2009年-世界发展银行全球_Serbia_-_Baseline_Survey_on_Cost_and_Efficiency_in_Primary_Health_Care_Centers_Before_Provider_Payment_Reforms_90页_5mb

Summary of the Baseline Survey on Cost and Efficiency in Primary Health Care Centers in Serbia

Core Content

This report presents the findings of a baseline survey conducted in Serbia to assess the cost and efficiency of Primary Health Care Centers (PHC Centers, or DZs) before the implementation of provider payment reforms. The study was carried out by a team from the World Bank and supported by the health sector strategy funds, with the aim of informing future payment system changes and establishing a benchmark for evaluating the impact of these reforms.

Main Purpose

The survey was conducted in 147 PHC Centers across Serbia, collecting data on their performance in terms of input use, output production, revenue sources, and productivity. The results are intended to:

• Inform the design of payment reforms (capitation and case-based payments like DRGs)
• Establish a baseline for assessing the efficiency and effectiveness of the health sector
• Provide insights into the current level of performance and the factors affecting it

Key Findings

1. Efficiency Variations

• PHC Centers (DZs) differ significantly in their efficiency.
• Despite similar staffing, equipment, and space, DZs produce varying levels of output such as consultations.
• Efficiency differences may be influenced by the age and gender structure of the population, particularly the number of children in the catchment area.

2. Cost Structure

• Personnel costs account for 70% of total expenditures in DZs.
• Cost efficiency is limited due to the pre-determined nature of DZ expenditures, which are largely based on national-level input prices.
• If personnel costs are excluded from capitation, only about 30% of total costs can be managed by DZs.

3. Utilization of Resources

• There is significant unused space in DZs, which reduces productivity.
• While many DZs have large equipment, diagnostic tests are underutilized.
• Reducing non-clinical space and using equipment more effectively could improve productivity.

4. Service Output and Quality

• DZs primarily provide curative visits, with an excessive number of laboratory tests and injections.
• Preventive care is underprovided, and referral rates are generally low, possibly due to a low severity case-mix.
• The current payment system does not incentivize quality improvements or preventive care.

5. Resource Allocation Inequality

• There is an unequal distribution of public resources across DZs.
• This is attributed to the line-item budget system, which is based on staff numbers and beds.
• A capitation payment system could help address this inequality by pooling funds and distributing them equally based on population.

6. Potential Impacts of Reforms

• Capitation is expected to increase preventive care, reduce unnecessary diagnostic services, and lead to higher referral rates to hospitals.
• However, there may be adverse effects on quality and access to care, and on hospital expenditures, if not properly managed.
• Additional measures are recommended to ensure that the payment reforms do not negatively affect care quality or access.

Recommendations

Phase 1: Payment System Design

• Pool PHC funds from the Health Insurance Fund (HIF) and other public sources, and implement a unified capitation rate with adjustments for cost variations.
• Include salaries in the capitation amount and adjust human resources policies to allow DZs more flexibility in managing costs.
• Specify referral guidelines to prevent unnecessary referrals and include measures like open enrollment, quality monitoring, and outcome-based bonuses to ensure appropriate service delivery.
• Adjust capitation rates for age, gender, and geographic factors to reflect varying service needs and costs.

Phase 1: Management Issues

• Assess regulations affecting DZs' ability to manage resources efficiently, including public procurement and labor laws.
• Evaluate essential medicines and consider their limited financing under capitation.
• Develop a cost-effective equipment package for DZs, possibly reducing equipment in areas near hospitals and focusing on more basic, productive tools like blood pressure cuffs and scales.

Phase II: Additional Measures

• Reorganize space in DZs, such as moving to smaller buildings or repurposing unused areas for other services.
• Prepare for hospital payment reforms like DRGs, which may lead to shorter hospital stays and higher patient turnover, requiring DZs to provide more follow-up care.
• Collect disease profiles and access data to develop quality and outcome measures for monitoring by DZs and the system.

Context and Background

• The Serbian Ministry of Health (MOH) and HIF are planning to transition from a line-item budget to capitation in PHC and DRG-based payments in hospitals.
• The current system incentivizes the use of more staff and beds but does not reward productivity or quality improvements.
• The goal of the payment reform is to improve efficiency, financial sustainability, and health outcomes.

Conclusion

The baseline survey highlights the need for a well-designed payment system that not only incentivizes efficiency but also ensures quality of care, preventive services, and equitable resource distribution. The study provides a foundation for evaluating the impact of the planned reforms and recommends a phased approach to implement changes effectively.

The findings emphasize that while capitation has the potential to improve efficiency, it must be supported by policy changes, improved data systems, and management support to avoid negative consequences on care quality and access.