reforms in the primary health care in macedonia: why and how? assoc. prof. tozija fimka md, phd...
TRANSCRIPT
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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
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Independence : 8 September 1991 8 April 1993 - OUN; 12 May 1993 - WHO
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AIM
> current organization and functional
activity of PHC in the health care delivery
system
>reform activities: WHY and HOW
>PHC in future
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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
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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
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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
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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
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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
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Net of health organizations in PHC
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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
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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%
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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
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Most frequent diseases with the children and youth in Macedonia in 2000
0
500
1000
1500
2000
2500
Pre-school School
School
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WHY REFORMS?
> SWOT analysis
> RAND’s research /survey Capitation Evaluation Program
> Research in IPU
> Needs assessment
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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
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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
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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
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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
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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
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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
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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
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Reform activities
3. Pharmaceutical policy and supply
>Promotion of rational pharmacotherapy
>Training for rational prescribing
>Therapeutical guidelines
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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
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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
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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
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CME CENTERSCME CENTERS
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HANDS-ON-HANDS-ON- educationeducation
CLINICAL SKILLSCLINICAL SKILLS
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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
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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
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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
Broj na karton___________
KARTON ZA BOLEN OD DI JABET
USTANOVA_______________________AMBULANTA_______________
I ME I PREZI ME
MMat. Br Datum nara|awe
Pol@
Adresa
Kontakt tel ef on
Adresa na nekoj bl i zok
Kontakt tel ef on
Doktor______________ Datum __________
1Di jabet tip
2
DaI nsul in
Ne
ANAMNEZA
Minatizabol uvawaFami l i jarnaanamnezaFarmakol o{kaanamnezaAku{erskaanamnezaPridru nisostojbi
LI EN KARTON NA BOLEN OD BRONHI JALNAASTMA
I me i prezi me___________________ Vozrast________
Adresa ___________________________________________
Doktor _________________ Ustanova________________
tel ._________ Li~en maksi mum PEFR_____________
LEKOVI
Preventivni : ____________________________________(Lek koj spre~uva)
Simptomatski : ___________________________________(Lek koj ol esnuva)
Zona Granica I nstrukci i
Crvena
@ol ta
Zel ena
Broj na karton _________
KARTON NA BOLEN OD BRONHI JALNA ASTMA
USTANOVA___________________AMBULANTA________________
I me i prezime
MMat. Br Datum na ra|awe Pol@
Doktor ____________________ Datum _____________
GODI NA KOGA PO NABOLESTA
VOZRAST PRI DI AGNOZA
SI MPTOMI TI P NA ASTMA DALI I MALO
KA[ LI CADEWE
KA[ LI CANO] E
SPUTUM VI ZI NG
KONTI NUI RANA EPI ZODNA SEZONSKA KOGA
BOLNI KOLEKUVAWE
AKUTNI NAPADI NAMALENA
RESPI RATORNA REZERVA
PU[
EW
E
SEGA
PORANO
NI KOGA[
KOLKU CI GARINA DEN
PASI VEN RI ZI K
DA NE
ALERGI I
GRADEN KO[
SRCE
BELIDROBOVI
K.P
TERAPI JA
VI SI NA
TE@I NA
I TM
RENTGEN(ako e indiciran)
DATUM
PREDVI DENPEFR
LI ENPEFR
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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
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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
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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
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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
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PROJECT CLOSED IN JUNE 2002-
HIGHLY SATISFACTORY
CHALLENGES FOR FUTURE REFORMS
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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
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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
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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
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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
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PHC IN FUTURE>Accessible
>Well organized
>Continuous
>Comprehensive
>Coordinated
>Oriented towards:
>Patient, family, community
>Cost-effective
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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
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EXPECTED OUTCOMES
! Better primary health care
! Better health for all