1. 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

3. Independence : 8 September 1991 8 April 1993 - OUN; 12 May 1993 - WHO

4. AIM >current organization and functional activity of PHC in the health care delivery system >reform activities: WHY and HOW >PHC in future

5. HEALTH STATUS OF THE POPULATION IN THE REPUBLIC OF MACEDONIA AND PRIORITY HEALTH PROBLEMS IN 2004

6. BASIC INDICATORS IN 2004 Area25 713 sq.km Population2.049.000 ( Urban 59.6/Rural 40.4) Administrative division84 municipalities Ethnicity/languagesMacedonian 64,2%, Albanian 25,2%,Turkish 3,9%,Roma 2,7%, Serbian 1,8%, Vlashos 1,0%, Other 1,2% ReligionsOrthodox Christian 67%, Muslim 30% Number of live births27761 Literacy rate94% Unemployment rate39% 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

7. Health care resources, utilization and costs in 2004 Number of hospitals54 Number of physicians, PP4573 Number of general practitioners, PP1619 Number of dentists, PP1183 Number of pharmacists, PP 332 Number of nurses, PP11056 Average length of stay in days, all hospitals11.8 Outpatient contact per person per year3 GDP$ 1690 Health expenditure of GDP6% Health expenditure of GDP per capita$ 106 Public health expenditure as % of total health expenditure 93.9

8. 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

9. 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

10. Net of health organizations in PHC

11. Medical units - PHC in 2000 Department: Medical units DoctorsPopulation/1p Facilities Spec. General medicine 457999 (19.%)1401 Children aged 0-6y. 82299 (53%)680 Schoolchildren 78175 (65%)2448 Labor medicine 91161 (69%) - Gynecology 51101 (97%)7830

12. 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%

13. Most frequent diseases with the adult population in Macedonia in 2000

14. Most frequent diseases with the children and youth in Macedonia in 2000

15. WHY REFORMS? >SWOT analysis >RAND’s research /survey Capitation Evaluation Program >Research in IPU >Needs assessment

16. 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

17. 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

18. World Bank in the Health Sector 1996-2004 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

19. Health Sector Transition Project 1996-2002 Key dates : Approved : 20/06/1996 Revised : 24/03/1999 Closed: 31/03/2002 Costs and financing: 17.1 million USD 14.5 World Bank IDA Credit 2.6 Government contribution

20. 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

21. 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

22. 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

23. Reform activities 3. Pharmaceutical policy and supply >Promotion of rational pharmacotherapy >Training for rational prescribing >Therapeutical guidelines

24. 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

25. 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

26. 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

27. CME CENTERS

28. HANDS-ON- education CLINICAL SKILLS

33. 15 GUIDELINES W For most frequent medical problems and diseases W Prepared by team of CME educators – local and international W Customised, translated, peer reviewed, edited and published

34. OTHER MATERIALS  Tables for cardiovascular risks: males/females W Normogram for Body Mass Index W Changes on the eye fundus for the most important diseases in PHC

35. MEDICAL DOCUMENTATION W Draft forms for record keeping for chronic diseases the  Final version customised, edited and published

37. LONG TERM CME STRATEGY Produced by :  Doctors, educators  Professors from UK  Professors from Medical Faculty Skopje,  Doctors Chamber  Macedonian Medical Association

38. MEMORANDUM OF UNDERSTANDING 17.12.99 i 26.12.2001 WMinister of health WPresident of Doctors Chamber WPresident of Macedonian Medical Association WDean of Medical Faculty WImprove the Standards of PHC in accordance with EU

39. INSTITUTIONALISATION OF CME WStrategy for CME and specialisation WInternational Centre for studies in PHC and CME within the Medical School (New Statute) WDepartment for PHC within the Medical Faculty

40. 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

41. PROJECT CLOSED IN JUNE 2002- HIGHLY SATISFACTORY CHALLENGES FOR FUTURE REFORMS

42. 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

43. Center for PHC and CME after 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

44. 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

45. 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

46. PHC IN FUTURE >Accessible >Well organized >Continuous >Comprehensive >Coordinated >Oriented towards: >Patient, family, community >Cost-effective

47. 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

48. EXPECTED OUTCOMES ! Better primary health care ! Better health for all