www.observatory.dk www.observatory.dk Moscow, 8th December 2005 Moscow, 8th December 2005 Josep Figueras Josep Figueras European Observatory on Health European Observatory on Health Systems Systems Developing effective primary Developing effective primary care: care: A systems approach A systems approach
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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.
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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
www.observatory.dkwww.observatory.dk
• 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?
www.observatory.dkwww.observatory.dk
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
Primary Care Reform Putting PC in the driving seat?
WHO WHR 2000
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• Beyond particular PC model of provision
• Need for broad health system approach
• Multilevel / simultaneous health system changes
• Key to implementation success
Primary Care Reform Putting PC in the driving seat?
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• Fragmented pools / multiple purchasers– Different sources (SHI, tax) / levels: local, regional,.– Diluted and sometimes contradictory incentives
Aligning financial incentives
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• Fragmented pools / multiple purchasers
• Performance related payment systems? Finding the right mix:
– Salary / Allowances
– Capitation
– Fee for service
– Performance incentives
Aligning financial incentives
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• Fragmented pools / multiple purchasers
• Performance related payment systems?
Aligning financial incentives
“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
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• Fragmented pools / multiple purchasers
• Performance related payment systems?
• 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
Aligning financial incentives
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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
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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
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• 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
Aligning financial incentives
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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
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• 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
• Giving primary care budgets / purchasing?
Aligning financial incentives
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• 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
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• 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
• 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
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• Gatekeeping vs consumer choice
• Coordination/integration vs market competition
• Substitution: not only transfer of patients…. but of skills, technology & financial resources
– 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
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• Aligning financial incentives
• Accompanying human resources strategies
• Adjusting to changing organizational structures
• Strengthening regulation
• Stepping up stewardship
Primary Care Reform Putting PC in the driving seat?