Report No. 32354-ECA Review of Experience of Family Medicine in Europe and Central Asia (In Five Volumes) Volume III: Bosnia and Herzegovina Case Study May 2005 Human Development Sector Unit Europe and Central Asia Region Document of the World Bank FMP Family Medicine Physician SITAP WB Social InsuranceTechnical Assistance Project FMSP Family Medicine Specialization Program STI Sexually Transmitted Illness FMT Family Medicine Team TA Technical Assistance GDP Gross domestic product THE Total Health Expenditure GP General Practitioner TOR Terms of Reference HE Health Expenditure UK The United Kingdom HIF Health InsuranceFund us The United States of America HI1 Health InsuranceInstitute USAID United States Agency for International Development HSEP Health Sector Enhancement Project VTS Vocational Training Scheme IDA InternationalDevelopmentAssociation WB The World Bank JICA Japanese International Cooperation Agency WBBHP The World Bank Basic Health Project in BIH MDG Millennium Development Goals WHO World Health Organization REVIEW OF EXPERIENCEOF FAMILY MEDICINE INEUROPEAND CENTRALASIA: BOSNIAAND HERZEGOVINA CASE STUDY CONTENTS ................... ............................................................................................................... 2 PhysicianTask Profile .................................................................................................................... 3 ........................................................................................................... 5 2.1. The Impact ofthe War Between 1992-1995.......................................................................................................... 2.2. Post-WarGovernanceArrangements. .............................. ....... 2.3. Economic Changes and Incre ..............................................................................................555 2.4. Changes inHealth Indicators ........................................................................................ 7 2.5. Backgroundto Bosnia and Herzego Prior to the War............................................................. 8 2.6. Health Expenditure in Bosnia and Herzegovina. ............................... 2.7. Reform Challenges inthe H e ..............................................................................................88 3. Key Legislative Changes and Health Reform Initiatives inthe BIHHealth System .................................................. 11 3.1. Key Legislative Changes inthe Federationof BIH.......................... .................... 11 3.2. Financing of the Health Systemand PHC inthe FBIH........................................................................................ 12 3.2.1. Collection. 3.2.2. Pooling..... .............................................................................................................................. 13 3.2.3. Health Expenditure Trends ................. 3.2.4. Out-of-pocket PaymentsinPHC ............................................................................................................. 15 3.3. Key Legislative Changes in RS . 3.4. Financing o fthe 3.4.1. Collection ............... 3.4.2. Pooling. 3.4.3. Health E 3.4.4. 4. Key DevelopmentsinPHC inFBIH........... Out-of-P 4.1, Organization of PHC in FBIH ............................................................................................................................. 19 4.2. Developmentof PHC Human Resources inFBIH ................................................................................... 20 4.2.1. UndergraduateTraining inFBIH.............. ............................... 4.2.2. 4.3. Key Changes inthe Delivery of PHC Services inFBIH........................................... Training of Health ManagersinFBIH............................... 4.3.1. Prescribing and Dispensing of Drugs inPHC...................................... PHC Gatekeeping,First Contact Function and Comprehensiveness ..... 4.3.2. 4.3.3. Role of PHC Nurses....... ..................................................................................................... 23 4.3.4. EmergencyOut-of-Hour Services................................... ........... .............................. 24 4.4. Resource Allocation for PHC in FBIH ................................................................................................................ 24 4.6. Infrastructure and Equipment at PHC Facilities in FBIH . ........................................ 4.7. PHC Information Systems inFBIH................................................ ................. 5. Key Developments in 5.1. Organisation o f PHC in RS...................................... 5.2. Development o f 5.2.1. Undergraduate Training in RS ...................................................... ............................................................................ 29 ...................... 29 5.3.3, Comprehensiveness o f Care 5.3.4. Coordination o f Care........................... 5.3.6. Role o f FMNurses.............................. ................ ...................................................................... 31 5.6. Infrastructure and Equipment at PHC Facilities in RS ............................................................................ 32 5.7. Licensing and Revalidation in RS................................................... ...................................................................... 33 6. Task Profile and Facility Survey Results............................ 6.1. Characteristics o f the Ordinations ........................ 34 6.2. Respondent 6.2.1. Education and Training .... 6.3. Patient List 6.4. Contacts with Patients....... 6.7. Collaboration with Other Medical Professionals ... 6.8. Face-to-Face Interaction with Other Health Profes ..................................................................... ....................... 41 6.9. Responsibility for Emergency Health Care...... ......................................... 41 7. .............................................................................. 54 7.1.4. Improved Commu ................... ........................................................................ .......................... 7.3. Critical Success Factors .... ........................... ........................ 58 7.3.2. "Improved Work Environment" 7.3.3. Effective Communication ......... ....................................................... 59 7.3.6. "Developing Trust" ............................................................ 7.3.7. "Bottom Up Versus T ......................................................................... 60 7.5. Understanding Stakeholder Needs ...................................................................................................................... .61 7.5.1. 7.5.2. "Incentives Matter" .................................................................................................................... 62 7.6. Managing Strategic Change ..................................... ........................ 7.6.1. 7.6.2. .................................... 7.6.3. "Demonstrating Success- Quic ................................ 63 7.7. "The role of InternationalAgents" .................... ........................... 7.8. "Importance o fNetworks and Exposure" ............................................................................................................ 63 7.9. "Health System As a Means to Maintaining Social Peace" 8. Key Achievements o f PHC Reforms ................................................................................................................ 8.1, Organization .................................................................................... 65 8.2. Resource Alloc ........................................ 8.3. Financing ........ ................................................................................ 66 8.4. Service Provi .................................................................................................................... 68 8.5. Resource Generation .............................................................................................. 68 9. Challenges Which Remai ....................... 9.1, Asymmetry inthe Pace o ............................................................................. 70 ............................................................................................................................................ 71 9.6. Quality ..................................................................................................................................... 9.7. Incentives and Retention...................................................................................................................................... 71 9.8. Communicating the Reforms ............... ...................... .................... 71 ................ 10 ....................... ...................... 10.2. Being Strategic ............................................................................................... 73 10.5. Beyond Pilots 10.7. Readingthe Context............................................................................................................................................. Institutions Versus Institutionalization ............................... 10.8. 74 10.9. Coordination 10.10. Communicati 10.11. Responsiveness ........................................................................................ 74 10.12. Monitoring an ............................................................................ 74 10.13. Dissemination 75 10.14. Exit Strategy .. ..................................................................................... 75 Annex 1: Family Medicine Contract from FBIH Annex 2: An Example of a Contract inthe Republika Srpska ............... Annex3: Standard Medical and Non-MedicalEquipmentfor GeneralIF ......................................................... 94 Annex 4: FM Clinical Guidelines Introduced in Annex 5: Curriculum for F M Specialist Training Program....................................................................................................... 97 Annex 6: In-Service Programfor Advance Training (PAT). ...................... Annex 7: Family Medicine Curriculum at UndergraduateM Annex 8: Data Regularly Collected at PHC Level........ Endnotes.................................................................................................................................................................................. 106 Boxes Box 1: Key Problems IdentifiedWith the Health System inthe Federationof Bosnia and Herzegovina Box 2: Goals of the Health Reform .................................................................................................. 11 Box 3: Reasons for Reforming PHC Level inFBIH...... Box 4: PHC Reform Objectives inFBIH...... ................................................................................................... 12 Box 5: Goals of the Health Reform and Heal argets ............................... .......................... 16 Box 6: PHC ReformObjectives in ....................................................................................... 16 Figures Figure 1: A Framework for Analyzing Health Systems. Figure 2: GDP Growth ( percent), 1998-2003............................................................ ................................................ 6 Figure 3: Life Expectancy, 1992-2002 Figure 4: Infant and Under-fiveMorta Figure 5: ................. Figure 6: Figure 7: Figure 8: Figure 9: Figure 10: Health InsuranceFund Expenditureby Category................................................. Figure 11: Figure 12: Managementof Common Conditions................ ...................45 Y Figure 13: Involvement of FPs and GPS inManaging Chronic Illness with No Difference .............................................. 5 1 Tables Table 1: IntervieweesDistribution ................................................................................................................................. 2 Table 2: Informants Categorization............................................... ..................... Table 3: ............................................................... 3 Poverty Levels inBosniaandHerzegovina.... Bosnia and Herzegovina:Number of Facilities and Phys Table 4: ................. Table 5: Number of F M Doctors inthe FBiH by June 30, 2004.......................................................................................... 21 Table 6: Analysis of GeneralPracticeand FM Specialist Service Delivery Patterns: Service Types of the Total ....................................................................................................... ...................23 Table 7: Analysis of GeneralPractice and F M SpecialistService Delivery Patterns: Service Types .................................. Table 8: Number of F M Doctors inRS by June 30, 2004 ............................................................ .............. ..23 28 Table 9: Number and Type Services Provided at EmergencyDepartment of DZ Banja Luka in2001 ............................... 3 1 Table 10: Accreditation Standards..................................................................... Table 11: Bosnia and Herzegovina:Number of Facilities and Family Physicia Table 12: Distributionof Ordinations with Family Physiciansor GPs.................................... Table 13: EstimatedNumber of Citizens in Places Where Ordinations Table 14: Location of An Ordination ................................................... Table 15: Age Distribution................................................... Distanceto the NearestGeneralHospital............................. Table 16: Table 17: Salaried or Self- employment and Additional Position ................... Specializationof Family Medicine Program..................................................................................................... 36 Table 18: Table 19: Number of Medical Doctors in SharedAccom Table 20: Hours Worked Weekly on Main Position.......... ......................... Table 21: Number of Hours Spent on ProfessionalDevelopmentPer D Table 22: Hours Spent on ProfessionalDevelopmentPer Month by ProfessionalCategory Table 23: Length of Training inFamily Medicine ................. Table 24: Year When Training inFamily Medicine Was ................................... 37 Table 25: Years Worked As A Medical Doctor............... Table 26: 38 Number of Patients on aDoctor's List .............................................................................................................. Years Worked As A Family PhysicianiGP Specialist ....................................................................................... Table 27: Table 28: Number of PatientsNot on the ListThat RequestMedical Care........................................ .................38 38 Table 29: Average Number of ConsultationsPer Do Table 30: ....................................... 39 Table 31: ............................................................................ 39 Table 32: Table 33: Table 34: Table 35: Frequencyof Meetings with Other He ................ Table 36: Responsibility for Out-of-Hours Eme Table 37: ......................... Table 38: Table 39: ................ Table 40: Orthopaedic Procedures ....................................................................................................................... 44 Table 41: Table 42: Table 43: Managementof Common Gynecological Conditions..... Table 44: Table 45: Table 46: GeneralConditions............................................................................................................................................ 48 Table 47: NeurodegenerativeConditions and Mental Illness............ ......... ................................. 48 Table 48: Psychosocialand Family Problems..................................................................... ..................49 Table 49: MeasuringBlood Pressure...... ........................................................................ 49 Table 50: MeasuringBlood Cholesterol Level............................... ...................... ..,.......................................................... 50 Table 5 1: Involvement in Health Education Activities Table 52: Table 53: Table 54: Table 55: Table 56: Table 57: Table 58: Neurological and Psychiatric Conditions .. Table 59: Table 60: Table 61: Table 62: Curriculum Structure and the Unitsof Teachingfor the Programfor Advanced Training .. Table 63: Family Medicine Curriculum Structure at UndergraduateLevel ............................................. ........... This volume is aproduct ofthe staff of the International Bank for Reconstructionand DevelopmentI The World Bank. The findings, interpretations,and conclusions expressed inthis paper do not necessarilyreflect the views ofthe Executive Directors of The World Bank or the governmentsthey represent. The World Bank does not guarantee the accuracyof the data included inthis work. The boundaries,colors, denominations,and other information shown on any map in this work do not imply anyjudgment on the part of The World Bank concerningthe legal status of any territory or the endorsement or acceptanceof suchboundaries. ACKNOWLEDGMENTS This report reviews the experience o f family medicine in Bosnia and Herzegovina. It is part o f a study comprising five volumes that reviewsthe experience o f family medicine in four countries inthe Europe and Central Asia (ECA) Region - Armenia, Bosnia and Herzegovina, Kyrgyz Republic and Moldova. The report reviews the experience, draws lessons, and establishes an evidence base for detailed analysis. The study presents best practices for policy dialogue and future investments by the Bank and other financial institutions. The detailed case studies compare these countries and draw common themes and issues. Comparisons are made with best-developed or existing models in the Organization for Economic Cooperation and Development (OECD) and other ECA countries that have already undertaken family medicine reform. The report was prepared with financing from a Dutch trust fund. It was prepared by Rifat Atun (Imperial College). Drazenka Rados-Malicbegovic, Gordan Jelic, and Ioannis Kyratsis assisted with data collection. The Task Profile Instrumentwas designed by Wienke Boerma. The study was prepared under the leadership o f Betty Hanan, Kees Kostermaans and Juan Pablo Uribe were the peer reviewers. Valuable comments were provided by Betty Hanan and Nedim Jaganjac. Carmen Laurente helped to prepare the document for publication. EXECUTIVESUMMARY INTRODUCTION 1. The objective o f the study was to review the experience o f family medicine in Europe and Central Asia (ECA), present best practices, and make recommendations for policy dialogue and future investments. Five countries were reviewed as part o f the study. Estonia was selected as pilot country to test the analytical framework and the instruments developed for research, which were subsequently refined. Four IDA countries -- Armenia, Bosnia and Herzegovina, Kyrgyz Republic, and Moldova were studied in detail. The findings o f the study are presented as four case studies --one for each of the four countries studied -- and a synthesis report (Executive Summary) that aggregates the findings and identifies policy implications for the World Bank and the transition countries undertaking primary health care (PHC) reforms inthe ECA Region. 2. The study comprises primary and secondary research and employed both qualitative and quantitative methods o f inquiry. 3. The study explored changes in four key health system levers as a result o f health care reforms: the regulatory environment and organizational structures, health system financing, resource allocation and provider payment systems, and service provision. KEYFINDINGS 4. A key finding o f the study is the paucity o f meaningful, systematically collected, and reliable data to ascertain impact o f policy interventions. Even when data are available, they are not analyzed (often due to resource constraints and limited analytical capacity) to inform decisions or to ascertain whether reform objectives have been achieved. In all five countries studied, there were no baseline studies to allow pre-and post-intervention studies. Further, there were no quasi-experimental designs that might have allowed comparison o f interventionsites with non-intervention sites. 5. Available monitoring and evaluation (M&E) systems in Bosnia and Herzegovina (BIH) are inadequate for monitoring and evaluating reform impact as they tend to focus on input activities rather than system outputs and outcomes and do not map onto reform objectives. Hence, data generation was challenging, but proprietary instrumentswere usedto generate both qualitative and quantitative data to inform the study. 6. The study findings show that despite a post-conflict setting and resource constraints, BIH has made very good progress with PHC reforms and rapidly expanded to cover 23 percent o f the country. 7. An enabling environment has been established through appropriate regulatory changes and laws for the reforms to be further extended and scaled up. There is evidence o f institutionalization o f family medicine (FM) team-centered PHC in both entities, incontrast to other countries inthe region, which have established family doctor-centered PHC systems. The laws have established FM as a specialty, defined core and unified curricula for their training in specialist residency and retrainingprograms, specified the infrastructure and the equipment needed to enable them to practice, and established chambers with responsibility for licensing and revalidation. Further, FM Associations have been developed in both entities and have been admitted to the membership o f World Family Medicine Association (WONCA). Following appropriate legislation, Agencies for Accreditation and Quality Improvement (AAQIs) have been established and operationalized in both entities. 8. At the end o f June 2004, around 413 FMdoctors/specialists and 286 FMnurses have been trained in the Federation o f Bosnia and Herzegovina (FBIH). In addition, 168 FM doctors/specialists and 154 FM ii nurses have been trained in Republika Sprska. Further, over 250 health professionals have been trained in health management through programs supported by the Bank-financed Basic Health Project (BHP). 9. Organizationally, there is separation o f purchasing and provision, with purchasing devolved to the Health Insurance Fund (HIF) in Republika Srpska (RS) and Cantonal Health Insurance Institutes (CHIIs) in FBIH. Family medicine teams have been established as the basic building block for PHC provider units in both entities. Inthe pilot regions, the HIF/CHII have established service contracts directly with dom zdravljas (health centers - (DZ) or through DZ with the FMteams. The ambulantas (doctors' offices) inpilot sites have been refurbished and appropriately equipped and are functioning. The users have been granted the right to choose their family physicians. 10. I n terms o f financing, there is a shift to a health insurance-based system. Both entities have specified in law that 40 percent o f the revenues of the CHI1and HIF (which come predominantly from health insurance contributions) should be allocated to PHC. 11. Changes have been made to resource allocation and provider payment systems. A simple per capita payment system has been successfully introduced in the demonstration sites to remunerate FM teams. The per capita model is weighted by age and in RS includes a performance-related element for health promotion and prevention activities. 12. In the pilot regions, the contracts between the CHII/HIF and the DZ/FM teams specify in detail the services to be provided by the FM teams as well as the equipment they need to use when delivering services. The scope o f services and the equipment used are broader than those specified for non-specialist general practitioners (GPs). Evidence-based guidelines have been introduced for 20 conditions to enhance the quality of services in PHC. The AAQIs have commenced accreditation o f PHC providers in RS. The accreditation, which is voluntary, attracts a bonus payment for the PHC provider. 13. The study shows that the family physicians, as compared with the non-specialist GPs, have expanded the scope and content o f their services, and the observed differences are statistically significant. Family physicians are more likely to: use an appointment system for consultations; provide health education, promotion, and prevention services; manage a wider range o f acute conditions; provide services for common chronic illnesses; use a broader range o f equipment; and apply a wider range o f medical techniques when managing patients. They are more likely to visit their patients in hospital but have been shown to reduce referrals for investigations and prescriptions. 14. The perceived benefits o f the FM for the users identified by key informants include, among others, a user focus; enhanced choice; holistic care; improved continuity; higher quality services; better doctor-patient communication and relationship; a broader set o f services with more health prevention and promotion activities; a shift from a biomedical model to a psychosocial model o f care; and having a named physician to whom the user can relate for all problems. 15. Key benefits o f the team-centric FM model for health professionals have been identified as, among others, empowerment o f the health professionals and in particular the FM nurses; enhanced professionalism through improved knowledge and skills; more transparent payment systems; ability to provide a broader set o f services, which helps increase status o f the professional; and improved teamwork. KEYCHALLENGES 16. Despite impressive achievements, a substantial number o f challenges remain if the PHC reforms are to be fully scaled up or sustained. There is clearly an asymmetry in the pace o f development and the rate at which new laws and regulations have been developed. Rapid pace o f development o f the FM model has 111 ... meant that the existing laws and regulations need to be modified to take into account the current level o f development and the expansion needs. New laws and regulations have to be developed to define the legal status o f FMteams in relation to the DZ and contracting institutions. The roles and responsibilities o f the FM team members need to be expanded and defined in law. The scope o f services for FM teams and the PHC level need to be clearly articulated. 17. Organizationally, the FBIHhealth system is adversely affected by the premature decentralization to a cantonal structure. Cantons have responsibility for managing health services for their populations and have their own ministers o f health and health insurance institutes. This has led to fragmentation o f the health system, created small risk pools, thinly spread available expert human resources, caused duplication of services, fractured horizontal linkages, and a created a cumbersome administrative system that is too inefficient and costly to be sustained. On the other hand, RS has a more centralized organizational structure, with a Ministry o f Health and Social Welfare (MOHSW) responsible for delivery o f health services. Although the MOHSW regulates and manages secondary and tertiary care providers, PHC is devolved to local governments. Financing and purchasing is the responsibility o f the Health Insurance Fund. This structure has led to a fragmentation o f services by separating primary and secondary care levels into silos with separate financing flows. 18. Financially, key problems relate to: small risk pools, inter-cantonal and interregional inequities in financing levels and access; high expenditure levels for the health sector, estimated to be 12.5 percent o f the gross domestic product (GDP); despite high expenditure levels, inability o f a substantial proportion o f the population to access freely an essential set o f services, hence creating a highrisk factor for poverty; lack o f transportability o f the health insurance entitlements; high out-of-pocket expenditure; and poor tadinsurance collectioncapacity. 19. The resource allocation systems do not take into account need or poverty levels. Thus, large interregional and inter-cantonal differences in the per capita expenditure for health care exist. Although the Federal Solidarity and Reinsurance Institute covers certain catastrophic expenses and vertical programs, it does not function as an equalization fund to correct interregional inequities inresource allocation. 20. Although per capita pay systems have been introduced in both entities, laws in FBIHdo not allow for creation o f incentive systems linked to improved performance. In both entities, there are no M&E systems or adequate capacity at CHII/HIF to progress to more advanced payment systems with greater performance- related elements based on fee-for-service and target payments. 21. The biggest barrier to development o f FM-centered PHC is the organization o f service delivery at the PHC level, where a large number o f narrow specialists provide services for common PHC conditions and can be accessed directly by the population. These narrow specialists act as substitutes for family physicians -- often crowding out the FM specialists, fragmenting first contact care, and fracturing gate keeping, continuity, and the comprehensiveness function o f the PHC system. Further, in PHC centers that have not yet adopted the model, services are delivered according to age, gender, and condition o f the users, hindering development o f holistic care and continuous care. 22. A further barrier to the development o f PHC is poor vertical linkages between PHC and secondary level and lack o f referral and counter-referral mechanisms. These impede the development o f integrated services and frustrate any attempts to establish a continuum o f care. LESSONSLEARNED 23. The study has identified a number o f critical success factors for expanding PHC: (a) branding FMand image building; (b) improved work environment; (c) improved communication between and within levels o f iv the health system and with the public; (d) improved coordination o f key institutions; (e) developing a holistic approach to reform; (0 developing trust through better engagement o f the operational level to create ownership; and (g) better coordinationbetween donors. 24. The study clearly demonstrates the importance o f a multifaceted, multilevel approach to reform: developing an enabling legal environment for change to occur while simultaneously intervening to refine organizational structures, financing, resource allocation, provider payment systems, and service provision. 25. Balancing short-term success and sustainability is important. Achieving system change takes time, and sustained support over a five- to eight-year period i s a realistic time scale to adopt for new PHC projects inthe region. 26. Moving out o f "pilot" and "experiment" mode is key to institutionalizing changes needed to sustain health system reform. 27. levels --Verticaland horizontal links should be formed to work simultaneously at both policy and operational the former to institutionalize changes and the latter to create shared ownership to implement policies. 28. While it is necessary to invest in key individuals to develop champions o f reform, this must be balanced with efforts to widely engage stakeholders to achieve consensus on reform objectives. 29. The fluidity o f the sociopolitical and economic environment in BIHmeans that the political economy o f health reforms and factors influencing strategic change must be analyzed and addressed in the designphase and throughout implementation o f programs. 30. Coordination of international agencies i s necessary to ensure that activities are not fragmented and duplicated, butto achieve this objective, the ministrieso f health must be actively supported. 31. Poor communication creates a fear o f the unknown and breeds resistance. A well-developed communication strategy must be aimed at users, health professionals, managers, and decision makers. 32. Given the fluidity o f the context, programs should adopt a flexible approach to implementation to adapt to changes and respond to windows o f opportunity, but without sacrificing a strategic approach. 33. There is an urgent need to develop appropriate metrics and information systems to monitor progress o f PHC reforms and systematically gather informationto verify progress against objectives. 34. The Basic Health Project was a highly successful project. It demonstrates that the World Bank can add much value to the reform process, but success bringswith it responsibility. A clear exit strategy needs to be developed to ensure that there are no gaps in support and to sustain the transformation process. V 1. INTRODUCTION 1. The objectives o f the study are to review the experience o f family medicine (The term "family medicine" i s used here, but other terms such as "primary health care (PHC)" or "general practice" are used frequently and interchangeably) in Europe and Central Asia (ECA), present best practices, and make recommendations for policy dialogue and future investments. 1.1. THEEVALUATIONFRAMEWORK 2. Kutzin suggests a three-step approach to evaluating health reforms, describing clearly: (a) key contextual factors driving reform, (b) the reform itself and its objectives, and (c) the process by which the reform was (is being) implemented.' To this approach, three further elements can be added: (a) describing clearly the changes introduced by the reforms, (b) analyzing the impact o f these changes on health system objectives and goals, and (c) establishing whether the reforms have achieved the policy objectives set by the government -or the agency leadingthe reforms. 3 , The evaluation used a framework to analyze key changes in health system elements and intermediate goals in relationto primary health care (PHC). This is shown infigure 1(see annex 1). Figure 1: A Frameworkfor Analyzing Health Systems I OrganisationalI ~~h arrangements allocation Effectiveness I I I 4. This framework builds on that developed by Hsiao and identifies four levers available to the policy makers and managers in health systems. Management and modification o f these levers enables policy makers to achieve different intermediate objectives and goals. The organizational arrangements lever refers to the policy environment, stewardship function, and structural arrangements in relation to funding agencies, purchasers, providers, and market regulators. Financing and resource allocation levers refer to resource collection, pooling, allocation, and the mechanisms and methods used for paying health service providers. The provision lever refers to the "content" -- the services provided by the health sector rather than the structures within which this content is delivered. The intermediate goals identified in the framework -- equity, technical and allocative efficiency, effectiveness, and choice are frequently cited by others as end goals in themselves, However, in this framework efficiency, equity, effectiveness, and choice are taken as means, contributing to attainment o f the health sector's ultimate goals o f health, financial risk protection, and user satisfaction. This framework was used analyze key changes in health system elements and intermediate goals. An important finding o f the literature search and country visits was the lack o f systematically collected 1 data at the PHC level. Therefore, primary research was undertaken to generate original data to complement secondary research findings. 1.2. PRIMARYRESEARCH 5. Primary research comprised three elements: (a) qualitative research; (b) Primary Health Care Facility Survey; and (c) Physician Task Profile Survey. 1.2.1. QualitativeResearch 6, Qualitative research involved 58 key informant interviews, including nine clinicians, six policy makers, 18 managers, 11 family physicians, 5 nurses and 9 patients. Number of Informants Republika Srpska Federation of Bosnia Bosnia & & Herzegovina Herzegovina Visit 1 9 10 19 Visit 2 18 21 39 Total 21 31 58 Table 2: InformantsCategorization 7. The interviews explored the perceptions o f key informants regarding the goals and objectives o f the reforms, changes in structures and processes, critical success factors, barriers and enablers that influenced the introductionand diffusion o f family medicine reforms, major achievements, and lessons learned. 8. A semi-structured questionnaire was specifically developed for the study for face-to-face in-depth interviews o f key informants. The questionnaire was piloted and then iteratively refined inthe four countries studied. 9. Purposive sampling was used over a two-stage pro~ess.~An initial set o f key informants were interviewed for the first stage o f the study usinga semi-structured questionnaire. The data emerging from the initial set o f interviews were analyzed to identify key emerging themes, which were explored further using a refined and shortened topic guide to allow in-depth exploration o f some o f the key themes emerging from the initial set o f interviews. The second stage also employed "purposive sampling" with "snowballing" to capture a multilevel, multi stakeholder sample o f key informants, representing the key stakeholders involved in PHC reforms in both policy development and implementation in urbanand rural areas. 10. A fieldwork diary was also kept to form a chronology and progress record of the research, and observational field notes were taken from the visited sites. This enriched the understanding o f the functioning o f the project's environment. To strengthen the validity o f the qualitative methods implemented, data were 2 triangulated by comparing the results o f interviews from different groups o f stakeholders with the outcome of the analysis o f official documents, 11, The analysis informed the detailed case study by capturing information on key structural and process changes, issues related to design and implementation o f PHC reforms, the drivers and barriers to reform, the factors influencing the establishment o f an enabling environment for change, and the lessons learned. 1.2.2. Primary Health CareFacility andPhysician TaskProfile 12. These two elements o f primary research were done concurrently to explore changes in service delivery and practice o f family physicians as a result o f the PHC reforms and training o f physicians as family medicine specialists. It was not possible to do a pre- and post-intervention study as there were no data or baseline studies that analyzed service delivery patterns and physician practices before the reforms and after the introduction o f changes. 13. Two cross-sectional studies were carried out simultaneously: (a) Primary Health Care Facility survey and (b) Physician Task Profile survey. 14. Each o f the instruments was translated into Bosnian and Serbo-Croat (local language). Local research teams were trained in the use and application of the instruments. Data analysis was undertaken in Bosnia and London. 15. Purposive sampling was used to provide a diverse sample. The dom zdravjlas were selected based on geography and the relative stage o f development o f PHC reforms. 16. The survey was conducted in 87 ordinations: 45 in Republika Srpska and 42 in Federation BIH. A total o f 199 doctors employed in dom zdravljas as FM specialists or non-specialist general practitioners were surveyed: 99 from Republika Srpska and 100 from Federation BIH. Ten dom zdravljas were surveyed: three in Republika Srpska (Banja Luka, LaktaSi, and Prijedor) and seven in o f BIH(Mostar, CeliC, Citluk, Kalesija, Tuzla, iivince, and LjubuSki) (Table 11:3). Table 3: Bosniaand Herzegovina:Number of Facilitiesand Physicians Surveyed Ordinations (Facilities) PhysiciansSurveyed Federationof Bosnia and 42 100 Herzegovina Republika Srpska 45 99 Bosniaand Herzegovina Total 87 199 1.2.3. PHCProviderFacility Survey 17. This component o f the primary research used a facility survey instrument developed specifically for the study. The instrument drew on guidance and methodologies developed by the Bank on facility surveys' and a number o f internationally available facility surveys. The instrument was developed by the research team (Atun and Ibragimov) and refined following discussions with collaborators in BIH, Kyrgyzstan, and Moldova to ensure appropriateness to the local context and piloted in each o f the four countries included in the study: Bosniaand Herzegovina, Moldova, and Armenia. 18. The instrument comprises sets o f questions to capture information on: (a) general characteristics of PHC facilities and the population size served, (b) scope o f services, (c) organization o f services, (d) availability and composition o f PHC staff, availability o f essential emergency drugs, availability o f equipment and services, (e) comprehensiveness o f services, and (f) quality o f services. 3 19. The instrument also initially had a section on financing o f the facilities, but this was later omitted as field testing revealed that most facilities did not have financing data at the facility level. A summary o f the elements o f the instrument is attached in Annex 2. 20. The instrument was coded and a computer program was written in Access@ for data entry and analysis. We performed statistical analysis (descriptive statistics and T-test) to test for observed differences. 1.2.4, Survey of TaskProfiles ofFamilyPhysicians 21. The second component of the primary research was a cross-sectional survey o f family physicians to explore their "Task Profiles" using a validated instrument developed by the NIVEL Group in the Netherlands.6 The instrument, previously tested and validated in 32 European countries, is available in several languages, including Russian and other Slavic languages. It enables collection o f detailed data on the preventative, promotive, and curative services provided by family physicians, their skills, knowledge base, attitudes, and workload. The latter is captured by use o f a seven-day workload diary. The instrument was obtained from the author, Dr.W. G. W. Boerma, and with his kind permission used inthe study. A summary o f the instrument is shown in Annex 3. 22. The survey o f the Task Profiles o f Family Physicians aimed to identify the scope and availability of services and skills o f doctors working at PHC level and to identify similarities and differences between FM specialists and non-specialist GPs. 23. The instrument was tested in the four study countries and minor modifications made to ensure contextual sensitivity. The instrument was coded and a data collection and entry program developed in Microsoft Access. Data were transferred to SPSSO for statistical analysis. 1.3. SECONDARY RESEARCH 24. Secondary research consisted o f a review o f international and in-country published literature to ascertain key legislative changes related to the reforms and to identify changes in financing, resource allocation, provider payment systems, organizational changes and regulation, and service provision. There were no a cross-sectional or longitudinal data on referrals and admissions for conditions commonly managed inPHC setting for analysis. 1.3.1. Literature Review 25. The literature review comprised analysis o f published articles in peer-reviewed journals, supplemented by documentary analysis o f published reports, key legal instruments and policy documents from the four countries, Bank publications, country Health Care Systems inTransition (HIT) published by the European Observatory on Health Systems Research, and other relevant studies (e.g. evaluation o f Bank- financed health projects inthe ECA Region by Dr.D.Miller).' 4 2. THE CHALLENGES FACEDBY THE HEALTHSYSTEMIN BOSNIA AND HERZEGOVINA 2.1. THEIMPACT OFTHE WAR BETWEEN 1992 AND 1995 26. The four-year war caused widespread physical damage and had a devastating effect on Bosnia and Herzegovina. Over 10 percent o f the population was killed or wounded and over two million people --nearly half the pre-war population were forced from or chose to leave their homes and became refugees, either abroad or displaced internally within BIH. With these population movements, community- and family-based social networks were seriously disrupted. Two-thirds o f homes were damaged, with one-fifth totally destroyed. An estimated 30 to 40 percent o f hospitals and 70 percent o f schools were destroyed or severely damaged, and 30 percent o f health care professionals and a similar share o f teachers were lost to death or emigration. 27. Economic situation deteriorated rapidly during the war. The economy collapsed and the per capita GDP fell five-fold, from US$2,429 in 1990 to US$456 in 1995.' 2.2. POST-WAR GOVERNANCE ARRANGEMENTS 28. Following three years o f civil war, a peace agreement, the Dayton Accord, was negotiated in November 1995. The Accord acknowledged the bitter ethnic divides that had led to war by establishing a government structure with a weak central state in which the ethnically based "entities" retained political, military, and economic authority. The Accord also provided for a strong international policy and military presence and an international overseer -the Office o f the HighRepresentative (OHR). 29. Under the 1995 Dayton Accord, four levels o f government were established in the Federation o f Bosnia and Herzegovina and three in Republika Srpska: (a) At the highest level, the state o f Bosnia and Herzegovina (the state); (ii)at the next level two constituent political entities, the Federation of Bosnia and Herzegovina (FBIH) and the Republika Srpska (RS), covering 5 1 percent and 49 percent o f the land area o f Bosnia and Herzegovina, respectively; and (iii)FBIH was divided into ten cantons, which in turn were divided into municipalities. In the RS, no cantons were established and local government was assumed directly by municipalities. In addition, Brcko, with three municipalities, was designated as a District. 2.3. ECONOMIC CHANGES AND INCREASING POVERTY 30. Immediately after the war a postwar Priority Reconstruction and Recovery Program(1996-1999) was put in place by the donors and development agencies. By the end o f 1999, around US$3.5 billion of the US$5 billion pledged for reconstruction had been disb~rsed.~ 31. Economic growth resumed in 1996, with a post-war rebound in growth o f the GDP by 86 percent in 1996 and 40 percent in 1997. Thereafter, the GDP growth has been stable at around 5 to 6 percent, underpinned by successful adherence to the currency board arrangement (whereby the Bosnian convertible mark was pegged to the German mark) and a monetary policy that succeeded in maintaining low inflation (Figure2:). 5 Figure2: GDP Growth (percent), 1998-2003 12 - 10 --- -E a -- I I I 6 - B e, W 4 - I I 1998 1999 zoo0 2001 2002 2003 Source: The World Bank. 32. However, the war and subsequent economic crisis led to significant unemployment and poverty levels. In 1997, around one-quarter o fthe population was classified as poor, and 15 percent were classified as extremely poor.I0Thepoverty level in 2001 was 20 percent -higher than that in Croatia (8 percent in 1999) and the Former Yugoslav Republic o f Macedonia (16 percent in 1999), but lower than that in Kosovo (50 percent in 2000)" (Table 4:). Poverty Rate ( percent) Share of BIH Poor ( percent) FBIH 16 52 RS 25 48 BIH 20 100 33. A Living Standards Measurement Survey done in 2000 showed that, in terms o f non-income poverty indicators, 16 percent o f those surveyed felt that health poverty affected them.'* 34. The study identified widespread health risks, including uninsured financial risks associated with becoming illas a risk factor that may thrust a non-poor household into poverty.13 The study report strongly emphasized the importance o f non-income vulnerability with respect to health, human rights, and limited mobility and that the poverty risks were not shared equally, being much higher than average for particular groups, including those living in rural areas, internally displaced persons (IDPs) and refugees, households with poor education, and women.I4 35. The report found "inefficient treatment protocols, duplication o f services, and neglect o f primary health care make the system not only one o f the most expensive in the ECA region in terms of its share o f GDP, but also one that provides inadequate services to the poor, especially to those who are not insured." Another interesting finding of the study was that the high costs o f the system crowded out resources that could otherwise be used for measures to support poverty reduction more effe~tive1y.l~ 36. The report concluded that investment to reform to health system was critical to alleviating and reducing poverty and that the health care reform, in particular, needed to take account o f (a) the many uninsuredpeople in both entities, most o f whom are poor; (b) differential utilization o f health services, which is subject to differential access between the insured and the uninsured; (c) the problems with access and 6 equity in a system that i s supposed to ensure universal coverage; (d) financial consequences o f health risks for the poor, who allocate a greater proportion o ftheir consumption to health care than the rich, and thus are more exposed to these risks; (e) the prevalence o f large out-of-pocket expenditures, which negatively affected access to health services; and (f) substantial public expenditures on health services.I6 37. In 1998, registered unemployment reached 37 percent inFBIHand 36 percent in Republika Srpska in 1998, among the highest inthe ECA region. " 2.4. CHANGES INHEALTH INDICATORS 38. In the post-war period, the population suffered significant post-traumatic stress due to ravages of the war, the subsequent socio-economic crisis, unemployment, migration, and displacement. However, general population indicators such as infant mortality, under-five mortality, and life expectancy have remained stable (Figure 3:). Figure 3: Life Expectancy, 1992-2002 39. In 2001, maternal mortality was 5.05 per 100,000 live-born children. Infant mortality declined from 11.2 per 1,000 in 2001 to 7.6 per 1,000 in 2002. In the same period, under-five mortality declined from 13 per 1,000 to 8.7 per 1,000 (Figure 4:). Figure 4: Infant and Under-five MortalityRates I 1995 2000 2002 l Infants m Under 5 Source: World Bank Statistics. 7 40. The leading causes o f death in 2000 were cardiovascular diseases (52 percent), malignancies (18 percent), and injuries and poisoning (around 5 percent) -similar to those inthe pre-war period. 41. In2002, immunizationcoverage inchildrenfor BCGwas 91.2 percent; for DTP3 73.9percent, OPV3 81.3 percent; and MMR 86.0 percent, 42. No systematic data are available on the quality o f antenatal services and heath outcomes. The Federal Public Health Institute estimates that in 2001 only 2.1 percent o f mothers were breastfeeding at six months - a very low figure by international standards. 2.5. BACKGROUND ON BOSNIAAND HERZEGOVINA HEALTH SYSTEM PRIOR TO THE WAR 43. The former Federal Socialist Republic o f Yugoslavia had a well-developed health care system with a large network o f clinics, hospitals, and public health facilities. The population health indicators were comparable to those o f OECD countries. In Bosnia and Herzegovina, there were 5.8 beds and 2.6 doctors per 1,000 people. 44. Prior to the war, BIH had a well-established network o f PHC centers comprising dom zdravljas (DZs), doctors' offices for ambulatory PHC services (podrucna ambulantas), and first aid and emergency service units (hitne pomoci). 45. Each municipality had its health center (a DZ), which coordinated a network o f smaller PHC community facilities (as outposts o f the DZ). The DZ was located in the main city or town and the smaller clinics (ambulantas) in smaller communes and villages. There were 109 DZs, each covering a commune o f 30,000 to 50,000 inhabitants. The DZs coordinated 900 doctors' offices (ambulantas), usually staffed by one doctor and a few nurses, which provided basic and first-line services to local populations. 46. Within the DZ, PHC was divided into seven distinct functions: (a) general practice; (b) occupational medicine; (c) pre-school pediatrics; (d) school pediatrics; (e) gynecology/obstetrics; (0 laboratory/)(-ray, and (g) hygiene and epidemiological unit. The PHC system was coordinated by the Ministry o f Health and Social Affairs and supplemented by additional health clinics that served special groups such as the police and military personnel. In addition, almost every large company had organized its own health services. 47. Public health services were also responsible for monitoring health status and epidemiological indicators, control o f communicable diseases and immunization, radiation control, water quality and sanitation control, nutrition monitoring, and health promotion. Public health services were provided through epidemiological surveillance departments within DZs and a network o f regional public health institutes throughout Bosnia and Herzegovina -with a main Public Health Institute in Sarajevo. 2.6. HEALTH EXPENDITURE BOSNIAAND HERZEGOVINA IN 48. Bosnia and Herzegovina allocates around 12 percent o f its total GDP to health: o f this, about 8 percent comes from the Compulsory Health Insurance System, State Budget Transfers, and donations; and around 4 percent comes from out-of-pocket expenditures in form o f co-payments for health services and drugs and under-the-table payments and fees for service in private sector. The total allocation to health, as a proportion o f GDP, is highcompared with developed countries inWestern Europe.I8 2.7. REFORM CHALLENGES INTHE HEALTH SYSTEM 49. Following the post-war Priority Reconstruction and Recovery Program (1996-1999), the donors began to identify sector specific programs to support sustainable development. The World Bank Bosnia and 8 Herzegovina Country Assistance Strategy (CAS) in 2000 for the financial years 2000 to 2002 identified key medium-term development challenges that needed addressing to increase economic opportunity and improve the quality o f life for all Bo~nians.'~These challenges were identified as (a) strengthening governance and public sector management; (b) Fostering private sector led-growth; (c) building social sustainability; and (d) completing reconstruction. 50. The CAS in 2000 identified weak and fragmented governance as the most serious impediment to implementingreforms needed for sustainable economic growth. Specifically for the health sector, the CAS identified key challenges as implementation o f laws that provide universal access to a basic package o f health care, equal access to services, and efficient financing and delivery. The CAS also noted that the post-war decentralization had resulted in an unreasonably low level o f risk pooling for health insurance funds despite a very large share o f GDP (over 12 percent) spent on health care, with over one-third o f these expenditures covered out o f pocket by private citizens (disproportionately by the poor, who identify the cost of health care as a key concern). The CAS identified as priorities institutional reforms to enhance risk pooling, build capacity, and increase use of modern health management methods.20 51. The "Strategic Health Systems Plan for the Federation o f BIH," published in 1998, identified a number o f key structural problems with the FBIHhealth system and articulated the need for health reforms2' (Box 1:). Box 1: Key Problems Identified With the Health System in the Federation of Bosnia and Herzegovina Inadequateaccess with inequalities inthe use of healthservices Largenumbers of inappropriateproceduresperformedinthe system Poor coordination betweencare providers and sub sectors of the system Inability of the system to meet the demands of an increasingly assertive population wishing to exercise choice anc participation in decision making Low income and poor working conditions for healthprofessionalswith consequent low morale and emigration Huge demographicshifts with refugees and intemally displacedpersons Health facilities and equipment destroyed inthe war Large number of wounded and disabledpeople as a consequenceof the war Worseningenvironmental conditions for health-waste disposal, water supply Excessive healthexpenditures Fragmentationofthe PHC levelwith multiple providers 52. The Appraisal in 1999 for the World Bank-financed Basic Health Project identified the principal issues in the health sector as (a) the absence o f a sustainable health finance system; (b) a mismatch between health needs and health services; and (c) a weak coordination o f international donor activity in primary health care and public health care. These problems were attributed to multiple factors related to the weak economy, political and social context, infrastructure, incentives, and management systems, as well as training and deployment o f staff.22 53. Financing problems were identified as high levels o f expenditure (as a proportion o f GDP), highly fragmented risk pools in FBIH(especially in small cantons), and wide variation in resource mobilization and expenditures among cantons and between the two entities. In terms o f the health care delivery system, the appraisal identified, among others, fragmented delivery systems, inequitable access, and wide variations inthe scope, content, and quality o f services among different cantons as key problems that needed addre~sing.~~ 54. A further important problem identified by the appraisal was the proliferation o f large number o f training programs for doctors and nurses in PHC without any common or agreed standards in scope, content, quality, and length o f training.24 9 55. The difficulties with co-coordinating the activities o f the donors working at the PHC level were attributed to large number o f donors active in BIH (around 140) and limited capacity at the Ministries o f Health inboth entities.25 56. A rapid appraisal o f the primary care equipment, undertaken with support from the World Bank in 1998, revealed wide variations among health facilities in availability, status, and use. In most cases, the installed equipment was found to be obsolete, not working, or unused due to lack o f consumables and personnel.26 57. The analysis undertaken for the Social Insurance Technical Assistance Project (SITAP) identified a number o f systemic and health sector specific problems that needed to be addressed to enhance development o f the health sector. The systemic issues identified were: (a) high wage tax and contribution burden, leading to tax evasion; (b) low compliance with wage tax obligations by those in the large informal economy; (c) inadequate contributions from farmers and the self-employed; (d) inadequate mechanisms for dealing with the uninsured non-working populations; (e) inadequate data access and exchange among agencies involved in contribution collection; and (f) lack o f portability o f health insurance benefits.27Key health system issues identified were: (a) premature decentralization, which led to limited institutional capacity and institutional fragmentation; (b) financial instability from the proportion o f GDP allocated to the health sector -as a result o f the high cost o f operating a fragmented and muttered structure with allocative and technical inefficiency - but with a low tax base, inadequate inclusion o f the self-employed and farmers as health insurance contributors, and a large proportion o f beneficiaries who are exempt from contribution; (c) inequities due to the substantial proportion o f the population not covered by health insurance; (d) small risk pools due to the devolution o f health insurance function to entities and cantons; (e) high variability in economic status and revenue generation capacity o f the cantons in FBIH; (0 inefficient service delivery; and (g) unequal access to care.28 58. Inequitable access to health services and excessive fragmentation o f the health system has been identified as key problems in subsequent analyses2', 30-- although empirical evidence demonstrating the direction and magnitude o f these problems is lacking. 59. The fragmentation is not confined to financing o f the health system. Service delivery i s fragmented by level o f care but also highly verticalized within these levels. For instance, at the PHC level, separate services exist for different age groups (e.g., dispensary for children), gender (e.g., dispensary for women), occupational groups (e.g., occupational medicine departments in different companies), as well as for specific illnesses (e.g., tuberculosis dispensary). 60. Although the Bosnian government is aware o f many o f these problems and, with donor support, has made efforts to address them, the complexity o f governance arrangements and premature decentralization, with consequent managerial inadequacy, have led to delays in implementing interventions to address priorities inthe health sector.31 10 3. KEY LEGISLATIVECHANGESAND HEALTHREFORM INITIATIVESINTHE BIHHEALTHSYSTEM 61. The Government o f BIH has tried to respond systematically to the socio-economic challenges by developing a number o f overarching frameworks and approaches that will guide its response, These included the Global Framework for Economic Development and Social Protection32(as a prelude to the Economic Development Strategy) and the Poverty Reduction Strategy Paper (PRSP), which was preceded by an interim paper. 62. The PRSP identifies a number o f priorities for health reform: (a) new health legislation to regulate health services, especially to improve solidarity and patient mobility; (b) reform o f the Health Insurance Funds system; (c) regulation o f the private health services; (d) more rational capacity utilization to improve referral between levels and reduce duplication; (e) improvement of operational transparency and expansion o f public services; (f) increasing the accountability o f health workers to the general public; and (g) improving the quality o f health services throughout the country.33 63. The post-war reconstruction and development programs in both entities, supported by the World Bank, aimed to develop a Basic Health Program comprising (a) primary health care based on the family medicine concept; (b) a shift from the pre-war emphasis on large hospitals and polyclinics toward more efficient use o f outpatient facilities and home-based care; and (c) a greater emphasis on cost-effective public health and disease prevention and control. A number o f policy and strategy documents were developed to articulate objectives and plans. 3.1. KEYLEGISLATIVE CHANGES INTHE FEDERATIONBIH OF 64. In the Federation, elements o f the reform strategy were outlined in several laws and strategy documents including: Federation Health Program: Health Reform and Reconstr~ction~~and Public Health and Health Care: Federation o f Bosnia and Herzegovina.35 65. The 1997 Health Care Law36and Health Insurance Law37were enacted. These, along with the related bylaws and regulations, divided the responsibilities o f the Federation and canton levels. The Federation level was given the authority to formulate policy and pass laws and the canton level the authority to formulate local policies, implement laws, and be responsible for financing and provision o f health services. 66, In 1998,the "Strategic Health System Plan for the Federation o fBosnia and Herzegovina" articulated the objectives for health system reform38(Box 2:). Box 2: Goals of the HealthReform System sustainability-affordable Equity and solidarity -universal coveragefor a "basic package" of services Efficiency - fair allocation of resources to priorities and maximizing available resources through effective management Satisfactionofusers and health professionals-higher quality healthcare with transparency and accountability Pluralism and ownership -recognizing the need for public/private balance 67, The Strategic Health Systems Plan also identified the major reasons for reforming the PHC sector and set a number o f reform objectives to address these reasons (Box 3: and 4). 11 Box 3: Reasons for Reforming the PHC Level in FBM FragmentedPHC system-care delivery segmentedby gender and age Poor gatekeeping-due to direct first contact with a large number of sub specialists working at the PHC level and a high hospital referral rate Limited continuity of care -due to frequent changes of general practitioners and multiple providers at the PHC level Low problem resolution capacity-with only 40 to 60 percentof problems solved at the PHC level, comparedwith over 90 percent in well-developed PHC systems Physician-centeredsystem-undervaluing other healthprofessionals Biomedical service model with curative focus -with insufficient diseaseprevention andhealth promotion activities Inequity incoverage and access - urban-rural and intercantonaldifferences 1 Poor infrastructure with low-quality, outdated, and poorly maintained equipment --compared with secondary and tertiarv care facilities Box4: PHCReformObjectives in FBM Developing auniversal "basic package" of good-quality services that is equitable, affordable, and cost-effective Providing freedom of choice with family physiciadgeneral practitioner Strengtheningcontinuity of care Strengtheningdoctor-patient relationship Enhancinggatekeepingto reduce unnecessary referralsto the secondary care level by establishingthe family doctor as the point of first contact inthe health system, and improving the capacity for problem resolution at the PHC level Improving the capacity of the family physiciansto coordinate healthcare services Improving the quality of PHC facilities and equippingthem appropriately 68. Under the 1997 Law on Health Care3', PHC was defined in FBIHto include activities o f the family doctor and general practitioner, school medicine, hygiene and epidemiology, dental care, occupational medicine, care o f women and children, and diagnostic and pharmaceutical activities. The Health Care and Health Insurance elements o f the law stipulated that each insured person was entitled to the "basic package of services" regardless o f available resources within a canton4' and that resources should be allocated to family medicine teams on the basis o f the number o f people served by each team. However, the law did not stipulate any entitlements for the uninsured and hence created huge inequities in access to an essential set of services, 69. The 1997 Law on Health Care broadly defined the activities for family physicians and the PHC teams, as well as the knowledge base and the skill sets they were expected to acquire. The law stated that one family medicine team should care for 1,800 to 2,000 residents. (As the population o f FBIH is around 2.4 million, the entity will require over 1,200 FM teams to achieve full coverage-a target set by the Federal Ministry o f Healthto be achieved by 2007.) 70. The Program for Specialization in FM developed by the Faculties o f Medicine in FBIH and RS was adopted by the respective Ministries o f Education and Health. (See section on resource generation and Annex 5). In FBIH the regulations ("The Rulebook") stipulating the curriculum and duration of training for the Family Medicine Specialization was published in the Official Gazette in February 1999.41(See section on FM training in FBIH,) 3.2. FINANCINGOF THE HEALTH SYSTEMAND PHCINTHE FBIH 3.2.1. Collection 71. In accordance with the FBIHLaw on Health Insurance,42health care is financed almost exclusively from the Compulsory Health Insurance (CHI) scheme. There are 10 Cantonal Health Insurance Institutes (CHIIS) and one Federation Health Insurance and Reinsurance Institute (FHIRI). 12 72. Income for the CHI scheme comes from the contributions paid by employers and employees. This income accounts for 94 percent o f the total income o fthe CHII. 73. The FHIRI has the responsibility for producing a financial plan for the FBIH health sector, drawing on the projections o f the CHII. The FHIRI, in collaboration with the Federation Solidarity Fund (FSF), estimates the total health expenditures and funds flow within the health sector. 74. In 2002, the total health insurance income was KM 694.5 million. Of this, KM 523 million (73.5 percent) came from the CHI and KM 171 million (26.5 percent) from other sources (Figure 5:). Figure 5: Sourcesof Incomefor HealthInsuranceInstitutionsinFBIH Sources of income for FBIH Health Insurance Institutions 80 70 60 50 40 30 20 10 0 Income from Income from Budget Income Other CMI co-payment Contributions Source 75. Average income o f each CHII from the employee and employer contributions varies based on the contribution base, different rates applied to specific categories o f insured persons, the number o f insured persons, level o f health insurance coverage, and the extent o f paid contributions (Figure 6:). Figure6: Incomefrom CHI per InsuredPersonand per Citizen 400 1 10Income by insuredperson 1 I 350 300 250 200 150 100 50 n 3.2.2. Pooling 76. Each cantonal government is responsible for determining the contribution rates for the CMI, appointing board members to the CHII, and recording and reporting payments and expenditures o f the CHII 13 to the Federation government. The FHIRI is responsible for implementing conventions and international agreements and providing reinsurance. 77. The FSF was established in2002 to reduce duplication o f services financed by insurance agencies and enable intercanton movement o f patients to receive health services when needed. This scheme is designed to reduce the fragmentation o f services between cantons and along ethnic lines, but also has an equity-enhancing effect, as patients from lower income cantons can access costly interventions previously available only to patients from better-off cantons. The FSF has eliminated the justification for ethnically based risk pooling. Consequently, in 2002, the Croat Inter-cantonal HealthInsurance Fundceased to exist. 78. The CHIIs contribute 8 percent of their revenue to the FSF. This amount i s supposed to be matched by contributions from the Federation budget, but in reality this does not happen. The FSF was established to finance priority vertical health care programs and help equalize health expenditures across the Federation. The FSF also finances complex and expensive health services, which are reviewed on an annual basis. Since the beginningo f 2004, the FSF has also started to finance some preventive programs, including immunization and the operating costs o fthe Agency for Accreditation and Quality Assurance. 3.2.3. HeaIthExpenditure Trends 79. In 2002, 41.7 percent o f the health insurance expenditures were for PHC, 34.4 percent for secondary care, and 4 percent for tertiary care (Figure 7:). Figure 7: CHIExpenditure by Category in 2002 ~~ Health Insurance Institutes Expenditures by Category (2002) 45 40 35 30 Perce 25 20 15 10 5 li 0 Primary Secondary Tertiary Federal Care care Care Solidarity E"nPnf4;tllt.PC Other 80. By purpose, the largest proportion o f expenditures was for salaries (45.6 percent) and drugs (21.3 percent) (Figure 8:). 14 Figure8: CHIExpendituresbyPurposein2002 I Compulsory Health Insurance Expenditures by purpose in 2002 50 45 40 35 30 25 20 15 10 5 0 Salaries Drugs and Other Capital Other medical materials investment Supplies Purpose 3.2.4. Out-of-Pocket Payments in PHC 81. The cantons set the guidelines for cost-sharing and determine the level o f co-payment for public services. The level o f co-payment changes according to the social status and income level o f the user. There is no regulation o f private sector out-of-pocket payments, which are determined by market mechanisms. A largely undocumented but significant amount o f under-the-table payments are made by patients to doctors when they receive services. 82. Although regulations stipulate that the patients pay half o f the co-payment to CHII and the other half to the provider, in practice, patients pay only the provider -which retains all co-payments. The providers credit this amount to CHII in their accounts, and then reallocate it as revenue from the CHII. Therefore, inthe provider accounts the co-payments appear as "payment to the provider institution from CHII," rather than out- of-pocket payment by patients. 3.3. KEYLEGISLATIVE CHANGES RS IN 83. The "Strategic Plan for Health System Reform and Reconstruction, 1997-2000" for Republika Srpska was published in 1997. It identified key structural problems with the RS health system and articulated the need for health reforms.43 The problems are similar to those identified for FBIH (Box 3:), but there is less fragmentation in service delivery due the more centralized nature o f decision making and the absence o f cantonal structures. 84. The health system reform objectives were articulated in the "Health Policy Targets and Measures in Republika Srpska by the Year 2020"44(Box 5:). 15 Box 5: Goals of the HealthReformand HealthPolicyTargets Health equity and solidarity Healthy life start -reduce infant and child mortality Reducerisk factors for health Reorientationto PHC Develop sustainable financing Establishneed-basedand fair resource allocation system Manage for quality of care Develop human resources for health Source: Ministry of Health and Social Welfare, RepublikaSrpska. HealthPolicy Targets and Measures in RepublikaSrpska by the Year 2020. BanjaLuka, 1999. 85. The "Strategic Plan for Health System Reform and Reconstruction, 1997-2000" and the "Health Policy Targets and Measures in Republika Srpska by the Year 2020" identified reasons for reforming PHC and the interventions to reform PHC. The reasons and objectives for reform are similar to those in FBIH (Boxes 3 and 4), but the policy documents identify clear targets in addition to general reform objectives (Box 6:). Box 6: PHCReformObjectives in RS Organizational reforms - restructuring PHC, refbrbishing centers, improving management capacity, introducing appointmentsfor consultation, and new data collection system Education reform - Establish Chair of F M at Banja Luka, develop new post-graduate curricula to train FM specialists, introduce F Mtraining in undergraduatestudies, training program for nurses Gradual introduction of the family doctor (FD) and the FM team -create 700 teams throughout RS, each serving approximately 1,800 to 2,000 patients Freedomof choice with family physicianigeneralpractitioner Enhance doctor-patient relationship to strengthen continuity of care Enhancinggatekeepingto reduce unnecessaryreferrals to the secondary care level -by establishingfamily doctors as the point of first contact inthe health system and improvingthe capacity for problem resolution at the PHC level Improve capacity of family physiciansto coordinate health care services PHC financing reforms -introduce weightedper capita and performance-relatedpay 86. In July 1999,the RS Parliament adopted The Law on Health Care, which introduced family medicine as a specialty.45 Article 23 o f the Law on Health Care stipulated, "The family medicine ambulanta (ordination) is the basic component o f primary health care in terms o f its organization. The family medicine team is the first point o f contact for citizens accessing the health care system." 3.4. FINANCINGOF THE HEALTH SYSTEM AND PHCIN RS 3.4.1. Collection 87. Following the introduction o f the 1999 Law on Health Insurance, the CHI system was established in RS, The family and household members o f the contributor to the Health Insurance Fund(HIF) are entitled to health insurance benefits. 88. The sources o f revenue for the HIF are (a) contributions to compulsory and extended health insurance (the extended health insurance has not yet been introduced); (b) budget contributions for the entity; (c) way o f applicable conventions; (0funds from state transfers; and (f) other funds, in accordance with the law. donations; (d) contributions from sales taxes on alcohol and tobacco (not yet introduced); (e) funds derived by 89. Contributions are based on a payroll tax and amount to 15 percent o f net pay (7.5 percent contributed by the employee and 7.5 percent by the employer). The self-employed contribute 15 percent o f net income, 16 pensioners, 3.75 percent o f the net pension, the unemployed, 10 Kh4 per month (paid by the unemployment fund); farmers contribute 16 percent of estimated property tax plus the difference to reach a minimum monthly contributionof 20 KM. 90. Around 75 percent of the HIF revenue comes from state sector employees andjust under 5 percent from public sector employees - indicating that a substantial proportion of those who are working in the privatesector and in particularthe informal economy do not contributetowardhealthinsurance(Figure 9:). Figure9: RSHIFSourcesofIncome I RS HIF Revenue by Source 90 80 70 3 60 E 50 1998 1999 - 0 2003 30 20 10 0 State sector Private RS Pension Farmers Other employees sector Government fund employees budget Source Source: Health ResourceAccounts, Bosnia and Herzegovina, Know How Fund and Health & Life Sciences Partnership, London, 1999. Business and Financial Report for the Fiscal Year 2003, RS Health Insurance Fund, BanjaLuka, March 2004. *2003 state sector and private sector employees aggregated. 91 Cnntrihiitinnc are naid hv each cinole entitv either niihlir nr nrivate tn the TTniniie Treaciini Arrniint (U IA), which is operated and controlled by the Ministry 01Finance - lreasury uepartment. Money rrom the UTA is transferred regularlyto the HIF. 3.4.2. Pooling 92. The only legal body responsiblefor the administrationandallocationof funds to health care providers in RS is the HIF. 93. The HIF has three levels: (a) the Central Office of the Fund, responsible for corporate strategy; planning and analysis; setting prices for health services; defining, signing, and monitoring contracts with providers; internal audit; and distribution of solidarity and risk funds; (b) regional offices, responsible for close monitoring of contracts and distribution of payments to providers; and (c) branch offices, responsible for providingsupport to their regionaloffices andmonitoringregistrationof membersandtheir entitlements. 17 3.4.3. HeaIth Expenditure Trends 94. In 2003, the HIF spent around 23.4 percent of its revenue on PHC, 32 percent on secondary care, and about 16 percent on tertiary care. Drugs accounted for around 10 percent o f the total expenditure (Figure 10:). Figure 10: Health Insurance Fund Expenditure by Category I YOof Total HIF Expenditure 35 30 % of Total HIF 25 120 e's $ '5 10 5 n - Rimry health Secondary health Tertiary heaith Drugs Haemdialysis care care Category cere Source: Business and Financial Report for the fiscal Year 2003, RS Health Insurance Fund, Banja Luka, March 2004. 3.4.4. Out-of-PocketPaymentsin PHC 95. The term "out o f pocket payment" in RS refers to legal co-payments and informal payments (gratitude and under-the-table-payments) to public providers, as well as formal payments to private providers. There are no systematically and regularly collected data showing the extent o f under-the-table payments, but these are assumed to be substantial in both entities and present the biggest barrier to health services, especially for those who are not entitled to receive "free" services covered by health insurance. A household survey in 1997, funded by the Know How Fund, showed that most citizens made direct payments to their public providers.46 18 4. KEYDEVELOPMENTSINPHCINFBIH 4.1. ORGANIZATIONOFPHCIN FBIH 96. Each o f the 87 municipalities in FBIH has a DZ, staffed by general practitioners, occupational medicine specialists, epidemiologists, obstetricians and gynecologists, pediatricians, and internal medicine specialists. 97. The DZs usually have a small laboratory and X-ray facilities, and in some cases ultrasound, endoscopes, electrocardiographs, and specialist advanced X-ray equipment. 98. Narrow specialists visit DZs on a regular basis to provide specialist services to patients. The frequency o f these visits depends on the size o f the DZ but also on influence o f local politicians and the DZ director. 99. There is a high referral o f patients from PHC to secondary-level hospitals or tertiary-level clinical centers because of: the low capacity o f the PHC level to resolve problems; the basic level o f training o f general practitioners; and disincentives created by the salary-based provider payment systems. Patients can go to hospitals directly without referral from GPs, further fracturingthe gate keepingfunction o f the PHC level. 100. Ambulantas are satellite units o f a DZ, located in rural areas and many villages. Usually staffed by a nurse and a GP, they provide basic ambulatory PHC services to a local population o f 2,000 to 6,000 people. Except for those refurbished by the World Bank and other donors, most ambulantas are structurally in poor condition and have only basic medical equipment. 101. First aid and emergency services are provided by dedicated emergency medicine units usually co- located with a DZ; some have their own premises. Very few o f these units have well-equipped emergency vehicles or ambulances. 102. Currently in FBIH, a total o f 2,220 doctors work in PHC -but o f these, only 316 work in family medicine, well short o f the 1,400 needed. 103. Primary health care professionals work in collaboration with specialists (such as the general internist, respiratory physicians, ophthalmologist, general and ear nose and throat (ENT) surgeons), who provide consultations in the PHC centers and take referrals from GPs and FM specialists. Even the PHC centers that have introduced the new FM model still have a large number o f narrow specialists. There are, as yet, no regulations stipulating the relationship between FM practitioners and narrow specialists. However, a bylaw stipulatingjob description and minimumstandards for FMspecialists is being developed. 104. There are plans to develop a system o f "patronage nurses'' who work independently o f the family physicians, but the role o f these nurses and the scope o f services they can provide are not defined. 105. Currently, the FM concept is being implemented in 60 rehabilitated FM ambulantas in three pilot cantons with 133 FMteams covering a population o f approximately 267,000. 106. A bylaw enabling establishment o f private practice was passed in2004. Regulatingprivate practice is the responsibility o f Cantonal Ministries o f Health. Private providers canjoin together to form private group practices, but are not entitled to sign contracts with the health insurance funds. Private practice is often organized in specialist polyclinics, but private FM does not yet exist. 19 4.2. DEVELOPMENT PHCHUMAN OF RESOURCES INFBIH 107. The Cantonal Ministries o f Health have the responsibility to develop an annual plan for training and development o f medical specialists. Since 1999, the cantons have prioritized the development o f FM specialization and have invested in in-service training programs. 108. A substantial proportion o f the large number of sub specialists in PHC centers do not want to be retrained as FM specialists. This has hindered the transformation o f these PHC centers into FM centers. Reducing the numbers o f sub specialists through natural attrition or redundancy is, at present, politically not feasible, and the FBIH government appears to have adopted a gradualist policy to address this issue. 109. The 1997 Law on Health Care, which established FM as a specialty, created FM departments as independent chairs (cathedra) within the faculties o f medicine. FMchairs have been appointed in Mostar and Tuzla but not Sarajevo. Teaching centers have been established at Sarajevo, Tuzla, and Mostar, with three satellite centers in Bihac, Ljubuski, and Zenica, operating effectively and providing training programs for FM teams. The teaching centers in Tuzla and Mostar are affiliated with the respective medical faculties. 110. The curriculum for specialist training in FM was developed in 1999 by the faculties of medicine in BIH and adopted by both the Federation and RS Ministries of Health. The details of the curriculum are published in both entities in the Rulebooks for FM, which specify the content and methods o f training for specialist and in-service FM training programs delivered by the FM chairs.47 The curriculum o f the FM specialist training program is based on internationally recognized principles (Annex 5). 111. Three training programs exist for family medicine: (a) a three-year FM specialist training program for new graduates with no work experience; (b) a two-year training program for PHC doctors who have less than 10 years' work experience and doctors who have over 10 years o f work experience and who have been granted the Certificate o f Doctor o f Family Medicine; and (c) a one-year in-service Program for Additional Training (PAT) for those who already have had training in related specialties and have a certificate from the Federal Ministry o f Healthrecognizing their specialty (Annexes 5 and 6). 112. Postgraduate studies for masters and doctorates in FM have not yet been introduced, although some FM specialists have postgraduate training in social medicine and public health. InFBIH,there are one family physician with a doctorate and six family physicians with master's degrees. 113. In FBIH in any one year, the number o f residents training in FM ranges from 40 to 50: clearly not adequate to meet current and future needs. This number is determined by the Rulebook on FMspecialization and the capacity o f the FM chair responsible for the residency training. To overcome this supply-demand gap, the World Bank Basic Health Project has supported the development o f PAT, in close collaboration with the Queen's University o f Canada, for in-service training o f physicians and nurses currently working in PHC centers.48 114. The curriculum for PAT, adopted in 2002, is used throughout Bosnia and Herzegovina (Annex 6). On successful completion o f PAT, doctors receive a Certificate o f FM Doctor or one-year credit toward the three-year F M specialist training Program. 115. In FBIH between 1995 and 2004, a total of 413 FM doctors/specialists were trained (Table 5:) representing around 30 percent o f the 1,200 FM teams needed. In the same period, a total o f 286 nurses graduated from PAT. 20 Name of the dom zdravjla Number of FM PAT1 PAT11 specialists/doctors Sarajevo 40 40 32 Tuzla 36 26 22 Mostar. Livno. MiddleBosnia 26 4 7 WH [spellout] 2 4 9 Other DZs 24 15 29 Subtotal 225 89 99 TOTAL 413 116. However, lack o f appropriate facilities and equipment, compounded by resistance from several DZ managers to introducing the FM model, means the trained FM teams are not fulfilling their role but instead delivering school medicine, occupational medicine, and emergency services. 117. Although the narrow specialists in PHC are less resistant to training as FM specialists, the ratio o f available to planned number o f FM specialist in the FBIH is 34.4 percent, compared with 28 percent in RS (amounting to 1.7 family doctors per 10,000 inhabitants inFBIHand 1.3 per 10,000 inRS). 118. In FBIH, in centers where the FM model has been implemented, the average list size per FMteam is 1,800, compared with 2,250 in RS -in line with international norms. In some PHC centers fully covered by the FM model, narrow specialists are also included in the FM teams and provide services for a smaller number o f registered patients -enabling the specialists to spend the rest o f their time working in specialist ambulantas. Nursing shortage is a problem, as the number o f trained FM nurses is less than that o f FM doctors/specialists. Although both entities have a target o f two FM nurses per FM specialist, it is difficult to see how this can be achieved in the medium term. Retention of trained FM specialists/doctors is a problem, as many leave their FMambulantas to attend postgraduate training programs inother specialties. 4.2.1. UndergraduateTrainingin FBIH 119. In both entities, FM training has been introduced in undergraduate medical studies. The training starts in the fourth year and comprises 150 hours o f theoretical classes and 255 hours o f practical trainin (Annex 7). In addition, there is training in the sixth year - with 30 hours o f theoretical classes (11 i semester) and 120 hours o f practical training (1lth 12'" semesters), which take place in the Tuzla and and Mostar FMteaching centers. 4.2.2. Trainingofwealth Managersin FBIH 120. With support from the World Bank Basic Health Project (WBBHP), a Health Management Center has been established in Sarajevo and fully refurbished to a high standard. The WB-financed BHP has also funded development o f curricula and training materials and training programs in health management for training o f trainers, short courses for top managers, and short courses for directors o f PHC centers. Around 25 trainers and 111 managers have been trained in these programs. In addition, a curriculum for a masters program in health management has been developed, Although it i s too early to evaluate the impact o f these training programs, a critical mass o f health managers have been trained in international health management concepts and practice to assist in scaling up the reforms. 21 4.3. KEYCHANGESINTHE DELIVERY OF PHC SERVICESINFBIH 121. The FM model introduced in FBIH extends the scope o f services delivered in the PHC setting to include health, education, promotion, prevention, diagnostic, curative, and rehabilitative services -enabling the FMteam to perform a gate keeping function and to provide comprehensive and continuous health care to its registered population, 122. Contracts between the FM teams and CHI1 specify the roles and responsibilities o f FM teams and their equipment (Annexes 1and 3). 123. An important feature o f the FM model in FBIH is that it is team- and not doctor-centric. The model emphasizes a psychosocial (as opposed to biomedical) approach, with a focus on holistic health, prevention, and promotion activities and the doctor-patient relationship. The FM specialists act as advocates for their clients -at both individual and family levels -to guide them through the health system and function as the link between different service providers. 124. The regulations do not clarify the boundaries between primary and secondary care. There are no guidelines on referral and counter-referral mechanisms or how hospital-based services can be shifted to the PHC. I n most PHC centers, FM is provided as an "add-on," along with general practice and narrow specialists' services. The result is fragmentation o f services, weakened gate keeping, and compromised first- contact functions o f the PHC. 4.3.1. PHC Gatekeeping, First ContactFunction, and Comprehensiveness 125. Inthe DZ where the FMmodel is established, the first point of contact for PHC services for patients is the FM specialist with whom they are registered. They usually access other PHC professionals or specialists following referral by the FMspecialist -except in case o f emergencies. 126. In PHC centers where the FMmodel is not yet established, the gate keepingfunction is compromised and first-contact access highly fragmented, as the services are organized according to age, gender, and health problems (as in the past) and in addition to non-specialist GPs, patients have direct access to a range o f narrow specialists (such as pediatricians, gynecologists, pre-school and school medicine specialists, occupational medicine specialists, and respiratory physicians). This i s a source o f considerable inefficiency, as the narrow specialists generally have a narrow and curative approach to patient care, with a tendency to excessive investigations and prescribing. In these centers, cervical smear tests for screening o f cancer o f the cervix are done by gynecologists, and immunization o f children is done by pediatricians. Inrural ambulantas without an FMspecialist, immunizationof school children is organized in an intermittent fashion. 127. In PHC centers that have implemented that FM model, there is emerging evidence o f improved patterns o f service provision by FM specialists compared with non-specialist GPs. For example, analysis o f services delivered by 24 FM specialists and 22 non-specialist GPs in PHC centers in Zenica-Doboj canton - covering 168,000 citizens, or 43 percent o f the cantonal population -showed that FM specialists were more likely to provide preventive services, refer less to hospitals, use fewer laboratory investigations, and undertake more home visits (Table 6: and 7). 22 Number of preventive Number of home Number of referrals to Number of referrals to services per 100 visits per 100 contacts specialist per 100 laboratory per 100 contactswith patient with patient contacts with patient contactswith patient General 6.8% 3.5% 28.3% 19.8% practice Family 17.4% 17.8% 23.8% 15.3% medicine Number of Number of Number of Number of Number of contactswith preventive homevisits per referrals to referrals to patient per team services per team team specialist per team laboratory per General 1 8,6 16 583 300 2,437 1,708 practice Family 7,266 1,266 1,478 1,73 1 1,111 medicine 128. Some PHC centers have developed community-based mental health services with wider community involvement to resolve mental health problems o f individuals or families. However, as mentalhealth services are still provided by specialists -even without a referral by family physicians -the full benefits o f these programs are not realized. Although the World Bank has provided a grant to train PHC providers to identify and treat mental health disorders in Middle Bosnia Canton, further training on mental health disorders is required throughout BIH. 129. In both types o f PHC centers (with or without FM specialists), the patients have a limited role in the referral process and are disempowered as regards the specialist and the secondary care unit to which they are referred. 4.3.2. PrescribingandDispensingofDrugsin PHC 130. The Federation Ministry o f Health has an approved essential drugs list, recommended for use in all cantons. The contract between the CHI1 and the PHC center or the FMteam stipulates an essential list to be used. However, as CHIIs do not have a commonly agreed essential drugs list, the number and range o f drugs available to patients varies by canton -in part determined by the financial strength o f each C H I . 131. Many pharmacies sell prescription-onlydrugs without a prescription. The pharmaceutical regulations are not stringently applied and the sales o f these drugs are not monitored. This further fragments the first- contact and gate keeping functions o f FM specialists. Injudicious use o f broad-spectrum antibiotics creates an increased risk o f antibiotic resistance. 4.3.3. Role ofPHCNurses 132. Prior to the PHC/FM reforms, the role o f a PHC nurse was mainly administrative -resulting in poor morale and low self-esteem, making nursing an unattractive career. Within the FM team model, the trained FM nurses have broadened roles and responsibilities. They work as valued members o f the FM team, delivering user-centered health services, including health education, promotion, prevention, and rehabilitation. 23 They work closely with families to provide necessary psycho-social and medical support. The FM nurses now play an important role in maintaining up-to-date records o f patient care, enhancing the continuity and coordination of health care. 4.3.4. Emergency Out-of-Hour Services 133. PHC centers are responsible for providing emergency care to patients in their catchment area between 4 pm and 8 am. In small health centers, emergency care is provided by FM physicians who organize a duty rota. In large health centers, ambulance services provide first aid services, emergency care, and support to the emergency departments attached to the DZ. When necessary, the ambulances transport patients to general hospitals, or in severe cases, directly to clinical centers (university hospitals). 4.4. RESOURCE ALLOCATIONFORPHCINFBIH 134. In 2003, total expenditure on PHC in the FBIH, without prescribed drugs, was KM161 million, accounting for 33.1 percent o f the total CHII health expenditures. The expenditure on prescribed drug was KM53.4 million, accounting for 11percent o f the total CHII expenditures. 135. In the same year, the expenditures on secondary and tertiary care (in-patients and out-patients) were KM177 million and KM20.4 million, respectively, accounting for 36.4 percent and 4.18 percent, respectively, o f the total CHII expenditures. 136. In addition to the CHII expenditures, the FSF spent a similar amount (around KM20.4 million) on tertiary care and vertical and priority health care program^.^' 4.5. PROVIDER PAYMENT SYSTEMS AND CONTRACTSFOR PHC INFBIH 137. The CHIIs contract health institutions to provide services to the beneficiaries - although most contracts specify the scope o f services to be provided, in some cases the CHIIs merely pay a fixed amount o f money to the providers. 138. The Federal Solidarity and Reinsurance Institute are responsible for contracting with specialized health providers for priority vertical health care programs and complex health services. 139. The scope o f the FM team health care program is determined according to the FM standards and norms defined in law, which specify (a) the structure o f health care services, (b) scope o f health care services by number o f users (insured persons), (c) the quality o f health care services, and (d) staffing norms, space, and equipment as a precondition for appropriate quality o f services. 140. According to regulations, the cost o f an annual health care program provided to a defined population by an FM team should be determined according to (a) the average time spent by the FM team on service delivery, their salary level, employment benefits, transport costs, and subsistence expenses; (b) recurrent operating costs; (c) depreciation o f fixed assets (space and equipment); (d) investment; (e) continuous maintenance; (0 the content o f services, and (g) the number o f users served by the FM team. However, in reality, the program costs do not take all o f these factors into account due to a lack o f data. 141. The WBBHP aimed to test two payment mechanisms: (a) direct contracting between the CHII and an FM team led by an FM specialist (Herzegovina-Neretva and West Herzegovina cantons) and (b) indirect contracting with contracts at two levels -between the CHII and a DZ and then between the DZ and an FM team led by an FM specialist. Although it was not possible to implement direct contracting due to inadequacy of laws, new payment mechanisms based on weighted capitation have been developed and successfully 24 introduced in Tuzla, Herzegovina-Neretva, and West Herzegovina cantons. Up to 66 FM teams have signed contracts with the CHI1 based on weighted capitation, providing them somewhat higher income compared with GPs. The weighted capitation formula uses varied weights for different age groups: for 0 to 7 years o f age, a coefficient o f 2 (KM35.18); for 7 -to 18 years o f age, a coefficient o f 1 (KM17.59); for 18 to 65 years o f age, a coefficient o f 1.5 (KM26.39); for over 65 years o f age, a coefficient o f 2.5 (KM43.98). 142. The contract defines the rights and responsibilities o f the contracting parties as regards provision o f PHC services, and stipulates (a) type and scope o f services; (b) structure o f family medicine team; (c) framework for physician accountability; (d) place for service delivery; (e) method o f delivering services; (f) funds allocated by the health insurance institute; (g) payment methods; (h) method by which the payment is calculated; (i)contract payment terms; 0) infrastructure specifications; (k) required documentation for reporting; (1) monitoring o f performance and quality; (m) obligations regarding fulfillment o f relevant decrees; and (n) contract rights and responsibilities. An example o f an FM contract is appended in Annex 1. 143. The contracts in FBIH do not cover preventive services or allow for bonus payments -unlike the contracts in RS, which do. Further, absence o f appropriate legislation means that introducing performance- related element to these contracts has not been possible. 144. Operationalizing these contracts has been challenging due to a deficient legislative base regarding the status o f the FM teams; a lack o f management and financial skills at DZ and FM team levels; absence o f appropriate monitoring and evaluation systems; and no indicators for measuring quality, effectiveness, or efficiency o f services. The authorities are testing the new provider payment systems for FMteams within the bounds o f the regulations so as not to create asymmetry with the prevailing pay levels in the PHC system. Preliminary evaluations show that the FM teams contracted by the new scheme have attracted new patients for registration. 145. The expansion o f the new payment mechanisms and contracts will require consensus o f key stakeholders and changes in existing legislation to (a) clearly define the roles and responsibilities o f the FM teams and other health providers; (b) address and correct anomalies in laws and standards relating to the contradictory definitions o f a "user" (according to the Law on Health Insurance, a health care user is a person covered by health insurance, but according to the 2003 Health Care Standards and Norms, a user is defined as a citizen o f FBIH); (iii)clearly stipulate health care entitlements for C H I beneficiaries and non-insured citizens -for instance, specifying an "essential benefits package" for all citizens and an "additional benefits package" for C H I beneficiaries; (d) clearly define who is responsible for covering the costs o f health services provided to the uninsured; (e) define the scale and scope o f services to be provided by FM teams; and (f) specify provider payment methods that can be used, along with incentives for performance related pay. 4.6. INFRASTRUCTURE AND EQUIPMENT AT PHC FACILITIESINFBIH 146. There is a standard list o f equipment adopted by both entities for FM specialists and PHC centers. Prior to the war, PHC centers had access to essential equipment, but after the war much o f the equipment was destroyed or became obsolete. 147. The FM ambulantas refurbished under the WBBHP have been provided equipment appropriate for FM practice. The equipment varies according to the number o f FM teams working in the ambulanta. The number o f FM teams working in a PHC center depends on the catchment's population. FM ambulantas situated at a distance o f 10 kilometers or further from a DZ have a mini-laboratory as well as test-strips for urinalysis. Plans to establish mini-reference-pharmacies in these ambulantas were prevented by lack o f legislation. FM ambulantas refurbished by other donor projects have medical equipment commonly used by family physicians. 25 4.7. PHCINFORMATION SYSTEMSIN FBIH 148. Data collection in PHC centers is uneven due to lack o f coordination among cantons and absence o f commonly agreed metrics and a shared core data set for PHC, among other things. Changes introduced by one canton are not adopted by others. Data collection forms currently in use generate an excessive amount o f data o f variable quality, which are collected and sent to the Ministry o f Health and Public Health Institute. However, many o f these data are not analyzed, and when they are analyzed, very limited information is fed back to the PHC level. There is, hence, no incentive for PHC providers to collect accurate and timely data. 149. New reporting forms are being designed by the Federation Health Insurance Institute (HII) for the newly restructured health centers to meet the needs o f the PHC level, the Ministry o f Health, and the HII. With the introduction o f performance-based contracts between the HIF and the PHC providers, there will be incentives to collect accurate and timely data. 150. A proprietary software program designed for collection o f patient information and other relevant data was piloted in some o f the FM ambulantas established with support from the WBBHP. The program is being used by the FM ambulantas for daily operations However, due to coordination problems between the Federation HI1and the Public Health Institute, the software program is not yet used to aggregate data at a higher level, Further, the existing laws require paper-based data submission, limiting the utility o f the electronically collected data. 4.8. LICENSING AND REVALIDATION FBIH IN 151. The 1997 Law on Health Care stipulated that the Chambers o f Medical Professionals are responsible for issuing licenses for health professionals. The Cantonal Ministries o f Health have the responsibility for monitoring the work o f these Chambers. However, as Chambers have not been established in all cantons, the licensing o f health professionals is uneven and there are no mechanisms for revalidation. 4.9. ACCREDITATION IN FBIH 152. An Agency for Health Care Quality and Accreditationwas established n 2004 under the WBBHP but not yet formally approved, as the Federation Parliament is currently considering the Law on Health Care Quality and Safety and Accreditation. With international technical assistance, the Agency has designed a framework for assessing quality standards in health provider institutions in three main areas: (a) organization governance; (b) risk management, and (c) patient-focused care, and specific services for both patient and team. 153. An information package on accreditation has been developed for PHC institutions, explaining the accreditation process and terms and conditions for contracts for accreditation. Quality standards have been developed for hospitals. A set o f basic tools for assessing quality standards o f health care providers has been developed and a cadre o f assessorstrained. However, to date, accreditation has focused on hospitals. 4.10. PROFESSIONALASSOCIATIONS IN FBIH 154. The FBIH Association of Family Medicine Physicians was established in 2000, along with its counterpart in RS, and in 2002 accepted to the membership o f WONCA - Europe. 26 5. KEY DEVELOPMENTSINPHC INREPUBLIKA SRPSKA 5.1. ORGANIZATION OF PHC INRS 15.5. The organizational structure o f PHC in RS is similar to that in FBIH, although following recent modificationsto the law, this is changing. 1.56. According to the Law on Health Care, the FMambulanta was the basic organizational unit at the PHC level: covering villages and rural areas usually with one or more FMteams and organizationally part o f a DZ. Cities and towns had a DZ with multidisciplinary teams. DZ Banja Luka, the biggest in RS, covers approximately 250,000 citizens. DZs and FM ambulantas are owned by local municipal authorities and employ salaried staff, except for pilot sites where contracts for FMteams have been introduced. 157. According to the planned new law on PHC, ambulantas will become autonomous FM units and have an option to create a group practice independent o f the DZ. Group practices were recently introduced in DZ Laktasi -a pilot municipality for PHC reforms. 158. An FM team in RS is composed o f two nurses and a family medicine doctor, who leads the team. The FM ambulantas are responsible for (a) organizing health education; (b) monitoring the health o f the population and taking steps to detect, prevent, and combat infectious and non-communicable disease; (c) diagnosing and treating common illnesses; (d) providing home-based treatment for those not requiring hospital care; and (e) providing extended care and rehabilitationfollowing discharge from hospital. 5.2. DEVELOPMENT OF PHC HUMAN RESOURCES INRS 159. InAugust 1999, the RS Ministry ofHealthand SocialWelfare (MOHSW) adopted"The Rulebook on Family Medicine Specialization Program" (FMSP)." The Rulebook specifies in detail the curriculum for the FMSP. 160. In May 2003, "The Rulebook on Program o f Additional Training in Family Medicine" (PAT) was ad~pted.~'The Rulebook on PAT also covers the training o f PHC nurses.52 161. Two training centers established by the WBBHP, Banja Luka Teaching Center and Doboj Satellite Teaching Center, work effectively. A pilot FM center has been established at Laktasi. Training in RS is supported by the WBBHP, the Canadian International Development Agency (CIDA), the Swiss Cooperation, Project Hope, and MCdecins Sans Frontihes (MSF), with Queens University o f Canada providing technical assistance. 162. There is a healthy demand for FM training - for instance, 11 narrow specialists in DZ Laktasi recently joined the PAT to become FM doctors. 163. In RS, to date, a total 168 FM doctors and 154 nurses have been trained through the PAT (Table 8:). The required number o f FM teams in RS is estimated to be around 600, although no PHC human resources plans exist. 27 Table 8: Number ofFMDoctorsinRSby June 30,2004 Source: RS Ministry of Health. [or MOHSW?] 5.2.1. UndergraduateTrainingin RS 164. The structure and content o f FMtraining in undergraduate curriculum is similar to that in FBIH(see section on undergraduate training in FBIHand Annex 7). 5.2.2. TrainingofHealthManagersinRS 165. With support from the WBBHP, an Institute for Health Management has been established in Laktasi and refurbished to a high standard. The WBBHP has also funded development o f curricula and training materials and training programs in health management for training o f trainers, short courses for top managers, and short courses for directors o f PHC centers. To date 20 trainers and 38 managers have been trained in RS. Inaddition, a curriculum has been developed for a masters program inhealthmanagement. 5.3. KEYCHANGESINDELIVERYOF PHCSERVICES INRS 166. The FM model in RS follows four core principles: (a) first contact, (b) longitudinality, (c) comprehensiveness, and (d) coordination. Key changes in the PHC system have focused on achieving these principles. 167. By April 2004, 233,000 people in RS (23 percent o f the population) were covered by FMteams. By end of 2004, this number was projected to increase to 250,000. The coverage in the pilot sites is greater: (a) Banja Luka 60 percent, (b) Laktasi 100 percent, (c) Doboj 40 percent, (d) Celinac 80 percent, and (e) Panjavor 35 percent. Although Panjovar was initially not part of the WBBHP, limited support provided to the municipality was leveraged by the local government to introduce FMteams. 168. The FM specialists have a broad scope o f services, including health, education, promotion, prevention, diagnosis, and curative and rehabilitative services. They perform gate keeping functions and provide comprehensive and continuous health care to their registered populations. FM specialists have a contract with the Health Insurance Fund through their DZ. This contract articulates their roles and responsibilities and identifies equipment they should have. (See Annexes 2 and 3 and the section on provider payment systems and contracts in RS.) 169. The workload o f the FM specialists and GPs in RS varies by region and typically comprises consultations, medical examinations, and a number o f additional services. A study that explored the workloads o f FM specialists and GPs in DZ Banja Luka showed that around 65 percent o f the GPs' activities and 78 percent o f the FM specialists' activities were consultations and clinical examination^.^^ 28 5.3.1. First Contactand GatekeeperRole ofFM 170. In its "Strategic Plan for the Reform and Reconstruction o f the Health Care System," published in 1997,54the MOHSW specified that each family should be registered with a named FM specialistldoctor and that the citizens should have the right and the freedom to register with an FM specialist o f their choice. This objective has been achieved to a large extent, 171. Inthe DZ where the FMmodel has been implemented, the users access their FMdoctor as the first point o f contact and the narrow-specialists in PHC centers and hospitals following a referral by their FM specialist (except for emergencies). In the PHC centers where the FM model is not established, the gate keeping function is compromised and first-contact access fragmented, as the services are organized according to age, gender, and health problems (as in the past). In addition to non-specialist GPs, the citizens have direct access to pediatricians, gynecologists, pre-school and school medicine specialists, occupational medicine specialists, and respiratory physicians. 5.3.2. LongitudinalCare and Continuityof Care 172. In PHC centers where the FM model is established, a patient appointment system has been introduced. Having named FM specialists has strengthened the doctor-patient relationship and enhanced continuity o f care. 5.3.3. Comprehensivenessof Care 173. In the refurbished PHC centers piloting the FM model, new equipment and infrastructure improvements have created a favorable environment for expanded service delivery for chronic illness, infectious diseases, pediatrics, gynecology, sexually transmitted diseases, mental health, tuberculosis, and minor surgery. 174. Further, following the implementation o f the Program for Prevention and Control o f Non- communicable Diseases (adopted by the MOHSW in2002)55and "Guidelines for Detection and Reduction o f Risks Factors and Early Detection o f Non-Communicable disease^,"^' the FM specialists now provide a broad spectrum o f health education, promotion, and prevention services to the populations they serve. 5.3.4. Coordinationof Care 175. Coordination o f health services has been enhanced through introduction and improvement of problem-oriented medical records and a referral counter-referral system. 176. Duringthe implementation o f the WBBHP, the RS Project Coordination Unitteam, together with the management o f pilot DZs, enforced the regular and systematic use o f patient medical records and introduced a proprietary software program for FMs to capture accurate and reliable patient information on patients, activities, and trends, This information will enable the FM teams to improve decision making by providing them timely information on health care needs o f their individual patients and the populationthey cover. 177. The "Rulebook on Referral System in Health Care o f Republika Srpska," produced with input from the FM specialists in RS and subsequently adopted by RS MOHSW,56has introduced evidence-based clinical guidelines for 20 o f the most common conditions encountered at the PHC level. The guidelines define management of these conditions by FM specialists and thresholds for referral to the specialist and secondary level (Annex 4). 29 178. Analysis o f the work o f FM teams in DZ Laktasi (the first DZ in the RS with a functioning FM model) following the introduction o f guidelines shows, when compared with levels for other DZs, a decline in referrals to hospitals and specialist services, reduced laboratory and imaging diagnostics tests, and fewer prescriptions. 5.3.5. Prescribing andDispensing ofDrugs 179. A "List o f Essential Drugs" was introduced in 1997 and revised in 1999 in collaboration with the World Health Organization (WHO). The manual, "`The Essential Drugs o f Republika Srpska (247)," published in collaboration with UNICEF in 1999, has been distributed to all health professionals in RS, including general/FM doctors, to promote rational pre~cribing.~'However, the FM training curriculum is not aligned with the essential drugs list, an issue that needs to be addressed. 180. Every year, the HIF in RS decides on a positive drug list o f over 300 drugs that can be used by general/FM doctors working at the PHC level. The state pharmacies are reimbursed for dispensing the drugs on this list according to a reimbursement system based on a reference price list that averages the prices o f drugs from the 10 largest wholesalers. The private pharmacies are excluded from the HIF reimbursement system. 5.3.6. Role ofFMNurses 181. As in the FBIH, prior to the PHC/FM reforms the role o f the FM nurse was mainly administrative, with consequent adverse effects on morale, self-esteem, and the attractiveness o f nursing as a career. Within the FMteam model, the trained FMnurses have broadenedroles and responsibilities and work as members of the F M team, delivering user-centered health services, including health education, promotion prevention, and rehabilitation. The trained FM nurses work closely with families to provide psycho-social and medical support and play an important role in maintaining up-to-date records o f patient care, enhancing continuity and coordination o f health care. 5.3.7. Out-of-Hours EmergencyServices 182. PHC centers are responsible for providing emergency care to patients in their catchment area between 4 pm and 8 am. In small health centers, emergency care is provided by FM physicians who organize a duty rota, and in large health centers by full-time physicians. 183. Ambulance services provide first aid services, emergency care, and support to the emergency departments attached to the DZ. When necessary, the ambulances transport patients to general hospitals, or in severe cases, directly to clinical centers. 184. In areas where the FM model has not been introduced, the emergency care system functions as an expensive substitute for the FM system. Analysis o f the type and range o f services provided by the emergency services at DZs where the FM model has not been fully implemented shows that over 65 percent of the services could be provided by an FM specialist. An analysis o f the number and structure o f health services provided at the emergency department inthe DZ Banja Luka demonstrates the extent o f this problem, with emergency services substitutingfor FM(Table 9:). 30 Table 9: Number and Type Services Provided at EmergencyDepartment of DZ BanjaLuka in2001 I Type of service 1 Number of services 1 percentof 1 Doctor's examination(all kinds of examinations) 18,438 35.35 Renderingemergency services (all kinds) 14,855 28.48 Injections (all kinds of injections and infusions) 16,351 31.35 Small wounds dressingwith stitches 123 0.23 Small wounds dressingwithout stitches 615 1.18 Incisions 16 .. Bandaging 1,757 3.37 Total 52,155 100 5.4. RESOURCE ALLOCATIONFORPHCINRS 185. In 2000, the HIF assembly adopted the Decision on the Distribution o f the Health Insurance Fund Revenues.s8 According to this decision, compulsory health insurance revenues, which account for 91.4 percent o f the HIF total revenues, will be allocated for financing health services according to a formula that will apportion 40 percent to PHC and 60 percent to secondary and tertiary health care services. This is one o f the highest proportions o f health expenditure allocated to PHC in the whole o f the ECA region, along with Moldova, which allocates 35 percent o f its public health budget to PHC. 5.5. PROVIDER PAYMENT SYSTEMS AND CONTRACTSFORPHCINRS 186. Salaries have been the predominant formal provider payment method used in the public sector. Physicians in RS have been remunerated according to a fixed amount in relation to time spent at work, with marginal differences in salary levels determined by the type o f institution in which the physicians work and their academic and professional qualifications. The general practitioners' income is just above average salaries in RS, while the hospital specialists earn around twice as much. 187. The FM reforms have introduced a contractual relationship between the HIF and DZs and remuneration according to simple and weighted per capita methods. The HIF sets a per capita pay rate by dividing the total funds allocated to PHC by the number o f citizens registered by the RS HIF. The DZ and HIF negotiate a pay level according to (a) the number o f insured people inthe catchment area; (b) the types o f PHC service providers it employs (e.g., FM specialists, general doctors, subspecialists); and (c) the PHC services it provides (e.g., general/family medicine, protection o f pre-school children, protection o f school children, protection o f women, pulmonary, mental health, physical rehabilitation, drugs, laboratory, X-ray and ultrasound, preventive dentistry, emergency, and hygiene and epidemiological services. (These PHC providers represent the current, classical structure o f DZs in which the model o f family has not yet been established.) 188. In 2004, a weighted capitation formula was introduced in DZ Laktasi, which is staffed by entirely by FMteams. This formula is risk-adjusted according to (a) gender, (b) age, (c) average utilization of services on the PHC level, and (d) average price per PHC service. The coefficient for age ranges between 0.94 and 2.73, depending on six age cohorts: 0 to 1year, 2 to 6 years, 7 to 15 years, 16 to 30 years, 3 1 to 64 years, and above 65 years. 189. A contract has been established between the HIFand the DZ director, who inturnhas signed separate contracts with each o f the 15 FMteams. The contract, which is signed by the director o f the DZ on behalf o f the FMteam, specifies (a) the roles and responsibilities o f the FMteam; (b) the scope and range o f services to 31 be provided; (c) population covered; (d) quality standards to be observed; (e) prescribing lists (positive list and the essential list o f drugs); (f)opening hours; (g) reporting mechanisms; (h) payment method and amount; (i)payment duration; and (`j)mechanisms for arbitration in case of disputes (Annex 2). Provision o f preventive services is part o f this contract and attracts additional remuneration. Further, a 10 percent bonus payment is payable to each FMteam if it is satisfactorily accredited by the RS AAQI. 5.6. INFRASTRUCTURE AND EQUIPMENT PHCFACILITIES RS AT IN 190. The Law on Health Care allows MOHSW to implement quality control programs for health services and to set standards for functioning health care institutions -specifying the number and structure o f human resources, infrastructure, and equipment -and ensure use of modern evidence-based interventions for health care. 191. The "Rulebook on Family Medicine Specialization Program" defines normative standards -interms o f space, equipment, and personnel - for every type o f health facility.59The Law on Health Care and the contract between the HIF and the DZ specify different equipment lists for ordinary ambulantas staffed by non-specialist general doctors and FM ambulantas staffed by FM specialists -reflecting the extended role and responsibilities o f the FM specialist as regards clinical care (Annex 3). 192. In the DZs that have introduced the new FM model, physical changes have been made to the work environment according to the needs o f the FMteams, and this has improved the privacy o f consultations. 5.7. LICENSING REVALIDATION RS AND IN 193. In July 2001, RS Parliament adopted The Law on Health Chambers,60 which established a unified Chamber for licensing o f health professionals working in RS. This law was amended in 2002, enabling the division o f the unified health Chamber into three Chambers - one each for doctors, dentists, and pharmacists. Article 1 o f the amended law obliges doctors who are working in public and private health facilities to be members o f the Doctors' Chamber. Article 5 stipulates that the "Doctors' Chamber has the responsibility to issue certificates (licenses) to its members." 194. The Chamber has an important role in quality assurance o f health services and is responsible for (a) determining professional rights and obligations, ethical and deontological rules o f conduct for health professionals; (b) verifying medical knowledge of health professionals and providing appropriate certification; (c) renewal or cancellation o f medical licenses o f health professionals; and (d) issuing opinions on medical training curricula. 195. All practicing medical doctors are obliged to become members o f the Chamber. Licenses are renewed every five years. Members o f the Chamber are required to engage in continuing professional development activities organized or approved by the Chamber and accumulate 60 points each year to renew their license to practice.. 5.8. ACCREDITATION INRS 196. Following the Law on Changes and Additions on the Law on Health Care6' adopted by RS Parliament in 2001, the AAQI was established in 2002 and operationalized in 2003.62The AAQI is a state agency that has a trained a cadre o f assessors, Accreditation is voluntary. The AAQI provides support to FM teams, practices, or departments o f FM in the PHC centers registered with the RS MOHSW that wish to be accredited. There are 11 accreditation standards, grouped into five main areas, which must be met by the FM team or PHC center to secure full accreditation (Table 10:). 32 Table 10: AccreditationStandards (i)Practiceservices Standard 1.1 Patientaccess Standard 1.2 Communication with patients Standard 1.3 Clinical care Standard 1.4 Promotion health and disease prevention Standard 1.5 Rights and needs of patients (ii)Medicaldocumentation Standard 2.1 Appropriate medical documentation (iii)Controlandqualityassurance Standard 3.1 Quality control (iv) Practice staff Standard 4.1 Qualifications and training (v) Physicalfactors Standard 5.1 Practicepremises Standard 5.2 Practiceequipment Standard 5.3 Physicalaccess 197. In 2004, 15 FMteams in DZ Laktasi were evaluated over two days by 18 assessors and fulfilled the requirements to be granted full accreditation. 5.9. PROFESSIONALASSOCIATIONSINRS 198. The Association o f Medical Doctors in RS was established in 1993, as recommended by the Law on Citizens' A~sociation.~~The Association covers all o f RS and is a professionally led voluntary organization with non-governmental organization status. The Association consists o f branches o f different specialties, one of which is the Association o f Family Physicians, which was registered in May 2000, and which has 120 members. Doctors voluntarily join their specialist branch o f the Association. Along with its FBIH counterpart, the Association was accepted in 2002 to membership o f WONCA - Europe. 5.10. PHCINFORMATION SYSTEMSIN RS 199. In most PHC providers in RS, there are no management information or monitoring and evaluation systems in place to regularly capture meaningful and timely data on activities o f the PHC teams and the health status o f their patients. 200. Although huge amounts o f health, financial, and administrative data are manually collected and sent by PHC centers to the Public Health Institute and the HIF (Annex 8), due to limited human resource capacity at these institutions and lack o f incentives, there is limited analysis o f these data to assess the performance o f the PHC team or to inform policy. This problem has been recognized, and through the WBBHP the RS MOHSW has developed a software application program for use by the FM teams to bundle administrative, medical, and financial data into a single application, integrated at a central metadata system to enable tracking, scheduling, and monitoring as well as to provide timely and reliable data to the FM team on daily activities, activity trends, and operating costs. This software is also being used in some pilot ambulantas in the FBIH. The software has been successfully piloted at DZ Laktasi and will be scaled up to cover all the PHC provider units in RS and FBIHto pool data inrespective metadata sets for processing and analysis. 33 6. TASK PROFILEAND FACILITY SURVEY RESULTS 201. As part o f this study, a cross-sectional facility survey o f 17 DZs inthe FBIHwas undertaken. The survey covered three DZs in Banja Luka, Laktagi, and Prijedor municipalities in RS and seven DZs inMostar, CeliC, Citluk, Kalesija, Tuzla, iivince, and Ljubugkiregions o f the FBIHand included 87 facilities: 42 from the FBIH and 45 from RS (Table 11:). The number o f PHC facilities with FM physicians and non-specialist GPs was evenly distributedand included 199 doctors: 99 from RS and 100 from FBiH(Table 12). Ordinations Physicians FM General (facilities) Surveyed Physicians Practitioners Federationof Bosniaand 1 42 100 45 55 Herzegovina Republika Srpska 45 99 55 44 Bosnia and Herzegovina 87 199 100 99 Table 12: Distribution of Ordinations with Family Physiciansor GPs 1 Federation of Bosnia and I Republika Srpska Herzegovina GP FMP GP I FMP 23 23 23 22 202. The main objective o f this cross-sectional survey was to identify similarities and differences between family medicine practice and general practice in terms o f quality, scope, and availability o f services. The survey was deigned to capture detailed information on how practices are organized, location and condition o f facilities used for practices and equipment in them, as well as population covered by practices. The survey also identified the scope o f services provided in PHC (curative, preventive, and promotive), the continuity of care for the population, availability o f necessary staff and changes to staff during the last few years, infrastructure, equipment for examination and treatment, and availability o f medications for common emergencies. 203. The survey was conducted by teams o f trained interviewers, using an instrument designed by Dr. Atun and his team, which was iteratively refined after piloting and discussions with field-based researchers. The survey implementation started in April 2004 with training o f surveyors and the survey took place from May to June 2004. Data entry started in June and was completed ended by the end o f July 2004 by two trained staff in RS who also undertook coding o f the instrument and the data captured. Statistical software SPSS 11Q was used for data entry and processing. 204. In addition, a task profile survey, using an instrument developed by the W. Boerma o f the Nivel Group in the Netherlands, was used to interview the 199 doctors (Annex 9). 6.1. CHARACTERISTICS OF THE ORDINATIONS 205. The ordinations surveyed were mainly situated in small towns, with 76 percent o f all ordinations in settlements with less than 50,000 inhabitants (Table 13:). 34 Table 13: EstimatedNumberof Citizens inPlacesWhere OrdinationsAre Situated I Populationin areaswhere ordinationis situated I N I percent under 10,000 1 74 11I 39.2 10,000 - 50,OO.O 70 37.0 50,000 - 100,000 15 7.9 over 100,000 30 15.9 Total 189 100 206. Around 67 percent o f the ordinations were in urban areas (Table 14:) and 60 percent were less that 10 km from the nearest hospital (Table 15). Table 14: Locationof Ordinations N percent city center 73 36.7 City 45 22.6 City suburb 15 7.5 Mixed suburb and country area 25 12.6 Country 41 20.6 Total 199 100 Table 15: Distanceto the NearestGeneralHospital N percen Less than 5 km 5-10km More than 10 km 74 39.6 Total 187 100 6.2. RESPONDENT CHARACTERISTICS 207. The sample consisted o f 47 male (24 percent), and 152 female doctors (76 percent). The average age o f the respondents was 40. The youngest respondent was 25 years old and the oldest 68 (Table 16:). Table 16: Age Distribution I F I Dercent I Under30 31 -40 41 -50 Over 50 *Total non-respondent [where 100 One should * appear in the table?] 208. Almost half the respondents were family physicians (99) and 100 were Family Medicine doctors o f whom 29 were intraining as FMspecialists (Table 17:). 35 Table 17: Specialization ofFamily Medicine Program f percent Sucha programdoes not exist inthe district 2 1.o No 63 32.6 Yes 99 51.4 Educationinprogress 29 15.0 Total 193 100 GP FMP Total Salariedemployment 93 99 192 No additionalposition 45 58 103 Additionalemployment-Salaried 2 2 4 5 ______- 1 3 4 Additionalemployment- Self-employedwithout contract 3 4 7 210. GPs were significantly more likely to work alone (p < 0.01) than with FPs, who were sign ficanf Y more likely (p < 0.01) to be in shared accommodationwith up to five or more other doctors (Table 19:). GP FP Total up to 5 19 29 48 6 to 10 3 14 17 11 and more I 6 1 3 1 9 I Totalsquare test Chi I1 p < 0.005 28 I 46 1 74 I 211. In line with the law, which prescribesaworking-week of 40 hours or less, most respondentsreported an average of 38 hours of work per week, with arange of 20 to 48 hours (Table 20:). N Min M a x Mean Std. Deviation Regularservices 199 20.00 48.00 38.22 2.83 Emergency1on call 11 2.00 20.00 9.72 5.65 62.1. Educationand Training 212. On average, the participants spent 32 hours a month on professional improvement activities, with a range of 2 to 150 hours. However, the results are skewed by the fact that 29 doctors were undergoing FM training. The mode was 16 to 30 hours (Table 21:). 36 Table 21: NumberofHoursSpent on ProfessionalDevelopmentper Doctor per Month I1 N percent Less than 15 hours 11 52 II 26.9 11 16-30 hours 3 1-45 hours 46 -60 hours More than 60 hours Total 193 100 213. There was no statistically significant difference in the time spent in professional development by general and family physicians, even though 29 GPs were intraining to become family physicians (Table 22:). Table 22: HoursSpent onProfessionalDevelopmentperMonth by ProfessionalCategory GP FP Total Less than 10 12 21 33 11-20 22 26 48 21 -30 21 28 49 31 -40 9 9 18 I 4 1-50 I 2 I 3 1 5 1 I 1Total 1 92 I 96 1 188 1 214. Around 47.5 percent o f the 99 doctors who were trained in FM had a three-year postgraduate education in FM. The length o f postgraduate training ranged from six months to eight years (Table 23:). Table 23: LengthofTraininginFamilyMedicine f perce 47.5 Morethan 3 years 3.O Total 215. A large majority o f those trained in FM (86.9 percent) undertook their postgraduate training between 1995 and 2004, with 38.5 percent graduating in2003 (Table 24:). Table 24: Year When TraininginFamilyMedicineWas Completed percent 1975- 1984 1985- 1994 1995-2004 86 86.9 Total 99 100 37 216. Although 75.4 percent o f the FM physicians surveyed had been in medical practice for over five- years (Table 25:), a majority (68.3 percent) had worked for less than five-years as FMphysicians (Table 26). Table 25: Years Worked as a Medical Doctor f Less than 5 49 24.6 I 5 t o 1 0 1 47 II 23.6 1 10to 20 77 38.7 20 to 30 20 10.1 More than 30 6 30 Total 199 100 I I I I Tabie 26: Years Worked as a Family Physician/GP Specialist I f I percent I Less than 5 5 to 10 20 to 30 More than 30 4.8 Total 6.3. PATIENTLISTSIZE AND REGISTER 217. Thirty percent of doctors had fewer than 1,500 patients registered, while a further 47.5 percent had between 1,500 and 2,500 patients. Statistically, there was no difference in the distribution o f list sizes between FPs and GPs. (But it is o f note that to be financially sustainable in BIH, it is estimated that an FM team needs 1,500 or more patients) (Table 27:). Table 27: Number ofPatients on a Doctor's List FP GP FP+GP percent Less than 500 7 7 14 9.9 500 - 1,500 28 13 41 29.1 1,500 -2,500 43 24 67 47.5 More than 2,500 10 9 19 13.5 Total 88 53 141 100 218. Both FPs and GPs had large numbers o f patients who were not registered with them but requested health care. Family physicians were more likely than GPs to have unregistered patients (Table 28:). GP FP Less than 500 29 30 111500 - 1,500 9 1 1 9 1 1,500 -2,500 1 1 6 1 More than 2,500 II1 19 1 16 38 6.4. CONTACTS WITH PATIENTS 219. The average number o f consultations per doctor per day varied. Around 30 percent o f the doctors saw fewer than 25 patients a day, and a further 30 percent saw between 26 and 40 patients (Table 29:). There was no statistically significant difference inthe average number o f consultations for FPs and GPs. Table 29: Average Number of Consultationsper Doctor per Day Total Less than 25 26 -40 41 -50 51 - 100 Total 93 98 191 220, Around 73 percent o f the doctors made one to five home visits per week: a low number compared with international figures. On average, around 81 percent FPs and GPs made one to five and 15 percent made six to ten telephone consultations per day. Statistically there was no difference in the number of telephone consultations made per day by FPs and GPs. Family physicians were more likely than GPs to visit their patients inhospital (p < 0.05) (Table 30:). Table 30: Average Number of Hospital Visits GP FP Total None 8 22 30 Less than 3 3 12 15 Total 11 34 45 1Chi sauare test I D = 0.021 I 6.5. CONSULTATION 221. FMspecialists were significantly more likely than GPs to use appointments 0,<0.01) (Table 30:). GP FP Total No appointments 47 13 60 Less than halfvisits ofnon-acutecases by appointment 8 15 23 More than half visits of non-acutecases by appointment 21 35 56 Almost all non-acutecases by appointment 17 36 53 1Total 93 99 192 Chi sauare test I <0.001 D 222. Family physicians were significantly more likely than GPs (p < 0.001) to allocate a dedicated length of time per appointment (Table 32:). 39 GP FP Total N A (no appointments) 28 8 36 Estimatedtime per patient exists 32 64 96 Varies (dependent on patient's complaint) 34 27 61 I I Total 94 I 99 I 193 Chi square test p < 0.001 223. Patients waited longer to see a GP for a consultation as compared with a FM specialist. This difference was statistically significant (p < 0.00 1) (Table 33:). Table 33: Length of Time Waited by Patientsfor Consultations 224. The average time for consultations was 10 to 15 minutes in most cases; statistically there was no difference between FPs and GPs. 6.6. PRACTICEPOPULATION 225. Family physicians were more likely to have a larger proportion o f elderly patients in their practice list compared to GPs and the BIH average (p < 0.003) (Table 34:). No significant differences were noted between FP and GP lists in relationto socially deprived patients and new residents (data not shown). Table 34: ElderlyPracticePopulationas Comparedto the Country Average GP FP Total Average 14 14 28 Above average 10 23 33 Don't know 38 18 56 Total 62 55 117 Chi square test p = 0.003 6.7. COLLABORATION WITH OTHER MEDICAL PROFESSIONALS 226. Almost all FPs and GPs were assisted by a practice nurse, 68 percent assisted by a laboratory assistant, and 50 percent by a medical secretary. There was no statistically significant difference in support levels between FPs and GPs. 40 6.8. FACE-TO-FACE INTERACTIONWITH OTHERHEALTH PROFESSIONALS 227. Both FM physicians and GPs had the least interaction with hospital specialists and social workers as compared with interaction with other health professionals with whom they met more frequently. The most frequent interaction was with other doctors who worked inPHC (FPs, GPs, and narrow specialists). 228. Statistically, there was no difference in the frequency o f meetings o f FM physicians and GPs with other health professionals such as FPs, GPs, nurses, and narrow specialist who worked in the ordination. However, there was a statistically significant difference between the frequency o f meetings o f FPs as compared with GPs for meetings with pharmacists and social workers and with nurses who performed home visits (Table 35:). Table 35: Frequency of Meetingswith Other HealthProfessionals NA 12 I 9 I 21 19 1 11 1 30 8 1 4 1 12 Total 89 1 95 I 184 89 I 91 I 180 90 I 96 1 186 Chi square p = 0.029 p < 0.001 p = 0.032 6.9. RESPONSIBILITY FOREMERGENCY HEALTH CARE 229. In 60 percent o f the cases, the emergency services were separately organized (Table 36:), and significantly higher when compared with the proportion o f FPs and GPs who provide a rota arrangement. There was no statistically significant difference in the way FPs and GPs organized out-of-hours emergency care. f No specific emergency service 7 A group of GPs on rotation basis (where respondent is amember) 45 A group of GPs on rotation basis (where respondent is not amember) 21 One or more doctors (not GPs) who are responsibleto the respondent, while respondentis not a 1 member Emergency servicethat is not responsibility ofthe respondent (separately organized) 118 Another arrangement 5 Total 197 6.10. EQUIPMENT USEDINPRACTICE 230. Most FPs and GPs had direct access to X-ray and laboratory facilities, but there was statistically different access between the two groups, with FPs more likely to have access (p <0.05) (data not shown). 41 23 1. Around 87 percent o f those surveyed regularly kept medical records for all patients, but around 50 percent did not possess a computer. The majority o f those who did not possess a computer were GPs. Unlike GPs, most o f the doctors trained in FM used computers on a regular basis, especially for research and quality monitoring. The difference in use o f a computer by FPs and GPs was statistically significant, with FPs more likely to use a computer (p < 0.01). 6.11. APPLICATION OFMEDICAL TECHNIQUES 232. The section o f the survey on the application of medical techniques commonly used inthe PHC setting explored first, the likelihood that, if the chance arose, the procedure would be carried out by FPs and GPs (where a scale with answers "always; usually; occasionally; never/seldom" was used to facilitate answers); and second, which other specialists in PHC were also performing this procedure - if there was no answer, it was assumed that there was no narrow specialist who performed this procedure. The respondents could identify more than one specialist for these procedures; hence, the total number of responses exceed the total number o f doctors surveyed (199 < n=x+y < 398). 233. In relation to commonly performed procedures such as: wedge resection o f ingrown toenail; removal o f sebaceous cyst from the hairy scalp; excision o f warts; insertion o f intrauterine device; removal of rusty spot from cornea; fundoscopy; joint injection; maxillary (sinus) puncture; myringotomy o f eardrum; applying a plaster cast; or cryotherapy (wart); the responses show that FPs and GPs surveyed "usually" perform these procedures and there was no statistically significant difference between the two groups. The FPs, as compared with GPs, were significantly more likely to perform suturing(p = 0.040), bandaging ankle injury(p =0.008) and setting up an intravenous infusion(p=0.004) (Figure 11:). 234. In the case o f setting up intravenous infusions, a procedure that was noted as not commonly performed in by FPs and GPs in BIH, no answer was given in 86 percent of the cases. This probably reflects the fact that the services delivered in PHC are predominantly ambulatory, with limited or no observation or day-care interventions that would require intravenous infusions. Figure11: Mean Score for Applicationof MedicalTechniques I FMPs GPs Suturing laceration Bandagingfor ankle sprain iV infusion Procedure Score: 4 = always, 3=usually, 2=occasionally, l=never/seldom. 42 235. Many procedures that would commonly be performed by family physicians in Western European countries are also performed ("always" or "usually" if the opportunity arises) by FPs and GPs in BIH. However, in BIH there are many narrow specialists who work in the PHC setting who also perform these procedures. For instance, key minor surgical procedures are performed by dermatologists as well as general and orthopedic surgeons (Table 37:). Table 37: Minor SurgicalProcedures Cryotherapy of wart perce 1.9 7 3.3 1 0.5 12 5.1 212 100 236. Around 83 percent o f the respondents identified that in BIH, insertion o f an intrauterine device, an intervention commonly performed by family physicians for contraception in Western European countries, is also performed by gynecologists inthe PHC setting. 237. Similarly, ophthalmological and ENT procedures commonly performed by FM specialist in Western European countries are also performed by ophthalmologists and ENT specialists (Table 38: and Table 39). Table 38: OphthalmologicalProcedures Table 39: ENTProcedures I I Maxillarv sinus puncture I Mvringotomv of eardrum I Response f percent 1 f percent No answer 68 33.8 ENTspecialist 168 82.8 98 48.8 Surgeon 25 12.3 12 6 Other 8 3.9 23 11.4 Total 203 100 201 100 43 238. As regards orthopedic procedures, commonly performed by FM specialist in PHC in Western European countries, the procedures were performed predominantly by orthopedic and general surgeons but also by tuberculosis specialists (phthysiatrists) (Table 40:). Table 40: Orthopedic Procedures Joint injection Applying a plaster cast Strapping an ankle Response f F percent f percent perce 6.12. FIRSTCONTACT HEALTH PROBLEMS 239. The first contact section o f the survey questionnaire aimed to elicit which o f the first-contact activities commonly performed by family physicians in Western European countries were undertaken by FPs and GPs inBIH. 240, The respondents were presented with a set o f health problems frequently encountered in the PHC setting and asked to what extent the population looked after by the respondent doctor would choose the respondent as the doctor o f first contact for these health problems. A scale with the choices o f "always; usually; occasionally; and neveriseldom" was provided to facilitate answers. If there was no answer to the question, it was assumed that there was no narrow specialist who performed this procedure. 241. Respondents also had to identify the narrow specialists who worked in PHC who were also accessed as a first contact point by patients. The "no answers" were treated as indicating that the respondent could not identify a narrow specialist and the respondent was the first point o f contact. The respondents could identify up to two specialists who could be accessed for the problem. Therefore, the number o f responses differs from the number o f respondents (n= 199