Primary Health Care in the NIS:
History and Current Situation

  
An Overview

By Zoya Shabarova

A. Primary Health Care: Overview of Definitions
  1. Primary Health Care: WHO (Alma-Ata) Approach

    Since mid-1970s, concept of Primary Health Care (PHC) has become an object of close attention on the part of the international community and health care services. One of the reasons for such an attention was the emergence of many new independent states, which liberated themselves from the colonial dependence, worldwide. It was the concept of PHC which, in WHO opinion, could become the backbone for development of national health care systems in those developing countries. After 1978 International Conference on Primary Health Care (Alma-Ata, USSR) which was organized by WHO and United Nations Children's Fund, primary health care (PHC) was defined as the main vehicle for attaining WHO strategic goal - to ensure the state of complete physical, spiritual, and social well-being of all world nations by the year 2000.

    According to Alma-Ata Declaration, PHC includes at least the following:

    (Report on the International Conference on Primary Health Care, Alma-Ata, USSR, September 6-12, 1978; WHO, Geneva, 1978).


  2. Primary Health Care: "Broad" and "Narrow" Definitions;
    Primary Health Care and Basic Health Services

    In a narrow sense, the concept of PHC implies health care only. In the broad sense, this concept comprises health care along with health education, disease prevention, and sanitation. PHC not only provides population with the initial access to the medical profession, but also acts as a basis for integration of activities of medical, educational, and economical forces with efforts by individuals and communities.

    According to WHO concept, PHC lays emphasis on a patient's health promotion, disease prevention, adaptation of the technologies to help people maintain their habitual lifestyle in their habitual environment as long as possible, and integration of all aspects of PHC.

    The essence of the difference between the WHO concept of PHC and the concept of basic health services is that PHC is a process concerned with equity, intersectoral action, community participation and involvement for securing health gain.

    PHC is not merely the professional delivery of medical care at local level. Involvement means that individuals and families assume responsibility for their, and the community's health and welfare and develop the capacity to contribute to their own and the community's development. The WHO concept of PHC assumes that investment in this process of PHC is more efficient, effective, acceptable and sustainable than other ways of promoting health gain within local communities.

    (Terminology for the WHO Conference on European Health Care Reforms. WHO, Regional Office for Europe. Copenhagen, 1996)

  3. Primary Health Care, Secondary Health Care and Tertiary Care

    Primary Health Care. It is the first level of contact with people taking action to improve health in a community. The concept of PHC world-wide has been transformed by the WHO policy of health for all. This defined PHC more broadly than hitherto and saw it as integral part of social and economic development.

    As the central part of health for all strategy, PHC is an essential part in making health care accessible at a cost the country can afford, with methods that are practical, scientifically sound and socially acceptable.

    At the very least it should include education for the community on the health problems prevalent and on methods of preventing health problems from arising or of controlling them; the promotion of adequate supplies of food and proper nutrition; sufficient safe water and basic sanitation; maternal and child health care, including family planning; the prevention and control of local endemic diseases; appropriate treatment of common diseases; and the provision of essential drugs.

    WHO sees PHC as the central function and the main focus of a country's health system.

    Secondary Health Care: Hospitals and outpatient specialist clinics, to which people go after referral from PHC services. These services are generally more specialized and farther from where people live. The principal difference between primary and secondary services is in the range and specialization of the staff available.

    Tertiary Care: Specialized care which offers a service to those referred from secondary care for diagnosis or treatment and which is not available in primary or secondary care. This kind of care is generally only available at the national or international referral centers.

    (Terminology for the WHO Conference on European Health Care Reforms. WHO, Regional Office for Europe. Copenhagen, 1996)

B. Soviet Primary Health Care system review
  1. General composition

    According to the Soviet Great Medical Encyclopedia, Primary Health Care (Primary Medical and Sanitary Care) is a set of medical, sanitary, and hygienic measures taken at the first (primary) level of population contact with the health care services (Great Medical Encyclopedia, 1982).

    In the USSR primary medical and sanitary care (primary health care) should been considered as a system of the following branches and services, ambulatory (clinic)-polyclinic services which include polyclinics, health stations (zdravpounkt), medical -and- sanitary units (MSU) (medsanchast'); ambulance and emergency medical services, obstetrical services; and, partly hospitals, where patients come themselves or are brought first. Feldsher stations and feldsher- midwife stations, catchment area hospitals in the rural areas also belong to primary health care institutions. Over 80% of all the patients start and complete their treatment within this system.

    Soviet primary medical and sanitary care system which is the main component of health care has gone through a complex and longlasting evolution closely connected with development of the Soviet health care.

    At the initial stages organization of primary health care was based on involving working people in health care and on creating a considerable network of medical stations (medpounkt) and health stations (zdravpounkt) both in cities and rural areas. Soon the wide scale development of ambulatory-polyclinic facilities, clinics (dispanser), ambulance and emergency medical services, sanitary- anti-epidemic services, maternal and child health care institutions began.

    The Soviet PHC system uses catchment areas, in which patients are assigned to internists and health centers based on their place of residence or place of work.

    The catchment area principle became the most important part of the activities of the basic components of primary health care organization in this country, such as ambulatory-polyclinic facilities (both affiliated to the hospitals or independent), located in cities or rural areas.

    Every physician catchment area provides integrated primary, social and specialized health care to the population of the area. Catchment area physician coordinates activities of medical stations (medpounkt) located on his territory and of their nursing staff, and of all those, who are engaged in sanitary and public activities in the area, as well as of physicians- specialists working at the ambulatory- polyclinic facility.

    Rural physician catchment areas function in a more difficult conditions due to the specificity of settings, peculiarities of the working and living conditions of rural population which results in provision of health care in stages. Rural physician catchment area is the first medical component in the system of health care provided to rural population. It is mainly responsible for the organization and rendering of primary care. The following health care facilities are located on the territory of the rural physician catchment area: catchment area hospital with an ambulatory facility or an independent ambulatory facility, feldsher-midwife stations, feldsher health stations, zdravpounkt at the state farms (sovhoz) and plants, maternity hospitals at collective farms (kolhoz), nursery schools for children. These institutions perform various activities in providing primary medical and sanitary care.

    PHC composition in urban and rural areas is shown on the scheme below:


    Polyclinic:
    State health care facility which provides ambulatory out-patient health care to the adults at the place of their residence.

    Medical and Sanitary Unit:
    City polyclinic or city hospital with polyclinic provides health care to the "blue-collar" workers of particular occupation (e.g. construction, transport, etc.)

    Children's (Pediatric) Polyclinic:
    State health care facility which provides ambulatory out-patient health care to the children from birth to 14 years of age included.

    Women's Consultation:
    Department of the polyclinic or maternity hospital which provides ambulatory out-patient Ob/Gyn health care.

    Houses of Sanitary Education:
    Sanitary education facility which provides administrative and methodological guidelines on health education to the health care facilities.

    Sanitary Epidemiological Service:
    Health care institution which develops, conducts and coordinates sanitary prevention activities.

    Feldsher and Midwife Station (FAP):
    Health care facility staffed with feldshers and midwifes which provides medical care, preventive and sanitary activities to the rural population.

    Ambulatory:
    Health care facility which provides out-patient medical care to patients at home or patients who can visit the health care facility.

    Feldsher Health Station (Zdravpounkt):
    Primary health care facility at the state farms, construction settings, etc.


  2. Analysis of the main components

    In the cities primary health care is provided at the place of a patient's residence (Polyclinic), at his place of work through medical territorial or work-shop areas, which belong to the territorial and plant polyclinics (Medsanchast').

    Primary care to children is provided mainly in the children's polyclinic according to the same principle of catchment area, and its fundamental method as in the rest of other institutions for treatment-and-prophylaxis is the regular medical examination .

    Specific ambulatory facilities - women's consultations are intended to provide primary health care to women. Regular medical examination method plays the leading part in their activity.

    Education of population plays a great part in the activities of medical personnel of both the physician catchment areas and the ambulatory and polyclinic institutions. They also guide and coordinate activities of houses of health education.

    The special place in the system of primary care is given to the ambulance and emergency medical services, as well as to some kinds of mobile health care service (home care). A vast network of institutions is created to provide ambulance service: ambulance hospitals, stations and facilities of ambulance and emergency care, which operate round the clock in the cities and rural areas.

    Mobile medical services, such as visiting teams of physicians, mobile ambulatory, laboratory, X-ray, dental and other facilities, as well as emergency medical units and units of planned counselling in oblast (kray and republican) hospitals with affiliated stations of sanitary aviation , perform various functions in rendering health care mainly to the rural population. Mobile services are created at central regional, oblast (kray, republic) and big city hospitals to provide screening of the population, regular medical examinations and high- quality treatment-and-consultative care.

    One of the major tasks of the primary care system is to carry out sanitary-hygienic and sanitary- antiepidemic activities, which in the Soviet Union was carried out not only by the medical personnel of the physician catchment areas and sanitary (public health) activists, but also by sanitary-epidemiological service. This service has the considerable network of health care institutions dealing with science and practice of medicine. It is responsible for working out drafts of state standards, sanitary norms and rules and other legislative documents to ensure sanitary protection of the environment, optimum conditions for work and life, physical development of the population, its nutrition, disease prevention. The staff of this service not only conducts sanitary surveillence , but also directly participates in sanitary and hygienic activities and prevention of epidemics.

    Hence, in the USSR the concept "Primary medical-and-sanitary care" should be interpreted as primary medical-and-sanitary care provided by a physician, combined on the state basis with all other forms of medical care to the population (Great Medical Encyclopedia, 1982).

  3. Conclusions

    In reality, the said Soviet concept of PHC had the following flaws:

    After the WHO Alma-Ata Conference, PHC concept has become a basis for development of health care in developing countries. The USSR has claimed to have an advanced system of PHC which, in reality, had a number of the said inconsistencies. The 1980s - the stagnation period - and 1990s - the USSR dissolution and emergence of the NIS - have weakened the existing PHC system still further.


C. Primary Health Care and the Health Care Reforms in the NIS

  1. West NIS

    Ukraine: Peculiarities of PHC and main directions of its reforming

    The last decades revealed a trend of excessive specialism in medicine which resulted in decline of catchment area physician's level of competency to such an extent that he is not able to do routine work of allied specialists regarding patient's treatment and diagnosis (to do eidoptometry, check auditory acuity, treat tonsillitis or external ear etc.). As a result of that, only 18-26% of those who visited catchment area physician finish their treatment at the same level vs. 70-75% in the World.

    Given the other countries' experience, Ukraine has decided to reform its primary health care to the population according the family physician concept as a model. It is a family physician who acts as a link in rendering health care to the population. He is expected not only to render health care to a patient, but also to assess the patient's personality and mental health. The latter is related to the problems of not medical nature only: that is largely related to housing, family's lifestyle, its well-being and so forth.

    The family physician's scope of responsibilities is substantially bigger than that of the catchment area physician, "narrow" specialist at the polyclinic, or, even that at the hospital. Family physician should actively identify the sick, have an eye for the family history, regard preventive care not only as prophylactic medical examination and follow-up, but also as his work with children, women, employees of enterprises, take into account risk factors and family health parameters, and so forth.

    The family physician's main responsibilities embrace rendering primary health care to all family members, namely:

    According to the May 1998 Resolution on "Directions of the Health care Reforms at the Oblast Level" made by the Ministry of Health Board, family physician approach to rendering health care to the population is one of the most effective and promising ways for organizing work of ambulatory (clinic)-polyclinic services.

    Example of Reform Project in Ukraine

    Family Health Care Experiment has been initiated in L'viv Oblast in 1988. Earlier, the concept of family health care and family physician's job description were worked out. Introduction of family health care was not completely smooth. There was certain lack of understanding of the innovation on the part of both health professionals and population. Ministry of Health support was not adequate. With that object in view, extensive educational activities regarding advantages of family health care were carried out among the population. There wasa necessity to persuade top officials at the Ministry of Health of Ukraine as well.

    Initially, primary health care under the family health care pattern was introduced at the City Polyclinic #2, L'viv. At the same time, at the said polyclinic, Drogobych City Hospital #1, Sambir, Yavoriv, and Zhovkiv Central Rayon Hospitals, the L'viv Medical University faculty carried out 200-hour in-service training courses on family health care for therapeutists, pediatricians, and other specialists. Issues of pediatric pathology, internal medicine, pediatrics, neurology, Ob/Gyn, surgery, otolaryngology, ocular diseases etc. were on the syllabus. At the Department of Continuous Education at the L'viv Medical University, 4-month, and now 5-month, courses on family health care were initiated. In 1998, two refresher courses on pathology in babies are being carried out for family physicians. For a long time the experiment stayed up due to the initiative of L'viv Oblast health professionals. In 1988, physicians of the L'viv City Polyclinic #2 gradually started rendering health care services to patients of 14 years of age and up, in 1992 they did that to patients of 7 years of age and up. In 1992, the Department of Family Physicians was organized at the Drogobych Central City Polyclinic. Employees of the City Hospital #1 followed the example of the L'viv City Polyclinic #2 creating 3 ambulatories of family physicians.

    In parallel with training of physicians, training of nurses was carried out. To provide highly qualified health care, the Medical University has organized the Department of Polyclinic Care using a polyclinic as its basis. In such a close cooperation, health practitioners, family physicians, and scientists work hand-in-hand.

    Given the importance of primary health care realized through the family physician approach, L'viv Oblast Administration supported the experiment and in 1993 the President's Official in L'viv Oblast has issued the Regulation "On Introduction of Primary Health Care through the Family Physician Approach in L'viv Oblast."

    With the subject of creating the health care system based on the principles of family medicine and advocating rights of L'viv Oblast family physicians, Association of L'viv Oblast Family Physicians was founded at the Constituent Assembly in November 1995. Now the Association enrolls 150 members. The Chair of Family Medicine at the Department of Continuous Education at the L'viv Medical University, first of its kind in Ukraine, was given functions of research and training center on family medicine issues.

    Nowadays, 118 physicians (38 pediatricians, and 80 therapeutists) work under the family physician pattern in L'viv Oblast; 40 of them render health care to their patients of 0 years of age and older. In 1995, the Board of Health Administration Headquarters at the L'viv Oblast Administration approved the Program for Development of Family Medicine, Model for the Outcomes of Family Physician's Activities, Interim Regulations On Family Physician, Department of Family Physicians and Nurses.

    Some results of family physicians' activities in the L'viv Oblast:

    Having approved the said L'viv Oblast experience in the primary health care reforms, the Ministry of Health Board identified transition to family physician approach in rendering of primary health care as a top-priority direction in the health care system reforms at Oblast level.

    Belarus: Peculiarities of PHC and main directions of its reforming

    Although the Belorussian health care system is in transition, main features of the old system can still be identified: funding and provision by the state with a central position of the hospitals, surrounded by polyclinics and smaller scale facilities. The main responsibility for all medical care, medical education and research , is with the Ministry of Health. The organization of health care is strictly geographical, according to the administrative structure; there are 13 regions (12 so- called Oblasts and the City of Minsk, which has a separate status); each region being subdivided by districts. The core facilities are the district hospitals, supported by a number of polyclinics rendering all kinds of specialist services.

    The primary health services are mainly provided by the so called health centers (zdravpounkt). In each settlement, which may vary considerably in the number of inhabitants, at every "selski soviet" there is at least one health center, where both curative and public health services are provided. Many health stations have a number of smaller feldsher-midwife stations (FAP) in villages, staffed with nurses or feldshers only. Especially in urban areas, there is a specialization in primary health care with pediatricians, gynecologists and catchment area physicians (internists) for children, women and adults respectively. In rural areas there are no gynecologists are absent in primary care and in the remote facilities internists also care for all age groups. Physicians are assisted by nurses, who are also in charge of all the paperwork. Community nursing or home care is virtually absent.

    The health care system has severely suffered from underfunding during the past decades; equipment is outdated, most premises are in a poor condition and there is a general lack of supplies. The level of competence of primary care physicians and the availability of equipment at their disposal are low; consequently they are hardly involved in diagnostics and treatments. Many patients are referred to the "narrow specialists" in polyclinics or hospitals. The system as a whole is highly inefficient and laborious.

    Example of Reform Project in Belarus

    In Krupitsy, which is a "selski soviet" 30 kilometers from Minsk consisting of 22 villages with a total population of 3,500 inhabitants, a modern health center has been created as a result of a joint project with two small cities in Germany and the Netherlands. In the years 1991- 1996 many volunteers from Krupitsy, Spelle (Germany) and Markelo (the Netherlands) and external experts supported by funds from TACIS have achieved the establishment of this model practice which can serve as a cornerstone in the further development of primary health care in Belarus.

    The project had the following major objectives:

    "improve the health care situation in the "selski soviet" (village) of Krupitsy by building a new health center and supporting the medical staff on introducing primary health care with general practice as a key element";

    Thus the project had two components: building new premises as well as running a health center, including the equipment and medical technical aspects, and including a program for the improvement of quality of care.

    The health center was opened on June 1, 1996 and is in full operation by now with medical personnel intensively trained in family practice in Western Europe. Since the opening of the center, step by step, new elements of primary care have been introduced such as out of hours care by the family doctors, a family planning program in order to increase the use of contraceptives and decrease the high abortion rate, rendering of minor surgery at the center, and a higher involvement of the doctors in treatment of common diseases. In 1997 the number of specialist consultations reduced by 50% as compared to the previous year; the number of patient contacts by general practitioners (GP) at the center increased by about 20%. An evaluation of the project showed satisfaction among the population; two- thirds of the respondents in a survey answered that the health care had been improved since the opening of the center. As the health center is a part of the regular health care organization, the Regional Health Care Administration of the Minsk Oblast are also involved and become more and more interested in this model of care.

    This resulted in a seminar on family medicine in October 1997. The Health Administration of the Minsk Oblast have expressed their intention to create other 15 to 20 centers with a similar approach as the Krupitsy center. It is also important to note the growing interest of other doctors outside the Minsk Oblast (e.g. Vytebsk in the north-east and one of the Minsk suburbs)

    At present, there is a positive attitude towards primary health care development and further training of the family doctors in Belarus.

    A number of major issues, mentioned below, need to be addressed in the near future.

    Starting from what has been achieved in Krupitsy, the general aim of the NIVEL (Netherlands Institute of Primary Health Care ) Project "Going Ahead with Primary Health Care in the Minsk Oblast" is to further elaborate and implement, both in quality and quantity, family medicine-based primary health care in the Minsk Oblast. Supporting structures for education and training, quality improvement, professional development and research will be developed for future expansion of primary care to other Oblasts (Project Description: Going Ahead with Primary Health Care in the Minsk Oblast, March 1998, NIVEL).

  2. Russian Federation

    Russian Federation: Peculiarities of PHC and main directions of its reforming

    Russia has inherited the Soviet health care system that was designed to maintain universal and relatively equitable access to comprehensive services. Being theoretically emphasized on primary and preventive care, the system was built around a network of primary health care centers comprising over 20,000 feldsher stations, polyclinics, women's consultations, and 3,500 ambulatories. However, due to a lack of sufficient funds to support the comprehensive service, scarcity of incentives to stimulate efficiency and neglected health promotion, the rendering of health care in reality was emphasized on curative and inpatient care. In 1991, the Russian health care expenditures were broken down as follows (The World Bank, 1996):


    Figure 2: Rendering of Health Care at the Oblast Level (Population: app. 2-2.5 million)

    As a result, interventions mostly occur after a disease has been contracted and treatment deals with a delayed hospitalization. The medical practice is supply driven by and reflects availability of hospital beds and physicians. Aggregating 2.0 million in-patient beds, the state health care system comprises 12,000 hospitals including 4,700 community and


    district hospitals. The rendering of the health care services at the Oblast level is shown in Figure 2. There is a layer of federally financed institutions that account for less than 2 percent of hospital admissions. These are research institutes and university clinics.

    Primary Care Level Services:


    Secondary Care Level Services:

    The discrepancy between theoretical design and the way it works in practice has become especially transparent during the country's economic transition. With liberalized prices and financial responsibility given to the regions, health care spending become even more supportive to inpatient care with major allocations for personnel salaries, as first priority.

    To maintain balance between population needs for health care and available resources, the Russian Ministry of Health initiated efforts in reforming health care of which the, major elements are: improvement quality and productivity, restructuring health care delivery through reduction of hospitalization and providing more out-patient services, implementation of effective clinical protocols. These elements were subsequently formalized in the Governmental Program on the Health Care and Medical Science development in the Russian Federation adopted on November 5, 1997.

    One of the key efforts in reorganizing health care towards more out-patient services at primary level is development and enhancing role of a family practitioner. The teaching curricula of a family doctor has been adopted in medical schools, and a large number of regions in Russia started introducing the program. In 1996, the Health Minister Dr. Tatyana Dmitrieva reported on 400 family practitioners providing services to one million patients. To support the effort, a number of international organizations initiated assistance programs on primary health care improvement. The World Bank provided $82 million loan to implement Health Reform Pilot Project in Kaluga and Tver Oblasts. To increase the availability, range and quality of services provided by primary health care facilities and rayon hospitals, the World Bank also initiated the Medical Equipment Project with a total cost of $300 million. The project will finance medical equipment, related supplies and training, furniture, spare parts and maintenance equipment to targeted health care facilities in 34 administrative regions. The target facilities will comprise primary (polyclinics, women's clinics and feldsher stations) and secondary (rayon hospitals and maternity hospitals) health care facilities. It is expected that providing medical equipment to these facilities would increase the availability and range of health services they are able to provide and would contribute to providing more cost-effective diagnosis and treatment. This intervention would de facto redirect a significant part of the health care investment budget to lower level, more cost-effective providers.

  3. Central Asia

    Kazakhstan: Peculiarities of PHC and main directions of its reforming

    In Kazakhstan, as in most parts of the Former Soviet Union, the Government financed and delivered all social services, including health care. During the Soviet period, the Government made significant investments in infrastructure and personnel, creating an extensive network of health care institutions. The health care system emphasized access to primary health care, but over time the incentives in the system pulled an increasing share of resources to specialized health care facilities. The number of hospitals, hospital beds and specialized physicians grew steadily. By 1994, hospital admission rates exceeded 20 percent of the population, and the average length of hospital stay reached 17 days. Nearly 80 percent of the government health care budget was consumed by inpatient institutions.

    According to the Kazakhstan Health Committee report (1998) the main goal of the reform process is to strengthen primary care. This means to improve the material and clinical base to expand the range of clinical services and to increase health promotion.

    There are several components to strengthening primary health care:

    1. Change in the organization of primary care away from a vertical structure to a horizontal one that combines areas of first contact primary care: pediatrics, therapy, gynecology and obstetrics.

      In addition, other vertical structures should be included over time such as: family planning, sexually transmitted diseases, dermatology, oncology, tuberculosis, and psychiatry.

    2. Effective patient selection of their primary care provider through creation of a network of primary care facilities will allow choice and a public information campaign to educate and inform patients of the reform process in primary care.

    3. An investment program to improve the material base of primary care practices. This include better equipment and an improvement of the physical structure more conducive to providing comprehensive primary health care.

    4. An educational program that will improve the clinical capabilities of primary care which will decrease need in consultations by specialists and hospitalization.

    5. To improve health education and health promotion in primary care.

    6. New incentive based payment systems which allow choice of primary care providers, improve efficiency and productivity of primary care providers and create appropriate incentives for referrals to the more costly parts of the health care system: specialized diagnostic tests and hospitalization.

    7. A computerized information system which allows the health care managers to track patients from visits in primary care, to specialized diagnostic services, to hospitalization. The key component is to be able to link back the utilization of hospital and specialized outpatient services to the primary care unit.

    8. The development of a training system for health care managers that will allow primary care providers to operate under the new payment systems with greater management autonomy.

      According to the Kazakhstan Health Committee plan of action, the first goal is to create a unit of primary care that can deliver integrated package of first contact primary care services. This requires re-organization of the polyclinic system which consists of three separate vertical structures: pediatrics, internal medicine, and women's consultation. These three elements should be unified into a single unit , though a combination of mixed polyclinics or family group practices (FGP).

      The general staffing pattern for an FGP is: two therapeutists, two pediatricians, Ob/Gyn, nurses and a practice manager, however, these patterns should be adjusted to the overall plan for restructuring of primary care. The key concept of the reform is to create the new primary care unit which provides comprehensive primary care and which can expand their range of clinical services to include part of all of the existing vertical programs.

      The most important point is that the vertical programs will be replaced by a horizontal system of primary care that fulfills the commitments made in the Alma- Ata Declaration. Investment in primary care should be the first priority.

      The next step is developing a clinical training program: there are many components of the clinical training program - it is important to clarify the competing goals of reform of the medical education system.

      A short term goal is to create a strong system of primary care by unifying pediatricians, therapeutists, and Ob/Gyns into a clinical and economic unit known as FGPs. By combining these three specialties, a comprehensive system of primary care will be established. The next step is to expand the range of clinical services that an FGP can provide.

      The next step is the process of the introduction of new payment system based on the principal of capitation. FGPs will be paid by capitation based on the number of patients who enroll in their practices. Thus, patient choice determines the overall budget of the FGP.

      (Health Care Reform in Kazakhstan in the context of Alma Ata Declaration by Dr. T. Rachipbekov, Chariman of the Health Committee of Kazakhstan. Seminar on Primary Health Care Reform, Almaty, September 24-25, 1998)

      Example of Reform Project in Kazakhstan

      The objective of the USAID funded ZdravReform program in Kazakhstan is to improve the efficiency and quality of health care by restructuring the service delivery system to bring primary care back to the center of the health care system, developing new methods of paying health care providers, increasing the management and clinical autonomy of health care providers, and increasing the population's involvement in health care decisions.

      The focus of ZdravReform program in the two intensive demonstration sites in Zhezkazgan and Semipalatinsk Oblasts, is on the market-based approaches to health care financing and delivery. Key results to date are:

      A. Restructuring of the Service Delivery System to Emphasize Primary Care:

      • Formation of Family Group Practices: More than 150 independent primary care facilities, Family Group Practices (FGPs), have been established in Zhezkazgan and Semipalatinsk. These FGPs are located in the community rather than in specialized polyclinics, which has improved access to primary health care. Through the establishment of FGPs, USAID has created an alternative service delivery system, which is critical for increasing the proportion of health services provided by the primary care sector and improving the quality of primary care services.

      • Rationalization of health facilities: Excess hospital capacity and associated fixed costs have been reduced by closing or consolidating underutilized inpatient facilities and reducing staff. To date a 13 percent reduction in the total number of hospital beds has occurred in the Zhezkazgan health reform areas. Hospital rationalization is critical for making available resources to be allocated to improving the primary care sector.

      B. New Provider Payment Systems

      Health care facilities in the demonstration sites are funded according to services provided rather than by historical budgets based on capacity (size of the building, number of beds and staff).

      • Hospital Payment Reform. In Zhezkazgan, hospitals are financed by a system that is modeled after the United States Medicare's Related Group payment system. Hospitals receive payment for each treated case that reflects the average cost of treating cases in that diagnostic group. A database, currently containing more than 40,000 records of hospital cases, has been established to support the payment system.

      • Primary Care Payment Reform. In Zhezkazgan and Semipalatinsk primary care providers are paid a monthly per capita payment for each enrolled member.

        • In Zhezkazgan a fee schedule for outpatient specialty services has been developed, and primary care providers will eventually serve as "fundholders", purchasing outpatient specialty services for their enrolled populations.
        • In Semipalatinsk, a bonus system rewards or penalizes primary care providers for their performance according to indicators of quality and health status in their enrolled populations.

      C. Consumer Participation

      Through public awareness campaigns about the role of family physicians in health care, 50% and 25% of the population in the Zhezkazgan and Semipalatinsk intensive demonstration sites, respectively, selected and enrolled in the primary care provider of their choice. A major enrollment campaign is scheduled for December 1997 in Zhezkazgan.

      D. Decrease in Public Sector Responsibility for Pharmaceuticals

      Ninety percent of all pharmacies are now privately owned and operated in Kazakhstan. Market data show that a wider range of drugs are now available at lower cost to consumers.

      Next steps:

      In May 1997, the demonstration sites were affected by a merger of Zhezkazgan into Karaganda Oblast and Semipalatinsk into East Kazakhstan Oblast. This has resulted in additional opportunities to expand USAID's technical assistance in health care reform to cover a wider population group. The Government has established a Joint Working Group to analyze the achievements of the health reform program and to plan the expansion of successful strategies with USAID technical assistance.


    9. Transcaucasus

      Azerbaijan: Peculiarities of PHC and main directions of its reforming

      According to the World Bank review, as in other former Soviet republics, the concept of integrated primary health care has not been developed. There are many different settings at which patients may have their first point of contact. Typically, those in employment will go first to a facility at their place of work while others, including mothers and children, will go to facilities based on geographical areas with the choice dictated largely by proximity. Patients have free choice of physician.

      At village level there are FAPs (feldsher-midwife station), ambulatories and rural hospitals. In rural districts and cities there are central district (town) or municipal hospitals and polyclinics. Factories often have their own nurse practitioner unit or ambulatory.

      In rural areas the major problem is the lack of services in the most remote villages, especially in mountainous areas, although almost all villages have FAPs and are doctors ambulatories, which have physicians on the staff, in each catchment area. The principal problems now are - low quality of care, lack of drugs and medical supplies, deteriorating conditions of facilities and obsolete medical equipment.

      There is over capacity throughout the system, in terms of both staff and health facilities and in both urban and rural areas.

      The following activities were planned to reform the primary health care in Azerbaijan:

      • strengthening of PHC, development of prevention programs, support for the PHC Kuba Project, extension of the project to the other districts;

      • in Kuba - establishment of a cost- recovery mechanism in health facilities, creation of an exemption system for vulnerable population, introduction of fees for health services;

      Example of Reform Project in Azerbaijan

      The Kuba Project, supported by the World Bank, is based on the following principles:

      • Rationalization of the system. The district will have a more cost-effective and sustainable structure in which the number of hospital beds will be reduced and treatment will shift from an in-patient to out-patient basis.
      • Consolidation of facilities: all the specialized clinics (maternity, dermatology, oncology, tuberculosis, psychiatric, and children polyclinics) will merge with the central hospital and instead of 116 feldsher-midwife stations (FAPs), ambulatories and health stations there will be 15 out-patient health centers, each serving a catchment population of about 10 000.
      • A strong public sector will form the basis of the service, although it will work with a private medical initiative under community supervision. At the village level, private feldsher-midwife stations will be introduced along with state backed national programs, which will be financed by the government (immunization, MCH, etc.).
      • Practically all health costs will be shared between the state and the communities, which also implies wide community participation through co-management.

      Community involvement will be supported by the establishment of the following structures:
      Health Councils in every village, Health Committees in every Health Center catchment area (typically several villages), and District Health Advisory Boards.

      The health councils will consist of influential individuals, an accountant from a local enterprise, school teachers, other volunteers, and the village feldsher or midwife. The health committees at the health centers will include one or two representatives of each village in its catchment area. Both of these structures will act as linking bodies between the local population and health units and support joint-management and co-financing of the health system. The district health advisory board will include leading doctors and community representatives from Kuba town and members from each health center catchment area.

      Public involvement in management will include:

      • coordination of health related activities with health stations, district health administration and local district authorities;
      • joint planning of health activities;
      • identification of local health problems and solutions;
      • facilitating the work of private nurses and midwives;
      • health promotion.

      The public role in co-financing will include:

      • adoption of fee-for-service and participation in setting salaries for doctors and the medical staff;
      • establishment of drug funds;
      • raising capital funds;
      • development of an exemption system for vulnerable individuals. (World Bank Report)


      Armenia: Peculiarities of PHC and main directions of its reforming

      Health system in the country is in a process of continuous evolution and reform.
      A challenge is presented to Government, communities and other agencies to find effective approaches, strategies and resources to reform and revitalize it.

      Reorientation of the health care system towards primary health care (PHC) has been identified by the Government as a crucial component of the health care reform. For better management and to promote an integrated approach for preventive and curative services, the projects for control of intestinal diseases, acute respiratory infections and safe motherhood have been integrated in the Primary Health Care Project. UNICEF assisted the Ministry of Health to establish National Policy for certain essential drugs to be available at primarily health care level, provided equipment and drugs for outpatient facilities for effective care of leading causes of maternal, infant and child mortality and morbidity. In 1996, UNICEF provided assistance to a project by Ministry of Health and AMERICARE to train 180 health professionals (nurses and physicians) in the areas of integrated preventive, curative care and child development. Through the process of training and feedback, a minimal set of preventive services as part of healthy child care will be identified: basic management of three components have already been elaborated - healthy child, sick child and child development. Regional efforts are also being made in cooperation with WHO to develop the guidelines for integrated management of childhood illnesses for nurses.

      There are many unresolved issues around the PHC strategy to which answers will need to be formed in the coming years.

      Disease prevention services within PHC are needed. The basic package should include continued attention and support of a healthy child care and child development monitoring. Cost analysis of basic services should be initiated to identify resource gaps and to establish an effective monitoring system.

      UNICEF will continue to assist the Ministry of Health to improve health care through integrated preventive and curative measures. This will make the existing health system work more efficiently, improve the quality of services and help to overcome constraints for implementation of PHC as a base for achieving the national goals by the year 2000.

      Example of Reform Project in Armenia

      The main objective of the UNICEF Project in Child Care was:

      To develop and integrate preventive services including Growth Monitoring and Promotion (GMP) at a PHC level with community participation; and support and expand basic services for their further universalization.

      Strategies: The Primary Health Care project has been characterized by community involvement and intersectoral cooperation within the context of reforming and development of the health care system to improve the access and quality of health care. The management, accountability and sustainability of the project will be ensured by the following strategies:

      1. National commitment to promoting the rendering of high quality and acceptable integrated primary health care services;

      2. Establishment of system financing and budgeting mechanisms to redistribute existing resources in a cost-effective way and according to community needs;

      3. Decentralization of decision making mechanisms for the management of primary health care and target-oriented planning;

      4. The establishment of National Policy for certain essential drugs to be available at the primary health care level;

      5. Equipment of primary health care facilities for effective care of leading causes of mother, infant and child mortality and morbidity;

      6. Training of primary health care level staff to implement new concepts and interdisciplinary approach to a sick child; and professional upgrading through workshops, conferences and seminars;

      7. Establishment of information system with local analysis to measure program outputs, outcomes and impact;

      8. Public information and education mini-campaigns to ensure child survival, protection and development;

      9. Supporting individuals and establishment of various community groups to participate in designing and implementing various programs within primary health care.

      The health reforms planned by the Government in cooperation with World Bank should reduce the existing disparities in children and maternal health services between rural and urban areas, in terms of availability of the necessary number of trained personnel, availability of basic equipment and essential drugs, access to services and funding. The roles of preventive services and outpatient care will be emphasized in the development of a primary health care network.

      Elimination of certain diseases, sustained immunization coverage, and achievement of the goals in the field of child health will require stronger cooperation from primary health care workers, parents and the community at large.
      (World Bank Report)

    D. Conclusion

    Thus many NIS countries in the process of reforming their primary health care mainly follow the family physician model. The said model is actively supported by the WHO. We think that this approach has a number of significant limitations.

    The family physician is a new medical specialty in the NIS health care system. Several countries started to train family physicians as an experiment. However the status of the latter within the primary health care makes them in many respects isolated. The appropriateness of retraining pediatricians, internists, gynecologists and surgeons to become family physicians is the discussion point and is not indisputable.

    The catchment area principle and the catchment area physician concept are the core components of the primary health care system existing in the NIS. The catchment area physician (or feldsher in the rural area) is that first health care professional to whom the sick person comes first. The catchment area physician is trained in the specialty "patient care, internal medicine". He is qualified to provide primary health care to the adult population of his catchment area. The catchment area pediatrician provides primary health care to children from 0 up to 14 years of age residing in his catchment area and his medical specialty is "pediatrics".

    Those primary health care problems, which were discussed above, stem mainly from the organization of the primary health care system as a whole. Substituting a family physician for a catchment area physician will not solve the said problems, but will result in the appearance of a somewhat artificial superstructure over the existing system.

    We think that changes in the primary health care should be introduced through the reforming of the existing system, namely:

    The above list is the discussion point.

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