SEMINAR ON PHC
NICOSIA UNIVERSITY
ANDREAS POLYNIKIS MD, MPH
CHIEF MEDICAL OFFICER
MINISTRY OF HEALTH
7 MAIOY 2007
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

2
3/16/2016
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)
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.
5
3/16/2016
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
6
- Increased equity and access
3/16/2016
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
3/16/2016
7
strategy
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.
8
3/16/2016
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)
9
3/16/2016
Range
Average
European
Region
High/Low
Doctors/ 1000 Population
2002 – 2006
0.3 - 5.0
3.2
High: Greece
Low: Bulgaria
Nurses/ 1000 Population
2002 – 2006
2.9 – 19.5
7.8
High: Ireland
Low: Turkey
Pharmacists/ 1000 Population
2002 - 2006
<0.1 – 1.1
0.2
High:
France/Finland
Belgium
Low: Several
Total Expenditure on Health as %
GDP
2005
3.9 – 11.4
8.6
High: Switzerland
Low: Kazakhstan/
Azerbaijan
19.5 – 90.7
74.3
High: Luxembourg
Low: Georgia
Per capita expenditure on health
– 5,521
1,649
Source: World Health106
Statistics
2008, WHO
International
$ PPP 2005
10
High: Luxembourg
Low: Tajikistan
3/16/2016
Government expenditure on health as
% total health expenditure 2005
THE HEALTH CARE DELIVERY DYNAMIC
11
INPATIENT
DAY PATIENT
DAY PATIENT
OUTPATIENT
OUTPATIENT
OFFICE
OFFICE
HOME CARE
HOME CARE
SELF CARE
3/16/2016
HOW IS THE CASE IN
CYPRUS TODAY
CHALLENGES
 AGING
 TECHNOLOGY
 NEW PHARMAEUTICALS.
 ADVANCES IN PROVISION
 INCREAS EXPECTATIONS
 HEALTH CARE REFORMS
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.
19 IN THE PROCESS
PHC AND NHIS
PHC TODAY
•PUBLIC SECTOR
•PRIVATE SECTOR
PUBLIC SECTOR
PROVIDES
 ALL LEVELS OF PHC
HEALTH CARE, HEALTH
PREVENTION,HEALTH
EDUCATION AND PROMOTION
16
3/16/2016
HCS in Cyprus
Β. ΙΔΙΩΤΙΚΟΣ ΤΟΜΕΑΣ




75 ΙΔΙΩΤΙΚΕΣ ΚΛΙΝΙΚΕΣ
1500 ΙΔΙΩΤΕΣ ΙΑΤΡΟΙ
ΚΥΡΙΩΣ solo practices
ΤΟΥΡΙΣΜΟΣ ΚΑΙ ΥΓΕΙΑ
Lack of Standards and Protocols.
235 SUBCENTERS OVER CYPRUS
Main PHCCs
Subcenters
• Each PHCC covers up to 18
subcenters*
• Team of GP, nurse and pharmacist visits 1-6 subcenters per day
• Subcenters are a ≤ 30 min drive
from the PHCC
* 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
18
Doctors per specialty offering primary care
300
250
247
236
233
206
200
149
150
100
149
147
133
124
95
84
50
89
41
38
25
Total
Private Sector
Other Specialties
Paediatrics
Internal Medicine
Cardiology/Internal Medicine
Doctors with no specialty
General Medicine
0
Public Sector
19
Age distribution of the doctors per specialty
300
250
200
150
100
50
0
Private
Public
Total
Private
INTERNISTS
Public
Total
CARDIOLOGISTS
<35
36-45
46-55
Private
Public
Total
GENERAL PRACTITIONERS
56-65
>66
N/A
Private
Public
Total
NO SPECIALTY DOCTORS
Total
20
942; (43%)
1250; (57%)
Total Specialists
Total GP's + pediatricians
21
Public sector expenditure on health
as % of GDP, WHO estimates
9
Austria
Belgium
Bulgaria
Cyprus
Czech Republic
Denmark
Estonia
Finland
France
Germany
Greece
Hungary
Ireland
Italy
Latvia
Lithuania
Luxembourg
Malta
Netherlands
Poland
Portugal
Romania
Slovakia
Slovenia
Spain
Sweden
United Kingdom
EU
8
7
6
5
4
3
2
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
Private sector expenditure on health as
% of GDP, WHO estimates
6
Austria
Belgium
Bulgaria
Cyprus
Czech Republic
Denmark
Estonia
Finland
France
Germany
Greece
Hungary
Ireland
Italy
Latvia
Lithuania
Luxembourg
Malta
Netherlands
Poland
Portugal
Romania
Slovakia
Slovenia
Spain
Sweden
United Kingdom
EU
5
4
3
2
1
0
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
The initiatives should be piloted in a big, urban PHCC
in Nicosia
Criteria
Aglantzia PHCC
Lakatameia PHCC
Strovolos PHCC
5
5+1 part-time
6
3
3
4
• 2 assistants
• 1 messenger
• 2 assistants
• 1 messenger
• 5 assistants
• 1 receptionist
• 1 messenger
Number of
pharmacists
• 2 pharmacists
• 1 assistant pharmacist
• 2 pharmacists
• 1 assistant pharmacist
• 3 pharmacists
• 1 assistant pharmacist
Number of
computers
6 (all doctors have
personal PC)
1
0
1
Number of GPs
2
3
4
5
6
Team
decision
Number of
nurses
Number of
administrative
staff
(common with
allied health
professionals)
Use of patient
files
Aglantzia
was already
used for a
pilot before
Source: MoH team
25
With NHIS, all 41 PHCCs will continue to offer non-FD
ALIGNMENT WITH MINISTER
services while 25 PHCCs in areas with insufficient private doctor coverage will
also offer public FD services
Services provided by MoH
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%)
16 PHCCs in areas with high
private doctor coverage
25 PHCCs in areas of low/no
private doctor coverage
Negotiation
with HIO and
CMA
necessary
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
26
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
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
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
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)
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
Our doctors, pharmacists
Up to 32% of the team’s working time is wasted travelling
and nurses can be utilized
in a better and more
impactful way
Coverage
10
* Estimate (~401 municipalities/communities in Cyprus – ~40 urban/suburban municipalities, and communities with PHCCs)
Source: MoH PHCC team; CYSTAT
27
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
235
235
148
Current
Impact
Option 3
87
No
Alternative
alternative
235
194
Current
235
41
No
Alternative
alternative
• Discontinue all subcenters
• Do not provide alternative solution
• 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
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
0
Current
No
Alternative
alternative
• Discontinue all subcenters
• Do not provide alternative solution
for any subcenters
• Medical personnel travel time
• Medical personnel travel time
• Medical personnel travel time
reduction of 24 FTEs
• Opportunity cost reduction EUR 1
million per year
reduction of 24 FTEs
• Opportunity cost reduction EUR 1
million per year
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
Transition period
required for full
implementation
28
The community nurse can provide basic care and facilitate prescriptions,
which is the primary reason patients visit sub-centers
Appointment
Scheduling
• Patient calls nearest • PHCC schedules
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
Planning
• CN checks with
Visit
• If prescription is
appointment in
doctor whether
approved,
system
prescription should
pharmacist at PHCC
• CN of PHCC is
be renewed
dispenses drugs
notified
• Patient’s medical
• CN brings drugs to
• If specific CN is not
history is available to
patient during visit*
available, CN from
CN and doctor in the
and provides help
closest PHCC is
system
with patient’s
notified
pharmaceutical
• CNs at PHCCs are
regimen
connected to
• CN checks patient
coordinate staffing
(e.g., blood pressure
for visits (e.g. in case
etc.)
of vacation or
• CN handles
sickness)
emergency
prescriptions
* The local authorities will be responsible to retain/improve/
maintain adequate space at their own cost
Source: MoH team
Follow-up
• If patient has any
questions or
concerns, he/she
can contact doctor
or pharmacist
29
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
Distribution of household
gross annual income
%
20
18
16
14
12
10
8
6
4
2
0
Under
5,000
7,001- 11,001- 15,001- Over
9,000 13,000 20,000 25,000
Gross Income
Income group composition
17%
10%
27%
46%
A-B
C1
C2
D-E
Type of doctor visited by each age group
(heads of household only)
80
70
60
50
% 40
30
Government
Private
Union
20
10
0
18-29
30-49
50-64
Age
65+
Type of doctor visited by each geographical region
60
50
40
% 30
Government
Private
Union
20
10
ph
os
ag
m
Fa
Pa
us
ta
a
rn
ac
La
as
so
l
m
Li
N
ic
os
ia
0
Type of doctor visited by each income group
80
70
60
50
% 40
Government
Private
Union
30
20
10
0
A-B
C1
C2
Income Group
D-E
Type of doctor visited by annual income
80
70
60
50
Government
Private
Union
% 40
30
20
10
0
Under
5,000
7,0019,000
11,00113,000
15,00120,000
Over
25,000
Top 10 reasons for visiting the doctor
Cold/Flu
Routine Check
Blood pressure
Gyn check-up
Diabetes
GI problems
Dermatological
Injury
Routine infant check
Difficulty moving
Other
Top 7 Specialists Visited







Internist/GP (40%)
Pediatrician (19%)
Ob/Gyn (8.5%)
Orthopedics (7.5%)
Cardiologist (6%)
Ophthalmologist (4%)
Other (15%)
Self-Reported Health Status
od
go
N
ot
So
So
d
oo
G
od
go
y
V
er
ce
lle
nt
Ex
%
40
35
30
25
20
15
10
5
0
Out-of-pocket health expenditures as share
of household income, 2002
Mean out-of-pocket payments as share of household income
(sub-sample: those who report any utilization)
7.0%
6.4%
5.7%
6.0%
4.6%
5.0%
3.8%
4.0%
4.1%
3.0%
3.0%
2.6%
2.5%
2.6%
2.0%
1.0%
0.0%
<5,000
5,0007,000
7,0009,000
9,000- 11,000- 13,000- 15,000- 20,000- 25,000<
11,000 13,000 15,000 20,000 25,000
Annual household incom e
Source: Hsiao & Jakab, 2003
Likelihood of Using Public or Private Physician for
minor injury
Would you go to a public or private
doctor for minor illness?
Alw ays to public
1
0.8
Nearly alw ays to public
0.6
Sometimes to public
0.4
Rarely to public
0.2
Never to public
0
1992
1996
2002
Source: Hsiao & Jakab, 2003
Proportion of the population with a personal
doctor in each geographical area
72
70
68
66
64
62
60
ph
os
ag
m
Fa
Pa
us
ta
a
rn
ac
La
as
so
l
m
Li
os
ia
58
N
ic
% with Personal Doctor
74
Type of personal doctor chosen by income level
100
90
80
70
60
% 50
40
30
20
10
0
Under 7,001- 11,001- 15,001- Over
5,000 9,000 13,000 20,000 25,000
Income
Governmental
Private
Union
Type of personal doctor chosen in 4 income
groups
100
90
80
70
60
% 50
40
30
20
10
0
Governmental
Private
Union
A-B
C1
C2
Income Group
D-E
Average time it takes to get to the GP:
Private vs. Government
8,27
9
8
7
6
5
Mean Time
4
3
2
1
0
0,65
Government
Private
Type of GP
HCS in Cyprus
NHIS

Law: 89 (I)/ 2001

Law: 134(I) /2002
Provision for the introduction of General
Insurance Health Scheme in Cyprus.
HCS in Cyprus
IMPLEMENTATION
4 YEARS?? 2006 ΠΑΡΕΧΕΙ ΥΠΗΡΕΣΙΕΣ
 HEALTH CARE REFORMS
a) HISS
b) Training of GPs
c) Reorganization of MOH
d) Reorganization of Government Hospitals
e) Harmonization of Private Clinics with the law
f) Development of DRGS
g) Regulations
h) Training – Continuous Medical Education

HCS in Cyprus
Reimbursement of the Providers
Primary H.C.:
 Capitation Fee (85%)
 Good Practice
 Filling Targets
15%
 Environment Provision
Secondary H.C.:
 Out- Patients Specialists: Fee for Services
 Hospitalization: DRGS
 Casualties: Grant Blocks
LAW 89(I)/2001
LAW 134(I)/2002
 General Practitioners
PROVISION FOR
 Other Specialists
 Pediatricians
Provision of care
GPs Provide health care to all
enrolled on their list.
24 hours coverage
provision to change the GP
Reimbursement of GPs
 Capitation fee (75%)
 Experience, good
practice, preventivepromotive programs
(25%)
Performance Measurement
Systems
 Accreditation
 Certification
 Utilization Management
 Peer Review
 Indicators
 Clinical Practice Guidelines and
Paths
 Report cards
 Productivity Profiles
Drs practicing general
medicine
 Physicians
 GPs
 Registered Medical
Practitioners
 Cardiologists
 Other internal subspecialties
Pediatricians: responsibility for the
children under 15 years of age.
LAW 89(I)/2001
LAW 134(I)/2002
 PROVISION FOR
General Practitioners
 Other Specialists
 Pediatricians
Provision of the law
 Records keeping
 Denied backward referral
 Measurement of the
performance
 Incentives for group practice
 Committee of Medical Audit.
 Safeguard of ownership of
Government medical institutions
Provision of the law (II)
 Adequacy
and satisfactory
condition of waiting and
examination rooms - spaces
for records keeping
 adequacy and satisfactory
condition of the necessary
medical equipment.
GPs List Size
 First 3 years (300)
 After 3 years (500)
 Maximum 2500
 Geographical
Restrictions???
Provision of care
 GPs Provide health care
to all enrolled on their
list.
 24 hours coverage
 provision to change the
GP
Provision of Care
 Medical Care
 Diagnostics, Laboratories
 Drug Prescriptions
 Home Visits.
Referrals
 Casualties direct access
 Agreed certain cases for
direct access to specialist
care
 Denied reimbursement for
direct access.
Setting up partnership
 incentives for the establishment of
partnerships
 Group practice
 subsidy for the construction or
acquisition of buildings
 subsidy for medical equipment
 subsidies for employing nurses and
other healthcare professionals
Medical Audit Committee
 Establishment of a medical audit
committee.
 for the purpose of securing high
standard of medical care and the
taking of suitable measures in
relation to particular cases for not
exercising reasonable skill or
attention on behalf of the supplier.
Performance Measurement
Systems
 Accreditation
 Certification
 Utilization Management
 Peer Review
 Indicators
 Clinical Practice Guidelines and Paths
 Report cards
 Productivity Profiles
Government Institutions
The Government shall take all the
necessary steps, so that the medical
institutions are updated in the
sectors of organization,
administration, management,
equipment and functioning costeffectively.
CONCLUSIONS
 Most countries have a sound health policy incorporating a well
articulated role for PHC. Weaknesses are not in the ‘what to
do’ but in the ‘how to do’ – the capacity to manage change
 PHC system design and implementation must also take account
of differing historical, developmental, social, cultural,
professional and other important issues – differing futures
 The future development of PHC in CYPRUS will need clear
66
principles not models; pragmatism and flexibility not polemic; a
deeper understanding of underlying health system histories,
culture and strategies and capacities for change in differing
3/16/2016
countries
POSTSCRIPTS
“Despite constantly rising health expenditures in European countries,
the health needs of growing subgroups of the population, such as
the chronically ill, the elderly and those in need of hospice
services in their homes, are not well met Over the past years these
needs have changed quantitatively and qualitatively and they will
continue to do so, as a result of the epidemiological transition
related to the ageing of populations and the general
increase in wealth in most countries.” (Boerma W. 2006)
Professor Alan Maynard continues to point out there are many simple
evidence-based and cost-effective health care interventions (many of
which relate to chronic disease management and the primary care
level) which are still not in common usage throughout international
health systems, even those with major resourcing problems.
67
3/16/2016
Finally…
 We all are suffering from a terminal sexually
transmitted disease called life. Death is
inevitable
 The role of doctors and health care managers is
to use society’s scarce resources efficiently
(EBM)
 Inefficiency is unethical as it deprives potential
patients of care from which they could benefit.
 Finally Voltaire remarked “ the role of the
doctor is to amuse the patient as nature takes its
course”!
Linchpins for Connectivity: Physician Offices Targeted
Source: Fitzgibbons, Steve “The health.net Indus try”
Hambrecht & Quist, January 1999
PHC AND NHIS
SUMMARY ΙΙ
•REFFERAL
•INFORMATION SYSTEM
•GROUP PRACTICE
•CME
•PCH TEAM
•SMART CARD