SEMINAR ON PHC NICOSIA UNIVERSITY ANDREAS POLYNIKIS MD, MPH CHIEF MEDICAL OFFICER MINISTRY OF HEALTH 7 MAIOY 2007.

SEMINAR ON PHCNICOSIA UNIVERSITY

ANDREAS POLYNIKIS MD, MPH

CHIEF MEDICAL OFFICERMINISTRY OF HEALTH

7 MAIOY 2007

Presentation aims:

DEFINITION OF PRIMARY HEALTH CARE (PHC)FUTURE & UNAVOIDABLE REALITIES THE HEALTH CARE DELIVERY DYNAMICIMPLEMENTATION ISSUESTO PRESENT THE STRUCTURE OF PHC To define the processes of PHC in

CyprusTo explain Key historical, developmental

and contemporary realities affecting, PHC and in extend the Present HCS in Cyprus

The Forth Coming Health Care Reforms and the New Role of PHC 04/11/232

Primary Health Care in Cyprus (Dr. Andreas Polynikis, M.D, MPH,

Chief Medical Officer of the Ministry of Health, Cyprus)

Primary Health Care in Cyprus

DEFINITION OF PRIMARY CARE

Refers to directly accessible, first contact ambulatory care for unselected health related problems;

Offers diagnostic, curative, rehabilitative and palliative services

Offers prevention to individuals and groups at risk in the population served;

Takes into account the personal and social context of patients;

Is provided by a variety of disciplines, either within primary care, secondary care or related sectors;

Assures patients continuity of care over time as well as between providers.

04/11/235

WHY PHCWHO health policy on a primary health care

model includes:- Improved population health outcomes for all

cause mortality, all cause premature mortality and cause specific premature mortality for major respiratory and cardiovascular disease

- Higher levels patient satisfaction

- Reduced aggregate health care spending - Increased equity and access

04/11/236

FUTURE & UNAVOIDABLE REALITIES 1

Differing approaches/developments in health system governance and management - centralisation/decentralisation /privatisation

Slow moving legal systems; Emerging variations in the development of new

financing systems and their influence on system dynamics – taxation financed, social health insurance, private insurance, privatisation, mixed systems and even developing voucher systems (Georgia)

Widely differing levels of health system resourcing and contributions of Government, legitimising greater influence over policy and strategy

04/11/237

FUTURE & UNAVOIDABLE REALITIES 2

Population behaviours based on historical customs and preferences

A continuing domination by secondary and tertiary care forces of educational, professional and political systems

Policy and strategy influences and ambiguities – gatekeeper role, curative care duplication, health promotion and health status improvement, health maintenance etc.

04/11/238

FUTURE & UNAVOIDABLE REALITIES 3

Perverse financial and commercial pressures operating in competing directions (pharmaceutical suppliers, medical consumable suppliers, prescribing pressures, and software development)

Lack of development in some countries of rehabilitation members of PHC team and of complementary social and welfare systems and models to work alongside primary care services

The fast pace of health care delivery innovation and potentialities (the pace of which is likely to increase over the next decade)

04/11/239

04/11/2310

Range Average European

Region

High/Low

Doctors/ 1000 Population2002 – 2006

0.3 - 5.0 3.2 High: GreeceLow: Bulgaria

Nurses/ 1000 Population2002 – 2006

2.9 – 19.5 7.8 High: IrelandLow: Turkey

Pharmacists/ 1000 Population2002 - 2006

<0.1 – 1.1 0.2 High: France/FinlandBelgiumLow: Several

Total Expenditure on Health as % GDP2005

3.9 – 11.4

8.6 High: SwitzerlandLow: Kazakhstan/Azerbaijan

Government expenditure on health as % total health expenditure 2005

19.5 – 90.7 74.3 High: LuxembourgLow: Georgia

Per capita expenditure on health International $ PPP 2005

106 – 5,521 1,649 High: LuxembourgLow: Tajikistan

Source: World Health Statistics 2008, WHO

THE HEALTH CARE DELIVERY DYNAMIC

INPATIENT DAY PATIENT

DAY PATIENT OUTPATIENT

OUTPATIENT OFFICE

OFFICE HOME CARE

HOME CARE SELF CARE

04/11/2311

HOW IS THE CASE IN CYPRUS TODAY

CHALLENGESAGINGTECHNOLOGYNEW PHARMAEUTICALS.ADVANCES IN PROVISIONINCREAS EXPECTATIONSHEALTH CARE REFORMS

PHC AND HIO

BACHGROUN

SINCE CYPRUS WAS A BRITISH COLONY

TRYING TO INTRODUCE HEALTH CARE SYSTEM

1987-1989: DECIDED PHC TO BE PRIVATE

1990: DECISION TO INTRODUCE NHIS.

19 IN THE PROCESS

PHC AND NHIS

PHC TODAY

•PUBLIC SECTOR

•PRIVATE SECTOR

PUBLIC SECTOR

04/11/2316

PROVIDES ALL LEVELS OF PHC

HEALTH CARE, HEALTH PREVENTION,HEALTH EDUCATION AND PROMOTION

75 ΙΔΙΩΤΙΚΕΣ ΚΛΙΝΙΚΕΣ 1500 ΙΔΙΩΤΕΣ ΙΑΤΡΟΙ ΚΥΡΙΩΣ solo practices ΤΟΥΡΙΣΜΟΣ ΚΑΙ ΥΓΕΙΑ

Lack of Standards and Protocols.

HCS in CyprusHCS in Cyprus

Β. Β. ΙΔΙΩΤΙΚΟΣ ΤΟΜΕΑΣΙΔΙΩΤΙΚΟΣ ΤΟΜΕΑΣ

18

235 SUBCENTERS OVER CYPRUS

• Each PHCC covers up to 18 subcenters*

• Team of GP, nurse and pharma-cist visits 1-6 subcenters per day

• Subcenters are a ≤ 30 min drive from the PHCC

Main PHCCs

Subcenters

*99 subcenters located in villages with children also receive weekly health visits for vaccinations and mother-and-child services. In some cases (remote locations) health visitors perform visits even if only one child is in the village

Source:MoH data; visits to PHCCs; Google Earth

19

20

21

2

3

4

5

6

7

8

9

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

AustriaBelgiumBulgariaCyprusCzech RepublicDenmarkEstoniaFinlandFranceGermanyGreeceHungaryIrelandItalyLatviaLithuaniaLuxembourgMaltaNetherlandsPolandPortugalRomaniaSlovakiaSloveniaSpainSwedenUnited KingdomEU

Public sector expenditure on healthas % of GDP, WHO estimates

0

1

2

3

4

5

6

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

AustriaBelgiumBulgariaCyprusCzech RepublicDenmarkEstoniaFinlandFranceGermanyGreeceHungaryIrelandItalyLatviaLithuaniaLuxembourgMaltaNetherlandsPolandPortugalRomaniaSlovakiaSloveniaSpainSwedenUnited KingdomEU

Private sector expenditure on health as % of GDP, WHO estimates

25

The initiatives should be piloted in a big, urban PHCC in Nicosia

Source:MoH team

Criteria Strovolos PHCC

Number of GPs 1

6

Number of nurses

24

Number of administrative staff

3 • 5 assistants• 1 receptionist• 1 messenger

Number of pharmacists

4 • 3 pharmacists• 1 assistant pharmacist

Number of computers

50

Use of patient files

6

Aglantzia PHCC

5

3

• 2 assistants• 1 messenger

• 2 pharmacists• 1 assistant pharmacist

6 (all doctors have personal PC)

Lakatameia PHCC

5+1 part-time

3

• 2 assistants• 1 messenger

• 2 pharmacists• 1 assistant pharmacist

1

(common with allied health professionals)

Team decision

Aglantzia was already used for a

pilot before

26

With NHIS, all 41 PHCCs will continue to offer non-FD services while 25 PHCCs in areas with insufficient private doctor coverage will also offer public FD services

*Other services include: school services, mother and child services, community nursing, community mental health, and dental services

Source:MoH team

Family doctor (FD) services(~85%)

Other services*(~15%)

16 PHCCs in areas with high private doctor coverage

25 PHCCs in areas of low/no private doctor coverage

41 Primary Health Care Centers (PHCCs)

PHCC network stays within MoH after implementation of NHIS

FD services provided by private initiative (unused space in PHCCs can be rented to private doctors)

Services provided by MoH

ALIGNMENT WITH MINISTER

Negotiation with HIO and

CMA necessary

27

The current sub-center concept has significant disadvantages

*Estimate (~401 municipalities/communities in Cyprus – ~40 urban/suburban municipalities, and communities with PHCCs)

Source:MoH PHCC team; CYSTAT

Medical and pharmaceutical care at subcenters does not have adequate impact, since • No sufficient infrastructure is available (e.g. no ECG/cardiac monitor, lack of heating/

telephone line sometimes, no blood testing facilitation, improper drug storage)• More than 70% of subcenter consultations are prescription renewals for patients with chronic

conditions

1

Coverage by subcenters is not uniform, since only 65% of all villages have subcenters (235 out of ~361* villages) covering ~72% of the population

9

There is almost no sufficient primary care coverage, since subcenters are open only once/twice a week, or once every two weeks

8

Even today, a need for private transportation exists at subcenter locations, because patients need to get to the PHCC or hospital themselves in case of referral, acute illness or regular checks

7

Up to 32% of the team’s working time is wasted travelling10

Infrastructure

Coverage

Operations

Visiting doctors do not have the opportunity to consult one another since only 1 doctor visits the subcenter at a time (as opposed to the group of doctors available at the PHCCs)

6

Patients do not have the opportunity to be seen by the same doctor since a different doctor visits the subcenter every time

5

Some subcenters are overcrowded because there is no appointment system and a lot of patients visit the subcenters without real need

4

Our doctors, pharmacists and nurses can be utilized

in a better and more impactful way

Consultation time is limited as the visiting team can only spend a limited amount of time at each subcenter before going to the next one

2

The subcenters do not offer significant prevention and health promotion services, which are basic primary health care objectives

3

28

The team recommends that sub-centers be discontinued and that an alternative solution be offered to selected rural villages

*A one-by-one examination of subcenters can be done at the implementation stage using more detailed criteria

Source:MoH team

Option 1 Option 2 Option 3

• Discontinue all subcenters• Do not provide alternative solution

for subcenters*:– In urban areas – Less than 5 km from next

PHCC– With less than 20 consultations

per month– With private doctor and private

pharmacy in the village• Provide alternative solution with

higher medical quality for remaining subcenters

• Discontinue all subcenters• Do not provide alternative solution

for any subcenters

148 87235

Current No alternative

Alternative

194 41

235

No alternative

AlternativeCurrent

• Discontinue all subcenters• Do not provide alternative solution

for subcenters**:– In urban areas – Less than 5 km from next

PHCC– With less than 40 consultations

per month– With private doctor and private

pharmacy in the village• Provide alternative solution with

higher medical quality for remaining subcenters

• Medical personnel travel time reduction of 24 FTEs

• Opportunity cost reduction EUR 1 million per year

• Medical personnel travel time reduction of 24 FTEs

• Opportunity cost reduction EUR 1 million per year

Impact • Medical personnel travel time reduction of 24 FTEs

• Opportunity cost reduction EUR 1 million per year

Politicalcost

0

235235

No alternative

AlternativeCurrent

Team recommendation

Transition period required for full implementation

29 *The local authorities will be responsible to retain/improve/maintain adequate space at their own cost

Source:MoH team

The community nurse can provide basic care and facilitate prescriptions, which is the primary reason patients visit sub-centers

• Patient calls nearest PHCC to schedule appointment with community nurse (CN)

• Patient notifies reason for visit (e.g. prescription renewal necessary)

• Patient also submits medical history to the PHCC

• PHCC schedules appointment in system

• CN of PHCC is notified

• If specific CN is not available, CN from closest PHCC is notified

• CNs at PHCCs are connected to coordinate staffing for visits (e.g. in case of vacation or sickness)

• CN checks with doctor whether prescription should be renewed

• Patient’s medical history is available to CN and doctor in the system

• If prescription is approved, pharmacist at PHCC dispenses drugs

• CN brings drugs to patient during visit* and provides help with patient’s pharmaceutical regimen

• CN checks patient (e.g., blood pressure etc.)

• CN handles emergency prescriptions

Appointment Scheduling Planning Visit

• If patient has any questions or concerns, he/she can contact doctor or pharmacist

Follow-up

PRIMARY HEALTH CARELACK OF ORGANISATIONPUBLIC AND PRIVATEDEFINITION OF THE ROLE OF THE PHC DOCTOR

NO CATCHMENT AEREANO GROUP PRACTICENO PHC TEAMLACK OF CME

02468

101214161820

Under5,000

7,001-9,000

11,001-13,000

15,001-20,000

Over25,000

Gross Income

Distribution of household gross annual income

%

Income group composition

10%

27%

46%

17%

A-B

C1

C2D-E

Type of doctor visited by each age group (heads of household only)

0

10

20

30

40

50

60

70

80

%

18-29 30-49 50-64 65+

Age

GovernmentPrivateUnion

Type of doctor visited by each geographical region

0

10

20

30

40

50

60

%

Nicosia

Limas

sol

Larnac

a

Famag

usta

Paphos

GovernmentPrivateUnion

Type of doctor visited by each income group

0

10

20

30

40

50

60

70

80

%

A-B C1 C2 D-E

Income Group

GovernmentPrivateUnion

Type of doctor visited by annual income

0

10

20

30

40

50

60

70

80

%

Under5,000

7,001-9,000

11,001-13,000

15,001-20,000

Over25,000

GovernmentPrivateUnion

Top 10 reasons for visiting the doctor

Cold/FluRoutine CheckBlood pressureGyn check-upDiabetesGI problemsDermatologicalInjuryRoutine infant checkDifficulty movingOther

Top 7 Specialists Visited

Internist/GP (40%) Pediatrician (19%) Ob/Gyn (8.5%) Orthopedics (7.5%) Cardiologist (6%) Ophthalmologist (4%) Other (15%)

05

10152025303540

Excell

ent

Very g

ood

Goo

dSo S

o

Not go

od

Self-Reported Health Status

%

Out-of-pocket health expenditures as share of household income, 2002

6.4%

5.7%

4.6%

3.8%4.1%

3.0%2.6% 2.5% 2.6%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

<5,000 5,000-7,000

7,000-9,000

9,000-11,000

11,000-13,000

13,000-15,000

15,000-20,000

20,000-25,000

25,000<

Annual household income

Mean out-of-pocket payments as share of household income(sub-sample: those who report any utilization)

Source: Hsiao & Jakab, 2003

Likelihood of Using Public or Private Physician for minor injury

Would you go to a public or private doctor for minor illness?

0

0.2

0.4

0.6

0.8

1

1992 1996 2002

Alw ays to public

Nearly alw ays to public

Sometimes to public

Rarely to public

Never to public

Source: Hsiao & Jakab, 2003

Proportion of the population with a personal doctor in each geographical area

58

60

62

64

66

68

70

72

74

% w

ith

Per

son

al D

octo

r

Nicosia

Limas

sol

Larnac

a

Famag

usta

Paphos

Type of personal doctor chosen by income level

0102030405060708090

100

%

Under5,000

7,001-9,000

11,001-13,000

15,001-20,000

Over25,000

Income

GovernmentalPrivateUnion

Type of personal doctor chosen in 4 income groups

0102030405060708090

100

%

A-B C1 C2 D-E

Income Group

GovernmentalPrivateUnion

Average time it takes to get to the GP:

Private vs. Government

8,27

0,65

0123456789

Mean Time

Government Private

Type of GP

HCS in CyprusHCS in Cyprus

Law: 89 (I)/ 2001

Law: 134(I) /2002

Provision for the introduction of General

Insurance Health Scheme in Cyprus.

NHIS

HCS in CyprusHCS in Cyprus

4 YEARS?? 2006 ΠΑΡΕΧΕΙ ΥΠΗΡΕΣΙΕΣ HEALTH CARE REFORMS

a) HISS

b) Training of GPs

c) Reorganization of MOH

d) Reorganization of Government Hospitals

e) Harmonization of Private Clinics with the law

f) Development of DRGS

g) Regulations

h) Training – Continuous Medical Education

IMPLEMENTATION

HCS in CyprusHCS in Cyprus

Primary H.C.: Capitation Fee (85%) Good Practice Filling Targets Environment Provision

Secondary H.C.: Out- Patients Specialists: Fee for Services Hospitalization: DRGS Casualties: Grant Blocks

Reimbursement of the Providers

15%

LAW 89(I)/2001 LAW 134(I)/2002

General Practitioners PROVISION FOR

Other Specialists

Pediatricians

Provision of care

GPs Provide health care to all enrolled on their list.

24 hours coverageprovision to change the GP

Reimbursement of GPs

Capitation fee (75%)Experience, good practice, preventive-promotive programs (25%)

Performance Measurement Systems

AccreditationCertificationUtilization ManagementPeer ReviewIndicatorsClinical Practice Guidelines and PathsReport cardsProductivity Profiles

Drs practicing general medicine

PhysiciansGPsRegistered Medical PractitionersCardiologistsOther internal subspecialties

Pediatricians: responsibility for the children under 15 years of age.

LAW 89(I)/2001

LAW 134(I)/2002

PROVISION FOR General Practitioners

Other Specialists

Pediatricians

Provision of the law Records keeping Denied backward referral Measurement of the performance Incentives for group practice Committee of Medical Audit. Safeguard of ownership of

Government medical institutions

Provision of the law (II)

Adequacy and satisfactory condition of waiting and examination rooms - spaces for records keeping

adequacy and satisfactory condition of the necessary medical equipment.

GPs List Size

First 3 years (300)After 3 years (500)Maximum 2500

Geographical Restrictions???

Provision of care

GPs Provide health care to all enrolled on their list.

24 hours coverageprovision to change the GP

Provision of Care

Medical CareDiagnostics, LaboratoriesDrug PrescriptionsHome Visits.

Referrals

Casualties direct accessAgreed certain cases for direct access to specialist care

Denied reimbursement for direct access.

Setting up partnership

incentives for the establishment of partnerships

Group practicesubsidy for the construction or

acquisition of buildings subsidy for medical equipment subsidies for employing nurses and

other healthcare professionals

Medical Audit Committee

Establishment of a medical audit committee.

for the purpose of securing high standard of medical care and the taking of suitable measures in relation to particular cases for not exercising reasonable skill or attention on behalf of the supplier.

Performance Measurement Systems

AccreditationCertificationUtilization ManagementPeer ReviewIndicatorsClinical Practice Guidelines and PathsReport cardsProductivity Profiles

Government Institutions

The Government shall take all the necessary steps, so that the medical institutions are updated in the sectors of organization, administration, management, equipment and functioning cost-effectively.

CONCLUSIONSMost countries have a sound health policy incorporating a well

articulated role for PHC. Weaknesses are not in the ‘what to do’ but in the ‘how to do’ – the capacity to manage change

PHC system design and implementation must also take account of differing historical, developmental, social, cultural, professional and other important issues – differing futures

The future development of PHC in CYPRUS will need clear principles not models; pragmatism and flexibility not polemic; a deeper understanding of underlying health system histories, culture and strategies and capacities for change in differing countries

04/11/2366

POSTSCRIPTS“Despite constantly rising health expenditures in European

countries, the health needs of growing subgroups of the population, such as the chronically ill, the elderly and those in need of hospice services in their homes, are not well met Over the past years these needs have changed quantitatively and qualitatively and they will continue to do so, as a result of the epidemiological transition related to the ageing of populations and the general increase in wealth in most countries.” (Boerma W. 2006)

Professor Alan Maynard continues to point out there are many simple evidence-based and cost-effective health care interventions (many of which relate to chronic disease management and the primary care level) which are still not in common usage throughout international health systems, even those with major resourcing problems.

04/11/2367

Finally…We all are suffering from a terminal

sexually transmitted disease called life. Death is inevitable

The role of doctors and health care managers is to use society’s scarce resources efficiently (EBM)

Inefficiency is unethical as it deprives potential patients of care from which they could benefit.

Finally Voltaire remarked “ the role of the doctor is to amuse the patient as nature takes its course”!

Source: Fitzgibbons, Steve “The heal th.net Indus try” Hambrecht & Quist, January 1999

Linchpins for Connectivity: Physician Offices Targeted

PHC AND NHIS

SUMMARY ΙΙ

•REFFERAL

•INFORMATION SYSTEM

•GROUP PRACTICE

•CME

•PCH TEAM

•SMART CARD