Primary Health Care and Non-Communicable Diseases (NCDs) in Eastern Europe and Central Asia:
Where do we stand and where to go?
Von Kaspar Wyss / Schweizerisches Tropen- und Public-Health Institut (Swiss TPH)
Many countries in Eastern Europe and the Commonwealth of Independent States have over the last two decades substantially strengthened family medicine services. For the prevention and especially for the treatment of Non-Communicable Diseases (NCDs), primary health care services do have an essential role to play. While improving the responsiveness of health systems to NCDs a range of challenges remain such as for example profiling health services addressing long-term care or risks of NCDs and multimorbidity.
The widely disseminated results of the Global Burden of Disease Study showed globally substantial reductions over last 20 years in premature death and disability-adjusted life years for communicable, maternal, neonatal, and nutritional disorders. The improvements are attributed to global and national efforts to address child survival, maternal health, and HIV/AIDS, TB and malaria through the Millennium Development Goals (MDGs). While a number of successes could be achieved globally and in many low- and middle-income countries, the situation looks grimmer for Eastern Europe and countries of the Commonwealth of Independent States (CIS). Indeed, mortality patterns have worsened in many countries of this region of the World with increasing number of persons suffering and dying from cardiovascular disease, alcohol related disorders, mental health problems or diabetes. The common risk factors going along these diseases are alcohol, smoking, poor diet, overweight and physical inactivity, high blood pressure, high fasting glucose and have all gained in importance over the last two decades.
Multi-sectoral approaches to NCD prevention and treatment
NCD prevention and control requires collaboration of various sectors if they are to work effectively. Indeed there is general consensus that a public health perspective to the control of NCDs requires strong collaborations and joint approaches with sectors beyond health (e.g. education, justice, finance, and welfare), entailing further collaborative partnerships of government, non-governmental organizations (NGOs) and associations. Overall commitment of policy makers and key governmental departments at national, regional and local level towards the importance of public health initiatives are required so to make positively evolve the behaviour of people for example in terms of diet, smoking or alcohol consumption is of high importance.
Many interventions addressing NCD risks factors such alcohol consumption, smoking or overweight, are beyond health services and in several instances even beyond the health system. Yet however, health services are increasingly confronted with patients suffering from one or several NCD. Many do recognise that thereby primary health care services – in a number of countries in the form of family medicine services – do have an essential role to play.
Underlying drivers for many CIS and Eastern European countries of strategic and policy decisions for the establishing family medicine services are that many services provided today through hospitals, especially outpatient services, can be handled more cost-effectively at primary health care level. Primary health care services are seen as a possibility to guarantee access to treatment and prevention services which are geographically close to people. They allow closer and more personalised relations between the patient and the provider, including a regular follow-up of patients. There is no need to travel over long and sometimes expensive distances, e.g. for elderly persons with a chronic disease. Primary care services offer also the possibility for flexibility in identifying local solutions taking into account the demand and need of communities. Compared to hospitals family medicine services can by this be more responsive and people can build up a higher sense of ownership over the provider.
Various barriers have to be overcome, if countries of Eastern Europe and the CIS are to have strong and well performing primary health care or family medicine services for addressing NCDs. It is of importance to further strengthen family medicine models embedded in a primary health care concept. For providing care to patients especially elderly suffering from chronic disease there will be a need to associate all relevant actors including social services, departments of finance and (social) health insurance companies. It is not obvious that these various actors involved will work together and in the same direction. There is awareness on this issue, but there is also a broader context which sets limits in overcoming constraints of the administration.
The growing percentage of elderly, further requires to better tailor family medicine services to them e.g. through new forms of home based care. To get global and national consensus on the future service package and the role of family medicine emphasising among else care for the elderly will need conceptual and strategic thinking across a range of actors and subsequently implementation skills.
The role of primary health care services for NCD treatment
Historically primary care services in Eastern European and CIS countries have been orientated towards identifying communicable disease patients and referring them then to hospital. Today many CIS and Eastern European countries emphasise the importance of family medicine and in some countries such as for example Moldova or Lithuania substantial progress has been made over the last decades. The packages of services to be provided at primary health care / family medicine level remain however focused on controlling for short, episodic, curative care, mother and child health care and vaccination. In many settings hardly any reference is made to family medicine services for patients with chronic health problems such as diabetes or hypertension. In consequence there is a need for family medicine services which profile better their role in terms of NCDs.
Similarly, along mental, neurological and substance-use disorders it is observed that an increasing proportion of people are facing co-morbid disorders, such as depression and HIV or posttraumatic stress disorder and coronary heart diseases. For family medicine services this implies that they do have to care for multiple disorders simultaneously. This in turn requires specific skills. It also entails that the provision of services is effectively coordinated, where it is very important that primary care is related to specialist support services, especially social care.
The classical understanding of healthcare is based on illnesses with abrupt onset and limited duration, which can usually be cured by qualified health staff. NCDs do however not fit into this understanding. It will be necessary to further consolidate the role of family medicine within the whole health system, including family medicine services - hospital referral. Mechanisms have to be identified and enforced setting incentives for health service use in a way that the use of primary care services by NCD patients is promoted. In those Eastern Europe and CIS countries with health insurance schemes this may for example imply to enact higher rates of co-payments in hospitals without referral from primary care level.
Financing and quality of care of NCD services
In many – but not all – countries of Eastern Europe and the CIS, primary care services are under-funded and are in an extremely difficult situation regarding their financing. Family medicine and the provision of services for patients with NCDs are somehow trapped between hospitals and pharmacies without offering in many instances a competitive advantage compared to these providers. First, public funding for prevention and promotional activities needs to increase. In those countries with an insurance scheme, for curative services to NCD patients a key role will be at the level of these schemes. The role of health insurances as purchaser will need to be strengthened; for the moment they are price takers and have very limited scope to play their role as active, efficient and effective purchaser. It is likely that the success and sustainability of primary care will also depend on the establishment of clear relations between primary health care services and insurance schemes.
Setting the right incentives for family medicine is a key challenge and the payment mechanisms are a key factor. More specifically capitation might offer opportunities especially in relation to chronic disease treatment. Yet however there is not much evidence existing on such pilot schemes in CIS and Eastern European countries. Whatever the measures will look like, it will require a significant change in existing practices by providers and patients, and it is not obvious how strong the political support to these measures will be.
Given the macro-economic context prevailing in many countries of Eastern Europe and Central Asia, it will be hard to find new sources of financing. In particular, people are already paying a lot of money in order to obtain hospital care, and will be unwilling to pay even more for health. Also, many people do not believe the quality of care of family medicine services is good, and there are shortages of well-qualified staff who are willing to work at this level.
For obvious reasons, quality of services has to be addressed. Number wise existing primary care services are generally adequately staffed but the staff is not sufficiently qualified. High quality family medicine services for NCD treatment will thus need well-trained and qualified health staff. A wide range of training, supervisory and incentive schemes to address these problems will be necessary, but they will take time to be effective and it can take several years to develop high-quality training programs and continuous education and learning systems emphasising capacity strengthening of family medicine providers in handling day to day problems and situations.
Emphasising quality of care entails also reinforcing the role of chronic patients to self-manage their conditions with support from professionals and families. Indeed, patients typically do have experience and knowledge on their condition complementary to that of health care providers. Chronic-disease management emphasising the role of patients seems here to be a promising direction. Such organisational forms may also allow to control for raising costs of NCD treatment by shifting health services towards coordinated and proactive community-based interventions.
Last but not least, it will be important to ensure community support and use for services through activities which do increase demand. Success of family medicine services will also depend on bringing services closer to the population and giving users a certain feeling of ownership over services.
Many countries in Eastern Europe and the CIS have made important policy decisions for the establishment and strengthening of family medicine services. Underlying reasons for this were that too many services are currently provided through hospitals. Doing so, a number of countries have made substantial progress and offer to today primary health care services of reasonable good quality to the population. Others are still in an initial phase. In terms of NCD prevention and treatment family medicine services entail the opportunity to offer services that are geographically and culturally easy to access by people are able to treat common kinds of NCDs such as diabetes and able to give continuing (long-term) advice and care. At the same time it will be necessary that family medicine services gradually evolve from acute episodic treatment to prevention and early intervention. Family medicine services have also to evolve toward models which profile the risks of NCDs and multimorbidity in their population, the provision of person-centred care with improved outreach and self-management as well as long-term care and risk management that includes follow-up at clinic and repeat prescriptions.
*Kaspar Wyss is a Public Health Specialist and Deputy Head of Department at the Swiss Centre for International Health, Swiss Tropical and Public Health Institute. Kaspar Wyss has strong management and leadership experience and is in charge of a team of 15 staff focusing on health systems development primarily in low- and middle income countries. Activities relate to both research and health system monitoring and performance assessment, with a specific interest in the role and importance of human resources for health. Contact: Kaspar.Wyss@unibas.ch