Overview of Context and Performance of Primary Care System in Serbia

TRANSHIS Meeting, Amsterdam, March 31, 2011

Milan Jevtić, Predrag Životić

Pharmacies

Institute of PublicHealth of Serbia

Health CareCentres

Regional Institutes of Public Health

GeneralHospitals Private Specialist

Services

Primary HealthCare Centres

Private GeneralMedicine Clinics

PrivatePharmacies

HealthStations

HealthAmbulantas

University Clinical Centres

ClinicalHospital Centres

Speciality Hospitalsand Institutes

National ExpertCommittees andWorking Groups

Chambers ofHealth Professionals

Government of theRepublic of Serbia

Health InsuranceFund

National HealthCouncil of Serbia

Ministry of Health

Finance

Policy

Organisational Structure of Health Care System in Serbia

Assembly of theRepublic of Serbia

GeneralHospitals

Primary HealthCare Centres

Pharmacies

Government of theAP Vojvodina

Assembly of theAP Vojvodina

AP VojvodinaSecretariat of Health

Local Self-Governances(Cities & Municipalities)

PHC Health Care Institutes (students,

emergrnecy, elderly...)

Amended from: Bjegović V. and Rasmussen BL. 2002

Primary Health Care Service Providers

• PC Doctors, “chosen by citizens” – Adults (Age 19+): a doctor of medicine or a doctor of medicine

specialist in general practice, or a specialist in occupational medicine

– Children (Age 15 –): a doctor of medicine, specialist in paediatrics, or a specialist in general practice

– Women (Age 15 +): a doctor of medicine specialist in gynaecology

• Dentists• Other Specialists (Consultants in PHC Centers)• Nurses, Midwifes, Physiotherapists, Lab technicians,

Radiology Technicians, Pharmacy Technicians…• Pharmacists (Community)

Key features

Hospital Care “Driven” System

Fragmentated Health System

Compromised continuity of andaccess to care (effec. coverage)

1

2

3

4

5 “Medicalized” Primary Care

Weak Primary Care

Overview of results from the WHO Primary Care Evaluation Tool (PCET)

Wienke Boerma, Dionne Kringos (NIVEL, NL)

Martina Pellny, Valentina Baltag (WHO Euro)

State of affairs in Primary Carein Serbia

PCET Serbia: 3 areas

• Vojvodina–Novi Sad–Sombor–Indija

• Belgrade–Stari Grad–Voždovac

• Central Serbia–Niš –Doljevac–Smederovo

• Patients are positive about professional skills of their doctor (especially GPs)• Patients are positive and confident about their PC doctors (especially patients of GPs) (% patients feeling better to cope with condition after consultation)0 10 20 30 40 50 60 70 80 90 100

Vojvodina

Centr Serbia

Belgrade

Pats of paed

Pats of GP

Patients and doctors...

Medical records are well kept but on paper• Difficult to retrieve information by categories (% easy to generate this information; according to physicians)

25

21

19

52

32

24

0 10 20 30 40 50 60 70 80 90 100

Vojvodina

Centr Serbia

Belgrade

Paediatr

GPs

Continuity

• Strong regional variation in use of computers(% using a computer; according to physicians)

•Physicians use computers sparsely (% using a computer; according to physicians)

69

21

94

60

12

100

0 10 20 30 40 50 60 70 80 90 100

Vojvodina

Centr Serbia

Belgrade

Paediatr

GPs

• Computers are not used for searching information (% using the computer for searching information; according to physicians)

4

1

12

0

0

8

0 10 20 30 40 50 60 70 80 90 100

Vojvodina

Centr Serbia

Belgrade

Paediatr

GPs

• At central level: fragmented coordination of PC• Recruitment problems for GPs• Weak organisation of PC physicians • Copayment in PC may threaten equity• PC physicians lack incentives for performance• Low use of guidelines; •Patients are positive about their PC doctor• Possibilities of ICT are hardly used• Cooperation and teamwork are poorly developed • Very limited clinical service profile in PC (spec. GPs)• PC physicians are poorly equipped

Key conclusions

• Regional variation in PC working conditions• Many patients referred from PC to secondary level• Regional variation in referrals to secondary level• ‘Chosen’ doctors are ‘by-passed’• Curative home care services poorly available • CME not focused on improving individual capacity• Quality could benefit from more use of guidelines• Potentials of nurses in PC are not used• Health promotion is a priority not recognised by patients

Key conclusions (continued)

Extensive network of PC services, with devoted workers and patients who are positive about their doctor

Fragmented system with little challenges to workers and many possibilities to improve service quality and efficiency

Overall:

Use of Transhis Based Software in Kraljevo

TRANSHIS Meeting, Amsterdam, March 31, 2011

Municipality of Kraljevo

•Kraljevo

– Population ≈ 127.000

– Surface ≈ 1.200 km2

– ≈No of PHC Doctors: 60 GPs, 15 Paed., 12 OB/GYN

Key features

Advanced organizational structure (compared to the rest of Serbia)

All staff of PHC center in Kraljevo use on a regular basis EPR

No system incentive to use EPR

Questionable reliability quality of data (compared to intl. standards)

1

2

3

4

5 Local staff initiatives

Challenges and Issues

• Absence of ownership

• Frequent personal changes

• Heath Care System design (ICPC vs. ICD)

• Attitudes

• Fragmentation

• Data Quality and Reliability

• Standardized approach

Solid ground for further development

• Many users in a defined catchment area

• Large amount of generated data over time

• Acceptance of certain principles (mainly in IT community)

• Standards for PHC software development in Serbia inclusive of core concepts (RfE, Episode of Care)

Use of Transhis Based Software in Kraljevo,GP Department Data Set 2008-2010

TRANSHIS Meeting, Amsterdam, March 31, 2011

Age-sex profile of database 2007-2010, baseline population 127.000

  Male Female Total

N % of male % of age N % of female

% of age N % of total

0-4 2323 5.194 52.13 2133 3.996 47.87 4456 4.542

5-14 4552 10.18 51.13 4351 8.151 48.87 8903 9.074

15-24 3746 8.375 47.32 4170 7.811 52.68 7916 8.068

25-44 10926 24.43 45.28 13206 24.74 54.72 24132 24.6

45-64 12736 28.47 43.96 16238 30.42 56.04 28974 29.5

65-74 5225 11.68 44.3 6570 12.31 55.7 11795 12.02

75+ 5213 11.65 43.71 6713 12.58 56.29 11926 12.16

Total 44728     53383     98111  

Scope of the Database, Basic Figures 2008-2010

  2008 2009 2010 Total

Number of Practices 55 61 65 60

Number of Encounters 452,686 610,357 651,003 1,714,046

No of Encounters by Practice 8,231 10,006 10,015 28,410

Number of Active Patients 61,494 67,370 68,277 87,864

No of Active Patients/Baseline Pop. 0.481 0.527 0.535 0.688

No of Male Patients 26,450 29,414 29,552 39,974

No of Female Population 35,044 37,956 38,725 47,890

No of Episode Encounters 705,588 969,858 1,058,373 2,733,819

No of Episode Encounters New 180,144 217,181 217,204 614,529

Ratio New / Repeated Episodes Enc. 0.255 0.224 0.205 0.225

No of Prescriptions 830,985 1,033,531 1,130,791 2,995,307

No of Referral Letters to Specialists 68,621 84,551 80,350 233,522

No of Referral Letters to Labs 35,872 49,903 50,975 136,750

No of Intermediate Interventions 1,105,421 2,186,367 3,015,081 6,306,873

No of RFEs 1,070,264 1,517,423 1,639,618 4,227,305

No of RFEs by Encouter 1.517 1.565 1.549 1.546

Baseline Population 127,719

Top ten Episodes of Care, year 2008

Rank ICPC code and label No. of episodes

% of all episodes

1 K86HIPERTENZIJA, NEKOMPLIKOVANA 109,011 15.450

2 T90DIJABETES MELITUS TIP II (INSULIN NEZAVISNI DIJABETES)

29796 4.223

3 R74AKUTNA INFEKCIJA GORNJEG RESPIRATORNOG TRAKTA

24572 3.483

4 K87HIPERTENZIJA, KOMPLIKOVANA 17743 2.515

5 R78AKUTNI BRONHITIS BRONHIOLITIS 17197 2.437

6 U71CISTITIS/URINARNA INFEKCIJA, OSTALO 16923 2.399

7 A98ODRŽAVANJE ZDRAVLJA, PREVENTIVA 15905 2.254

8 K74ISHEMICNA BOLEST SRCA SA ANGINOM PEKTORIS

14988 2.124

9 L86SINDROM BOLNIH LEDJA SA RADIJACIONIM BOLOM

13777 1.953

10 K85POVIŠEN KRVNI PRITISAK 13329 1.889

  Total for top 20 episodes 273,241 38.727

  Total 705,558 100

Top ten Episodes of Care, year 2009

Rank ICPC code and label No. of episodes

% of all episodes

1 K86HIPERTENZIJA, NEKOMPLIKOVANA 154,258 15.905

2 T90DIJABETES MELITUS TIP II (INSULIN NEZAVISNI DIJABETES)

40124 4.137

3 R74AKUTNA INFEKCIJA GORNJEG RESPIRATORNOG TRAKTA

32731 3.375

4 A98ODRŽAVANJE ZDRAVLJA, PREVENTIVA 26751 2.758

5 R78AKUTNI BRONHITIS BRONHIOLITIS 24317 2.507

6 U71CISTITIS/URINARNA INFEKCIJA, OSTALO 22550 2.325

7 K87HIPERTENZIJA, KOMPLIKOVANA 21525 2.219

8 L86SINDROM BOLNIH LEDJA SA RADIJACIONIM BOLOM 19973 2.059

9 P76DEPRESIVNI POREMECAJ 19779 2.039

10 D07DISPEPSIJA/INDIGESTIJA 18694 1.927

  Total for top 20 episodes 380,702 39.253

  Total 969,858 100

Top ten Episodes of Care, year 2010

Rank ICPC code and label No. of episodes

% of all episodes

1 K86HIPERTENZIJA, NEKOMPLIKOVANA 176,348 16.646

2 T90DIJABETES MELITUS TIP II (INSULIN NEZAVISNI DIJABETES)

45261 4.276

3 R74AKUTNA INFEKCIJA GORNJEG RESPIRATORNOG TRAKTA

35251 3.331

4 R78AKUTNI BRONHITIS BRONHIOLITIS 31130 2.941

5 P76DEPRESIVNI POREMECAJ 25054 2.367

6 U71CISTITIS/URINARNA INFEKCIJA, OSTALO 24453 2.310

7 A98ODRŽAVANJE ZDRAVLJA, PREVENTIVA 23553 2.225

8 K87HIPERTENZIJA, KOMPLIKOVANA 21907 2.070

9 D07DISPEPSIJA/INDIGESTIJA 21815 2.061

10 L86SINDROM BOLNIH LEDJA SA RADIJACIONIM BOLOM

21101 1.994

  Total for top 20 episodes 425,873 40.223

  Total 1,059,373 100