Reforms in the Primary Health Care in Macedonia:

Why and How?

Assoc. Prof. Tozija Fimka MD, PhD Prof. Gjorgjev Dragan MD. PhD

Republic Institute for Health Protection - Skopje

Independence : 8 September 1991 8 April 1993 - OUN; 12 May 1993 - WHO

AIM

> current organization and functional

activity of PHC in the health care delivery

system

>reform activities: WHY and HOW

>PHC in future

HEALTH STATUS OF THE POPULATION IN THE HEALTH STATUS OF THE POPULATION IN THE REPUBLIC OF MACEDONIA AND PRIORITY HEALTH REPUBLIC OF MACEDONIA AND PRIORITY HEALTH

PROBLEMS IN 2004PROBLEMS IN 2004

BASIC INDICATORS IN 2004

Area 25 713 sq.km

Population 2.049.000 ( Urban 59.6/Rural 40.4)

Administrative division 84 municipalities

Ethnicity/languages Macedonian 64,2%, Albanian 25,2%,Turkish 3,9%,Roma 2,7%, Serbian 1,8%, Vlashos 1,0%, Other 1,2%

Religions Orthodox Christian 67% , Muslim 30%

Number of live births 27761

Literacy rate 94%

Unemployment rate 39%

Life expectancy at birth (2002) 73.4

Mortality - rate per 1000: 8.9

Infant mortality rate – per 1000 live births: 10.2

Neonatal deaths per 1000 live births: 8.6

* Health for all - WHO

Health care resources , utilization and costs in 2004

Number of hospitals 54

Number of physicians, PP 4573

Number of general practitioners, PP 1619

Number of dentists, PP 1183

Number of pharmacists, PP 332

Number of nurses, PP 11056

Average length of stay in days, all hospitals 11.8

Outpatient contact per person per year 3

GDP $ 1690

Health expenditure of GDP 6%

Health expenditure of GDP per capita $ 106

Public health expenditure as % of total health expenditure

93.9

HEALTH and SOCIO-ECONOMIC PROBLEMS

• Poverty and unemployment• High rates of mortality and morbidity from CVD• High rates of mortality and morbidity from cancer • Explosion of addictive drug abuse• Increased violence and injuries• Hyper production and surplus of staff (doctors)• Lack of properly qualified experts in public health• Lack of qualified managers of health programs• Underutilization and deterioration of the health

facilities

HEALTH CARE SYSTEM - MACEDONIA

• Parliament• Government• Ministry of Health• Health Insurance Fund• Medical Chamber, Dentistry Chamber, Pharmaceutical Chamber• Health Institutions

– Tertiary health care: RIHP, Clinical Center,Special Hospital and Institutions

– Secondary health care: IHP, Spec.consul.services, General and Special Hospitals, Rehabilitation Centres

– Primary Health Care: Units of the IHP, Health stations, Health Centers, Medical centers-part of Health Centers, private health organizations, pharmacies

Net of health organizations in PHC

Medical units - PHC in 2000

Department: Medical units Doctors Population/1p

Facilities Spec.

General medicine 457 999 (19.%) 1401

Children aged 0-6y. 82 299 (53%) 680

Schoolchildren 78 175 (65%) 2448

Labor medicine 91 161 (69%) -

Gynecology 51 101 (97%) 7830

Functional activity in PHC

 Insufficient preventive activities:

General medicine only 0.5%;Labor medicine 8.8%;Health care of school children and youth 10.4%;Health care of children aged 0-6y. is 20.9%;Health care of women 40.6%

Most frequent diseases with the adult population in Macedonia in 2000

0

50

100

150

200

250

300

Respiratory Circulatory Musculo-sceletal Digestive Genito-urinary

General medicine

Labour medicine

Most frequent diseases with the children and youth in Macedonia in 2000

0

500

1000

1500

2000

2500

Pre-school School

School

WHY REFORMS?

> SWOT analysis

> RAND’s research /survey Capitation Evaluation Program

> Research in IPU

> Needs assessment

ADVANTAGES

> Accessibility (geographical, financial, temporal)

> Well developed net of organizations in PHC

> Increasing number of private organizations

> Large number of doctors with theoretical knowledge

> Very high % of immunization

> High rate of solidarity

> Large package of health services

WEAKNESSES

> Hyper production and surplus of staff (doctors)

> Disparity between urban and rural

> Lack of CME and clinical protocols

> Lack of therapeutically guidelines (non-rational prescribing)

> Bad status of the clinics

> Lack of equipment and drugs

> Lack of information technology

> Lack of financial motivation

> Lack of managers

> Financial insustainability

World Bank in the Health Sector1996-2004

1996-2002 - Health Sector Transition Project: Highly satisfactory ranked PHC CME and Perinatal Project

2002- 2004 – Preparation of the Health Sector Management Project – PHRD Grant Government of Japan

Public Sector Management Adjustment Credit - PSMAC) – support to the HIF and MOH- Grant Government of Netherlands

2004- Health Sector Management Project – Loan agreement signed

Health Sector Transition Project1996-2002

Key dates:Approved: 20/06/1996Revised: 24/03/1999Closed: 31/03/2002

Costs and financing:

17.1 million USD

14.5 World Bank IDA Credit

2.6 Government contribution

HEALTH SECTOR TRANSITION PROJECT 1996-2002

AIMS:

> Better health of the population

> Better choice for patients

> Better quality of services

> Better efficiency of PHC

> Better fiscal sustainability of PHC

PHC Reform activities

1. Component: Financing and management

> Defining a new package of health services

> New method of payment – capitation for private physicians

> Contracting of private physicians

> Establishing of Information System in HIF

Reform activities

2. Basic health services

>Improvement of the net of primary health organizations

>Improvement of the infrastructure in PHC - rural

>Professional development of the doctors: CPD, CME

Reform activities

3. Pharmaceutical policy and supply

>Promotion of rational pharmacotherapy

>Training for rational prescribing

>Therapeutical guidelines

ACHIEVED RESULTS - REGULATION

>Selected doctor - 1997

>Capitation - private doctors - July 2001 (contracted 500 private doctors)

>Basic Benefit Package - By-law 2000

>New By-law on Co-payment - 2001

>Provision of staff in the rural clinics:prepared plan for redistribution of 200 doctors in 169 rural clinics, 1998

>Establishing teams in PHC - plan for reorganization of services -2001

ACHIEVED RESULTS – EQUIPMENT

Prepared standard for equipment in PHC (for the doctors and clinics)

Procurement of EQUIPMENT through bidding (tenders) (value of 3M $)

> for 4 CME Centers

> for attendees

> for PHC clinics

ACHIEVED RESULTS – CONTINUOUS MEDICAL EDUCATION

Pilot Project: November 1998 - September 2000

Second phase: October 2000 - December 2001> 4 CME Centres -> 32 Educators> 15 Guidelines> Courses - Foundation course and short courses> 1086 attendees

Strategy for specialization in PHC and CME

Strategy for accreditation of the doctors in MK

CME CENTERSCME CENTERS

HANDS-ON-HANDS-ON- educationeducation

CLINICAL SKILLSCLINICAL SKILLS

15 GUIDELINES

For most frequent medical For most frequent medical problems and diseasesproblems and diseases

Prepared by team of CME Prepared by team of CME educators – local and internationaleducators – local and international

Customised, translated, peer Customised, translated, peer reviewed, edited and publishedreviewed, edited and published

OTHER MATERIALSOTHER MATERIALS

Tables for cardiovascular Tables for cardiovascular risks: males/femalesrisks: males/females

Normogram for Body Normogram for Body Mass IndexMass Index

Changes on the eye Changes on the eye fundus for the most fundus for the most important diseases in important diseases in PHCPHC

MEDICAL DOCUMENTATIONMEDICAL DOCUMENTATION

Draft forms for record Draft forms for record keeping for chronic keeping for chronic diseases thediseases the

Final version customised, Final version customised, edited and publishededited and published

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LONG TERM CME STRATEGY

Produced by:

Doctors, educators Professors from UK Professors from Medical

Faculty Skopje, Doctors Chamber Macedonian Medical

Association

MEMORANDUM OF UNDERSTANDING

17.12.99 i 26.12.2001

Minister of health President of Doctors Chamber President of Macedonian Medical Association Dean of Medical Faculty

Improve the Standards of PHC in accordance with EU

INSTITUTIONALISATION OF CME

Strategy for CME and specialisation

International Centre for studies in PHC and CME within the Medical School (New Statute)

Department for PHC within the Medical Faculty

ACCREDITATION - LICENCING

STRATEGY for ACCREDITATION AMANDMANS FOR THE HEALTH CARE LAW

- delegated by the Minister of health DOCTORS CHAMBER STATUTE

BY-LAWS: By-Law for Basic Licence By-Law for Practicing Licence By-Law for Register of doctors By-Law for CME

PROJECT CLOSED IN JUNE 2002-

HIGHLY SATISFACTORY

CHALLENGES FOR FUTURE REFORMS

Primary Health Care - challenges

Different payment mechanisms in private and public PHC clinics:

Different motivation and limitations for private and public health providers in PHC

Different levels and quality of health care private

Unequal distribution of recourses

Center for PHC and CMEafter the completion of the CME Project

“Status quo” situation results with:

Potential loses of the investments in the HSTP Discontinuity of the CME activities Problems with Capacity building – educators for specialisation in PHC Lower quality of PHC services Slower EU integration

Support from the Second World Bank Project is needed

Priorities for the Health Sector Management Project

Implementation of the contracts based on capitation for all PHC providers – private and public

Institutional development of PHC (CME and PHC specialization)

CME Centers – sustainability and financing of the operational costs

Priorities for the Health Sector Management Project

Support for central institution responsible for developing evidence based medicine guidelines

Health Strategy Development – Strategy for Primary Health Care

PHC IN FUTURE>Accessible

>Well organized

>Continuous

>Comprehensive

>Coordinated

>Oriented towards:

>Patient, family, community

>Cost-effective

Until 2 010 people from the Region will have a much better access to the primary health care oriented towards the family and community, supported by a flexible and responsible health system.

WHO - Strategy Health for All in 21 Century

Target 15: Integrated health system

EXPECTED OUTCOMES

! Better primary health care

! Better health for all