P rimary Health Care Expert Group Sixth Meeting Oslo, Norway September 30 October 1st 2008

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PHC Project Proposal within the BSR Programme


rimary Health Care Expert Group

Sixth Meeting

Oslo, Norway

September 30 - October 1st 2008


PHC 6/6/1


Concept of PHC Project Proposal to BSR Programme

Submitted by


Summary / Note

This draft of the project concept is developed by consultant Carsten Bayer from agency “Sustainable Projects”, contracted by Swedish East Europe Commitee.

Requested action

It will be discussed during the EG meeting and is expected that Experts will be ready to propose potential partners of the project from their countries and activities/results actual for their countries. These activities should fit into the frame but can vary a lot. The scope of activities of the project should reflect the specific interests of the project partners and should not be an additional burden that the partners have to do for the sake of the project only.

Project Proposal: “Improvement of public health by promotion of equitable distributed high quality primary health care systems”

Background & Problem

In the Baltic Sea Region (BSR) large differences exist in health condition among population groups. Large population groups enjoy good health, while underprivileged ones suffer from high disease prevalence and premature mortality. Contributing causes to these differences include social and economic problems associated with high morbidity rates from cardiovascular diseases, violence, alcohol and drug abuse and spread of infectious diseases such as TB and HIV/AIDS.

Primary health care (PHC) is of special importance in addressing these health problems. PHC is the level of care nearest to the community and with a continuous relationship with all people. Strong primary care is the core element of meeting community health care needs, preventing of communicable infectious and non-infectious diseases and also for ensuring effective management of health problems. Strong PHC helps to control the costs of the health system through coordinating care and managing interfaces with other specialities.

Hence PHC takes responsibility for a needs-based allocation of scarce resources. It can be used as an efficient tool for health promotion and disease prevention and for more equitable allocation of overall health care resources to all population groups.

While the importance of PHC is without controversy, the equitable availability of high quality primary health care personnel and resources is a big challenge for all BSR Countries. In urban centres the provision of PHC is often assured but in the remote rural parts of the BSR countries PHC is often more difficult to master from a human resource perspective.

BSR countries show a high diversity in the way health care in general and primary health care in particular is organized. On the one hand the Nordic countries (Denmark, Finland, Iceland, Norway, Sweden) have established general practice oriented models of primary health care. On the other hand Poland, Lithuania, Latvia, Estonia, Russia and Belarus are experiencing different stages of primary care transition from the "Semashko system" of policlinics, in which district paediatricians and internists work together with a number of specialists as the first contact doctors, towards a more comprehensive and efficient model of PHC based on family medicine.

Several BSR countries are experiencing unequal distribution of primary health care resources, and not all population groups have access to qualified primary health care professionals. The long traditions of the specialist - driven health care systems also result in population groups with lower accessibility to qualified primary health care becoming high users of secondary health care.

The unequal availability of quality primary health care services is related to a number of problems, which include:

o Political strategies for the establishment and development of a system of equitably distributed and high quality PHC are frequently inadequate

o Overall PHC resources (human & financial) are insufficient. Underlying reasons for that include the small share of PHC in the overall health care financing, and the little room that is given to PHC staff in the medical training system.

o Geographical distribution of primary health care services in BSR is unequal. One underlying reason for this is the absence of financial incentives within the remuneration system for family doctors or nurses to work in more remote, rural areas.

o Quality of PHC services in BSR varies considerably. Underlying reasons for that include that the PHC personnel (doctors & nurses) need to receive better continuous medical education and the remuneration system does not reward high quality in PHC activities enough.

o Health systems often focus on doctors. However, in highly developed countries the contributions, through teamwork and independent activities, of nursing professionals including not only nurses but also rehabilitation professionals, are indispensable for a high quality and cost effective health system. Thus the professional training of nursing professionals must be improved including preventive advice on life style issues & community-based work.

o The benefits of PHC are not sufficiently demonstrated/communicated to the key stakeholders and the wider public.

Interreg BSR Programme 2007 - 2013

The Baltic Sea Region (BSR) Programme 2007-2013 has been designed under the European Community’s territorial cooperation objective. It is built on the experience of its two predecessor programmes supporting transnational cooperation in the Baltic Sea region under the Community Initiatives “INTERREG IIC” (1997-1999) and “INTERREG III B Neighbourhood Programme” (2000-2006).

The overarching strategic objective of the Baltic Sea Region Programme is to strengthen the development towards a sustainable, competitive and territorially integrated Baltic Sea region by connecting potentials over the borders. As part of Europe, also the Baltic Sea region is expected to become a better place for its citizens to invest, work and live. The programme will thus address the European Union’s Lisbon and Gothenburg strategies in order to boost knowledge based socio-economic competitiveness of the Baltic Sea region and its further territorial cohesion.

One of the four priorities of the BSR Programme aims at “Ensuring co-operation of metropolitan regions, cities and rural areas to share and make use of common potentials that will enhance the BSR identity and attractiveness for citizens and investors”. The PHC project proposal can be submitted under this priority as more specifically one of the planned results of priority 4 is “To strengthen the social conditions and impacts of regional and city development” by implementing “joint actions in the field of public health to counteract major communicable diseases and to address social and environmental factors of health problems”.

Thus the PHC project fits very well to a specific niche of the overall BSR programme, which in turn could provide funding for the necessary action towards promoting an equitably distributed primary care system in the BSR.

The eligible area includes the whole territory of Denmark, Estonia, Finland, Latvia, Lithuania, Poland and Sweden, and Northern parts of Germany as EU member states. Also the neighbouring countries of Norway (whole country), Russia (North-Western regions) and Belarus (whole country) belong to the programme area.

Eligible beneficiaries comprise public authorities from national, regional and local level as well as public equivalent bodies (such as research and training institutions, business development institutions and other non-profit organisations).

The contribution from the European Regional Development Fund (ERDF) amounts to some 209 million EUR. Norway will make available 6 million EUR national funding. Some 23 million EUR will be provided by the European Neighbourhood and Partnership Instrument (ENPI) for the benefit of the eligible regions in Russia and Belarus. The total of approx. 238 million EUR will cover:

o up to 75 % of eligible project costs generated by partners from Denmark, Germany, Sweden, Finland

o up to 85 % of eligible project costs generated by partners from Estonia, Latvia, Lithuania and Poland

o up to 50 % of eligible project costs generated by partners from Norway

o up to 90 % of eligible project costs generated by partners from Russia and Belarus

The PHC project needs to present a single joint application to the programme, which integrates the objectives of EU and Norwegian territorial cooperation as well as actions supported by the European Neighbourhood and Partnership Instrument.

The project duration is usually three years. Project partners are expected to co-finance activities with 10%, 15%, 25% or 50% of the budget (depending on their country of origin). As staff costs (of permanent or temporary staff employed anyway by the partner but working for the project) are eligible costs this co-financing share does not need to be provided necessarily in cash (often the staff costs takes a bigger share than 25% of the overall individual partner budget).

The PHC project proposal is planned to be submitted for funding within the second call for project applications intended to open November 2008 and close January / February 2009. The project activities would then start approximately in the summer of 2009.

Project Objective and Project Results

The overall objective, which is in line with the BSR Programme and to which the PHC project will contribute, is:

To improve public health by counteracting communicable diseases and targeting health problems related to social factors

In order to contribute to the overall objective the project aims at achieving the following specific objectives:

o To promote equitable distribution of high quality PHC system

o To balance patients’ preferences more towards primary health care

o To better address health risks related to gender and social factors

o To counteract communicable diseases through preventive measures and evidence based clinical management
Specific results to be accomplished in the course of the project, which would lead to the achievement of above-outlined specific objectives, include:
o Framework for increasing PHC resources created

o Mechanisms for equitable distribution of PHC system elaborated

o Quality of PHC services improved

o Knowledge and skills of PHC professionals in addressing health risks related to social factors and counteracting communicable diseases improved

Expected outcomes and related activities

In order to tackle the problems identified above and to achieve the objectives defined it is important to establish a network of equal partners, who can learn from each others’ experiences on how to improve PHC services.

Partnerships and pilot projects in this area could be very useful in finding the balance between the needs of the patients and the communities and promote effective working mechanisms in the primary care systems. Other appropriate tools might comprise study tours or internships.

Payment schemes with incentives to increase health promotion and disease prevention activities would be very relevant for most BSR countries. Sharing of experiences in this field and lessons learned from mistakes would be appreciated by the majority of health care decision makers of the BSR countries.

Special focus in the field of PHC human resources and professional training shall be put on the role of nurses in clinical and preventive care. Here the project intends to exchange and apply different audit measures (including ICT-based tools), in order to ensure continued medical education and quality development from a bottom-up perspective.

Expected outcomes of the project will be on the one hand on the operational level by developing and piloting action plans and exchanging lessons learnt and good practice solutions. These outcomes might include:

o Further evidence for benefits of PHC generated, demonstrated & communicated to key stakeholders and communities

o Mechanisms for equitable distribution of high quality PHC system piloted and evaluated

o New payment schemes piloted and evaluated

o PHC personnel trained in methods on lifestyle issues and in community based work

On the other hand the project will include joint activities that lead to outcomes such as strategies and conclusions for policy approaches. They might include:

o Conclusions on financial incentives to PHC service personnel within medical remuneration system, rewarding rural posting as well as quality achievements

o Conclusions for policy making that support promoting equitably distributed PHC services

o Conclusions for balancing health care financing towards PHC

o Conclusions for emphasizing education of PHC staff
All potential partners are invited to specify activities that fit into the frame sketched above (Objectives-Results-Outcomes) and that are of relevance and interest to them. As an example the following activities could be sub-summarized under the outcome “Conclusions for policy making that support promoting equitably distributed PHC services

- Situational analysis identifying distribution of PHC personnel within BSR countries (outputs: country reports/studies)

- Workshops exchanging results from country studies (outputs: transnational workshops)

- Assessment and comparison between the countries on the interrelation between availability of PHC services and key indicators for public health (outputs: thematic reviews)

- Assistance to health care planners at national and regional levels to develop appropriate strategies for equitable distribution of qualified PHC personnel (outputs: regional strategies / preparation of pilot projects)

- Development of conclusions for further improvement of the policies for equitable distribution of PHC (outputs: reports)

- Meetings with key stakeholders of the health sector presenting and introducing conclusions of the PHC project (outputs: dissemination meetings)

- Dissemination of results (outputs: conference, flyer, handbook etc.)

Project Partner Structure

Possible Project Partners suggested:

- Russia:

- Belarus:

- Sweden:

- Finland:

- Lithuania:

- Latvia:

- Estonia:

- Poland:

- Norway:

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