Comprehensive PHC Assessment in Albania: Recent Challenges and Opportunities

1. Comprehensive PHC assessment in Albania WHO Regional office for Europe Division of Health Systems and Public Health

2. Recent opportunities and drivers Well recognized Challenges in Albania People seek health care only when ill Changing attitudes of people to seek preventive care (check ups) Outdated PHC premises, equipment, with exception for check up “islands” Investing in rehabilitation of PHC facilities Changing requirements for professional development and (re)-licensing Burden of patients demanding emergency/specialised care Strengthening capacities for governance and operational management Dysfunctional referrals and fragmentation of services Strengthening e-health system creates new opportunities Low salaries and no incentives fro better performance

3. Objective of comprehensive assessment to provide in-depth analysis of primary health care system and identify the constitutive elements of a future PHC model in Albania

4. Methodology: process of development/adaptation of assessment tools Rapid PHC assessment WHO TA mission JAN 2018 Tool for monitoring impact, performance and capacity of PHC in WHO European region WHO in consultations with MOH advisory group

5. Methodology: steps of assessment MOH , NC with TA from WHO WHO WHOTA team, NC WHO and MOH Capacity questionnaire WHO in consultation MOH Development of tools for assessment International experts for TA (2) Data collection and validation Data analysis and prelim. concllu- sions and recommendations Round-table with key stakeholders (verification of conclusions and recommendations) Sampling of national and reg. stakeholders and key informants for capacity survey Workshop with National counterparts to present draft report of Assessment Translationand validation questionnaires Data collec- tion and vali- dation Selection and training of field work team (5) Sampling of PHC centres and key informants for facility survey Facility questionnaire Final report with feasible policy recommendations National coordinator (NC) MOH , with TA from WHO NC , with TA from WHO Field work team, NC,

6. Questionnaires and key informants Facility questionnaire 27 drs & 47 nurses 71 questions • 2 urban HC (Tirane) • + 4 ambulatories • 2 suburban HC (Tirane) • + 2 ambulatories • 2 rural plain HC (Fier) • + 19 ambulatories • 2 rural mountain (Kukes) • +15 ambulatories • MOH, • CHIF and regional directorates of Health Insurance; • National Centre for Quality, Safety and Accreditation of Health Institutions, • Regional directorate of Public Health, • Faculty of Medicine, • Order of Physicians, Order of Nurses, • Local government Capacity questionnaire 25 informants 44 questions

7. PHC performance and monitoring framework

8. Impact Subdomains assessed Impact Health system outcomes Health system outcomes

9. Outcomes Avoidable hospital admissions per 100000 pop • HYPERTENSION: • Albania - 136 • United Kingdom – 17 • Sweden - 40 • DIABETES • Albania - 134 • United Kingdom – 77 • Slovenia - 93 • ASTHMA • Albania - 97 • Italy – 14 • Sweden - 36

10. Care contact Subdomains assessed Health outcomes Performance of primary care Capacity of primary care Care contact Impact Model of primary care Primary care structures Health system outcomes Care contact Primary care outputs Social determinants and context (political, social, demographic, socioeconomic)

11. Utilization of PC services Utilization of PHC services and overall outpatient care Visits to PHC physicians - 1,96 per 1 inhabitant per year Increasing patients flows Albaniahas lowest overall outpatient contacts per person per year in WHO European Region: Albania - 2,5 (2013) WHO EURO - 7,5 (2014)

12. Utilization of PC services Average visits and coverage with PHC services • Higher visit rates are in urban HC s(2,5) and in HC with higher density of PHC physicians • Lowest in rural mountain HCs (1,24), where also is lowest density of GPs (0,68 in KukesGolaj) • No reliable data on what percentage of population used PHC service at least once per year. • GPs reported - from 40% (suburban Tirana) to 90 % (rural mountain PHC, Tirana). • Consensus - 50% (Strong PHC International - 70% per year, 90% per 3 years)

13. PC model Subdomains assessed Health outcomes Model of primary care Performance of primary care Capacity of primary care Impact Model of primary care Primary care structures Health system outcomes Care contact Primary care outputs Social determinants and context (political, social, demographic, socioeconomic)

14. SELECTION OF SERVICESFindings

15. PC selection of services Health needs assessment and stratification of population • Intensive process in health data collection and reporting there are no any systematic work in health needs assessment to inform and adapt PHC services to priority health needs • Population stratification is limited to register of patients with NCDs: • Data from preventive check-up is not used enough to stratify population by risk

16. PC selection of services Preventive care • Individual risk assessment is provided only in check-up rooms, with SCORE methodology applied for CV risk assessment, PHC teams responsible for particular district are not involved • Counselling services for population with NCD risk factors is provided episodically (max once per year) after preventive check ups: • supported by methodological recommendations, • no structured repeated intervention (by well trained nurse/health educator)

17. PC selection of services Preventive care and laboratory services • Urban PHC centres have rather fragmented paediatric services with some PHC paediatricians responsible only for preventive check-ups and vaccinations separate paediatricians or GPs responsible for ill children • Vaccination services are well planned and implemented for children with support of national programme recommendation,. • Low accessibility to essential PHC laboratory tests, with exception for preventive check up programme (35-70 years)

18. PC selection of services Accessibility of medicines • Both formulary and reimbursement list of medicines exist and are revised annually. • List of reimbursed medicines 2018 contains 1175 commercial alternatives 568 first alternatives and 344 active alternatives and it well reflect needs to get good accessibility and affordability of medicines • Only PHC physicians can prescribe reimbursable medicines • …but narrow specialists influence the demand and GPs follow their recommendations (polypragmasia). • PHC physicians have limited prescribing authority for some actual and widely used by NCD patients, medicines.

19. SELECTION OF SERVICESRecommendations

20. Primary health care selection of services • To better support health needs assessment, stratification of population by risk and setting health care priorities: • (Re)defined model of cooperation and integration of PHC with public health services (PHD) • Revise reporting system and statistical data flows. Health and health care statistics should be reported to PHD (reorganized structures) and support health needs assessment • Establish follow up system using tools and data collected during preventive check-ups, also morbidity and mortality data from reports to CHIF and PHD/RHA (merge into one database)

21. Improved early detection of NCDs and risk assessment • Medical examination and diagnostics • Referral to narrow specialist • Treatment and management plan (shared plan with nurse and narrow specialist) • Individual risk assessment and risk stratification during preventive check ups • Referral to GPs • Coordination of referrals for laboratory and diagnostic test • Identification of population at risk and call for preventive check ups during home visits • Motivational counseling • Follow up and recall PHC nurse GP Check –up room’s nurse • Sending Invitations for preventive check ups • Making ECG and point of care laboratory tests • Distributing printed resources for patients and nurses • Collecting and monitoring data on newly detected cases for whole PHC centre • Collect and analyze data on newly detected cases at the regional level (monitoring NCD and NCD risk factors) • Population awareness campaigns • Support in attracting disadvantaged population groups Public health specialist (PHD)

22. Primary health care selection of services (3) • Improve accessibility of diagnostic and laboratory services, defining: • (1) laboratory and diagnostic services which need to be compulsory for delivery at the point of care at every PHC facility; • (2) laboratory services recommended to be centralised, for tests taken at the point of care and transported to the centralised HC laboratories. • (3) diagnostic services recommended as “mobile” and provided through systematic visits of narrow specialists to HC centres (from remote districts, where such services are in high need, but not available) • Revise scope and frequency of laboratory and diagnostic tests provided during population-based check-ups, leaving only evidence-informed procedures and increase accessibility of the same advanced laboratory and transportation capacities for follow up tests

23. Laboratory and diagnostic services in PHC package: Lithuania Included in PHC capitation fee Included but paid fee-for- service (limited per risk group) • Laboratory tests • Blood count • CRP • Glucose test • Cholesterol test • Urine test • potassium, natrium • creatinine, urea • ALT, AST, • Bilirubin, GGT, alkaline phosphatase • Ferrum • Diagnostics • ECG • micro spirometer (FVC, FEVI); • visual test • tonometer for intraocular pressure • Testing of blood clotting condition for patients at risk • Glycosylated hemoglobin test • Blood group, RH test, syphilis, HIV antibody test for pregnant women • Pregnant women urine culture • Blood tests needed for elective surgery • Rapid A beta-hemolytic streptococcal antigen tests for children 2-7 years

24. Primary health care selection of services (4) • Integrate fragmented preventive services for children into PHC teams for all urban PHC centres (for more comprehensive, holistic and continuous care for children by one paediatrician, supported by team of nurses) • Integrate tuberculosis prevention and management into PHC (example from TB- REP project) • Revise prescription rules and protocols giving more mandate for GPs to prescribe without referrals to specialists for getting better accessibility to medicines

25. PC DESIGNFindings

26. PC design Referral system, care pathways

27. PC design Referral system, care pathways • Gatekeeping system with compulsory referral system is not applied • there are no any guidelines with referral criteria to narrow specialists, except for prescription. • approved by MOH referral system limits options for referrals to the nearest hospital (often with low capacity for investigation) • Not properly addressed complex needs of patients with multi-morbidity • very limited examples of shared care plans, • not established case managers role

28. PC DESIGNRecommendations

29. Primary care design: referral system, care pathways • Establish more flexible system for e-referrals • Allow for GP to choose most appropriate narrow specialist, better balancing needs for urgency (waiting time) and availability of diagnostic capacities for particular health problem • Motivate patients to use PHC as a first contact and to avoid direct visits to narrow specialist and hospitals. • population awareness campaigns on benefits from coordinated, person centred PHC care (patient experiences from best PHC practices/pilots) • higher fee for direct visits to narrow specialist • Monitor direct patients flows to narrow specialists and use it as PHC performance measures

30. Primary care design: referral system, care pathways • Include clear referral criteria in all clinical guidelines • Increase access to specialized care by introducing site visits to PHC • Introduce shared care plans for patients with multiple conditions and complex health needs, • (re)defined roles and responsibilities of general practitioners, nurses, social workers and narrow specialists, • Shared accountability for better outcomes for patients • Case managers

31. PC SERVICE MANAGEMENT AND QUALITY IMPROVEMENTFindings

32. PC service management Managing facilities and strategic planning • Lack of managerial capacity of PHC managers, without any requirements for compulsory circles of training in management • Lack of autonomy in decisions of PHC providers. • Lack of accountability to local and regional authorities on performance and for health outcomes

33. PC quality improvement Performance assessment and quality improvement mechanisms • Accountability for PHC performance is limited to monthly reports to CHIF and RHD • CHIF monitors PHC performance through site visits at least 4 times per year (mainly for checking prescriptions) • RHD/PHA monitors through visits (mainly for sanitation and infectious disease control) • Peer review groups exists only in 2 out of 8 surveyed PHC (pilot areas of SDC HFA project) • Patient complains boxes are used in 6 out of 8 surveyed PHC, but no any patients experience surveys

34. PC SERVICE MANAGEMENT AND QUALITY IMPROVEMENTRecommendations

35. Primary care management and quality improvement • Increase managerial capacities of PHC providers, • introduce compulsory training of all health care managers with (re)licenzing system • create accountable networks with more autonomy in managerial decisions • Introduce outcome-oriented approach in performance measurement • Introduce mechanisms and tools for internal quality improvement at PHC, as example: • Continuous quality improvement committees for every HC, responsible for internal quality improvement circles • Peer review groups (prioritize for professional development of nurses; use examples from pilots in Fier)

36. PC WORKFORCE ORGANISATIONFindings

37. PC workforce organisation Practice population & PHC professionals’ density Number of doctors per HC is aligned to the size of population served but varies from 1,400to 7,730 inhabitants per one GP Distribution of nurses varies to a very high extend (from 34 to 7) per 10000 which is difficult to explain by specific health needs

38. PC workforce organisation Practice population & PHC professionals’ density • A fragmentation of HR in PHC - too many categories of health workers (doctors and nurses) are involved in delivery of PHC services • Not clear job descriptions/profiles of all categories of PHC health workers (doctors and nurses) • Despite the fact that there is a relatively sufficient number of PHC nurses their potential to enhance the capacity of PHC and community-based preventive activities is underused

39. PHC physicians = 1550 OB/GYN GP for all ages - 889 rural – 708 urban - 181 Pediatrician for sick children Specialists in HCs 67 Physician children consultory - 69 GP for adults 470 Specialists in polyclinics in Tirana 141 Physician women consultory - 40 GP/ Pediatrician for all children - 191 Other specialists

40. PC workforce organisation Scope of practice of practitioners • Health workers complain that devote too much time to secretarial work in place to deal with patients - too much paper work - for to register their activities regarding delivery of services they have to fill 45 registers and forms of CHIF and 13 forms of MoH

41. PC WORKFORCE ORGANISATIONRecommendations

42. PHC workforce organisation Working Group on HRH will do: rapid assessment of all HRH in PHC per pilot regions and totally rapid assessment of the structure of PHC in the country and its HCs, ambulatories and polyclinics mapping the country population to the number of PHC health professionals in order to make a standardization taking into accounts all factors not only the population in the catchment area, but package of services, distances, relief, etc.

43. Different models in the world GP for adults + Pediatrician + OB/GYN Only GP for all ages GP + Pediatrician + Specialists GP for adults + Pediatrician

44. PHC workforce organisation WG on HRH to: • Revise the nomenclature of medical professions in PHC for both physicians and nurses defining categories and profiles required for PHC according to the international classification of health workers (International Standard Classification of Occupations - ISCO, 2008 revision) • Make analysis of medical and statistical documentation in PHC and develop poposal for optimization of reporting system

45. Medical doctors (ISCO): Generalist Medical Practitioners Nursing professionals Nursing professionals: Professional nurse Specialist nurse Nurse practitioner Clinical nurse District nurse Operating theatre nurse Public health nurse Nurse anaesthesist Nurse educator GPs: Medical doctor (general) Medical officer (general) Physician (general) General practitioner Family medical practitioner Primary health care physician District medical doctor Resident medical officer specializing in general practice

46. PC structure Subdomains assessed Health outcomes Performance of primary care Capacity of primary care Primary care structures Impact Model of primary care Health system outcomes Care contact Primary care outputs Social determinants and context (political, social, demographic, socioeconomic)

47. PC QUALITY ASSURANCEFindings

48. PC quality assurance Quality assurance of health professionals • Well established re-licensing system with compulsory continuous professional development for doctors and nurses • No synchronization between the period of valid licence (5 years) and CME education - accumulation of credits (4 years) CME Licensing

49. PC quality assurance Quality assurance of facilities • Voluntary accreditation of facilities is enforced while most of HCs are not ready to meet the standards because of their poor conditions • At the moment there are no accredited HCs - all HCs participated in the study reported to have started the process of accreditation by February 2018 • Accreditation standards for PHC exist and includes requirements for equipment, infrastructure conditions, and clinical standards • ….but not specific enough criteria for assessment

50. PC quality assurance Development of PHC clinical guidelines • National stakeholders report on availability of guidelines (around 20 most outdated) which rarely applied in practice • The clinical performance of PHC nurses is not well supported by clinical guidelines, protocols and standards, especially in educational counselling to help nurses to self-manage the risk factors • There is noticed a weak role of PHC Professional Associations, Order of Physicians and Order of Nurses, Associations of Patients in development of PHC protocols and professional standards • There are no rules on implementation of protocols and standards