general scope of the PHC Reform Programme and the philosophy of service that all parties agree are integral to the delivery of high quality medical and nursing training. The following illustrates the sentiments to be expressed and agreed in the contract, “the current approach to the concept of PHC and its delivery to the citizens of Georgia are unsatisfactory in matters of access to care and the quality of the care that is delivered. This causes dissatisfaction to both the providers of care and their patients. It is also detrimental to the future prospects of Georgia and threatens the sustainability of the PHC system. “improvement of the health of the Georgian population will be best achieved by improved access to and quality of services, a more equitable approach to health needs, more responsiveness to patients’ demands and preferences and more efficiency in the use of resources. The parties agree that improvement will be a continuous process which will start with the successful training of GPs and GPNs “the success of FMTP will be indicated by the number of trainees who successfully pass the assessment at the end of each course and, in the case of GPs, who subsequently are licensed as GPs;. “The chances for success of the program will be greatly increased if the organisation institutes a Quality Assurance program (QA) which sets standards of performance for inputs to the course, the processes of training and management and the outputs of the course.” 5. Details of Courses and Number of Trainees covering, -

Number of Programs to be provided, identifying GP and GPN programs separately Starting & Finishing Dates of each program Number of candidate to be trained in each program Date by which assessments must be provided to the candidates

6. The responsibilities and obligations that the organisation agrees to accept as the party which will be directly responsible for the delivery of training. These will include agreement to, -

116

Comply with all provisions of the Contract Comply with the regulations approved by the MoLHSA covering the Family Physician ReTraining Program and the General Practice Nurse Re-Training Program – ideally these regulations should be an annex to the contract

Master Plan for Retraining PHC Doctors and Nurses in Georgia

-

-

-

-

-

-

-

Provide sufficient training rooms, furniture and equipment and licensed Family Medicine Trainers to train the number of candidates specified. The minimum number of training rooms and the minimum levels of equipment must be provided as an annex to the Contract; Minimum and maximum sizes of groups for each type of training Approvals by MoLHSA of all training materials to be used in the programs with provisos that the materials must be submitted to MoLHSA at least (say) 15 days prior to the commencement of the program and the approval must be obtained before the materials are used. To institute a QA system addressing the issues of teaching quality and maintaining all necessary records. These records should be specified in detail in an annex to the contract. To advise MoLHSA of any circumstances which arise and which will cause omissions from the approved curriculum and the steps proposed to overcome the deficiency. (Note, this will place a corollary responsibility on MoLHSA to agree to the solution to the deficiency, see under that heading below) Where practical and appropriate to provide individual candidates with additional assistance and instruction to address identified weaknesses or deficiencies in coping with the course of study; Regularly advise each trainee of the trainee’s rate of progress towards satisfactory completion of the course of study both in terms of normative assessments of technical progress and regarding attitude and diligence; To advise MoLHSA of any trainee who, in the opinion of the organisation is not fully participating in the course and/or who is unlikely to successfully complete the course. This advice will propose either a method of remedial action or recommend to MoLHSA that the Trainee’s contract and right to participate in the course be terminated; To cooperatively assist MoLHSA in resolving complaints raised by a trainee who is dissatisfied with any aspect of the content, delivery or management of the program.

7. The rights that the organisation has under the contract which should include the right to , -

-

Be paid amounts due under the contract including specification of the intervals at which payments will be made, the basis for calculation of amounts due, the means of payment and the documentation which must support each request for payment. To be immediately advised of the substance of any complaint received by MOLHSA related to any aspect of the content, delivery or management of the program but does not have the right to the identity of the complainant

8. The responsibilities and obligations that MOLHSA agrees to accept as the party which will be responsible for the coordination of training. These will include agreement to, -

-

Comply with all provisions of this Contract; Use its best efforts to ensure that the organisation complies fully with the terms and conditions of this contract; Regularly monitor the training activities of the organisation including the satisfactory operation of the QA system as outlined in the annex referred to above Provide the organisation with all specified training and reference materials and, where appropriate to promptly determine whether particular materials proposed to be used by the organisation are approved or rejected; Provide mechanism whereby complaints by candidates related to the content, delivery or management of the program are formally and confidentially handled;

117

Primary Health Care: Service Delivery – Volume 2

9. The general rights that MOLHSA agrees to accept as the coordinator and financier of the retraining program, with particular mention of the basis on which the contract may be terminated. It should cover issues such as, -

-

118

The right of MOLHSA to terminate the contract if it is of the opinion that the quality of the training being provided is unlikely to result in a majority of the trainees successfully completing the course(s) of training. The process which must be followed before termination is effected The process to be followed if there is a dispute on this or any other matter covered by the contract

Master Plan for Retraining PHC Doctors and Nurses in Georgia

Annex 6.6 board

Role and membership of the family medicine advisory

Role and Membership of the Family Medicine Advisory Board In order to train the 3,840 primary care clinical staff required by the Government from 2007 in time, with the required quality levels and within the available resources, the Ministry of Labour, Health & Social Affairs (MOLHSA) will run PHC staff training during 4 years (2007-2010 included) as a special “Professional Development” project, supported by the necessary institutional arrangements. One of the critical organisations to be involved in this programme (together with the Training Purchasing Unit) is the Family Medicine Advisory Board whose roles and responsibilities are described next. A. General functional specifications 1. The role of the Family Medicine Advisory Board (FMAB) is to be the prime source of professional advice to MoLHSA on all aspects of professional practice in Family Medicine. It provides guidance to the training of Family Medicine medical and nursing specialists and suggests strategies to avoid problems of timescale, cost and quality by better coordinating the training of doctors and nurses with other Primary Health Care Reforms (construction, equipment, reform of PHC organisations and financing, etc). 2. The FMAB will not determine its own agenda but rather will address specific issues referred to it by the MoLHSA structures, such as the Regulation Department of the MoLHSA, the Reform Implementation Unit, Regional MoLHSA Departments and MOLHSA Purchasing Unit. 3. The role of the FMAB is explicitly based on the functions of regulation and quality assurance, as different from purchasing and service delivery, and thus it will be articulated around the Regulation Department of the MoLHSA. The FMAB will also advise the MoLHSA Reform Implementation Unit on issues of activity coordination with Regional MoLHSA Departments, on how to coordinate the re-training process, including the development of the Centre for Continuing Professional Development in each Region. The FMAB will also advice the MOLHSA Purchasing Unit on criteria to ensuring the effective planning and procurement of training. Also, in the event that revisions are proposed to the agreed (May 2005) re-training curricula for GP and GPNs or if a curriculum is developed for midwives, FMAB will advise MOLHSA on these issues. 4. The Family Medicine Advisory Board (FMAB) is a transitory entity. It will be disbanded at the end of 2010, once the Special Programme on Training FM Doctors and Nurses is completed and training is handed over to the regular Higher Medical Education system and the institutions in charge of pre- and post-graduate training (like the Post Graduate and Continuous Education Board). In fact, one of the functions of the FMAB is to support the setting up of a Human Resource Development Unit within MOLHSA. B. Detailed functions of the FMAB The FMAB performs the following lines of activity: 1. Advise MoLHSA on any revisions to the re-training curricula of GPs and GPNs (approved in May 2005) during the transitional period. -

Curricula development for midwives

119

Primary Health Care: Service Delivery – Volume 2

2. Review the implementation of the training programme’s four components, namely Principles of family medicine practice, Practical exposure to the organisation of family medicine, Clinical teaching and Clinical experience, with particular emphasis on. -

Encouraging an increase in the number of trainees per group where the teaching methodology allows; Putting more emphasis on organization of clinical practice; Gradually shifting the training concentration from Tbilisi to regions Supporting the development of additional training resources. Standards of training facilities Combination of theoretical/classroom teaching and clinical practice sessions; Availability of patients (clinical material) according to the specific needs of trainees (rural/ urban, age groups, etc); Breadth of coverage in clinical experience to all clinical aspects of Family Medicine. Appropriate rotations with clinicians; Assessment of skills and broader competencies; Continuing professional development and mentoring for students returning to regions.

3. Advise the MOLHSA on standards and criteria for training providers, family practice placements, clinical placements, and examination arrangements. 4. Supervise implementation of the 3-year Training the Trainers programme and the Clinical Supervisors Training Programme 5. Supervising the process of training decentralization within the required trainer resource numbers 6. Support MOLHSA with an independent assessment of the competence of trainees both before and after the training has taken place. 7. Participate in the national assessment process of the trainee selection (after nomination by an employing organisation and MOLHSA Regional Department) by producing criteria, written test and interviews. 8. Set the required standards (contract specifications) for the MoLHSA to undertake the purchasing of re-training delivery from different training providers (public and private) through open competitive tendering. 9. Support Quality Assessment ensuring through supervisory visits that training providers: -

Do cover the whole content of the curriculum Do ensure adequate clinical practice with accredited centres and specialists Do ensure adequate exposure to the organisation of family medicine practice Do undertake the training with competent trainers and in appropriate facilities Do make use of high quality training materials Are fully transparent in all their work, comply with standards, and are open to financial and professional audit

10. Develop materials amenable to being used as a reference by the training providers in preparation of their own teaching plans and associated materials for regular training, “training of trainers” courses and “clinical supervisors” courses. 11. Develop mid term and final assessment tests, to be approved by MoLHSA, of the mid term and final four–part summative assessment (consisting of a knowledge-based (MCQ) examination, a

120

Master Plan for Retraining PHC Doctors and Nurses in Georgia

written case-based examination (termed a MEQ – Modified Essay Question), a project; and an oral examination which may be carried out as a role-played patient interview). These assessments will include the involvement of independent / international assessors. 12. Accredit the mentors in charge of formally supporting newly qualified family practitioners for a period of one year after qualification and thereafter as part of the continuing professional development scheme. 13. Advise on the content and standards for continuing professional development. 14. Review the Capability Statements submitted by organisations invited to participate in the provision of retraining indicating their capability to provide training according to specifications. 15. Participate (together with the Purchasing Unit and the Regional MoLHSA) in the programme of pre-arranged and random Quality Assurance Supervisory Visits to be made covering all aspects of training. Criteria for Membership In order to participate in the effective governance of the retraining process the Family Medicine Advisory Board needs to pay specific attention to 3 criteria: technical qualification, dedication and conflicts of interest Technical qualification. Members of the FMAB should be prominent members of the medical and nursing community of Georgia. Experience in the development of Primary Health Care will be a plus but will not be treated as a sine qua non condition during the four-year special training programme. Commitment and Dedication. Members of the FMAB will be offered a contract for a number of dedicated, paid hours, to be determined according to the amount of work foreseen and of the total number of members (in principle, not more than 10 but not less than 6). Additional members may also be co-opted by the government on particular issues for particular periods; they will also be paid for their services. Conflicts of interest. Members of the FMAB cannot have any economic interest in the field they will be regulating. They cannot, for example own in total or in part training providing organisations. The FMAB may advise on the content and process of tenders for teaching services but must not be directly involved in the selection of teaching contractors. In any event, when providing advice on tender conditions or responses etc each member of the FMAB must advise MOLHSA of any arrangements he/she has to deliver paid training or to perform other paid work for any training provider organisation, etc. The name of the training organisation must be declared. Membership of the FMAB will be established by Ministerial Decree.

121

Report on Review of Training Programmes for Doctors and Nurses in Family Medicine

7

Report on Review of Training Programmes for Doctors and Nurses in Family Medicine Carl R. Whitehouse

September/ October 2005

123

Primary Health Care: Service Delivery – Volume 2

7.1

Introduction and summary of proposals

7.1.1

Background

In accordance with the workplan for Stage III of the Human Resources & Service Delivery Workstream of the Georgia Primary Health Care Programme II, supported by DfID (UK), Professor th

th

Carl Whitehouse made a visit to Georgia from 26 September – 6 October, 2005. The Terms of Reference of the visit were: • • •

To undertake a review of the training programmes for doctors in family medicine in terms of both the quality of the training and the relevance to the development of family medicine based primary health care in Georgia To give consideration to the most appropriate institutional arrangements for the future oversight of family doctor training with a view to its continuing effectiveness and quality in accordance with international good practice. In view of the plans to develop family medicine teams of doctors and nurses to provide primary health care and the multidisciplinary input into the training, it was not considered appropriate to review the training programmes for doctors in isolation from those of nurses. Consideration was therefore given to the nurse training programmes and future institutional arrangements for both professions, whilst recognising that further advice would be required from experts in nursing.

The review consisted of consideration of: • •



the current “Family Physician Retraining Programme” accredited by the State Postgraduate and CME board, May 2005. the current “General Practice Nurse Re-training Programme” revised collaboratively by the National Institute of Health and Social Affairs, the Georgia Family Medicine Association, the National Family Medicine Training Centre and the UK DfID Primary Health Care Programme in 2005. the State Medical Academy Residency Programme in Family Medicine Practice.

Discussions took place with Georgian leaders in the reform process from the National Institute of Health and Social Affairs, The Tbilisi State Medical University, the State Medical Academy, The Georgia Family Medicine Association, the Georgia Nursing Association, staff from three Family Medicine Training Centres and residents from two Family Medicine Training Centres and the State Medical Academy Residency Programme. Discussions also took place with staff of donor agencies or technical aid organisations associated with the primary care reforms. A full list of those consulted is appended. The following areas were considered as part of an overall quality framework: • • • • •

Curricular content and design in the current programmes. Teaching and Learning Training resources Assessment and Licensing Student selection, support, career guidance and continuing education.

These are considered in more detail in chapters 2-6 of the following report.

124

Report on Review of Training Programmes for Doctors and Nurses in Family Medicine

7.1.2

Key areas

Three key areas emerged which require further work in order to develop an effective and wellregulated training programme for family medicine. These are summarised below and discussed in greater detail in Section 7.7 of the following report. 7.1.2.1

Fitness for Purpose

The curricula of the retraining programmes were, on the whole, well designed for the early stages of the reform process where the main aim was to train family physician and general practice nurse leaders who would be working in a mainly urban environment and who would train others. They were also adapted to a situation where, de facto, much of the input would have to come from specialists. They appear less relevant to the current situation for a number of reasons: • • • •

Teachers consider the basic level of knowledge and skills of the students is inadequate. Insufficient consideration has been given to the needs of people working in isolated areas such as high mountain regions and to the nature of those societies and their needs and health beliefs. The educational load is too great for a six-month period. The resources are insufficient to provide the expected experience and training in skills for the numbers involved.

At the same time the Retraining Programme for doctors lacks relevance for future development because it does not necessarily fit well with the Residency Programme, or with the proposed Educational Agenda of General Practice in WONCA-Region Europe. Anticipated developments in basic nurse training and the changes in undergraduate medical education following restructuring at Tbilisi State Medical University will also impinge on the future relevance of these programmes. 7.1.2.2

Monitoring

Monitoring the process and outcomes of training is essential if government and society are to be assured of the quality of care that is available. Such monitoring requires impartiality and objectivity and this is not necessarily consistent with heavy involvement in the training process. Work needs to be done to develop structures that will facilitate independent monitoring of training and assessment. There are particular weaknesses in the current assessment processes for both doctors and nurses: • • • •

Current students are unaware of the exact nature and timing of the assessment process they will undertake (except for the State Examination for doctors). the State Examination for doctors focuses on knowledge. there is no external monitoring of the assessment of skills and broader competencies within the training programmes. There is no formal national recognition of the competencies achieved by general practice nurses.

125

Primary Health Care: Service Delivery – Volume 2

7.1.2.3

Support

Both monitoring and support of students and trainers are elements of quality enhancement. At present there appears to be lack of adequate support in a number of areas: • • • •

7.1.3

Students are unclear what the prospects of working in the field of family medicine are once they have completed the training. There is no effective continuing supervision or educational support available outside Tbilisi/Mtskheta. Access to educational resources outside the capital appears limited. There are insufficient resources for trainers to receive support and develop their teaching skills.

Proposals

A number of different Georgian organisations are currently involved in the Primary Health Care Reforms. Although individuals may be associated with more than one organisation, there seems to be insufficient co-ordination. In a situation of limited resource it is essential that there is coordination to ensure that personnel, skills and facilities are used to the greatest advantage. Individual organisations should take responsibility for specific areas of development and quality management in which they are best qualified. Possible approaches to this will be found in the matrices in Section 7.7. However, resolving these issues requires a round-table conference of all stakeholders in the training programmes. It is proposed that this should be the next major step in the development. Whilst setting up such a conference there are however a number of urgent actions that are required in view of the current retraining (and residency) programmes that will soon be completed. 7.1.3.1

Step 1: Clarify assessment process

The National Institute for Health & Social Affairs must clarify urgently the assessment process for the end of the retraining programme. This is required within two months. If available, some Technical assistance might be helpful on the logistics and/or monitoring the process (assessment of skills can be monitored with help of interpreters) but would be difficult to find in the time available. 7.1.3.2

Step 2: Initial Review of curricula

The current curricula need some urgent modifications, in particular to deal with requirements that are not feasible. Some of these details will be found in Section 7.2. This is required as soon as possible and needs both medical and nursing technical assistance to work with Georgian counterparts. Discussions might take place with other donors who are bringing in such assistance within the next four months. 7.1.3.3

Step 3: Round-table conference

A round-table conference should be set up early next year to enable all the stakeholders to discuss how to set up effective structures for the management of all areas of the training programmes both during the period of intensive retraining and in the continuing full-time residency and nurse training programmes.

126

Report on Review of Training Programmes for Doctors and Nurses in Family Medicine

This conference should consider the procedures for: determination of competencies, licensing and revalidation, assessment procedures, approval of training sites, curricular design, teaching and student support. A three-day conference with prior presentation of working papers by appropriate stakeholders would be a minimum. It is proposed that chairing of the working sessions of the conference should be by an external consultant (or consultants) seen as neutral by all parties. This should be negotiated with all those involved in PHC Reform and will require technical assistance in planning. Further details will be found in Section 7.8. 7.1.3.4

Step 4: Building capacity

Following the above it would be hoped that individual Georgian institutions would take on responsibility for different areas of Quality management of training. This will need help in building the capacity. Possibilities would include the development of capacity for “Trainers Groups” within the Georgian Family Medicine Association and within the Georgian Nurses Association, the development of the HR Departments in Regional Health Departments, as well as further development of the appropriate departments of the Ministry of Labour, Health and Social Affairs concerned with competencies and with licensing and revalidation. Determination of the Technical Assistance required in these areas should follow the conference. If possible this capacity development should take place in 2006 7.1.3.5

Step 5: Full review of Curricula and Assessment procedures

Following the conference it should be possible to undertake a full review of the curricula and the assessment procedures for both doctors and nurses in the light of the clarification of the competencies required. This should enable future re-training programmes to be part of a continuing professional development programme leading to a family doctor who fully fits the European definition of a family doctor but is able to provide an appropriate primary care service within the Georgian contexts (whether urban, rural or high mountain) or a general practice nurse who can take a truly independent nursing role within the same contexts. Determination of the Technical Assistance required in these areas should follow the conference. If possible this review should take place in 2006.

7.2

Curricular content and design in the current programmes

1. The curricula under review are the three-year residency programme for family physicians (30 months), the short retraining programme for family physicians (940 hours) and the short retraining programme for general practice nurses (816 hours). The retraining programmes were constructed within the context of the Primary Care development project supported by DfID (UK) (referred to as the DfID1 project), whilst the residency programme was prepared with support from teams from the USA 2. Family physician re-training programme. The general regulations for this programme state that it “must provide acquisition by the resident of the clinical competencies (knowledge, skills, and attitudes) necessary to conduct independent activities in Family Medicine in accordance with Duties and Competencies approved for FPs”. It is therefore a competency-based curriculum. However some of the indicative duties and competencies suggest an influence from specialists with insufficient understanding of primary care or family medicine: for instance there is a marked emphasis on knowledge of specific conditions or the statement that all FPs should have the skills to perform a range of procedures and manipulations in surgery and trauma. On the other hand there is insufficient emphasis on competence in communication, problemsolving, prioritising, managing uncertainty and adjusting the management to the individual

127

Primary Health Care: Service Delivery – Volume 2

patient with their particular needs and health beliefs. The balance of hours within the modules also suggests a strong emphasis on basic clinical knowledge and skills. Whilst this may be necessary in view of inadequate or outdated basic medical education, it does not allow for sufficient emphasis on developing the core skills of primary medical care. 3. State medical academy residency programme in family medicine practice. This programme is organised around a series of rotations in different clinical specialties together with regular (and increasing) attendance at a family doctor clinic. Whilst it is stated that the basic approaches that should be taken are family doctor oriented and time is provided for theoretical input on these issues, details of individual rotations suggest an emphasis on specialist knowledge and skills that should, preferably, be achieved in basic medical education. There is no clear statement of the competencies to be achieved and again there appears to be insufficient emphasis on competency in communication, problem-solving, prioritising, managing uncertainty and adjusting the management to the individual patient with their particular needs and health beliefs. 4. General practice nurse re-training programme. The aims and objectives of the core programme are set out in terms of knowledge and skills and working “within his/her competencies”. There is therefore some evidence that the curriculum is intended to be competency-based. However there is concern about some of the statements: e.g. that nurses should know (3.11) “advanced methods of diagnosis, treatment and management of prevailed chronic diseases…” or the annex listing indicative core competencies of the general practice nurse that might imply a range of medical knowledge that is likely to be inappropriate for either the educational level or local context of Georgian nurses or for the development of nursing skills. Evidence of the UK origin of this list is seen in statements like: “Sectioning – How the UK Mental Health Act works”!! The modules are comprehensive but the balance may be inappropriate to the current needs of the students: for instance in the hours devoted to areas such as audit and evidencebased practice rather than health promotion or family planning or elderly care. 5. Overall the curricula show evidence of two contrasting influences: A clinical focus strongly based on specialisms seeking to impart basic medical knowledge as against a sophisticated (and strongly UK/US influenced) view of the potential future position of family physicians and general practice nurses. The result of this is a heavily overloaded curriculum (particular for the short retraining programmes) that does not seem well adapted to the existing level of knowledge and skills of potential trainees, or to their immediate needs. 6. Whilst the two main curricula for doctors, each have their strengths there are a number of gaps in both of them. This is shown in Table 7:1 at the end of this Section (where they are also compared with the EURACT Educational Agenda 2005 (see below)). Specifically the Residency programme appears weak on the organisation and management of primary health care and clinical epidemiology, whilst the retraining programme is weak in theoretical input on psychological, social and economic factors in disease. In comparison with the European profile of a family doctor and the EURACT Educational Agenda, both curricula appear to lack adequate input on a number of areas including the following important aims: a. “the learner will be able to adopt appropriate working principles using incremental investigation, time and tolerating uncertainty.” (3.1) b. The learner will be able to reconcile the health needs of individual patients and the health needs of the community in which they live, in balance with available resources (5.1) c. The learner will be able to use a bio-psycho-social model taking into account cultural and existential dimensions. (6.1) 7. Reports from trainers and students in the retraining programmes, especially nurses, complained of curricular overload: one student comment was “The volume of the materials to be learned is huge and the time of training is limited. Due to the time limitations it is very

128

Report on Review of Training Programmes for Doctors and Nurses in Family Medicine

difficult to study all the materials.“ They also felt there was a failure to focus on the skills they would need ranging from “first aid” to management of chronic disease and the elderly. Physicians also suggested that the problem of overload would be helped if greater note was taken of their own prior knowledge (e.g. flexible curricula that dealt with paediatricians differently from adult therapists). 8. Trainers on the retraining programme stressed the low initial base of knowledge and skills. The original basic medical education may have been adequate but, over time, both knowledge and skills had become outdated or lost. Initial nursing education had been of a much lower level and there has been even less chance for updating. In the residency programme students had initially been trained in the Faculty of General Medicine, which meant there was a low knowledge in certain aspects of paediatrics. For these differing reasons there are mismatches between the competency levels of the student intake and the expected learning outcomes (objectives) of the courses. 9. As was detailed in the “Roles and Functions” paper presented by OPM in September 2004, there is a need to ensure that Basic Medical Training/General Professional Training ensures that the entrant to Family Medicine training has an adequate level of general medical knowledge and skills. This should cover the majority of clinical skills currently detailed in the Residency course or the Physician re-training programmes. Changes at Tbilisi State Medical University that will lead to a single undergraduate training programme (rather than separate general medicine and paediatric streams) should hopefully facilitate this. However, even if introduced in 2006, graduates of the new course will not emerge until 2011. It is however essential that TSMU and other schools providing undergraduate medical education should be involved in the curricular planning process so that Basic Medical Training and residency programmes are seen as a continuum. 10. The current 30 month residency programmes should provide adequate opportunities to achieve the necessary basic general medical competencies. However in the current situation it may be insufficient to also achieve specific family medicine competencies and an increase to the European norm of 36 months should be considered. 11. The initial retraining courses of 6 months were adequate for a core group of highly motivated participants who will have started with a reasonable general medical competency. This period seems to be inadequate for the retraining of a large cohort of staff who, for no fault of their own, have had limited opportunities to maintain or develop their knowledge and skills in recent years. It is realised that the rapid introduction of a new primary care system requires equally rapid development of a suitable workforce. It is also realised that one cannot expect personnel to spend extremely long periods on courses away from their families. In the light of this further consideration should be given to the previous proposal (in the OPM report of March 2005 “Retraining for Staff in the Reformed Village Ambulatory Clinics”) that an initial retraining course should only lead to provisional (intermediate) licensing to work as a family doctor, and that a longer period of 18-24 months supervised education and experience should precede final licensing. Consideration will need to be given to a range of issues including: • • •

The availability of competent supervisors, especially for people working in remote areas. Determining a level of competence PRIOR to entry on a retraining course Assessing the clinical competencies of students and providing training adapted to their personal needs (e.g. short-term attachments to suitably trained specialists OR family doctors/nurse trainers before, during or after retraining as fitting).

12. In the case of the curricula for retraining physicians and the residency programme, there is already to a large extent a separation of the competencies required to be a generalist (i.e. a range of basic medical knowledge and skills) from those required as a family physician. With

129

Primary Health Care: Service Delivery – Volume 2

suitably trained teachers (see below) it should be possible to teach both of these at the same time; however in the current Georgian situation there may be reason to separate the two elements in terms of curricular design and programme timing, especially in retraining programmes. All retraining students are likely to have the same needs with respect to family medicine training, whereas the requirements for clinical skills training are likely to be more varied depending on the individual and their previous experience. Students are also unlikely to be able to focus on areas of family medicine training (such as problem-solving, personcentredness and managing uncertainty) whilst feeling that their basic clinical skills are inadequate (e.g. a paediatrician with little experience of adult medicine and even use of some basic equipment). For these reasons it would be preferable if basic clinical skills training could be tailored to the individual and carried out BEFORE starting the family medicine retraining course. If time, facilities and logistics (lack of facilities outside Tbilisi) prevent this, then the clinical skills training should be individually tailored during the course. 13. With such a separation it should be possible to ensure that the training of family physicians is more closely related to the emerging European consensus on the definition of the discipline of general practice/family medicine and the core competencies derived from that definition in terms of primary care (clinical) management, person centredness, specific problem–solving skills, a comprehensive approach (promoting health and managing the whole spectrum), community orientation and a holistic approach . This would enable the curricula to be adapted to the EURACT (European Academy of Teachers in General Practice) Educational Agenda (See http://www.euract.org/html/pdf/agenda.pdf), although at the same time being tailored to the Georgian context. Materials produced for the European Agenda could then be modified for Georgian purposes. As SMA is already in close contact with EURACT and the Georgian Family Medicine Association is already a member of WONCA (the parent body of EURACT) this would strengthen links and make resources available. 14. The future (long-term) norm for Family Medicine training will be a residency programme of at least three years. Curricula for retraining will need to be aware of this to ensure that retrained doctors can provide some of the examples and fieldwork supervision for residents. 15. Similar approaches may be appropriate for nurses. However, in the case of nurses, there is less international consensus on the role of a nurse in a family medicine centre or a community. At the same time the nurses being retrained have widely varied education and experience (with a limited, secondary basic education). In the light of this, and the experience of the first cohorts, it is important to review the competencies expected of a general practice nurse before revising the curricula. Training programmes may need to be much more tailored to the individual circumstances of nurses (urban, rural or isolated high mountain), and probably focussed more intensively on skills. 16. Programme flexibility , with tailoring to specific groups of even individuals, causes some difficulties in terms of: • • •

Ensuring there is equivalent number of hours Arranging an administering the rotations Monitoring attendance and achievement

However teaching is currently carried out in small groups of six and these proposals may make better use of resources available. That some attempts may already being made in this direction was shown by the trainer who said that they felt that some trainers were more learner-centred than the curriculum! 17. If tailored programmes are to be successful it is important that students can identify their weaknesses and needs. This is part of developing adult learning skills. The short evaluations carried out by the author, particularly with nurses in training, showed that they found it difficult

130

Report on Review of Training Programmes for Doctors and Nurses in Family Medicine

to determine ways that the courses could have been better adapted to their needs (except in terms of duration and the terminology used). This may suggest a need to provide some training in adult learning skills or "How to learn effectively" prior to the course. 18. There is no doubt that the current curricula are achieving a number of the required outcomes. It was noticeable that the SMA residents just completing the 30-month course expressed patientcentredness or understanding of patients as the main difference between GPs and other medical professionals. This also emerged in some of the feedback from short-term retraining doctors. However more effective outcomes could be achieved with a review of the curricula. 19. In the light of this the following proposals are made: •









The Indicative Competencies attached to the current curricula should be urgently reviewed with a view to removing items which are NOT appropriate to the Georgian PHC situation (e.g. the UK Mental Health Act) or those which are not feasible with the current resources available (e.g. the requirement for specific numbers of surgical and gynaecological manipulations. (Summary - Step 2) The current retraining curriculum for doctors should be urgently rewritten to alert all teachers to the need to cover family medicine competencies such as primary care clinical management, comprehensive and holistic approaches and patient-centredness. (Summary – Step 2) The current retraining curriculum for nurses should be urgently rewritten to reduce overload. One way to do this would be to reduce the time on Modules 15-17, which cover areas where they would be unlikely to have suitable resources at their work places initially. An introduction to the importance of these areas could be the basis of continuing professional development at a later stage. The use of IT for record-keeping and some of the audit processes could be included in module 18. (Summary – Step 2) A major review of the curricula should be carried out in 2006 in the light of redefined competencies for Georgian family physicians and general practice nurses. For doctors (both retraining and residency programmes) consideration should be given to the EURACT Educational Agenda: the current relationship is shown in Table 2:1. For nurses there should be consideration of international examples outside the UK/USA. (Summary – Step 5). Tbilisi State Medical University and other schools providing undergraduate medical education should be involved in the curricular planning process so that Basic Medical Training and residency programmes are seen as a continuum. (Summary – Steps 4/5)

131

Primary Health Care: Service Delivery – Volume 2

Table 7.1

Comparison of curricular elements

Retraining programme Module

Theme

Element

1. Primary Care Development

Understanding PC

Definition & elements of PC Philosophy of PC

Primary care development

SMA resident programme

Euract Educational Agenda

Particular Issues of Professional Activity

Objective Number (see document)

12. constant availability of the services and accountability towards patient.

Role of PC Role of FP

?2.1.3, 4.1.1,6.1.1-5 5.1.5/5.1.8?

12. evaluation of one’s own professional abilities, provision of the timely referral to the specialist

Primary care in the future Role of PC Team

12. Multi-discipline approach to the patient care, ….

1.3.2

14. Patient care continuousness and availability of medical care 2. Organization of PC management

Planning and development

strategic plan

5.1.1-9

business plan

HR management

financial management

7.1.3

HR management and development

1.3.2, 1.3.3

selection & evaluation team working

132

15. Effective working of health team with other members

1.3.2, 1.3.3, 4.3.1, 4.3.3

Audit

clinical & organizational audit

5.1.7

IT

information management

1.5.2,4.1.3

basic skills of IT

1.5.2

Report on Review of Training Programmes for Doctors and Nurses in Family Medicine Retraining programme Module

Theme

Personal development

Element

SMA resident programme

Euract Educational Agenda

Particular Issues of Professional Activity

Objective Number (see document)

critical appraisal of medical literature

4.1.4, 7.3.3

leadership skills

1.6.2

change management effective management 3. Basic clinical skills

Clinical theory & practice

1.5.2

Examination skills

Individual systems – q.v.

1.2.3,3.2.1,3.2.4

Diagnostic skills

Individual systems – q.v.

1.1.2,1.2.3,3.2.1,3.2.4,3.5.1, 4.1.2

Consultation models

16.Environment selection, conversation with the members of the patient and his family, assessment, the skills of asking relevant questions and expressions to the patient and/or his family members while telling “bad information”. Considering the impact of process on patient and family.

1.1.3, 1.5.1, 1.6.1,2.2.1,2.2.2, 2.3.1,3.2.2

18. Specific issues related to the men health care: a. Men’s desire to actively participate in the process of decision making. 19. Specific issues related to the adult health care: c. Adult confrontational attitude towards society, parents and other people. Chronic diseases management

EBM

Treatment

Clinical guidelines for commonly encountered diseases/conditions

Prevention

4.1.4,7.3.3 Individual systems - q.v.

1.2.4 ?, 3.2.3

Cost-effective treatment

Individual systems - q.v.

3.2.3

General principles

3. Working out the desire and skills of disease prevention and treatment methods in the patient.

1.2.1,1.2.2, 4.2.1-4

4. Evaluation of the patient readiness and skills for changing life style.

133

Primary Health Care: Service Delivery – Volume 2 Retraining programme Module

Theme

Element

SMA resident programme

Euract Educational Agenda

Particular Issues of Professional Activity

Objective Number (see document)

6d. The role of the socio-economic factors in revealing diseases and in their progress: Health and life style (related circumstances, diseases, skills). 7. Besides medical, the role of the family, life style, interpersonal factors, society, profession, social situation and social perspective in the encouragement of the patient health. 8. Evaluation of the patient readiness and skills to change life style. 9. Working out the feeling of responsibility for the own health. 10. Importance of the doctor’s health, doctor working as positive model. 19g. Specific issues related to the adult health care: Health encouragement and working out prophylactic skills 20. Specific issues related to the children health care: b.Encouragement for the healthy life style of children and family members. c. Infant and children care, which might demand special attention and consultation. d. Social, cultural and other factors, which negatively affect children health. 21b. Problems related to the elderly, existence of chronic diseases, invalidity and death: Support for patient defence in one’s own care and maintaining skills. Individual systems – q.v.

Emergency in general practice

134

Cost-effective health care skills

3.6.2, 4.3.2

Screening

4.2.3

Management of prevalent emergencies in general practice

Individual systems – q.v.

1.2.2.,3.4.1,3.4.2

Report on Review of Training Programmes for Doctors and Nurses in Family Medicine Retraining programme

SMA resident programme

Euract Educational Agenda Objective Number (see document)

Module

Theme

Element

Particular Issues of Professional Activity

4. Long-term supervision

Management of chronic conditions

Secondary & tertiary prevention

21b. Problems related to the elderly, existence of chronic diseases, invalidity and death: Support for patient defence in one’s own care and maintaining skills.

Rehabilitation

21b. Problems related to the elderly, existence of chronic diseases, invalidity and death: Support for patient defence in one’s own care and maintaining skills.

clinical management of chronic diseases

Individual systems - q.v.

functional assessment

Individual systems - q.v.

pain control

21k. Problems related to the elderly, existence of chronic diseases, invalidity and death: Pain control of the dying.

1.2.4

managing the relatives

21 Problems related to the elderly, existence of chronic diseases, invalidity and death: most sections

1.5.1

confidentiality

19f. Specific issues related to the adult health care: Confidentiality and relations between patient and doctor.

role of professionals

5. Cooperation between patient and doctor.

Palliative care

5.Ethical & legal issues

Medical ethics

2.4.1

1.1.4,1.2.2,1.2.4,1.3.4,1.4.1

? 2.2.3 ,7.2.1-4

11. Examination and treatment restriction for the patient. professional standards Medico-legal aspects

good practice

7.2.1-4 21g. Problems related to the elderly, existence of chronic diseases, invalidity and death: Preliminary declared will and authorities of the legal representative.

7.1.3

13. Preliminary declared will and utilization of the authority of legal representative and restrictions. 6.Clinical epidemiology

Basic terminology (glossary)

Incidence, prevalence, morbidity, mortality, riskfactors, relative and absolute risk, etc

1.1.1 as exemplar,3.1.1,3.6.1,7.3.1

main types of research & their importance

7.3.1,2

135

Primary Health Care: Service Delivery – Volume 2 Retraining programme Module

Theme

Element

SMA resident programme

Euract Educational Agenda

Particular Issues of Professional Activity

Objective Number (see document)

health programs management at population level 7.Project

8. Trainer's skills

Audit and research

Methods of adults learning and teaching

determination of sphere of interest

5.1.7

problem formulation

5.1.7

search of literature

5.1.7,7.3.3

collection of data

5.1.7

analysis of data

5.1.7

principles of adult teaching teaching methodologies evaluation methods 1. Patient psychological and economic impact on the patient itself and family. 2. Importance of the family on patient health status or life.

NO PARALLEL

6. The role of the socio-economic factors in revealing diseases and in their progress a. Cultural factors (family, society, ethnicity, religion); b. Social-economic factors (Meal buying capacity, life conditions); c. Psychical health role (Depression, anorexia, dimension, life conditions). 17. Specific issues related to the women health care: a. Women refer to the medical services more frequently then men; b. Women refer to the medical services more frequently then men;

136

2.1.1,2.1.2

Report on Review of Training Programmes for Doctors and Nurses in Family Medicine Retraining programme Module

Theme

Element

SMA resident programme

Euract Educational Agenda

Particular Issues of Professional Activity

Objective Number (see document) 2.2.4 , 2.3.2 3.1.2, 3.2.5, 3.3.1 - 3.3.3.

NO PARALLEL

NO PARALLEL

4.2.5 5.1.1-6,5.1.8-9 6.1.1-5 7.1.1,2,4

137

Primary Health Care: Service Delivery – Volume 2

7.3

Teaching and learning

It was not possible to carry out a detailed review of teaching quality because of limitations of time and language. However four Training Centres were visited: National Family Medicine Training Centre (director - Irina Karosanidze), the Tbilisi Family Medicine Practice and Training Centre (director - Marina Shikhashvili), the Family Medicine Clinic of JSC “Medical Concern Curatio” and the Mtskheta Family Medicine Centre (Director - Ketevan Loria). It was possible to meet trainers and students and, on one occasion to watch a 90-minute multidisciplinary group session on management. The student feedback from both doctors and nurses was very positive. Doctors commented on the competence of the trainers, that they were well-prepared, well-organized and that there was a good relationship with trainees. Nurses commented on an interesting programme and on the interactive approach to teaching. The session watched showed extremely good group teaching skills with a high level of participation from the whole group. On the evidence available there is a group of well-skilled Family Medicine teachers (both doctors and nurses) who are able to effectively use modern educational methods in a way that is appropriate to the topic. This group is, however, small and it is unclear how the teaching pool is being enlarged. The adequacy of the pool of teachers is discussed in Section 7.4. There is a considerable amount of teaching material in Georgian. Much of this has been translated (as would be expected) from British or American sources. The State Medical Academy has been granted the right to translate an American family medicine book into Georgian. This material will provide an international perspective on family medicine and some introduction to the terminology. However it is now important that material is adapted to the Georgian context if the concepts are to be owned and used by Georgian doctors. The travel report of Antonio Moreno (May 2005) noted some concerns about the materials available for teaching General Practice Nurses. Although a Nurse Trainer has been appointed to develop further materials, particularly relating to Module 18, there appear to be difficulties with this. It would appear that, particularly in terms of terminology, materials do not effectively relate to the Georgian context in PHC nursing. The majority of teaching currently takes place in the urban environment of Tbilisi. There is a question as to how many Tbilisi trainers have worked in rural situation and how well they can relate to the needs of their students. At present there are three courses carried out in rural situations but each has problems: • • •

The course at Mtskheta is currently attended only by nurses and the town of Mtskheta is very close to Tbilisi. The course for doctors in doctors in Gori is carried out by trainers from Mtskheta visiting Gori twice a week. Whilst this enables theoretical group work to be carried out it is not clear how these doctors are receiving skills training. The course for doctors in Guria is carried out by doctors from Tbilisi visiting for one week each month. Again it is not clear how these doctors are receiving skills training.

Concern was expressed about some of the teaching received on rotations, especially when specialists provide training. It was clear that in many instances, especially relating to skills

138

Report on Review of Training Programmes for Doctors and Nurses in Family Medicine

important for family doctors, learning was limited to observation with little opportunity for practice of skills under supervision. In some instances multidisciplinary training seems to be working effectively and is applied to relevant topics (such as practice management and palliative care). However the allocation of training groups has at times separated groups so that no multidisciplinary training can take place (e.g. the lone nursing group from Adjara & Imereti placed at Mtskheta. The one multidisciplinary session seen was carried out by a physician on her own. Whilst this seemed to work satisfactorily, a better plan would be to have doctor and nurse teachers working together. As already noted (2.17) there is a need to help students set their own personal learning objectives and develop suitable adult learning skills. Currently 16 hours of the Physician retraining programme is devoted to “Trainer’s skills” and methods of adult learning and teaching. This is insufficient to teach teachers, but could effectively be used to help students explore their own learning approaches. This is particularly important so that they can continue learning when they have returned to more isolated situations. It is therefore important that it covers the following areas: • • •

Identifying lack of competency Identifying resources (peers, potential supervisors, books, IT, videos, etc.) Skills in “distance learning”

Trainers and supervisors also need to develop their teaching skills. Whilst the time pressures are extremely great, it is important that the current group accept the responsibility for maintaining teaching standards. Where possible peer review of teaching sessions should be carried out at regular intervals. One centre showed the considerable amount of student evaluation that is carried out. This relates to both the curriculum and the teaching. Such feedback is commendable, but again raises questions: • • •

Is there time and administrative help available to analyse the feedback? Is this carried out at all centres, and is there sharing of information? How is the feedback used?

A small group of trainers, many of whom were trained in the same environment, can build a strong informal network. Informality can, however, exclude people who do not naturally meet often and makes it difficult for newer members to involve themselves. The growing number of trainers require a formal “Trainers’ Group” that can meet regularly, encourage peer review of teaching, evaluate the student feedback and provide continuing education for trainers. It could also provide educational input for supervisors from other medical specialties and might also provide advice to any institution developing curricula. At present the appropriate institution to organise such a Trainers’ Group would be the Georgian Family Medicine Association. Consideration might be given to a separate Nurse Trainers’ Group under the Georgian Nursing Association; although it is possible greater benefit might be achieved with a joint group at this stage of development. In the light of the above the following proposals are made: •

A “Trainers’ Group” should be set up as part of the Georgian Family Medicine Association with the aims of supporting all teachers involved in family medicine education (including nurse training) and improving the quality of training provided. (Step 4) This group should be responsible for:

139

Primary Health Care: Service Delivery – Volume 2



7.4

Evaluating feedback on teaching Developing programmes for continued trainer education including the use of peer review Offering educational advice to other relevant groups Developing training materials in a Georgian context

When the Georgian Nursing Association has achieved sufficient capacity it should determine whether to develop a separate Nurse Trainers’ Group.

Training resources

Training Resources include training centres, number of trainers, training equipment, books and IT materials. Patients can also be considered a training resource, as it is essential for students to have direct opportunities to interact with patients whilst taking into account their dignity and rights. Prior to the start of training for the first cohort of doctors and nurses Antonio Moreno carried out an assessment on the true capacity of the National Family Medicine Training Centres to carry out the training. This is detailed in his report of May 2005. A further analysis was not made on this visit and only three of the centres were visited. However from discussions it appeared that the capacity has not altered substantially. In the short term further pressure on the resources will be caused by the decision to speed up the training of Family Medicine Teams in Kakheti province, with overlapping of the blocks of 39 teams (to start in November) and 46 teams (to start in January), especially as the teams from Adjara and Imereti do not complete until end of December. In the longer term requirements for undergraduate experience in family medicine, retraining, residency and revalidation are likely to increase the demand for training facilities considerably. It would also be more fitting if much of this training could be carried out in regions outside Tbilisi. Planning the number of facilities and number of trainers required requires clear decisions in human resource planning for primary medical care reform. Without this the pressure on existing facilities and trainers is likely to increase, be unsustainable and lead to a fall in quality. Structures are required to approve training centres in terms of capacity and level of facilities and the quality of teaching. The National Institute of Health (NIH) currently has responsibilities for this in making contracts for retraining, whilst the State Medical Academy makes its own contracts for residency programmes and it appears that in the case of Shida Kartli (Gori) and Guria other organisations have also made contracts. In future a single organisation should be responsible for assessing the standard of training facilities and approving them. This body will require professional expertise from trainers (especially in determining the quality of teaching) but should be independent of any “Trainers group”. No organisation currently has the capacity for this, but it could be placed within the National Institute of Health with some delegation to Regional Health Departments A major training resource is the availability of clinical supervision from specialists, whether in ambulatory or stationary (hospital) settings. Evidence received showed the current inadequacy in this field and it is clear that some specialists (especially in women’s medicine) are unwilling or unable to provide the required input, especially in terms of specific skills training. Retraining students reported that they had not been able to carry out any gynaecological examinations, despite the requirement for 30 such “manipulations” and the crucial requirement for this skill within a family medicine structure. Whilst patient rights are a key factor here, and the use of simulators

140

Report on Review of Training Programmes for Doctors and Nurses in Family Medicine

might provide some alternative experience (v.i.) it is clear that further discussions are required to ensure that specialist supervision works effectively. Students returning to the regions require continued support and supervision. At present there is no adequate supervision in these situations. Consideration needs to be given to alternative ways of providing this supervision such as: • • •

regular visits by trainers from Tbilisi/Mtskheta training of regional trainers use of existing regional staff (specialists or primary care providers) with provision of short courses on field-work supervision skills.

In the medium to long term it is essential people with an understanding of family medicine and general practice nursing provide that supervision. During the retraining courses it should be possible to identify individuals with an ability to teach and to provide more modules on education and teaching for them. Such courses should be a recognised part of continuing professional development. There are problems with resources for learning clinical skills, manipulations and communication. These could be eased by the availability of simulation models. There is already a Skills Laboratory at the Tbilisi State Medical University and one is due to be set up in the new facilities for Family Medicine at the State Medical Academy. It is important that these relatively expensive facilities are fully used and they should be accessible for booked sessions for all training groups. A small number of further facilities may be required to give sufficient facility, and smaller facilities might be required at regional centres. Self-learning requires adequate books and computer facilities. Two problems emerge here: the lack of material translated into Georgian language and the lack of accessibility to computer facilities. Both these need to be addressed. •



The development of a Georgian Family Medicine Journal (similar to the Polish journal – Lekarz Rodzinny) would be one possibility if suitable translators, writers and editor emerged. Pharmaceutical company support would be acceptable as long as there is no editorial control. It is important that an IT infrastructure is set up, and adequate funding provided to enable doctors and nurses in regional areas, especially remote villages, to access and use it. Internet access is important but needs to be considered together with language training and skills in critical appraisal of material. In the medium term, however, this will be the most important way for doctors and nurses practising in remote areas to keep up to date and to obtain advice when required.

There is a particular lack of literature suitable for nurse training. International support would be required to identify suitable literature and resources for translation are required. Patients are in themselves an important training resource. By talking to patients students can learn much about their health beliefs, their health wants and about the effects of the illness on their lives. Training to think in a person- (patient-) centred way and to take a holistic (biopsychosocial) approach can only be achieved with patient contact. Many skills can only be fully achieved by experience with patients. At the same time the dignity of patients and their rights have to constantly be taken into account. A number of comments stated that Georgian patients “did not like being practised on by students”. Consideration needs to be given into how to make the best use of this resource. Possibilities include:

141

Primary Health Care: Service Delivery – Volume 2

• • • • •

Ensuring there is a high patient:student ratio, so that patients are not overburdened. Ensuring that all student-patient contacts are properly supervised Ensuring prior experience with simulation models (or even simulated patients – i.e. people who are willing to submit themselves to role-play a patient for history-taking, or even examination) Explaining to patients the importance of student experience and how it will be monitored so that they are protected, Using patients for “non-threatening” learning experiences – such as discussion of health beliefs, ideas concerns and expectations.

In the light of the above the following proposals are made: •

• • • • •

7.5

In future a single organisation should be responsible for assessing the standard of training facilities and approving them. This body will require professional expertise from trainers (especially in determining the quality of teaching) but should be independent of any “Trainers group”. No organisation currently has the capacity for this, but it could be placed within the National Institute of Health with some delegation to Regional Health Departments. [Steps 3/4] Consideration needs to be given to ways of providing continued educational supervision for students returning to regions. Financial support is required to develop a network of regional training or supervisory facilities. [Step 4] There is a need to ensure that “Skills laboratories” are efficiently used and that there is an adequate network of such resources. [Step 4] Refurbishment of primary care facilities should include setting up an IT infrastructure with adequate funding provided to enable doctors and nurses, especially in remote villages, to access and use it. [Step 4] International support is required to identify suitable training literature for nurses. [Step 2] Consideration of how to promote patient input into training is required. [Step 4]

Assessment and licensing

The Government through the Ministry of Labour, Health & Social Affairs (MoLHSA) is responsible, on behalf of society, for ensuring that those licensed to carry out certain tasks have acquired the requisite competency. In advanced societies those involved in health care have to be licensed in this way. Georgia currently has such a procedure for doctors but not for nurses, although temporary measures have been put in place for general practice nurses within the Primary Health Care reforms. MoLHSA itself, with professional advice, should determine what competencies are appropriate for licensing. The lists of “Indicative duties and competencies of family physicians” and “Indicative core competencies of the general practice nurse” show that some thought has been given to this process. Neither list provides a simple and clear guide to the expected roles and functions of these two professions or the way they should work together. European authorities have been exploring these issues, especially for family doctors, since the original job definition and goals of training were published in the “Future General Practitioner “ in the UK in 1972. The most relevant current document for Georgia is the new European definition published by WONCA Europe in 2002. MoLHSA, with technical and professional advice, needs to revise the core competencies with particular consideration of the Georgian context.

142

Report on Review of Training Programmes for Doctors and Nurses in Family Medicine

Licensing, including revalidation of licenses, requires assessment against the core competencies. Within the structure of the MoLHSA, the Postgraduate and Continuous Medical Education Board is responsible for approving programmes and the State Certificate Granting Board for the following functions: • • • •

To approve state certification exam programme, criteria of knowledge evaluation, the rule, schedule and place of exams; To create the exam commissions together with higher medical institutions and doctor’s professional associations; To discuss and approve the results of state certification exams; Board makes decision on the issuance or refusal to issue the state certificate based on submitted documents.

In terms of the state examination commission for residencies it appears that it consists of representatives of 53 specialties mostly from the SMA together with 5 members of the MoLHSA under the chairmanship of a deputy minister. In Family Medicine the state examination is apparently collated by the Program Director in Family Medicine at the SMA with the help of specialists in other relevant specialties and consists of a bank of multiple choice questions. It is therefore solely concerned with assessment of factual knowledge and therefore the current state examination is not a valid approach to assessing competency. . It is appropriate for the MoLHSA and its Postgraduate Medical and Continuous Medical Education Board to delegate the process of assessment to a relevant professional body. The State Examination Commission for Residencies appears to be too large a body and it would be more appropriate to have a small Family Medicine Assessment Board that could consider a more effective competency-based assessment for Family Medicine. At the end of physician retraining students have had to complete a four–part summative assessment consisting of a knowledge-based (MCQ) examination, a written case-based examination (termed a MEQ – Modified Essay Question – after the British equivalent), a project and an oral (viva voce) examination which may be carried out as a role-played patient interview. This format increases the validity but there is still no assessment of clinical skills (other than possibly consultation skills in the oral examination). The certificate of completion of the programme requires success in all four parts. However those not on the retraining programme can still sit the state examination without such prior summative assessment. A previous report (The Roles & Functions Paper – September 2004) considered assessment in the Residency Programme. It stated “competency …. would be expected to be determined by assessment through supervised evidence of skills applied in real practice to a given standard. There appears to be no mechanism in this system for this to happen. The residency Programme is based on a series of clinical rotations in terms of specialist work domains but it does not specify the actual clinical activity that each individual resident doctor has undertaken during their residency to establish their skill level in each particular clinical technique. In other words there is no effective mechanism to assess their fitness to practice family medicine. The supervision of their clinical rotations has no system of accountability. The supervisor is not required to certify that they have evidence through observed practice of the technical skills of the resident family doctor.” To provide a valid and reliable assessment of family medicine competency will require a number of changes. The first step towards this would be considering the most appropriate way to assess each competency. Reliance cannot be placed totally on final examinations and a degree of direct observation of clinical activity will be required, e.g. by using a signed log book pre-certifying

143

Primary Health Care: Service Delivery – Volume 2

competence before allowing students to sit the examination. One example of this used for many years in the UK has been the Manchester Rating Scales (http://www.gptraining.net/training/nmrs/nmrs.htm) A further development may be an Objective Structure Clinical Examination (OSCE) which would enable the achievement of specific skills to be assessed more reliably (and act as a partial check of the direct observation). Introduction of an improved assessment process will require training of assessors, whether those providing assessment by direct observation, or those carrying out the written or oral examinations. Assessors also need to develop their skills, particularly by the use of statistical feedback on their marking. The changes required to produce a valid and reliable assessment will take time (including the training of assessors). They should not be introduced until it is clear that the resources are available to make it feasible. It is also important that potential students should be given plenty of notice so that they can prepare appropriately for any new assessment procedures. This must therefore be considered a medium-term project In the short term a number of immediate actions are required: • •



Students say they are unaware of what assessments to expect and when they will be carried out. It is an educational imperative that students should be aware the nature and timing of assessment at the beginning of any course. This must be urgently rectified. Plans for carrying out the summative assessments at the end of the Adjara/Imereti placements were not laid at the time of the visit. Students should NOT be assessed at their own centre and plans must be urgently made to co-ordinate this and produce any new assessment materials required. There should be an external monitor at the assessments to ensure that they are fairly applied.

The above paragraphs relate mainly to doctors. There are further problems with respect to nurses. The current retraining programme for nurses seems to rely mainly on continuous assessment with written examinations or project work in each module. Although certain modules speak of “regular review taking place through nurse placements” there is no clear requirement for signed confirmation that specific skills are achieved. At the same time there is the lack of any national qualifying examination for nurses together with the absence of any higher educational institution responsible for nurse qualification (or licensing). All this means it is difficult to ensure that nurses are competent for their functions. Urgent consideration should be given to developing a process for nurse licensing. In association with this a suitable academic nursing body is required to provide professional advice: this could be a higher educational institution devoted to nursing or a new faculty within the State Medical Academy (or even in the Tbilisi State Medical University). Once a licensing process has been determined it will be possible to develop a competency-based qualification for general practice nurses (rather than simply a certificate of course completion). This will enhance the status of the profession. Such changes for doctors and nurses will mean that the standards required for qualification will rise. Early graduates will not necessarily have achieved these standards. The process of

144

Report on Review of Training Programmes for Doctors and Nurses in Family Medicine

continuing professional education and revalidation can be used to ensure that everyone eventually achieves a similar standard. Those consulted were not aware of any projects currently under way to ensure that assessment, and hence licensing, was a valid and reliable procedure that could be carried out efficiently and effectively in a feasible way. In the light of the above the following proposals are made: •

• • •



7.6

Urgent steps are required to ensure that the next set of retraining summative assessments are planned effectively, that they are carried out fairly and that students have adequate advance notice of exactly what is happening. It should be possible for Kakheti students to have relevant information at the beginning of their course. (Step 1) As soon as possible a system for assessing individual skills as part of an overall competency evaluation should be introduced. (Step 1) The MoLHSA, with professional advice and in the light of recent international publications, should review the competencies appropriate for licensing family doctors and for the work of general practice nurses. (Step 5) A specific board for developing Family Medicine Assessment should be set up, under the State Certificate Granting Board or the State Examination Commission for Residencies and should be provided with external technical assistance to develop competency-based assessments and to train assessors. This role could be delegated to the State Medical Academy but should also involve professional bodies. (Step 5) Urgent consideration should be given to developing a process for nurse licensing and ensuring that suitable academic nursing advice is available. An independent nursing assessment board will be required. (Step 5)

Student selection, support, career guidance and continuing education

Providing support for students is as essential to providing quality education as monitoring the training environment, teaching and assessment processes. Such support should begin even before selection and continue after qualification in the form of continuing education. There was evidence from students of both retraining courses and in the residency programme that they appreciated the relationship with teachers and, in many cases, got considerable support from this. There was, however, also evidence of lack of appropriate support at key points. The following were particularly noted: •

The lack of any attempt to motivate students to join the courses other than through the economic route: whether through the negative pressure that, unless they participate, they will be unlikely to have contracts to provide care or through the positive pressure of the promise of refurbished premises. One agency said the only motivator was "unless you adapt you will be out of job ". There did not appear to be an adequate policy of providing information that would enable potential students to accept the new primary care approach as a better way to provide care for patients, or one that would give them personally more job satisfaction.

145

Primary Health Care: Service Delivery – Volume 2

• • • • • •

The short interval between the meeting to inform potential Kakheti students about the programme and the deadline for applications, with no clear evidence of a system whereby they could raise personal concerns, particularly about logistics. The lack of information for those involved in the Adjara and Imereti retraining programmes about future contractual arrangements (as one said “We are not familiar with the contracts yet? Why?”) The fact that all five residents completing their programmes in November 2005, had no idea of what job prospects there were and, apparently, this had not been discussed with them. The lack of information about the assessments (noted above – Section 7.5). The lack of any supervisory support structure on return to regions (noted above – Section 7.4). The fact that since the change in rules concerning continual professional development and revalidation were changed the Family Medicine Association had not been able to run postgraduate courses for the last year.

Although there are criteria for selection of potential students, it is questionable whether these actually help students to make a satisfactory decision whether to enter the retraining programmes and what prior level of competency is required to successfully complete the course. In some countries students take an examination prior to entering family medicine training to ensure they can make the best use of it. Consideration should be given to ensuring that entrants to retraining programmes have an appropriate level of basic medical knowledge and skills: it should be possible to provide “pre-training” courses, possibly in the regions, to help those who lack the necessary skills. Advice on “change management” techniques may be required to enable those involved in human resource development within regions to motivate the best people to consider this new approach. Potential family doctors have to realise that the biopsychosocial approaches required in primary care are very different from the bioscientific approaches that they learnt during their basic medical education and be prepared to change their style. Potential general practice nurses have to consider the differences being part of a family medicine team will make: for many there will be an increase of professional independence, for others who have been working in isolated situations there may be a reduction. Students need to be kept informed of their job prospects and any contractual arrangements after the course. Support is also required for any students who have to miss parts of the course through illness or family reasons. If students are being sent from Regions that are developing new primary care structures, it would seem that those regions should have a human resource capability within their Health Departments to provide the necessary support. All long residency programmes should include an element of career guidance and provide support in providing information about job prospects and making job applications. Responsibility for support should continue until students are settled in a job. Educational support may be required within the course. Whilst most tutor-student relationships within courses seem to be good there needs to be a structure to activate if this relationship breaks down. The proposed tutors group in the Georgian Family Medicine Association may be one way to develop such a structure (so that students can seek advice from a respected tutor outside their own training institution). In due course Regions might provide such advice. Educational support is required after the course. This has been discussed above. An alternative approach to developing such support is to set up Peer groups. Groups of recently qualified family

146

Report on Review of Training Programmes for Doctors and Nurses in Family Medicine

doctors or general practice nurses (or teams) could support each other through regular meetings in the region. Such groups could request advice, information or further training from local specialists or from Tbilisi-based trainers on an occasional basis. Regions could provide facilities and administrative support for such groups. It is likely that such groups would form a nucleus from which future regional field supervisors would emerge. Two donor agencies concerned with regional primary care development (World Bank and EU TACIS programme) have accepted the need for continued supervision and, if appropriate proposals were produce, might consider some funding to develop these programmes. In the light of the above the following proposals are made: •

• • • •

7.7

Consideration should be given to ensuring that entrants to retraining programmes are given suitable advice and support. This may be advice on change management or ensuring an appropriate level of basic medical knowledge and skills through regional “pre-training” courses. (Step 4) Regional Health Departments (or Primary Care employment institutions) require a human resource management capacity to enable them to provide in-course and post-course support on employment issues and job prospects. (Step 4) Career guidance should be an essential part of residency programmes. (Step 4) Capacity for a personal mentoring system or some other structure to assist students with difficulties during the course should be developed, possibly by a “Trainers’ Group within the Georgian Family Medicine Association. (Step 4) Peer Support groups should be set up within regions to provide continuing support for newly qualified staff. (Step 4)

Key findings

The review visit was short and there are a number of limitations to this report: • • • • • • •

There was not time to see all the providers of training or to experience more than a small amount of the teaching that is going on. No discussions were held with specialist medical providers of teaching. It was not possible without a full-time translator to review the teaching materials in Georgian. It was not possible to visit the Regions (other than Mtskheta town) and experience the problems likely to be faced by the students. The consultant is a medical practitioner and therefore might be considered to have an inappropriate bias when considering nursing issues. It was not always possible to follow-up discussions by return visits to people seen early in the visit. It was not possible to meet directly with those responsible for the state examination at ministerial or professional level.

Despite these limitations every attempt was made to confirm findings through discussion with more than one person and to relate findings to previous documentation produced by OPM in the course of this programme. It is hoped that these findings will provide a basic structure for future internal review by the Georgian authorities with the support of suitable technical assistance.

147

Primary Health Care: Service Delivery – Volume 2

Three key areas emerged which require further work in order to develop an effective and wellregulated training Programme for family medicine

7.7.1

Fitness for purpose

It is clear that the curricula of the retraining programmes were designed for the early stages of the reform process where the main aim was to train family physician and general practice nurse leaders who would be working in a mainly urban environment and who would train others. These people would be the innovators. They were also suitable for the highly motivated early adaptors who would be more effectively able to pick and choose what they needed to learn. The main focus of retraining programmes is now on regionally-based staff who are being almost forced to consider retraining by “economic” pressures. In these circumstances the programmes appear less fit for purpose for a number of reasons: •

• • •

The basic level of knowledge and skills of the students is inadequate meaning that the development of general clinical competencies is a priority and thereby making it more difficult for staff to relate to the specific primary care skills of a family doctor or general practice nurse. The educational load is excessive for a six-month period requiring either “pre-training” in general clinical skills, and/or a prolonged supervision period post-training. Insufficient consideration has been given to the needs of people working in isolated areas such as high mountain regions and to the nature of those societies and their needs and health beliefs. The resources are insufficient to provide the detailed experience and training in skills set out in the documentation for the numbers involved.

At the same time, as shown in Section 7.2 and Table 2:1, the Retraining Programme for doctors does not necessarily fit well with the Residency Programme, or with the proposed Educational Agenda of General Practice in WONCA-Region Europe. In view of this it does not necessarily prepare the retrained doctors for a role a fieldwork supervisors for the increased numbers of residents and other doctors retraining that will be required in the near future if the plan of having one family-doctor team for every 2000 population is to be achieved within a realistic time-scale. This will require somewhere between 2000 and 2500 teams to be trained, or a training capacity of 200-250 per annum over a ten year period. If nursing is to be developed as a key health profession, then there need to be urgent changes in basic nurse training, including community (or general practice) nurse training. This will impinge on the requirements for field work placements and again there is a need to ensure that nurses emerging from the retraining courses at least understand the changes in nursing role and are able to impart skills themselves. Changes in undergraduate (basic) medical education following restructuring at Tbilisi State Medical University will also affect the future relevance of these programmes, especially the residency programme which will build on basic medical education. In the light of these facts a review of curricula will need to be carried out.

148

Report on Review of Training Programmes for Doctors and Nurses in Family Medicine

7.7.2

Monitoring

Monitoring the process and outcomes of training is essential if government and society are to be assured of the quality of care that is available. Such monitoring requires impartiality and objectivity and this is not necessarily consistent with heavy involvement in the training process. A number of bodies are already involved in monitoring, ranging from MoLHSA through its Postgraduate and Continuous Medical Education Board to individual training centres using their own assessment and evaluation approaches. Work needs to be done to develop structures that will facilitate independent monitoring of training and assessment, however considerable concern was expressed that new bodies should not be set up. There was a feeling that existing bodies could provide the necessary resource and, in view of the small number of people currently involved, it was clear that developing further structures would only spread the expertise even thinner. Internal monitoring is an important aspect of quality management, especially as it should lead to internal changes and quality improvement. It is important therefore that internal appraisal approaches including student feedback and peer review should form part of the basis of a monitoring structure. At the same time these have to be vetted externally to ensure that the processes are being used properly and external monitoring of assessments to ensure that standards are being maintained is essential. In the light of this it seems appropriate that the quality monitoring process should be divided between different organisations (Ministry, National Institute of Health and Social Affairs, State Medical Academy and Professional Associations) in a way that best uses their particular strengths. A regional role to promote decentralization also seems appropriate. No organisation currently has adequate capacity for this and capacity building will be an essential aspect of technical assistance in the near future. A quality assessment process is a key part of this monitoring and there are particular weaknesses in the current assessment processes for both doctors and nurses which have been detailed above (Section 7.5): • • • •

7.7.3

Current students are unaware of the exact nature and timing of the assessment process they will undertake (except for the State Examination for doctors). the State Examination for doctors focuses on knowledge. there is no external monitoring of the assessment of skills and broader competencies within the training programmes. There is no formal national recognition of the competencies achieved by general practice nurses.

Support

As well as monitoring, support of both the educational process and of the students themselves is an essential part of quality enhancement. Development of curricula & of training resources and materials is one element of this support as is enhancing the quality of teaching. At present there are insufficient resources for trainers to receive support and develop their teaching skills. Much of this work could be delegated to appropriate professional bodies or academic institutions such as the State Medical Academy.

149

Primary Health Care: Service Delivery – Volume 2

As Section 7.6 details support of students is, at present, one of the weaker areas of the training programmes. There appears to be lack of adequate support in a number of areas of which the following are particularly important: • • •

Students are unclear what the prospects of working in the field of family medicine are once they have completed the training. There is no effective continuing supervision or educational support available outside Tbilisi/Mtskheta. Access to educational resources outside the capital appears limited.

Decisions as to which organisations take responsibility for the different elements of quality management, monitoring and support should come from a national meeting of Georgian organisations currently involved in different areas (See Section 7.8) However Tables 7.2 and 7.3 show one possibility of the way that the work could be divided for doctors and for nurses. Unfortunately in the case of nursing there are probably insufficient existing structures to perform these activities.

150

Report on Review of Training Programmes for Doctors and Nurses in Family Medicine

Table 7.2

Responsibility for areas of quality management – Doctors

Area

MoLHSA

NIHSA

SMA

GFMA

Other

Comments

1. Competency Determination

RESPONSIBLE

Advice

Advice

Advice

Regions Advice

Needs Recent Graduate Input TA Required

2. Licensing & Revalidation

RESPONSIBLE

3. Assessment

Responsible for Approval

? revalidation process Organisation

RESPONSIBLE For management

Advice PRECERTIFICATION

RESPONSIBLE [Could delegate to regions]

Advice on Trainer approval

Advice on Trainer approval

Regions – possible delegated

No current capacity TA Required

Advice

RESPONSIBLE Potentially or joint

RESPONSIBLE Potentially or joint

Regions, TSMU Advice

TA Required at all levels

Organisational supervision

Advice Training of specialist teachers

RESPONSIBLE [Trainers’ group]

Peer support

TA Required to develop Trainers Group

7a. Student Selection

Regions RESPONSIBLE TSMU Basic exam

TA Required

7b. Student Support – Employment issues

Regions RESPONSIBLE

Human Resource TA Required

Regions – Organise supervisors

TA Required for distance learning and support

4. Approval of Training Resources 5. Curricular Design & Development 6.Teaching Support & Development

7c. Student Support - Educational

Responsible for Approval

RESPONSIBLE

RESPONSIBLE

TA Required – work on process & quality

151

Primary Health Care: Service Delivery – Volume 2

Table 7.3

Responsibility for areas of quality management – Nurses

Area

MoLHSA

NIHSA

Nursing HEI

GFMA/GNA

Other

1. Competency Determination

RESPONSIBLE [? Health Policy Unit]

Advice

Required

Advice

Regions Advice

2. Licensing & Revalidation

RESPONSIBLE

3. Assessment

RESPONSIBLE for approval

Organisation

Required

Advice

FMTCs do continuous assessment

RESPONSIBLE

Required

Advice

Currently RESPONSIBLE but not appropriate

Required

Advice – could be responsible if capacity

Advice

Organisation & supervision

Develop Trainers Subgroup - ? which organisation

Region – Peer support groups

Contracts

Advice on criteria

Regions RESPONSIBLE

4. Approval of Training Resources 5. Curricular Design & Development

Responsible for Approval

6.Teaching Support & Development 7a. Student Selection

Legal decision

7b. Student Support – Employment issues 7c. Student Support - Educational

152

Regions RESPONSIBLE Through Nurse Specialist

RESPONSIBLE

Regions to organise supervision

Report on Review of Training Programmes for Doctors and Nurses in Family Medicine

7.8

The future

Previous chapters have set out a number of recommendations. These are listed at the end of this chapter.

In the immediate future there is a need to address one or two urgent issues with respect to the curriculum :

7.8.1

Step 1: Clarify assessment process

The National Institute for Health & Social Affairs must clarify urgently the assessment process for the end of the retraining programme. See R.14 This is required within two months. If available, some Technical assistance might be helpful on the logistics and/or monitoring the process (assessment of skills can be monitored with help of interpreters) but would be difficult to find in the time available.

7.8.2

Step 2: Initial review of curricula

The current curricula need some urgent modifications, in particular to deal with requirements that are not feasible. See Section 7.2 & R.1-R.3 This is required as soon as possible and needs both medical and nursing technical assistance to work with Georgian counterparts. Discussions might take place with other donors who are bringing in such assistance within the next four months. At a later stage there are a number of recommendations (Steps 4 & 5) which will need support of external technical assistance:

7.8.3

Step 4: Building Capacity

Following the above it would be hoped that individual Georgian institutions would take on responsibility for different areas of Quality management of training. This will need help in building the capacity. Possibilities would include the development of capacity for “Trainers Groups” within the Georgian Family Medicine Association and within the Georgian Nurses Association, the development of the HR Departments in Regional Health Departments, as well as further development of the appropriate departments of the Ministry of Labour, Health and Social Affairs concerned with competencies and with licensing and revalidation. Determination of the Technical Assistance required in these areas should follow the conference. If possible this capacity development should take place in 2006

7.8.4

Step 5: Full review of Curricula and Assessment procedures.

Following the conference it should be possible to undertake a full review of the curricula and the assessment procedures for both doctors and nurses in the light of the clarification of the competencies required. This should enable future re-training programmes to be part of a continuing professional development programme leading to a family doctor who fully fits the European definition of a family doctor but is able to provide an appropriate primary care service within the Georgian contexts (whether urban, rural or high mountain) or a general practice nurse who can take a truly independent nursing role within the same contexts.

153

Primary Health Care: Service Delivery – Volume 2

Determination of the Technical Assistance required in these areas should follow the conference. If possible this review should take place in 2006.

7.8.5

Step 3: Round-table conference

It is proposed that between these two elements there should be a round-table conference early next year to enable all stakeholders to discuss how to set up effective structures for the management of all areas of the training programmes both during the period of intensive retraining and in the continuing full-time residency and nurse training programmes. Participants in this conference should include: • • • • • • •

relevant departments of MoLHSA, academic institutions such as State Medical Academy, Tbilisi State Medical University and the Medical Faculty of State University, the National Institute of Health & Social Affairs, Professional Associations (Georgian Family Medicine Association, Georgian Nursing Association and Georgian Family Doctors’ Association) Representatives of all the Family Medicine Training Centres including Doctor and Nurse Trainers Student Representatives (both resident programmes and retraining programmes) Representatives of Regional Health Departments involved in Primary Care Reform

Consideration should be given to inviting a few public representatives such as Members of Parliament with an interest in health issues. Representatives of Donor Agencies (including external technical assistance) should be invited as participant observers. This conference should consider the procedures for: • • • • • •

determination of competencies, licensing and revalidation, assessment processes, approval of training sites, curricular design, improving the quality of teaching student support.

A three-day conference with prior presentation of working papers by appropriate stakeholders would be a minimum. It is proposed that chairing of the working sessions of the conference should be by an external consultant (or consultants) seen as neutral by all parties. The most appropriate person might well be a Council Member of WONCA-Europe or of EURACT who has not previously been involved in a Georgian project. The outcome of the conference would be a structure and set of procedures for quality management of the training process that effectively involves all the relevant resources within Georgia. The conference should NOT expect to produce a final document containing new curriculum, new assessment processes, etc.

154

Report on Review of Training Programmes for Doctors and Nurses in Family Medicine

7.9

List of recommendations

Section 7.2 R.1. The Indicative Competencies attached to the current curricula should be urgently reviewed with a view to removing items which are NOT appropriate to the Georgian PHC situation (e.g. the UK Mental Health Act) or those which are not feasible with the current resources available (e.g. the requirement for specific numbers of surgical and gynaecological manipulations. (Step 2) R.2. The current retraining curriculum for doctors should be urgently rewritten to alert all teachers to the need to cover family medicine competencies such as primary care clinical management, comprehensive and holistic approaches and patient-centredness. (Step 2) R.3. The current retraining curriculum for nurses should be urgently rewritten to reduce overload. One way to do this would be to reduce the time on Modules 15-17, which cover areas where they would be unlikely to have suitable resources at their work places initially. An introduction to the importance of these areas could be the basis of continuing professional development at a later stage. The use of IT for record-keeping and some of the audit processes could be included in module 18. (Step 2) R.4. A major review of the curricula should be carried out in 2006 in the light of redefined competencies for Georgian family physicians and general practice nurses. For doctors (both retraining and residency programmes) consideration should be given to the EURACT Educational Agenda: the current relationship is shown in Table 1.1. For nurses there should be consideration of international examples outside the UK/USA. (Step 5). R.5. Tbilisi State Medical University and other schools providing undergraduate medical education should be involved in the curricular planning process so that Basic Medical Training and residency programmes are seen as a continuum. (Steps 4/5) Section 7.3 R.6. A “Trainers’ Group” should be set up as part of the Georgian Family Medicine Association with the aims of supporting all teachers involved in family medicine education (including nurse training) and improving the quality of training provided. (Step 4) This group should be responsible for: • • • •

Evaluating feedback on teaching Developing programmes for continued trainer education including the use of peer review Offering educational advice to other relevant groups Developing training materials in a Georgian context

R.7. When the Georgian Nursing Association has achieved sufficient capacity it should determine whether to develop a separate Nurse Trainers’ Group. Section 7.4 R.8. In future a single organisation should be responsible for assessing the standard of training facilities and approving them. This body will require professional expertise from trainers (especially in determining the quality of teaching) but should be independent of any “Trainers group”. No organisation currently has the capacity for this, but it could be placed within the National Institute of Health with some delegation to Regional Health Departments. [Steps 3/4]

155

Primary Health Care: Service Delivery – Volume 2

R.9. Consideration needs to be given to ways of providing continued educational supervision for students returning to regions. Financial support is required to develop a network of regional training or supervisory facilities. [Step 4] R.10. There is a need to ensure that “Skills laboratories” are efficiently used and that there is an adequate network of such resources. [Step 4] R.11. Refurbishment of primary care facilities should include setting up an IT infrastructure with adequate funding provided to enable doctors and nurses, especially in remote villages, to access and use it. [Step 4] R.12. International support is required to identify suitable training literature for nurses. [Step 2] R.13. Consideration of how to promote patient input into training is required. [Step 4] Section 7.5 R.14. Urgent steps are required to ensure that the next set of retraining summative assessments are planned effectively, that they are carried out fairly and that students have adequate advance notice of exactly what is happening. It should be possible for Kakheti students to have relevant information at the beginning of their course. (Step 1) R.15. As soon as possible a system for assessing individual skills as part of an overall competency evaluation should be introduced. (Step 1) R.16. The MoLHSA, with professional advice and in the light of recent international publications, should review the competencies appropriate for licensing family doctors and for the work of general practice nurses. (Step 5) R.17. A specific board for developing Family Medicine Assessment should be set up, under the State Certificate Granting Board or the State Examination Commission for Residencies and should be provided with external technical assistance to develop competency-based assessments and to train assessors. This role could be delegated to the State Medical Academy but should also involve professional bodies. (Step 5) R.18. Urgent consideration should be given to developing a process for nurse licensing and ensuring that suitable academic nursing advice is available. An independent nursing assessment board will be required. (Step 5) Section 7.6 R.19. Consideration should be given to ensuring that entrants to retraining programmes are given suitable advice and support. This may be advice on change management or ensuring an appropriate level of basic medical knowledge and skills through regional “pre-training” courses. (Step 4) R.20. Regional Health Departments (or Primary Care employment institutions) require a human resource management capacity to enable them to provide in-course and post-course support on employment issues and job prospects. (Step 4) R.21. Career guidance should be an essential part of residency programmes. (Step 4)

156

Report on Review of Training Programmes for Doctors and Nurses in Family Medicine

R.22. Capacity for a personal mentoring system or some other structure to assist students with difficulties during the course should be developed, possibly by a “Trainers’ Group within the Georgian Family Medicine Association. (Step 4) R.23. Peer Support groups should be set up within regions to provide continuing support for newly qualified staff. (Step 4) Section 7.8 R.24. It is proposed that there should be a round-table conference early next year to enable all stakeholders to discuss how to set up effective structures for the management of all areas of the training programmes both during the period of intensive retraining and in the continuing full-time residency and nurse training programmes.

157

Primary Health Care: Service Delivery – Volume 2

Annex 7.1

List of contacts

Dr. Tamar Gaburnia – Chief Specialist in Family Medicine, Health Policy Unit and Family Physician Trainer Maia Gogashvili – Nurse Trainer Consultant Giri Javashvili – Head of Cathedra of Family Medicine of the State Medical Academy Irine Karosanidze – Director National Family Medicine Training Centre & President Georgia Family Medicine Association Merab Kavtaradze, Vice-Rector Georgian State Medical Academy Irma Khonelidze – Project Manager – WB Primary Health Care Reform Project Levan Kobaladze – Project Manager – EU/GVG project on Financing Primary Health Care Reform Ketevan Loria – Director of Mtskheta Family Medicine Training Centre Kakha Paposhvili – Director NIHSA & Co-ordinator of PHC Colette Selman – Project Manager – EU Social & Health Assistance Programme David Simpson – Team Leader – EU TACIS Support to Primary Health Care Reform, Retraining of Medical Workforce for Kakheti Region Dr. Revaz Tataradze, Head of Family Medicine, Faculty of General medicine, Tbilisi State Medical University

Mtskheta Family Medicine Training Centre - Nurse Trainers and Doctor Trainers National Family Medicine Training Centre – Doctor & Nurse Training groups State Medical Academy Final year Residents in Family Medicine - Tbilisi Family Medicine Practice & Training Centre – Doctor & Nurse Trainer and Nurse Training Group

158

Road Map for PHC Reform from the Perspective of Pharmaceuticals and Drug Benefit Scheme

8

Review of the Road Map for PHC Reform in Georgia from the Perspective of Pharmaceuticals and Drug Benefit Scheme for Primary Health Care in Georgia Health Services and Human Resources Workstream

Frank Stobbelaar

February 2005

159

Primary Health Care: Service Delivery – Volume 2

8.1

Introduction

The importance of drugs in the access to PHC cannot be underestimated. Affordable drug treatment is one of the important preconditions for patient’s access to primary care, but also a necessary condition for the effectiveness of this care and for patients to recover. Without the affordable vital and essential drugs, most primary care interventions, like diagnosis, testing, and advice are only costly activities without much real health impact. This paper offers some conceptual options for defining a drug benefit scheme in Georgia. The Minister of Labour, Health and Social Affairs issued a Roadmap for Primary Health Care reform in November 2004. In addition to a policy statement on the context and process of PHC reform, it should be seen as a policy management tool to better coordinating and managing reform proposals. Such is the context in which the present document has to be understood. This document is a draft for discussion and should be read in conjunction with other documents prepared by the HR and HS workstream. It has two parts: • •

Part I is a review of the Road Map from the viewpoint of Pharmaceuticals Part II is a proposal of how a Drug Benefit Scheme could be organised in Georgia

8.2

Review of the road map for primary health care reform in Georgia from the perspective of pharmaceuticals

8.2.1

Pharmaceuticals and the concept of the roadmap

The issues described in the Roadmap regarding the assessment of the PHC situation are true also for pharmaceuticals. From a patient point of view, pharmaceuticals are an important component of the access to health care in general (and to PHC in particular). Surveys over the past years have indicated that many patients in Georgia avoid PHC and doctor’s visits because of the cost of medication that these visits may generate. Often people visit the pharmacy only for “more serious” conditions without seeing a doctor or after consulting a medically trained family member. The PHC situation as characterized in the MOLHSA Roadmap and its parallel regarding pharmaceuticals is as follows:

160

Road Map for PHC Reform from the Perspective of Pharmaceuticals and Drug Benefit Scheme

Table 8.1 PHC situation as characterized in the MOLHSA roadmap and its parallel regarding pharmaceuticals PHC

Pharmaceuticals

• A complex combination of high public expectations with severe economic difficulties.

• Expect free drugs, but lack of budget and lack of personal income make even simple treatment unaffordable

• An unstable situation with frequent changes in government.

• Unstable availability of free drugs in State programs; unregulated sector with annual sales growth rates of 15-30%

• A context in which the main stakeholders (doctors, citizens, universities, etc.) have not been properly involved in the process of reform.

• Outdated practices, lack of rational prescribing, brand name prescribing, lack of quality in pharmacies, substandard outlets and products; commerce before health care

• A series of well meant reform initiatives that have been either not properly implemented and/or not necessarily compatible with each other.

• Different ‘free’ drugs and reimbursement initiatives. Unsustainable and uncoordinated; various financing and budget allocations (thinly spread)

• A severe institutional weakness by which the MoLHSA has found it difficult to play a proper leadership in the process so far.

• Regulatory Agency not functioning, policy department involved in supply and control, no balance of powers.

Pharmaceuticals not seen as part of PHC  often not clearly included in PHC strategies

8.2.2

Pharmaceuticals and the objectives of the roadmap

The Roadmap stated objectives are applicable to the field of pharmaceuticals. As one of the major health technologies, pharmaceuticals should be seen as a variable that should enable Primary Care (and Hospital Care!) to function properly. As indicated, the lack of affordable pharmaceutical products to large parts of a population may limit access to (primary) care and reduce or nullify the impact of any health care intervention.

8.2.3

The role of stakeholders

The positive impact of a sustainable pharmaceutical policy for PHC can only be achieved when all stakeholders subscribe to the importance of this health technology. For this decision makers must be prepared to include a pharmaceuticals component in their plans, and recognize that for the citizens of Georgia, access to affordable pharmaceuticals is a prime concern. Stakeholders also must be aware that pharmaceutical expenditure currently is largely private, thus largely out of influence of any cross-subsidization between those who have and those who have not. State budget and Health Insurance Fund budget contributions are minimal. A sustainable system of pharmaceutical care should find ways to mobilize the available private funds with some level of redistribution.

8.2.4

Pharmaceuticals and the management of the roadmap

The Road Map rightfully distinguishes between ‘Quick wins’ and ‘Longer-term solutions’. Possible measures in the field of pharmaceuticals should make the same distinction:

161

Primary Health Care: Service Delivery – Volume 2

Table 8.2

Pharmaceuticals and the management of the roadmap

PHC

Pharmaceuticals

Tangible immediate achievements (Quick wins) • The investment plans of our donors offer us the opportunity to refurbish, equip and staff a number of premises in the regions of Kakheti, Imereti and Adjara. We want to build on that opportunity and reform around 100 facilities in total, re-train those doctors, nurses and PHC managers involved and offer a set of services that would have an impact on the health status and the satisfaction of the population concerned. At the same time, they will serve as demonstration sites.

• Assess the pharmaceuticals component in the donors’ proposals for the reformed areas. • Design and test a simple Drug Scheme addressing priority PHC interventions fundable trough combined financing (donor contribution, state budget, patient’ co-payments). • Support this by: a) including rational prescribing in PHC curricula, b) including quality pharmacies in the program (develop criteria by Agency), c) training of pharmacists (GPP, generics, etc.). • The scheme should make use of existing drug supply system (private), using and encouraging high quality services (licensing).

Mid- and long-term solutions • A list of policy options for reforming PHC with clear indication of advantages and disadvantages will be proposed that will build on the tangible achievements referred to above and will pave the way for a sustainable PHC system in Georgia. The MoLHSA will then choose the most suitable alternatives in agreement with interested stakeholders.

Pharmaceutical policy development for PHC: • Role of DRA, MoLHSA, and other – Drug financing: – Role of State funding – PHC – co-payment, • Hospitals – include in treatment costs but with separate budget line • Licensing of pharmacies, removal of non-licensed outlets (substandard quality, false competition, adverse health effects)

Ways of solving critical problems The decisions regarding both of the above areas of development will have to be taken with a threepronged approach: • Policy leadership to be provided by the MoLHSA and its support structures, including the Health Policy Unit, through the Georgian PHC Coordination Board, • Broad involvement and consensus of both national and international stakeholders throughout the process, • Process management by a set of four Working Groups in line with the above, and under the responsibility of the National PHC Reform Coordinator and the Director of the National Institute of Health and Social Affairs. The working groups will deal with (i) Human Resources and Service Production, (ii) Financing, (iii) Health Management Information Systems, and (iv) Health Promotion and Public Relations, respectively.

162

Solving critical problems: • Raise awareness about the role of pharmaceuticals in access to/ outcome of care. • Redefine the policy leadership roles and responsibilities of key institutions: DRA, MoH • Strengthen the MoH Policy Department to coordinate international interventions. • Add pharmaceutical expertise to each reform working group. • Key attention points in pharmaceuticals are: – HR: Continuous training, licensing, GPP, generic prescribing and supply. – Financing: mixed financing, role & duties of the HIF, budgeting, co-payments, pricing, and reimbursement mechanisms. – Information: essential drug list, prescribing and consumption information, pricing. – Health Promotion: use pharmacies for health promotion campaigns; fight irrational prescribing & use (reporting).

Road Map for PHC Reform from the Perspective of Pharmaceuticals and Drug Benefit Scheme

PHC

8.2.5

Pharmaceuticals – Regulation: a proper functioning regulatory framework, enforcement (non-licensed pharmacies and pharmacists), balance of powers (Ministry, Agency, private supply).

Expected outputs

The expected outputs for pharmaceuticals will be partly depending on the choices and priorities of the PHC plan. Prioritization on the basis of population groups, disease groups or a family medicine concept will have implications on how the pharmaceuticals component is organized. In agreement with the output categories of the Roadmap, suggestions for pharmaceuticals (with an indication where pharmaceutical policies are linked with PHC choices and proposals) are:

Table 8.3

Proposal regarding immediate action

PHC

Pharmaceuticals

Link

• Selection of the precise approximately 100 facilities for refurbishment, in which one doctor and one nurse will work,

• Selection of facilities  Will determine locations and areas of intervention for: a. Drug financing b. Pharmacy involvement

YES

• Standards for reconstruction and equipment of those facilities,

• Standards for pharmacies to be included in a program

• List of services to be provided / that those facilities should be able to provide in the short term and which will be funded from the state budget,

• List of services  list of pharmaceuticals to be provided free or in a cost-sharing system • Develop Drug Scheme concept matching the PHC priorities and selected services

• Curriculum for re-training the staff concerned in line with the services that will be provided,

• Rational drug prescribing in staff CVs • Training component for continuous education program in licensing pharmacists

• Organizational structure and management of those PHC centres, including the HMIS needed to make them work properly,

• Link with pharmaceutical care (therapeutic groups or committees)

YES

• Financial aspects of the proposed arrangements, including sources of funds and methods as well as levels of staff payment, be it time-based, service based, or a combination of both, and how payments will be managed,

• Free of charge and cost-sharing  depending on PHC priorities and proposals. • A general pharmaceuticals system concept will have to be developed.

YES

• Public relations and health promotion-related activities, with emphasis on a public information campaign to inform the population and the political forces about the meaning and implications of the proposed changes.

• Use pharmacies in health promotion and disease prevention. • Include pharmacists (licensed) in PHC programs

YES

163

Primary Health Care: Service Delivery – Volume 2

Table 8.4

Proposal of critical steps to achieve substantial progress

A proposal of the critical steps needed to achieve substantive progress in PHC reform in the months and years ahead (two to five years) for pharmaceuticals should include: Critical steps

In pharmaceuticals:

• The areas in which decisions are needed, with mention of the key stakeholders and institutions involved

• Role of Ministry, Drug Agency and the Health Insurance Fund in pharmaceuticals • Drug financing - PHC – co-payment; reimbursement scheme (MoH, MoF, HIF) - Hospitals – drugs in treatment costs, separate budget line • Licensing of pharmacies; control and law enforcement (DRA, MoJ)

• The measures to be adopted as well as their sequence

• On how to trigger off a process for longer-term improvements, see Part II, section 4 of this document

• The policy alliances needed to make the above feasible

• A coherent approach to be adopted by MoH, DRA and HIF. • Acceptance by international donors and national stakeholders / consensus-based introduction of new concept in pilot areas.

• The recommended mechanisms and institutions to govern those steps

• PHC-CB present solutions and supervise their implementation • Drug policy conference with high-level national and international participation • Clear mandate and powers to DRA, MoH and HIF to implement

8.3

Drug benefit scheme for primary health care in Georgia

8.3.1

Introduction

An accessible primary care system is of great importance to the health of a population and the most cost-effective way of providing health care. Effective and widely accessible primary care permits early interventions when patient conditions are at an early stage, and so it may prevent patients from seeking unnecessary expensive specialist care and hospital care. Access to primary care in Georgia has been identified as a critical issue and is mostly determined by a few key factors: • • •

12

The expected (official and non-official) payments for a visit. This barrier is significant in Tbilisi but far worse in rural areas12 The perceived level of expertise in a PHC facility (specialist care is generally preferred above general practice in all former Soviet countries, partly due to a wrong perception of general practice). The drug cost a doctor’s visit may generate (useless to see a doctor when you have no money for drugs anyway).

See Household Survey, DFID I, 2001. The costs of health care services, which are born by patients on an out-ofpocket basis, are a significant barrier to accessing care. Nearly 40% of people falling sick during the past 30 days refused to seek care, self treated rather than sought professional help, or had to stop treatment prior to completion due to financial reasons. The interaction of high medical expenditures and low incomes also appeared to affect choice of provider and likelihood of completing treatment for hospitalized patients. Although financial barriers were most significant for the poor population, they can also create problems for the wealthiest. It was quite common for respondents to report that there was insufficient money available in the household to cover the costs of outpatient services.

164

Road Map for PHC Reform from the Perspective of Pharmaceuticals and Drug Benefit Scheme



8.3.2

Access to and availability of alternative forms of care. Such alternatives are offered by a) direct access to specialist care in hospitals and polyclinics, b) a high number of doctors or other medically trained persons in the population (family, friends) that provide advise for free or against delayed payment or payment in kind, and c) private medical centres (mostly set up by foreign companies).

Objectives of a drug benefit scheme

The objectives of a Drug Benefit Scheme in the abovementioned context should address two fundamental questions: 1. How can the MOLHSA improve access to pharmaceuticals in PHC in the 100 facilities to be immediately reformed? 2. How to generate money in a sustainable way from different sources to reduce the financial burden of the patient? 8.3.2.1

Tangible immediate achievements (Quick wins)

A pharmaceuticals component in the 100 reformed PHC sites (as part of the renewed PHC-service package) in the regions of Kakheti, Imereti and Adjara would have an impact on the health status and the satisfaction of the population concerned. At the same time, they will serve as demonstration sites for longer-term development. The approach is as follows: • • • •

Use (and if needed13 modify) the state financed free drugs program to facilitate an extended drug supply for priority services as identified for the 100 facilities. Design and test a simple Drug Scheme addressing high priority PHC interventions fundable trough combined public financing and/or cost sharing (donor contribution, state budget, patient co-payments). Support this by: a) rational prescribing in PHC curricula, b) quality pharmacies in the program, and c) training of pharmacists. The scheme should make as much use as possible of existing drug supply system (private), while encouraging high quality services (licensing).

This immediate action requires: •

Determine in the 100 selected PHC locations. - List of drugs and their coverage - Supply mechanism - Procurement mechanism - Dispensing procedure - Involvement of existing pharmacies (standards)



- Design the Drug Cost Sharing Concept and pilot it in a limited number of locations of the 100 facilities (ultimately this concept should be run through a health financing structure. - Concept development - Select pilot sites - Set-up pilot management unit, supervisory group.

13

An assessment should be made of the current state program offering free drugs. Recommendations should be produced for performance improvements and the feasibility of expanding it with limited number of extra items to serve patients in the 100 facilities.

165

Primary Health Care: Service Delivery – Volume 2

• 8.3.2.2

Run pilots, monitor, evaluate

Include rational drug prescribing in the PHC staff curriculum; set up regional Drug & Therapeutic Groups to monitor and improve drug prescribing and use. Mid- and long-term solutions

A list of policy options for reforming PHC with clear indication of advantages and disadvantages is proposed in this document intended to build on the tangible achievements referred to above. The MoLHSA will then choose the most suitable alternatives in agreement with interested stakeholders and pave the way for a sustainable PHC system in Georgia. The first and most important issue is discussing policy options in the area of drug financing; the lack of a functioning health financing structure has made it impossible for years to develop premium collection or cost sharing – also in pharmaceuticals. Other key attention points in pharmaceuticals are: • • • •

8.3.3

Improving prescribing (and use of prescription forms), as well as removing non-licensed outlets (substandard quality, false competition, adverse health effects. Information: essential drug list, prescribing and consumption information, drug formulary. Continuous training, licensing, GPP, generic prescribing and supply. It is important to raise the awareness of the critical role of pharmaceuticals in the success of treatment and access to care (perception of health professionals and the people). Use pharmacies for health promotion campaigns, rational prescribing & use (reporting).

Pre-conditions

When designing a pharmaceuticals component for Primary Health Care the following dimensions should be taken into account: 8.3.3.1

Mixed financing (cost sharing)

Mixed financing (cost sharing) will raise the amount of money that is available for the Drug Scheme. No doubt about it, in the short run the State will continue lacking sufficient funds to finance all prescription drugs in a free-drugs program. The patient will also not have sufficient income (certainly in the case of serious illness) to afford drug treatment. A fee-for-service scheme (or its equivalent in drug supply) puts the burden of disease largely on the patient, while no money is raised from the wealthy and healthy. Mixed financing for drug treatment in priority PHC interventions will reduce the financial burden for each of the contributors and improve access to drug treatment (and the success of primary care). 8.3.3.2

A Drug Scheme should be set up with the patient at the centre

A Drug Scheme that is patient driven according to PHC priorities will offer a certain level of reimbursement of drugs regardless of who is financing the remaining part. The state or health insurance budget contribution then depends on a) the priority of the treatment in PHC, b) the financial burden for the patient, c) the budget available from the state, and d) possible contribution of a Health Insurance Fund or equivalent institution. As the economic situation in Georgia will continue to be insecure and budgets as well as personal income levels may grow only gradually, state and insurance budgets for PHC and related pharmaceuticals will also grow only gradually. Different from countries and systems where full financial coverage is applied, a Georgian PHC linked Drug Scheme should be designed to facilitate different levels of reimbursement. Certain components may receive full funding through the state

166

Road Map for PHC Reform from the Perspective of Pharmaceuticals and Drug Benefit Scheme

budget; others will be partly financed by a Health Insurance (or possibly donors). Reimbursement levels can also be linked to a certain reference price and a list of drugs adequate for this PHC intervention. Ideally it should be possible to vary patient contribution by population group (elderly, children under 4, etc.), or by patient category (chronic patients). 8.3.3.3

The supply of pharmaceuticals

The supply of pharmaceuticals is now largely in the hands of the private sector. Although it is tempting to think in concepts of centralized public drug supply systems (in the assumption that this is cheaper and better controlled), such supply systems have shown in many countries a number of disadvantages: a) it behaves as a parallel system, leaving the good pharmacies out and often destroying the regular supply system, b) it requires a new organization and separate financing of the procurement, logistics, and staff that is currently not available (to be separately contracted), c) it often suffers from wrong needs assessments and irrational procurement, d) it is vulnerable to corruption and e) it could be suitable to supply ‘free drugs’ but it never is suitable for cost sharing and variable co-payments. In view of this, setting up a separate public drug supply system is not the recommended option. Using a private supply system has of course its own disadvantages such as: a) supervision and price control is required, b) quality of services and products needs to be controlled, and c) efficient delivery concepts may become more complex to implement. However, involvement of the private sector drug suppliers can work as long as the following measures are implemented: a) licensed and controlled pharmacies, b) with maximum reimbursement prices for listed prescription-only drugs, and c) action taken against substandard products and illegal pharmacy selling points (false competition, adverse health effects). 8.3.3.4

Past experiences

As a result of the technical assistance provided to Georgia under DFID-I and in collaboration with WHO EURO, use can be in fact made of a trained drug reimbursement team formed by the five pilot sites for Family Medicine in Tbilisi. Such team is currently on stand-by, has undergone training in Latvia and Denmark, and has a fully equipped office available located in one of the Family Medicine Centres. It should also be noted that part of the mentioned WHO/DFID-I intervention has been the development and publication of a comprehensive Drug Formulary for Primary Care. This formulary will be published by April 2005.

8.3.4

PHC drug benefit options

8.3.4.1

Global options

Global options for drug benefit schemes include logistics of the drug supply system (public / private), the preferred mix of free drugs and (co-)paid drugs, and elements of cost-sharing between the patient, the state, a health insurance fund and sharing the burden of disease (by the wealthy and healthy). Free drug options • •

The State runs a drug supply system in primary care facilities through State run dispensaries (inside or outside the facilities). The State contracts a free drug supply system to existing suppliers through a tender procedure. - Contract the whole supply out to a wholesaler, including agreed prices for listed drugs and the complete distribution (for example Azerbaijan – UNICEF) - Contract suppliers and distribution separately, where free drugs are dispensed in a separate window in existing pharmacies (for example Kosovo).

167

Primary Health Care: Service Delivery – Volume 2



The State agrees the reimbursement of free drugs at agreed prices on a contractual basis with existing pharmacies (for example through health insurance fund contracts).

Cost-sharing options •

Co-payment schemes for listed drugs. Co-payment rate is: - Flat rate for each item (or each prescription) dispensed. - Percentage of the drug costs. - Irrespective of the price (in several central European countries) - With maximum or minimum cumulative amount (in some Scandinavian countries) -

Decreasing co-payments with growing drug consumption



Membership fees. Participation per family or per person in a given scheme, on an annual, quarterly or monthly basis. - Voluntary membership - Compulsory membership (health insurance premium payment included) - Deductibles. The first expenses with a higher co-payment (or full payment); above a certain level of expenditure per year, co-payment is less (or zero).



Corporate contributions. This source is often overlooked, but it has a useful potential in the Georgian context. Companies, corporations and institutions may be offered collective benefit schemes, which may partly compensate for the limited public resources available. - Corporate memberships and adjusted benefits - Donations from various domestic and foreign sources (but will require a comprehensive program and program management unit). Such donations are more likely when a wellmanaged transparent cost-sharing scheme is operated with the support of the Ministry of Health, a Health Insurance Fund and international organizations.

8.3.4.2

Evaluation of the above global options in the Georgian context

Short term time frame. It is understood that offering a certain group of drugs under a free drugs program will substantially lower the financial barrier to utilize the primary care services and improve access to this level of care. Including a free drugs component should therefore be recommended in the 100 reformed PHC centres. Of course such an offer is limited by budget constraints, which need to be calculated in detail. Currently the Georgian state provides certain drugs for free within the Health State Program, managed by a state-run pharmaceutical wholesaler. In essence, drugs included cover: vaccines (largely financed through UNICEF), oncology drugs for outpatients and TB-drugs. In recent years, however, such State supply has proved unable to cover the demands for these items in any consistent way and patients have needed to buy the concerned pharmaceuticals in pharmacies. In this context, the top priority seems to be that the current state supply of drugs under the State Programs for priority conditions (e.g. immunization or TB) is guaranteed in the 100 reformed PHC centres. A short investigation of the current functioning of this system is required to assess its shortcomings (see Annex I, where an appraisal of the PHC funding for PHC I 2003-04 is included). A re-design and/or re-tendering of the suppliers and services under this programme may be necessary. Additionally, it may be possible to include other drugs in this free drugs program (current or redesigned) that are directly linked with priority services and treatments in the reformed 100 facilities. Unless otherwise proved, the available information suggests that there are no resources available for this now.

168

Road Map for PHC Reform from the Perspective of Pharmaceuticals and Drug Benefit Scheme

Mid- to long-term time frame. In a longer-term perspective, the above short-term priorities should evolve to the design and piloting of a drug benefit scheme that is able to do the following: • •

Share costs between patient, some form of health insurance fund and/or the state for essential treatments (in particular for care that may prevent patients from seeking or needing more expensive health care forms); Raise private payments and contributions from the healthy and wealthy (get the burden of disease away from the sick). In other words to increase the willingness to pay with the people that are able to pay. This may also include contributions from companies, institutions, donors, NGOs, etc.

Ideally, the most convenient evolution would be that the above mentioned short-term arrangements could lead to a co-payment-based drug benefits scheme run as one single comprehensive PHC program in which those who can contribute would do so and the State would finance those who cannot pay at all. Here some important discussions will emerge, as it generally is more difficult to manage a co-payment scheme under a state budget-run programme than with an executive agency or a health insurance scheme. 8.3.4.3

A proposal of PHC pharmaceutical services in Georgia

In line with the OPM-paper presented to the Working Group on PHC services, the scheme below shows the possible relationship with a pharmaceutical benefit scheme.

Table 8.5

proposal of PHC pharmaceutical services in Georgia

PHC Services

Conditions

Payment

Pharmaceuticals

Conditions

Payment

Preventive care

Immunization

Free of charge

Vaccines available in the PHC

Immunization program

Free of charge

Other preventive services

Fee for service

-

Only real emergencies

Free of charge

In emergency kit

-

Free of charge

‘Fake’ emergencies

Fixed charge (fine)

Prescription drugs in co-payment scheme

Prescription

Cost-sharing scheme

Unconditional

Free of charge at certain hours

Prescription drugs in co-payment scheme

Prescription

Cost-sharing scheme

Prescription drugs in co- payment scheme

Prescription

Cost-sharing scheme

Emergency care

PHC consultation PHC treatment

List of services

Free of charge

Remaining treatment

Fee for service

Specialist care in PHC centres

Agreed patient / doctor

Fee for service

Prescription drugs in co-payment scheme

Prescription

Cost-sharing scheme

Mother & child care

Child < 1 year

Free of charge

Vital drugs

-

Free of charge

Essential drugs

Prescription

Cost-sharing scheme

TB

Free of charge

Drugs available in PHC facility

Free of charge

169

Primary Health Care: Service Delivery – Volume 2

Thus in principle patients in primary care can obtain medicines in three ways: a) free drugs in the PHC for immunization, emergencies and tuberculosis, b) partly reimbursed products in selected pharmacies using a drug co-payment scheme for serious conditions and for vulnerable groups, and c) fully privately paid prescription and non-prescription drugs for non-priority conditions as well as for non-vulnerable groups of the population.

Figure 8.1 benefits

Presentation of primary care services and related pharmaceutical

PHC Services Free of charge

Fee for service

Pharmaceuticals Free of charge

Preventive Preventive care care

Vaccines Vaccines

Emergencies Emergencies

Emergency kit Emergency kit

Cost Sharing

PHC PHC Consultations Consultations Prescription Prescription drugs drugs included included in a in a co-payment co-payment scheme scheme

PHC PHCTreatment Treatment

PHC PHC Specialist care Specialist care Mother Mother&&Child Child Care Care TB TBProgram Program

TB TBdrugs drugs

The chart shows how certain primary care services can be moved from the free-of-charge to the fee-for-service (or co-payment) category, while independently the pharmaceuticals related to these services or conditions can be moved either from or to the free drugs program or the drug costsharing scheme. Of course, the relationship between free services and free drugs can be maintained for health policy or primary care access reasons.

8.3.5

Articulating drug benefits in the mid- to long-term; main approaches

8.3.5.1

Fundamental choices

In the Georgian case, where budgets are hardly sufficient to cover the services and salaries of medical staff, some fundamental choices must be made as to what priority diseases or population groups the highest drug benefits should be rewarded. Principally the choice is between one of the following three coverage methods, or a combination of the three: •

170

Horizontal coverage (population – entire or groups) – Insurance principle. This option requires a certain element of compulsory membership. Membership can be against a flat rate (x GEL per participant per year) or relative to a person’s official income. In the Georgian situation with its large number of unemployed and large gray economy, a flat rate is probably more feasible.

Road Map for PHC Reform from the Perspective of Pharmaceuticals and Drug Benefit Scheme

• •

Vertical coverage (disease based) – Negative selection, budget principle. As a diseasebased coverage is (by definition) generating negative selection, such a system can only be based on state subsidies. Health care cost coverage (combine economic and disease burden) – Increase benefits with growing health care costs relative to income.

The last option in fact combines the burden of disease (second option above) and the low income of certain vulnerable groups (first option above) into one concept. 8.3.5.2

Free drugs program

As already indicated, the Georgian state has run a free drugs program for several years, with variable success. Problems were caused by instable funding and by inefficiencies. However poorly run, the current free drugs’ State program seems to be the only available source of drugs for many patients. In general, a – state financed – free drugs program works better as disease or drugs based (firstly because of the uninsurable risks of some diseases, secondly because it is easy to contain costs as the medication for such conditions can easily be listed according to Standard Treatment Guidelines). With the limited finances available in Georgia there is a dilemma on which priority diseases to include in this program. It is probably impossible to reduce the current free drugs programs by substituting certain disease categories (like oncology drugs) with others. This implies that any change will generate a cost increase in the free drugs coverage program. In case a free drugs program was population group based, the implication would be that a lot of people get very little benefits. This implies that the impact of such a system would be negligible. Some people could probably afford to pay such small contributions, while others are in need of much higher benefits to maintain their health. Coverage Linked to the Services Concept (see 4.3), and including the current free drugs for outpatients, the following pharmaceuticals would be covered by a Free Drugs Program: • •





Immunization  Vaccines. Currently vaccines are largely supplied through UNICEF and also the financing of basic vaccines is partly done by UNICEF. Mother & Child care  Various drugs. This requires building up a special package of drugs commonly used in these circumstances. However, mother & child care is also an area where people are willing to invest and a good entry point for joining and using a Drug Cost Sharing Scheme based on co-payments. The inclusion of various drugs in a completely free drugs program in this area therefore needs to be discussed in view of the feasibility of a new cost sharing system (see an example in Annex II). TB Program  TB drugs. The existing TB program is according to the available information heavily relying on international aid and NGOs. It is unclear whether including such program in the regular primary care will lead to additional costs for the State compared with keeping the management of this program under the same NGOs. Emergency services  Emergency Kit. Such emergency drug kits should be available in every PHC facility and in the ambulances. The abuse of emergency care should be discouraged, partly by limiting the number of drugs in such an emergency kit, partly by fining people that make unfair use of these free services for ordinary medical care (like antibiotic treatment, etc.)

171

Primary Health Care: Service Delivery – Volume 2

Possible additions, would resources permit (ACP program – see Annex I), may be: • •

Oncology  Painkillers for terminal patients. This group of chronic patients will not be able to finance their care and exclusion of this group seems politically not feasible. Diabetes  Desmopressin and/or Insulin. - Patients with diabetes insipidus receiving desmopressin (approximately 300 cases) - Patients with diabetes mellitus receiving insulin (15,400 cases)



Kidney transplants  Cyclosporin. This covered 55 patients as per the end of 2003

Cost The total cost of the abovementioned package is currently unknown. It is possible to calculate the cost based on the prevalence and cost per treatment, but in the Georgian situation this may well not come particularly close to the real annual expenditure. The OPM financing analyses are expected to shed some light on the current costs, but one needs to be careful here, as in several occasions the State Program was not realized 100% resulting in shortages in supply. It is thus necessary to collect information on the expenditure and budgets for the current State Programs of free drugs (formerly SMIC), the current financing levels of primary care drugs (previous ACP) and the drug treatment costs per case for mother & childcare. In addition it is necessary to determine the efficiency of the state program and to see whether the program can be made more costeffective. 8.3.5.3

Cost-sharing drug program

As it has already been mentioned, while free drugs programs heavily rely on the scarce state budget funds, and fee-for-service heavily rely on direct patient contributions (often from very low or non-existing personal incomes), a cost-sharing mechanism spreads the financial burden over more participants and in time. The main question here is how money can be generated from a lowincome population, and from other sources (companies, employers, and co-payments from patients). It is unlikely that the healthy people will contribute voluntarily (for example on a monthly basis) to a system with zero or very little immediate benefits for themselves. This is only possible in an approach with either a) compulsory membership, or b) guaranteed benefits for all members. At the same time the reality is that the Georgian pharmaceutical market is growing by 15-30% per year (according to sales of major multinational companies), indicating that people anyway does spend an increasing amount of money on pharmaceuticals. Compulsory membership Although compulsory membership schemes exist and operate successfully in several countries, introducing such a concept in Georgia would face serious problems. Firstly it needs to overcome the general mistrust with the population of any new system that looks like taking money without offering anything in return. Secondly, collecting the membership fee will be a difficult task, especially in rural areas and from the vulnerable population. However difficult, it may be the most reliable source if income for a system to function in the mid-term. The alternative is that employed people would pay the premium (flat fee) themselves or through employers, while the vulnerable and non-employed fees be paid by the state (or some health insurance fund). Experience shows that in the Georgian setting however, it is likely that the state will not have the necessary resources and the vulnerable will not pay, so the money generation potential from such a scheme – except patient co-payments – is very little.

172

Road Map for PHC Reform from the Perspective of Pharmaceuticals and Drug Benefit Scheme

Voluntary membership Voluntary schemes should offer real and immediate benefits to their members in the form of priority access to certain forms of care, substantial discounts on essential or listed prescription drugs, or discounts on other drugs or items bought in a pharmacy. Voluntary schemes work best in specific family areas (for example for mother and child care, and older children care). Of course such schemes rely on the ability to pay relative to the anticipated risk-reduction and benefits. In the present context of Georgia, voluntary schemes could be an addition but not the only basis for a drugs benefits program. 8.3.5.4

Three basic options for a cost-sharing drug benefits program

Option I. Drug- or disease-based system This option is based on either a list of diseases or a list of drugs. Based on the household survey a reimbursement scheme could be targeted at: List of diseases:

Oncology Chronic diseases Neurological Gall stones

Or

List of drugs:

Drugs costing more than 5 GEL per pack; i.e., 9% of the drugs for adults and 14 45% of the drugs for children.

A drug reimbursement scheme based on one or both of these lists could compensate a certain percentage of a listed drug for every case, or benefits may be depending on population group or age. For administrative reasons it would be easy to differentiate according to drug price and listed drugs rather than to differentiate according to disease.

Table 8.6

Drug based model – an example

Example

Participation fee

Benefits

Financed by

Drug based model

All registered patients free entry

x% discount on drugs priced > 5 GEL

State

y% discount on fee for GP

Policlinics / FMC’s

A cost-sharing system for PHC in Georgia focusing on diseases will largely depend on State contributions and patients’ co-payments. It is difficult to see how membership fees can be collected for that other than through compulsory fees (some form of taxation). Option II Selected social groups The approach here is to only seek compensation for excessive drug costs for patients who belong to a certain well-defined population group, such as: identified vulnerable people, elderly, single parent families, or children. This automatically implies negative selection so the scheme becomes a single financing mechanism of public funds that are made available for this purpose. The positive element is the targeted approach to these families that are certainly in need of assistance. But this can only be realized when the identification of patients is easy and simple (for example, age). A potential problem is the identification of the concerned groups and the avoidance of misuse and fraud. Experience shows that when including poor families, this approach may very well not work, as these groups tend to avoid special programs targeted at them and generally prefer to belong to a commonly accepted and used system, in which they can obtain special benefits. 14

Based on Drug Requirements Analysis carried out by the Family Medicine Centres (pilots) in Tbilisi, 2004

173

Primary Health Care: Service Delivery – Volume 2

Table 8.7

Population group based model – an example

Example

Participation fee

Benefits

Financed by

Group based model

Free entry for selected defined groups

x% discount on prescription drugs

State

y% discount on fee for GP

Policlinics / FMCs

Also in this option it is difficult to generate contributions from groups other than the vulnerable. Instead of negative selection of patients with an excessive burden of disease (Option I a negative selection of patients with a low ability to pay (due to their socio-economic situation) has to be created. Option III Family Medicine model with differentiated benefits (groups/diseases) This option offers a more differentiated scheme of benefits per population group based, depending of the price of the drug, on family participation. The idea is that the system must be attractive for population groups who today spend money on drugs and have an (official or non-official) regular income. Although many of these groups are currently not using the official primary care facilities, certain groups do, for example mothers and children. Linking a (compulsory) enrolment fee to the drug scheme could generate extra income for the scheme. Such enrolment fees may vary and the State may finance certain vulnerable groups. This scheme also may provide differentiated benefits and – with sufficient coverage (avoiding negative selection) – offer higher benefits for people with higher drug expenditure. These differences can be simplified into easy-to-understand drug benefit packages. For example:

174

Road Map for PHC Reform from the Perspective of Pharmaceuticals and Drug Benefit Scheme

Table 8.8

Family Medicine model – examples

Example

Participation fee

Family scheme standard

4 GEL per family

Family scheme vulnerable

Family scheme elderly

Benefits 20% discount on drugs priced > 5 GEL

State / pharmacies

50% discount on prescription drugs when expenses above 25 GEL per quarter

Scheme

10% discount on GP fee in FMC

FMC

1 GEL per family

1 GEL by participants, 3 GEL by State 20% discount on all prescription drugs

State / pharmacies

60% discount on prescription drugs when expenses above 25 GEL per quarter

Scheme

50% discount on GP fee in FMC

FMC

2 GEL per family

Family scheme Corporate

Financed by Participants

2 GEL by participants, 2 GEL by State 20% discount on all drugs priced > 5 GEL

State / pharmacies

50% discount on prescription drugs when expenses above 15 GEL per quarter

Scheme

20% discount on GP fee in FMC

FMC

4 GEL per family

Company 20% discount on all drugs priced > 5 GEL

State / pharmacies

50% discount on prescription drugs when expenses above 25 GEL per quarter

Scheme

10% discount on GP fee in FMC

Company

10% discount on all prescription drugs

Company

As the PHC reform is intended to have a Family Medicine approach the drug scheme should preferably be based on family participation. This implies that single persons may join the scheme, but at a family price level. This will encourage families to join, by which healthy people could be included in the scheme. 8.3.5.5

Definition of benefits

In all options, the benefits should be based on an agreed list of drugs and an agreed price per product. When including regular pharmacies the options are: • •

Prices of listed drugs to be fixed by the Ministry of Health. This may be difficult in Georgia, in view of the larger political setting which encourages free market development not interfering in the pricing of products. The reimbursement price of listed drugs to be set at a certain level. This level could be equal to the average of the 2 or 3 lowest priced items in a generic group. Such (reference) price is then the basis of all calculations (co-payment, state payment, etc.). If patients demand a higher priced item, they need to pay the difference with the set reimbursement price in addition to their regular co-payment.

175

Primary Health Care: Service Delivery – Volume 2

Additional benefits may come from contracted pharmacies. They may be willing to provide a discount on the listed drugs, possibly compensating this by increasing the prices (margins) of other items. Such extra benefits can be negotiated when contracting the pharmacies or pharmacy chains (wholesalers) to join the Drug Scheme. In the framework of testing a pilot scheme under DFID-I, some distributors offered to finance plastic membership cards for easy identification of patients as well as the administrative maintenance of the system through adjustments on their pharmacy computers. This offer is more likely to succeed in Tbilisi than in rural areas. 8.3.5.6

Financial evaluation of the above presented options

The financial picture of each of the presented options needs to be worked out in detail by the Financing Working Group. Some work has been done in the past during the DFID I project (see Annex III). However, the policy choices on what to include in the Free Drugs Component and then which Drug Benefits Cost Sharing model to be chosen will influence the financial picture substantially. Once there is more clarity on the most favoured options and solutions, the calculations could be done in more detail. The basis of such calculations should NOT be prevalence data and standard treatment guidelines. Instead estimates and budgets should be based as much as possible on the actual situation in PHC in Georgia (not only in the 100 PHC centres to be reformed but for example on the number of cases per 1000 enrolled in the Family Medicine Centres in Tbilisi, their actual prescribing patterns and real drug costs). For this work the WHO financed team in Tbilisi (formed under the DFID I program) can be used to collect the necessary information. Information from rural areas could be obtained in collaboration with the Kakheti PHC manager and the EU program. 8.3.5.7

Running the scheme

Schemes like the ones presented above may be run by state departments or by specialized departments in a Health Insurance Fund. As the future status of the health insurance fund in Georgia is not yet clear, its role in financing primary care, drug schemes and in managing such schemes is also unclear. Action on this is urgently needed. Bluntly speaking, it is questionable whether such a scheme can even be launched within the MoLHSA, as the trust of the population in a scheme directly managed by the Ministry of Health will probably be rather limited. The preferable organizational setting is to place the management of the scheme in a specialized department within some sort of Health Insurance Fund or PHC Executive Agency. In case such a Fund will not be operational in Georgia, a separate Drug Benefits Scheme Management Unit outside the MoLHSA may be needed as an indispensable arrangement to collect co-payments or enrolment fees. 8.3.5.8

Drug use management mechanisms

In a well-organized health care system drug lists, formularies, treatment protocols (or guidelines), drug use monitoring, monitoring or prescribing and the use of prescription forms to follow the drug and/or the patient are common either in the context health care delivery or monitored/managed by an insurance fund. In Tbilisi the situation is as follows:

176

Road Map for PHC Reform from the Perspective of Pharmaceuticals and Drug Benefit Scheme

Table 8.9

Drug use management mechanisms in Tbilisi

Mechanism

Available

Comment

Implication for drug scheme

Drug lists

Yes

Especially developed for FMC’s

Is reimbursement list

Formularies

Yes

Developed recently for primary care specifically

Determines the drug list and improves compliance

Treatment protocols

Some available

Others are used from other countries (UK)

Determines the drug list and improves compliance

Drug use monitoring

No

-

Drug scheme records can be an excellent basis for monitoring

Prescribing monitoring

No

On ad hoc basis

Drug scheme records can be an excellent basis for monitoring

Prescription forms

No

Only for narcotics

Introduction is necessary precondition.

Introducing specific prescription forms is a major precondition for any drug scheme to function avoiding misuse or fraud. The fact that patients shop around for outpatient care is a serious complicating factor. In the case of the newly reformed 100 PHC centres, should patients stick to those institutions this approach would be made easier.

8.3.6

Discussion and recommended actions

Discussion. Developing simple technical solutions in pharmaceuticals in PHC in countries like Georgia can be misleading. For example: allocating budgets for free drugs or free care, refurbishing the facilities, and subsidizing chronic patients or vulnerable groups are efforts which focus on the people most in need. While certainly logical from a social perspective, these solutions are clearly not systemic solutions, but rather measures addressing various problems with services targeted at the poor. What is needed as soon as circumstances permit is rather a system that will last and can be developed into a comprehensive and financially sustainable concept. Such a pharmaceuticals system needs to include services that are attractive for people who are willing to or asked to pay (compulsory). In due course, such system will include the services and benefits for the poor and for chronic patients without any substantial extra cost, as the bulk of the system’s running cost are already covered. (In other words, the free drugs program and the cost-sharing program can be merged into one). Part of the success of such a systematic approach is to include a gatekeeper function. In particular in the Georgian situation there is a lot of non-professional advice, free access to specialists and to hospitals, etc. all of which goes against stable solutions in the field of realistic cost-sharing for pharmaceuticals. A drug benefit scheme for PHC should definitely exclude patients who received care outside the regular PHC system. This implies strict lists of drugs, use of prescription forms and certified prescribers, a referral system that works, etc. An additional difficulty stems from the fact that previous experience has shown that it is quite difficult to ask the public’s opinion about the above schemes. The only way to find out whether something would work or not in reality in Georgia is to put it to a test in the field and give the scheme management team enough freedom to change, in order to adjust and to communicate as appropriate. Recommendations. This Note is intended to make Primary Care more attractive and accessible for patients in Georgia assuming that a well-designed drugs benefit scheme can contribute to these goals. However, as pharmaceuticals are a health technology that is dependent on the way the

177

Primary Health Care: Service Delivery – Volume 2

services are designed and financed, decisions on pharmaceutical services and benefit schemes should only be taken after the PHC services concept is better defined. Once this is the case, the following is recommended: • • • • •

• •

178

Assess the suitability of the current free drugs program for wider application in the PHC reform program (investigate whether the current way of supply, distribution and financing can be improved or made more transparent). Define the free drugs package (list of drugs and the way they are supplied), in conjunction with the defined priority list of health services in the 100 facilities. Decide on which department should manage the drugs programs (whether this is the MOLHSA, a Health Insurance Fund – that is, whether the scheme is financed by state budget or by member premiums - is not relevant in this case) Make a basic choice in the cost sharing drug benefit package or indicate which of the presented options should be rejected. Present a financial picture of the favoured options, including: - Define list of drugs (or conditions) - Estimated cost of treatment per 1000 population for the listed drugs - Estimate revenues from enrolment fees, co-payments, state and/or health insurance fund contributions, and employer’s contributions (corporate). Present a full description of each option and package, including costs and revenues, benefits, as well as the administrative mechanisms to run the scheme. Decide which option(s) or parts of it to: - Implement on a national or regional scale (including the organizational arrangements for such an implementation) - Test in rural as well as urban environments preceding a later up-scaling

Road Map for PHC Reform from the Perspective of Pharmaceuticals and Drug Benefit Scheme

Annex 8.1

Primary care funding 2003/4 and pharmaceuticals

Government funding for health care in Georgia is very low (app. US$5.57 per capita or 13% of total health expenditure). Furthermore this amount is spread over a wide range of programs and disbursed in a very complicated and non-transparent way. By far the most common sources of private health expenditure are unregulated and unaccounted for payments made direct to providers. On average 15%15 of Tbilisi municipal funding was actually spent on Primary Health 15 Care services; that is 2.9 GEL in per capita terms . The introduction of the ACP program by the Tbilisi municipality as per 1 October 2002 contained budget contributions on a per capita basis (Drugs are not included in these per capita amounts): • • •

For age groups of 65 years and older: For 14 to 65 years: For 3-14 years:

15.25 GEL per capita 1.39 GEL per capita 7.46 GEL per capita

With regard to drug financing the following programs were active:

Table 8.10

Health financing programs and drug coverage

Program

Current status

Beneficiaries

Drug cover

SMIC program

Active

Cost of 3 pharmaceuticals only for 3 groups of patients:

Direct procurement or reimbursement of pharmacies:

300 patients with Diabetes Insipidus

Desmopressin

55 patients with kidney transplants

Cyclosporin

15,400 patients Diabetes Mellitus

Insulin

PHD Program

Active

Expanded Program of Immunization

Vaccines

Municipality Program

Active

ACP Program for Primary Care

No

Active

Oncology Patients

Painkillers for terminal patients

Intended 2004

Program for vulnerable groups (200 to 400,000 GEL)

??

Drug reimbursement scheme for Family Medicine Centres (pilots)

Essential Drugs Scheme ??

Scheme under discussion

The current active programs only cover drugs for selective target groups. The main purpose of the current health financing mechanism is financing primary care services, while 50% or more of the patient’s health expenditure is spent on drugs (covering more than 95% of all drug costs in the country). The average fee paid per outpatient consultation was 48.22 GEL. Care provided by specialists was significantly more expensive than that provided by district doctors and nurses. Care provided in hospital setting is significantly more expensive than in the polyclinic. The outpatient fee contains the cost of medicines (54.45%), i.e. 24 GEL per capita.

15

Average figure for the period 1997-1999

179

Primary Health Care: Service Delivery – Volume 2

The costs of health care services, which are born by patients on an out-of-pocket basis, are a significant barrier to accessing care. Nearly 40% of people falling sick during the past 30 days refused to seek care, self-treated rather than sought professional help, or had to stop treatment prior to completion due to financial reasons (in 20% of the households). More than half of the outpatient illness burden is caused by the cost of pharmaceuticals. In addition, in case of hospitalization, many people will need to buy their medication out-of-pocket in pharmacies. The burden of disease therefore increases substantially when people are hospitalized after a period of outpatient treatment, or vice versa, when outpatient treatment follows a hospitalization period. The average expenses per treatment period then are 108 GEL per case, but with significant differences per diagnosed disorder or disease and income group (up to 1,107 GEL per case). Drug requirements Based on the Standard Treatment Guidelines (STG) that are used in the family medicine practice in Georgia (and incorporated in the Family Physician training curricula) the drug requirements per 1,000 people have been calculated. The list of required drugs as derived from these STG was corrected by including only items that are on the Essential Drugs List of Georgia and of the World Health Organization. A further correction was made to include forms that are more commonly used in Georgia (although not on the essential drugs list). The diagnosis for which the drug is required and the ICD-10 diagnostic code have completed this list. In addition, the pharmacy retail price of each drug was added to the list and the total cost per drug treatment, based on required quantities per STG. This gave indications of (a) the consumer price per treatment case, and (b) the total cost per drug in a population of 1,000 people.

Table 8.11

Cost categories of required drugs for adults and children

Price category

Adults

Children

Nr.

Total costs

Share

Nr.

Total costs

Share

Drugs < 5 GEL per treatment

74

71.584

91,3%

37

1.941

54,9%

Drugs 5-10 GEL per treatment

6

3.233

4,1%

7

848

24,0%

Drugs > 10 GEL per treatment Total

3

3.548

4,5%

3

748

21,1%

83

78.365

100,0%

47

3.537

100,0%

For adults drugs priced at 5 GEL or more account for 9% of the total requirements whereas for children this percentage is higher, namely 45%. When looking at the total cost of the required drugs, this adds up to 82,000 GEL per 1000 inhabitants per year. This would imply that for outpatient drugs the market would be 400 million GEL per year. This is not in line with the current estimations of the total market in Georgia, which is assessed at 60 to 80 million USD, i.e. 130 to 175 million GEL. Therefore we have to conclude that the current drug requirements (in terms of cost) are an overestimation by 7-8 times. This also illustrates the level of under-consumption of outpatient care and the potential for growth in case these drugs would be fully reimbursed.

180

Road Map for PHC Reform from the Perspective of Pharmaceuticals and Drug Benefit Scheme

Table 8.12

Summary of conclusions

Issue

Status

Impact

Primary care funding

Primary care state funding is still very low and the ACP program could make available a certain % of the funds for drugs.

High patient payments High % drug costs Less effective treatment

Drug funding

Almost no contributions for drugs are made. The intention to include 1 GEL per capita for drugs is a necessary and welcome start, and a necessary precondition to attract poor people to the scheme.

People avoid seeing a doctor Policy makers do not see pharmaceuticals as an essential health care intervention Vulnerable people have no access to effective primary care

Drug expenses

Half of the patient expenses on outpatient care are on drugs. Certain providers and certain conditions increase substantially the cost of care (and drugs).

Drug scheme to focus on high cost categories Drug scheme to exclude certain providers and existing programs (avoid duplication)

Vulnerable

Low-income groups have special ways of avoiding risks and find in family and friends their own risk pooling mechanism (for the lucky ones). They avoid insurance like schemes (no priority when not sick).

State contribution essential Drug scheme to include short term benefits Scheme to work with middle class and not with vulnerable alone

Family Medicine Centres

Registration and attendance figures are promising. But they are in a competitive situation with alternative providers of care. Expansion of the concept is sluggish.

Positive synergy between FMCs and Drug Scheme Expansion of the scheme to other districts dependant on speed of primary care reform Scheme be competitive, attractive and simple (coverage, package, financing)

Coverage

The lack of solidarity in the health care system (insurance principle), and the lack of public funds, increases the risk of negative selection of only chronic patients.

A community contribution necessary to make any drug scheme accessible for poor people and to cope with negative selection

181

Primary Health Care: Service Delivery – Volume 2

Annex 8.2

An example: Mother and child care

Prenatal and antenatal period for prevention - Folic acid Pregnancy (local data) 0.8% (8) • •

Folic acid -1mg tab (average dose per day 200-500 micrograms) 1/2 tab during 3 months 0,5x90x8=360 tab Folic acid - 5mg tab 2 patients need to be treated with anaemia, average dose 1 tab in a day during 4 months. 1x160x2=320 tab

Table 8.13 Drug requirements for adults per 1000 population based on standard treatment guidelines Generic name

Dosage

Form

Quantity for standard treatment (per 1000 pop.)

Pharmacy price in GEL

Total Pharmacy cost

WHO list

GE O list

State Progr. 2004

Indication

Folic acid

1mg

Tab

360

0.01

2.15

+

+

Municipa l Federal

Prenatal and Antenatal Period

Folic acid

5mg

Tab

320

0.06

18.59

+

-

-

Prenatal and Antenatal Period

20.73 Source: Family Medicine Centres Tbilisi, 2004

182

Road Map for PHC Reform from the Perspective of Pharmaceuticals and Drug Benefit Scheme

Annex 8.3 sharing)

Financial overview of a drug benefits program (cost-

During the development and implementation of the scheme WHO/DFID funding was foreseen in the management and training in running this drug reimbursement scheme. It was expected that doing so might contribute to improved drug prescribing and use through training, monitoring and the introduction and use of a comprehensive Primary Care Drug Formulary (currently in print). The (voluntary) Drug benefits program (cost-sharing) itself is budgeted for 2 options: • •

No contribution from the State, regional or municipal budget (Public Funds) With a contribution from State, regional or municipal budget of 1 GEL per capita.

The financial details are presented on the next page. A summary of the differences with and without the Public Funds is presented below. Figures are based on Pilot FMC’s in Tbilisi and the results of a limited scale pilot scheme. The basis of the calculations is the frequency distribution of drug costs over a population (in simple terms: 85% of all outpatient drug costs are borne by 15% of a population), and an ABC/VEN analysis.

Table 8.14 Drug scheme with and without Public Funds contribution (catchment area 100,000 pop.) Feature

Without Public Funds

With Public Funds

6,000

9,000

-

YES

Family Package - Member families - Reduced membership fee children Elderly Package - Members (nr. of people)

4,000

8,000

- Reduced membership fee members

-

YES

- Increased reimbursement percentage

-

YES

500

1,000

- Reduced membership fee members

-

YES

- Increased reimbursement percentage

-

YES

30,000

48,000

Vulnerable Package - Member families

Total potential no of participants (persons)

Remarks •



The total number of participants is less than the population, under the assumption that not all families enrol. In particular in the situation that an enrolment fee was levied, there are very few possibilities to enforce membership. Participation estimates were based on indications of the Pilot FMC’s in Tbilisi. In case the scheme was part of an obligatory health insurance fund and membership fees are included in a premium payment mechanism, the financial overview needs to be recalculated. Adding Public Funds to the scheme allows (a) more members to participate, (b) higher compensations for these members, and (c) lower membership fees for children, elderly and vulnerable people. All Public Fund additions were to be spent on patient benefits.

183

Primary Health Care: Service Delivery – Volume 2

• •







184

Risk management is done through limiting the list of reimbursable drugs, and fixing the reimbursement price in agreement with the participating pharmacies (wholesalers or pharmacy chains). Simplicity. Although the scheme seems complicated, it is simple for patients in reality. Patients receive a card or booklet of a certain colour, indicating their benefit level. The rest is managed by pharmacies back-office (either by printed lists, or by a computer system the software of which the Benefits Management Program provides). Lists of reimbursable drugs (and their max reimbursable price) are displayed in pharmacies. Membership cards. Early negotiations with interested wholesalers indicate that they might be willing to take the costs of membership cards. In any case, an external donor should probably finance the membership booklets or cards (budget allocation within WHO programme foreseen for pilot scheme). Memberships could be issued by Primary Care Centres or by the participating pharmacies. External funds. Additional benefits could be offered with increased external funds. These funds and donations are not included in the financial overview. However, introducing a cost-sharing benefit scheme that is properly managed may very well be an attractive fundraiser to support the poor and vulnerable and increase the list of reimbursable drugs. Benefits. X% discount (to be negotiated by pharmacies) on all prescription drugs priced above 5 GEL per pack. For drugs above a certain level of expenditure (example threshold 25 GEL per quarter) the reimbursement was 50%. Extra reimbursement, lower threshold or reduced enrolment fees for certain groups depending on the Public Funds available.

Road Map for PHC Reform from the Perspective of Pharmaceuticals and Drug Benefit Scheme

Table 8.15

Financial overview drug cost-sharing program (Family based package)

In GEL (GEL)

Without Public Funds #

Debit

With Public Funds

Credit

#

Debit

Credit

Budget

GENERAL REVENUES External funds

Anticipated funds for social marketing and promotional discounts to early members

23,200

23,200

Pharmacies discounts

10% discount pharmacies on >5GEL drugs

20,000

20,000

PROGRAM ACCOUNTS Family Program Basis = nr of families Participants Member contributions Family Program

1 GEL per participant; max 4 GEL/fam

50% reimbursement family members

For above baseline expenses

6,000

9,000

24,000

36,000 24,000

Reduced membership fee children

31,500

48,000

72,000

0

18,000

Contribution Public Funds

0

26,000

26,000

Elderly Program Basis = nr of elderly

4,000

Participants

4,000

8,000 8,000 8,000

Member contributions Family package Reduced membership fee

4,000

0

Contribution Municipality

For reduced membership fee

50% reimbursement family members

For above baseline expenses

12,000 0

16,000

12,000

42,000

42,000

32,000

Extra 10% reimbursement Contribution Public Funds

12,000

8,000 For extra reimbursement

0

Vulnerable Program Basis = nr of families Participants Member contributions Family Program

500

1,000

2,000

4,000 2,000

1 GEL per participant; max 4 GEL/fam

Reduced membership fee

500

0

Contribution Public Funds

For reduced membership fee

50% reimbursement family members

For above baseline expenses

3,000 0

4,000

Extra 10% reimbursement

3,000

17,000

17,000

179,200

100,000

4,000

Contribution Public Funds

For extra reimbursement

Reserve

Minimum 10% of total

Grand totals

3,000 9,000

0 9,200 -

77,200

21,200 77,200

-

179,200

185

Health Services in the Reformed Village Ambulatory Clinics

9

Health Services in the Reformed Village Ambulatory Clinics Health Services and Human Resources Workstream

Antonio Duran

February 2005

187

Primary Health Care: Service Delivery – Volume 2

9.1

Introduction

9.1.1

Background

All countries in post Soviet Central Europe (including Georgia) have tried in the past 15 years various approaches to health service reform with varying degrees of success. While no approach could be singled out as particularly successful, the overriding message over this period (as highlighted by the European Office of the WHO in Saltman and Figueras (1996)) was that while the content of those reforms has been exhaustively debated, little emphasis was given to the process of reforms, including its political dimension. In a more recent review (Roberts et al 2004), emphasis has also been made on the ideological nature of much of the advice given to countries (“many recent disappointments can be traced back to the uncritical advocacy of some favoured policy solution by international experts or agencies, without an adequate understanding of local conditions”). The Government of Georgia published in November 2004 a two-staged Roadmap stating as its explicit goal to improve the health of the Georgian population by means of • • • •

improved access to and quality of services more equitable approach to health needs, more responsiveness to patients’ demands and preferences and more efficiency in the use of resources

The Minister himself has often stated that the immediate reforms should only focus on incremental change to developing the existing village ambulatory services without major disruption to the current service provisions from polyclinics or other out patient services.

9.1.2

Objectives of the paper

This document has been prepared to provide evidence in support of the proposal forwarded by the OPM HS-HR work stream in the report of 15th January 2005 on the short-term reform of 100 rural PHC centres. It is submitted to the National Coordinator of PHC Reform and presented as a Paper for Discussion to the HS&HR Working Group in order to obtain consensus among all stakeholders and make decisions that are as informed as possible. Together with documents from other donors and actors, it should contribute to the final paper(s) to be presented to the government by the Working Group. This paper has been produced according to the output specifications contained in both the MoLHSA Roadmap of November 2004 and the document “Basic Instructions for the PHC Reform Working Groups” produced immediately afterwards. It intends to advocate the proposal forwarded as a tailored solution to the Georgian environment and consists of (i) evidence to support our proposals, (ii) the list of services to be provided and (iii) the organisation structure and management of the centres to be reformed.

9.2

The Georgian context 2005

9.2.1

A worrying health picture which calls for urgent action

By all existing evidence, in the last 12-15 years there has been a significant deterioration in the health status of the Georgian population. Georgia’s current health status is amongst the lowest in East and Central Europe. This was well illustrated by a detailed statistical analysis undertaken

188

Health Services in the Reformed Village Ambulatory Clinics

among others by the World Bank (2004). The report highlighted the deterioration over the past 10 years in the key health status indicators of infant and maternal mortality.

Figure 9.1

Infant deaths per 1000 live births

25 Infant mortality has increased by more than 50% since 1995 and is 4 times higher than the EU average

20 15 10 5 0 1991

1995

2002

EU Av

Source: World Bank Report No29413 GE

According to the WHO EURO Health for All data base16, some of the key component parts in which infant mortality can be decomposed are climbing in Georgia:

Figure 9.2

Components of infant mortality in Georgia

Error! Objects cannot be created from editing field codes. HFA database www.who.org, 2004

The diagram above is revealing because, as it is well known, infant mortality is the result of a number of problems, some of them related with the situation of the pregnant woman (nutrition, education, etc) and some others directly related to the care delivered to the expectant mother and to the baby at different stages (which in turn influence the general status of both mother and baby). In other words, high infant mortality figures are also the product of service failure in some areas during different stages as per the diagram below:

Figure 9.3

Infant mortality

Error! Objects cannot be created from editing field codes. Source: Donaldson & Donaldson, 1985, Essential community medicine, p.302

Worse, neonatal deaths in Georgia are now the highest in Europe and (contrary to most other countries) it seems to continue worsening:

Figure 9.4

070101 Neonatal deaths per 1000 live births

Error! Objects cannot be created from editing field codes. HFA Database www.who.org, 2004

Figure 9.5

Maternal mortality per 100,000 live births

The picture with maternal mortality is also severe:

16

WHO EURO HFA database, www.who.org, last consulted in January 2005

189

Primary Health Care: Service Delivery – Volume 2

60 Maternal mortality has also more than doubled since 1991 and is now almost 10 times higher than the EU average.

50 40 30 20 10 0 1991

1995

2002

EU Av.

Source: World Bank Report No29413 GE

Something similar can be said of morbidity in children, as per the following diagram:

Figure 9.6

Children <14 morbidity per 100,000 children

25000

The reported incidence of illness in children under 14 years of age in Georgia has also increased by almost 50% in 5 years since 1997.

20000 15000 10000 5000 0 1997 2000 Source: World Bank Report No29413 GE

2002

Health status over the last 10 years has also suffered significant deterioration in Georgia in the form of increasing incidence of infectious and parasitic diseases:

Figure 9.7

Incidence of infectious and Parasitic diseases per 100,000 population

1200 1000 800 600 400 200 0 1992

1994

1996

1998

2000

2002

The incidence of infectious and parasitic diseases has more than doubled in the past 10 years. In particular there are alarming trends in the incidence of the communicable diseases such as measles, rubella, tetanus, and infections by e coli and salmonella.

Source: World Bank Report No29413 GE

Particularly worrying trends can also be observed in the incidence of TB

190

Health Services in the Reformed Village Ambulatory Clinics

Figure 9.8

TB incidence per 100,000 Georgia and other countries

Error! Objects cannot be created from editing field codes. HFA Database www.who.org, 2004

The summary message from the above statistics is that urgent action needs to be taken in many fields. Based on the above figures the OPM proposal has selected mother and child health, immunisation and TB control in Georgia.

9.2.2

Access to health services, the critical issue

Although the above picture is clearly the result of a number of factors, ranging from social stability to nutrition, education, poverty and a number of multi-sectoral causes, the main thesis defended in the OPM proposal is that a substantial proportion of the above mentioned deterioration in outcome indicators is directly linked to lack of access to health services. The evidence for that starts with a review of the number of PHC consultations per patient per year, Georgia, 1990-2002.

Figure 9.9

Number of PHC consultations per patient per year, Georgia, 1990-2002

9.0 8.0

8.0

7.0

7.0

visits to doctor in policlinics call for ambulance total calls

6.0 5.0

4.7

4.0 4.0 3.3

3.0 2.8 2.0 1.0

1.5

1.3

1.3 1.2

0.03

1.2 0.02

1.4 0.22

0.04

0.02

0.0 1990

1994

1995

1996

1997

0.02 1998

1.5 1.4 0.03 1999

1.4 1.2 0.04 2000

1.5

1.6

1.4

1.4

0.03

0.04

2001

2002

Source: Georgian National Centre for Disease Control & Medical Stats, (2003), ‘Statistics Reference Book 2002’. Tbilisi

A catastrophic decline in the utilisation of state services by the population from Soviet times (from between 7-8 visits per person per year in 1990 down to 1.5 visits per year 1996) has taken place, remaining at this very low level of utilisation until now. From the same source, this decline in service utilisation by the public (all types of visits including prevention and curative care and are an average for all ambulatories and specialist centres such as polyclinics, dispensaries and women’s consultation centres) is expressed in caseload terms in the table below, based on: • •

an Average Norm for 1 ambulatory clinic Team of 1 doctor + 1 nurse : 2000 population (averaged for district therapists and paediatricians) the average Number of days ambulatory clinic is open per year = 250 days (365-weekends and public holidays)

191

Primary Health Care: Service Delivery – Volume 2

Total visits per above table

1990 = 8 visits

2002 = 1.6 visits

Team caseload per day (all services including curative and preventive activities)

8 x 2,000 visits = 16,000 per annum 16,000/250 = 64 patients visits per day

1.6 x 2,000 visits = 3,200 per annum 3,200/250 = 13 patient visits per day

The more detailed research by the EU master-planning exercise in Kakheti in 2004 (European Commission 2004) indicates that utilisation rates in village ambulatories is less than 1 visit per person per year. This is equivalent to a daily caseload of less than 8 patient visits per day inclusive of all medical and nursing care activities. International statistics also show that Georgia has the lowest service utilisation levels (Outpatient contacts per person in 2002 or latest year available)17 in the whole of Europe and Central Asia as shown in the table below. The average number of visits per patient per year in Georgia is 1.6 which compares with an EU average of more than 6, a CSEC average of 7 and the CIS average of 8.8. Of the other 42 countries in this WHO survey only Armenia and Albania have utilisation rates lower than 2.6 per person per year.

Figure 9.10 Average number of visits per patient per year in different countries Error! Objects cannot be created from editing field codes. Source: WHO Regional Office for Europe, 2004, Health for all database

A recent paper (Balabanova et al 2004) also reveals the following statistical comparisons in post soviet countries: • • •

Georgia had the lowest numbers of people who had sought healthcare in the previous 12 months (24.4%) Georgia had the highest (49%) probability of NOT seeking professional healthcare when the illness seemed justified Georgia had the lowest proportion (43%) of those who had received care in a primary care setting

According to the authors, this disengagement by the population with the state funded services is due to issues of (i) quality (the perceived low quality of service provision at the local ambulatory level); (ii) trust (a lack of trust by the population in the local providers whose income levels may be dependent upon the numbers of referrals, tests or drug items prescribed); and (iii) affordability: the inability of most of the population to pay for services, particularly in the rural areas. Of these three reasons the research evidence indicates that affordability is the most significant factor for not seeking health care advice in Georgia: • •

17

70 % of those reporting to be ill said they had been unable to afford treatment by a healthcare professional Georgia reported the highest probability (65%) of those who had consulted a health professional who said they had to make an out-of-pocket payment or gift.

WHO EURO, HFA Database, prepared as per data consulted in July 2004

192

Health Services in the Reformed Village Ambulatory Clinics

In fact, similar results were found in the analysis carried out by the above mentioned World Bank Report (reference 3): • •

- For those suffering with chronic diseases in Georgia affordability at over 73% was the most significant factor for people not seeking care - For those people who are prepared to seek care for chronic illness out-of-pocket payments are a significant burden (e.g. for one third of respondents it represent 20 % of ‘total household’ income).

Finally, the Multi-Sectoral Survey of Households in Georgia 2002 by Save the Children (2003) found that “of those who had been ill in the last 3 months but did not go to a doctor 50% stated the reason was that they could not afford it, and rather alarmingly this percentage has doubled the figures from the last survey in 1996 (22.3%)”.

9.2.3

The real causes of the current situation. Our understanding

How has this situation come into being? While of course no simplistic explanation would suffice and more research would be welcome, a number of factors can be identified. The essentials of such analysis have been produced by OPM in our previous Institutional Mapping and Roles and Functions Papers (OPM 2004a, 2004b. See Volume 1). The starting point is that the current situation for PHC services in Georgia can only be understood in the context of the collapse of the Soviet system and the turbulent period of war and economic collapse that ensued. The Government launched a not well discussed health system reform replacing the Soviet Semashko model with something resembling a European Bismarck Model. At PHC level, the essential feature was a health insurance fund purchasing for citizens a basic package of services through contracts with independent clinical service providers working from State owned ambulatory and polyclinic surgeries. Under this system, the basic package of services is paid on a fee for service basis to approved suppliers. A specified quantum of these services are provided freely to particular categories of the population who are deemed eligible as per greatest need or vulnerability (e.g. by age, gender or people suffering from specific chronic diseases). Beyond this level, services are provided on a tariff-charging basis to the patients by the clinicians directly. In addition to this, the Georgian Government provided specific funding to address priorities at a primary care level through various State and Municipal Vertical Programmes. However experience shows that most of these packages have failed not only to make any significant impact on health trends; they have also led to a pattern of virtually systematic charging for every visit (perhaps also favoured by the cultural tradition in Georgia of giving a present to the doctor and the multiplicity of schemes that the population find hard to understand). This was very clearly illustrated in the above-mentioned World Bank report when in its section on maternal health it states: “maternal mortality, connected with the complicated pregnancy, delivery and abortions is a specific indicator reflecting not only health status of pregnant women, but also incidence of diseases in women population, the quality of surveillance of pregnant women and obstetric care in general, and the level of the physicians’ competence. Maternal mortality rates have more than doubled since independence” and “currently both prenatal and delivery care is covered under the Basic Benefit Package (BBP) but not all patients have access to the same level of care particularly in more remote areas and informal payments have also increased the burden of access to these services.” The message emanating from the above mentioned study by Balabanova, McKee et al is very similar and is corroborated by abundant anecdotal evidence obtained by the OPM team during our

193

Primary Health Care: Service Delivery – Volume 2

work in Georgia in recent months. In spite of the policy mechanisms used by the government in implementing its reforms since 1995, service utilisation has not improved. The State whilst continuing to fund basic packages of services has effectively lost its ability to influence the health seeking behaviour of the population. The reason for that is that the current PHC service configuration is controlled (dominated!) by specialists working in polyclinics, specialist diagnostic centres, dispensaries and ambulatory centres. Only very minor ailments are dealt with at the village ambulatory level and lack of trust in generalist doctors prevail. Key elements of the former medical model have been perpetuated, there is an absence of any appraisal or supervision system, there is no effective staff retirement policy and the web of administrative and legal arrangements governing medical activities is too complex and un-manageable for the average citizen. In this context, the health seeking behaviour of the population remains directed towards high demand for specialist treatment. As a consequence of their market power, specialists are able to command a higher income in the market place through out of pocket payments (which obviously undermines the principle of equity of access for the whole population). However honourable the original intentions of the reform designers the Georgian health system has proved unable to administer a complex system of fees and exceptions. The lack of any effective inspectorate has made doctors and nurses prone to achieving target income figures by charging patients. And the comparatively high number of health professionals per 1000 population has done the rest to lead to generalised charges in every visit. The entire society has a sharp perception of the principle that “health care in Georgia has to be paid for in all cases”. In our understanding, such lack of direct affordability, as already explained, has in turn led to a severe decrease in the uptake of all kinds of medical services. Even the intake of services which (by definition!) should be provided for free has plummeted down, as the increased incidence of vaccine-preventable diseases shows. It thus is not only a matter of resource availability (there has been and remains financial support of the international community -in the case of TB, from WHO “Global Emergency” funding for control and prevention of TB since 1995, vaccines donated by UNICEF, drugs facilitated by numerous NGOs, etc). Thus merely increasing the level of state funding for priority diseases through specific packages would hardly improve both the health seeking behaviour of the population and the health outcomes. In summary, in the understanding of the OPM HS and HR workstream, if access to effective PHC (preventative, diagnostic, curative and rehabilitative) services is not improved, there will be no health gain and most likely the proposed reform of PHC services will fail to gain the hearts and minds of the Georgian population.

9.3

Strategic intent of the proposed short term measures

9.3.1

The objective

Improved service utilisation is the critical objective of PHC reform in the coming years. Patient utilisation rates will be a reasonable indicator of short term progress towards perceived improvements in quality, responsiveness to patient demand and more efficient use of resources through increased caseloads of the state funded professionals. This proposition accepts that ‘de facto’ any change must begin from the current service configuration and circumstances. Also as patient utilisation is already monitored annually it does not pose unnecessary additional burdens on health information systems in terms of recording and measurement systems over the short term. We will also explain next how this proposal for short-term reform fits into a strategic intent for longer-term reform. The following table summarises our position:

194

Health Services in the Reformed Village Ambulatory Clinics

Policy Assumption

Long-Term objectively verifiable Indicator

Short-Term objectively verifiable indicator

In Georgia’s current situation, a quantum of service utilisation of Statefunded medical service activity by appropriately competent professionals will improve the overall health status of the country

Improvements in the epidemiological trends in morbidity and mortality such as those outlined above

Improved utilisation of PHC services in the 100 ambulatory PHC centres included under the Roadmap reforms

Simple calculations can be made involving the number of hours of work available, the duration of each visit, the number of staff working days per year and the total number of persons visited to establish objectively verifiable indicators with which progress could be monitored at the local level, depending on the specific circumstances.

9.3.2

The means

To achieve the above, PHC services are needed as a ‘best fit’ over a range of clinical and functional criteria including: • • • • • •

Health need: services should be relevant as per the epidemiological information in terms of morbidity and mortality rates; Geographical accessibility: services should be geographically accessible to the catchment population, measured in terms of optimal travel time or distance; Affordability to users (financial accessibility). Services that can be afforded by the population who need to use them; Clinical viability: services should be effectively deliverable in the new rural PHC centres to an acceptable standard within their medical capability in terms of the competencies of the staff and the technology that will be available to them; Customer focus: services should meet the demands of local people; Sustainability: services should continue to be required to meet local needs beyond the initial “pilot” period and resources should be mobilised for that.

OPM has proposed that free access to the time of a doctor and a nurse should be the cornerstone of the new approach to immediately reforming PHC services in Georgia. This option is favoured against charging any fee to patients during that time (although doing so is not rejected as a mater of principle). The proposed mechanism is to have doctors and nurses practising for a number of hours during morning sessions in which patients would not be charged while permitting private practice after those hours. Explaining this critical element is the objective of this section. The essence of a good health system is one in which the population can trust a medically trained professional who is competent to carry out an initial diagnosis, offer appropriate medical intervention and advise them on their best course of action. This advice has to be equitably given without any unfair pecuniary advantage to the service delivery professional. The subsequent course of action may mean seeking specialist treatment and long term management of a chronic problem, or visits to special clinics etc. If the State cannot afford to fund the subsequent course of action then at least the individual knows the situation and can plan accordingly. In Georgia this means to us that without a clear offer of free services, the population will keep on using more informal health systems (diagnosis and treatment within the family or through friends with a medical background) coupled with direct attendance at a hospital or specialist setting for an

195

Primary Health Care: Service Delivery – Volume 2

acute episode or crisis intervention (but then having to face the barrier of paying a fee plus the risk of catastrophic costs in case of a severe disease)… or not seek health care at all. No doubt, Georgia is a country with a serious shortage of resources and the offered coverage to citizens can only be very limited. One possible source of saving in PHC would be a substantial cut in the number of professionals contracted by the State, but this has been explicitly ruled out by the government for the sake of social stability. So if not all doctors’ time can be contracted for the moment (i.e. all doctors have to be contracted), the only options left are either to contract them full time in a scheme with multiple fees (a system that has proved unworkable in Georgia so far) or to contract them on explicit part-time bases. In any case, the economic figures say that it is almost unavoidable that some co-payments will soon have to be established if coverage beyond very basic services is to be increased, informal payments are to be reduced and providers are to be motivated by better income. But in our opinion this should be done only after the confidence of the population has been re-gained. The proposal herewith presented is thus compatible with the existing contracting arrangement by which the State agrees with private health service providers some conditions of service delivery for those covered (in this case, and rightly so, the entire population). It is not proposed in this paper to change this policy as part of short term reforms; what is being proposed instead is to make such agreement more transparent and realistic: if the State can only afford to pay for a number of hours, let the doctor choose what he/she wants to do in the remaining hours of the day, including practice privately. Our request that the right to use public premises for providing private services in the afternoon should be supported by a rental contract with the service provider (albeit at a symbolic price of 1 GEL at first) serves the same purpose. Indeed, under a system of dual practice (State-sponsored and no-pay in the morning, private and fee for service in the afternoon) the risk of patients being abused and referred to the afternoon session will be very high. The only way to tackle this risk is by a combination of several approaches: (i) an effective inspectorate of the conditions of staff work and service, which should be performed by a number of managers/ developers with direct supervision of the scheme (see below); (ii) a patients’ claims system that should be easy to understand and use by all patients, and especially by the very poor; (iii) incentives to doctors and nurses in the form of higher pay, and (iv) an appeal to the ethics of the professions, who should be directly involved in the process of implementing the scheme. Careful monitoring of these issues will be needed, so that corrective action could be taken if necessary (see below, 3.3.2 on Organisation and Management Arrangements). Physicians who repeatedly abuse the system would undergo sanction – e.g. having the permit to use the public premises in the afternoon removed. In summary, the Roadmap listed 3 specific objectives for short-term reform; this proposal addresses these objectives with some design proposals Roadmap Specific Objective

Proposal Design

• To offer tangible improvements in PHC services to the population as soon as possible • To ensure progress in specific areas while gaining space for resolving most complex issues • To give room to a process of learning by doing in the Georgian context while drawing on international experience

• Specifically address the current Health Priority areas as determined by the deteriorating health indicators • Bring patients back to the village ambulatory PHC centres whilst leaving much of the current services configuration intact • Introduce reforms in the reformed village PHC centres within a system of managerial control aimed at minimizing corrupt practices and developing patient rights • Due to failure of previous reform initiatives, try a new approach in these pilot centres that has not been tried before in Georgia

196

Health Services in the Reformed Village Ambulatory Clinics

9.3.3

Technical details of the OPM proposal

In technical terms the scope of this short-term reform proposal includes: • • 9.3.3.1

- service specifications for State funded activities at the 100 PHC centres concerned, including quantity and quality of these activities that can be provided - organisation and management arrangement Specification of Service Provision in the 100 PHC Reformed Centres

What types of services? The health care services needed to improve (promote, restore or maintain) the health of the population at the level of Primary Health Care include both personal services (those addressed at individuals) and public health services (those addressed at the community or the environment). A rough comparison between them in most western European countries (as a sort of aspirational ‘Gold Standard’) and Georgia is illustrated in the table below. Primary Health Centre Western European ‘gold standard’ of Comprehensive PHC Services

Current Georgian Village Ambulatory Baseline Services

Full range of PHC Family Medicine Service: • History Taking /Patient Records for acute disease episodes, continuous care and monitoring health risk • Health promotion/sickness prevention for their defined population area including Immunisations. • Curative Care (within GP Competency) • Physical Diagnosis • Tests and Investigations (within GP Competency) • Reproductive Health • Ante Natal Care • Child Health inc. EPI and growth monitoring • Long Term Management of Priority Chronic Diseases of their defined population under clinical protocols: - Ischemic heart disease - Diabetes - Respiratory Diseases - Palliative care - Minor Injuries - Emergency Care • Prescribing + dispensing of basic drugs • Referral of complex cases (beyond GP Competency) • Systematic Provision of Health Trend/ Management Information on their defined population to PHC Executive Agency

A very narrow range of services for adults and a separate narrow range of services for children: • Basic History Taking /Patient Records for acute disease episodes • Immunisations. • Basic Curative Care (within narrowly defined Therapist /Paediatrician Competency) • Basic Physical Diagnosis by Therapist or Paediatrician • Basic Child Health and growth monitoring by paediatrician/ nurse • Referral of most cases to specialists • Prescribing pharmaceuticals • Providing management information on their catchment population to the Rayon polyclinic manager

197

Primary Health Care: Service Delivery – Volume 2

The HS & HR Working Group has thoroughly debated the issue of a ‘Georgian comprehensive PHC service’ at its first 2 meetings in December 200418. There is a clear intention by all stakeholders that the reformed village PHC centres should offer a comprehensive service within the significant constraint of the limited resources available. For the purposes of this document it is proposed to group services as “competent curative services” and “preventative other services”. The newly reformed pilot PHC centre staffed by a Family Medicine Team of 1 doctor and 1 nurse for a catchment population of 2000 people will offer “competent curative services” to their local community population together with some priority “preventative and other” services. In medical terms they should have the capability to address: • • •

all diseases in all their presentations (e.g. communicable and non-communicable, acute and chronic, physical and mental) the needs of all segments of the population, irrespective of their defining attributes, such as age (child, young, adult, elderly), gender (male, female), income (rich and poor), place of living (rural urban), religion, ethnicity, etc. the full range of types of services needed to tackle disease in different stages (namely, prevention and health promotion, diagnosis, treatment, rehabilitation and care),

The following diagram represents this: Any member of the local population present with an episode of illness

REFORMED VILLAGE AMBULATORY PHC CENTRE

“Competent Curative” First Contact Medical Curative Intervention advice, self help prevention + possibly pharmaceutical remedy

“Preventative & Other” Referral for more serious complaints or health priorities

? PHC OR SECONDARY CARE, FREE OR PAY

?

Quantity and quality of services As repeatedly explained, the overriding restriction on the scope of these proposals for immediate reform of village ambulatory PHC centres is the sustainable financial envelope provided by the State from within existing public resources. Clearly this is an issue for more detailed consideration 18

Minutes of both meeting, available upon request (they will be included as annexes in the final proposal)

198

Health Services in the Reformed Village Ambulatory Clinics

by the Finance Working group, a dialogue with which is essential in the coming weeks. For the purpose of organizing the supply of these comprehensive services it is necessary to determine the appropriate units of measurement of service activity produced. International experience shows that there are three ways that such measurement is done in different countries: • •



Output-related, with activities categorized into types of single actions (e.g. a consultation, a specific treatment or test, a pharmacologic item prescribed…) Time for a caseload in which all functional service activities are expressed in terms of a time-bound case period of a competent medical professional team measured as the availability of time of that professional team to receive patients with any condition presented to them. Mix of both A mix of output related activity for certain specified activities (e.g. preventative activities such as immunisation rates) and staff time for the rest (e.g. time devoted to patient consultations).

In content terms, the proposed services would therefore include: •

A dedicated state-funded quantum of time per day when the FM team would undertake “curative” patient visits. During these periods the FM Team would hold surgery sessions or home visit (whenever indispensable) in which they would: - Take the history and record the activity for each episode of health care when presented by any member of the local catchment population - Perform some curative care, including (technically feasible) physical diagnosis, tests and investigations, prognosis and recommended course of action (within the FM team competency) - Prescribe (within FM doctors’ competency) some basic drugs from an approved list (+ dispense them where no pharmacy is available) - Refer complex or severe cases (beyond FM team competency) to the existing specialist arrangements with accompanying information summarizing the initial examination /prognosis. Patients referred to another level of care will receive follow up attention by the GP as necessary (e.g. visits, phone calls, enquiries, etc).



In addition the FM team would make arrangements to be available for emergency care at any time of day for patients who present themselves with life-threatening situations. Such emergency care will also be provided free of charge for as large a proportion of these rural catchment populations as possible (precise number to be determined after due links with the Finance WG) A dedicated period of time per day when the FM team would undertake work in the fields of (i) Immunisations; (ii) Maternal and reproductive health (including ante-natal care of the mother and care of the child including EPI and growth monitoring); and (iii) TB. Such time will be as much as possible organised in connection with the particular health priorities of the local area. Clearly it would not be appropriate to allocate disproportionate amounts of time to services that do not meet local needs (e.g. DOTS services in rayons with no TB patients). It is thus not proposed that this should be a centrally determined rigid target for each priority group but rather a process of dialogue between the MoLHSA (for national priorities) and local rayon community (for local needs). Should that be justified according to the local conditions, long term monitoring of chronic diseases such as diabetes etc. could for example be included.



There has been significant discussion in the HS and HR workgroup over the specific preventative services (e.g. well baby clinic Vs fenil- kaetonuria blood test) that should be funded by the State in

199

Primary Health Care: Service Delivery – Volume 2

the short term reform. These services will only be determined with precision within the context of these short term reforms in Georgia after a full clinical and financial appraisal of the options plus with more refined epidemiological data. Technical experts should put forward evidence of particular preventive actions that could be taken in the context of rural village ambulatories (clinical expertise required, time and/or drugs needed, etc; the finance working group would then indicate the likely cost of such service). Included in the annex to this document is a proposed methodology for determining the optimum preventative services that could be offered at this stage. The consultation with the doctor The detailed specification for the doctor’s activity during this consultation event is summarized as follows (OPM 2004a): •

• •





Interviewing and history taking. This involves introductions and listening carefully, allowing the patient time to explain their problem fully and identifying patients’ reasons for consulting as well as asking them specific questions. It also includes reading and eliciting relevant and specific information from the patient’s records; Physical examination. This involves undertaking appropriate physical examination of the patient and correctly eliciting physical signs through the use of appropriate instruments and basic tests in a selective, competent and sensitive way. Problem-solving (diagnosis). It includes correctly interpreting and applying information obtained from patient records, history, physical examination and investigations. It also includes identifying problem and generating appropriate working diagnoses within the limits of their competence; Patient management (prognosis). It includes formulating management plans appropriate to the findings and circumstances in collaboration with patients, seeking to reassure them through clear explanation and proposing appropriate therapeutic course of action with discriminating use of referral and drug therapy; Record-keeping. It includes making accurate, legible and appropriate record of every doctor-patient contact and referral. The minimum information recorded should include date of consultation, relevant history and examination findings, any measurements carried out, the diagnosis or problem, investigations planned, follow up and referral arrangements. If a prescription is issued, the name and dose of the drug, the quantity provided and special precautions should all be recorded

The nurses function Given the parlous state of the nursing profession in Georgia at present (reference 10) the proposal at this stage is that the nurses function in these reformed PHC centres would be more restrictive than those of the Western European models but more professionally focused than the current situation of the nurses in many of the existing village ambulatories. Therefore the nurses would have the following functions: •



200

Direct curative nursing care. They will respect human life and the dignity, rights and values of the individual while applying modern ethical principles to nursing sick patients that are referred to them. This care will be provided both in the PHC surgery and in the patients’ homes where that is deemed necessary. Nurses may also undertake some limited testing e.g. blood pressure and record the information systematically in the patients’ records Preventative care. Nurses will fulfil monitoring and measuring roles by taking weight and height measures in particular priority groups (e.g. infants). They would also administer injections and immunisations in particular target groups. They would also take the

Health Services in the Reformed Village Ambulatory Clinics



9.3.3.2

opportunity to promote healthy lifestyles and encourage community participation and self reliance in their interactions with the population. An administrative function. Since the ambulatory centres chosen for reform will be based around small facilities of 1 doctor and 1 nurse, it is envisaged that the nurse would also be required to undertake some administrative functions in support of the clinical activities (e.g. some appointment and reception time to welcome and receive patients, filing and storing of patient records and some data recording for managerial purposes -see also below, service organisation). The Organisation and management arrangements

Redressing the balance A previous paper by OPM (2004a) explained that the successful development of healthcare systems require a balance of power between stakeholders (the government, the professions and the people/ patients). That paper identified health systems as having 4 levels of care: (i) self care (personal and familiar), (ii) primary professional care (general practitioners, nurses, others); (iii) specialist care, and (iv) super-specialist care. In the current situation in Georgia, people have opted generally for self-care and then in acute cases they pay a fee for specialist care. This in fact reflects significant informal power by the specialist professions and very limited informal power by either Government or the patients (it indeed also has a detrimental effect on the poor since they cannot afford specialist care!). Therefore it is proposed to introduce some new approaches to the organisation and management of the reformed village PHC centres with the potential to begin to redress such imbalance and establish a foundation for an effective PHC system. As indicated above, the proposed services would be provided in the following way: • • • •

by a team of medical and nursing staff working together in a co-ordinated way involving a range of “production activities” (e.g. consultation time, laboratory tests, pharmaceuticals, etc); including the capability of delivery in a planned regular manner (e.g. open surgery hours, appointments, planned home visits, special clinics etc) as well as in response to unplanned emergency situations; including the systematic provision of health and management information on their defined population to appropriate managerial organisations including a clear system of accountability to their local communities, funding organisations and professions, supported by an effective inspectorate.

A free service It is proposed that there will be up to 5 hours (dependant on Finance WG deliberations on resources available) for the delivery of State funded services. The FM team would be required to provide the same level of service to any member of the local population who present themselves at the PHC regardless of their age, gender or level of income. This would probably be in the morning session at the PHC centre, but would be finally decided after consultation with the local community. Such dedicated time would then be published locally in unambiguous terms as a time in which patients would not be asked to make direct co-payments to the FM team at the time of service delivery. This does not exclude that some less-vulnerable groups of people in the community may not be asked to make a contribution towards this “free

201

Primary Health Care: Service Delivery – Volume 2

service” and they may also be required to make a contribution towards the costs of some tests and drugs dispensed, an issue which will become clearer after discussions with the Finance WG. Patient and community involvement Effective customer (patient) feedback is an essential element of any service organisation and is a formal feature of the many European PHC systems. It is proposed to establish a patient complaints and comments system from the outset of the short term pilot. The information thus generated would be actively used for managerial purposes to ensure that the services provided by the state address the genuine needs and concerns of the local population. This system should be developed through consultation with the local community but as a minimum it would include: • • •

An independent patient “complaints help line” telephone and/or a physical location within the village for patients to express their concerns confidentially to a local “ombudsman” A patient satisfaction system including an opportunity for qualitative comment Periodic (possibly bi-monthly at first) focus group meetings with local people.

Organisation of the “Competent curative services” As already explained, there will be a daily open surgery time to receive any member of the local catchment population who presents themselves with a medical problem. The timings are to be determined locally with the community but should probably include 2-3 hours in the morning clearly posted and advertised at various places in the village. There will also be specific home visits without charge for particular patients who cannot attend the clinics (and these would be planned to take place ‘outside’ the dedicated surgery times). Should the number of home visits represent an unreasonable burden in terms of time commitment, specific action will be undertaken by the responsible manager. Patients will be invited into the premises where they will be treated with respect as customers and allowed to wait in a comfortable room until their turn to be received by the doctor or nurse. Each consultation event with the doctor will take place in a separate consultation room in which patient confidentially and privacy will be maintained. They will establish a friendly but professional relationship with patients with due regard to the ethics of medical practice. All patients will be treated in the same manner regardless of gender, age, status, income level or complaint (with the exception of emergency care for life threatening episodes). As demand increases this may require the development of an appointments system which would also necessitate the installation of a reception telephone. Each patient would have a personal medical record recording their episodes of medical care. This information will be kept at the surgery and will be stored in a manner that ensures due confidentiality and respect for the patients rights. Organisation of the “Preventative and other services” There will be a specific clinic time (possibly 1 – 2 hours within the total State-funded time) which would be planned over a monthly cycle to receive patients with specific needs (e.g. ante-natal clinics, or TB, or immunisation sessions). The timings are to be determined locally with the community but should possibly include up to half hour per day for special clinics, to be clearly posted and advertised at various places in the village. Some incentives could be offered to encourage patients to attend clinics such as discounted cost of drugs or baby foods etc. This would reduce the need for some home visits. If necessary due to population dispersal, these clinics could be offered as an outreach service in a suitable building or room away from the main PHC centre. The opportunity will be taken during the episodes of curative consultation described above

202

Health Services in the Reformed Village Ambulatory Clinics

to sensitively enlist the co-operation of patients to promote change to healthier lifestyles and to explain to patients possible preventive initiatives. Required arrangements. The manager/ developer function The above organisation of service activity will require a managerial capability sufficient to ensure good governance and clear accountability to the Government through the MoLHSA, to patients in the local communities as well as to other professionals. For reasons of ensuring proper implementation of the reform, and irrespective of future adjustments at later stages, the reformed centres will initially be managed directly by the MoLHSA through the PHC Co-ordinator outside the current institutional arrangements. Specific ring fenced funding will be allocated by MoLHSA to PHC Board with executive accountability through the PHC Co-ordinator who in turn would manage the system through a new professional cadre of PHC staff working in an Executive Agency as illustrated below:

203

Primary Health Care: Service Delivery – Volume 2

MoLHSA PHC Board PHC Executive Agency PHC Co-ordinator

Kakheti

District Managers (6– 8 PHC Centres each)

Imereti

District Managers (6– 8 PHC Centres each)

Adjara

District Managers (6– 8 PHC Centres each)

This PHC Agency would be responsible for all operational aspects of the new system: •

• •

contractual relationships /methods of payment/incentives with the service providers in the PHC Centres; setting service specifications re. the above services including both qualitative and quantitative measures/standards/targets for achieving a range of PHC objectives; monitoring achievement of the above standards; collation, co-ordination and analysis of managerial information on: - financial performance - service specification performance - evidence of good practice



Reporting formally every 3 months through the PHC Co-ordinator to PHC Board



The managerial role of PHC in the Western European (reference 11) was defined as: …“to ensure that the community they serve will receive the highest possible standards of patient care from the PHC system in an efficient and effective way.” The situation in Georgia critically requires this together with a more wide reaching role to promote the new PHC. Rayon PHC manager/developers will thus be assigned to several village ambulatories (possibly up to 6-8 each) with the following duties: •



204

Managing Resources. They will monitor the use of human and physical resources in terms of attendance, hours of opening, travelling and visit times together with inventory and purchasing requirements, proper use of public premises, etc. They would also co-ordinate budget management information and financial data flows between the village centres and the MoLHSA PHC Executive Agency. Managing Activities. They will monitor the patient activity and attendance at each category of service in order to determine trends in service utilisation. They would also monitor and report on patient complaints regarding service activities, possible abusive practices, etc. This would NOT include monitoring of clinical quality which is deemed outside their professional competence and would remain the domain of the MoLHSA Licensing Control Department.

Health Services in the Reformed Village Ambulatory Clinics





Supportive Supervision. The manager/developed will have an important responsibility in ensuring that professionals receive adequate feedback of their performance. He/she is also responsible for promoting innovative practice and change as per the best practices among the 100 reformed PHC centres. Promotional Development Activities. They would be involved in liaising with the community to develop responsive services that meet local needs, including implementing specific promotional initiatives. In addition they would liaise with other health professionals locally and nationally to foster this PHC model, sharing good practice and exploring opportunities to develop more effective services (the HP and PR WG to advise on this).

As explained, this pilot short term reform must be led by the MoLHSA and therefore it is initially proposed that these Rayon PHC managers would be accountable directly to the MoLHSA PHC Executive Agency. This would be feasible in the short term since there will only be 100 centres in the pilot across 3 regions. In the longer term this central control would be devolved possibly to the regions. Evaluation of the pilot reform One of the specific objectives of the Roadmap was that the MoLHSA should develop a longer term policy reform through a process of learning by doing and evaluation. The activities and organisational arrangements for these reformed village ambulatory clinics will need to be evaluated carefully from the outset. Baseline data will need to be established for each centre once these have been identified by the EU and WB before implementation (refer to the HMIS WG). Also to enable these pilot sites to be effectively evaluated specific legal and functional changes to “ring fence” the pilots for a period of time (possibly up to 3 years) will be needed. These measures would need to be taken before implementation could take place. Evaluation should be continuous throughout the period of the pilot reforms. A range of evaluative frameworks will need to be established to analyse the effects of the various elements of this proposal in practice (e.g. PHC teams, retraining, new curative model, priority services, management arrangements etc). A vital element in this evaluation process will be the abovementioned district manager/promoter/developer who will act as a means to integrate the diverse range of potential outcomes from this pilot process into a coherent analysis that will inform the longer term policy for PHC in Georgia.

9.4

References

Balabanova, D., McKee, M., et al, (2004) ‘Health Services Utilisation in 8 former Soviet Countries’, Health Services Research 39:6 part II, 1927-1950 European Commission Delegation in Georgia, (2004), ‘Development of a Regional Master plan for the Primary Health Care system in Kakheti Region, Final Report’, July 2003 - January 2004 OPM for DFID, (2004a), ‘PHC Roles and Functions in Georgia; the Current Situation, Georgia Health Sector Reform Programme’. [This collection: Volume 1 Document 3] OPM for DFID, (2004b), ‘Institutional Map Of Agencies Involved In Hr & Service Delivery In Georgia, Georgia Health Sector Reform Programme’. [This collection: Volume 1 Document 4] Roberts, M., Hsiao, W., Berman, P. and Reich, M., (2004), Getting Health Reform Right. Oxford University Press.

205

Primary Health Care: Service Delivery – Volume 2

Saltman, R. and Figueras, J., Eds., (1996), European Health Care Reform, Analysis of Current Strategies, WHO, Copenhagen Save the Children, (2002), ‘Household Multi-Sectoral Survey, Georgia’. World Bank, (2004), ‘Georgia Review of Health Sector,’ Report No29413 GE June 2004

206

Health Services in the Reformed Village Ambulatory Clinics

Annex 9.1 Proposed timing for determining optimum preventative services for short term reform Mid February 2005

Determine Full List of possible Preventative Services Detailed epidemiological analysis of health need in the current situation in Georgia

Evidence the clinical activity at PHC level that will effectively address this need

Brief description of clinical activity in terms of necessary resource inputs required i.e. doctor/nurse time, drugs etc

Proposal of the benefits

Identify & quantify the costs of short-listed options

End of Feb HS & HR WG Score Benefits (as stakeholders not decision makers)

F &P WG Rank Costs Inter Group Meeting

Mid March 2005

Propose preferred options

Assess sensitivity to risk e.g. longer term trends

April 2005

MOLHSA approval

Prepare Implementation Plan for Proposed Option

207

Primary Health Care: Service Delivery – Volume 2

Annex 9.2 Scoring the benefits of the preventative services options for immediate reform Benefit Criteria In order to make a judgement on the relative non-financial benefits of a the various options for preventative services to be delivered from the selected newly refurbished village ambulatories it may be necessary to for the WG to rank theses services in order of preference from a non-financial perspective. The criteria that are relevant for preventative services outlined in the proposal above are: Clinical Need. Preventative services that are relevant to epidemiological information that meets the health needs of the population usually expressed in terms of morbidity and mortality rates for the various categories of clinical risk. Clinical Viability. For the purposes of this process to what extent would a particular preventative service have sufficient throughputs (volume) of patients to ensure that the specific clinical skills required for that service are developed and practiced on a regular basis and by definition professional competence can be attained in that service. Sustainability as a PHC Preventative Service. This criterion reflects the degree to which these preventative services should have the potential to serve as the foundation for the development of the PHC staff team’s competency and confidence towards achieving the full range of PHC services at the local level in the long term. They should present an opportunity to motivate and stimulate staff to want to work as Family Physicians at the PHC level. Scoring Options for Preventative Services The current situation is included not as a future option, but as a baseline of reference for relative scoring of the possible options. A baseline figure of 2 could be given to the current situation (status quo) for each criterion and then participants are asked to score the options relative to that baseline19. The HS&HR working group should discuss each of the proposed options and consider how well they meet each of the agreed benefit criteria. Participants then allocate their individual scores between 0 and 10 for each option against each criterion and these are then summed as a total and averaged for the group. The scores are determined as follows: • •



19

A score of 2 means that an option was expected to achieve a level of performance against a particular benefit criterion which is equal to that achieved by the existing service provision. This did not mean that the do nothing option scored 2 for all of the criteria. A score of 3 - 10 means that an option was expected to achieve a level of performance against a particular benefit criterion which exceeds that achieved by the existing service provision. A score of 10 would indicate that this option would yield a fivefold improvement in that particular benefit over the current situation. A score of 1 means that an option was expected to achieve a level of performance against a particular benefit criterion which is poorer than that achieved by the existing service provision.

It may be necessary to apply some degree of weighting to the 3 criteria if the WG believe that some of these criterion are more important than others e.g. if clinical need is deemed more important than access then a suitable weightings should be applied to the raw scores to determine whether the resultant ranking is any different

208

Health Services in the Reformed Village Ambulatory Clinics



A score of 0 means that an option does not achieve a particular benefit criterion. The scores given by the group to each of the options could then be summarised in the table below.

Short Listed Options Option 0. Status Quo

Clinical Need

Clinical Viability

Sustainable

Total Raw Scores

2

2

2

6

Option 1. Option 2.

The raw total scores would then indicate the option that the group believed would yield the greatest benefits i.e. the one with the highest raw score. It would also indicate the degree of preference for that option above others by the range of scores. In other words how closely do other options score compared with the highest. The options would then be ranked in terms of non-financial benefits with the highest score ranked first in order of preference. Then after the Finance WG list the respective costs of each of these services it will be possible in a cross WG meeting to determine the cost of the concerned services in terms of relative benefits scores per 000 GEL of cost. This full clinical and financial appraisal would then inform the decision making process in terms of which preventative services could be provided with State funding in the new village pilot PHC centres as part of this short term reform process.

209

Loading...

Volume 2: Primary Health Care: Service Delivery

PRIMARY HEALTH CARE: SERVICE DELIVERY Volume 2 Acknowledgements Oxford Policy Management would like to thank all the individuals, too numerous to n...

937KB Sizes 4 Downloads 22 Views

Recommend Documents

Improving Access and Delivery of Primary Health Care Services in
1 College of Family Physicians of Canada (October 2009) Patient-centred primary care in Canada – Bring it on home. (Di

Primary Health Care Intelligence - Canadian Primary Care Sentinel
CPCSSN was initiated in 2008 to use routinely collected electronic medical record (EMR) patient ... Med Access EMR. Nigh

Primary Health Care - World Health Organization
World Health Organization 2008. All rights reserved. Publications of the World Health Organization can be obtained from

Primary Health Care Strategy - Ministry of Health
The Primary Health Care Strategy. 3. NEW ZEALAND HEALTH STRATEGY. POPULATION HEALTH OBJECTIVEÓ. The 13 population healt

management of type 2 diabetes focus on primary health care
Kebutuhan untuk Diselenggarakannya. Sistem Rujukan. RS Rujukan. Sekunder dan. Tersier “menjadi. Puskesmas. Raksasa”.

Applying Economic Principles to Health Care - Volume 7, Number 2
While the perspectives of consumers, producers, and society converge in a perfectly competitive market, hospital patient

quality management for health care delivery - GHDonline
continuing resource constraints and rising customer expectations. We hope that Quality Management for Health Care Delive

health care delivery in india - SRM University
HEALTH CARE DELIVERY IN. INDIA. Page 2. HEALTH CARE SYSTEMS. In India, it represented by five major sectors or agencies

Community Health Associates: Newtown Doctor - Primary Care
Newtown Doctor - Primary Care & Family Medicine Physicians with over 35 years as trusted medical providers for Newtown,

Health Assessments in Primary Care - AHRQ
Park Meadows. • Exempla Oasis Family Medicine. • Walsh Medical Clinic. We also thank the practice-based research net