Report No. 32354-ECA Review of Experience of Family Medicine in Europe and Central Asia (In Five Volumes) Volume I: Executive Summary May 2005 Human Development Sector Unit Europe and Central Asia Region Document of the World Bank REVIEW OF EXPERIENCE OF FAMILYMEDICINE INEUROPEAND CENTRALASIA: EXECUTIVE SUMMARY CONTENTS ACKNOWLEDGEMENTS ......... .................. .......................................................................... 1 1, Introduction................ ...................................................................................................... 1 1.1. Why Family Medicine-Centered Primary Health ............. 1.2. Definition of Family Medicineand Primary Heal ........................................................... 1.3. Role o f Family Medicine-CenteredPHC inHealth Systems...................................... 1.4. Advantages of Health Systems Based on FM-centeredPrimary Care................................................... 3 1.4.1. Equity and access......................... Population health and aggregate health expenditure...................................................... 1.4.2. 1.4.3. Quality and efficiency of care............................................................................................ 1.4.4. Cost effectiveness............................................................................................ 1.4.5. Patient satisfaction............................................................................................................................ 4 1.5. Factors which Impactthe Quality of Care Delivered by Family Physicians......................................... 4 1.5.1. 4 Why FM-centered PHC Reforms inECA Region?............................................................................... Impact of specialisttraining inFamily Medicine on the quality of care delivered........................... 1.6. 4 ...................................................................................................................................................... 5 2.1. Objectives ofthe Study.......................................................................................................................... 5 2.2. The Evaluation Framework .......... 2.3. Primary Research.......................... 2.3.1. Qualitative research. ............................ ................................................................ 2.3.2. Primary health care facility andphys 2.3.3. PHC provider facility survey ............ 2.3.4. Survey o ftask profiles of family phy 2.4. Secondary Research................................................................. 2.4.1. Literature review...................... 2.4.2. Quantitative analysis................ 3. Case Study of Armenia ... ..................................................................................................... 3.1. Background.............................................................................. 3.2. Key Achievements.......... ........................................................................................... 3.2.1, Organizational and regulatory changes.................................................. 3.2.2. Financing, resourceallocation and provider payment syste 3.2.3, Professionalassociations ......... Resource generation........................ 32.4. 3.2.5. Serviceprovision..................... 3.3. Remaining Challenges To Be Add 3.3.1. Organization and regulations.......................................................................................................... 12 3.3.2. Serviceprovision................... ......................................................................................... 3.3.3. Resource generationinPHC.......................................................................... 3.3.4. Resource allocation andprovider paymentsystems ...................................... 3.3.5. Communicating the reforms .......................................................................... 3.4. Conclusion............................. ............................................. 14 4. Case Study of Bosnia and Herzegovina ....... 4.1. Background. ........................................................... ............................................................................................ 15 4.2.4.2.1, KeyOrganization Achievements................. and regulatio ............................................. 16 4.2.2. Financing .................................... ......................................................... i 4.2.3. Resourceallocation and provider payment systems ....................................................................... 16 4.2.4. Service provision 4.3.3. Financing, resour 4.4. Conclusion ........................................................................................................................................... 20 5. Case Study o f Estonia .................................................................................................................................... 21 5.1. Background.............................................................................................................................. 5.2. Key Achievements................................................................................................................... 5.2.1. Changes in organization and legal environment for PHC......... 5.2.2. Changes infinancing andprovider paymentsystems......................................................... 5.2.3. Changes in servicedelivery pattems......................................... ................................................ 22 5.2.4. .............................................. Remaining ChallengesTo Be Addressed.... User perceptions ......................................... 5.3. ............................................................ .22 5.4. Conclusion................................................... 6. Case Study o f Kyrgyz Republic ..................................................................................................................... 6.1, Background...... ........ ...24 24 6.2. Key Achieveme .......................................................................... .24 6.2.1. Organizational and regulatory changes........................................................................................... 24 6.2.2. Financing, resourceallocation and provider payment systems......................... 6.2.3. Service provision ............................................................................................................................ 25 6.2.4. Resource generation.. ................................ ...... 6.3. Remaining ChallengesT ............................................................................................ 27 6.3.1. Negotiating the glas ................................... 6.3.2. Organization andregulation............................................................................................................ 27 6.3.3. Service provision... ystems .............................................................. ................................................................................... 27 6.3.4. Resourceallocation 6.3.5. Resource generation............................................................................................. Limited incentives ................................................................................................................. 6.3.6. 6.4. Conclusion................................................................................................................ 7. Case Study of Moldova.................................................................................................................................. 30 7.1. Background......... ............................................................ 7.2. Key Achievement .......................................................................................................................... 31 7.2.1. Organizational and regulatory changes............................. 7.2.2. Financing, resourceallocation and provider paymentsystems....................................................... 3 1 7.2.3. 3 1 Remaining Challenges To Be Addressed.................. Resourcegeneration....................................... Service provision............................................................................................................................ 7.2.4. 7.3. 7.4. Conclusion............................................................................................... 8. Discussion.............. 8.1. Organization 8.5. Resource Generation........ 9. Conclusions.................................................................................................................................................... 41 9.1, Critical SuccessFactors. ............................. 41 11 9.2. ManagingStrategic Change...... .................................................................... 41 9.3. Holistic Approach..... 9.4. BeyondPilotsto Syst 9.5. Institutions versus Institutionalization.................................................... 9.6. BalancingShort andLong-termTime Horizons 9.7. Readingthe Context ......... ................................................................ 9.8. ........................................... .42 9.9. 9.10. 9.11. Responsiveness.................................... 9.12. Monitoring and Evaluation........................................................................ 9.13. Disseminationand Cross Learning................ 9.14. Exit Strategy........................................................................................................................................ 43 .............................................. 44 10.1.2. Primary care as a level ............................ 10.1.3. Primary care definedinterms of content 10.1.4. Primary care definedinterms ofteam m 10.1.5. Primary care as a key process ............... 10.2. Annex 2: DefiningFamily Medicineandthe 10.3. Annex 3: Factors Which Influence Quality of 10.3.2. Financingand providerpaym 10.3.3. Continuingmedical education ................................................................................... 50 11. References ................................................................................................................................ 57 Figures Figure 1: A Frameworkfor Analyzing HealthSystems ................................................ Figure2: Scope of Services Providedby the FM-led PHC Team inTransitionCountr ......................................... 37 Figure3: Scope of Services Providedby the FM-led PHC Team inKey OECD Countries ....................................... 38 38 Figure5: Influence of Family Physicians on PatientCare .................. Figure4: Attractiveness ofFamily Medicineas A Specialty .................................................... ............................. ................................................................... 39 Figure6: Capacity of Family Physicians to Resolve Problems..................................................................... ....39 Figure7: Regardfor Family Medicine........................................................................................................................ 40 ... 111 Tables Table 1: Role o f the Family Physician ................................... .................................... Table 2: Organizational Cha Table 3: Financing.............. Table 4: Resource Allocatio Table 5: Expansion o f Servi ...................... Table 6: Training Programs.......................................................................................................................... Table 7: Primary Care Services. Table 8: Membership o f the Table 9: Family Medicine Characteristics ................................................................................................................... 46 Table 10: Effectiveness Indicators - FirstContact Care 55 Table 11: Effectiveness Indicators: Continuity o f Care............................................................................................... 55 Table 12:Educational Requirements for Family Physicians....................................................................................... 56 This volume is a product o f the staff o f the International Bank for Reconstruction and Development/The World Bank. The findings, interpretations, and conclusions expressed in this paper do not necessarily reflect the views o f the Executive Directors ofThe World Bank or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map inthis work do not imply any judgment on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance o f such boundaries. iv ACKNOWLEDGEMENTS This report summarizes the findings o f four case studies that review the experience o f family medicine in Europe and Central Asia (ECA) Region. It is part o f a study comprising five volumes that review the experience o f FM in four countries in ECA - Armenia, Bosnia and Herzegovina, Kyrgyz Republic and Moldova. The report reviews the experience, draws lessons and establishes an evidence- base for detailed analysis. The study presents best practices for policy dialogue and future investments by the WB and other financial institutions. The detailed case studies compare these countries and draw common themes and issues. Comparisons are made with best-developed or existing models in the OECD and other ECA countries that have already undertaken FMreform. The report was financed by a Dutch Trust Fund. It was prepared by a research team led by Rifat Atun (Imperial College London) and included Alisher Ibragimov, Greta Ross, Adilet Meimanaliev, Samwel Hovhannasiyan, Evelina Cibotaru, Lilia Turcan, Viorica Berdaga, Ioannis Kyratsis, Gordan Jelic, Drazenka Rados-Malicbegovic, Zdravko Grubac, Nine1 Kadyrova, Ainura Ibraimova and Yevgeniy Samyshkin. The Task Profile Instrument was designed by Wienke Boerma. The study was prepared under the leadership of Betty Hanan. Kees Kostermans and Juan Pablo Uribe were the peer reviewers. Valuable comments were provided by Betty Hanan, Nedim Jaganjac, Joe Kutzin, Melitta Jakab, Sarbani Chakraborty, Jan Bultman, Enis Baris, Toomas Paalu, Sussanna Hayrapetyan, Paul Fonken, Asta Kenny and Sheila O'Doherty. Annie Milanzi, Carmen Laurente, Julie Wagshal and Anna Goodman helped to prepare the document for publication. 1 1. INTRODUCTION 1.1. WHY FAMILYMEDICINE-CENTEREDPRIMARYHEALTH CARE? 1. Many countries fall short o f their performance potential to achieve health system objectives o f equity, efficiency, effectiveness and responsiveness.' Health system performance can be enhanced if a strong FM-centered primary health care (PHC) level is present.2 PHC i s seen as an effective vehicle to "improve health-care access and outcomes while narrowing equity gap^."^-^ Scaling-up health care systems based on the principles o f PHC is identified as a key priority7and as the "means by which the goals o f health systems are balanced"*, as it deals with single or multiple health problems taking into account the context in which illness exists. 1.2. DEFINITIONOFFAMILYMEDICINE PRIMARYHEALTH AND CARE 2. The definition o f primary care varies in terms o f concept, level, service content, team membership and process. In the industrialized countries o f Europe and North America, the core PHC team consists o f a family physician, a community nurse, a practice nurse, a social worker, a therapist, a manager and administrative staff.'' As with the definition o f primary care, the definition and the role of the family physician (FP) vary by country"-12 (see Annex 1 for definitions o f PHC) whereas `specialist care' is defined as those services delivered by a narrow specialist - usually in hospital or in ambulatory setting, referring to services not delivered inprimary care. 1.3. ROLEOF FAMILYMEDICINE-CENTERED PHCINHEALTH SYSTEMS 3. Vuori describes the constituent components o f PHC as: (i)a set o f activities, (ii) level o f care, a (iii)astrategy fororganizinghealthservices, and(iv) aphilosophythat should permeatethe entirehealth system.I3 4. Family physicians manage key processes within health systems, including: (i)first contact care accessible at the time o f need; (ii)ongoing care, which focuses on the long-term health o f a person, not on the short-term duration o f the disease; (iii)comprehensive care, providing a range of services appropriate to common problems in the population; and (iv) coordination, by which the family physician or the PHC team act to coordinate other specialist services which the patient needs.l4> 5. Family medicine is an integral part o f PHC, but the terms are not always synonymous. The role of the family physician (also called a general practitioner, family practitioner or FM specialist) gives an indication as regards the breadth o f PHC services provided in the country. (See Annex 2 for definitions of family physician.). In industrialized countries, the PHC is staffed by family physicians who are trained as specialists, and not narrow specialists or doctors who have not specialized in FM. The family physician is the only clinician who operates inthe nine levels o f care.16 Table 1:Role of the FamilyPhysician Prevention o f disease Pre-symptomatic detection of disease Early diagnosis of disease Diagnosis o f established disease Management of disease Management of the complication of disease Rehabilitation after active treatment has been completed Terminal care Counseling o f the bereaved 6. The scope and pattern o f practice o f FM varies according to health system characteristics (organizational structure, financing, and payment systems), availability o f specialist family physicians, I the extent and quality of the training o f the family physicians, availability o f primary care team members and presence o f professional associations. 7. In most countries, family physicians play an important gate keeping role, with the family physician being the first point o f contact in the health system, with the exception o f some emergencies when a hospital emergency department or ambulance service may be accessed directly. In countries where the gate keeping function is well established, a patient cannot access a hospital specialist unless referred by a family physician. The gate keeping role o f family physicians is well established in the UK, Netherlands, Australia, New Zealand, Finland, Canada, and within the Health Maintenance Organizations inthe US, 8. In OECD and middle-income countries, the primary-secondary care interface is dynamic and changing, as are the boundaries that define the role o f the family physician or hospital specialist. In OECD countries, the scope o f activities undertaken by the family physician is expanding rapidly. Many hospital and outpatient services traditionally provided by narrow specialists have shifted to PHC setting. For instance, family physicians provide emergency care for conditions traditionally provided in hospital accident and emergency departments, manage chronic conditions in shared-care schemes, undertake hospital-care-at-home, or even manage community hospital^.'^-'^ 9. In the UK, the roles and responsibilities o f the family physicians are clearly defined and demarcated from the hospital specialists. In contrast, in the U S and Canada, there is some overlap with specialists taking on primary care practitioner roles in outpatient clinics in hospitals, the so-called `hidden primary care, and family practitioners undertaking hospital specialist roles.20-21For instance, in the US and Canada, family physicians are granted hospital privileges to admit and treat patients in hospitals. In Britain, Finland, and Australia, family physicians generally do not undertake inpatient care, and refer their patients to hospital-based consultants for both consultation and admission, but work closely with the hospital specialist to arrange follow-up o f the patient after hospital discharge. In Britain, some family practitioners manage community hospitals and work inhospitals as associate specialists. 10. InOECD countries, most common acute first contact problems and common chronic illnesses are managed by family physicians. Typically these include chronic obstructive airways disease, asthma, hypertension, diabetes, cardiovascular disease, rheumatic disorders, benign prostatic hypertrophy, skin conditions (eczema, psoriasis) and mental health. This care is made possible by improved training o f family physicians and diagnostic tools enabling near-patient testing. 11. In most systems, the family physicians provide family planning services and antenatal care. In the US, because o f shortages o f family physicians, family planning and antenatal services are also provided by an obstetrician/gynecologist.22 12. In the US and Canada, family physicians are granted rights to manage normal deliveries in hospital or at home. In the UK and Netherlands, with a strong tradition o f midwifery, many deliveries in hospital are managed by midwives, with hospital specialists overseeing the process in secondary setting. Family physicians, and sometimes midwives, in these countries undertake home deliveries for low-risk cases although this is becoming less common.23 13. Family physicians usually manage sexually transmitted illness (STI) and many care for tuberculosis (TB) and HIV/AIDS patients, especially in the UK or Netherlands. In Japan, the Government contracts the family physicians to treat TB patients. Post-Soviet countries are exception, where `dispensaries' staffed with specialists still manage STIs, TB and HIV. Mental illness, which accounts for 15.4 percent o f the total disease burden in developed countries24and 20 percent o f family physicians' workload, is effectively managed by family physician^.^^ 14. Family physicians are increasingly involved in palliative care o f patients with cancer, chronic obstructive airways disease, Alzheimer's disease, senile dementia and AIDS. A UK study found that breast cancer patients were more satisfied when returned to their family physicians for follow-up rather 2 than being followed in an outpatient oncology clinic.26 Family physicians also play an important role in planning and aftercare of the patients discharged from the hospital, ensuring continuity o f care, a hallmark o f FM. 'Hospital at home' schemes in some countries such as the UK have made it possible to manage complications and rehabilitation o f many conditions inthe community setting. 15. As family physicians manage a diverse range o f conditions in most countries, they are able to prescribe a wide range of drugs. In many countries, especially in rural areas where pharmacies are not available or not within easy reach, the family physicians also take on a dispensing role. This role is well established in Britain, Canada, and Japan. However, this practice sometimes has adverse consequences on patient care and cost. For instance, in Japan where the physicians earn a dispensing fee for each medication given to the patient, there is an incentive to increase the number o f patient visits by dispensing relatively small quantities o f multiple 1.4. ADVANTAGES OF HEALTH SYSTEMS BASED FM-CENTERED ON PRIMARY CARE 16. A review o f the empirical evidence, derived from both developing and developed countries, demonstrates that health systems with strong FM-centered PHC are able to effectively discharge first contact, comprehensiveness, continuity and coordination functions, and perform well in relation to health system goals and objectives o f improved health outcomes, equity, efficiency, effectiveness and responsiveness.28 1.4.1. Population health and aggregatehealth expenditure 17. Strength o f a country's PHC system (where family physicians play a key role) influences population health outcomes. Health systems with stronger PHC have better health outcomes.2g This relationship is significant, even after controlling for determinants o f population health at macro-level (GDP per capita, total physicians per one thousand population, percent o f elderly) and micro-level (average number o f ambulatory care visits, per capita income, alcohol and tobacco consumption). A higher PHC orientation o f a health system is more likely to produce better population health outcomes at lower cost and with greater user ~atisfaction.~' 18. Absence o f PHC is an important factor in determining poor health.31 Health systems dominated by narrow specialists, such as that inthe US, suffer from higher total health care costs and reduced access to health care by the vulnerable population^.^^`^^ The high cost is attributed to proportionately low numbers o f family physicians and consequent impairment o f the gate keeping Services delivered by narrow specialists are higher in cost as compared with comparable services delivered by family physicians - due to curative orientation o f narrow specialists who tend to use expensive technology, which pushes up health care costs without visible health gain at population leveL3* 19. Recent evidence demonstrates that a higher ratio o f family physicians to population results in lower overall mortality rates, as well as that for heart disease and cancer. By contrast, a higher ratio o f narrow specialists to population does not improve mortality rates3' 1.4.2. Equity and access 20. Within a developing country context, there i s evidence showing that expenditure on PHC is more pro-poor than that expenditure on hospitals. Expenditure on PHC has a desirable distributive impact, improving equity and benefiting the poorer segment o f the population proportionately more than the richer ~egment.~'-~' An orientation toward a health system based on narrow specialists enforces inequity in access.42Diminished access to family physicians results inworsening health status o f citizen^.^^-^^ 1.4.3. Quality and efficiency of care 21, Studies which compare care delivered by family physicians to that delivered by narrow specialists show that the quality and health outcomes are equal, even when family physicians substitute for secondary care specialist^.^^ Family physicians are more likely than specialists to provide continuity and comprehensiveness, which help improve health outcomes.46 Improved access to family physicians and 3 the gate keeping function they exercise lead to added benefits such as diminished ho~pitalization~"~~,less utilization o f narrow specialists and emergency center^'^-^', and reduced risk o f being subjected to inappropriate health intervention^.'^ Evidence from a systematic review suggests that broadening access to family physicians in PHC can reduce demand for expensive and narrow specialist-led hospital care.53 1.4.4. Cost effectiveness 22. In low-income settings PHC is co~t-effective.~~PHC activities, such as infant and child health, nutrition programs, immunization and oral hydration are `good buys' when compared with hospitalcare," and interventions delivered in PHC setting could avert a large proportion o f deathsaS6Even in resource- poor settings, it is possible to implement and sustain key PHC service^.'^ 23, Shifting care from narrow specialists to family physicians and from secondary to primary care has been shown to be cost-effective, without adverse affect on health outcome^.^^^^^ 1.4.5. Patient satisfaction 24. The `Euro barometer' survey o f citizens o f 15 EU Member States shows that countries with strong PHC systems tend to have higher public satisfaction with health care.65 Patient satisfaction with family physicians is strongly influenced by the mode o f care delivery, physician style, availability o f out- of-hours care, having a named physician, continuity o f care and provision o f routine ~ c r e e n i n g . ~ ~ - ~ ~ 1.5. FACTORS WHICH IMPACT THE QUALITY OF CAREDELIVEREDBY FAMILYPHYSICIANS 25. Quality o f care delivered by family physicians in PHC settings i s influenced by a number o f factors, including: (a) training in FM; (b) organizational arrangements -- management, extent o f teamwork, interface with secondary care, resource availability, gate keeping role, information systems, provider networks; (c) financing and provider payment systems; (d) physician characteristics -- education level, age, gender, postgraduate education, CME, approach to care, importance afforded to status, degree of altruism, value system and beliefs; (e) doctor-patient relationship -- trust and the degree o f asymmetry o f information (Annex 3). 1.5.1. Impact of specialist training in Family Medicine on the quality of care delivered 26. There is good empirical evidence to suggest that vocational training and C M E improves the knowledge, skills, competencies and attitudes o f family physicians, which in turn benefits patient care.7o There are limited studies that look at the impact o f vocational training on patient outcomes, as most studies focus on assessment and achievement o f trainees and their satisfaction with trainings7' Additional training of general practitioners in patient-centered care resulted in greater attention to the consultation process with improved communication with patients, greater treatment satisfaction and well-being.'* 1.6. W H Y FM-CENTEREDREFORMS ECA REGION? PHC IN 27. Empirical evidence shows that health systems with strong FM-centered PHC can better achieve health system objectives o f improved equity, efficiency, effectiveness and responsiveness. Further, having more narrow specialists or higher specialist-to-population ratios to family physicians offer no advantages in meeting health needs o f the population and may lead to unnecessary care with adverse health consequences. However, despite this evidence, introduction o f FM-centered PHC has been challenging. Even in countries with advanced health systems there is still much variation in extent o f PHC services delivered and the experience o f citizen^.'^ In the ECA region, there is much room to enhance FM-centered PHC to deliver safe, effective, timely and patient-centered care. Many o f the inherent challenges faced by the health systems intransition countries inthe E C A region can be addressed ifastrongFM-centeredPHCsystemcanbeestablished. 4 2. METHODS 2.1. OBJECTIVES OF THE STUDY 28. The objectives o f the study were to review the experience o f FM in Europe and Central Asia, present best practices, and make recommendations for policy dialogue and future investments. 2.2. THEEVALUATION FRAMEWORK 29. The evaluation used a framework to analyze key changes in health system elements and intermediate goals in relationto primary health care (See Annex 4.) Figure 1:A Frameworkfor Analyzing Health Systems Organisational Financing Effectiveness J \r---zq Provision Satisfaction Source: Atun RA and Lennox-Chhuggani 30. This framework builds on that developed by H s i a and~ identifies four levers, available to the ~ ~ policy makers and managers in health systems. Management and modification o f these levers enables policy makers to achieve different intermediate objectives and goals. The `organizational arrangements' lever refers to the policy environment, stewardship function, and structural arrangements in relation to funding agencies, purchasers, providers and market regulators. Financing and resource allocation levers refer to resource collection, pooling, allocation, and the mechanisms and methods used for paying health service providers. The `provision' lever refers to the `content' -the services provided by the health sector rather than the structures within which this `content' i s delivered, The intermediate goals identified inthe framework -- equity, technical and allocative efficiency, effectiveness and choice -- are frequently cited by others as end goals in themselves. However, in this framework efficiency, equity, effectiveness and choice are taken as means -- contributing to attainment of the health sector's ultimate goals o f health, financial risk protectionand user satisfaction. 3 1. An important finding o f literature search and initial country visits was the lack o f systematically collected data at PHC level; hence, primary research was undertaken to generate original data to complement secondary research findings. 5 2.3. PRIMARY RESEARCH 32. Primary research comprised three elements: (i)qualitative research, (ii)primary health care facility survey, and (iii)physician task profile survey. 2.3.1. Qualitativeresearch 33. Qualitative research involved key informant interviews to explore their understanding o f the goals and objectives o f the reforms, changes in structures and processes, key enabling factors and obstacles to reforms, major achievements and lessons learned, and to ascertain their perceptions o f the FM reforms, critical success factors, barriers and enablers which influenced the introduction and diffusion o f FM reforms. 34. A semi-structured questionnaire was specifically developed for the study for face-to-face in-depth interviews o f key informants. The questionnaire was piloted initially in Estonia, then refined and iteratively tested in the four countries studied. Purposive sampling was used over two stages.76 An initial set o f key informants was interviewed for the first stage o f the study using a semi-structured questionnaire. The data emerging from the initial set o f interviews were analyzed to identify key emerging themes, which were explored further usinga refined and shortened topic guide to allow in-depth exploration o f some o f the key themes.77 The second stage also employed `purposive sampling' with `snowballing' to capture a multi-level, multi-stakeholder sample o f key informants, representing the key stakeholders involved in PHC reforms in both policy development and implementation. 35. The analysis informed the detailed case study by capturing key structural and process changes, issues related to design and implementation o f PHC reforms, the drivers and barriers to reform, the factors influencing the establishment o f an enabling environment for change and the lessons learned. 2.3.2. Primary health carefacility andphysician taskprofile surveys 36. These two elements o f primary research were done concurrently to explore changes in service delivery and practice o f family physicians as a result o f the PHC reforms and training o f physicians as FM specialists. It was not possible to do a pre- and post-intervention study as there were no baseline studies that analyzed service delivery patterns and physician practices before and after the reforms. Two cross- sectional studies were conducted simultaneously: (i)primary health care facility survey, and (ii) physician task profile survey. PHC directors were interviewed for the Facility Survey and doctors working in the PHC facilities for the Task Profile Survey. A two-stage sampling was followed with probability proportional to size. Regions were selected based on the relative stage o f development o f FWPHC reforms (advanced, intermediate and early/low) and geography (urban/rural). In the second stage o f sampling, a random sample o f PHC facilities was used, proportional to the size o f the population served in the region, Around 100 PHC facilities and 200 doctors working within these facilities were surveyed ineach ofthe four countries. 2.3.3. PHCproviderfacility survey 37. A facility survey instrument was developed by the research team specifically for the study, drawing on guidance and methodologies developed by the World Bank and other international agen~ies.~' The instrument was refined following discussions with local collaborators to ensure appropriateness to the local context and field-tested before application in the countries included in the study (Annex 5). The instrument was coded and a computer program was written in Access@ for data entry and analysis. The researchers performed statistical analysis to test for observed differences. 2.3.4. Survey of taskprofiles of family physicians 38. The second component o f the primary research was a cross-sectional survey o f the `Task Profiles of Family Physicians' aimed to identify the scope and availability o f services and skills o f doctors working at PHC level and to explore similarities and differences between FM specialist and non-specialist GPs. An instrument developed by the NIVEL Group inthe Netherlands was used. This was validated in 6 32 European c~untries.~'The instrument is available inRussian (Annex 6). The instrument was obtained from the author, Dr W. Boerma, and with his permission used in the study after minor modifications following field-testing to ensure contextual sensitivity. 2.4. SECONDARY RESEARCH 39. Secondary research comprised: (i) review o f published international and in-country literature to a ascertain key legislative changes related to the reforms and to identify changes in financing, resource allocation, provider payment systems, organizational changes and regulation, and service provision, and (ii)whereavailable, analysisofcross-sectional andlongitudinalreferralandadmissiondata. 2.4.I. Literature review 40. The literature review was supplemented by documentary analysis o f published reports, key legal instruments and policy documents from the four countries, WB publications (including missions' aide memoires), Health Systems in Transition (HIT) reports published by the European Observatory on Health Systems Research, and relevant studies on WB HNP projects inthe ECA region. 2.4.2. Quantitativeanalysis 41. Secondary research involved aggregation and analysis o f quantitative data (cross-sectional and, where available, longitudinal data) from studies undertaken in the country, from the routinely collected statistics and from Health Insurance Funds. Drawing on internationally validated instruments and indicators, key outcomes influenced by effective delivery o f PHC-- forconditions commonly managed in PHC, such as acute respiratory illness, anemia, diabetes, ischemic heart disease, hypertension and heart failure -were analyzed.80(Annex 7.) 7 3. CASE STUDY OF ARMENIA 42. This chapter summarizes the findings o f a detailed case study o f FMreforms in the Republic o f Armenia, which is published as a separate volume.8' 3.1. BACKGROUND 43. The Republic of Armenia inherited a health system based on the Soviet Semashko Model characterized by centralized and hierarchical organization and a large provider network with a curative focus, dominated by hospitals and with poorly developed PHC level. The system was characterized by parallel sub-systems for line ministries and large organizations; fragmented delivery model in PHC with a tripartite polyclinic system staffed by narrow specialists, which provided services separately for adults, women and children, as well as a large number o f vertical programs delivered by narrow specialists. 44. The health system suffered a number o f shortcomings, such as: (i)overly specialized and fragmented care, poor physical condition o f health facilities, and lack o f modern equipment; (ii) excess human resources concentrated in cities; (iii)inequitable resource allocation based on historic activities and inputs which favored large hospitals in urban centers at the expense o f rural areas; (iv) line-item budgeting o f provider units and salary-based payment systems, which encouraged inefficiency and discouraged improved performance; (v) care delivery protocols, which encouraged excessive referral to secondary care level; and (vi) limited user empowerment, where the citizens were allocated to doctors and unable to exercise choice o f providers. 45. Following independence, economic recession led to a rapid decline in the level o f public funding available for the health system, which felt to around 1 percent o f the GDP, thereafter increasing to 1.4 percent in 2004. This resulted in a substantial funding gap between the level o f financing needed by the health system and the available resources. From 1995 onward, the Government sought to introduce multifaceted health reforms centered on developing a strong PHC system to address organizational complexity; excess infrastructure and human resources; allocative inefficiency and inequities in financing; inefficient service provision; limited incentives; and low pay levels for health personnel. 3.2. KEY ACHIEVEMENTS 3.2.1. Organizational and regulatory changes 46. Despite a highly resource-constrained environment, Armenia has been able to introduce the FM- centered PHC reforms to parts o f the country and achieve structural changes with separation o f purchasing and provider functions. Several key laws have been enacted to create an enabling environment to develop the health system. In 1996, the Government approved the "Program for development and reform o f the healthcare system in the Republic o f Armenia", with a special focus on financial reforms,82followed by the Medical Care The latter act introduced mixed financing o f the health system enabling health providers to mobilize funds from various sources, including local budgets, external aid, health insurance payments and direct private out-of-pocket payments, which were introduced in 1997 for the majority o f health care services beyond the basic package applicable to all non-vulnerable and non-targeted groups o f the population. 47, Subsequently, all State health care establishments were granted the status of `state enterprises` and transformed into `state owned closed joined stock companies' in 2000. During the same period, polyclinics were given an autonomous status and were no longer subordinated to hospitals and defined as the primary care level o fthe health system. 48. In 1998, the PHC Working Group established under the Bank-financed Health Financing and Primary Health Care Development Project drafted the provisions on "Family doctors" and "Family nurses". The "Family Doctors Provision Guidelines" were approved in 1999 and provisions adopted in 8 2000.84 In 2003, the Government adopted a decree outlining a new PHC Strategy for the Republic o f Armenia, outlining the Government's vision for developing PHC between 2003 and 2008. 49, Family medicine is recognized as a specialty in Law. The scope and content o f FM services have been articulated in law and defined in detail in the State Guaranteed Basic Benefits Package. In some regions o f the country, the tripartite system o f pediatric, women's and adult polyclinics has been consolidated into unified PHC centers. Three FM training centers and many PHC centers in the pilot marzes have been refurbished and now provide unified services for adult men and women and children. 50. New PHC provider organizations have autonomy to manage budgets and contract with the State Health Agency (SHA), which was created in 1997 to assume a strategic purchasing role. In effect, the integrated public health system based on the Semashko Model has been replaced by a public-contract model: with the S H A acting as the purchaser from a network o f semi-autonomous provider units providing a publicly funded 'basic package' o f services and additional services not covered by this package, which must be paid through out-of-pocket from private means. The gate keeping function o f PHC has been established with family physicians acting as the first point o f contact for patients in reform areas. In areas where the reforms have not been introduced, users are able to access narrow specialists, hence fragmenting first contact and gate keeping functions o f PHC. 3.2.2. Financing, resource allocation andproviderpayment systems 5 1. Health system financing is mixed, but public sector expenditure is low by European and regional standards. Data from the WHO Health for All Database suggests that, between 1997 and 2001, health expenditure from private sources accounted for 60 to 65 percent o f total expenditures while from the public sector they ranged from 30 to 40 percent. The Bank estimates the total health expenditures in the same period to have been between 1.43 and 1.34 percent o f GDP while the health public expenditures relative to the State budget expenditures were 5.6 percent inaverage for the mentioned period. The target for 2015 set inthe PRSP is 2.5% of GDP for public expenditures and 4.6-5.3% from private sources. 52. Traditionally, the amount o f funds allocated to PHC have been low and have represented less than 20 percent o f the total public health expenditure. However, in recent years, the Govemment has increased public funding for PHC at the expense o f hospitals allocations. Duringthe period 2002 to 2004, public sector expenditure for PHC and polyclinic base ambulatory services increased from 20 to 28 percent o f the total while that for hospitals declined from 57 to 48 percent. 53. The provider payment systems have changed from line-item budgeting to payment for volume o f services for hospitals and to a weighted per capita mechanism augmented by fee-for-service payments for PHC level. Primary health care providers also receive payments from non-vulnerable populations in the form o f user fees for services outside the BBP and fees for home visits and payments for diagnostic tests. In addition, there are 'unofficial fees' and in-kind payments, but the extent o f these payments are not quantified. In the areas where the Bank-financed project was implemented and where the PHC services were provided by family physicians, the extent o f informal payments has been shown to be less as compared with control regions. Project studies showed that the informal payments for medical examinations were less in project sites as compared with control areas.85 Further, following the introductiono f the BBP, the affordability o f PHC services increased. 54. The perceived quality o f health services provided by PHC centers with family physicians is higher than those PHC units that do not have family physicians. The shift from line-item-budgets for hospitals to contracts with a global budget based on volume o f services (number o f hospital cases treated) has helped remove perverse incentives created by input-based payment system for hospitals, which encouraged frequent and lengthy hospitalization o f patients. The new payment system has helped the rationalization o f the hospital sector, with the number o f beds per 1,000 population declining from 8.4 in 1992 to 4.25 in 200I. 9 3.2.3. Resourcegeneration 55. There are three public teaching institutions with FM departments: (i)in Yerevan State Medical University (SMU) where the Faculty of FM was founded in 1997, and the Chair o f FM was established with two full-time and 11part-time teaching staffwith responsibilityfor both UGand PGteaching inFM; (ii)the National Institute of Health (NIH), established in 1992through merger of several researchand continuing medical education institutes. NIH is responsible for postgraduate training of doctors and nurses. The Chair of F M was created at the NIH in 1997; (iii) Yerevan Basic Medical College (BMC), a nursing college dedicated to training of family nurses. In addition, both NIHand SMU utilize six other training centers as training bases for family medicine. 56. In 1995, the Pediatric Faculty at Yerevan State Medical University was closed as part of the educational reforms, which aimed to create a general medical education program. The role of FM is defined in law, which recognizes FMas a medical specialty. A Unified Curriculum for Family Medicine, comprising 33 modules and developed in 2002 by the Armenian Association of Family Physicians with support from the World Bank and the USAID-funded Social Transition Project (implemented by Abt Associates), was adopted in July 2003 by the Ministry of Health. (The Ministry of Health of Armenia, Order No 613, 21st July 2003). The Unified FM Curriculum has been fully adopted by NIHand is also utilized by the SMU. The curriculum is regularly reviewed by the Armenian Association of Family Physicians. Inaddition to the Unified FM Curriculum and respective curricula at S M U and NIH,there is a clearly articulated 'Procedure for training and assessment o f FM physicians' adopted by the Boards of EducationMethodology inthe SMUand NIH. 57. There are now two routes to train as a family physician: (i)an 1l-month retraining program for doctors trained in the Soviet system and currently working in PHC delivered by the S M U and supported by the Bank-financed Health Project. This was accredited by WONCA to be of internationally acceptable standard and (ii)a two-year FM residency program for medical graduates who qualified recently. In addition, the Ministry plans to introduce a system of continuous training for FMphysicians.. 58. It is estimated that around 350 family physicians have already graduated from S M U andNIH. At present, a further 120physicians are in training at both institutions. The objective of the Government is to retrain around 160 family physicians each year to reach the target o f around 1200 family physicians inthe next five years. In addition, 150 general nurses have been retrained as family nurses. The number of family physicians and nurses meets 23 percent o f the numbers needed in Armenia (about 1500 FM physicians is a total need for the country). 3.2.4. Professional associations 59. The Armenian Association of Family Physicians was founded in 1999. It i s actively involved in development of FM and PHC, and plays an important advocacy role, establishing standards and working with the Government to develop guidelines. 3.2.5. Serviceprovision 60. Primary health care is typically delivered through regional polyclinics or rural ambulatories with one physicianper 1200-2000 population and one pediatrician to 700-800 children. In rural settings with less than 2,000 population, the Primary Health Care services are provided through health posts/feldsher stations. There are 37 regional general polyclinics, most o f which employ a PHC team that includes a general physician, an obstetriciadgynecologist and a pediatrician, as well as nurses and midwives. These polyclinics typically offer: (i)general ambulatory care for the adult and elderly population; (ii)antenatal, obstetric and prenatal services; (iii)pediatrics, basic investigations, minor surgery; (iv) rehabilitation; (v) home visits; and (vi) health education. In addition, larger urban areas, in particular Yerevan, also have specialist polyclinics for children and women with reproductive problems. In 1998, the polyclinics, 10 which were previously attached to regional hospitals, were granted autonomous status. Around 500 medical posts, or feldsher stations, typically one in every village, offer a nurse-led service which includes basic care o f children and adults, antenatal care, developmental checks for infants, prescribing, first aid, home visits and immunization and health education. Clusters o f villages share PHC centers staffed by a general practitioner or a family physician, which offer a broader range o f PHC services as compared with rural posts. 61. Delivery o f PHC services in Armenia is fragmented as it i s provided by a number o f different health professionals: (a) family physicians, district therapists and pediatricians providing PHC services in rural ambulatories or polyclinics in towns and cities; (b) gynecologists and nurses who provide ante-natal and post-natal care; (c) a large number o f narrow specialists who provide 'specialist services' for chronic conditions; and (d) dispensaries (specialized outpatient facilities) for TB, oncology, mental health, dermatovenereology, endocrinology and narcology services. 62. A State Guaranteed Basic Benefits Package (BBP) has been introduced for the entire population and provides free PHC services for all citizens, regardless o f their status. An expanded BBP exists for the vulnerable population. With the reforms, the first contact function o f the PHC has been enhanced with the requirement that patients wishing to see a narrow specialist need to have referral from a PHC physician. However, despite this change, the old practice o f self-referral to narrow specialists, especially to those in hospital, prevails. 63. There is excellent coverage o f immunization. Basic PHC services are provided throughout most o f the country, although access in rural areas remains a problem. Although users now have the freedom to choose their family physicians, limited number o f physicians in rural areas limit this choice. Evidence- based guidelines for family physicians have been introduced for 127 common conditions encountered in PHC as well as 56 guidelines for FMnurses. This will enhance quality o f PHC services delivered, reduce unnecessary interventions and diminishreferrals to hospitals. 64. The task profile analysis shows clearly that in the polyclinics and rural PHC centers, which have introduced the FM model, the scope and content o f services have significantly expanded. There is increased health education, disease prevention and promotion services; enhanced gate keeping; more frequent application o f medical techniques and procedures; expanded management o f key first contact and chronic conditions as compared with low reform areas where the FMmodel has not been introduced. 65. Analysis o f the referral data shows a decline inthe number o f hospital referrals from PHC centers staffed by family physicians for key acute and chronic conditions typically managed in PHC setting. These findings demonstrate that FM reforms changes are having the desired benefits o f enhanced care management in PHC setting with reduced referrals to hospital -- with consequent improvement in efficiency and effectiveness. 3.3. REMAININGCHALLENGESToBEADDRESSED 66. In its PHC Strategy for 2003-2008, the Government has identified that key weaknesses of the existing PHC system to be: (i)inadequate knowledge base and skills o f doctors working in ambulatories; (ii)poor infrastructure and equipment; (iii) integrationof general medical, pediatric and obstetric poor services; (iv) inadequate provision o f preventive measures, especially for non-communicable conditions; (v) approach to care, which fails to focus on the family as the unit o f intervention; (vi) poor coordination of key functions; (vii) inefficient use o f limited financial resources; and (viii) lack o f financial incentives to further develop services. Further progress in introducing FM based PHC requires important decisions on the policy level, like open enrollment, clear legal standing for family practices - independent (autonomous) solo or group practice and performance-based reimbursement schemes.86 11 3.3.1. Organization and regulations 67. The contracts between the S H A and providers do not adequately recognize the contribution made by family physicians or provide incentives for them to expand their services. The contracts, based on per capita payment mechanisms, need to be augmented to include quality and performance criteria and commensurate incentives to reward FMteams and PHC centers. Organizational structure 68. The tripartite provider system at PHC level has not yet been consolidated to give way to new PHC units that provide unified services by family physicians for all citizens. Polyclinics are still staffed by pediatricians and general therapists, as well as narrow specialists. Uncertain regulatory environmentand support 69, The evaluation of the Bank-financed project highlighted the difficulties faced by PHC providers due to deficiencies in the regulatory environment, especially as regards the tax code and social insurance contributions for the employees, which led to excessive taxation o f the providers and requests for social insurance contributions for employees for amounts that were higher than the employees' salaries. Limited autonomy 70. At present, FDs do not have a legal standing with a dedicated budget line that recognizes FMas a distinct specialty. Instead, FDs reclaim reimbursement for services as "other physician". Poor in@astructure 71. Except for the centers that have been refurbished duringthe implementation o f the Bank-financed Health Project, the capital stock in PHC is run down. The majority o f polyclinics and rural ambulatories need to be equipped and renovated. Excesspaperwork 72, As in other post-Soviet countries, PHC level is overburdened by paperwork. There are approximately 400 forms at PHC that need to be completed to report activity levels as well as public health parameters, Typically, a PHC physician who sees 25 patients a day spends approximately 2 hours a day to fill in forms.87 Monitoring and evaluation 73. There is no monitoring o f quality levels in PHC or systematically collected data that can be analyzed to demonstrate ifthere have been changes inkey reform objectives. 3.3.2. Serviceprovision Access 74. Although the patients have the right to choose their PHC physician, uneven distribution o f human resources, with staff shortages in rural and mountainous areas, makes it difficult to exercise this choice. Inequitable access remains a fundamental problem: limited accessibility o f services compounded by a large proportion o f the population who are unable to afford out-of-pocket payments for services. Although, officially, PHC services in polyclinics are free o f charge, the providers frequently request unofficial payments for their services. These out-of-pocket payments deter use o f polyclinics as both the amount of payment and the quality o f service are unpredictable.88 Fragmentationof PHCServices 75. Many PHC services that could be provided by family physicians or generalists are still provided by narrow specialists. Further, in Yerevan, PHC services are still provided in a tripartite model from adult, women consultations and pediatric polyclinics. These structural arrangements fragment key PHC functions o f gate keeping, continuity and comprehensiveness, and reduce efficiency and effectiveness o f the PHC level. Integration, continuum of care andreferral systems 76. There are few incentives to achieve a substantial secondary-to-primary shift and develop extended primary care to move beyond a gate keepingrole. DiJJculties in Practicing Family Medicine 77. Trained family physicians who participated in the evaluation o f the Bank-financed project identified a number of obstacles which prevent them from optimally discharging their duties and effectively integrating into PHC system. These include: overcrowding o f polyclinics with general physicians, pediatricians and narrow specialists, and consequent competition; insufficient numbers o f patients registered with family physicians; insufficient financing; low salaries; lack o f medicines; and inadequate technical resources. 3.3.3. Resourcegeneration in PHC 78. Although a large number of physicians and nurses have been trained in FM, this represents only 23 percent of what is needed in Armenia and training needs to be scaled up. A further concern relates to the aging workforce in PHC: 30 percent o f rural physicians and nurses and 20 percent o f physicians and nurses inYerevan are above 50 years o f age. Limited capacityfor scale-up of family medicine 79. Limited resources to train family physicians have been identified as a major constraint to PHC development. Although good capacity exists inthe three main training institutions, this i s not adequate to meet the needs o f Armenia. 3.3.4. Resourceallocation andprovider payment systems Incentives 80. Lack o f incentives and poor salary levels o f FM specialists are two major problems that need addressing in immediate term. The current remuneration system does not adequately distinguishbetween family physicians and traditional PHC providers (adult physicians and pediatricians) and does not confer privileges which are given to narrow specialists (such as the possibility o f attracting user fees). Hence, many family physicians question whether additional retraining o f 11 months improves their prospects in the health system. This dampens the enthusiasm o f doctors to enter residency programs and of narrow specialists to retrain in FM. 81. Inclusion o f trained family physicians in the PHC system is more difficult in urban than rural areas as the urban PHC providers have the specialists they need. This problem is compounded by the provider payment systems for government-subsidized services, as the services o f a family physician are government-subsidized and cannot be rendered for a fee, while specialists are a major source of income for the polyclinics and receive preference. Equity and allocative efficiency 82. Major differences in access to services and funding exist. Resource allocation does not reflect health needs or poverty levels and there are clear differences in the level o f resources provided to urban and rural regions. 13 3.3.5. Communicatingthe reforms Poor awareness 83. The benefits o f an FM-centered PHC system are not adequately communicated to citizens and health professionals. There is, hence, a limited understanding o f FM and modern PHC among health professionals, citizens and politicians. In particular, the awareness o f health reforms and role o f the family physician among the general population inArmenia is Opposition to reforms 84. Narrow specialists, who work in PHC and in hospitals, and managers oppose the introduction o f FM-centered PHC are a key barrier to further development o f FM in Armenia. There are misperceptions o f FM among some health professionals who see this as a retrograde step from the `advanced' Soviet medicine." 3.4. CONCLUSION 85. The achievements in Armenia are commendable. Although many problems remain, much has been achieved in a resource constrained environment and platforms have been put in place to further develop PHC. To date, introduction o f FM and PHC reforms in the target regions has been successful. Platforms are in place to accelerate the pace o f reforms through a second phase o f development, particularly to: (i) further broaden the role o f family physicians and the scope o f services they deliver; (ii) introduce more flexible contracts with incentives to improve performance, quality, and provide additional health promotion, prevention and extended PHC services by family physicians; (iii)increase remuneration for family physicians and nurses; (iv) refine resource allocation mechanisms to reflect need and enhance equity; (v) place more emphasis on evidence-based medicine; and (vi) change reporting mechanisms in PHC, which reinforce the old tripartite model and hinder unified service provision. Much needs to be done to consolidate achievements and expand the reforms. Strong political support and technical assistance for the next phase o f reforms is critical to sustain what has been achieved. 14 4. CASE STUDY OF BOSNIA AND HERZEGOVINA 86. This chapter is summary o f a detailed study of FM reforms in Bosnia and Herzegovina (BIH) which is published as a separate volume.'' 4.1. BACKGROUND 87. The four-year war between 1992 and 1995 caused widespread physical damage and had a devastating effect for BIH. Over 10 percent of the populationwas killed or wounded. Over two million people, nearly half the pre-war population, were forced from or chose to leave their homes and became refugees, either abroad or displaced internally within BIH. Two-thirds of homes were damaged, with one-fifth totally destroyed. An estimated 30 to 40 percent of hospitals and 70 percent of schools were destroyed or severely damaged and 30 percent of health care professionals and a similar share of teachers were lost to death or emigration. The economic situation deteriorated rapidly during the war, The economy collapsed and the per capita GDP fell five-fold from US$2,429 in 1990 to US$456 in 1995. Economic growth resumed in 1996, and since 2000, GDP growth has been stable at around 5 to 6 percent. 88. Following four years of civil war, under the 1995 Dayton Agreement, different levels of government were established in the Federation of Bosnia and Herzegovina (FBIH) and in Republika Sprska (RS): (i)at the highest level, the State of Bosnia and Herzegovina (the State); (ii)at the next level two constituent political Entities of the FBIH and RS covering 5 1 percent and 49 percent of the land area of BIH, respectively; (iii)FBIH was divided into ten cantons, which in turn were divided into municipalities. Inthe RS, no cantons were established and the local government was assumeddirectly by municipalities. In addition, Brcko, with three municipalities, was designated a separate district. This led to premature decentralization of the health system with consequent problems which persist to date, 89. The war and subsequent economic crisis led to significant unemployment and poverty levels. In 1997, around one-quarter o f the population was classified as poor, and 15 percent were classified as extremely poor. In the post-war period, the population suffered significant posttraumatic stress due to ravages of the war, the subsequent socioeconomic crisis, unemployment, migration and displacement. However, general population indicators such as infant mortality, under five mortality and life expectancy have remained stable. 90. The former Federal Socialist Republic o f Yugoslavia had a well-developed health care system with a large and high-quality provider network. The population health indicators were comparable to those of OECD countries. BIHhad a well-established network of PHC centers comprising dom zdravljas (DZ), doctor's offices for ambulatory PHC services, and first aid and emergency service units. Each municipality had its health center (a DZ) which coordinated a network o f smaller PHC community facilities (as outposts of the DZ). The DZ was located in the main city or town and the smaller clinics (ambulates) in smaller communes and villages. There were 109 DZ, each covering a commune of 30,000 to 50,000 inhabitants. These coordinated 900 doctors' offices (ambulantas), were usually staffed by one doctor and a few nurses, which provided basic and first-line services to local populations. 91. Within the DZ, PHC was divided into seven distinct functions: (i)general practice, (ii) occupational medicine, (iii) pre-school pediatrics, (iv) school pediatrics, (v) gynecology/obstetrics, (vi) laboratory/)<-ray, and (vii) Hygiene and epidemiological unit. The PHC system was coordinated by the Ministry of Health & Social Affairs, and supplemented by additional health clinics that served special groups - such as the police, military personnel, etc. In addition, almost each large company had organized its own health services. 92. Following the war, the health system could no longer be sustained because of the destruction of the infrastructure; a mismatch between health needs and health services; inequitable access to health services; refugees, internally displaced persons, wounded and disabled people; low income and poor working conditions for health professionals with consequent low morale; fragmented PHC level with 15 multipleproviders; poor coordinationbetween care providers; and absence o f a sustainable health finance system with excessive, but ineffective health expenditures. 93. The post-war reconstruction and development programs in both Entities (FBIH and RS), supported by the Bank-financed Basic Health Project, aimed to develop a Basic Health Program comprising: (i)a PHC system in demonstration sites based on the FM concept; (ii)a shift from the pre- war emphasis on large hospitals and polyclinics toward more efficient use o f outpatient facilities and home-based care; and (iii)a greater emphasis on cost-effective public health, disease prevention and control. Policy and strategy documents were developed to articulate objectives and plans and laws enacted to create an enabling environment for the FM-centered PHC reforms to progress. 4.2. KEYACHIEVEMENTS 94. Within a short period, despite a complex post-conflict and resource-constrained environment, there have been remarkable achievements in FIWPHC reforms in both entities. There is strong high-level and local support for FM reforms with significant financial contributions by cantons and municipalities- as counterpart financing -toward refurbishment o f FMambulantas inthe demonstration sites. 95. There is a genuine attempt to institutionalize the changes introduced in the demonstration sites supported by the Bank and other agencies (CIDA, Swiss Cooperation) by developing appropriate legal frameworks --creating an enabling environment for the FM-centeredPHC model. 4.2.1. Organizationand regulation 96. Several laws have been enacted to define health system objectives and strategy, and to support development o f FM. For instance: (i)FM is recognized in Law as a specialty; (ii)team-centered FM model has been developed and team composition defined; (iii) scope and content o f FM services have the been defined; (iv) FM teams can legally contract `directly' with Health Insurance Institutions or `indirectly' with the DZ to deliver PHC services. 97. Organizational changes have enhanced the gate keeping function o f PHC, with the FM team acting as the first point o f contact for patients, improve user-centeredness of services and provide a greater choice for users. For instance: (i)users now have the freedom to choose their family physician; (ii)alargenumberofFMcenters havebeenrefurbishedinthepilotsitesofbothentitiestocreate `patient friendly' and functional PHC units; (iii) appointment systems has been introduced in the PHC that have adopted the FM model; and (iv) electronic data collection systems are being developed in the demonstration PHC centers to address serious shortcomings in monitoring and evaluation systems. 98. Agencies for Accreditation and Quality Improvement have been established in both Entities to accredit health care providers. These agencies have trained assessors, developed appropriate tools and mechanisms and have already undertaken accreditation o f some FM centers. The Law on Medical Chambers has enabled the establishment o f medical chambers that have the responsibility for licensing and revalidation o f all practicing doctors. 4.2.2. Financing 99. The health expenditure is around 12 percent o f the GDP, and high by OECD and ECA Region and for a country at the stage o f economic development as that o f BIH. Expenditure comes from mixed revenue sources, predominantly from the health insurance premiums collected as a salary-tax, budget transfers from each entity, State transfers, and out-of-pocket payments. The pooling is fragmented, with a single Health Insurance Fund in RS and 10 Health Insurance Institutes in the FBIH, i.e. one in each canton. 4.2.3. Resourceallocation andprovider payment systems 100. The Cantonal Health Insurance Institutions and RS Health Insurance Fund have a target o f allocating 40 percent o f the health insurance expenditures to PHC. In 2004, this amounted to 43 percent 16 o f the CHI1 expenditure in FBIH and 23 percent o f the HIF expenditure in RS -- a high proportion compared to other countries in the ECA Region and OECD. In addition, as noted earlier, there has been significant local counterpart investment to refurbish infrastructure for FMAmbulantas. 101. New provider payment mechanisms, based on simple and weighted per capita models, have been successfully introduced inthe demonstration sites to contract FMteams. It is too early to judge the effect o f new provider payment mechanisms, but qualitative research findings suggest that new models used in the demonstration areas are perceived to be more meritocratic and transparent. Direct and indirect contracts between the CHIIIHIF and DZ/FM teams have been successfully piloted - one pilot includes performance related pay element inaddition to per capita pay. The contracts specify the scope o f services to be provided by FM teams, and include in RS incentives to provide health prevention and promotion services and to demonstrate increased quality through accreditation by the AAQI. 4.2.4. Serviceprovision 102. In the demonstration sites that have introduced the FM model, the scope and content of services have expanded significantly. The task profile survey demonstrates statistically significant difference in the breadth o f preventive, first contact and chronic disease management services provided by FM specialists as compared with non-specialist GPs. There is strong evidence from the qualitative research undertaken as part o f the study that the new model is welcomed by the users. Many o f the key informants identify benefits o f the new system for the users, such as: user-centeredness o f the model; holistic approach to health and the person; emphasis on health education, promotion and prevention; having a named doctor; user choice; more comprehensive nature o f FM model empowerment o f FM team to increase quality; and an increased emphasis on teamwork with enhanced continuity. Expandedhealth education,promotion andprevention 103. Family physicians, as compared with GPs without training in FM, demonstrate a clear shift from curative biomedical care model to one which emphasizes disease prevention, health promotion and holistic care. The task profile survey shows statistically significant difference in the level o f health education, promotion and prevention activities delivered by family physicians as compared with GPs. Qualitative research findings identify the provision o f health promotion, education and prevention activities as key strengths o f the FM model and valued by users and FM providers. The emphasis on health education, promotion and prevention is encouraged through contracts between the HIF/HII and the FMteams. For instance, inRS, contracts between the HIF and PHC centers stipulate a penalty for failure to perform specified preventive tasks and include a bonus payment for promotion and prevention activities. Managementoffirst-contact conditions 104. Both FM physicians and GPs `usually' manage many o f the common conditions encountered at PHC setting, but family physicians are more likely to manage several o f the first-contact conditions as compared with GPs with no FM training, This difference is statistically significant. The study demonstrates that family physicians provide more comprehensive care as compared by GPs and have adopted more psychosocial approach to care. Managementof chronic conditions 105. The task profile survey shows a greater involvement o f FM specialists, as compared with GPs with no FMtraining, in the management o f several key chronic conditions. This difference inbreadth o f service provision is statistically significant and signals that the FM specialists are applying the knowledge and skills gained during their training. Secondary toprimary shift 106. There is, as yet, no evidence to demonstrate a shift from secondary to primary level, a decline in the number of hospital admissions, and a reduction in the length o f hospital stay. The health information 17 systems do not capture information on referral patterns. Unfortunately, there has been no base lining or subsequent monitoring and evaluation to undertake pre- and post-intervention comparison in pilot and non-pilot sites to ascertain the impact o f FM. Teamwork 107. A FMmodel based on teamwork has been introduced. This is incontrast to many countries inthe region that have developed FD-centric PHC models. The teamwork approach is highly valued by the members o f the FMteam, who identify benefits such as improved productivity and communication, Evidence-basedcare guidelines 108. Evidence-based guidelines have been introduced for 20 common conditions encountered in PHC. This will enhance quality o f care delivered but also reduce unnecessary interventions. 4.2.5. Resource generation 109. Chairs of Family Medicine have been established and are functioning within the three o f the four Faculties o f Medicine in - Banja Luka, Mostar and Tuzla. Curricula for Specialist Training in FM, based on internationally recognized principles, were jointly developed in 1999 by the Faculties o f Medicine in BIH, and adopted by both the FBIHand RS. The details o fthe curricula are publishedinboth entities in the Rulebooks for FM, which specify the content and methods of.trainingfor specialist and in-service FM training programs delivered by the FM Chairs. Three training programs exist for FM: (i) three-year FM Specialist Training Program for new graduates with no work experience; (ii)two-year training program for PHC doctors who have less than 10 years' work experience, and doctors who have over 10 years o f work experience and who have been granted the `Certificate o f Doctor o f Family Medicine'; (iii)one-year in-service Program for Additional Training (PAT) for those who already have had training in related specialties and have a certificate from the Federal Ministry o f Health recognizing their specialty. 110. The FM training programs have been successfully implemented in both entities. Regardless o f the source o f financing, the same curricula are used for FM training, in contrast to the period prior to the Basic Health Project when varied approaches and several curricula were used in programs funded by different donors. By June 2004, 80 FM trainers had been trained and a total o f 368 health professionals (173 doctors and 195 nurses from both entities) completed the P A T in FM in programs supported by Swiss Development Corporation (SDC). In addition, by 2005, with donor support from CIDA, Swiss Cooperation and the European Union (EU), FM specialists and PAT programs will graduate 1215 health professionals, including 410 FM specialists, 212 doctors trained in PAT, 465 nurses trained in PAT, and an additional 141 nurses trained in FM training courses. In addition to the WB, SDC, EU and CIDA supported programs, a further 85 doctors have been trained in FM in programs supported by MSF- Belgium, WHO and PHARE. The FMteams trained in both entities now cover intotal 23 percent o f the entire population o f BIH. 111. As o f June 2004, 18 generations o f 6th year medical students (representing over 750 medical students) have received education in FM. Health Management Centers have been established and fully refurbished in both entities with support from the Bank-financed BHP. A cadre o f 30 trainers has been trained in training o f trainers program. In addition, around 150 middle- to senior-level managers have been trained in modern health management subjects (111 managers in FBIHand 38 in RS). 18 Professional associations in FBIH 112. Associations of Family Medicine Physicians were established in 2000 in both entities and in 2002 accepted to the membership o f the World Family Medicine Association. 4.3. REMAINING CHALLENGES BEADDRESSED To 4.3.1. Organizationand regulation Asymmetry in thepace of development 113. The pace of development in FMhas exceeded the rate at which the legislative changes have been achieved. This is a source of concern and anxiety for many stakeholders who wish to see acceleration o f the rate at which new laws are enacted - in particular to: (i)define the role o f FM team in the health system and articulate more clearly the scope o f services provided by the FM team; (ii) establish a legal base for the new payment mechanisms to create incentives for FMteams; (iii) clarify the role o f narrow specialists at PHC level, the boundaries with secondary care, and referral and counter-referral mechanisms; and (iv) resolve the confusion surrounding the rights o f citizens and the insured; (v) redefine the status of FMteams inrelationto dom zdravljas as regards contracts. Strategicplanningfor scaling up 114. FM reforms have been rapidly introduced and now cover 23 percent o f the population. Clear strategic plans have been developed identifying human and financial resources needed for scaling up the FM model. The Bank approved on March 30, 2005 a new project - Health Sector Enhancement Project, which inter alia supports the scaling up o f family medicine country wide. This project is being cofinanced with the Council o f Europe Development Bank. Although around 200 health professionals have been trained in health management, there needs to be rapid scale-up o f health management training to prepare a cadre of professionals to manage change, the scale-up process, and the transition from pilot status to a fully-institutionalized FM model. The WB Health Sector Enhancement Project will support the expansion o fmanagerial capacity. Role models to catalyze change 115. Lack o f role models in the BIH context is a problem, but the emergence o f some DZ managed solely by FMteams provides an opportunity to demonstrate what can be achieved. Communicatingthe reforms 116. Key informants identify limited communication between and within levels o f the health system as a critical problem. The population has not been adequately informed about the nature o f the reforms, the reasons and the expected benefits. Inadequate communication and poor engagement o f the operational level in decision-making lead to the perception that reforms are `top-down' and `imposed'. This is a major barrier to successful scale-up and sustainability o f an FM-centeredPHC system. Monitoring and Evaluation 117. As with the other countries inthis study, for the PHC reforms in BIH, there was no base lining in the demonstration sites to enable before- and after-intervention analysis or studies to compare and contrast demonstration sites with matched non-pilot sites. In the BIH context, although large amounts o f data of variable quality are collected regularly, due to limited analytical capacity, these are not analyzed to generate meaningful information to inform decisions. It i s encouraging to see that the new Health Sector Enhancement Project will address issues o f M&E to develop and operationalize a system to monitor and evaluate health sector performance. 4.3.2. Serviceprovision 118. A large number o f narrow specialists work in PHC and manage acute and chronic conditions commonly encountered in PHC. These narrow specialists act as substitutes for FM specialists, fragment 19 gate keeping and compromise key FM functions o f first-contact, comprehensiveness, continuity and coordination. Further, the emergency services and occupational health system act as parallel PHC services, further weakening first contact and gate keeping functions o f PHC. Integration, Continuum of Care and Referral Systems 119. Although an effective FM-centered PHC system is being introduced in BIH, the boundaries between primary and secondary levels and the regulatory environment for referral and counter-referral systemshave not yet been established. There are, as yet, no incentives to achieve a secondary-to-primary shift and develop extended primary care. Decentralization in FBIH has fragmented the health system. Horizontal integration remains a problem - adversely impacting on risk pooling, freedom o f movement o f citizens and development o f entity-wide strategic plans for optimizing resource utilization and allocation. Vertical integration is limited, with PHC and the hospital levels operating as two sub-systems with precarious links between them. As the financing o f the two systems are unlinked, there is a risk o f cost- shifting between levels - especially as a per capita payment system without performance indicators will eventually lead to increased referrals to reduce workload at PHC level. This will undermine the gate keeping, continuity and comprehensiveness functions o f the PHC level. Without development o f effective interface between primary and secondary levels, it will be difficult to develop an integrated system with a continuum o f care. The Health Sector Enhancement Project will support the development o f an interface between PHC and higher levels o f care. 4.3.3. Financing, resource allocation andprovider payment systems 120. Detailed contracts have been successfully introduced in the demonstration sites. This i s to be commended, as the platforms have been put in place to use contracting as a tool to improve service quality, efficiency and effectiveness. However, to achieve these objectives there needs to be a move from simple cost-volume contracts based on inputs to more sophisticated contracts based on performance, outputs and outcomes. This shift will require: (i)significant analytical and execution capacity at PHC and CHII/HIF levels to manage and monitor more sophisticated contracts; (ii) robust information systems in these domains to capture relevant and timely data on activities and outcomes; and (iii)appropriate incentive systems to improve performance. Currently in BIH, the quality o f services delivered in PHC i s not monitored. It is very encouraging to witness the development o f the Quality and Accreditation Agencies that have started accreditingPHC facilities. Incentives and Retention 121. Unsystematic anecdotal evidence suggests that some o f the health professionals trained in FM specialist training program and in P A T may be leaving or planning to leave FMto join training for other specialties. It is important that at this stage o f the reforms, incentives are introduced to retain the `early adopters' and leaders. Failure to do so will result in rapid demoralization o f the FM team and adversely affect sustainability o f the reforms. Although the new payment mechanisms in demonstration sites provide some incentives, there needs to be a much stronger indication that FM is valued on par with hospital specialties. The Health Sector Enhancement Project will address these issues. 4.4. CONCLUSION 122. Despite a post-war environment, Bosnia and Herzegovinahas been able to introduce a novel FM- centered PHC model and achieved rapid scale-up with appropriate legislative platforms which create an enabling environment for change. The Basic Health Project has been a successful project and demonstrates that the Bank can add much value to the PHC development process, but success brings with it responsibility. A clear exit strategy, agreed with local counterparts, is neededto ensure that there are no gaps in support to sustain the transformation process. 20 5. CASE STUDY OF ESTONIA 123. This chapter is a summary o f a detailed study o f FM reforms in Estonia, which was not the subject o f this study and as such has been published ~eparately.'~ 5.1. BACKGROUND 124. Estonia, a Baltic State with a population o f 1.38 million, regained its independence from the Soviet Union in 1991 and in 2004 joined the EU. Estonia is the first post-Soviet country to fully scale-up and institutionalize FM-centered PHC reforms. Prior to independence, the Estonian health system was based on the Soviet Semashko model, characterized by a large network o f secondary care institutions and a fragmented PHC level with a tripartite system o f adult, children and women's polyclinics and specialized dispensaries. Family medicine specialty did not exist. Polyclinics were staffed by therapeutists, pediatricians, gynecologists and sub-specialists. PHC level exercised limited gate keeping, further compromised by the citizens who bypassed PHC to directly access emergency and specialist services in dispensaries or hospitals. All hospitals and PHC units were publicly owned and health personnel were salaried public employees. Doctors who worked at PHC level had low status and pay as compared to specialists. The system had curative focus with excessive secondary care structures to be financially sustainable. 125. In 1992, Estonia introduced health reforms to separate planning, purchasing and provision functions and to develop a FM-centered PHC system. Strategic planning was retained by the MoSA, contracting and purchasing devolved to the newly established EHIF and provision delegated to PHC units owned by the municipalities and to hospitals which were established as autonomous legal entities with own boards accountable to the State and the local governments. Between 1993 and 2001, the number of hospitals declined from 115 to 67 and hospital beds from 14,400 to 9,200, while the average length o f hospital stay declined from 15.4 to 8.7 days. 5.2. KEYACHIEVEMENTS 5.2.1. Changesin organizationand legal environmentfor PHC 126. In 1993, FMwas designated as a specialty -the first post-Soviet country to do so. A three-year residency program for new graduates and in-service training for specialists working in PHC were introduced. In 1997, changes in health service regulations required Estonian citizens to register with FPs contracted by EHIF to provide PHC services to their registered population. Ministerial regulations defined responsibilities o f FPs and the practice o f the specialty, and introduced a new weighted per capita payment system mixed with fee-for-service and allowances, including a special payment for doctors trained and certified as FM specialists. 127. `The Health Services OrganizationAct', subsequent regulations 93-97and the Health Insurance Act o f 2002 defined the eligibility criteria for health insurance.98 By 2003, 94 percent o f the population was covered by public health insurance. PHC reforms were rolled out rapidly in all regions except for the capital Tallinn, where the heads o f polyclinics supported by Tallinn Municipal Health and Social Care Department resisted change and advocated retention o f polyclinics with salaried doctors. In 2001, there were 557 doctors trained as FMspecialists. In 2004 this number had reached over 900 - enough to cover all o f Estonia. By 2003, all FM specialists working in Estonia had a patient list o f around 1,600 and a contract with the EHIF. 5.2.2. Changesinfinancing andproviderpayment systems 128, Health system financing changed from tax-funded to a mixed system, funded predominantly from health insurance with contributions from the State and official out-of-pocket payments. In the period 1992 to 2002, total health expenditure as a percentage o f GDP increased from 4.5 to 5.5 percent; below the EU Member State average o f 9 percent but similar to levels in the 10 new EU Member States and 21 post-Soviet republics.99 In 2002, public sector financing accounted for 76.3 percent and private expenditure for 23.7 percent, o f which majority (20% o f total expenditure) was out-of-pocket expenditure. The bulk o f the public sector financing came from health insurance revenues (65-67%). The State contributed 8-9 percent o fthe total, inform o f main transfers through the MOSA.''' 129. In 2003, 14 percent o f total EHIF expenditure on health services was allocated to PHC, 77 percent to hospitals, 8 percent to dental services and 1 percent to health promotion. The expenditure on PHC, as a proportion o f the total health expenditure, declined from 8.2 percent in 1998 to 5.5 percent in 2000, thereafter increasing to 8 percent in 2002. Contracts with EHIF replaced salaries o f FM specialists with mixed payment system comprising age-adjusted capitation, fee-for-service, basic practice payment, additional allowances and cost-sharing for home visits payable by patients, except for the exempt groups such as children and the pensioners. 5.2.3. Changesin service deliverypatterns 130. FM specialist training and the EHIF contract broadened significantly the scope o f services delivered in PHC setting. Evidence-based guidelines on management o f acute and chronic conditions commonly encountered in PHC were introduced in the late 1990s, encouraging FM specialists to manage these conditions previously managed by narrow specialists. 5.2.4. Userperceptions 131. Most o fthe respondents interviewed duringthe evaluation o f PHC reforms in Estonia emphasized the key achievements to be: (i)coverage o f the whole population; (ii)focus on the user; (iii)more personalized service; (iv) enhanced "continuity o f care and overview"; (v) ability to treat all age groups; (vi) horizontal view o f the patient and illness; (vii) increased professionalism at PHC level - enhanced role o f family physicians and nurses; (viii) increased independence for the health professionals (family physicians and nurses); and (ix) clearer responsibilities to the users, as now a single professional was responsible for the patient in contrast to "the polyclinic model o f the past where the responsible person was not clear." An important and novel feature of the new PHC system cited was the ability o f the users to choose their family physicians. The contract and the law on cost sharing encouraged transparency and help clarify responsibilities. 5.3. REMAININGCHALLENGES BEADDRESSED To 132. A number o f challenges remain and needto be addressed to build on the successful PHC reforms. These include, but are not limited to: (i) human resource shortage, which is exacerbated by emigration o f health professionals to neighboring countries. This shortage is likely to worsen now that Estonia has become a member o f the EU. In particular, there i s a shortage o f family nurses who feel their skills are undervalued; (ii) low income levels for PHC professionals are creating barriers to entry into practice and increasing risk - in the last few years, at constant prices, there have been no increases at income levels o f family physicians; (iii)Out-of-pocket expenditures are increasing and this may adversely affect the doctor-patient relationship if further cost sharing is introduced at PHC level; (iv) health expenditure levels that are well below the EU average and need to be increased to meet expanding demand - lengthening waiting lists is a cause for concern and a source o f dissatisfaction; (v) health expenditures for primary care as compared with hospital care are low by European standards. Inparticular PHC infrastructure is in need o f capital investment to bring PHC centers to a standard that will encourage provision o f expanded services, enable development o f extended PHC and achieve secondary-to-primary shift; (vi) fragmented first contact element o f primary care remains a structural weakness that needs to be addressed - with multiple providers who provide ambulatory care (outpatient) services and who can be accessed by citizens without referral; (vii) high land and rent prices in cities, especially Tallinn - which makes it difficult for the family physicians to secure appropriate premises and increases financial risk to family physicians. This risk is actively discouraging young residents and graduates o f FM training programs from entering practice; (viii) limited incentives for highperformersand a lack o f monitoring and evaluation systems that 22 can be used to reward highquality care and innovative practice; (ix) limited flexibility at practice level to reconfigure human resource requirements to enable more efficient use o f available skills; (x) existing legislative framework prevents development o f partnerships, appointment o f part-time family physicians with personal lists and expansion o f a practice size beyond 2,000 patients. This limits flexible working practices and i s a barrier to faculty who have appointments at university but also women practitioners who wish to practice part time because o f family commitments; (xi) although Estonia has achieved impressively high health insurance coverage o f 94 percent of the population, 6 percent o f the citizens do not have access to health insurance and face catastrophic financial risk. This needs to be addressed in the short term. 5.4. CONCLUSION 133. While most post-Soviet countries struggle with their PHC reforms, Estonia has successfully introduced and institutionalized multifaceted PHC reforms, scaled-up to cover urban and rural areas. Structurally, the public-integrated Semashko model has been transformed to a 'Bismarckian' public- contract model with separation o f purchasing and provision functions. Hospital sector has been rationalized; new Laws have established for FM specialty and defined scope and content o f FM services; organizationally, the tripartite polyclinic structure has been rationalized into unified FM centers which manage all citizens irrespective o f age and gender. 134. Novel organizational structures, such as independent practitioners and partnerships, have been established. Financing reforms have transformed a tax-funded health system to a mixed model, funded predominantly by health insurance supplemented by official private out-of-pocket payments and State contributions; budget-based resource allocation system has been replaced by purchaser-provider contracts and new PHC provider payment system incorporating weighted-per-capita pay, fee-for-service and allowances. As patients have a choice o f their FPs, money follows the patient; service provision has changed with broadened scope o f PHC services driven by evidence-based guidelines. 135. The new PHC model is accepted by the majority o f the population. Surveys undertaken by EHIF show that 79 percent of the people surveyed in 2001 and 88 percent in 2003 were either very satisfied or generally satisfied with PHC services. 90 percent o f the population knew their personal FP and only 15 percent had changed their FP, mainly because o f change o f residence.'" There i s increased effectiveness o f PHC with enhanced continuity and comprehensiveness o f services, evidenced by improved management o f chronic illness in PHC setting with increased number o f consultations, reduced hospital admissions and changing prescribing patterns, which point to increased uptake o f best-developed practice. 23 6. CASE STUDY OF KYRGYZREPUBLIC 136. This chapter summarizes the findings o f a detailed study o f FMreforms inthe Kyrgyz Republic, which is published as a separate volume."* 6.1. BACKGROUND 137. Following independence in 1991, Kyrgyz Republic inherited a health system based on the Soviet Semashko Model characterized by: (i)centralized and hierarchicaladministrative organization; (ii)a large provider network dominated by hospitals with a curative focus; and (iii)parallel health systems for line ministries and large organizations. Primary health care level was poorly developed with a fragmented delivery model comprising in cities a tripartite polyclinic system which provided services separately for adults, men and children, as well as a large number o fvertical programs delivered by narrow specialists in dispensaries. There were no family physicians and the polyclinics were staffed by narrow specialists and general physicians for adults, pediatricians and obstetriciadgynecologists. Inrural areas, ambulatory care centers were staffed by adult physicians or by feldshers in feldsher stations. 138. In line with excess infrastructure, there were excess human resources which were concentrated in cities, Inequitable resource allocation, based on historic activities and inputs, favored large hospitals in urban centers at the expense o f rural areas. Provider payment systems, based on line-item budgeting o f provider units and salaries for staff, encouraged inefficiency and hindered improved performance. Provision o f effective health care services were hampered by care delivery protocols which failed to draw on best-developed practice and evidence and which encouraged excessive referrals to secondary care level. There was limited user empowerment and the citizens were allocated to doctors and unable to exercise choice o f providers. 139. Prior to independence, the Kyrgyz Republic devoted 3.5 percent o f its GDP to health. This diminished following rapid economic decline - creating a substantial funding gap between the level o f financing needed by the health system and the resources available. Following independence, the Kyrgyz Government sought to introduce multifaceted health reforms with an emphasis on developing a strong FM-centered PHC system to address: (i)organizational complexity; (ii)excess infrastructure and human resources; (iii)allocative inefficiency and inequities in financing; (iv) provider payment systems which hindered service improvements; (v) inefficient service provision; (vi) limited incentives to improve quality; and (vii) low pay levels for health personnel. 6.2. KEYACHIEVEMENTS 140. From 1992, in collaboration with international agencies, the Kyrgyz Government introduced key legislations to create an enabling environment for health reforms and establish platforms for comprehensive and multifaceted change in the health system to reduce inefficiencies; enhance equity and access (financial and geographic); and improve quality. High-level support for FM reforms has been strong. The MOH has a clearly articulated health reform strategy and has succeeded in coordinating donor agencies to ensure alignment o f inputs, reduce duplication and optimize value add by multilateral and bilateral organizations actively involved in the health sector. Exemplary collaboration between the donor community and the Kyrgyz Government ledto emergence o f an `operational and informal SWAP'. 6.2.1. Organizationaland regulatory changes Structural changes 141. Despite a highly resource-constrained environment, the achievements o f FM-centered PHC reforms in the Kyrgyz Republic have been remarkable with expanded scope o f services, enhanced gate keeping and first contact functions o f PHC, and substantial shift between secondary and primary health care, In urban areas, the tripartite system o f pediatric, women's and adult polyclinics in cities has been consolidated into unified Family Medicine Centers (FMCs). Inrural areas, family group practices (FGPs) 24 have been established with autonomy to contract with the Mandatory Health Insurance Fund (MHIF) and to manage their own budgets. FGPs can also establish independent units within FMCs and contract with the MHIF to deliver PHC services. In addition, feldsher-ambulatory care centers serve remote rural villages (FAPs). Many o f the PHC centers have been refurbished and now provide services for adult men and women and children. 142. Family medicine was recognized as a specialty in Law and new PHC provider organizations, FMCs and FGPs, have been established with autonomy to manage budgets and contract with the Mandatory Health Insurance Fund. Institutionalization of family medicine 143, The scope and content o f FGP services have been articulated in law and defined in detail in the State Guaranteed Benefits Package. The gate keeping function o f PHC has been established with FGPs acting as the first point o f contact for patients. The Association o f Family Doctor Groups, established in 1997, has a limited role in licensing and accreditation activities, and plays an important advocacy role to inform key stakeholders at different levels on the benefits o f reforms. The Association o f Family Doctor Groups is active in lobbying parliamentarians and in 2003 became a member o f the World Family Doctors Association (WONCA). Accreditation has been introduced and a number o f PHC and hospital facilities have been accredited. 6.2.2. Financing, resource allocation andprovider payment systems 144. Despite a declining public expenditure on the health sector, the proportion o f financing allocated to PHC has increased from 7 percent o fthe total public health expenditure in 1994 to around 25 percent in 2003. A mixed system o f financing has been established with mandatory health insurance, official co- payments and budget transfers. A Single Payer System has enabled pooling o f all sub-national budget funds for health care in the Territorial Department o f the MHIF in a `single-pipe funding' to fund the State Guaranteed Benefits Package. Co-payments provide limited additional resources to the health system but create a transparent environment as regards payments to health service providers and have benefited the poor by increasing transparency and reducing unofficial under-the-table payments for providers. 145. New provider payment methods have been successfully introduced inthe regions for FGPs based on simple per capita mechanism. Direct and indirect contracts have been introduced for FGPs, including partial fund holding, where FGPs control budgets for essential drugs. 6.2.3. Serviceprovision 146. A State Guaranteed Basic Package has been introduced covering the entire population and provides free PHC services for all citizens, regardless o f their insurance status and enrolment. Citizens not covered under the MHI scheme are subject to formal co-payments for referral services in outpatients or hospital inpatient services provided by narrow specialists. Citizens insured under the MHIF receive additional benefits of access to an outpatient drug package which provides certain drugs at reduced rates and lower co-payments for referral services in outpatients and as inpatients in hospital. The gate keeping strength o f PHC level has been enhanced by a mechanism which stipulates that patients who access hospitals without a referral from family physicians incur higher levels o f cost sharing. Users are more empowered and can choose their family physician and in some regions participate in community-led needs assessmentto plan service delivery. 147. The access and accessibility to PHC centers has significantly improved, except in rural and mountainous areas where access can be very difficult. There is excellent coverage o f immunization and widespread provision o f basic PHC services throughout the country. In the regions which have introduced the FGP model, the scope and content o f services have significantly expanded, with increased health promotion services. 25 148. Analysis of the MHIF data demonstrates a substantial and appropriate shift from secondary to primary level with a decline in the number o f hospital referrals for key acute and chronic conditions typically managed in PHC setting. This finding is critical to demonstrate that changes are having the desired benefits o f enhanced care management in PHC setting with reduced referrals to hospital - with consequent improvement in efficiency and effectiveness. Evidence-based guidelines have been introduced for 162 common conditions encountered in PHC. This will further enhance quality o f PHC services delivered, reduce unnecessary interventions and diminish referrals to hospitals. There is evidence from the qualitative research that the new model is welcomed by the users and health professionals who identify many benefits which, amongst others, include user-centeredness o f the model, having a named doctor, user choice, more comprehensive nature o f FMmodel, empowerment o f FMteam and increased emphasis on teamwork. 6.2.4. Resourcegeneration 149. Excess human resource capacity in the health sector has been rationalized, but although the total number o f doctor and nurses have declined to levels in line with those in the European Region, the number and proportion o f family doctors and nurses have steadily increased. National efforts, supported by international technical assistance, aimed to institutionalize FMtraining at five levels: (i) undergraduate training for medical students; (ii)post-graduate training - a two-year FMresidency for doctors graduating from medical school; (iii)Retraining program for physicians practicing as general practitioners; (iv) continuing medical education (CME) for FM teachers, and for practicing family doctors and nurses (v) and a bachelors degree program for PHC nurses. These programs have been established. There are now two chairs o f FM: (i)at the Kyrgyz State Medical Academy, and (ii) at the Kyrgyz State Medical Institute for Retraining and CME. 150. By 2003, up to 63 FM trainers have been trained inthe one-year training o f FMtrainers (TOT) program introduced in 1997 at the Centre for Continuous Medical Education in Bishkek. In addition, 64 family nurse trainers have been trained in the one-year TOT program for nurses. This able body o f FM and nurse trainers has led highly successful short-course retraining programs, with support from international experts. A critical mass o f around 2,500 FM specialists has been trained in the four-month retraining program in addition to around 3,000 nurses trained inthe two-month retraining program. These family physicians and nurses now meet approximately 70 percent o f the numbers needed in the Kyrgyz Repub1ic. 151. Two FM residency programs have been established: one in Bishkek, which has graduated over 40 doctors, and the other in Osh, which currently has 24 doctors in the program. A national CME for family physicians and for FM nurses has been established. Around 1000 family doctors and 1400 family nurses currently involved with the C M E system receive ongoing training on an annual basis from the FM trainers associated with the Centre o f Continuous Medical Education. This new CME system, which began in Issyk-KulOblast in 2001, was expanded in 2004-2005 to include 3 pilot rayons in Osh and Chui Oblasts, and all the FGP doctors in the other oblasts. In 2005, a similar C M E program will begin for the FGP doctors in Bishkek and Osh cities. 152. The task profile survey shows that the family physicians trained in the FM retraining programs and who are now working in areas where the FM centered reforms have been implemented have expanded the scope o f their services. Family physicians provide expanded services for health education, promotion and disease prevention. In addition, as compared with PHC doctors who have not been retrained, family physicians more frequently apply medical techniques and procedures commonly used in PHC setting, and have greater involvement in management o f key first-contact and chronic conditions. The differences observed between the family physicians and doctors who have not been retrained are statistically significant and demonstrate the positive benefits o f the retraining on expanding the scope and content and enhancing the quality o f service. 26 6.3. REMAININGCHALLENGES BEADDRESSED To 6.3. I. Negotiating theglass ceiling 153. Family medicine and PHC reforms in the Kyrgyz Republic have been successful and evolved rapidly, but have reached a glass ceiling which needs to be negotiated. Further legislative changes are needed to support the next major phase o f development. Many o f the key stakeholders wish to see acceleration in the pace o f reforms, particularly to: (i) broaden the role o f FGPs and the scope o f services they deliver; (ii)build on the payment mechanisms, contracts and the autonomy afforded to the PHC providers to introduce more flexible contracts with incentives to improve performance, quality, and provide additional services - health promotion, prevention and extended PHC; (iii)increase remuneration for FGPs and FM nurses trained as specialists; (iv) further refine resource allocation taking into account need and equity o f access, favoring rural and poorer areas with higher health needs; (v) place more emphasis on evidence-based medicine; and (vi) change reporting mechanisms which reinforce the old tripartite model and hinder unified service provision. 6.3.2. Organization and regulation Excess capacity 154. Although introduction o f FM-centered PHC has enhanced gate keeping function o f the health system and led to shifts from secondary to primary health care, there is still excess capacity inthe hospital sector. Attempts at rationalizing the hospital sector have achieved partial success, especially after the introduction o f the health insurance and hospital payment systems based on DRGs, with rationalization o f rayon-based hospitals, but with limited impact on the Republican hospitals which consume a disproportionate amount o f the health resources. Flexible contracting to enhance quality 155. FM and PHC reforms in the Kyrgyz Republic have been highly successful and evolved rapidly. Minimum quality standards and equitable level o f services have been established for Kyrgyz citizens. However these contracts do not differentiate between those who provide high-quality services and those who do not. The contracts, while encouraging equity, do not provide enough flexibility to encourage innovation. Contracts with the FGPs can be used to encourage innovation and to extend the scope o f services provided in PHC. Communication 156. Communication between and within levels o f the health system and with the public is critical activity that needs to be enhanced to rectify misperceptions o f FM which create barriers to full scale-up and sustainability o f an FM-centered PHC system. A clear and all-embracing communication strategy i s necessary to increase visibility o f PHC reforms, inform key stakeholders o f the expected benefits and increase ownership. Analytic capacity 157. Although the Kyrgyz Republic has developed an impressive M&E system within the MHIF, the PHC component o f the system needs enhancing and analytic capacity at MHIF further expanded to regularly analyze data to generate timely information to inform decisions. 6.3.3. Serviceprovision Narrow specialists at PHC level 158. Although the tripartite provider system at PHC level i s consolidated to give way to new FMCs that provide unified services for all citizens, many family physicians have not changed their practices and continue to practice their narrow specialty (pediatrics, obstetrics & gynecology, and adult medicine). The reporting systems at PHC level, which require returns by sub-specialty, reinforce this practice. Further, 27 guidelines, which require screening of newborn and older children, pregnant women, workers, and conscripts by narrow specialists, are used as an argument to maintain narrow specialists inPHC. 159. Narrow specialists at FMCs, who can be accessed directly by patients: (i)fragment the first- contact function of primary care level; (ii)create a potential source of inefficiency; (iii)fracture of the gate keeping function of PHC, encouraging excessive referrals to narrow specialists in PHC setting and cross-referrals between narrow specialists; (iv) adversely impact on continuity of care as the care is fragmented; (v) Hinder family physicians from practicing an integrated and holistic family medicine; (vi) prevent the development of extended primary care; (vii) duplicate the role of hospital outpatient departments and FMCs; and (viii) create an artificial and potentially destructive perception of separate rural and urban models of primary care - the former managed by FGPs and the latter by narrow specialists. Integration, continuum of care and referral systems 160, Incentives to further expand the secondary-to-primary shift, are limited, hindering the ability of PHC level to develop extended primary care and move beyond a gate keepingrole. Vertical integration is limited. In effect PHC and the hospital levels operate as two sub-systems with precarious links between them. As the financing of the two systems are unlinked, there is a future risk o f cost-shifting between levels. 6.3.4. Resource allocation andproviderpayment systems Inequities and allocative inefjciency 161. Despite the State Guaranteed Basic Package, which has achieved universal coverage for PHC services, major inequities in access to services and funding exist, with the rural poor particularly disadvantaged. As with financing and access, inequities exist between urban and rural areas in the distribution of trained FM specialist and FM nurses. While in urban areas the number of registered citizens per FGP physician is 1500, in rural areas there is a net shortage o f physicians. Consequently, in some remote areas the number of citizens per FGP physiciancan reach between 10-12,000 persons.'03 6.3.5. Limited incentives 162. Limited incentives and poor salary levels of health professionals working at FGPs are key problems that need addressing in the immediate term. Although the new payment mechanisms provide incentives and establish an excellent platform on which to build, there needs to be stronger indication that FMis valued on par with hospital specialties. 6.3.6. Resource generation Recruitment and retention 163. Against a backdrop o f successful retraining program for family physicians and nurses, the shortage of health personnel in rural areas has worsened over the last five years, as medical graduates are unwilling to work in rural areas, and there is no obligation to spend a period in rural areas - as was the case in the Soviet period with amandatory three-year posting to rural areas. There are very few incentives to attract and retain health professionals inrural and mountainous areas. Undergraduate training 164. There are seven medical schools that admit over 1,000 medical students each year; around four times the number needed for Kyrgyz Republic. Undergraduate training is not aligned with international trends, is highly curative in focus and is designedto produce narrow specialists. 6.4. CONCLUSION 165. The study identified, among others, a number of critical success factors for the reforms. These include: (a) branding FM and image building, to improve the status o f FM specialists as compared with 28 narrow specialists; (b) improved work environment and conditions for FM teams; (c) investing in communicationbetweenandwithin levels of the healthsystem andwith the public to share objectives and values of FM, develop trust and increase ownership; (d) improved coordination of key agencies; (e) developing a holistic approach to reform with simultaneous multifaceted interventions to achieve an enabling legal environment, organizational restructuringto enable emergence new provider forms with increased autonomy, new financing methods, resource allocation mechanisms that address inequities, provider payment methods that overcome limitations of systems based on line-item-budgeting and salaries, contracts and evidence-based care guidelines to enhance quality and establish minimum standards; (f, approaching reforms as a strategic change process; (g) ensuring sensitivity and responsiveness to rapidly changing context; (h) ensuring robust M&E systems are put in place to assess impact of reforms; and (i)having a clearly articulated and planned exit strategy between projects to ensure sustainedtransformation. 166. The achievements in development of FM-centered reforms in the Kyrgyz Republic are outstanding and one of the most advanced in ECA Region. Strongpolitical support for the next phase of reforms is critical to sustain and further develop the highly successful reforms. 29 7. CASE STUDY OF MOLDOVA 167. This chapter summarizes the findings o f a detailed study o f FM reforms in Moldova which is published as a separate v01ume.''~ 7.1. BACKGROUND 168. Moldova inherited a health system based on the Soviet Semashko Model characterized by centralized and hierarchical organization; a large provider network with a curative focus, dominated by a surfeit o f hospitals and human resources concentrated in the capital Chisinau. The health system was fragmented by parallel sub-systems for line ministries. The PHC level was poorly developed and did not provide unified service by family physicians. It was based on a tripartite polyclinic system staffed by narrow specialists, which provided services separately for adults, men and children, as well as a large number o f vertical programs delivered separately as vertical programs. 169. Although there was an excess o f human resources, these were concentrated in cities. Regional and socioeconomic inequities existed for resource allocation, service utilization, morbidity and mortality. Resource allocation system based on historic activities and inputs favored large hospitals in urban centers at the expense o f rural areas. Provider payment systems based on line-item budgeting o f provider units and salary-based payment systems for staff encouraged inefficiency and discouraged improved performance, 170. There was limited user empowerment, as the citizens were allocated to a particular polyclinic or a rural PHC center, but they had direct access to narrow specialists at PHC level, which did not have a meaningful gate keeping function. Gate keeping and first-contact functions o f PHC level were further fractured by care delivery protocols which encouraged excessive referral to secondary care level. The health system, as a whole, was highly curative and disease focused (in part attributable to the biomedical nature o f medical training) with limited health promotion or disease prevention. 171. Breaking up from the Soviet Union led to rapid economic decline. Between 1993 and 1999, the GDP declined by 60 percent. By 2000, the GDP per capita was US $354 with almost 90 percent o f the population living on less than U S $ l.OO per day. In the transition period, level o f funding to the health sector declined substantially - creating a major funding gap between the level o f financing needed by the health system and the available resources. L o w funding levels from the public sector and low salaries o f health professionals led to many health professionals leaving the health sector - particularly inrural areas -substantial inequities, emergence ofrent seekingbehavior, and informal payments which acted as a barrier to many citizens to accessing health services. Early in the transition period population health indicators worsened, with explosion o f TB, STI, intravenous drug use and HIV. Since the year 2000, the health indicators have recovered to levels witnessed in 1990, but communicable diseases remain a problem. 172. The Government o f Moldova sought to reform the health system to address key problems, namely: (i)organizational complexity; (ii)excess infrastructure and human resources; (iii)allocative inefficiency and inequities in financing; (iv) inefficient service provision; limited incentives and (v) low pay levels for health personnel. The Law on Health Protection was adopted in 1995 and in 1997 the Moldovan Government approved a Health Sector Strategy for the period 1997-2003.'05 The Strategy aimed to address structural inefficiencies, reduce human resources and improve financing o f the health sector through: (a) organizational and structural changes; (b) modifications to financing system; (c) reform o fthe education and training system for medical staff; and (d) pharmaceutical reform.lo6 These themes were developed into the "five pillars" o f the health reform strategy and articulated inthe appraisal report o f the Bank-financed Health Investment Fund Project (HIF)lo7as: (i) restructuring the network o f medical services and redistributing resources from tertiary level to PHC; (ii)strengthening PHC by establishing an efficient network o f family physicians; (iii)legalizing illegal payments, eliminating payments for unnecessary or excessive medical services, especially those which burden the poor 30 population; (iv) creating apackage o f medical services in line with budgetary resources, with an emphasis on PHC; and (v) centralizing health system financing to improve distribution of funds between levels. 173. Between 1998 and 2002, there were 54 Regulations of the Council of Ministers regarding PHC to operationalize the Health Sector Strategy for 1997-2003.Io8 These legislations formed the foundation for the reforms of the PHC reforms. 7.2. KEYACHIEVEMENTS 7.2.1. Organizational and regulatory changes 174. The Law on Local Public Administration in 19991°9established 11 regional administrative units comprising 10 counties audets), one metropolitan area (the city of Chisinau) and the territorial autonomous unit (TAU) of Gagauzia. In the judet administrative structure, local health budgets were allocated directly to PHC units, sectoral/judet hospitals and emergency services and managed autonomously by each of the units. However, The Public Administration Law 123/2003 enacted in 2003"0~"1abolished the judet structure and stipulated that health services should be reorganized into one legal entity comprising rayon hospital, PHC, emergency and ambulatory specialist services, with separate budgets for each of the different services, but managedby the rayon ChiefDoctor. 175. The tripartite system of pediatric, women's and adult clinics has been consolidated into unified PHC centers providing services for all citizens. FM is recognized as a specialty in law and the scope and content of PHC services have been articulated in law and defined in detail in the State Guaranteed Benefits Package. Users have been given the freedom to choose their family physicians. There has been a remarkable rationalization o f the hospital sector, the most substantial amongst the FSU countries, and 280 PHC have been refurbished with support from the Bank-financedHIF."* 7.2.2. Financing, resource allocation andproviderpayment systems 176. There is mixed financing o f the health system. In 2003, Mandatory Health Insurance with co- payments was introduced, creating a transparent environment as regards payments to health service providers. A Single Payer System has been established which allows integration o f state and local budget revenues with MHIF contributions to fund the Guaranteed Minimum Package of Services for the whole population as well as the Basic Benefits Package under the Mandatory Health Insurance Fund (BBP- MHIF) for the insured and those in exempt categorie~."~ 177. The Health Insurance Company (HIC) has become the purchaser of health services. The health funds are transferred from the HIC and local government to the rayon hospital administration. The rayon chief physician then allocates the funds to the sub-units s/he directly manages but is requiredto comply with MOH budgeting norms, which stipulate allocation of 35 percent of resources to PHC, 15 percent to emergency services, and 50 percent for hospital services. The HIC agrees an annual contract with the rayon administration with pre-specified price and volume of services to be provided. PHC providers are paid according to a per capita contract and hospitals are paid per discharged patient and per case for emergencies. 178. Since the introduction o f the MHI, in the first three months o f 2004 the number of PHC visits was about 2,900,000, an increase o f over 20 percent, as compared with the same period of 2003.'14 An important achievement of health reforms is increased resource allocation to PHC level. The proportion of health expenditure allocated to PHC has gradually increased from 10 percent of the total government health expenditure in 1999 to 26 percent in 2003, while hospital expenditure declined in proportion to this increase. 7.2.3. Serviceprovision 179. PHC network consists of four types of PHC providers: (i)Centers for Family Medicine, based on the former district polyclinics and often serving large populations of over 50,000; (ii)Health Centers, based on former SVAs (selkskiye vranchnii punkt); (iii)Family doctor offices based on former rural 31 ambulatories covering populations greater than 1001 in number; and (iv) Health posts for family doctors assistants for villages/areas with populations numbering less than 1000. A Guaranteed Minimum Package of Services has been introduced for the whole population and includes: (i)PHC services provided by general practitioner/family doctor in ambulatory care unit or at home; (ii)consultative services provided by physician-specialists in polyclinics and hospitals (when patient is included on the list of GP/FD and is referred by the GPRD); (iii)limited range o f diagnostic tests and elementary investigations conducted in ambulatory laboratories (when prescribed by the GPRD); (iv) immunization; (v) urgent and emergency services for life-threatening situations; and (vi) hospital care for treatment of TB, mental disorders, oncology, asthma, diabetes, AIDS and "social-related diseases". 180. Citizens with health insurance have right to an expanded program o f services (BBP-MHIF) as compared with the Minimum Package of Services. The gate keeping function o f the family physicians has been significantly enhanced by the introduction of the BBP-MHIF which stipulates that citizens must first see a family physician before being referred to hospital, The hospital costs of the patients referred are covered by the HIF (except for any co-payment). Those who self-refer to hospital without first consultinga family physician have to bear the full cost of hospital care. 181. Although all Moldovan citizens are entitledto a Guaranteed Minimum Package of Services and have relatively good geographic access to PHC services except for rural areas, significant financial barriers to health care exist. The utilization of PHC services, as measured by the number of visits to family physicians, increased by 17 percent between 2000 and 2002. A limited number of care guidelines have been developed with support from UNICEF, and the HIFProject is providing support to the M O Hto develop additional guidelines in line with the services provided in the Basic Benefits Package under the Mandatory Health Insurance Fund. 182. There is excellent coverage of immunization and widespread provision of basic PHC services in all regions. Many o f the basic PHC services for managing common conditions are provided inmost PHC centers which also manage common chronic illnesses and apply simple diagnostic and therapeutic interventions. The task profile survey shows statistically significant differences in the application of medical techniques, use of medical equipment, and management of common first contact and chronic conditions by family physicians working in PHC centers situated in advanced reform regions as compared with those working in PHC centers from intermediate and early reform regions. 183. The task profile survey demonstrates that family physicians in advanced reform region provide more systematic health education and promotion activities and more frequently manage common psychosocial problems as compared with those family physicians intermediate or early reform regions. There is evidence from the qualitative researchthat the new model is welcomed by the users and health professionals who identify many benefits, which amongst others include user-centeredness of the model, having a named doctor, user choice, improved continuity and more comprehensive nature of FM model, empowerment o f FMteam, and an increasedemphasis on holistic care. 7.2.4. Resourcegeneration 184. The number o f doctors and nurses has been declining due to low salaries and emigration, but this decline has hit the rural regions particularly hard. Family doctor training program began in Moldova in 1996. The Faculty o f Family Medicine was established at the State Medical University in 1998. A Chair in Management Training and Public Health was created in 2000. Two model family practices were established in Chisinau and have been used as training practices. The FM Chair has 15 faculty including four associate professors and eight assistant professors. It has strong support from the State University. 185. The Faculty has been providing four different training programs to train family physicians: (i)a three-year specialist residency program in FM; (ii)a four-month retraining course, which started in 1998; (iii)a four-week retraining course, supported by the WB, which started in 2003; and (iv) short-term thematic courses, supported by UNICEF since 1998. 32 186. Between 1996 and 2001 the Faculty provided `some training' in F M to over 2,000 doctors in residencyand short course programs and was selected by the WB in2003 as the implementing agency for retraining of PHC doctors in FM. In 2002, with financing from the HIF and UNICEF, a four-week training program for training of FM and nurse trainers (TOT) was established. A total of 34 FMtrainers and 20 family nurse trainers were trained in the TOT program who have worked with intemational consultants to develop a six-week retraining course to train 750 family physicians and 1500family nurses. The State University of Medicine and Pharmacy was contracted in 2003 to implement the training program. By the end of March 2005, the University had finalized training of 550 GPs and 1,010 nurses (52%). With support from the HIF, five regional FMTraining Centers were established. 7.3. REMAINING CHALLENGES BEADDRESSED To 187. There has been good progress with the FMand PHC reforms in Moldova, but this progress needs to be sustained and acceleratedto address many challenges which remain. 7.3.1. Organization and regulation Balancingpower betweenprimary and secondary level 188. The power among the health service providers rests with the hospital sector. Recent administrative changes have reduced the autonomy of PHC departments at rayon level and re-centralized power in the hands of the chief rayon doctor, who is also the director of the rayon hospital. This is a retrograde step and will hinder the development of PHC, which is now subordinated to the secondary care level. Monitoring and evaluation 189. There is a lack of systematically collected data at PHC level which can be analyzed to demonstrate whether key reform objectives have been achieved. The PHC component of the M&E system at the Institute of Public Health and Management needs to be enhanced and analytic capacity expanded to regularly analyze data to generate timely information to inform decisions. Communication 190. The benefits of an FM-centered PHC system are not adequately communicated to citizens and health professionals. Although the HIF Project has significantly invested in communication and advocacy activities, more investment is needed to improve communication between and within levels of the health system and with the public to rectify misperceptions of family medicine. 7.3.2. Financing, resource allocation andproviderpayment systems Incentives 191. Lack of incentives and poor salary levels of FM specialists are two major problems that need addressing in immediate term. A key problem with the image of FM is that the family physicians have to work longer hours then specialists, undertake excessive administrative tasks without commensurate pay or professional recognition (by peers and citizens). This dampens the enthusiasm of doctors to enter residency programs and narrow specialists to retrain in FM. The Government has identified this as an issue and recently introduced changes to pay scales to increase remuneration of family physicians, and in particular those working in the rural areas. However, this is a policy priority and should be closely monitored. 192. There are no incentives to achieve a substantial shift from secondary-to-primary health care, limitingthe ability of PHC levelto develop extended primary care and move beyond a gate keepingrole. Equity and allocative eficiency 193. There are clear differences in the level o f resources provided to urban and rural regions. In particular Chisinau City attracts much higher funding levels than other regions. Allocative inefficiencies 33 between levels o f care and type of institution also persist. Inparticular, Republican Hospitals in Chisinau still consume a significant proportion of the health system budget. Consequently, major inequities in access to services and funding exist. The next phase of reforms should place an emphasis on changing resource allocation mechanisms to take into account poverty and health needs and substantially modify the current patterns whichcurrently favor urban areas andRepublican hospitals. 7.3.3. Serviceprovision 194. The retraining programs have been successful in rapidly scaling up FM in Moldova, but are too short to convert narrow specialists to generalist family physicians. Existing training programs need to be extended and further strengthened to produce family physicians of higher competence and to counteract criticisms leveled by narrow specialists and opponents of reforms at FM institution. Countrywide standards on scope and quality o f services have succeeded in establishing minimumquality standards and basic level PHC services as compared with OECD countries, the scope and content of services provided in PHC setting in Moldova are still basic and there is much room for expanding the scope of services provided in PHC. The current contract introduced by the HIC and the BBP-MHIF will help enhance equity by providing a uniform package o f servicesto the whole country. Much work needs to be done in the next few years to further institutionalize this system. To further develop PHC, over time, there needs to be a move to more flexible contractingbasedon performance. 195. The presence of narrow specialists at PHC centers is a source of inefficiency and a barrier to developing PHC as it adversely impacts on first contact, continuity and comprehensiveness functions of PHC. All narrow specialists at PHC level should be trained as family physicians and roles modified so that they practice FM. 7.3.4. Resource generation 196. There are several concerns regardingtraining and FM: (i) short nature of the training; (ii) the no career structure for graduates of FM programs; and (iii)inadequate incentives for FM physicians. Existing training programs need to be extended and further strengthened to produce family physicians of higher competence and to counteract criticisms leveled by narrow specialists and opponents of reform. It has been estimated that around 20-30 percent of FM graduates go back to work in posts in hospitals. To address the problem of low salaries and incentives, the M o H has developed new guidelines stipulating mechanism for wage calculations, which allows from 2005 to increase wages, especially for GP in rural areas, where there is an acute shortage of staff. 7.4. CONCLUSION 197. Although impressive, the achievements are fragile given the systematic reduction of public funding for health system, low pay levels, limitedvisibility of FMamong the health professionals and the recent changes in the Public Administration Law, which has abolished judet structure and autonomous PHC units and has handed over the management of PHC to rayon hospital directors. Key stakeholders interviewed wish to see acceleration in the pace of reforms, to: (i) broaden role o f family physicians and strengthen the competence o f the PHC team; (ii)refine payment mechanisms to introduce incentives and performance related pay to encourage innovation, enhance quality and provide of additional services -for instance, greater health promotion and prevention activities, and to attract doctors to rural areas; (iii)modify resource allocation by introducing systems that are pro-poor and enhance allocative efficiency, such as differential per capita pay to PHC centers based on need and difficulty of access - to favor rural and poorer areas which have higher health needs; (iv) develop capacity to manage strategic change; (v) better define referral and counter-referral mechanisms to establish a continuum of care; (vi) improve communication to reduce misunderstanding and resistance; and (vii) increase autonomy of PHC units vis-a-vis the rayon hospitals; and (viii) Develop a strong M&Ecapacity. 34 8. DISCUSSION Armenia Bosnia and Estonia KYrgYz Moldova Herzegovina Republic New Family FMTeam Family Family group Family organizational physicians physicians practice physician form Contracts with Direct Direct and Direct Direct Indirect fundingagency indirect Degree o f Limited Limited High High Limited autonomy Ownership Joint stock Public Private Public Public status company in cities User choice with Yes Yes Yes Yes Yes enrolment Scale up I 15% 123% 1100% I70% 140% Armenia Bosnia and Estonia KYrgYz Moldova Herzegovina Republic Financing Mixed Mixed Mixed Mixed Mixed State Health Agency, HI, state, entity HI,OOP HI,state HI, local state, local, OOP Co-payment Yes for services Not for PHC Yes for home visits Not for BBP Not for Basic outside Basic Benefit and outside benefit inPHC Package in Package package PHC 35 8.3. RESOURCE ALLOCATION AND PROVIDERPAYMENT SYSTEMS 201. As compared with the levels inthe 1990s, the proportion o f health system funds from the public budget allocated to PHC has increased in all the countries evaluated. The lowest proportion was in Estonia and the highest in the Federation o f the Bosnia and Herzegovina (Table 3). All the countries had replaced salary-based payment systems with per capita or mixed provider payment systems. Table 4: ResourceAllocationand ProviderPaymentSystems Armenia Bosnia and Estonia Kyrgyz Republic Moldova Herzegovina % ofPublic 28 FBIH43 14 25 35 Expenditure for RS26 PHC Payment Weighted ISimple per Weighted per systemfor capita + capita capita PHC practice allowance+ fee-for- service Fundholding No No No Partial, for No pharmaceuticals Incentives No InRS for Fee-for- No No ~ health service momotion 8.4. SERVICE PROVISION 202. All the countries had introduceda defined benefit package or minimumstate guarantees. All the countries had expanded the scope o f services provided by family physicians in PHC, especially by introducing health education, health promotion and disease prevention. Further, the comprehensiveness of services provided had increased as more o f the first contact and chronic illnesses were being managed by family physicians as compared with PHC doctors not trained as FM specialists. The extent o f this expansion varied, with most extensive being in Estonia and the Kyrgyz Republic. Generally, access and accessibility to PHC had improved in all the countries studies in areas where FM reforms were introduced. 203. Gate keeping and first contact function was fractured in all the countries studied due to the ability of the users to directly access narrow specialists in PHC setting or inhospital outpatients. The continuity and comprehensiveness functions o f family physicians working in PHC had been enhanced in all the countries studied but varied in magnitude. There was limited coordination function for the PHC level except for managing referrals. The number o f referrals to hospital for first contact and chronic conditions had declined in three o f the five countries studied and intwo, Estonia and the Kyrgyz Republic, there was a shift between secondary and primary health care. 204. All the countries had introduced evidence-based guidelines for doctors and nurses. This was most extensive in Estonia and the Kyrgyz Republic, followed by Armenia, Bosnia and Herzegovina and Moldova (where only a few had been introduced) (Table 4). 36 Table 5: Expansion of Service Provision hnction Score: 1= low to 5= very high 205. The countries studied have expanded the scope of services provided in PHC along key functions (Figure 2) with limited coordination, except for referrals, but the gate keeping function is fractured due to presenceof narrow specialistswho can be directly accessedinPHC or inhospital. Figure 2: Scope of Services Provided by the FM-led PHC Team in Transition Countries Scope of FM-led PHC in transition countries in ECA Region First-contact .Acute-demand led services .Health promotionand Prevention Coordination .ChronicLongitudinaiitydisease management -@- .Very Limited Comprehensiveness .Limited Diagnosticservices 37 206. There is still a discernible gap between the scope of services provided in the countries studied when compared with those providedin OECD countries which have advanced FM-led PHC systems, such as Canada, Finland, Netherlands, Norway, Spain, and UK, where PHC has an extended role beyond gate keeping and managing first contact conditions (Figure 3). In these countries PHC actually `manages' majority of the healthproblems (between 90-95%), includingmost of the acute and chronic illnesses both at home and in the community setting. Figure3: Scope of Services Providedby the FM-led PHC Team inKey OECD Countries The new Primary Care in OECD countries First-contact .Acute-demand led services .Health promotion and prevention -Accident and Emergency -Community Hospitals Longitudinality Co-ordination Chronic disease management -Budgetary responsibility .Out of hours serwces .Needs assessment .Palliative care -Strategic Planning .Purchasino .Service reconfigiiration Comprehensiveness -Diagnostic services Commiinity based care *Hospital at home .Specialist nursing and medical serwces 207. However, although the countries studied have not yet reached levels of `extended PHC' services provided in OECD countries with advancedPHC systems, there is substantialprogress. Attractiveness of FM as a specialty has increased (Figure 4), but much needs to be done to reduce uncertainty surrounding the status of the specialty as regards doctors working in PHC without specialist FM qualification and narrowspecialists who work in PHC andhospitals. This will requirea visible boostto provide incentives for family physicianswith specialisttraining. Figure4: Attractivenessof Family Medicineas A Specialty Attractiveness of the FM speciality Growth opportunity High ~l Start Low 38 208. The ability o f family physicians to influence decisions on the management of patient care has increased (Figure 5) due to enhanced gate keeping, broadened scope of services, evidence-based care guidelines which stipulate service boundaries and thresholds hospital referrals, and mechanisms which enable family physicians to manage hospital referrals (for instance, in Moldova and the Kyrgyz Republic, patients have to be referred to hospital to qualify for insurance coverage; those attending without referral have to bear the full costs). Figure5: Influenceof FamilyPhysicianson PatientCare Influence on decisions and managing patient care influence on decisions High Control of patient care High I '. .'0 Start Low 209. Doctors trained in FM have increased application o f medical procedures, their use o f diagnostic medical equipment, and expanded the scope o f services they provide. This has increased their capacity to resolve problems at PHC level (Figure 6). However, the capacity o f PHC needs to be further expandedto increase capacity for problem resolution and enable secondary to primary shift. Figure6: Capacityof FamilyPhysiciansto Resolve Problems Capacity to resolve problems Capacity to resolve problems High Capacity for investigations I I Now I Low 39 210. Improved training, strong advocacy by professional associations, establishment o f chairs o f FMat universities, recognition o f FM as a specialty, provision o f better quality services has helped increase the regard for FM among the medical profession and the public (Figure 7). However, there needs to be significant investment in communication activities to increase understanding o f FM and improve understanding o f the benefits o f moving to an FM-centered PHC system. Figure7: Regard for FamilyMedicine Regard for Family Medicinelprimary Care I Public High Medical Professionals High "0 Start Low 8.5. RESOURCE GENERATION 211. All o f the countries studied have improved retraining programs to convert doctors working in PHC to FM specialists as well as residency programs for FM- the structure, program length, curriculum content, and location of training for the FM retraining and residency programs. The length of retraining programs varies from four months in the Kyrgyz Republic to three years inEstonia (Table 5). Table 6: TrainingPrograms Armenia Bosnia and Estonia KYrgYz Moldova Herzegovina Republic Retraining Two programs: One-year Three years Four months Six months program 11 months and program of (80% in- (with four 18 months additional service weeks (both basedon training training and additiona1 unified 27 weeks retraining) curriculum) university- based) Residency Two years Three years Three years Two years Three years program 212. The FM residency programs in the countries surveyed have been developed in countries with support from international experts and in terms o f structure and content are in line with FM residency programs offered by countries in Europe and the Americas (Annex 8). 40 9. CONCLUSIONS 9.1. CRITICAL SUCCESS FACTORS 2 13, The study has identified a number o f critical success factors. These include: (i) branding FM and image building to improve the status o f FM specialists as compared with narrow specialists; (ii)improved work environment and conditions for FMteams; (iii) improved communication between and within levels o f the health system and with the public to share objectives and values o f FM, develop trust and increase ownership; (iv) improved coordination o f key agencies; (v) a holistic approach to reform with simultaneous multifaceted interventions to achieve an enabling legal environment, organizational restructuring to enable emergence o f new provider forms with increased autonomy, new financing methods, resource allocation mechanisms that address inequities, provider payment methods that overcome limitations o f systems based on line-item budgeting and salaries, contracts and evidence-based care guidelines to enhance quality and establish minimum standards; (vi) approaching reforms as a strategic change process; (vii) ensuring sensitivity and responsiveness to rapidly changing context; and (viii) having a clearly articulated and planned exit strategy. 9.2. MANAGING STRATEGIC CHANGE 214. Implementing PHC reforms is a complex strategic change process and there i s insufficient managerial capacity to accelerate the pace o f development. It is necessary to rapidly develop a critical mass o f middle and senior level managers and health professionals to act as change agents along with local capacity to deliver training programs. Moving out o f `pilot' and `experiment' mode is critical to institutionalize and systematize changes by timely update o f laws and regulations to sustain the momentum. 215. Although it is necessary to invest in key individuals to develop champions of reform, this must be balanced with wider engagement o f stakeholders to achieve consensus on reform objectives. Combining bottom-up and top-down approaches with simultaneous investment in key individuals, institutional development at different levels, and institutionalizationwill help increase chances o f sustainability. 9.3. HOLISTIC APPROACH 216. The study clearly demonstrates the importance o f a multifaceted and multi-level approach to reform. While new laws and regulations are developed and existing ones modified to create an enabling environment for change to occur, simultaneous interventions are needed to refine organizational structures, health system financing, resource allocation, provider payment systems, and service provision. 9.4. BEYOND PILOTSTO SYSTEM CHANGE 217. Moving out o f `pilot' and `experiment' mode is necessary to institutionalize and systematize changes to sustain health system reform. Continuing development in a pilot mode, with multiple projects, result in sprinklings o f pockets of innovationwithout coherent systemic change. 9.5. INSTITUTIONS VERSUS INSTITUTIONALIZATION 218. While it is necessary to invest in key individuals to develop champions o f reform, this must be balanced with efforts to widely engage stakeholders to achieve consensus on reform objectives. The experience o f the five countries studied confirms the importance o f combining bottom-up and top-down approaches with simultaneous investment in key individuals, institutional development at different levels, and institutionalizationthrough appropriate laws and regulations. 9.6. BALANCINGSHORTAND LONG-TERM HORIZONS TIME 219. Balancing short-term success and sustainability i s important. Achieving system change takes time. Short-term projects have value, but sustained support over a further five to eight year period is a realistic time scale to achieve and institutionalize change in the countries studied. 41 9.7. READINGTHE CONTEXT 220. The fluidity of the socio-political and the economic environment inthe ECA Region means that political economy of health reforms and factors influencing strategic change must be adequately analyzed and addressed in the design phase and throughout implementation of programs. This analysis and monitoring should be continuous to ensure that generic technical solutions are not applied to complex socio-political contexts. 9.8. BRANDINGFAMILYMEDICINE 221. Among the health professionals and the users, there are misperceptions o f what F M is and how it can add value to the health system. This is in part due to limited efforts at communication. Inadequate and ineffective communication breeds resistance and creates barriers to change. The `fear of the unknown', frequently quoted by the key informants, needs to be addressed through a well-developed communication strategy aimed at users, health professionals, managers and decision makers. There is a need to communicate the rationale and the substance of the FM reforms to the public at large; develop ways of assessing and benchmarking customer satisfaction; and through surveys of users elicit their expectations and experiences with PHC services. 222. Demonstration of `quick wins' and effective communication of success stories will catalyze the development process in PHC. However, lack of successful role models in FM-centered PHC reforms in the region remains a problem. 9.9. COORDINATION 223. Coordination of international agencies i s critical to ensure that development activities are not fragmented or duplicated and a coherent sector development program emerges. There are genuine efforts by international agencies to improve collaboration with evidence o f a loose `operational SWAP' emerging in some countries. However, complexity of coordinating the donor agencies or managing a SWAP should not be overlooked and appropriate and sustained support should be provided to the local counterparts. 9.10. LEVEL INTERVENTION OF 224. It is necessary to establish strong vertical and horizontal links and simultaneously work both at policy and operational levels - the former to institutionalize changes and the latter to create shared ownership, reduce resistance, learn lessons and develop a critical mass of professionals to implement policies. Governance structures can limit what can be achieved within the health system, at regional or organizational level, if there is no clear link to national policy level. A good example of policy disconnect is public administration reforms that do not adequately take into account impact on the health sector. Without linkages, local level initiatives and innovations have limited impact on central policies and cannot diffuse to other regions. 9.11. RESPONSIVENESS 225. The fluidity of the socio-political and the economic context in the ECA Region means that political economy of health reforms and factors influencing strategic change must be continually analyzed to ensure that generic solutions are not applied to complex socio-political problems. Given this fluidity, programs should adopt a flexible approach to implementation - allowing timely adaptation to contextual changes and responding to windows o f opportunity, but without sacrificing a strategic approach. 9.12. MONITORINGEVALUATION AND 226, A fundamental problem with the PHC reforms in the ECA region is the lack of systematically collected data that can be analyzed to demonstrate changes in health system objectives (such as equity, efficiency, effectiveness and choice) and health outcomes which can be attributed to developments in PHC. There is insufficient investment in monitoring and evaluation and limited analytical capacity inthe 42 countries studied. Resources are needed to develop appropriate metrics, information systems and analytical capacity to monitor progress of PHC reforms and inform policy. 9.13. DISSEMINATIONAND CROSS LEARNING 227. Regional collaborations and regular exchanges to share lessons are highly valued by the respondents and should be encouraged and supported, with dissemination o f experience within and between countries. Key documents (such as technical reports) should be available in local languagesand disseminated widely to local counterparts. 9.14. EXITSTRATEGY 228. On the whole, countries studied have succeeded in introducing FM-centered PHC systems, with significant scale up and institutionalization in the Kyrgyz Republic and Estonia. Good collaboration has been achieved between the international agencies and the government with an operational SWAP established. The case studies demonstrate that the World Bank can add much value to the reform process. However, success brings with it responsibility. It is important that clear exit strategies are developed and agreed with local counterparts to ensure there are no gaps between projects to sustain the transformation process. 43 10. APPENDIX 10.1, ANNEX1:DEFINITIONSOFPHC 229. Defining FMand primary care is fraught with difficulties. An attempt at defining primary care in the US yielded 92 definitions.116 10.1.1. Primary care as a concept 230. Inthe Alma Ata declaration, the WHO definedprimary healthcare as `essential healthcare based on practical, scientifically sound and socially acceptable methods and technology, made universally available to individuals and families in the community through their full participation and at a cost that the community and the country can afford to maintain at every stage o f their development in the spirit o f self-reliance and self-determinati~n.'"~Although many transition countries have yet to attain a PHC level defined in the Alma Ata declaration, many industrialized countries in the European Region have surpassed it.11*For many countries, PHC is viewed as `a strategy to integrate all aspects o f health services' .`I9 10.1.2. Primary care as a level 231. In 1920, the Dawson Report distinguished three major levels o f health services in the UK: (i) primary health centers, (ii)secondary hospitals, and (iii) teaching hospitals.120 Although this structure prevails in most countries, the content and the process o f what is delivered in primary and secondary care has changed significantly in the last decades. As a level o f care in the health system, PHC is the point o f first contact and where 90 percent o f health problems are dealt with. As a strategy, PHC envelopes the notion o f accessible care relevant to the needs o f the population, functionally integrated, based on community participation, cost-effective and characterized by collaboration between sectors o f the society. As a philosophy, primary care underpins equitable service delivery to the individual and the society through an inter-sectoral approach. 10.1.3. Primary care defined in termsof content 232. In many health systems, particularly in developing and transition country contexts, PC is defined in a constrained manner as `basic' or `essential' set o f health interventions enshrined in the Alma-Ata Declaration.'21 In low income countries PHC is often equated with `selective vertical programsy122-123and provided as an `essential package o f services' to address the main causes o f the disease burden - communicable disease, perinatal and maternal deaths.124 This reductionist approach can lead to a conceptual fixation - equating primary care with selective vertical programs125126 or just as an `essential package o f services'. The `selective primary care' approach has been widely criticized for lacking empirical foundation127,as a reinvention o f the traditional technically oriented vertical programs.12* It is seen by some as being based on value judgements129-130 and often counterproductive131 - adversely impacting on the health developmental process.132 233. Alternative to `selective PC' is `comprehensive PC' which prevails in many developed countries and comprises a wide range o f promotive, preventive, curative and rehabilitative activities. It is argued that comprehensive PC is also affordable and deliverable in a developing country context.133 44 Table 7: Primary Care Services Health educationand promotion Health maintenance(reassuranceof worried, well, maternity care) Prevention of disease through immunization, screeningand case finding Diagnosis and management of common emergencies, as well as acute andchronic conditions, delivered ina clinic or in the patient's home Antenatal and postnatalcare Contraceptiveadvice and provision Follow up and continuing care of chronic and recurring disease Rehabilitation after illness Provision of ancillary services such as physiotherapy and dietetics Terminal care Coordinatedservices for the mentally ill,elderly and children Help for patientsto make use of appropriateservices Health development (cross-sectoralaction to improve the environmentaleconomic and social inputs into health) Medical Paramedical Administrative Therapists Social General Community nurse Practicemanager Physiotherapist Social worker practitioner Dentist Practicenurse Receptionist Chiropodist Community psychiatrist Community Ophthalmic Assistant Speechtherapist Psychologist geriatrician School medical Midwife I I optician 1 Secretary I Osteopaths ICounselor 1 Health Visitor I Dietician I Domiciliarv aid I Pharmacist I I I I 10.1.5. Primary care as a key process 235. Primary care is often equated with a `gate keeping' role.136However, it plays a more fundamental role than just gate keeping. Primary care is a key process within the health system.'37 It is first contact, front-line care, ongoing care, comprehensive care and coordinated care.13* First contact care is accessible at the time o f need; ongoing care focuses on the long-term health o f a person, not on the short-term duration o f the disease; comprehensive care is a range o f services appropriate to the common problems in the population available at the primary care level; and coordination is a role by which primary care acts to coordinate other specialist services that the patient may need. 45 10.2. ANNEX2: DEFININGFAMILYMEDICINE THE ROLEOF THE FAMILY AND PHYSICIAN 236. The WHO Regional Office for Europe defines the characteristics o f FM in terms o f its scope, function and ~ r i e n t a t i o n . ' ~ ~ Table 9: Family Medicine Characteristics General-unselectedhealth problems ofthe whole population Continuous - primarily person-centeredrather than disease-centered, long-standing personal relationship between patient and doctor Comprehensive-provides integratedhealthpromotion, disease prevention, curative, rehabilitative and supportive to individuals Coordinated-dealing with krther referrals to other healthprofessionals Collaborative - working with other medical, health and other social care providers delegating care where necessary -theyaremanagersoftheirpatientcare Family-orientated - addressing health problems of the individual in the context of the family incorporating their cultural and social circumstances Community-orientated- patient's problems seen inthe context of the community, doctors being aware of the health needs ofthe generalpopulation 237. WONCA Europe and the European Society o f General PracticeRamily Medicine, define family medicine as: `General practice/family medicine is an academic and scientific discipline, with its own educational context, research, evidenced base and clinical activity and clinical specialty oriented to primary care.'I4'The "European Definition for the discipline and specialty o f General Practice/Family Medicine" articulates that general practice/family medicine i s an academic and scientific discipline, with its own educational content, research, evidence base and clinical activity, and a clinical specialty orientated to primary care.141 The document, agreed by 25 countries in Europe, elaborates on the `specialty o f General Practice/Family Medicine' and states that "Family doctors are specialist physicians trained in the principles o f the discipline. They are personal doctors, primarily responsible for the provision of comprehensive and continuing care to every individual seeking medical care irrespective o f age, sex and illness. They care for individuals in the context o f their family, their community, and their culture, always respecting the autonomy o f their patients. They recognize they will also have a professional responsibility to their community. In negotiating management plans with their patients they integrate physical, psychological, social, cultural and existential factors, utilizing the knowledge and trust engendered by repeated contacts." 238. The characteristics o f family medicine are that it: (a) is normally the point o f first medical contact within the health care system; (b) makes efficient use o f health care resources through coordinating care, working with other professionals in the primary care setting, and by managing the interface with other specialties taking an advocacy role for the patient when needed; (c) develops a person-centered approach, orientated to the individual, hidher family, and their community; (d) has a unique consultation process, which establishes a relationship over time, through effective communication between doctor and patient; (e) is responsible for the provision o f longitudinal continuity o f care as determined by the needs o f the patient; (f) has a specific decision making process determined by the prevalence and incidence o f illness in the community; (g) manages simultaneously both acute and chronic health problems o f individual patients; (h) manages illness which presents in an undifferentiated way at an early stage in its development; (i)promotes health and well being; (j)has a specific responsibility for the health o f the 46 community; (k) deals with health problems intheir physical, psychological, social, cultural and existential dimensions. 239. These Eleven Core Competencies are recognized as being essential to the discipline - irrespective of the health care system in which they are applied - and are the central characteristics which define the discipline. These competencies are clustered into six core competencies (with reference to the characteristics): (i)primary care management (a,b); (ii) person-centered care (c,d,e); (iii) specific problem solving skills (f,g); (iv) comprehensive approach (hj); (v) community orientation 6); and (vi) holistic modeling (k). To practice the specialty the competent practitioner implements these competencies in three areas: (i)clinical tasks; (ii)communicationwith patients; and (iii)management o f the practice. 240. The interrelation of core competencies, implementation areas and fundamental features, characterizes the discipline and underlines the complexity of the specialty. It is this complex interrelationship o f core competencies that guide and are reflected inthe development of related agenda's for teaching, research and quality improvement. 47 10.3. ANNEX 3: FACTORS WHICH INFLUENCEQUALITY OF CARE DELIVERED FAMILY BY PHYSICIANS 241. Determiningwhich variables influence the care process and outcome is a complex task - given the difficulty in controlling for the variables and confounding. A further difficulty relates to defining quality. Frameworks used to assess quality and the indicators used to measure quality vary by country. Patient perceptions of quality differ from those used by the regulators, financing agents and providers. Even when there is consensus on the indicators these may not be good predictors of q ~ a 1 i t y .However, l ~ ~ many studies have exploredthese factors. 10.3.1. Organizationalarrangements 242. The quality o f care - as measured by process and outcome o f health care, outpatient referrals, uptake of breast and cervical screening, prescribing patterns, and night visits - varies significantly between general practices in England due to a number of factors.143-153 Campbell et al. found that four variables were good predictors of quality of care: (i) thebooking interval for routine consultations -with longer consultations leading to higher quality care; (ii) size of the practice - smaller practices scored the better than larger ones for access to care. However, larger practices had had higher quality scores for diabetes care as compared with smaller ones; (iii) deprivation predicted poorer uptake of preventive care, highlighting that quality of care in general practice is strongly influenced by environmental factors; and (iv) an environment that was conducive to teamwork was associatedwith high quality care for diabetes, improved access, enhancedcontinuity, and increasedoverall patient satisfaction.lS4 243. Although longer consultations are associated with higher patient satisfaction, the consultation length in F M varies greatly in different countries. A study of six European countries showed that the consultation length was influenced by: (i)new and old problems - consultations lasted longer for new problems; (ii)practice characteristics - consultations lasted longer in city based practices than rural practices; (iii)doctors' characteristics - positive orientation to psychosocial problems meant longer consultations; (iv) age and gender o f the doctor had no impact on the duration of the consultation; (v) doctors' workload - workload had a negative influence on consultation time; and (vi) patient characteristics - the patients' sex and age - women and older patients had longer consultations."' Quality of care is influencedby structural and process aspects of practice organization. Smaller practices are seen as more accessible and achieve higher levels of patient satisfaction.156-157 Availability of equipment and medical records have positive relationship with quality. Time spent on continuing medical education was positively associated with better performance o f doctors. Efficient organization of practice, especially with data collection, prescription and referrals, predicted improved performance. Increasing age of FP predicted poorer performance and solo practice adversely affected communication with patients."' Gate keeping role 244. Gate keeping strengthens the position of the family physician as the point of first contact in the health system and expands the range o f conditions managed without adversely influencing the diagnostic or management style of the family physicians or their coordination o f patient care.159-161 Increase in the frequency of first contact episodes with the family physician reduces the extent of self-referral and may influence referral rates but one study showed that 75 percent of the variation inreferral rates for specific conditions was attributable to the characteristics o f the presenting problem.'62 Information Systems 245. A systematic review o f impact o f computerized decision support systems on quality of care provided by physicians concluded: 'I...strong evidence exists that some computerized decision support systems can improve physician performance.. . This I' was particularly true with the use of preventive 48 reminder systems and drug dosing.163Similarly, a different systematic review o f the use o f computers in primary care found an increase in immunization rates and other preventive tasks with a minimal increase in consultation length.164 Other studies conclude that the use o f electronic medical records improves quality o f care but makes extra demands on physicians' time.'65-'66 10.3.2. Financing andproviderpayment systems 246. Impact o f different financing schemes on behavior o f family physicians has been widely studied. For instance, in the UK, several studies explored the behavior o f family physicians to incentives introduced by the GP Fund holding scheme - when the GPs were given budgets to purchase hospital services and to provide incentives to increase PHC based management o f patients and reduce unnecessary referrals to hospital. Some o f these studies produced equivocal results on referral patterns, 167-169 while others found an increase in referrals in the year preceding entry to fund holding followed by a decrease in the first year o f the scheme17', lower referral rates as compared with non-f~ndholders,'~~or slower rate o f rise in referral rates as compared with non-fund holding practices.172 D ~ s h e i k o 'and~ G r a ~ e l l e ' ~ ~ ~ empirically confirmed that fund holders referred patients to narrow specialist less often than non-fund holders. The general conclusion o f these studies is that the GPs behaved as economic agents (income maximizers), as there were positive and statistically significant increases in overall referrals in the year before entry to the scheme (as the budgets were set according to the referral volume in the year prior to entry) and a decline after entry. 247. Iffamily physicians are paidby fixed budgets and bear the full monetary and non-monetary cost o f providing services to patients, then they provide an efficient mix o f services to patients but the level falls to a minimumas the physician has no incentive to provide additional or highquality services beyond the minimum required.175 Payment by salary, with no financial incentive to provide high quality services, creates an incentive to minimize effort and refer excessively to hospitals to reduce work10ad.I~~ 248. When family physicians are paid by capitation they receive a fixed payment for each patient on their list and bear full monetary and effort cost o f providing care for their patients. Therefore, they have incentives to employ inputs efficiently, but also to provide high quality services to increase demand to register new patients.'77 A national study o f the referral ractices o f U S physicians found that paying physicians by capitation did not influencerates o f referral.'8 Fee for service (FFS), especially selective FFS, can help improve the quality o f services.179However, there i s a risk o f overprovision o f services as FFS creates an incentive for physicians to provide excessive services that are remunerated."' When there i s competition between providers, FFS may help improve quality but will not prevent overprovision o f services.'8' 249. Empirical work from Nordic countries suggests that change from pure capitation to a mixed payment system, including FFS elements, led to an increase in the intensity o f diagnostic and curative services provided by family physicians, but reduced the referrals and prescriptions.182-183 A change in payment mode from practice allowance-cum-FFS to capitation-cum-FFS resulted in increased referral rates, as the new mode o f payment gave an incentive to GPs to increase referrals to reduce workload and create space for new services to be provided to attract new patients - thereby attracting greater FFS and per capita payment.184 250. Linking family physician remuneration to quality targets improved quality o f services, as represented by achieving health targets for immunization and cervical screening.185Professional behavior of the family physician is influenced by not just economic considerations, but also by status seeking, intrinsic motivation and altruism.186-187 Studies demonstrate a reasonably strong and consistent association between continuity and satisfaction for both the patient and the doctor. A patient's enablement and satisfaction with a consultationis strongly associated with visiting the same doctor. When doctors know patients well, compliance and the accuracy o f diagnosis are increased.188- 190 Patient satisfaction is higher infamily practices that are not too large and havepersonal lists."l 49 25 1. Additional training o f family physicians to deliver patient-centered care results in greater attention to the consultation process - leading to improved communication with patients and greater patient satisfaction with treatment and well-being. 192 A patient-physician partnership, with collaborative goal-setting that involves agreed joint action plans, improves patient care and can improve outcomes in asthma, diabetes, arthritis, and other chronic conditions.lg3 10.3.3. Continuingmedical education 252. There are several studies which demonstrate good outcomes for the provision o f Continuing Medical Education (CME) programs for GPs to improve performance, competencies and changes to p r a ~ t i c e . ' ~A `systematic review o f CME for family physicians found that C M E increased effectiveness ~ ' ~ ~ of GP work. The study concluded that "Controlled trials o f CE strategies suggest effectiveness is enhanced by personal feedback and work 253. A systematic review o f 99 trials, which included 160 CME programs for physicians that evaluated the effect o f CME on physicians' performance and health outcomes, concluded that "almost two thirds o f the interventions (101 o f 160) displayed an improvement in at least one major outcome measure. The review showed that around 70 percent o f the studies demonstrated a change in physician performance. There was a positive change in health outcomes in 48 percent o f CME interventions which aimed at improving health care outcomes. The review concluded "...widely used CME delivery methods such as conferences have little direct impact on improving professional practice. More effective methods such as systematic practice-based interventions and outreach visits are seldom used by CME providers." i99 50 10.4. ANNEX4: THEEVALUATIONFRAMEWORK 254. A health system is made up of elements that interact. The sum o f the system element is greater than its parts. The interactions of these elements affect the achievement of health system goals and objectives, Therefore, any framework for analyzing health systems should be able to capture notjust the changes ingoals and objectives, but also changes in system elements. 255. An evaluation should describe key features of the main policies, structural changes, new financing and care provision mechanisms and processes introduced as a result of reforms. Where possible, the evaluation should also describe and measure changes in health system performance and try and establish causal linkages between intervention and outcome - to assess the extent to which the changes observed can be attributed to the reform implemented. However, in real life attribution and establishing causal links are not easy. Health reforms do not happen in a laboratory.2oo They are not 'ahistorical' or 'acontextual', but tend to follow a trajectory of development and changes over a period of time - and hence can be considered to be part of a continuum rather than a discrete event. Further, reforms are not isolated and clearly discernable experimental interventions in a controlled setting, but are multifacetedand complex organizationalchange programs. 256. A further difficulty with evaluation of health reforms arises with measuring health outcomes which are often influenced by multiple personal and non-health factors - such as the stage o f economic development in the country, income and education levels, environment and housing.201-202 In practice, it i s difficult to separate and control for the contextual factors from the policy interventions and clearly establish causal links. Given these difficulties, any method usedto evaluate complex policy interventions will have limitations in establishing causal links. A further difficulty arises in comparing different countries or settings where it often difficult to draw conclusions from international healthcare systems c~mparisons.~'~Nevertheless, a systematic approachto evaluation can yield usefulinformation which can be used to reach plausible conclusions about cause and effect. 257. A number of frameworks have been developed for analyzing the performance of health systems. For instance, the WHO Performance Assessment Framework (WHO PAF) i s used for comparative evaluation of health systems performance of the member countries and provided the basis of the World Health Report 2000.204The WHO PAF assesses health systems performance in terms of attainment of a number o f goals - average health level, distribution of health, average responsiveness, distribution of responsiveness and fairness o f financial contribution. Both the World Health Report 2000 and the WHOPAF generated significant debate on measuring health system performance and the framework has been further developed and refined.205 258. There are other frameworks that focus on efficiency, financing, equity o f access and financial sustainability. In relation to PHC, there are evaluation frameworks that focus on measuring q ~ a l i t y . ~ ' ~ ' ~ ~ ~ These frameworks have strengths, but also limitations. Many o f the existing frameworks for health systems/PHC performance assessment and evaluation measure health sector inputs, resources utilization, activity levels and changes in processes rather than outputs or outcomes. This is probably because health sector inputs and processesare easier to measure and the data on these can be obtained inthe short-term. Any analytical framework used to assess health systems should capture notjust inputs and processes but also outputs and outcomes o f the system, as well as the interrelationships between the system components.*" Moreover, the wider context, within which the health system functions and interacts, also needs to be understood and contextual changes captured inthe a n a l y ~ i s . ~ " - ~ ~ ~ 259. Kutzin suggests a three-step approach to evaluating health reforms describing clearly: (i)key contextual factors driving reform; (ii)the reform itself and its objectives; and (iii)the process by which the reform was (is being) implemented.214 To this approach three further elements can be added: (iv) describing clearly the changes introduced by the reforms; (v) analyzing the impact of these changes on 51 health system objectives and goals; and (vi) establishingwhether the reforms have achieved the policy objectives set by the Government - or the agency leadingthe reforms. The approach used in this study builds on that developedby Kutzin, but also draws on a framework developedto assess healthsystems. 52 10.5. ANNEX 5: SUMMARY OFFACILITYSURVEYINSTRUMENT Section Subjects 1. General information Classificationby the type of facility and administration about PHC facility Demographic and geographic data Sanitation and conditions 2. Scope o f services A list of services providedby PHC facility, characterizing: Breadthof services, extended care, support services 3. Organization A list o f questions characterizing general management of PHC facility, managementof finances and provision of services. Inclusiveness into decision making 4. Availability Data Questions about the availability of: Personnel and changes in staffing; Buildingsand utilities Medical and non-medical equipment. Medical equipment is divided into general, obstetric/gynecological, ophthalmology, ENT, respiratory, sterilizationand surgical Drugsand other consumables, with subdivision on vaccines and contraceptives Services and workload of personnel 5. Comprehensiveness A list of 11activities at first contact, such as: - Emergency, Chronic Illness, Antenatal care, Postnatal care, Vaccination, Certification and administrative forms Questions about investigationprocedures and referrals. 6. Quality Data on supervision activities, use of clinical guidelines, availability of essential drugs and ability to use them. Data on quality on such activities as: Vaccination, Prenatal consultation, Family planning, Other preventative programs, Management of equipment and the data routinely collected Evolution of budgets and expenditures ~~ 7. Financial data 53 10.6. ANNEX6: SUMMARY OFNIVELTASKPROFILEINSTRUMENT Section Parameters 1. Practice and Demographic data; Education andtraining; Employment status; normal personal working hours; Characterization of the population and locationof the information practice; Working arrangement; teamwork; Average workload; home visits; emergency services; Practice organization: staff and equipment; Medical record keeping; use of computer 2. Provision of A list of 14medicaltechniques, suchas: Wedge resection of ingrowing medical toenail; Wound suturing; Insertionof IUD; Fundoscopy; Strapping an technical ankle; Settingup an intravenous injection etc. Perceived involvement of procedures the GP ifpatients inthe practice populationneed suchprocedures- indicatedusinga five-point scale ranging from '(almost) always' to 'seldodnever'. 3. Provision o f 27 Short case descriptions of patients' health problems such as: Child with first contact care a rash; Woman aged 18 asking for oral contraception; Man aged 24 with chest pain; Man aged 50 who burnthis hand; Woman aged 50 with a lump inher breast; Woman aged 60 with acute symptoms ofparalysis/paresis; Man aged 29 with lower back pain; Couple with relationship problems; Woman aged 50 with psychosocial problems relatedto her work. Perception regardingprevalence of these conditions and presentation to the FP-indicatedusinga five-point scale rangingfrom '(almost) always' to 'seldomhever'. 4. Provision of Questions about the routine of the GP concerning: Measuring blood screening, pressure; Measuring blood cholesterol level; Taking cervical smears for preventive care cancer screening; Examination for breast cancer screening. etc. Questions about involvement of GPs in: Health education clinics on smoking cessation, food intake and alcohol consumption; Intra-partum care; Pediatric surveillance clinics; Family planningkontraception; Homeopathic medicine 5, Provision of A list o f 17diseases, such as: Hyperthyroidism; Peptic ulcer; Congestiveheart disease failure; Peritonsillarabscess; Uncomplicateddiabetestype 2; Depression management Perceived involvement of the GP inthe treatment ifthese cases occur in the practice population could be indicatedon a five-point scale ranging from '(almost) always' to 'seldomhever'. 6. Job Seven statements on aspects of GPs' work, such as: 'My work still satisfaction interests me as much it ever did'; 'Assuming that pay and conditions were similar, Iwould do non-medical work' Agreement expressed on a five- point scale, varying from 'agree strongly' to 'disagree strongly'. 54 10.7. ANNEX7: QUANTITATIVE ANALYSIS OF REFERRALAND ADMISSION DATA 260. This element of the evaluation aimed to establish to what extent the reforms led to attainment of key attributes o f a PHC system - namely, first contact, continuity, comprehensiveness and coordination. First contact refers to care accessible at the time of need, especially for common acute conditions which the PHC team should be able to diagnose and manage - without referral to secondary care. This is measured by looking at `avoidable hospitalizations' for common acute conditions - acute ENT problems, urinary tract infections (UTI) and bronchiolitis. Table 10: EffectivenessIndicators-First Contact Care Acute conditions Aggregate referrals by FPs to hospital outpatients for acute ENT problems (Otitis media ICD 10 codes H65 and H66 and tonsillitis ICD 10 code 503) Aggregate referrals by FPs to hospital for acute UTI (ICD 10 code N39.0) Aggregate referrals by FPs to hospital for LRTI (bronchitis, bronchiolitis, pneumonia) in children aged under 5 (ICD 10 codes 510-18 and ICD 10 codes 520 and 521) 261. Ongoing care focuses on the long-term health of a person where PHC manages the health of the person to prevent illness and worsening of chronic conditions. Evaluation in this area focused on management o f common chronic conditions, which should be effectively managed by the PHC team with low referral rates to secondary level - for instance hypertension, ischemic heart disease, non-insulin dependent diabetes mellitus, depression and asthma (Table 7). Table 11: EffectivenessIndicators: Continuityof Care 262. In the Kyrgyz Republic, the researchers were able to access three-year data on referral and admission patterns from the Health Insurance Fund; but this data was not routinely and systematically collected in Armenia, Bosnia and Herzegovina and Moldova. 55 10.8. ANNEX8: SUMMARY OFFAMILYMEDICINE TRAININGPROGRAMSINEUROPE AMERICAS AND 263. The requirements for training of family physicians vary by country. In European, North American, Australian and some Latin American countries, formal specialist training i s required. Table 12: EducationalRequirementsfor Family Physicians ing inhospitals andhealthcenters 264. The countries with the most successful primary care programs tend to have specialist family physicians that are called general practitioners in some countries. In Britain, for example, General Practitioners (GPs) have three years o f training after medical school, which specifically prepares them for their primary care role. 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