Problem: Service delivery concentrated in higher-level care settings; weak gatekeeping at the primary care level; care quality perceived by patients to be superior in higher-level care settings; health resources strained by overuse of specialized care.
Solution highlights: The district of Voznesensk experimented with initiatives, such as provider payment mechanisms, designed to align service delivery with the principles of family medicine, becoming an example for broader primary care reform across Ukraine; effective local leadership, combined with political and financial support, created a stable platform from which bottom-up reforms were built; aligning local initiatives with national priorities proved valuable for gaining legitimacy and support for the initiative; availability and capacity to collect and share data was fundamental for improving communication between health providers and increasing continuity of care. A district-wide electronic patient registration and medical records system was created to support this.
Description of practice
Ukraine’s health system remained largely centralized and disease-oriented. Gatekeeping at the primary level was weak, and service delivery was concentrated in specialized settings. The population often sought care directly from specialists, perceiving services in higher-level settings to be better quality. These conditions led to the overuse of hospital services and strained health system budgets, skewing the allocation of resources to higher-level settings to the detriment of primary care.
In the early 2000s, following national reforms that decentralized financial and managerial control over the health system, the district of Voznesensk began an innovative local reform process with the aim of strengthening primary care and introducing family-based medicine. After examining their local health system, health officials in Voznesensk understood the need to increase efficiency. However, as closing hospitals was politically unpopular, another method to drive efficiency improvements was needed. With political support from the Voznesensk City Mayor and grant funding from the Ministry of Health, the Chief Physician at Voznesensk Nykolai Homenyuk Central Regional Hospital pushed forward an initiative to indirectly stimulate efficiency improvements. Local overhaul of provider payment mechanisms replaced fixed salaries for general practitioners with fee-for-service payments. Investments in technological infrastructure, supported with grant funding from the Ministry of Health, created a district-wide electronic patient registration and medical records system to facilitate increased communication across care levels and help promote continuity of care between providers. Preventive services were prioritized through the introduction of an annual medical exam in primary care. Additional services now available in primary care include basic diagnostic and lab testing, immunizations, maternal and child health services, and a wide spectrum of acute and chronic disease management services. With the appropriate mix of incentives and tools put in place, general practitioners and nurses work as a team to implement necessary changes. General practitioners located in outpatient clinics across the district now oversee the majority of patient care, including the management of patients admitted to day hospitals attached to these clinics. Local support for the initiative remains strong and Voznesensk continues to pilot new financing mechanisms and serve as an innovator of primary care reform in Ukraine.
Implementation of practice
What stage is the practice currently in?
Who was/is responsible for the implementation of the practice?
The Ministry of Health’s prioritization of primary care inspired the initiative; however, most of the initiative’s activities were championed at the local level. The Chief Physician at Voznesensk’s Nykolai Homenyuk Central Regional Hospital was a key actor who led the diagnosis of service delivery barriers in Voznesensk and designed innovative local solutions to overcome challenges. These efforts were further supported by the Mayor of Voznesensk who was a strong advocate for the initiative and helped secure necessary funding for activities.
The majority of care (72%) in Voznesensk is now initiated in primary settings (up from 20%). Also, more than 85% of patients who start treatment with a general practitioner now complete treatment with a general practitioner. Quality indicators for primary care show service delivery improvements, and the local population generally reports satisfaction with care. Economic analysis indicates that efficiency and quality improvements have been achieved in Voznesensk: the number of hospital beds declined, bed turnover increased and cost-benefit ratios improved.
This case was prepared as part of a larger effort by the WHO Regional Office for Europe and published (2016) in the document, "Lessons from transforming health services delivery: Compendium of initiatives in the WHO European Region".
© Copyright World Health Organization (WHO), 2016
The methodology used for the development of this case is slightly different from the templates used on the IntegratedCare4People web platform, in particular in the analysis of enabling factors and barriers to change.
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- Vitaly Lukov
- Voznesensk City Council