Evaluation of primary health care reform in Estonia

Estonia began to reform its health care system by reorganizing primary health care (PHC). Ten years ago, the health care system was inefficient, supply was biased towards institutional care, and PHC was almost non-existent in the western understanding: it was provided by different specialists in policlinics, and the financial basis of the system was in crisis. The reform had the following aims: to develop PHC by introducing family medicine, to guarantee the whole population access to family doctors' services, and to secure stable funding for these services. In 1998, a new phase in the reform was introduced through the creation of a new funding system for primary care services. The aim of this paper is to present a practically applicable set of indicators to evaluate PHC reform in terms of health economics criteria and then to apply these indicators in evaluation of the Estonian PHC reform.     

Diffusion of complex health innovations--implementation of primary health care reforms in Bosnia and Herzegovina

Most transition countries in Central and Eastern Europe and Central Asia are engaged in health reform initiatives aimed at introducing primary health care (PHC) centred on family medicine to enhance performance of their health systems. But, in these countries the introduction of PHC reforms has been particularly challenging; while some have managed to introduce pilots, many have failed to these scale up. Using an innovation lens, we examine the introduction and diffusion of family-medicine-centred PHC reforms in Bosnia and Herzegovina (BiH), which experienced bitter ethnic conflicts that destroyed much of the health systems infrastructure. The study was conducted in 2004-05 over a 18-month period and involved both qualitative and quantitative methods of inquiry. In this study we report the findings of the qualitative research, which involved in-depth interviews in three stages with key informants that were purposively sampled. In our research, we applied a proprietary analytical framework which enables simultaneous and holistic analysis of the context, the innovation, the adopters and the interactions between them over time. While many transition countries have struggled with the introduction of family-medicine-centred PHC reforms, in spite of considerable resource constraints and a challenging post-war context, within a few years, BiH has managed to scale up multifaceted reforms to cover over 25% of the country. Our analysis reveals a complex setting and bidirectional interaction between the innovation, adopters and the context, which have collectively influenced the diffusion process. Family-medicine-centred PHC reform is a complex innovation-involving organizational, financial, clinical and relational changes-within a complex adaptive system. An important factor influencing the adoption of this complex innovation in BiH was the perceived benefits of the innovation: benefits which accrue to the users, family physicians, nurses and policy makers. In the case of BiH, policies or the innovation are not simply disseminated, but rather assimilated into the health system. The assimilation and implementation of the new PHC model relied on the consensus of a diverse group of adopters; the changes brought by the reforms were aligned with the expectations of the adopters: this created a 'receptive context' for adoption and diffusion of the innovation. The new family-medicine-centred PHC service model had a major impact on professional identity, inter-professional relationships and organizational routines. The post-conflict context was perceived as an opportunity to introduce the new model and implement transformational change, while the complex government structure meant the process of diffusion was as important as the innovation itself. In BiH, a holistic approach-comprising multifaceted and simultaneous interventions at multiple levels of the health system-reduced 'policy resistance' and enhanced the adoption and diffusion of the PHC reforms.     

Market reforms and public incentives: finding a balance in the Republic of Macedonia

The Republic of Macedonia is undertaking sweeping reforms of its health sector. Funded by a World Bank credit, the reforms seek to improve the efficiency and quality of primary health care (PHC) by significantly strengthening the role of the market in health care provision. On the supply-side, one of the key reform proposals is to implement a capitation payment system for PHC physicians. By placing individual physicians on productivity-based contracts, these reforms will effectively marketize all PHC provision. In addition, the Ministry of Health is considering the sale or concessions of public PHC clinics to private groups, indicating the government's commitment to marketization of health care provision. Macedonia is in a unique position to develop a new role for the private sector in PHC provision. The private provision of outpatient care was legalized soon after independence in 1991; private physicians now account for nearly 10% of all physicians and 22% of PHC physicians. If the reforms are fully realized, all PHC physicians-over 40% of all physicians-will be financially responsible for their clinical practices. This study draws on Macedonia's experience with limited development of private outpatient care starting in 1991 and the reform proposals for PHC, finding a network of policies and procedures throughout the health sector that negatively impact private and public sector provision. An assessment of the effects that this greater policy environment has on private sector provision identifies opportunities to strategically enhance the reforms. With respect to established market economies, the study finds justification for a greater role for government intervention in private health markets in transition economies. In addition to micro-level payment incentives and administrative controls, marketization in Central and Eastern Europe requires an examination of insurance contracting procedures, quality assurance practices, public clinic ownership, referral practices, hospital privileges, and capital investment policies.     

The 2017 reform to improve financial sustainability of national health insurance in Estonia: Analysis and first lessons on broadening the revenue base

In 2017, the Estonian government addressed the longstanding challenge of financial sustainability of the health system by expanding its revenue base. As a relatively low-spending country on health, Estonia relies predominantly on payroll contributions from the working population, which exposes the system to economic shocks and population ageing. In an effort to reduce these vulnerabilities, Estonia will gradually introduce a government transfer on behalf of pensioners, although long-term sustainability of the health system could still prove challenging as the overall health spending as a percentage of GDP is not expected to substantially increase. Estonia has rolled out the reform according to plan, but it has led to debate about the need to achieve universal population coverage (currently at about 95%). Moreover, the Estonian experience also holds important lessons for other countries looking to reform their health system. For example, policymakers should recognize that reforms require extensive preparation using consistent messaging over a long period of time, also to prevent prioritising short term and popular fixes over structural reforms. Additionally, collaboration between the health and financial ministries throughout the reform increases the buy-in for the reform and likelihood of adoption. Furthermore, health professionals play a significant role in advocacy, and seeking support from this group can smooth the path towards health system reform.     

Primary care and reform of health systems: a framework for the analysis of Latin American experiences.

The article first proposes a framework within which to assess the potential of health sector reforms in Latin America for primary health care (PHC). Two dimensions are recognized: the scope of the reforms, content, and the means of participation that are put into play. This framework is then complemented through a critique of the often-sought but little-analyzed PHC reform strategies of decentralization and health sector integration. The analytical framework is next directed to the financing of health services, a chief aspect of any reform aiming toward PHC. Two facets of health service finance are first distinguished: its formal aspect as a means for economic subsistence and growth, and its substantive aspect as a means to promote the rational use of services and thus improvement of health. Once finance is understood in this microeconomic perspective, the focus shifts to the analysis of health care reforms at the macro, health policy level. The article concludes by positing that PHC is in essence a new health care paradigm, oriented by the values of universality, redistribution, integration, plurality, quality, and efficiency.     

Primary health care system in transition: the patient's experience.

OBJECTIVE: To find out how Estonian people evaluate the changes in primary health care (PHC), how they perceive the acceptability of the new PHC system, and to assess patients' satisfaction with their primary care doctor. DESIGN: Face-to-face interviews using structured questionnaires. SETTING: Estonia. STUDY PARTICIPANTS: A random sample of Estonian residents aged 15-74 years (n = 997). MAIN MEASURES: Acceptability of PHC system (accessibility, the patient-practitioner relations, amenities, and patient's preferences) and patients' satisfaction with primary care doctor. RESULTS: Of the 997 respondents, 46% were sufficiently informed about the transition to the general practitioner (GP)-based PHC system; however, 45% of respondents had not personally experienced any changes. Of the 997 persons interviewed, 68% were registered on the patient list of a GCP, and 62% of those who had health problems preferred to consult the primary care doctor first. The waiting time for an outpatient appointment was brief (0-2 days). Of the 997 respondents, 68% were satisfied with their primary care doctor. Satisfaction was dependent on: (i) how patients evaluated the competence of the physician; (ii) comprehensibility of doctor's explanations; and (iii) comfort of the clinic. The right of patients to choose their own primary care doctor and having sufficient information about the changes in PHC system had a positive influence on the level of satisfaction. CONCLUSIONS: Patients' opinions are important in the evaluation of PHC. To increase the level of satisfaction, people need to understand the nature and intent of the primary care reforms. Personal choice of primary care doctor and good patient-doctor relationships are important factors too.     

The role of payment and financing in achieving health equity

Objective

The aim was to identify healthcare payment and financing reforms to promote health equity and ways that the Agency for Healthcare Research and Quality (AHRQ) may promote those reforms.

Data Sources and Study Setting

AHRQ convened a payment and financing workgroup–the authors of this paper–as part of its Health Equity Summit held in July 2022. This workgroup drew from its collective experience with healthcare payment and financing reform, as well as feedback from participants in a session at the Health Equity Summit, to identify the evidence base and promising paths for reforms to promote health equity.

Study Design

The payment and financing workgroup developed an outline of reforms to promote health equity, presented the outline to participants in the payment and financing session of the July 2022 AHRQ Health Equity Summit, and integrated feedback from the participants.

Data Collection/Extraction Methods

This paper did not require novel data collection; the authors collected the data from the existing evidence base.

Principal Findings

The paper outlines root causes of health inequity and corresponding potential reforms in five domains: (1) the differential distribution of resources between healthcare providers serving different communities, (2) scarcity of financing for populations most in need, (3) lack of integration/accountability, (4) patient cost barriers to care, and (5) bias in provider behavior and diagnostic tools.

Conclusions

Additional research is necessary to determine whether the proposed reforms are effective in promoting health equity.     

The desirability and feasibility of scaling up community health insurance in low-income settings--lessons from Armenia

There is growing evidence that community financing mechanisms can raise additional revenue, increase equitable access to primary health care (PHC), and improve social protection. More recently there has been interest in scaling up community financing as a step towards universal coverage either via tax-based systems or social health insurance. Using key informant interviews and focus group discussions, this study sought to assess the desirability and feasibility of scaling-up community health insurance in Armenia. The results suggest that there is broad-based political support for scaling up the schemes and that community financing is synergistic with major health sector reforms. High levels of social capital within the rural communities should facilitate scaling up. Existing schemes have increased access and quality of care, but expansion of coverage is constrained by affordability, poor infrastructure, and weak linkages with the broader health system. Long-term subsidies and system-building will be essential if the expanded schemes are to be financially viable and pro-poor. Overall, successfully scaling up community financing in Armenia would depend on addressing a range of obstacles related to legislation, institutional capacity, human resources and resistance to change among certain stakeholders.     

日本健康保险制度演变历程及启示

对日本医疗保险制度实现全民覆盖的历程以及现状进行分析,发现日本的健康保险制度演变有以下特点：以法律为依据,逐步实现全民覆盖;建立了健康保险基金的合理分担机制;不同保健制度覆盖人群的服务包逐渐趋同、补偿水平逐渐统一;不同保险方案之间建立了风险分担和资金转移机制;加强对供方的约束力,控制医药费用快速上涨。最后针对日本健康保险制度的演变特点给出我国医疗保险制度改革的政策建议：健全医疗保险的法律法规;调整筹资机制,逐步提高个人筹资责任;推进不同医保制度覆盖人群保障待遇的统筹和统一;建立不同健康保险制度之间的风险分担机制;积极探索支付方式改革,控制医药费用快速上涨。     

Health insurance reform in Vietnam: a review of recent developments and future challenges

Vietnam is undertaking health financing reform with a view to achieve universal coverage of health insurance within the coming years. To date, around half of the population is covered with some type of health insurance or prepayment. This review applies a conceptual framework of health financing to provide a coherent assessment of the reforms to date with respect to a set of key policy objectives of health financing, including financial sustainability, efficiency in service provision, and equity in health financing. Based on the assessment, the review discusses the main implications of the reforms focusing on achievements and remaining challenges, the nature of the Vietnamese reforms in an international perspective, and the role of the government. The main lessons from the Vietnamese experiences, from which other reforming countries may draw, are the need for sustained resource mobilization, comprehensive reform involving all functions of the health financing system, and to adopt a long-term view of health insurance reform. Future analysis should include continued evaluation of the reforms in terms of impacts on key outcomes and the political dimensions of health reform.     

Reform strategies in Georgia and their impact on health care provision in rural areas: evidence from a household survey

The transition resulting from the break-up of the Soviet Union significantly affected the health care systems and population health status in the newly independent States. The available body of evidence suggests that contraction of public resources resulting from economic slowdown has led to the proliferation of out-of-pocket payments and private spending becoming a major source of finance to health service provision to the population. Emerging financial access barriers impede adequate utilization of health care services. Most transition countries embarked on reforming health systems and health care financing in order to tackle this problem. However, little evidence is available about the impact of these reforms on improved access and health outcomes. This paper aims to contribute to the assessment of the impact of health sector reforms in Georgia. It mainly focuses on changes in the patterns of health services utilization in rural areas of the country as a function of implemented changes in health care financing on a primary health care (PHC) level. Our findings are based on a household survey which was carried out during summer 2002. Conclusions derived from the findings could be of interest to policy makers in transitional countries. The paper argues that health financing reforms on the PHC level initiated by the Government of Georgia, aimed at decreasing financial access barriers for the population in the countryside, have rendered initial positive results and improved access to essential PHC services. However, to sustain and enhance this attainments the government should ensure equity, improve the targeting mechanisms for the poor and mobilize additional public and private funds for financing primary care in the country.     

医保支付方式由后付制向预付制改革对供方医疗服务行为影响的机制和发展路径

全民医保制度下,支付方式提供了影响供方医疗服务行为的手段,成为调节卫生资源配置的重要杠杆.医保支付方式由后付制向预付制的改革,通过财务风险的转移调整对医疗机构和医生行为的激励,控制供方诱导需求行为带来的费用上涨,成为医疗保险制度改革的重要方向.但其发挥作用的基础是医疗服务提供方对支付方式的反应.医疗服务目标的多维性、医...     

A policy of introducing a new contract and funding system of general practice in Estonia

The socialist bloc of post-war Europe was obliged to follow the Soviet example with a hierarchical, centrally controlled health care system based on polyclinics and other facilities providing extensive specialist services at the first level of contact. All the countries of Central and Eastern Europe have now expressed their wish to totally change their health care systems. Changes in these countries include: the introduction of market economy mechanisms in health care, an increased focus on population health needs in guiding health care systems, and the possibility of introducing a more general type of care at primary level. Patient expectations of access, choice and convenience are factors in shaping new models of health care delivery. Appropriate timing is the key determinant of the success of reforms. In Estonia the beginning of the 1990s was the time when several interest groups in society supported changes in the health care system. The first step after regaining independence was the reintroduction of a Bismarck-type insurance system. In the late 1990s the primary care reforms have changed the initial plans and elements of a National Health Service were introduced, especially general practitioners' lists, capitation payment and gate-keeping principles. The family medicine reform in Estonia has two main objectives: introduction of general practice as a specialty into Estonian health care and changing the remuneration system of primary care doctors. The specific tasks are: to provide practising primary care doctors with opportunities for retraining to gain the specialty status of a general practitioner, to create a list system for the population to register with a primary care doctor, to introduce a partial gate-keeping system and to give the status of the independent contractor to primary care doctors.     

Administrative reform and pay‐for‐performance methods of primary health service delivery: A comparison of 3 health districts in Cambodia, 2006‐2012

Since 1999, performance‐based financing or pay‐for‐performance (P4P) methods have been piloted in the Cambodian public health sector, first as one part of external contracting approaches with international nongovernment organizations and from 2009 as a part of internal contracting arrangements between units within the Ministry of Health under a wider public sector administrative reform. This study analyses these reforms and compares outcomes in 3 health districts. The study analysed routine quantitative data for primary care service delivery by using the interrupted time series method. Qualitative data were collected from key informant interviews. Both the level and the trend line of key service delivery indicators during earlier contracting/P4P models were at least maintained and in most cases increased with the move to internal contracting. The results of the interrupted time series analysis were mixed, mainly due to contextual issues. Qualitative results indicated an increased sense of local ownership and financial sustainability. Despite the gains, the management of personnel and the implementation and the integrity of contract monitoring were found to be compromised in this case. To be fully effective, contracting and P4P approaches must be accompanied by changes in the structure and culture of government administration.     

中国台湾地区创新医疗技术支付进展及经验

从中国台湾地区二代全民健康保险制度、“卫生福利部健康保险署”对新医疗服务项目的管理流程、全民健康保险按疾病诊断相关分组支付制度下的新增全新功能类别医疗技术因应方案三方面,介绍了中国台湾地区全民健康保险对创新医疗技术支付的做法和经验。在此基础上为我国创新医疗技术支付政策改革提供参考和借鉴,包括构建多渠道的筹资体系、引入第三方评估机制、推进疾病诊断相关分组付费制度下的医疗保险支付改革。     

A baseline survey of the Primary Healthcare system in south eastern Nigeria

A baseline survey to audit the PHC operations and determine community perception and expectations of PHC service delivery was conducted in 72 communities in Enugu state, southeastern Nigeria. The study was intended to facilitate the development of intermediate performance indicators for monitoring the progress of an ongoing health sector reform and to gather baseline data for planning and policy formulation. The tools used for the operations audit assessed indicators for evaluating: (a) Stewardship, (b) Service Provision and (c) Administrative and financial management; while the community survey was assessed by, (a) utilization of health services, (b) perception of service delivery and (c) health care financing. One hundred and sixteen respondents from each of the facilities in the sample frame were interviewed using a structured self-assessment questionnaire and a qualitative assessment was undertaken in 53 of the facilities using an audit guide. Focus group discussions (FGD) were conducted with the policy makers and planners in each of the 17 LGAs in the state. A total of 832 respondents were interviewed in the communities (using a structured questionnaire) and 42 community FGDs were conducted. The results indicate a lack of operational efficiency in the majority of the facilities audited. It was also observed that majority of the facilities do not provide all services required of it, are poorly maintained, do not have enough skilled health workers and operate without a budget. There appears to be no formal financial management system in place and no policy on financial resource generation. The community survey identified two major problems; low utilization of PHCs and poor service provision. The key indicator identified by the community for evaluating performance of the PHCs remains "access to essential drugs". The major prospect was the willingness of an appreciable number of respondents to invest in health financing through insurance schemes and payment of health tax among others. It was evident that poor funding, bad management practices and infrastructural decay is the bane of efficient PHC delivery. Consequently, we propose that cost determination studies, to establish the financial implication of the minimum package for provision of primary healthcare services, should be an essential prerequisite to the reform process. Some critical cross-cutting issues identified from the data obtained which could form the basis for major policy thrust include, development of strategies for sustainable promotion of public-private-partnership for enhanced community involvement in healthcare management, ensuring that interventional investment is proportional to the felt health needs of the populace and funding of healthcare through equitable integration of user fees/charges.     

老龄化背景下日本医保体系与卫生体系的协同变革与启示

少子老龄化是我国学术界和政策制定者共同关注的问题,少子老龄化带来的健康需求、疾病谱的变化以及代际失衡问题,对医疗保险筹资和服务提供模式提出了新的要求和挑战。20世纪90年代以来,日本面临少子老龄化和经济低迷的双重挑战,一直在进行卫生服务提供和社会保障制度改革,本文将系统梳理日本医疗保障应对老龄化的改革历程,根据世界卫生组织的卫生系统框架和协同理论,从政府治理、多层次保障、筹资与支付、基金预算与卫生资源、整合型服务等方面总结日本医疗保障和卫生体系的变革给我国带来的启示,为我国完善卫生服务和医疗保障体系,走向健康老龄化提供参考。     

我国公立医院医疗服务支付制度改革与发展的思考

医疗服务支付制度改革是深化医改的组成部分,我国将大力推行支付制度改革试点,逐步完善医疗服务的支付制度.本文在对当今的公立医院补偿机制以及与其密切相连的、按项目付费支付制度的负面作用产生的历史根源、理论根源进行分析研究的基础上,对公立医院的性质、公立医院的补偿机制的理论基础进行了论述.探讨了新形势下推行支付方式改革的原则和要点,提出了当前应以医疗服务支付制度改革为契机,将其与解决公立医院补偿机制顽疾紧密相连,把实现"控制费用、强化管理、确保质量、转换机制、实现多赢"作为支付制度改革的核心目标,将公立医院改革引向深入.     

Service accountability and community participation in the context of health sector reforms in Asia: implications for sexual and reproductive health services

This paper examines the concept and practice of community participation in World Bank-supported health sector reforms in Asia, and how far such participation has strengthened accountability with regard to provision of sexual and reproductive health (SRH) services. It argues that the envisaged scope of community participation within a majority of reforms in Asia has been limited to programme management and service delivery, and it is occurring within the boundaries of priorities that are defined through non-participatory processes. Setting up of community health structures, decentralization and community financing are three important strategies used for promoting participation and accountability within reforms. The scant evidence on the impact of these strategies suggests that marginalized groups and sexual and reproductive rights based groups are poorly represented in the forums for participation, and that hierarchies of power between and amongst health personnel and the public play out in these forums. Community financing has not lead to enhanced service accountability. As a result of the above limitations, community participation in health sector reforms has rarely strengthened accountability with respect to provision of comprehensive SRH services. In this context, rights (including sexual and reproductive) based groups and researchers need to engage with design, monitoring and evaluation of health sector reforms, both from inside as participants and outside as pressure groups. Participation contracts enhancing powers of civil society representatives, quotas for participation (for women, other marginalized groups and rights-based organizations), and investment in capacity building of these stakeholders on leadership and sexual reproductive rights and health are pre-requisites if participation is to lead to health and SRH service accountability. Community participation and service accountability hence requires more and not less investment of resources by the state.     

我国城乡卫生投入公平性的影响因素及其对策

从卫生筹资结构和财政体制角度分析了导致城乡卫生投入不公平的原因。卫生筹资过度依赖个人,各级政府财力不均,农村卫生发展主要靠县级财政,以及现有转移支付难以保障农村卫生投入。提出了强化政府作用、完善保障制度、合理划分各级政府的事权、增强中央政府在农村卫生筹资中的作用以及调整转移支付内部结构、增加专项补助和过渡期转移支付所占比重、改善城乡卫生投入公平性的建议。