TA for Capacity Building for Tertiary Care Services

1. Republic of Serbia MINISTRY OF HEALTH • Politicians and policy makers – • where are managers in policy creation? • An inclusive approach for Tertiary health care policy in Serbia • Katrava A, • Jekić I.M, Boulton G, Rupert P, Christensen SB, Obrovački M, Novak S, Janković-Vuković T, • Đukić V*, Peško P*, Dmitrović T*, Drašković D** Dujmović F**, Trenkić S***,Pavlović R**** • EAR/EU SOFRECO Technical Assistance-TA Team, Belgrade • * Clinical Centre of Serbia, Belgrade • ** Clinical Centre of Vojvodina, Novi Sad • *** Clincal Centre of Niš • **** Clinical Centre of Kragujevac TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstruction

2. Context • Background / Current situation • Methods • Results • Conclusions TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstruction

3. Context • Traditionally, politicians and policy makers dictate to health care institutions managers national strategy for service delivery. • The EU/EAR Projectprovided to the Ministry of Health-MoH has been charged with • reforming tertiary care services • developing and implementing 4 CC’s business plans and introducing change management training • implementing an EIB loan of EUR 200M (project value EUR 280M ) for reconstruction and reequipping of the 4 beneficiary institutions: • Clinical Centres in Belgrade, Novi Sad, Nis and Kragujevac. • All policy decisions made at a political level and in these 4 out of 120 inpatient institutions will have a trickle down effect to the rest of the system for • patient care • teaching • research TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstruction

4. CONTEXT HOSPITAL SYSTEM IN THE RS Inpatient health institutions in the RS 122 inpatient institutions* MoH - Govt’ Agencies - HIF - PHI High 4 + 24 = 28 4 CC 4 CHC, 5 Clinics, 15 Institutes 56 (40 General hospitals,16 Special hospitals) 38 (20 DZ, 18 zavodi) THC Cost SHC PHC Low Primary HC – outpatient care Chronic / prolonged / palliative care TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstruction

5. Context4 Clinical Centers of Serbia • The four Clinical Centres, with • over 14.000 employees • approx. 240.000 admissions • approx. 110.000 surgeries and • approx. 1.745.000 outpatients visits • approx. 270.000 emergency visits • approx. 222.000.000 EUR annual operating budget • represent one-quarter of the activity and budget of the Serbian health care system, and are leaders for innovative changes in other sectors (primary and secondary health care). • Managers of this small number of big institutions are increasingly asked to be members of policy bodies, along side top opinion leaders in the country - and they are influencing change at many levels. • THC policy and renewed services delivery model is to be implemented by managers in the four Clinical Centres. TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstruction

6. Background • In Europe, HC systems are gradually shifting from centrally to regionally and locally regulated and financed HC systems • Traditionally, in the Serbian health care system policy and decision-making is centrally planned, regulated and managed. TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstruction

7. ContextFundamentals that will transform the health care system • Economic pressures will mount – annual budget – approx. EUR 220 mil – increase 2,5 times over last 5 years • Professional expectations are growingaboutdelivery patterns to which Serbian health care system should aspire – overall over 14.000 employees – over 1000 University Professors and over 2500 MD • Patient expectations about health servicewill rise in the years ahead – over 2.300.000 patients annually – over 110.000 surgeries TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstruction

8. GOVERNMENT MINISTER OF HEALTH HEALTH INSURANCE FUND NATIONAL HEALTH COUNCIL NATIONAL ETHICS BOARD DEPUTY MINISTER OF HEALTH NATIONAL AGENCY FOR ACCREDITATION OF HEALTH CARE FACILITIES ASSISTANT MINISTERS Health Insurance + Financing Sanitary Inspection + Public Health International Relations + Project Coordination Organization of Health Service + for Health Inspection Health Policy + Planning NATIONAL PUBLIC HEALTH INSTITUTE PRIMARY HEALTH CARE CENTERS REGIONAL + MUNICIPAL OFFICES REGIONAL + MUNICIPAL OFFICES HOSPITALS PATIENTS BackgroundAdministration of the Serbian Public Health Care System TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstruction

9. CURRENT SITUATION – Legal framework to address strategic planning / Reform of the THC services • For tertiary level health care the current Health Law andvarious decrees suggest that tertiary level services should : • Occupy approximately 6,000 beds representing0.8 per 1,000 population • Much of the current law and regulation concentrates on “inputs” (size of facility, staff numbers, equipment etc.), whereas contemporary THC planning (and indeed primary and secondary care planning) should focus on: • An overall service perspective (rather than an institutional perspective) covering the whole range of health care interventions for particular patient groups and the identification of the respective role of each level of health care in the health care continuum (e.g. the cancer network); • Outputs, types of output and outcomes (e.g. cardiac surgery – numbers and types of revascularization procedures) with inputs being inferred from outputs, using a variety of quantitative and qualitative measures; • Matching service need/demand with viable units of clinical organization from the perspectives of clinical and economic effectiveness (given that a number of tertiary level services often require access to high cost infrastructure and technologies), affordability and clinical governance. TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstruction

10. Hospital system in the RS – Facts and figures Tertiary health care, number of beds per 1000 population Catchment area THC beds per 1000 pop 1.7 M population 1.5 per 1000 pop. 3.2 M population** 2.5 per 1000 pop.2.6 M population 1.1 per 1000 pop. 7.5 M population Target: 0.8 per 1000 pop. North Central South TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstruction

11. CURRENT SITUATION – Inefficiencies and Drawbacks created by the current situation • Lack of strategic planning of network and health services over the past 15 years. • Weakness of refferal system. • Hospital and health sector standards (set by IPH) are rigid, historical, normative, and largely input – based are not related to new organisational models and modernisation. • Hospital reimbursement systems arenot linked to efficiency, effectivness, output and performance (outcome). The change alone would have a profound impact on the size and nature of the hospital network. • Data systems at hospital level are extensive, yet information for operational and performance management of a large modern health care and hospital system is inadequate and under developed. • The application of inconsistent data definitions, the quality assurance of data and variable methods of dealing with data, hampers reliable inter regional and inter hospital comparison. TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstruction

12. CURRENT SITUATION • Limitations of current legislation underpinning services planning • Services planning is occurring in context of significant organizational change • Legislation has its part to play in facilitating or hindering such change • However, there is recognition of the complexity of health care environment and stakeholders within it • In an attempt to introduce services planning as strategic planninginvolving key stakeholders/managers TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstruction

13. Methods • The EU/EAR Project inclusive approach that links • organizational change in institutions and • policy change at a national level • is endorsed by the MoH, and for the first time provides the opportunity for mangers to be involved in both. • For the first time, planning at a national level • is service/patient group rather than institution based • involves practitioners • managers in Tertiary Health Care - THC institutions - providers • Institute for Public Health-IPH - planners • Health Insurance Fund-HIF – purchasers TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstruction

14. Methods Health sector reform – strategic shifts in future role and organisation of the hospital sector • Improve accessibility to tertiary level care for patients. • Move from input – based planning (eg.size of facility, number of staff, equipment etc.) to focus more on outputs (eg. cardiac surgery – number and types of revascularization procedures) and outcomes (eg. improved health status of population) • Role of standards, accreditations and clinical guidelines. TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstruction

15. The Goal • MoH aim is, to produce a modern tertiary health care policy for Serbia and to establish distinct policy development, business planning, commissioning and financing and performance management processes and capacities for tertiary level health care. • Appropriate CARE, in the appropriate SETTING, at the appropriate TIME Major issues: • Access to Care • Quality of Care • Costof Care The extent of the health system contribution of the 4 CCsmeans that any change in their organization and financing aimed to enchance efficiency and quality will have a further “trickle down” positive impact on the entire health care system. TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstruction

16. Methods – to achieve the goal • The official EAR/TA mechanisms include: • Project Steering Committee • THC Expert Group andTask Forces (mandated by the Ministerial Decree) • the Clinical Centres Senior Managment • Clinical Directors • Business Planning Work Groups TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstruction

18. Results • Areas the MoH is seeking advice on include: • THC service provision models • Organizational structure of institutions • Redefinition of capacity plans and capital investments (facilities and equipment) for THC institutions and redefined THC services • HR planning • Models for financing of and contracting with THC institutions • Health technology assessment (HTA) TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstruction

19. Results • Since establishment in June 2006 • THC Expert Group has developed, completed and presented most general parts of the THC policy • now needs to address the more detailed issues to convert THC policy into strategy. • Additionally, THC service-specific Task Forces have been formed by Ministerial Decree to advise on practical issues of • THC policy, strategy and implementation • for Serbia’s three population catchment areas (North, Center and South) until end 2008. TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstruction

20. Results - Implementation Possibilities THC ServicesPolicy and Strategy Implementation MoH THC Expert Group with EAR/TA Tertiary Care Project: • Definition for THC in the RS • Criteria for identifying tertiary level care services • Categorisation and Classification of Tertiary level care (national level provision, regional level provision and complex case - mix) • Task Forces (specialty/patient group - specific) to be established in January 2008 for tertiary level service planning and organisation of care delivery across the network TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstruction

21. Results • Hospital Managers of 4 big university institutions and their teams are increasingly involved in THC policy development through all mentioned bodies and mechanisms. TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstruction

22. Conclusions 3 steps towards a healthy and viable future • Build bridges / network partnerships across the 3 levels of care • Pivotal role of physicians/managers • Relationship building • Leadership and trust • Incremental and “ big – bang ” approach • Alligned incentives • Enhance efficiency and quality • Invest in modern management tools • Build HR talent and core competencies • Capable managers need access to appropriate information to enhance decision - making • Need standard coding system (activity and financial data, diagnostic procedures) • Measure outcomes • Data performance tools (activity and financial data – ABC) • Patient empowerment • Informed patients – access to information • Active participation in process / well -being • Manage expectations TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstruction

23. THANK YOU Annette Katrava Deputy Team Leader & Hospital Manager EAR/EU Project Capacity Building of the Ministry of Health for Tertiary Care Services Technical Assistance – TA Sofreco Project Office 11000 Belgrade, Serbia Pasterova st. 1/III katrava@sofreco-tcs.com TA for Capacity Building for Tertiary Care Services An EU-funded project managed by the European Agency for Reconstruction