PHC Models in Europe
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PHC Models in EuropeTeppo Heikkilä, MD
Budapest June 201120.04.23 PHC Models in Europe / Teppo Heikkilä 1
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Five Models of PHC
• PHC Model 1: Direct access to any GP or specialist
• PHC Model 2: Referral required from GP, mainly solo-practices in PHC
• PHC Model 3: Referral required from GP, mainly group-practices in PHC
• PHC Model 4: GPs working mainly in health care centres
• PHC Model 5: Polyclinics (Shemasko). Not necessarily GPs at all
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”Solo practice” basic model based mainly on specialists’ services
Local health services; preventive services, elderly care, some public health functions, etc.
Various primary care doctors, that can be accessed directly
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”Solo practice” basic model based mainly on generalists’ services
Local health services; preventive services, elderly care, some public health functions, etc.
Through referral to other services
Direct access to the chosen generalist
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”Group practice type of arrangement”
Local health services; preventive services, elderly care, some public health functions, etc.
Through referral to other services
Direct access to the chosen group service/own GP/FD
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”Health centre type of arrangement”
Usually no separate local health services, apart from possibly local public health services
Through referral to other services
Direct access to the health centre usually determined by residency (or choice)
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”Policlinic-based arrangement”
Usually no separate local health services, apart from possibly local public health services
Through referral to other services
Direct access to the policlinic usually determined by residency (or choice)
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Five Models of PHC
• Simple and relatively easy to observe
• Do not offer complete answers to the European PHC structure
• Do not define if the system is financially based on health insurance funds or taxation
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European PHC Models
• We went through the European PHC systems and compared them to the five PHC Models created beforehand
• We used WHO’s Health in Transition (HiT) reports– HiT reports contain information about health care
systems structured in the same format
• For countries in EU Primecare we also used the answers to the questionnaire
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HiT Reports of European Countries
• HiT report released 2006 – 2010 26 countries
• HiT report released 2000 – 2005 16 countires
• HiT report released 1999 2 countires
• No HiT report 9 countries
• In total 53 countries
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Challenges
• There are different kinds of local solutions and partial solutions in different countries with their own models e.g. in referral systems and health care service coverage in PHC
• Different systems can coexist in one country– Different systems in different regions– Public and private systems working side by side– Each health insurance fund providing own system
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Challenges
• Difficulty to classify each country to one PHC Model exactly
• The PHC Model system can be described as a continuum where each country settles somewhere between the PHC Models
– E.g. kind of partial referral system (Austria) or a mix of solo- and group-practices (e.g. Denmark, Estonia, Italy)
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PHC model 4
PHC model 4
PHC Model 3
PHC Model 3
PHC Model 2
PHC Model 2
PHC Model 5
PHC Model 5
PHC Model 1
PHC Model 1
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Challenges• Some basic elements of the PHC Models could
have been understood differently in different countries
• E.g. gate-keeping– Can a patient go to the specialist
• Only with referral• If paying a formal or informal fee for the specialist• In some defined cases without a referral• To some defined specialists without a referral?
• E.g. group-practice– Is it a practice owned by a group of practitioners, or a
facility in where a group of independent practitioners are working side by side?
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Challenges
• In some countries (e.g. former Soviet Countries) there is going on a progress in developing health care systems
• During the process the health care system can represent different PHC Models
– In these cases some of the HiT reports could have been too old to describe the present PHC Model
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Challenges
• There can also be some human errors when reading the HiT reports and trying to understand and assess the elements of the PHC Models
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PHC Model 1Direct access to any specialist
• Andorra (HiT 2004)– No mention about referral systems in HiT report
• Austria (HiT 2006)– Partial referral system, where the patient in theory
needs a referral to go to a specialist, but• Patient can choose a specialist to be the first contact
in health care system • Patient can change the first contact in every three
months
• Czech Republic (HiT 2009)– In practice PHC Model 1. Patients can go directly to
the specialist if they want to
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PHC Model 1Direct access to any specialist
• France (HiT 2004)
• Germany (HiT 2004)
• Turkey (HiT 2002)– Many actors in PHC. Public system is close to the
PHC Model 4, but undeveloped. Most patients go directly to the private specialist
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PHC Model 2Referral required, mainly solo-practices in PHC
• Croatia (HiT 2006)– There are some health centres (PHC Model 4), but
most of the GPs work in solo-practices
• Cyprus (HiT 2004)– Implementing new model, where there are solo-
practices and heath care centres. Most of the GPs in solo-practices
• Hungary (No HiT Report)– Assessed based on questionnaire in EU Primecare
• Ireland (HiT 2009)– At present PHC Model 2, implementing PHC Model 4
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PHC Model 2Referral required, mainly solo-practices in PHC
• Italy (HiT 2009)– Both solo- and group-practices, mainly solo-practices
• Latvia (HiT 2008)– Trying to create PHC Model 4. In practice more close
to the PHC Model 2
• Malta (HiT 1999)– Old HiT Report. Public (PHC Model 4) and private
(PHC Model 2) system side by side. Private system dominant
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PHC Model 2Referral required, mainly solo-practices in PHC
• Norway– Health centres, but GPs working in private solo-
practices
• Romania (HiT 2008)
• Slovakia (HiT 2004)– PHC Model 2, although PHC doctors are working
mainly in shared facilities
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PHC Model 3Referral required, mainly group-practices in PHC
• Belguim (HiT 2007)
• Bulgaria (HiT 2007)
• Denmark (HiT 2007)– Both solo- and group-practices, but group-practices
more common and growing
• Estonia (HiT 2008)– Both solo- and group-practises, but group-practices
more common (and growing?)
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PHC Model 3Referral required, mainly group-practices in PHC
• Israel (HiT 2009)– Four health insurance funds, which all run their own
health care system. The biggest one is close to PHC Model 3 with features of PHC Model 4. The second biggest one is close to PHC Model 1.
• Lithuania (HiT 2000)– Old HiT Report. PHC Model 3 based on the answers
to the EU Primecare questionnaire.
• Netherlands (HiT 2010)
• United Kingdom (HiT 1999)– Old HiT Report. The UK has gone through a health
care reform after that. Does that affect their PHC Model?
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PHC Model 4Health care centres in PHC
• Albania (HiT 2002)– Old HiT Report. Planning to develope PHC Model 4.
Has that been put into effect?
• Bosnia and Herzegovina (HiT 2002)
• Finland (HiT 2008)
• Iceland (HiT 2003)
• Moldova (HiT 2008)
• Portugal (HiT 2007)– The role of the private sector seems to be small but
is not clear in the HiT report
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PHC Model 4Health care centres in PHC
• Slovenia (HiT 2009)– At present PHC Model 4 but going towards PHC
Model 2 as health care is getting privatized
• Spain (HiT 2006)
• Sweden (HiT 2005)– Quite old HiT Report. Some changes happened after
that. Do they affect the PHC Model?
• Macedonia (HiT 2006)
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PHC Model 5Polyclinics (Shemasko)
• Many former Soviet Countries are developing their health care systems. Many countries seem to go more or less towards PHC Model 4, but some also towards other PHC Models.
• They have started to train general practitioners / family doctors almost in all former Soviet Countries
• Difficult to define the PHC Model at present because of ongoing plans and progress
• In practice, based on HiT reports the PHC Model in most countries is still very close to the Shemasko model
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PHC Model 5Polyclinics (Shemasko)
• Armenia (HiT 2006)
• Azerbaijan (HiT 2010)
• Belarus (HiT 2008)
• Kazakhstan (HiT 2007)
• Kyrgyzstan (HiT 2005)– Trying to go towards PHC system based on family
doctors (PHC Model 4)
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PHC Model 5Polyclinics (Shemasko)
• Russian Federation (HiT 2003)
• Taijikistan (HiT 2010)
• Turkmenistan (HiT 2000)
• Ukraine (HiT 2004)
• Uzbekistan (HiT 2007)
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Hard to Define the PHC Model
• Poland (HiT 2005)– Some basic elements of PHC Model could not be
found in HiT report, such as • Is there a referral system? • Do family doctors work mainly in solo- or group-
practises or is there any kind of health care centre based system?
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No HiT Report
• Georgia
• Greece
• (Hungary)
• Luxenbourg
• Monaco
• Montenegro
• San Marino
• Serbia
• Switzerland
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Countries in EU Primecare
• PHC Model 1– Germany
• PHC Model 2– Hungary– Italy
• PHC Model 3– Estonia– Lithuania
• PHC Model 4– Finland– Spain
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