1. Primary Health Care in North East Europe Countries
Arnoldas Jurgutis, PhD , assoc. prof., head,
Public Health Department Klaipeda University,
ITA, Primary Health Care Expert Group of the Northern Dimension Partnership in Public Health and Social Wellbeing
EFPC Conference The Future of Primary Care in Europe
III Pisa August 2010

2. Northern Dimension Partnership
Oslo Declaration of 27 October 2003 – ND Partnership in Public Health and Social Wellbeeing (NDPHS) – four Expert Groups till June 2010 (reorganisation is going-on):
HIV/AIDS Expert Group
SILWA Expert Group
Prison Health Expert Group
Primary Health Care Expert Group of the NDPHS
Lead country Sweden,
Chair Dr. Goran Carlsson, Senior advisor MoH&SA
Active participation:
Northern Dimension Partnership
Finland
Estonia
Lithuania
Norway
Poland
Russia
Sweden
Latvia
Belarus
WHO European
Region
One six priority areas in cooperation between
The Northern Dimension Partnership in Public Health and Social Well-being (NDPHS) is a cooperative effort of eleven governments, the European Commission and eight international organisations. The NDPHS provides a forum for concerted action to tackle challenges to health and social well-being in the Northern Dimension area and foremost in North-West Russia
Northern Dmension Partnership established to expand cooperation between EU countries in the North East,
Environment, Nuclear Safety and Natural Resources
Research, Education and Culture
External Security, Civil Protection
Freedom, Security and Justice
Economic Cooperation
Social Welfare and Health Care
Coordinating healh priorities ifor the EU BSR Strategy
Report: PHC in ND countries:

3. Objectives of presentation
To overview shortly the development of Primary Health Care in North East Europe Countries and to address recent challenges
Countries in focus - Belarus, Estonia, Latvia, Lithuania, Russia (active East Europe members in NDPHS network)
Pirma skaidre 2 min
EFPC Conference The Future of Primary Care in Europe III Pisa August 2010

4. Semashko model of health care system
Common past...
Semashko model of health care system
very centralized health care system with hospitals leading health care
primary care– a lowest chain in hierarchy of health care system
primary health care doctors trained mainly in hospitals as specialists in internal medicine, pediatrics, gynecology etc.
exaggerated role of narow specialists for improvement of population health
Law No.1000 on dispanserisation overproduction of “specialoids”
Nuotrauka su trecia poliklinika
Ir plikiais
EFPC Conference The Future of Primary Care in Europe III Pisa August 2010

5. Common ideas since early 1990-ies
Strategies on Primary Care reforms:
Estonia - “National Development Program” 1991
Lithuania - “National Health Concept” 1991
Latvia –MoW approved model of PHC based on family doctors
Belarus MoH decree regarding the gradual transition of the organization of primary care
Russia – started postgraduate training in 1992, main legal requirements for new speciality in 2000
Basic care program in Latvia – division of functions of primary and secondary health care,
Belarus No immediate and fundamental
reforms have been implemented; changes have been modest and implementation was
on a limited scale rather than nationwide.
Russia: The introduction of a three-year post graduate training
program for general practitioners in 1992 was a
first step in developing a strong primary care
system, and is expected to raise standards and
enhance public confidence. In support of primary
care based on general/family practice, a Ministry
of Health order in 2000 defined training
requirements, rights and obligations of general
practitioners, and specified the legal,
organizational and financial mechanisms upon
which family medicine is to be based.
“Regulations of the Cabinet of Ministers on Financing of Health Care”
(1999)
These Regulations establish health care financing rules specifying the source
and management of health care financing. The key changes they initiate are:
(a) 70% of funding for the state programme on prevention/immunization is to
be included into the Basic Care Programme defining the minimum package
of health care services, and financed through the regional sickness funds; and
215
Health systems in transition Latvia
(b) physician remuneration in primary care based on the capitation model.
These Regulations have been replaced by the “Regulations on Financing and
Organization” (2004, with amendments in 2005).
“Regulations of the Cabinet of Ministers on the Specialty of a Family
Doctor (General Practitioner)” (1999)
These Regulations specify the range of services to be provided by family
doctors.
Ideas on the reform
of primary care were first expressed in a detailed document published by the
Latvian Physicians Association in 1991, which included a precise description
of the GP, also referred to as the family physician. In 1992 the Ministry of
Welfare approved the model of PHC based on the GP. Reform of the system
was initiated in 1993, and is based on the principle of primary care provision
with an emphasis on prevention, with a universal, effective health insurance
system that will guarantee the accessibility of health care and an institutional
structure that functions well. Development of PHC is based on the establishment
of family doctor practices with a team model, i.e. consisting of a family doctor
and nurse or doctor’s assistant.

6. 1990-ies - External drive and support
International support to PHC reforms:
WB investment in East Europe and Central Asia –
200 mln US $
EU PHARE, TACIS Projects
USAID
Swedish International Development Agency (SIDA), through NGO Swedish East Europe Commitee (SEEC)
Matra projects supported by the Dutch Ministry of Foreign Affairs and implemented by NIVEL
Support from FM associations (WONCA, Canadian FD association)
Other...
Papildytiapie support is ast europe sumas is WB
In 1999–2004 the World Bank implemented a project involving a loan of US$
12 million for the “Latvia Health Reform Project”
€247.3
million for health purposes in the period 2004–2013.

7. 20 years – intensive reforms...
Introduction of new speciality of family doctors training/accreditation system in all countries (residency 3years - Lith, Lat, Est, 2years - Russ, 6month - Bel)
Decentralisation – responsibility for municipalities for PHC
Separated PHC and SC (in Estonia, Latvia, Lithuania (partly)
Autonomy of PHC – FD - private (independed) contractors (Est 100%, Lat, Lith 50%, political suport for intruduction in Russia))
Free choice and listing to PHC institutions and FD,
Gatekeeping (Est, Latv, Lith, in some regions of Russia) ..
Intensive multifaceted [›m™ltˆ‹fœsˆtˆd] a daugiaaspektis
reforms
Pabrezti: specialybes, kiek stiprios
Very painful separation of primary health care and secondary health care, resistance from

8. One step forward two steps back...
Lack of internal drive, political intentions to step back since late 1990th, 2000
primary health reform - hot political issue, possibility of lobbying for “populistic” parties
Active reformists – kamikaze experience
Since late 1990 health reforms become hot isuue

9. Estonia – success story of PHC reform
strong leadership of Tartu university, FD association
practical approach to implementation,
careful change-management strategy to avoid health reforms being politicized too early in the process,
early investment in training to establish a critical mass of best model of health professionals
Health Policy Nov;79(1): Epub 2006 Jan 6.
Introducing a complex health innovation--primary health care reforms in Estonia (multimethods evaluation).
Atun RA, Menabde N, Saluvere K, Jesse M, Habicht J.
Centre for Health Management, Tanaka Business School, Imperial College London, South Kensington Campus, London SW7 2AZ, UK.
Abstract
All post-Soviet countries are trying to reform their primary health care (PHC) systems. The success to date has been uneven. We evaluated PHC reforms in Estonia, using multimethods evaluation: comprising retrospective analysis of routine health service data from Estonian Health Insurance Fund and health-related surveys; documentary analysis of policy reports, laws and regulations; key informant interviews. We analysed changes in organisational structure, regulations, financing and service provision in Estonian PHC system as well as key informant perceptions on factors influencing introduction of reforms. Estonia has successfully implemented and scaled-up multifaceted PHC reforms, including new organisational structures, user choice of family physicians (FPs), new payment methods, specialist training for family medicine, service contracts for FPs, broadened scope of services and evidence-based guidelines. These changes have been institutionalised. PHC effectiveness has been enhanced, as evidenced by improved management of key chronic conditions by FPs in PHC setting and reduced hospital admissions for these conditions. Introduction of PHC reforms - a complex innovation - was enhanced by strong leadership, good co-ordination between policy and operational level, practical approach to implementation emphasizing simplicity of interventions to be easily understood by potential adopters, an encircling strategy to roll-out which avoided direct confrontations with narrow specialists and opposing stakeholders in capital Tallinn, careful change-management strategy to avoid health reforms being politicized too early in the process, and early investment in training to establish a critical mass of health professionals to enable rapid operationalisation of policies. Most importantly, a multifaceted and coordinated approach to reform - with changes in laws; organisational restructuring; modifications to financing and provider payment systems; creation of incentives to enhance service innovations; investment in human resource development - was critical to the reform success
Pinas iki sutrumpinimu
strong leadership,
good co-ordination between policy and operational level,
practical approach to implementation emphasizing simplicity of interventions to be easily understood by potential adopters,
careful change-management strategy to avoid health reforms being politicized too early in the process,
early investment in training to establish a critical mass of health professionals to enable rapid operationalisation of policies.
Atun RA, Menabde N, Saluvere K, Jesse M, Habicht J Introducing a complex health innovation--primary health care reforms in Estonia (multimethods evaluation). Health Policy Nov;79(1): Epub 2006 Jan 6.

10. Deviations from core Primary Care principles
How strong organisational PC features to apply and nurture proper compentences in primary care?
First Contact
Coordination, continuity
Comprehensiveness
Family orientation
Community orientation
Different developments
Every country have good examples to demonstrate
.. Where not countries have such succesful story, but from othr hand lot of learning from different approaces to reform phc

11. First Contact Very ambitious goal for Semashko model countries III III
> 50 % health problems
<20 % health problems FD DI DP I I
As to regards to first contact and accesibility, East Europe countries moving from the health sysytem, were patients’ rights were without any boundaries. Familiarity and undetable payments were importnat factors, still there were possibilities for free access to any specialist, and there were extensive use of inpatient treatment. Studies done before the reform indicated that over 50% of encounters were directly with specialists, i.e. bypassing district internist or district pediatritians.
Transition meet obstacls, both with regrds of medical doctors – traditional attitudes – better to reffer more than solve themselfes, patients – overestimated role secondary health care and specialists – suplyer induced demand,
Listing in all countries....
To be specialists
Idesiu skiadre su pacientu srautais
Neturintys patirties , norui specialistu... Specialoidai zaidzia...
Belarus: A primary care model based
on GPs was adopted – but only applied in rural areas. In addition, as perceived by
some stakeholders, GPs can not act as gatekeeper as this would violate the patients’
constitutional right of access to any health care.
Semashko model
New model
Over 50% direct contacts to the specialists (out of all encounters with physicians)
FD – first contact with overall health care system

12. First Contact – intentions to step back
Patients are looking for easier access to the specialists:
More then half the respondents would be willing to pay higher patient fees in order to have easier access to specialized care (TDRC study, Latvia, HIT 2008)
Free access to any health care - constitutional right (Belarus)
Strong political intensions to open free access to the secondary health care specialists in Lithuanina, Latvia, 2008
Unequal competences and conditions of PHC physicians to play a role of gatekeeper
GPs after 3 years residency
Retrained from district physicians
District physicians
Private independent contractors vs. policlinics
Even implemented gatekeeping functions in all countries, patients still highly demand free access to the specialists, esspecialy it is
Isemiau:Increasing international evidence on the role of FD as first contact physician
Lack of internal drive, comprehensive policy to implement reform (arba perdeti)
Example – I have got a call from journalist – that what to do for diabetes patients – they will die without insulin, because waiting time to the specialists more than one month and they can prescribe insulin only for one month.

13. Coordination, continuity
most intensive changes in Lith, Latv, Est,
listing (free choice) to FD– coordinator of care
with referal free choice of any specialist within country
Estonia:
90% of population new their FD and only 15% changed during last year (Atun et all, 2006)
recently advanced e-health technology used for shared pt records
Belarus – % of patients indicated they would address problem to their GP or therapist, before seeking help from spec
(WHO, NIVEL study 2009)
Projects aimed to foster teamwork in PHC (Lihuania 2000)
Coordination with other sectors - recent priority in PHC development policies – Estonia , Lithuania

14. Specialists – keeping power in first line care
Often more political power, including municipality boards
Suplier induced demand
Specialists’ driven privat clinics in Lith
From FD gatekeeper to FD gateopener
Capitation payment for FD services +fee for service for consultations
Overproduction of specialits in sSemashko system and everestimated their role for out-patient care scepticizm

15. Comprehensiveness
Increased scope of diagnostic and treatment services if service provided by FD (Jurgutis 2002, Atun 2006, Jankauskiene 2007, Liseckiene 2009,)
In Belarus FD have a much more comprehensive role when compare with district interninst (WHO, NIVEL study 2009)
No significan changes in preventive & health educational services in Lith (Liseckiene, 2009)
Less comrehensiveness if FD working in the same premisses with secondary care specialists (Raila G, 2007)
Lack of incentives
Overloaded wih work

16. Comprehensiveness and chronic diseases
Improtance of comprehensive family doctor’s care for patients with several chronic diseases (high comorbidity):
Patients with high comorbidity who have registered with family physicians more often visit their primary health care physicians, and need specialist care less often, compared to patients who registered with district physicians
consistent finding for adults with several chronic conditions, including asthma, diabetes, hypertension, and IHD
similar finding for children with hypertension, but not for children with asthma
(Jurgutis A., Martinkenas A., Lemke K, Bumblys A., 2008)

17. Family orientation
Ideas on GPs for children and GPs for adults (Bel, Rus)
Better satisfaction with FD care, no difference in performance (Est)
Belarus – 70% FD serves both children and adults (Atun, 2006)
First visit to the child by family doctor and nurse in rural district of Klaipeda region, Lithuania
Political lobying of pediatritians to get back responsibility for primary care of children (Lat, Lith)

18. Community orientation
Community oriented primary health care – limitted to some very good examples could be found in all East Europe countries
Lith case: Through team based PC community interventions in rural community succesfully controled arterial hypertnesion increased from 1,2% in1998 until 23, 6% in (Andriauskas, 2005)
Free choice of FD – lost defined geografic area
Dificult to overcome traditional “top-down” approach in community health need assessment

19. Challenges to be addressed (1)
Unequal accesibility of proffesionals
with core FM competences
“Excuse” policy for district internist and district pediatritians (not trained as family doctors):
Estonia – the only country from former soviet which have only FD since 2005
Lithuania – still 31% population served by district internist and pediatritians
Belarus – only 15% of FD, mainly in rural areas
Russian Federation: Emphasised priority to Primary Health care through National Programm “Zdorovie” :
since 2006 plus rub! per month to every PHC physician (average drs salaries in 2006 about 8000)
still equal policy FD, DI, DP,

20. Challenges to be adressed (2)
More responsibility and competence for PHC nurse:
managemnt of patients with chronic conditions
role in community health need assesment
leadership in primary health care team
Teamwork and cooperation with other sectors – social workers, public health specialists, schools etc.:
to emphasize role of social workers for chronic conditions
Latvia: Nurse assist doctor in consultancy room. Also often case in Lith, Rus, Bel

21. Challenges to be adressed (3)
As reported by FD and nurses in NDPHS Workshop “Tomorrows role of Family doctors and Nurses” (Baltic Conference of Family Medicine, Piarnu, Estonia Sept 2009)
Unequal distribution of PHC practices – not attractive rural areas
Increasing workload – burnout , particular problem for solo practices
Lack of tools for patients empowerment, motivational counceling
Extended PHC team needed
More emphasis to patient centered, holistic care (informed patinets, emigrants, needs to empower for selfcare)
Introduction of EB performance indicators
Internal quality assurance tools
Appropriate incentive payment scheems

22. Opportunities for for further PC development in North East Europe
Recent years role of primary care was again reinforced by national policy makers:
Financial shortcuts forced to rationalise health care systems
Closing hospitals – needs for stronger care in the community
Less patients’ complains and political tensions if strong PC team
More internal drive and plans for ambitious PC reforms in in East Europe Countries
forced to rationalise health care systems and one response to that is that the role of primary care was again reinforced. It is now high time for commited national policy makers to fortify genuine primary care in the East countries of the Baltic Sea region.

23. Russia – plans for more efficient PHC
Kaliningrad oblast 1mln inh:
trained 77 FD, working only 22
stronger primary care – expressed public need
plans for FD – independed contractors with Mandatory Health Inssurance (MHIF)
piloting new payment scheems – FD partly fundholding
New Minister of Health of Kaliningrad oblast Mr. V. E. Golikov observs privat FM practice in Lithuania (August 2010, Klaipeda)

24. Belarus – rethinking primary health care
Strategy for HC development 2011 – 2015:
Residency of Family Medicine up to 2-3 years (recently 6 month retraining)
Introduction of quality indicators for PHC
New payment scheems for PHC providers
Family doctor’ consultation in Family Medicine Center in Belarus

25. Opportunities through joint project activities
Initiated by NDPHS EU BSR project IMPRIM – “Improvement of public health by promotion of equitably distributed high quality primary health care systems”
13 organisations from 6 countries (Bel, Latv, Lith, Est, Swe,Fin)
6 MoH as associate partners (Bel, Latv, Lith, Est, Swe,Fin)
3 years 2,6 mln Euro
Opportunities for Kaliningrad oblast to joint project activities (SIDA funding)
Should be tald links with other EG 25

26. Conclusions
All North East contries since 1990-ies are in the process of reform of their primary health care systems, still implementation of PC principles varies between the countries and within the countries
Estonia has experienced most ambitious reform and fully introduced based on family medicine PHC model
Recent financial shortcuts forced to rationalise health care systems and primary care is reinforced once again
It is now high time for commited national policy makers to fortify genuine primary care in the East countries of the Baltic Sea region

27. Thank you for your attention!