PHC Models in Europe

PHC Models in EuropeTeppo Heikkilä, MD

Budapest June 201120.04.23 PHC Models in Europe / Teppo Heikkilä 1

Five Models of PHC

• PHC Model 1: Direct access to any GP or specialist

• PHC Model 2: Referral required from GP, mainly solo-practices in PHC

• PHC Model 3: Referral required from GP, mainly group-practices in PHC

• PHC Model 4: GPs working mainly in health care centres

• PHC Model 5: Polyclinics (Shemasko). Not necessarily GPs at all

20.04.23 PHC Models in Europe / Teppo Heikkilä 2

”Solo practice” basic model based mainly on specialists’ services

Local health services; preventive services, elderly care, some public health functions, etc.

Various primary care doctors, that can be accessed directly

20.04.23 3PHC Models in Europe / Teppo Heikkilä

”Solo practice” basic model based mainly on generalists’ services


Through referral to other services

Direct access to the chosen generalist


”Group practice type of arrangement”



Direct access to the chosen group service/own GP/FD


”Health centre type of arrangement”

Usually no separate local health services, apart from possibly local public health services


Direct access to the health centre usually determined by residency (or choice)


”Policlinic-based arrangement”

Usually no separate local health services, apart from possibly local public health services


Direct access to the policlinic usually determined by residency (or choice)


Five Models of PHC

• Simple and relatively easy to observe

• Do not offer complete answers to the European PHC structure

• Do not define if the system is financially based on health insurance funds or taxation


European PHC Models

• We went through the European PHC systems and compared them to the five PHC Models created beforehand

• We used WHO’s Health in Transition (HiT) reports– HiT reports contain information about health care

systems structured in the same format

• For countries in EU Primecare we also used the answers to the questionnaire


HiT Reports of European Countries

• HiT report released 2006 – 2010 26 countries

• HiT report released 2000 – 2005 16 countires

• HiT report released 1999 2 countires

• No HiT report 9 countries

• In total 53 countries


Challenges

• There are different kinds of local solutions and partial solutions in different countries with their own models e.g. in referral systems and health care service coverage in PHC

• Different systems can coexist in one country– Different systems in different regions– Public and private systems working side by side– Each health insurance fund providing own system


Challenges

• Difficulty to classify each country to one PHC Model exactly

• The PHC Model system can be described as a continuum where each country settles somewhere between the PHC Models

– E.g. kind of partial referral system (Austria) or a mix of solo- and group-practices (e.g. Denmark, Estonia, Italy)


PHC model 4

PHC model 4

PHC Model 3

PHC Model 3

PHC Model 2

PHC Model 2

PHC Model 5

PHC Model 5

PHC Model 1

PHC Model 1

Challenges• Some basic elements of the PHC Models could

have been understood differently in different countries

• E.g. gate-keeping– Can a patient go to the specialist

• Only with referral• If paying a formal or informal fee for the specialist• In some defined cases without a referral• To some defined specialists without a referral?

• E.g. group-practice– Is it a practice owned by a group of practitioners, or a

facility in where a group of independent practitioners are working side by side?


Challenges

• In some countries (e.g. former Soviet Countries) there is going on a progress in developing health care systems

• During the process the health care system can represent different PHC Models

– In these cases some of the HiT reports could have been too old to describe the present PHC Model


Challenges

• There can also be some human errors when reading the HiT reports and trying to understand and assess the elements of the PHC Models


PHC Model 1Direct access to any specialist

• Andorra (HiT 2004)– No mention about referral systems in HiT report

• Austria (HiT 2006)– Partial referral system, where the patient in theory

needs a referral to go to a specialist, but• Patient can choose a specialist to be the first contact

in health care system • Patient can change the first contact in every three

months

• Czech Republic (HiT 2009)– In practice PHC Model 1. Patients can go directly to

the specialist if they want to


PHC Model 1Direct access to any specialist

• France (HiT 2004)

• Germany (HiT 2004)

• Turkey (HiT 2002)– Many actors in PHC. Public system is close to the

PHC Model 4, but undeveloped. Most patients go directly to the private specialist


PHC Model 2Referral required, mainly solo-practices in PHC

• Croatia (HiT 2006)– There are some health centres (PHC Model 4), but

most of the GPs work in solo-practices

• Cyprus (HiT 2004)– Implementing new model, where there are solo-

practices and heath care centres. Most of the GPs in solo-practices

• Hungary (No HiT Report)– Assessed based on questionnaire in EU Primecare

• Ireland (HiT 2009)– At present PHC Model 2, implementing PHC Model 4



• Italy (HiT 2009)– Both solo- and group-practices, mainly solo-practices

• Latvia (HiT 2008)– Trying to create PHC Model 4. In practice more close

to the PHC Model 2

• Malta (HiT 1999)– Old HiT Report. Public (PHC Model 4) and private

(PHC Model 2) system side by side. Private system dominant



• Norway– Health centres, but GPs working in private solo-

practices

• Romania (HiT 2008)

• Slovakia (HiT 2004)– PHC Model 2, although PHC doctors are working

mainly in shared facilities


PHC Model 3Referral required, mainly group-practices in PHC

• Belguim (HiT 2007)

• Bulgaria (HiT 2007)

• Denmark (HiT 2007)– Both solo- and group-practices, but group-practices

more common and growing

• Estonia (HiT 2008)– Both solo- and group-practises, but group-practices

more common (and growing?)


PHC Model 3Referral required, mainly group-practices in PHC

• Israel (HiT 2009)– Four health insurance funds, which all run their own

health care system. The biggest one is close to PHC Model 3 with features of PHC Model 4. The second biggest one is close to PHC Model 1.

• Lithuania (HiT 2000)– Old HiT Report. PHC Model 3 based on the answers

to the EU Primecare questionnaire.

• Netherlands (HiT 2010)

• United Kingdom (HiT 1999)– Old HiT Report. The UK has gone through a health

care reform after that. Does that affect their PHC Model?


PHC Model 4Health care centres in PHC

• Albania (HiT 2002)– Old HiT Report. Planning to develope PHC Model 4.

Has that been put into effect?

• Bosnia and Herzegovina (HiT 2002)

• Finland (HiT 2008)

• Iceland (HiT 2003)

• Moldova (HiT 2008)

• Portugal (HiT 2007)– The role of the private sector seems to be small but

is not clear in the HiT report


PHC Model 4Health care centres in PHC

• Slovenia (HiT 2009)– At present PHC Model 4 but going towards PHC

Model 2 as health care is getting privatized

• Spain (HiT 2006)

• Sweden (HiT 2005)– Quite old HiT Report. Some changes happened after

that. Do they affect the PHC Model?

• Macedonia (HiT 2006)


PHC Model 5Polyclinics (Shemasko)

• Many former Soviet Countries are developing their health care systems. Many countries seem to go more or less towards PHC Model 4, but some also towards other PHC Models.

• They have started to train general practitioners / family doctors almost in all former Soviet Countries

• Difficult to define the PHC Model at present because of ongoing plans and progress

• In practice, based on HiT reports the PHC Model in most countries is still very close to the Shemasko model



• Armenia (HiT 2006)

• Azerbaijan (HiT 2010)

• Belarus (HiT 2008)

• Kazakhstan (HiT 2007)

• Kyrgyzstan (HiT 2005)– Trying to go towards PHC system based on family

doctors (PHC Model 4)



• Russian Federation (HiT 2003)

• Taijikistan (HiT 2010)

• Turkmenistan (HiT 2000)

• Ukraine (HiT 2004)

• Uzbekistan (HiT 2007)


Hard to Define the PHC Model

• Poland (HiT 2005)– Some basic elements of PHC Model could not be

found in HiT report, such as • Is there a referral system? • Do family doctors work mainly in solo- or group-

practises or is there any kind of health care centre based system?


No HiT Report

• Georgia

• Greece

• (Hungary)

• Luxenbourg

• Monaco

• Montenegro

• San Marino

• Serbia

• Switzerland


Countries in EU Primecare

• PHC Model 1– Germany

• PHC Model 2– Hungary– Italy

• PHC Model 3– Estonia– Lithuania

• PHC Model 4– Finland– Spain


PHC Models in Europe

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