Www.observatory.dk Moscow, 8th December 2005 Josep Figueras European Observatory on Health Systems Developing effective primary care: A systems approach

www.observatory.dkwww.observatory.dk

Moscow, 8th December 2005Moscow, 8th December 2005

Josep FiguerasJosep Figueras

European Observatory on Health SystemsEuropean Observatory on Health Systems

Developing effective primary care:Developing effective primary care:A systems approachA systems approach


• Giving more power and control to PC– Coordination and integration

• Expanding range of interventions in PC

Primary Care Reform Putting PC in the driving seat?


Stewardship(oversight)

Financing (collecting, pooling

and purchasing

Health

Fair (financial) contribution

Responsiveness (to people’s non-medical

expectations

Creating resources(investment and

training)

Delivering services

(provision)

Primary Care


WHO WHR 2000


• Beyond particular PC model of provision

• Need for broad health system approach

• Multilevel / simultaneous health system changes

• Key to implementation success



• Fragmented pools / multiple purchasers– Different sources (SHI, tax) / levels: local, regional,.– Diluted and sometimes contradictory incentives

Aligning financial incentives


• Fragmented pools / multiple purchasers

• Performance related payment systems? Finding the right mix:

– Salary / Allowances

– Capitation

– Fee for service

– Performance incentives




• Performance related payment systems?


“The only way to pay doctors is to change the system every three years, because by then they will have found ways to get round it to their own advantage”

Bob Evans




• Poor complementarity of design– E.g. capitation in PC & fee for service specialist care

• Large share of out of pocket informal payments– Need to formalizing into cost sharing schemes



Croatia: wrong mix of incentives

0

2

4

6

8

10

12

14

16

1992 1993 1994 1995 1996 1997

Admissions Per 1,000

J Langenbrunner, 2005


Out Of Pocket PaymentsAs a % of Health Expenditures (2002)

Czech , 8Slovakia, 10

Macedonia, 15Estonia , 21

Belarus , 25Croatia, 27Poland, 28

Lithuania, 31Hungary , 31

Romania, 34Latvia, 35

Serbia, 38Bulgaria, 41

B&H, 50Russia, 54

Kazakhstan, 58Armenia, 83

Georgia, 85

0 20 40 60 80 100

World Bank, 2005


• Fragmented pools / no single payer• Performance related payment systems?• Poor complementarity of design• Large share of out of pocket informal payments • Lower income of GPs vis-à-vis specialists• Lower share of budget to primary care

– In spite of increased emphasis/substitution policies– Less than 25% of overall budget in most countries– Only marginal increases in few countries



Inpatient expenditure as a % of Total expenditure - Selected Western European countries

0

10

20

30

40

50

60

1995 1996 1997 1998 1999 2000 2001 2002

Source: HFA Database, WHO 2005

Austria

Belgium

Denmark

France

Germany

Italy

Luxembourg

Netherlands

Spain

Sweden


• Fragmented pools / no single payer


• Poor complementarity of design

• Large share of out of pocket informal payments

• Lower income of GPs vis-à-vis specialists

• Lower share of budget to primary care

• Giving primary care budgets / purchasing?




• Numbers alone mean little• PC reform constrained by professonal competence• Produce right number & mix of skills according to

health needs, PC requirements & resources available– Coherent curricula development linked to PC model

Accompanying human resources policy


• Strengthen professional recognition (nurses & GPs)– Specific field of knowledge is accepted– Academic body to develop it– Production of literature– External recognition by other specialties & society e – Strong professional organization

• Self regulation • Representation • Quality standards

Accompanying human resources policy


• From command & control to steer & row

• Decentralization to lower levels of government

• Strategic purchasing / contracting

• Privatisation of provision

• Increased consumer choice

• Self employed GPs under public contract

Adjusting to changing

organizational structures


• Gatekeeping and referral systems• Setting expanded task profiles

– Substitution between levels of care

• Framework and rules for contracting• Open information, monitoring, evaluation• Licensing, certification and accreditation• Self regulation? • Information / communication systems

Strengthening regulation


• Gatekeeping vs consumer choice

• Coordination/integration vs market competition

• Substitution: not only transfer of patients…. but of skills, technology & financial resources

Issues


Provider competition

Hospital

Primary care Primary

care

Primary care

Hospital

Hospital

M McKee


Primary care

Primary care

Primary care

Integrated model

Hospital Hospital Hospital

Diagnostics

Clinical networks

M McKee


Shifting patients: substitution


• Managerial difficulties: power, tools, technical skills• Institutional / organizational weaknesses

– Overlap / fragmentation of responsibilities between institutions

• Economic obstacles (substantial transaction costs)• Political obstacles

– Distrust of the role of government per se– Weaknesses to enforce statutes and legislation

• Cultural and organizational difficulties– Closed social networks between gov officials and providers– Change in the management culture of command and control

Stepping up stewardship


• Aligning financial incentives

• Accompanying human resources strategies

• Adjusting to changing organizational structures

• Strengthening regulation

• Stepping up stewardship



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Www.observatory.dk Moscow, 8th December 2005 Josep Figueras European Observatory on Health Systems Developing effective primary care: A systems approach