1. Arnoldas Jurgutis, ITA NDPHS Primary Health Care Expert Group Primary Health Care in Northern Dimension Countries

2. Objectives of the presentation: To introduce the role and recent activities of primary health care expert group To give an account of PHC Expert Group report Highlight important gaps in primary health care in Northern Dimension Countries To present key recommendations for possible project based activities in ND countries

3. Mission and objectives of the Expert Group on the Primary Health care Mission of PHC EG established in 2005 is to promote general awareness concerning the role and significance of comprehensive community oriented primary health care as one of the cornerstones of a well –functioning health care system Objective of ND PHC work is improved public health for all groups of the whole population through developing primary health care services, responding appropriately and equitably to the needs of the people PHC EG is the focal point for national inputs on primary health care from the Partner Countries and Organisations PHC EG has an advisory role and provides professional input to the preparation and implementation of joint activities carried out within the framework of the Partnership

4. Why expert group of primary health care? Policy makers in all countries of Northern dimension region try to find solutions about how to cope with an increasing demand and the costs of overall health care Health systems should be accountable for their performance through ● measurements of better public health with rational use of resources ● and to meet the requirements of equity, quality and accessibility Countries, which have attached proper attention to community oriented and based on family medicine primary health care, are now reaping benefits of improved population health through more efficient health care systems

5. Partner representatives in the Primary Health Care Expert Group Sweden (lead partner) Poland (Co leadpartner) Finland Norway Russia Estonia Lithuania Latvia WHO/Euro

6. Main activities of PHC EG In 2007 it was elaborated a strategy which covers four working areas: WA 1: Framework for PHC EG functions WA 2: Production of thematic reports and situation analysis WA 3: Support to planning, implementation and monitoring of projects WA 4: PHC EG contribution to database and project pipeline activities as cross-cutting principles

7. WA 2: Production of thematic reports and situation analysis Three thematic reports have been planned Situation of PHC in Northern Dimension region and the different remuneration systems of PHC and their implications ● report on PHC situation in Northern Dimension Countries, draft ready Role of PHC in health promotion and disease prevention in the ND region Implications of demographic changes for PHC

8. Tematic report ”PHC situation in Northern Dimension Countries” Objective of this report - to overview the primary health care system developments in the countries emphasizing possible gaps and to provide stake-holders with recommendations for possible improvements through project-based activities Report provided input to the NDPHS Database project, co-financed by the EU Commission.

9. Scope of differences in the Northern Dimension Countries Obvious gap if we compare the core public health indicators Life expectancy at birth, in years Source: WHO Health For All Database

10. Scope of differences in the Northern Dimension Countries (2) People dying much younger in ● Russia ● Belarus ● Latvia ● Lithuania ● Estonia Reduction of life expectancy through death before 65 years Source: WHO Health For All Database

11. Scope of differences in the Northern Dimension Countries (3) The differences in socio- economic development could be one of the main reasons of these differences in public health situation between two groups of countries Total health expenditure as % of Gross Domestic Product (GDP) Source: WHO Health For All Database

12. The role of health care systems for improved population health is limited Still… There is international evidence to prove that structural features of a national health system impact on the cost-effectiveness and the equity effects ● example of the United States health system, ● International comparison of health care systems of developed countries (Barbara Starfield and others)

13. Crisis in health care systems – well-known reasons More advanced and expensive health care technologies Open access to specialized care Supplier induced demand (including pharmaceutical companies!) Ageing of population and more chronic diseases Percentage of population having two or more chronic conditions is increasing, ● 5% of population consume 40% of health care recourses

14. What does strong primary health care mean to the health care system? There is the evidence that strong PHC helps to better achieve population health indicators by better meeting the health care needs of vulnerable groups who are usually most at risk Strong PHC is associated with higher patient satisfaction levels with the health system in general. PHC helps to control the costs of the health system in general. The reasons for the cost effectiveness are numerous

15. Differences in Primary Health Care in ND countries Different traditions of health care system before Alma Ata ● Sweden – strong community nurses, lack of doctors ● Countries with Semashko system – overestimated role of specialists (specialoids) in out-patient care, hospital oriented health care system, lack of responsibility for health from the community ● Public health centers in Finland, Sweden versus dominant private, mainly solo practices in Denmark and Norway Different tempo of the reform in the countries reforming from Semashko system ● Estonia – quickly implemented reform ● Lithuania – good strategy, but step back to retain policlinics and specialists in PHC ● Russia – emphasis of primary health care, higher salaries than to secondary health care specialists (still equal priority for family physicians, district internists and pediatricians) Lack of up-to date information on PHC situation in ND Countries

16. Gaps in regulation and stewardship In the majority of the ND Countries there is a high control on the distribution of the primary care practices although the mechanisms of regulations are different ● Sweden, it is up to each county council to decide how to deliver primary care to the population for which it is responsible ● Highest prevalence of self-employed practices in Denmark 100%, Germany 100%, Norway 58%, Estonia ?? regulated differently Equitable distribution of the primary care personal and resources is a big challenge for all the countries in our region;

17. Gaps in requirements for the competence of the primary care doctors and nurses There is pronounced gap in the requirement for professional training of primary health care doctors and nurses In terms of duration of the postgraduate training (residency) ● 6 years - Finland, 5 years – Sweden, Norway, Denmark, Germany ● 3 years – Estonia, Latvia, Lithuania, 2 years in Russia, ● 6 months retraining program in Belarus In terms of content and quality of training ● Dominance of narrow specialists in training of family doctors and training in hospitals ● Lack of community - oriented education Gaps even higher in requirements for the competence of PHC nurses

18. Gaps in the performance of PHC providers Involvement in the preventive services Role of primary health care professionals and the tools used for disease prevention and health promotion in the community and for the empowerment of the community varies between the countries Application of communication tools needed for more holistic approach towards patient problem and for the brief interventions …

19. Gaps in organization of PHC services for better quality for the patients Availability and the quality of home care and other forms of institutional care for elderly people (nursing homes, shelters, elderly houses) Availability of essential equipment relevant to primary health care of the primary care physicians Information exchange between primary and secondary health care and computerised patient records

20. Recommendation for project based activities (1) Contribution to the development of appropriate policies for equitable distribution of qualified primary care personnel in all EG countries ● Primary health care system, focused on qualified primary health professionals – family doctors and community/family nurses should be introduced in all ND countries ● Most actual – Belarus, Russia, Lithuania, Latvia, Poland To fulfil the gap between countries in professional requirements for the training of primary health care doctors and nurses ● Better training programs in terms of: Duration, especially more exposure in PHC practices more community - focused methods of training, More training in communication skills, patient centred consultation methods ● Appropriate infrastructure for PHC education More PHC training practices – (not under supervision of secondary/tertiary care!)

21. Recommendation for project based activities (2) More efficiently to use primary health care as a tool to reduce risky behaviour and to achieve better health in the communities through: ● Educational activities (ToT, peer review activities) on proper motivational counselling in the primary care settings and support of the modern informational materials on smoking cessation, nicotine replacement treatment, cutting down alcohol, diet and exercise would be very important ● Training on leadership, teamwork (multiprofessional training courses) for empowerment of community to contribute in health need assessment and to play active role in solving priority health problems Training/ retraining of nurses to achieve more autonomy of the profession ● Most actual Belarus, Russia, ?Lithuania, ?Latvia

22. Recommendation for project based activities (3) More appropriate and equal use of health care services, ● Reduction of unnecessary ambulance visits through Developed guidelines for appropriate use of ambulance Telephone counselling on common conditions ● Appropriate strategies are needed to address different needs according to the different level of morbidity of population and to limit unnecessary use of expensive health care technologies ● Guidelines for improved cooperation between PHC and secondary health care specialists and better care of patients with chronic diseases, especially with several chronic diseases (high co morbidity)

23. Recommendation for project based activities (4) Sharing experiences between ND countries for finding more appropriate payment schemes with incentives to increase health promotion and disease prevention activities would be very relevant Activities on defining the requirements for the use of IT technologies in PHC Sharing experiences and defining guidelines for information registered in electronic patient charts will be very helpful both for the countries who will face the need to switch to electronic charts and for the countries with already developed IT products to find common ground for comparing key statistical data on GPs' performance

24. Recommendation for project based activities (5) Introducing evidence based guidelines for primary health care and avoiding obsolete, ineffective or potentially hazardous practices could positively impact the quality of the primary care Improvement of quality of care through introduction of internal quality assurance tools based on demand for improvement of personal performance – priority for Russia, Lithuania, Latvia, Estonia, Belarus, Poland? Projects supporting professional home care for the elderly and chronically ill patients are very welcome in the Lithuania, Latvia, Estonia, Russia and Belarus

25. Recommendation for project based activities (6) There are evident gaps in research possibilities in primary care in the ND Countries. No doubt that all the above-mentioned areas for possible project-based activities will stimulate data collection and research in relevant fields. Countries receiving advice and help would be most appreciative. Research on monitoring the performance of PHC would be very important (the tool developed by WHO)

26. The ground for new proposals is opened … Thank you! …