Post on 12-Apr-2017
PRIMARY CARE: Regional strategies to improve efficacy and equity while
guarateeing economic sustainability
W O R K S H O P
José L. ROCHAGeneral Secretary for Quality and ModernisationRegional Ministry of HealthGovernment of Andalusia, Spain. josel.rocha@juntadeandalucia.es
Strategies and results in Primary Healthcare
in Andalusia
• Andalusia and the APHS: Quick facts• Primary Care in Andalusia:
• Historical overview• Main Features• Outcomes• Troubles and Challenges
Overview
Andalusia and the Andalusian Public
Healthcare System:Quick Facts
Andalusia:Geographical situationand population
• 87,597 Km2.• 8.302.923 inhabitants
• 526.942 foreigners • 50% Europeans• 24% Americans• 21% Africans• 3% Asian
• + 1.531.668 andalusian people living in other Spanish regions• + 140.000 andalusian people living outside Spain
RegionalParliament
Regional Court of Justice
Andalusia:Political context
• Political Autonomy since 1981• Regional Institutions
• Parliament• Government (“Junta de Andalucía”)• Court of Justice (TSJA)
Jose A Griñán. President of Government
Fuensanta Coves. Speaker of the Parliament
Lorenzo del Río. Chief JusticeRegional
Government
Andalusia:Social and Economic trends
Gini Index in Andalusia1970-2005
0,310,3150,32
0,3250,33
0,3350,34
0,3450,35
1970 1975 1980 1985 1990 1995 2000 2005
% of GDP (PPP) growth1986-2007
69
110127
EU 15 Spain Andalusia
Source: Eurostat Source: Centro de Estudios Andaluces
Andalusian Public Healthcare System: Main features
1,146 Primary care centers 360 Auxiliary offices for primary care 47 Public Hospitals (16,821 beds)102,000 Healthcare professionals 9,390 M € Health Budget 2011, 6.67% GDP
Primary Care in AndalusiaHistoric
overview
Legislation Timeline
• 1978: Spanish Constitution• Establishment of the Autonomous Communities• Settlement of the Health protection as a fundamental right
• 1978: Creation of the Family Medicine specialty• 1981: Statute of Autonomy of Andalusia
• 1981: Transfer to the Andalusia Region’s Administration the responsibility on Public Health • 1984: Transfer to the Andalusia Region’s Administration the public network of hospitals, ambulatory clinics and rural offices
• 1984: National Decree on basic structures for primary care (1st step of primary care reform) • 1986: Healthcare National Act
• Change from a social security model to a NHS model• Healthcare as a right for all the population •Consolidation and extension of primary care level
Situation Before the reform:
Individual work of general practitionersNo specific trainingNo health prevention/promotion/educationIsolated rural medicineHospital-centric modelLower salaries than specialistsLow prestige and self-esteem
Primary Care in Andalusia
Main Features
Primary Care in Andalusia:Main features
Organisation and planningAccessibilityTeamworkExtended careIntensive use of ICT
GP as a GatekeeperCapitation: 1 GP/1,400 inhabitantsTeam of professionals working in a PC CentreHomogeneous territorial distribution Aggregation of PC Centres in “Districts” Supportive teams at Districts for Public Health purposes: Epidemiologists, Vets, Pharmacists… Professionals are civil servantsFocus on health promotion and prevention
Primary Care in Andalusia:Main features
Organisation and planningAccessibilityTeamworkExtended careIntensive use of ICT
Accessibility
% of increase of physicians in Andalusia 1984-2008
2353
196
Population Hospital Doctors Primary Care Doctors
1146 Primary Care Centers (and360 auxiliary offices) vs. 33 at 1986Less than 15 min away for anybody
1 Family Physician every 1.400 people on average
Primary care doctors represent 41% of APHS doctors (29% at 1986)
Primary Care in Andalusia:Main features
Organisation and planningAccessibilityTeamworkExtended careIntensive use of ICT
Primary Care in Andalusia:Main features:
Organisation and planningAccessibilityTeamworkExtended careIntensive use of ICT
Primary Care professionals
Family PhysiciansCommunity NursesPediatriciansMidwivesDentistsPhysiotherapistsSocial WorkersPsychiatrists/psychologistsEpidemiologistsCommunity PharmacistsVeterinariesAdministration workersAuxiliary workers
Primary Care in Andalusia:Main features:
Organisation and planningAccessibilityTeamworkExtended careIntensive use of ICT
Health Care Information and Management Integrated System
Appointment Prescription
Radiology
Waiting lists
Functional tests
Pathology
Lab tests
Inpatient care
Referrals
Outpatient care
Primary care
Hospital admission
Data warehouse
Emergency care
105 Million of e-prescriptions/year
95 Million of appointments/year
7.9 Million of individual EHR
3 Million of e-referrals/year
3.5 Million of x-Ray images/year
Primary Care in AndalusiaOutcomes
Outcomes: Life expectancy and amenable mortality
Mortality index in Andalusian municipalities vs. Spanish average
Trend to convergence to Spanish average
96% of municipalities have an index equal or lower than
the Spanish average for people 65 years old or less
The south-west area of Andalusia shows a mortality
index higher than the Spanish average for the group of 65-74
years old people
The majority of municipalities have a
mortality index higher than the Spanish’ one for people
with more than 75
2005 - Women 15-44 years old
2005 - Women 45-64
2005 - Women 65-74
2005 - Women 75-84
Higher than Spanish averageNon significative differencesLower than Spanish average
Source: Atlas Interactivo de Mortalidad en Andalucía (AIMA). Revista Española de Salud Pública 2008; 82(4)
Outcomes: Health Expenditure
Figure 3. Health expenditure per capita, US$ PPP, 2008 (or latest year available)
7538
5003
4627
4210
4079
4063
3970
3793
3737
3696
3677
3540
3470
3359
3353
3129
3008
2902
2870
2729
2687
2683
2151
1801
1781
1738
1437
1213
999
852
767
3060
0
2000
4000
6000
8000
Unite
d St
ates
Norw
ay
Switz
erla
nd
Luxe
mbo
urg
1
Cana
da
Neth
erla
nds
Aust
ria
Irela
nd
Germ
any
Fran
ce
Belg
ium
2
Denm
ark
Swed
en
Icel
and
Aust
ralia
Unite
d Ki
ngdo
m
OEC
D
Finl
and
Spai
n
Italy
Japa
n
Gree
ce
New
Zea
land
2
Port
ugal
Kore
a
Czec
h Re
publ
ic
Slov
ak R
epub
lic
Hung
ary
Pola
nd
Chile
Mex
ico
Turk
ey
USD PPP
Diff. Serie4
1. Refers to insured population rather than resident population. 2. Current expenditure. Source: OECD Health Data 2010 .Data are expressed in US dollars adjusted for purchasing power parities (PPPs), which provide a means of comparing spending between countries on a common base. PPPs are the rates of currency conversion that equalise the cost of a given ‘basket’ of goods and services in different countries.
OECD Health Data 2010.
Social and Economic Council of Spain, 2010.
Outcomes: Health Expenditure
Regional health expenditure (€ per capita). Spain 2007
% of public health budget on Primary Care, Spain 2008
12,4 1315,3 15,7
17,6
Ministry of Health and Social Policy. Spain, 2010.
Outcomes: Health Expenditure on Primary Care
AndalusiaSpainCataloniaValenciaMadrid
• Conclusions: Between 1995 and 2008, Andalusia makes a firm decision assign a greater increase in its budget for primary care than for hospital care, contrary to what occurred in the other autonomous regions.
Simó J. The public expenditure on health in Andalusia between 1995 and 2008: a comparison with other autonomous regions. Med Fam Andal 2011; 1:12-19
Outcomes: EfficiencyThe Swedish Healthcare System: How does it compare with other EU countries, the United States and Norway?Swedish Association of Local Authorities and Regions,2008
Desired direction
Health spending in OECD countries: Obtaining value per dollars. GF Anderson, BK Frogner. Health Affairs 2008; 27:1718-1727
Satisfaction survey. Users of primary care services
85,987,2 86,7
87,4
89,789
86,8
88,7 88,389,5
90,6
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Outcomes:Patient satisfaction
General satisfaction on Primary care. Satisfied + Very satisfied (2/5).
Institute for Social Studies of Andalusia. Spanish Scientific Research Council (CSIC)
Primary Care in Andalusia:Key factors:
UniversalityLack of economic barriers for people DecentralisationEquitable planning of public resourcesCoordination and integration of careCommunity focusExtended basket of servicesTeamworkClinical ManagementProfessional commitmentLong-term policies
Troubles and Challenges
- High Frequentation- Work overload- Chronic Patients- Excess of bureaucracy- Lack of Coordination with Hospitals- Continuous Medical Training- Feminisation- Desertification of Rural areas- Physician Shortage- Professional Migration
http://www.opimec.org/