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Neda Milevska Kostova is Executive Director of Centre for Regional Policy Research and Cooperation "Studiorum" and PhD candidate at School of Health and Related Research (ScHARR), University of Sheffield, UK
Brankica Mladenovik, MD, MSc PH, PhD, is Head of the Institute for Mother and Child Health, Skopje
Primary Health Care (PHC) in Macedonia could be defined as directly accessible, free of charge, first contact outpatient care for unselected health problems, which offers preventive, diagnostic and curative services, provided by a variety of disciplines, taking into account the personal and social context of patients and assure continuity of care to patients over time as well as between providers.
In recent years, there has been an acceptance of the important role of PHC in achieving equity, efficiency, effectiveness and responsiveness of the health system to the growing demands and changing health needs of the population.
Reforms in the health care system in Macedonia started in 1996 and have been running parallel with the political and socio-economic transformation. As elsewhere in Central and Eastern Europe (CEE), the World Bank was a key player in the healthcare reforms. At the start of the reforms, the healthcare system had strong orientation towards specialist care and curative services. Dominant perception about PHC among policy makers and health care providers two decades ago was that it is a low-grade activity with little effect on mortality and on severe morbidity, with predominant role in triage of access to secondary care and hospitals. One of the main goals of the reforms of PHC was the transfer of some services from secondary to primary care, strengthening its gate-keeping role and creation of PHC as comprehensive response to the people's expectations and needs, and to the demographic and epidemiological transition.
Reforms in PHC started with the introduction of Continuous Medical Education (CME), creation of guidelines and equipping of facilities, but substantial changes actually started in 2005 with the transformation of the once public PHC providers into concession-type contractors to the Health Insurance Fund, using the capitation method of payment.
The capitation payment model that was introduced is a patient-based capitation model, in which the physician receives a payment that is dependent on the number and type of patients registered. The PHC providers that have been working in the public sector as general practitioners (GPs), paediatricians, dentists, gynaecologists, school medicine doctors and pharmacists have been obliged to open private PHC offices and sign a productivity-based capitation contract (for payment per registered patient) with the HIF.
However, for ensuring quality of care and sufficient service coverage, the system has imposed ceiling on the number of patients that can actually register with one PHC physician. Additionally, the capitation model includes incentives, among others, for physicians for rational prescribing and performing preventive services.
In general, the contract includes two major payment categories: 70% of the capitation fee is transferred each month based on the number of registered patients. The remaining 30% of the capitation fee per patient is conditioned with fulfilment of the so-called preventive goals of the PHC, all in line to strengthen the gate-keeping role and to broad the scope of activities, mainly preventive. These preventive goals are defined each trimester: rational prescribing (7%), rational referrals and sick-leaves (4%) and preventive services and early detection of malignancies and deformities in children (combined 19%).
The preventive goals are planned at the beginning of each trimester (as per calendar year), implemented and reported.
In this sense, women have to choose two type of PHC providers: general practitioner (GP) and gynecologist. As a part of PHC, in March 2012 HIF has signed contracts with 1675 GPs and paediatricians, 135 gynaecologists and 1036 primary dental doctors. Since 2006, more resources have been directed towards primary health care. According to recent official data, total expenditure on health as percentage of GDP is 6.9%; 32% are spent on PHC, 30% on secondary care and 38% on hospitals. There are 2.5 physicians per 1,000 citizens.
Different health profiles are part of primary care (GPs, gynecologists, pediatricians, school-medicine specialists, occupational health specialists, dentists, patronage nurses, practice nurses). What is specific for PHC in Macedonia is the existence of preventive health teams (doctor and nurse) which are providing only preventive health services (immunizations, systematic check-ups and counseling) to children under 18, and are paid by fixed salary.
Reforms in PHC resulted with several positive outcomes: higher provider satisfaction; broadening the scope of activities (PHC providers are stimulated to operate at more levels of care including promotional and preventive services, counseling, pre-symptomatic detection, early diagnosis and treatment); higher patient satisfaction (providers are more motivated to improve their knowledge and communication skills and started to improve their facilities and equipment); introduction of specialization in family medicine; introduction of integrated electronic health information system; reduction of referrals to specialists and hospitals with expectation to lower the health costs; patients are expected to be less submitted to unnecessary and inappropriate interventions and hospitalization; pro-poor orientation is extremely important due to the rising social inequalities; and, what is very important, there is a process of creating a culture that values PHC as essential pillar of the healthcare system.
There are also some disadvantages as a result of reforms in PHC: unequal geographical distribution (some remote and rural areas are left without PHC services due internal brain-drain), despite the decision of the Ministry of Health for subsidizing the PHC offices in rural areas; profit orientation and commercialization; providers working in isolation, overwhelmed with administration and paperwork, yet they start to recognize the importance of group practicing.
As of now, there is still no consensus among policy makers and practitioners in Macedonia on optimum structure, content and way to deliver cost-effective PHC. The experience showed that reforms in PHC are complex and long-term process, which has to take into account key historical and developmental contexts but also contemporary realities and capacities and skills of countries to manage change. Key challenges remain to be: greater community involvement, human resources development including strengthening of the capacities of PHC providers for public health, continuous dialogue between policy makers and health workforce and ensuring financial and political sustainability. There is also a need for more systematic approach and use of scientific evidence about the relation between access to primary care and equity, accessibility, health outcomes, patient satisfaction and costs. Development of National PHC Strategy will be required to guide current and future policy and practice in the primary health care sector.
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