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SEMINAR ON PHCNICOSIA UNIVERSITY
ANDREAS POLYNIKIS MD, MPH
CHIEF MEDICAL OFFICERMINISTRY OF HEALTH
7 MAIOY 2007
Presentation aims:
DEFINITION OF PRIMARY HEALTH CARE (PHC)FUTURE & UNAVOIDABLE REALITIES THE HEALTH CARE DELIVERY DYNAMICIMPLEMENTATION ISSUESTO PRESENT THE STRUCTURE OF PHC To define the processes of PHC in
CyprusTo explain Key historical, developmental
and contemporary realities affecting, PHC and in extend the Present HCS in Cyprus
The Forth Coming Health Care Reforms and the New Role of PHC 04/11/232
Primary Health Care in Cyprus (Dr. Andreas Polynikis, M.D, MPH,
Chief Medical Officer of the Ministry of Health, Cyprus)
Primary Health Care in Cyprus
DEFINITION OF PRIMARY CARE
Refers to directly accessible, first contact ambulatory care for unselected health related problems;
Offers diagnostic, curative, rehabilitative and palliative services
Offers prevention to individuals and groups at risk in the population served;
Takes into account the personal and social context of patients;
Is provided by a variety of disciplines, either within primary care, secondary care or related sectors;
Assures patients continuity of care over time as well as between providers.
04/11/235
WHY PHCWHO health policy on a primary health care
model includes:- Improved population health outcomes for all
cause mortality, all cause premature mortality and cause specific premature mortality for major respiratory and cardiovascular disease
- Higher levels patient satisfaction
- Reduced aggregate health care spending - Increased equity and access
04/11/236
FUTURE & UNAVOIDABLE REALITIES 1
Differing approaches/developments in health system governance and management - centralisation/decentralisation /privatisation
Slow moving legal systems; Emerging variations in the development of new
financing systems and their influence on system dynamics – taxation financed, social health insurance, private insurance, privatisation, mixed systems and even developing voucher systems (Georgia)
Widely differing levels of health system resourcing and contributions of Government, legitimising greater influence over policy and strategy
04/11/237
FUTURE & UNAVOIDABLE REALITIES 2
Population behaviours based on historical customs and preferences
A continuing domination by secondary and tertiary care forces of educational, professional and political systems
Policy and strategy influences and ambiguities – gatekeeper role, curative care duplication, health promotion and health status improvement, health maintenance etc.
04/11/238
FUTURE & UNAVOIDABLE REALITIES 3
Perverse financial and commercial pressures operating in competing directions (pharmaceutical suppliers, medical consumable suppliers, prescribing pressures, and software development)
Lack of development in some countries of rehabilitation members of PHC team and of complementary social and welfare systems and models to work alongside primary care services
The fast pace of health care delivery innovation and potentialities (the pace of which is likely to increase over the next decade)
04/11/239
04/11/2310
Range Average European
Region
High/Low
Doctors/ 1000 Population2002 – 2006
0.3 - 5.0 3.2 High: GreeceLow: Bulgaria
Nurses/ 1000 Population2002 – 2006
2.9 – 19.5 7.8 High: IrelandLow: Turkey
Pharmacists/ 1000 Population2002 - 2006
<0.1 – 1.1 0.2 High: France/FinlandBelgiumLow: Several
Total Expenditure on Health as % GDP2005
3.9 – 11.4
8.6 High: SwitzerlandLow: Kazakhstan/Azerbaijan
Government expenditure on health as % total health expenditure 2005
19.5 – 90.7 74.3 High: LuxembourgLow: Georgia
Per capita expenditure on health International $ PPP 2005
106 – 5,521 1,649 High: LuxembourgLow: Tajikistan
Source: World Health Statistics 2008, WHO
THE HEALTH CARE DELIVERY DYNAMIC
INPATIENT DAY PATIENT
DAY PATIENT OUTPATIENT
OUTPATIENT OFFICE
OFFICE HOME CARE
HOME CARE SELF CARE
04/11/2311
HOW IS THE CASE IN CYPRUS TODAY
CHALLENGESAGINGTECHNOLOGYNEW PHARMAEUTICALS.ADVANCES IN PROVISIONINCREAS EXPECTATIONSHEALTH CARE REFORMS
PHC AND HIO
BACHGROUN
SINCE CYPRUS WAS A BRITISH COLONY
TRYING TO INTRODUCE HEALTH CARE SYSTEM
1987-1989: DECIDED PHC TO BE PRIVATE
1990: DECISION TO INTRODUCE NHIS.
19 IN THE PROCESS
PHC AND NHIS
PHC TODAY
•PUBLIC SECTOR
•PRIVATE SECTOR
PUBLIC SECTOR
04/11/2316
PROVIDES ALL LEVELS OF PHC
HEALTH CARE, HEALTH PREVENTION,HEALTH EDUCATION AND PROMOTION
75 ΙΔΙΩΤΙΚΕΣ ΚΛΙΝΙΚΕΣ 1500 ΙΔΙΩΤΕΣ ΙΑΤΡΟΙ ΚΥΡΙΩΣ solo practices ΤΟΥΡΙΣΜΟΣ ΚΑΙ ΥΓΕΙΑ
Lack of Standards and Protocols.
HCS in CyprusHCS in Cyprus
Β. Β. ΙΔΙΩΤΙΚΟΣ ΤΟΜΕΑΣΙΔΙΩΤΙΚΟΣ ΤΟΜΕΑΣ
18
235 SUBCENTERS OVER CYPRUS
• Each PHCC covers up to 18 subcenters*
• Team of GP, nurse and pharma-cist visits 1-6 subcenters per day
• Subcenters are a ≤ 30 min drive from the PHCC
Main PHCCs
Subcenters
*99 subcenters located in villages with children also receive weekly health visits for vaccinations and mother-and-child services. In some cases (remote locations) health visitors perform visits even if only one child is in the village
Source:MoH data; visits to PHCCs; Google Earth
19
20
21
2
3
4
5
6
7
8
9
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
AustriaBelgiumBulgariaCyprusCzech RepublicDenmarkEstoniaFinlandFranceGermanyGreeceHungaryIrelandItalyLatviaLithuaniaLuxembourgMaltaNetherlandsPolandPortugalRomaniaSlovakiaSloveniaSpainSwedenUnited KingdomEU
Public sector expenditure on healthas % of GDP, WHO estimates
0
1
2
3
4
5
6
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
AustriaBelgiumBulgariaCyprusCzech RepublicDenmarkEstoniaFinlandFranceGermanyGreeceHungaryIrelandItalyLatviaLithuaniaLuxembourgMaltaNetherlandsPolandPortugalRomaniaSlovakiaSloveniaSpainSwedenUnited KingdomEU
Private sector expenditure on health as % of GDP, WHO estimates
25
The initiatives should be piloted in a big, urban PHCC in Nicosia
Source:MoH team
Criteria Strovolos PHCC
Number of GPs 1
6
Number of nurses
24
Number of administrative staff
3 • 5 assistants• 1 receptionist• 1 messenger
Number of pharmacists
4 • 3 pharmacists• 1 assistant pharmacist
Number of computers
50
Use of patient files
6
Aglantzia PHCC
5
3
• 2 assistants• 1 messenger
• 2 pharmacists• 1 assistant pharmacist
6 (all doctors have personal PC)
Lakatameia PHCC
5+1 part-time
3
• 2 assistants• 1 messenger
• 2 pharmacists• 1 assistant pharmacist
1
(common with allied health professionals)
Team decision
Aglantzia was already used for a
pilot before
26
With NHIS, all 41 PHCCs will continue to offer non-FD services while 25 PHCCs in areas with insufficient private doctor coverage will also offer public FD services
*Other services include: school services, mother and child services, community nursing, community mental health, and dental services
Source:MoH team
Family doctor (FD) services(~85%)
Other services*(~15%)
16 PHCCs in areas with high private doctor coverage
25 PHCCs in areas of low/no private doctor coverage
41 Primary Health Care Centers (PHCCs)
PHCC network stays within MoH after implementation of NHIS
FD services provided by private initiative (unused space in PHCCs can be rented to private doctors)
Services provided by MoH
ALIGNMENT WITH MINISTER
Negotiation with HIO and
CMA necessary
27
The current sub-center concept has significant disadvantages
*Estimate (~401 municipalities/communities in Cyprus – ~40 urban/suburban municipalities, and communities with PHCCs)
Source:MoH PHCC team; CYSTAT
Medical and pharmaceutical care at subcenters does not have adequate impact, since • No sufficient infrastructure is available (e.g. no ECG/cardiac monitor, lack of heating/
telephone line sometimes, no blood testing facilitation, improper drug storage)• More than 70% of subcenter consultations are prescription renewals for patients with chronic
conditions
1
Coverage by subcenters is not uniform, since only 65% of all villages have subcenters (235 out of ~361* villages) covering ~72% of the population
9
There is almost no sufficient primary care coverage, since subcenters are open only once/twice a week, or once every two weeks
8
Even today, a need for private transportation exists at subcenter locations, because patients need to get to the PHCC or hospital themselves in case of referral, acute illness or regular checks
7
Up to 32% of the team’s working time is wasted travelling10
Infrastructure
Coverage
Operations
Visiting doctors do not have the opportunity to consult one another since only 1 doctor visits the subcenter at a time (as opposed to the group of doctors available at the PHCCs)
6
Patients do not have the opportunity to be seen by the same doctor since a different doctor visits the subcenter every time
5
Some subcenters are overcrowded because there is no appointment system and a lot of patients visit the subcenters without real need
4
Our doctors, pharmacists and nurses can be utilized
in a better and more impactful way
Consultation time is limited as the visiting team can only spend a limited amount of time at each subcenter before going to the next one
2
The subcenters do not offer significant prevention and health promotion services, which are basic primary health care objectives
3
28
The team recommends that sub-centers be discontinued and that an alternative solution be offered to selected rural villages
*A one-by-one examination of subcenters can be done at the implementation stage using more detailed criteria
Source:MoH team
Option 1 Option 2 Option 3
• Discontinue all subcenters• Do not provide alternative solution
for subcenters*:– In urban areas – Less than 5 km from next
PHCC– With less than 20 consultations
per month– With private doctor and private
pharmacy in the village• Provide alternative solution with
higher medical quality for remaining subcenters
• Discontinue all subcenters• Do not provide alternative solution
for any subcenters
148 87235
Current No alternative
Alternative
194 41
235
No alternative
AlternativeCurrent
• Discontinue all subcenters• Do not provide alternative solution
for subcenters**:– In urban areas – Less than 5 km from next
PHCC– With less than 40 consultations
per month– With private doctor and private
pharmacy in the village• Provide alternative solution with
higher medical quality for remaining subcenters
• Medical personnel travel time reduction of 24 FTEs
• Opportunity cost reduction EUR 1 million per year
• Medical personnel travel time reduction of 24 FTEs
• Opportunity cost reduction EUR 1 million per year
Impact • Medical personnel travel time reduction of 24 FTEs
• Opportunity cost reduction EUR 1 million per year
Politicalcost
0
235235
No alternative
AlternativeCurrent
Team recommendation
Transition period required for full implementation
29 *The local authorities will be responsible to retain/improve/maintain adequate space at their own cost
Source:MoH team
The community nurse can provide basic care and facilitate prescriptions, which is the primary reason patients visit sub-centers
• Patient calls nearest PHCC to schedule appointment with community nurse (CN)
• Patient notifies reason for visit (e.g. prescription renewal necessary)
• Patient also submits medical history to the PHCC
• PHCC schedules appointment in system
• CN of PHCC is notified
• If specific CN is not available, CN from closest PHCC is notified
• CNs at PHCCs are connected to coordinate staffing for visits (e.g. in case of vacation or sickness)
• CN checks with doctor whether prescription should be renewed
• Patient’s medical history is available to CN and doctor in the system
• If prescription is approved, pharmacist at PHCC dispenses drugs
• CN brings drugs to patient during visit* and provides help with patient’s pharmaceutical regimen
• CN checks patient (e.g., blood pressure etc.)
• CN handles emergency prescriptions
Appointment Scheduling Planning Visit
• If patient has any questions or concerns, he/she can contact doctor or pharmacist
Follow-up
PRIMARY HEALTH CARELACK OF ORGANISATIONPUBLIC AND PRIVATEDEFINITION OF THE ROLE OF THE PHC DOCTOR
NO CATCHMENT AEREANO GROUP PRACTICENO PHC TEAMLACK OF CME
02468
101214161820
Under5,000
7,001-9,000
11,001-13,000
15,001-20,000
Over25,000
Gross Income
Distribution of household gross annual income
%
Income group composition
10%
27%
46%
17%
A-B
C1
C2D-E
Type of doctor visited by each age group (heads of household only)
0
10
20
30
40
50
60
70
80
%
18-29 30-49 50-64 65+
Age
GovernmentPrivateUnion
Type of doctor visited by each geographical region
0
10
20
30
40
50
60
%
Nicosia
Limas
sol
Larnac
a
Famag
usta
Paphos
GovernmentPrivateUnion
Type of doctor visited by each income group
0
10
20
30
40
50
60
70
80
%
A-B C1 C2 D-E
Income Group
GovernmentPrivateUnion
Type of doctor visited by annual income
0
10
20
30
40
50
60
70
80
%
Under5,000
7,001-9,000
11,001-13,000
15,001-20,000
Over25,000
GovernmentPrivateUnion
Top 10 reasons for visiting the doctor
Cold/FluRoutine CheckBlood pressureGyn check-upDiabetesGI problemsDermatologicalInjuryRoutine infant checkDifficulty movingOther
Top 7 Specialists Visited
Internist/GP (40%) Pediatrician (19%) Ob/Gyn (8.5%) Orthopedics (7.5%) Cardiologist (6%) Ophthalmologist (4%) Other (15%)
05
10152025303540
Excell
ent
Very g
ood
Goo
dSo S
o
Not go
od
Self-Reported Health Status
%
Out-of-pocket health expenditures as share of household income, 2002
6.4%
5.7%
4.6%
3.8%4.1%
3.0%2.6% 2.5% 2.6%
0.0%
1.0%
2.0%
3.0%
4.0%
5.0%
6.0%
7.0%
<5,000 5,000-7,000
7,000-9,000
9,000-11,000
11,000-13,000
13,000-15,000
15,000-20,000
20,000-25,000
25,000<
Annual household income
Mean out-of-pocket payments as share of household income(sub-sample: those who report any utilization)
Source: Hsiao & Jakab, 2003
Likelihood of Using Public or Private Physician for minor injury
Would you go to a public or private doctor for minor illness?
0
0.2
0.4
0.6
0.8
1
1992 1996 2002
Alw ays to public
Nearly alw ays to public
Sometimes to public
Rarely to public
Never to public
Source: Hsiao & Jakab, 2003
Proportion of the population with a personal doctor in each geographical area
58
60
62
64
66
68
70
72
74
% w
ith
Per
son
al D
octo
r
Nicosia
Limas
sol
Larnac
a
Famag
usta
Paphos
Type of personal doctor chosen by income level
0102030405060708090
100
%
Under5,000
7,001-9,000
11,001-13,000
15,001-20,000
Over25,000
Income
GovernmentalPrivateUnion
Type of personal doctor chosen in 4 income groups
0102030405060708090
100
%
A-B C1 C2 D-E
Income Group
GovernmentalPrivateUnion
Average time it takes to get to the GP:
Private vs. Government
8,27
0,65
0123456789
Mean Time
Government Private
Type of GP
HCS in CyprusHCS in Cyprus
Law: 89 (I)/ 2001
Law: 134(I) /2002
Provision for the introduction of General
Insurance Health Scheme in Cyprus.
NHIS
HCS in CyprusHCS in Cyprus
4 YEARS?? 2006 ΠΑΡΕΧΕΙ ΥΠΗΡΕΣΙΕΣ HEALTH CARE REFORMS
a) HISS
b) Training of GPs
c) Reorganization of MOH
d) Reorganization of Government Hospitals
e) Harmonization of Private Clinics with the law
f) Development of DRGS
g) Regulations
h) Training – Continuous Medical Education
IMPLEMENTATION
HCS in CyprusHCS in Cyprus
Primary H.C.: Capitation Fee (85%) Good Practice Filling Targets Environment Provision
Secondary H.C.: Out- Patients Specialists: Fee for Services Hospitalization: DRGS Casualties: Grant Blocks
Reimbursement of the Providers
15%
LAW 89(I)/2001 LAW 134(I)/2002
General Practitioners PROVISION FOR
Other Specialists
Pediatricians
Provision of care
GPs Provide health care to all enrolled on their list.
24 hours coverageprovision to change the GP
Reimbursement of GPs
Capitation fee (75%)Experience, good practice, preventive-promotive programs (25%)
Performance Measurement Systems
AccreditationCertificationUtilization ManagementPeer ReviewIndicatorsClinical Practice Guidelines and PathsReport cardsProductivity Profiles
Drs practicing general medicine
PhysiciansGPsRegistered Medical PractitionersCardiologistsOther internal subspecialties
Pediatricians: responsibility for the children under 15 years of age.
LAW 89(I)/2001
LAW 134(I)/2002
PROVISION FOR General Practitioners
Other Specialists
Pediatricians
Provision of the law Records keeping Denied backward referral Measurement of the performance Incentives for group practice Committee of Medical Audit. Safeguard of ownership of
Government medical institutions
Provision of the law (II)
Adequacy and satisfactory condition of waiting and examination rooms - spaces for records keeping
adequacy and satisfactory condition of the necessary medical equipment.
GPs List Size
First 3 years (300)After 3 years (500)Maximum 2500
Geographical Restrictions???
Provision of care
GPs Provide health care to all enrolled on their list.
24 hours coverageprovision to change the GP
Provision of Care
Medical CareDiagnostics, LaboratoriesDrug PrescriptionsHome Visits.
Referrals
Casualties direct accessAgreed certain cases for direct access to specialist care
Denied reimbursement for direct access.
Setting up partnership
incentives for the establishment of partnerships
Group practicesubsidy for the construction or
acquisition of buildings subsidy for medical equipment subsidies for employing nurses and
other healthcare professionals
Medical Audit Committee
Establishment of a medical audit committee.
for the purpose of securing high standard of medical care and the taking of suitable measures in relation to particular cases for not exercising reasonable skill or attention on behalf of the supplier.
Performance Measurement Systems
AccreditationCertificationUtilization ManagementPeer ReviewIndicatorsClinical Practice Guidelines and PathsReport cardsProductivity Profiles
Government Institutions
The Government shall take all the necessary steps, so that the medical institutions are updated in the sectors of organization, administration, management, equipment and functioning cost-effectively.
CONCLUSIONSMost countries have a sound health policy incorporating a well
articulated role for PHC. Weaknesses are not in the ‘what to do’ but in the ‘how to do’ – the capacity to manage change
PHC system design and implementation must also take account of differing historical, developmental, social, cultural, professional and other important issues – differing futures
The future development of PHC in CYPRUS will need clear principles not models; pragmatism and flexibility not polemic; a deeper understanding of underlying health system histories, culture and strategies and capacities for change in differing countries
04/11/2366
POSTSCRIPTS“Despite constantly rising health expenditures in European
countries, the health needs of growing subgroups of the population, such as the chronically ill, the elderly and those in need of hospice services in their homes, are not well met Over the past years these needs have changed quantitatively and qualitatively and they will continue to do so, as a result of the epidemiological transition related to the ageing of populations and the general increase in wealth in most countries.” (Boerma W. 2006)
Professor Alan Maynard continues to point out there are many simple evidence-based and cost-effective health care interventions (many of which relate to chronic disease management and the primary care level) which are still not in common usage throughout international health systems, even those with major resourcing problems.
04/11/2367
Finally…We all are suffering from a terminal
sexually transmitted disease called life. Death is inevitable
The role of doctors and health care managers is to use society’s scarce resources efficiently (EBM)
Inefficiency is unethical as it deprives potential patients of care from which they could benefit.
Finally Voltaire remarked “ the role of the doctor is to amuse the patient as nature takes its course”!
Source: Fitzgibbons, Steve “The heal th.net Indus try” Hambrecht & Quist, January 1999
Linchpins for Connectivity: Physician Offices Targeted
PHC AND NHIS
SUMMARY ΙΙ
•REFFERAL
•INFORMATION SYSTEM
•GROUP PRACTICE
•CME
•PCH TEAM
•SMART CARD