SEMINAR ON PHC NICOSIA UNIVERSITY

1. SEMINAR ON PHCNICOSIA 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

4. Primary Health Care in Cyprus Primary Health Care in Cyprus (Dr. Andreas Polynikis, M.D, MPH, Chief Medical Officer of the Ministry of Health, 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.

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

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

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.

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)

10. Source: World Health Statistics 2008, WHO

11. The Health Care Delivery Dynamic INPATIENTDAY PATIENT DAY PATIENT OUTPATIENT OUTPATIENTOFFICE OFFICEHOME CARE HOME CARESELF CARE

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. 19IN THE PROCESS

15. PHC AND NHIS PHC TODAY • PUBLIC SECTOR • PRIVATE SECTOR

16. PUBLIC SECTOR PROVIDES • ALL LEVELS OF PHC HEALTH CARE, HEALTH PREVENTION,HEALTH EDUCATION AND PROMOTION

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

18. Main PHCCs Subcenters • 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 235 SUBCENTERS OVER CYPRUS * 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

25. (common with allied health professionals) ü Team decision The initiatives should be piloted in a big, urban PHCC in Nicosia Criteria Aglantzia PHCC Lakatameia PHCC Strovolos PHCC 1 Number of GPs 5 5+1 part-time 6 2 Number of nurses 3 3 4 3 Number of administrative staff • 2 assistants • 1 messenger • 2 assistants • 1 messenger • 5 assistants • 1 receptionist • 1 messenger 4 Number of pharmacists • 2 pharmacists • 1 assistant pharmacist • 2 pharmacists • 1 assistant pharmacist • 3 pharmacists • 1 assistant pharmacist 5 Number of computers 6 (all doctors have personal PC) 1 0 6 Use of patient files ü ü Aglantzia was already used for a pilot before Source: MoH team

26. Services provided by MoH 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 ALIGNMENT WITH MINISTER PHCC network stays within MoH after implementation of NHIS Family doctor (FD) services (~85%) FD services provided by private initiative (unused space in PHCCs can be rented to private doctors) Other services* (~15%) Negotiation with HIO and CMA necessary 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) * Other services include: school services, mother and child services, community nursing, community mental health, and dental services Source: MoH team

27. 6 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) 2 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 3 The subcenters do not offer significant prevention and health promotion services, which are basic primary health care objectives Our doctors, pharmacists and nurses can be utilized in a better and more impactful way The current sub-center concept has significant disadvantages Infrastructure 1 • 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 Operations 4 Some subcenters are overcrowded because there is no appointment system and a lot of patients visit the subcenters without real need 5 Patients do not have the opportunity to be seen by the same doctor since a different doctor visits the subcenter every time Coverage 7 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 8 There is almost no sufficient primary care coverage, since subcenters are open only once/twice a week, or once every two weeks 9 Coverage by subcenters is not uniform, since only 65% of all villages have subcenters (235 out of ~361* villages) covering ~72% of the population 10 Up to 32% of the team’s working time is wasted travelling * Estimate (~401 municipalities/communities in Cyprus – ~40 urban/suburban municipalities, and communities with PHCCs) Source: MoH PHCC team; CYSTAT

28. 41 Transition period required for full implementation The team recommends that sub-centers be discontinued and that an alternative solution be offered to selected rural villages Team recommendation Option 1 Option 2 Option 3 Current No alternative Alternative Current No alternative Alternative Current No alternative Alternative • 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 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 • Discontinue all subcenters • Do not provide alternative solution for any subcenters Impact • 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 • Medical personnel travel time reduction of 24 FTEs • Opportunity cost reduction EUR 1 million per year Political cost * A one-by-one examination of subcenters can be done at the implementation stage using more detailed criteria Source: MoH team

29. The community nurse can provide basic care and facilitate prescriptions, which is the primary reason patients visit sub-centers Appointment Scheduling Planning Visit Follow-up • 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 • If patient has any questions or concerns, he/she can contact doctor or pharmacist * The local authorities will be responsible to retain/improve/ maintain adequate space at their own cost Source: MoH team

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

48. HCS in Cyprus IMPLEMENTATION • 4 YEARS?? 2006 ΠΑΡΕΧΕΙ ΥΠΗΡΕΣΙΕΣ • HEALTH CARE REFORMS • HISS • Training of GPs • Reorganization of MOH • Reorganization of Government Hospitals • Harmonization of Private Clinics with the law • Development of DRGS • Regulations • Training – Continuous Medical Education

49. HCS in Cyprus Reimbursement of the Providers 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 15%

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