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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.
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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
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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
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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
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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
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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
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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
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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
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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.
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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.
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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.
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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).
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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
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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
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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
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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.
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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).
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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.
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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.
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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
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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
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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.
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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
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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
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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).
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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
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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.
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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).
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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).
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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).
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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).
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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
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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-
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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
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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.
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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.
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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.
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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
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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).
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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
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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.
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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.
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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.
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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,
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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).
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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.
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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
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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
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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.
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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)
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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.
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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
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policy. An agenda for the European Union. Aldershot: Dartmouth.
Arrowsmith J, French S, Gilman M, and Richardson R., (2001), ‘Performance-related pay in health
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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
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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.
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Health Policy 31: 183-195
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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.
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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
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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
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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:
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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,
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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
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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
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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.
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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
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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
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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.
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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
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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
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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
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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).
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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.
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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
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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.
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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.
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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.
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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
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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.
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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.
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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.
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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).
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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.
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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
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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).
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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.
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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.
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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.
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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
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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.
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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.
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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
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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
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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.
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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.
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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
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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).
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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;
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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
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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
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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.
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7
Report on Review of Training Programmes for Doctors
and Nurses in Family Medicine
Carl R. Whitehouse
September/ October 2005
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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.
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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.
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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.
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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
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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
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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
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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
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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)
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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.
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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
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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;
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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
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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
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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:
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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
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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:
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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.
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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
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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
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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.
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•
•
•
•
•
•
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
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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.
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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.
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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.
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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.
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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
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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
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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.
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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.
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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]
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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)
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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.
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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
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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
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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:
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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:
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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
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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.
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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.
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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
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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).
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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.
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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
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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.)
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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.
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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
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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:
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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.
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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:
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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
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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
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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.
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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
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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
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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.
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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
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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
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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
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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
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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)
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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
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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:
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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
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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
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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
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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)
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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
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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
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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
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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:
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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.
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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
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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
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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
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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