Moscow, 8th December 2005 Josep Figueras European Observatory on Health Systems Developing effective primary care: A 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 Primary Care Reform Putting PC in the driving seat? WHO WHR 2000

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?

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 Aligning financial incentives

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

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

Croatia: wrong mix of incentives J Langenbrunner, 2005

Out Of Pocket Payments As a % of Health Expenditures (2002) 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 Aligning financial incentives

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

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 S trengthening 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 M McKee

Primary care Primary care Primary care Integrated model 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 Primary Care Reform Putting PC in the driving seat?

The European Observatory