2005年-世界发展银行全球_Review_of_Experience_of_Family_Medicine_in_Europe_and_Central_Asia_Volume_3_Bosnia_and_Herzegovina_Case_Study_126页_8mb

Summary of the Review of Family Medicine Experience in Bosnia and Herzegovina

Core Content

This report, part of a five-volume study on family medicine in the Europe and Central Asia (ECA) region, focuses on Bosnia and Herzegovina (BIH) and evaluates the progress, challenges, and lessons learned from family medicine reforms. It outlines the experience of BIH in implementing primary health care (PHC) reforms, highlighting both the successes and the remaining obstacles to further development and sustainability.

Main Views and Key Information

1. Introduction and Study Objectives

• The study aimed to review the experience of family medicine in ECA, present best practices, and make policy recommendations.
• Five countries were included: Estonia (as a pilot), Armenia, Bosnia and Herzegovina, Kyrgyz Republic, and Moldova.
• The report uses both qualitative and quantitative methods to analyze the reforms and their impact.

2. Challenges in the Health System

• War Impact (1992-1995): Severe disruption of the health system, leading to underfunding and fragmentation.
• Post-War Governance: Complex governance structures with two entities (Federation of BIH and Republika Srpska) and multiple health authorities.
• Economic Constraints: High poverty levels and limited financial resources affecting service delivery.
• Health Indicators: Decline in life expectancy and increase in infant and under-five mortality rates during the war.
• Pre-War System: BIH had a centralized health system before the war, which was disrupted and required significant reform.

3. Legislative and Financial Reforms

• Legal Framework: New legislation has established family medicine (FM) as a specialty, defined training curricula, and set up regulatory bodies.
• Financing Models:
  • Both entities have shifted to a health insurance-based system.
  • 40% of health insurance revenue is allocated to PHC.
  • A per capita payment model has been introduced, weighted by age and including performance-based elements in Republika Srpska (RS).

4. PHC Developments in BIH Entities

Federation of BIH (FBIH)

• Organization: Family medicine teams are the basic units of PHC.
• Human Resources:
  • 413 FM doctors and 286 FM nurses trained by June 2004.
  • Training includes both specialist and general practice (GP) components.
• Service Delivery:
  • FM teams provide a broader range of services than non-specialist GPs.
  • They manage chronic conditions, offer health education, and use a wider array of medical equipment and techniques.
  • Emergency out-of-hours services are provided by FM teams.
• Infrastructure and Equipment: Ambulantas (doctors’ offices) have been refurbished and equipped.
• Payment Systems: Per capita model is used, with performance incentives in RS.
• Accreditation: Agencies for Accreditation and Quality Improvement (AAQIs) have been established and are working on accreditation.

Republika Srpska (RS)

• Organization: Centralized structure with a Ministry of Health and Social Welfare (MOHSW) overseeing health services.
• Human Resources:
  • 168 FM doctors and 154 FM nurses trained by June 2004.
  • Training programs include both undergraduate and in-service components.
• Service Delivery:
  • FM teams focus on first contact care, continuity, and comprehensive services.
  • They are involved in the management of common conditions and chronic diseases.
  • Out-of-hours emergency services are available.
• Resource Allocation:
  • PHC is devolved to local governments.
  • Health Insurance Fund (HIF) is responsible for financing and purchasing.
• Accreditation: AAQIs are operational and provide bonuses for accreditation.

5. Task Profile and Facility Survey Results

• Doctor Characteristics:
  • FM doctors and GPs have different service delivery patterns.
  • FM doctors manage a wider range of conditions and use more medical techniques.
  • They have a higher involvement in health education and prevention.
• Patient Interaction:
  • FM doctors use appointments more frequently.
  • They have better continuity of care and more frequent interactions with other health professionals.
• Facility Survey:
  • Ambulantas and DZs are the main PHC facilities.
  • FM teams are more involved in the management of chronic and acute conditions.
  • Equipment and infrastructure are improving, though not uniformly across all regions.

6. Qualitative Findings

• Perceived Benefits of FM:
  • Empowerment of health professionals.
  • Enhanced choice for patients.
  • Holistic and comprehensive care.
  • Improved doctor-patient communication.
  • Better quality and prevention services.
  • Shift from biomedical to psychosocial models.
  • Named physicians for all patient needs.
• Critical Success Factors:
  • Branding and image building.
  • Improved work environment.
  • Effective communication.
  • Speaking the same language (alignment of stakeholders).
  • Holistic approach to reform.
  • Developing trust.
  • Bottom-up engagement and ownership.
• Barriers to Change:
  • Resistance from users and professionals.
  • Inadequate monitoring and evaluation (M&E) systems.
  • Asymmetry in development pace and legal framework.

7. Key Achievements of PHC Reforms

• Organization and Regulation: FM teams are now the core of PHC units.
• Resource Allocation: Per capita models and performance-based incentives have been introduced.
• Financing: Health insurance-based financing and legal mandates for PHC funding.
• Service Provision:
  • Increased focus on health education, prevention, and chronic disease management.
  • Enhanced teamwork and coordination.
  • Introduction of evidence-based care guidelines for 20 conditions.

8. Remaining Challenges

• Asymmetry in Development: Inconsistent pace of reform and legal implementation between entities.
• Strategic Planning: Need for scaling up and long-term sustainability.
• Service Integration: Poor coordination and referral systems between PHC and secondary care.
• Quality and Incentives: Limited capacity for M&E and performance-based incentives.
• Communication and Branding: Need for better communication and branding of FM to enhance public perception.
• Administrative Efficiency: Complex administrative systems hinder efficiency and cost-effectiveness.

9. Lessons Learned

• Critical Success Factors:
  • Branding and image building.
  • Improved work environment.
  • Effective communication.
  • Holistic approach to reform.
  • Developing trust.
  • Bottom-up engagement and ownership.
• Strategic Considerations:
  • Being strategic in reform implementation.
  • Long-term planning and time horizon.
  • Moving beyond pilots to system-wide change.
  • Linkages between institutions.
  • Institutionalization of FM models.
  • Reading the context of local needs.
  • Coordination and communication.
  • Responsiveness to user needs.
  • Importance of M&E and dissemination of knowledge.

Conclusion

The report highlights the progress made in BIH in developing family medicine as a core component of PHC, despite the challenges of post-war fragmentation and resource constraints. It emphasizes the need for a more integrated, sustainable, and performance-driven approach to PHC reform, with attention to the local context and stakeholder engagement.