Strengthening primary care in weak primary care systems
Prof. Peter P. Groenewegen
NIVEL – Netherlands Institute for Health
Services research

• Strong primary care is …..
• The need to strengthen primary care
• How weak primary care systems strengthen primary care
- Western Europe
- Eastern Europe
• Social Health Insurance systems, but different conditions

• A generalist approach
• The point of first contact with health care
• Context-oriented
• Continuity
• Comprehensiveness
• Co-ordination
Simple single indicator: gatekeeping GPs

Demand side challenges
• Multiple health and social problems
• Increasing and changing health care needs
• Better educated, more demanding patients
• People live longer, stay longer at home
Supply side challenges
• Organization: teams, networks, single practices
• Manpower: limited work force, more part-time work
• Incentives: regulation, payment
• Shifts from hospital to primary care

Multiple health and social problems

• Better health outcomes
• Good quality care
• Lower costs
• Better opportunities for cost containment
• Better opportunities for monitoring health, health care utilisation, quality, and preparedness

Stronger:
• UK
• Denmark
• Spain
• Netherlands
• Italy
• Finland
Weaker:
• Portugal
• Belgium
• Greece
• Germany
• Switzerland
• France

Weak primary care systems in
Western Europe
• (mainly) Bismarckian systems: Belgium,
France, Germany
• Small scale primary care, GP practices
• Strong emphasis on freedom of choice
• Demand channeling via co-payments

Organisation of primary care:
Transformation from cottage industry to modern community health service

Policy changes to strengthen primary care
Weak incentives and voluntary basis
• Germany: GP model
(‘Hausarztmodelle’)
• France: preferred doctor scheme
(‘médecin traitant’)
• Belgium: capitation
(‘forfaitaire betaling’) and medical file (‘globaal medisch dossier’)

Germany: GP model
(‘Hausarztmodelle’)
• Based on individual contracts between insurers and GPs
• Patient list; referral system; patients may switch once a year
• Appr. one fifth of publicly insured (2007)
• Incentive for patients: lower copayment
• Incentive for GPs: additional reimbursement, registration fee
• Effects seem to be very small

France: preferred doctor scheme
(‘médecin traitant’)
• Patient list and personal medical record
• Referral system
• Covering appr. 80% of the French (2007)
• Patient incentives: higher reimbursement
• Doctor incentives: capitation for follow up of certain chronic diseases; income loss compensation for some specialties
• Little information about effects

Belgium: medical file
(‘globaal medisch dossier’)
• If patients choose to be with one GP (or practice), their GP can keep their medical file
• Incentive for patients: lower level of costsharing when they visit the GP who keeps their medical file
• Incentive for GPs: fixed amount per year

(‘forfaitaire betaling’)
• Capitation fee for listed patients
• Mainly with group practices and health centres in more deprived areas
• 80 practices and 165.000 insured (2007)
• Incentive for patients: no cost-sharing
• Incentive for GPs: capitation
• Lower prescriptions, referrals and hospitalisations, more prevention

• State funded, parallel systems
• Salaried employees, large policlinics, specialist orientation, underdeveloped primary care system
• No patient choice of provider
• Strong role of government, central planning, command-and-control

• From state funding to Social Health
Insurance: back to Bismarck
• From state provision to privatisation
(especially primary care)
• From allocated care to more patient choice
• From centralised role of government to shared power

Gatekeeping in former communist countries
• Primary care as starting point for reforms
• Introduction of gatekeeping
• Training of GPs
• Retraining of district doctors, paediatricians, gynaecologists

Former communist countries with stronger and weaker primary care
Former Soviet Union – non EU
• Belarus – non gatekeeping
• Georgia - non gatekeeping
• Kazakstan - non gatekeeping
• Moldavia - non gatekeeping
• Ukraine - non gatekeeping
Current EU member states
• Bulgaria – gatekeeping
• Czech Rep. – direct access if costs paid privately
• Estonia - gatekeeping
• Hungary - gatekeeping
• Latvia - gatekeeping
• Lithuania - gatekeeping
• Poland – direct access if costs paid privately
• Romania - gatekeeping
• Slovakia – direct access if costs paid privately

Training and retraining GPs in Lithuania: activity (numbers, scale score)
1994 district therapists
1994 district paediatricians
20,8 Contacts
(office + home visits)
Medical technical procedures
Management and follow up of disease
19,4
1,10
2,40
1,04
1,55
2004 retrained district therapists
28,4
2004 retrained paediatricians
30,1
2004 newly trained
GPs
23,4
1,51
2,71
1,35
2,41
1,36
2,41

Training and retraining GPs in
Lithuania: prevention (%)
High blood pressure
1994 district therapists
90,6%
1994 district paediatricians
24,1%
2004 retrained district therapists
88,6%
2004 retrained paediatricians
83,7%
2004 newly trained
GPs
76,0%
Blood cholesterol
39,4
Smoking 6,6
8,6
9,7
42,0
9,1
40,8
8,2
22,7
1,3
Alcohol 7,2 11,3 7,4 10,2 1,3

• Urgency of reform in transitional countries
• Past experience of low patient choice versus strong ideology of patient choice
• (Ambulatory) medical specialist opposition in Western European SHI systems

Upcoming policies and problems
Bismarckian systems
• Disease management
• Vertical systems
• Performance payment
--------------------------------
Transitional countries
• Patient choice
• Prevention
--------------------------
Weak incentives
PD  list system 
Strong incentives profiling  P4P
GP model  individual contracts  benchmarks

Unintended consequences of P4P?

• Strengthening primary care: Important differences in context and national strategies
• Weak incentives and voluntary basis: Is it enough?
• How to convince governments, doctors, insurance organisations, patients of the urgency?
• How to balance paternalism and patient choice?
• EU-countries provide a laboratory for comparative research