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

2. Presentation aims: DEFINITION OF PRIMARY HEALTH CARE (PHC) FUTURE & UNAVOIDABLE REALITIES THE HEALTH CARE DELIVERY DYNAMIC IMPLEMENTATION ISSUES TO PRESENT THE STRUCTURE OF PHC To define the processes of PHC in Cyprus To 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 1/15/2015 2

4. 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

5. 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. 1/15/2015 5

6. WHY PHC WHO 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 1/15/2015 6

7. 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 1/15/2015 7

8. 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. 1/15/2015 8

9. 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) 1/15/2015 9

10. 10 RangeAverage European Region High/Low Doctors/ 1000 Population 2002 – 2006 0.3 - 5.03.2High: Greece Low: Bulgaria Nurses/ 1000 Population 2002 – 2006 2.9 – 19.57.8High: Ireland Low: Turkey Pharmacists/ 1000 Population 2002 - 2006 <0.1 – 1.10.2High: France/Finland Belgium Low: Several Total Expenditure on Health as % GDP 2005 3.9 – 11.48.6High: Switzerland Low: Kazakhstan/ Azerbaijan Government expenditure on health as % total health expenditure 2005 19.5 – 90.774.3High: Luxembourg Low: Georgia Per capita expenditure on health International $ PPP 2005 106 – 5,5211,649High: Luxembourg Low: Tajikistan Source: World Health Statistics 2008, WHO

11. T HE H EALTH C ARE D ELIVERY D YNAMIC INPATIENT DAY PATIENT DAY PATIENT OUTPATIENT OUTPATIENT OFFICE OFFICEHOME CARE HOME CARE SELF CARE 1/15/2015 11

12. HOW IS THE CASE IN CYPRUS TODAY

13. CHALLENGES AGING TECHNOLOGY NEW PHARMAEUTICALS. ADVANCES IN PROVISION INCREAS EXPECTATIONS HEALTH CARE REFORMS

14. 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

15. PHC AND NHIS PHC TODAY PUBLIC SECTOR PRIVATE SECTOR

16. PUBLIC SECTOR 1/15/2015 16 PROVIDES ALL LEVELS OF PHC HEALTH CARE, HEALTH PREVENTION,HEALTH EDUCATION AND PROMOTION

17. 75 ΙΔΙΩΤΙΚΕΣ ΚΛΙΝΙΚΕΣ 1500 ΙΔΙΩΤΕΣ ΙΑΤΡΟΙ ΚΥΡΙΩΣ solo practices ΤΟΥΡΙΣΜΟΣ ΚΑΙ ΥΓΕΙΑ Lack of Standards and Protocols. HCS in Cyprus Β. ΙΔΙΩΤΙΚΟΣ ΤΟΜΕΑΣ

18. 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

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25. 25 The initiatives should be piloted in a big, urban PHCC in Nicosia Source:MoH team CriteriaStrovolos PHCC Number of GPs 1 6 Number of nurses 2 4 Number of administrative staff 3 5 assistants 1 receptionist 1 messenger Number of pharmacists 4 3 pharmacists 1 assistant pharmacist Number of computers 5 0 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. 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. 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 travelling 10 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. 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 1Option 2Option 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 CurrentNo alternative AlternativeNo 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 Political cost No alternative AlternativeCurrent Team recommendation Transition period required for full implementation

29. 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 AppointmentSchedulingPlanningVisit If patient has any questions or concerns, he/she can contact doctor or pharmacist Follow-up

30. PRIMARY HEALTH CARE LACK OF ORGANISATION PUBLIC AND PRIVATE DEFINITION OF THE ROLE OF THE PHC DOCTOR NO CATCHMENT AEREA NO GROUP PRACTICE NO PHC TEAM LACK OF CME

31. Distribution of household gross annual income %

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

34. Type of doctor visited by each geographical region

35. Type of doctor visited by each income group

36. Type of doctor visited by annual income

37. Top 10 reasons for visiting the doctor

38. Top 7 Specialists Visited Internist/GP (40%) Pediatrician (19%) Ob/Gyn (8.5%) Orthopedics (7.5%) Cardiologist (6%) Ophthalmologist (4%) Other (15%)

39. Self-Reported Health Status %

40. Out-of-pocket health expenditures as share of household income, 2002 Source: Hsiao & Jakab, 2003

41. Likelihood of Using Public or Private Physician for minor injury Source: Hsiao & Jakab, 2003

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

43. Type of personal doctor chosen by income level

44. Type of personal doctor chosen in 4 income groups

45. Average time it takes to get to the GP: Private vs. Government

47. HCS in Cyprus Law: 89 (I)/ 2001 Law: 134(I) /2002 Provision for the introduction of General Insurance Health Scheme in Cyprus. NHIS

48. HCS 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

49. HCS 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%

50. LAW 89(I)/2001 LAW 134(I)/2002 General Practitioners PROVISION FOR Other Specialists Pediatricians

51. Provision of care GPs Provide health care to all enrolled on their list. 24 hours coverage provision to change the GP

52. Reimbursement of GPs Capitation fee (75%) Experience, good practice, preventive- promotive programs (25%)

53. Performance Measurement Systems Accreditation Certification Utilization Management Peer Review Indicators Clinical Practice Guidelines and Paths Report cards Productivity Profiles

54. Drs practicing general medicine Physicians GPs Registered Medical Practitioners Cardiologists Other internal subspecialties Pediatricians: responsibility for the children under 15 years of age.

55. LAW 89(I)/2001 LAW 134(I)/2002 PROVISION FOR General Practitioners Other Specialists Pediatricians

56. 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

57. 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.

58. GPs List Size First 3 years (300) After 3 years (500) Maximum 2500 Geographical Restrictions???

59. Provision of care GPs Provide health care to all enrolled on their list. 24 hours coverage provision to change the GP

60. Provision of Care Medical Care Diagnostics, Laboratories Drug Prescriptions Home Visits.

61. Referrals Casualties direct access Agreed certain cases for direct access to specialist care Denied reimbursement for direct access.

62. Setting up partnership incentives for the establishment of partnerships Group practice subsidy for the construction or acquisition of buildings subsidy for medical equipment subsidies for employing nurses and other healthcare professionals

63. 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.

64. Performance Measurement Systems Accreditation Certification Utilization Management Peer Review Indicators Clinical Practice Guidelines and Paths Report cards Productivity Profiles

65. 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.

66. C ONCLUSIONS Most 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 1/15/2015 66

67. P OSTSCRIPTS “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. 1/15/2015 67

68. 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”!

70. PHC AND NHIS SUMMARY ΙΙ REFFERAL INFORMATION SYSTEM GROUP PRACTICE CME PCH TEAM SMART CARD