primary health care in north east europe countries arnoldas jurgutis, phd, assoc. prof., head,...

Primary Health Care in North East Europe Countries

Arnoldas Jurgutis PhD assoc prof head Public Health Department Klaipeda University ITA Primary Health Care Expert Group of the Northern Dimension Partnership in Public Health and Social Wellbeing

EFPC Conference The Future of Primary Care in Europe III Pisa 30-31 August 2010

Oslo Declaration of 27 October 2003 ndash ND Partnership in Public Health and Social Wellbeeing (NDPHS) ndash four Expert Groups till June 2010 (reorganisation is going-on)

HIVAIDS Expert Group SILWA Expert Group Prison Health Expert Group

Primary Health Care Expert Group of the NDPHS

bull Lead country Sweden bullChair Dr Goran Carlsson Senior advisor MoHampSA

bull Active participation

Northern Dimension Partnership

Finland

Estonia

Lithuania

Norway

Poland

Russia

SwedenLatvia

Belarus

WHO European

Region Report PHC in ND countries httpwwwndphsorgdatabaseviewpaper2120

Objectives of presentation

To overview shortly the development of Primary Health Care in North East Europe Countries and to address recent challenges

Countries in focus - Belarus Estonia Latvia Lithuania Russia (active East Europe members in NDPHS network)


Common pastSemashko model of health care system

bull very centralized health care system with hospitals leading health care

bull primary carendash a lowest chain in hierarchy of health care system

bull primary health care doctors trained mainly in hospitals as specialists in internal medicine pediatrics gynecology etc

bull exaggerated role of narow specialists for improvement of population health

bullLaw No1000 on dispanserisation overproduction of ldquospecialoidsrdquo


Common ideas since early 1990-ies

Strategies on Primary Care reforms

Estonia - ldquoNational Development Programrdquo 1991

Lithuania - ldquoNational Health Conceptrdquo 1991

Latvia - 1992 ndashMoW approved model of PHC based on family doctors

Belarus 1998 MoH decree regarding the gradual transition of the organization of primary care

Russia ndash started postgraduate training in 1992 main legal requirements for new speciality in 2000

1990-ies - External drive and support

International support to PHC reforms WB investment in East Europe and Central Asia ndash

200 mln US $EU PHARE TACIS ProjectsUSAIDSwedish International Development Agency (SIDA)

through NGO Swedish East Europe Commitee (SEEC)Matra projects supported by the Dutch Ministry of

Foreign Affairs and implemented by NIVELSupport from FM associations (WONCA Canadian FD

association)Other

20 years ndash intensive reforms

Introduction of new speciality of family doctors trainingaccreditation system in all countries (residency 3years - Lith Lat Est 2years - Russ 6month - Bel)

Decentralisation ndash responsibility for municipalities for PHC

Separated PHC and SC (in Estonia Latvia Lithuania (partly)

Autonomy of PHC ndash FD - private (independed) contractors (Est 100 Lat Lith 50 political suport for intruduction in Russia))

Free choice and listing to PHC institutions and FD

Gatekeeping (Est Latv Lith in some regions of Russia)

One step forward two steps back

Lack of internal drive political intentions to step back since late 1990th 2000

primary health reform - hot political issue possibility of lobbying for ldquopopulisticrdquo parties

Active reformists ndash kamikaze experience

Estonia ndash success story of PHC reform

strong leadership of Tartu university FD association

practical approach to implementation

careful change-management strategy to avoid health reforms being politicized too early in the process

early investment in training to establish a critical mass of best model of health professionals

Atun RA Menabde N Saluvere K Jesse M Habicht J Introducing a complex health innovation--primary health care reforms in Estonia (multimethods evaluation) Health Policy 2006 Nov79(1)79-91 Epub 2006 Jan 6

Deviations from core Primary Care principles

How strong organisational PC features to apply and nurture proper compentences in primary care

First Contact Coordination continuity Comprehensiveness Family orientation Community orientation

Different developments

Every country have good examples to demonstrate

First Contact

II

I

II

I

III III

gt 50 health problems

lt20 health problems

New model

DI DP FD

Semashko model

Over 50 direct contacts to the specialists (out of all encounters with physicians)

FD ndash first contact with overall health care system

Very ambitious goal for Semashko model countries

First Contact ndash intentions to step back

Patients are looking for easier access to the specialists More then half the respondents would be willing to pay higher patient fees in order to

have easier access to specialized care (TDRC study Latvia HIT 2008)

Free access to any health care - constitutional right (Belarus)Strong political intensions to open free access to the secondary health care specialists in Lithuanina Latvia 2008

Unequal competences and conditions of PHC physicians to play a role of gatekeeper

GPs after 3 years residency Retrained from district physicians District physicians Private independent contractors vs policlinics

Coordination continuity

1996-99 most intensive changes in Lith Latv Est listing (free choice) to FDndash coordinator of care with referal free choice of any specialist within country

Estonia 90 of population new their FD and only 15 changed

during last year (Atun et all 2006) recently advanced e-health technology used for shared pt

records

Belarus ndash 75 - 90 of patients indicated they would address problem to their GP or therapist before seeking help from spec

(WHO NIVEL study 2009)

Projects aimed to foster teamwork in PHC (Lihuania 2000)

Specialists ndash keeping power in first line care

Often more political power including municipality boards

Suplier induced demand

Specialistsrsquo driven privat clinics in Lith

From FD gatekeeper to FD gateopener

Capitation payment for FD services +fee for service for consultations

Comprehensiveness

Increased scope of diagnostic and treatment services if service provided by FD (Jurgutis 2002 Atun 2006 Jankauskiene 2007 Liseckiene 2009)

In Belarus FD have a much more comprehensive role when compare with district interninst (WHO NIVEL study 2009)

No significan changes in preventive amp health educational services in Lith (Liseckiene 2009)

Less comrehensiveness if FD working in the same premisses with secondary care specialists (Raila G 2007)

Lack of incentives

Comprehensiveness and chronic diseases

Improtance of comprehensive family doctorrsquos care for patients with several chronic diseases (high comorbidity)

Patients with high comorbidity who have registered with family physicians more often visit their primary health care physicians and need specialist care less often compared to patients who registered with district physicians

consistent finding for adults with several chronic conditions including asthma diabetes hypertension and IHD

similar finding for children with hypertension but not for children with asthma

(Jurgutis A Martinkenas A Lemke K Bumblys A 2008)

Family orientation

Ideas on GPs for children and GPs for adults (Bel Rus)

Better satisfaction with FD care no difference in performance (Est)Belarus ndash 70 FD serves both children and adults (Atun 2006)

First visit to the child by family doctor and nurse in rural district of Klaipeda region Lithuania

Political lobying of pediatritians to get back responsibility for primary care of children (Lat Lith)

Community orientation

Community oriented primary health care ndash limitted to some very good examples could be found in all East Europe countries

Lith case Through team based PC community interventions in rural community succesfully controled arterial hypertnesion increased from 12 in1998 until 23 6 in 2004 (Andriauskas 2005)

Free choice of FD ndash lost defined geografic area

Challenges to be addressed (1)

Unequal accesibility of proffesionals

with core FM competences

ldquoExcuserdquo policy for district internist and district pediatritians (not trained as family doctors)

Estonia ndash the only country from former soviet which have only FD since 2005 Lithuania ndash still 31 population served by district internist and pediatritians Belarus ndash only 15 of FD mainly in rural areas

Russian Federation Emphasised priority to Primary Health care through National Programm ldquoZdorovierdquo

since 2006 plus 10 000 rub per month to every PHC physician (average drs salaries in 2006 about 8000)

still equal policy FD DI DP

Challenges to be adressed (2)

More responsibility and competence for PHC nursebull managemnt of patients with chronic conditionsbull role in community health need assesmentbull leadership in primary health care team

Teamwork and cooperation with other sectors ndash social workers public health specialists schools etc bull to emphasize role of social workers for chronic conditions

Latvia Nurse assist doctor in consultancy room Also often case in Lith Rus Bel


As reported by FD and nurses in NDPHS Workshop ldquoTomorrows role of Family doctors and Nursesrdquo (Baltic Conference of Family Medicine Piarnu Estonia Sept 2009)

Unequal distribution of PHC practices ndash not attractive rural areas

Increasing workload ndash burnout particular problem for solo practices

Lack of tools for patients empowerment motivational counceling

Extended PHC team needed

More emphasis to patient centered holistic care (informed patinets emigrants needs to empower for selfcare)

Introduction of EB performance indicators

Internal quality assurance tools

Appropriate incentive payment scheems

Opportunities for for further PC development in North East Europe

Recent years role of primary care was again reinforced by national policy makers

Financial shortcuts forced to rationalise health care systems

Closing hospitals ndash needs for stronger care in the community

Less patientsrsquo complains and political tensions if strong PC team

More internal drive and plans for ambitious PC reforms in in East Europe Countries

Arnoldas

Russia ndash plans for more efficient PHC

New Minister of Health of Kaliningrad oblast Mr V E Golikov observs privat FM practice in Lithuania (August 2010 Klaipeda)

Kaliningrad oblast 1mln inhbull trained 77 FD working only 22bull stronger primary care ndash expressed public need

bull plans for FD ndash independed contractors with Mandatory Health Inssurance (MHIF)

bull piloting new payment scheems ndash FD partly fundholding

Belarus ndash rethinking primary health care

Strategy for HC development 2011 ndash 2015

Residency of Family Medicine up to 2-3 years (recently 6 month retraining)

Introduction of quality indicators for PHC

New payment scheems for PHC providers

Family doctorrsquo consultation in Family Medicine Center in Belarus

Opportunities through joint project activities

Initiated by NDPHS EU BSR project IMPRIM ndash ldquoImprovement of public health by promotion of equitably distributed high quality primary health care systemsrdquo

13 organisations from 6 countries (Bel Latv Lith Est SweFin)

6 MoH as associate partners (Bel Latv Lith Est SweFin)

3 years 26 mln Euro

Opportunities for Kaliningrad oblast to joint project activities (SIDA funding)

wwwoekseimprim

Conclusions

All North East contries since 1990-ies are in the process of reform of their primary health care systems still implementation of PC principles varies between the countries and within the countries

Estonia has experienced most ambitious reform and fully introduced based on family medicine PHC model

Recent financial shortcuts forced to rationalise health care systems and primary care is reinforced once again

It is now high time for commited national policy makers to fortify genuine primary care in the East countries of the Baltic Sea region

Thank you for your attention


Slide 2


Common past







First Contact




Comprehensiveness


Family orientation









Conclusions

Slide 27

Oslo Declaration of 27 October 2003 ndash ND Partnership in Public Health and Social Wellbeeing (NDPHS) ndash four Expert Groups till June 2010 (reorganisation is going-on)

HIVAIDS Expert Group SILWA Expert Group Prison Health Expert Group

Primary Health Care Expert Group of the NDPHS

bull Lead country Sweden bullChair Dr Goran Carlsson Senior advisor MoHampSA

bull Active participation

Northern Dimension Partnership

Finland

Estonia

Lithuania

Norway

Poland

Russia

SwedenLatvia

Belarus

WHO European

Region Report PHC in ND countries httpwwwndphsorgdatabaseviewpaper2120
























association)Other























First Contact

II

I

II

I

III III



New model

DI DP FD

Semashko model














records










Comprehensiveness





Lack of incentives







Family orientation





































Arnoldas
















3 years 26 mln Euro


wwwoekseimprim

Conclusions







Slide 2


Common past







First Contact




Comprehensiveness


Family orientation









Conclusions

Slide 27
























association)Other























First Contact

II

I

II

I

III III



New model

DI DP FD

Semashko model














records










Comprehensiveness





Lack of incentives







Family orientation





































Arnoldas
















3 years 26 mln Euro


wwwoekseimprim

Conclusions







Slide 2


Common past







First Contact




Comprehensiveness


Family orientation









Conclusions

Slide 27























First Contact

II

I

II

I

III III



New model

DI DP FD

Semashko model














records










Comprehensiveness





Lack of incentives







Family orientation





































Arnoldas
















3 years 26 mln Euro


wwwoekseimprim

Conclusions







Slide 2


Common past







First Contact




Comprehensiveness


Family orientation









Conclusions

Slide 27











records










Comprehensiveness





Lack of incentives







Family orientation





































Arnoldas
















3 years 26 mln Euro


wwwoekseimprim

Conclusions







Slide 2


Common past







First Contact




Comprehensiveness


Family orientation









Conclusions

Slide 27







Comprehensiveness





Lack of incentives







Family orientation





































Arnoldas
















3 years 26 mln Euro


wwwoekseimprim

Conclusions







Slide 2


Common past







First Contact




Comprehensiveness


Family orientation









Conclusions

Slide 27







Family orientation





































Arnoldas
















3 years 26 mln Euro


wwwoekseimprim

Conclusions







Slide 2


Common past







First Contact




Comprehensiveness


Family orientation









Conclusions

Slide 27

































Arnoldas
















3 years 26 mln Euro


wwwoekseimprim

Conclusions







Slide 2


Common past







First Contact




Comprehensiveness


Family orientation









Conclusions

Slide 27
















3 years 26 mln Euro


wwwoekseimprim

Conclusions







Slide 2


Common past







First Contact




Comprehensiveness


Family orientation









Conclusions

Slide 27

Conclusions







Slide 2


Common past







First Contact




Comprehensiveness


Family orientation









Conclusions

Slide 27



Slide 2


Common past







First Contact




Comprehensiveness


Family orientation









Conclusions

Slide 27

primary health care in north east europe countries arnoldas jurgutis, phd, assoc. prof., head,...

Documents

health care primary

primary care reforms

future of primary care

centralized health care

phc separated phc

phc reforms

phc institutions

expert groups