Effectiveness of primary care-led health systems: choices facing Serbia and the region Professor Naomi Chambers Head of Health Policy and Management Manchester Business School

Summary Remember Alma Ata? Messages from WHO 2008 Report Cross country learning Alternative models of primary care Power of path dependency

Alma Ata Declaration 1978 Recognition of centrality of PHC Government responsibility for it Acknowledgement of unacceptability of inequality Right and duty of citizens to participate Intersectoral collaboration Health For All by the year 2000

30 years on Longer and healthier lives and 6.7 million fewer children die but Inequalities persist Poor primary care exists Patchy participation Still a focus on curative care PHC seen as ‘poor care for poor people’

Primary Health Care Now More Than Ever WHO Report common shortcomings of health care: Inverse care, impoverishing care, fragmented care, unsafe care, misdirected care

WHO Report recommendations Universal coverage reforms to improve health equity Service delivery reforms to make health systems people-centred Public policy reforms to promote and protect the health of communities Leadership reforms to make health authorities more reliable

Strengthening leadership capability Individual capacity building shaped by formative experiences, large scale planning exercises & coaching At a system level, large-scale programmes (learning by doing), collaborative dialogue more important than tools and training Strengthen policy dialogue with innovations from the field

Leadership Reforms Replace command and control and hands- off approaches by government Wide engagement in policy dialogue Use of information systems that go beyond outcome and resource use indicators and include patient experience and impact

Agenda for Serbia and the Region? Benchmark against these challenges Recognise and work with the street-level bureaucrats Be willing to learn from each other and from other countries

Cross-cultural learning: the benefits Most sectors/countries are experiencing the same difficulties Comparison allows identification of wider range of policy options and management solutions for similar problems Better understanding of conditions under which policies succeed or fail

Cross-cultural learning : pitfalls Technical and clinical innovations more transferable than policy and management innovations Significance of country-specific cultural contexts, value systems and beliefs Complexity of confounding factors Lesson learning is not politically neutral Uncritical adoptions of ‘bright ideas ’

Cross-cultural learning : potential Focus on learning about policy options & about good practice rather than league tables Ways of learning : value of seeing own setting more clearly by examining contrasts & differences Health care systems are complex ecologies but approaches can be adapted & worthwhile

Alternative models for primary health care Typology Gatekeeping List sizes Changing professional roles

Typology extended general practice managed care enterprise reformed polyclinic district health system community development agency outreach franchise (Meads, 2006)

Gatekeeping/Referral system Variation in the extent of First contact/entry point Generalism Comprehensiveness Collaboration Continuity

List sizes From 0.4 GP per 1,000 population ( Slovakia, Latvia, Switzerland) to 2.1 GP per 1,000 population (Belgium) 1.1 PHC doctor per 1,000 population (Serbia) Size of practice ( single-handed to managed care enterprise)

Changing professional roles Uni/multi disciplinary Role expansion and extension Outreach from/inreach into secondary care Membership of clinical networks Doctors managing in health systems

Power of Path Dependency Power of history, previous decisions, institutions, structural forces 3 economic logics of cost control, equitable distribution of services and efficiency always compromised Policy occasionally forced into new trajectory by combination of pressures

Choices? Critically examine array of models Utilise policy dialogue ( cf Balkan Primary Health Care Policy Project) Make use of WHO challenges Work with, not against hospital services Develop management & leadership and policy entrepreneurship capacity Evolution not revolution