1. Service Delivery
PHRplus is helping to define the primary health care scope of services to be provided in Albania and to develop a list of supplies and equipment necessary to provide those services. PHRplus helped pilot facilities design and implement a new medical records system, upgrade provider knowledge and skills in family medicine topics, develop clinical practice guidelines and quick reference sheets and introduce continuous quality improvement processes. The project targeted and improved the management of the health center itself, as well as the clinical and diagnostic management of the patients. Documentation standards and guidelines were established. In addition, PHRplus worked closely with facility staff to enable them to better use data collected from a new patient encounter form to monitor and eventually improve quality.
The community was actively engaged in this process to address the needs of the community that the pilot site serves. For instance, to begin integrating reproductive health services into primary health care, PHRplus worked closely with pilot facilities to launch a Women’s Health Awareness Campaign that consisted of training midwives to conduct community meetings to educate on reproductive health issues, developing health education materials in the PHC centers, and providing appropriate referrals to OB/GYN specialists. The community campaign reached more than 2,500 women in rural areas. Additional community outreach efforts focused on disease screening, improving diagnosis and monitoring of common chronic diseases.
2. Quality Improvement
Improving the quality of primary health care delivered at the pilot facilities increased the efficiency of the health centers. A technical report describing the quality improvement interventions in the four pilot sites will be available soon. PHRplus worked with facility staff and local authorities to implement quality improvement mechanisms in the four pilot PHC centers. Implementation followed a traditional quality improvement framework identifying key obstacles to improving quality of care and developing processes to address obstacles and measure improvement in a systematic and sustainable way. Quality management processes were established within facilities, paired with invigorated quality monitoring by external regional boards. The scope of services and standards of care (including referral guidelines) were clearly defined to serve as benchmarks against which quality improvement could be measured. Providers were trained according to these new standards and medical charting was improved. Finally, a number of tools were introduced a health information system, patient satisfaction survey, and chart auditing system to continuously measure quality improvement.
Through these quality improvement processes, it has been demonstrated that groundbreaking results can be achieved in spite of the limited overall broader health reform and lack of monetary incentives for the participating medical staff. The activities also demonstrated that internationally recognized improvement processes could be adapted and effectively implemented in the Albanian context. The PHRplus quality improvement model ensured that pilot facilities had the necessary inputs (equipment, standards of care and CPGs and refresher training for providers) and sustainable processes (quality committees, routine measurement of quality improvement using chart audit, HIS data and patient satisfaction surveys, and monthly reports and meetings to review findings) to improve quality. Patients already notice the differences in quality of care as reflected in their surveys and providers are feeling more empowered to create systems to improve quality themselves. The next step is to work with facilities and providers to achieve improved outcomes in terms of better quality of care, improved service delivery, and improved patient health.
3. Health Information System
PHRplus has provided technical assistance to design and implement a health information system for primary health care to provide information for quality improvement planning and management decision-making at the clinic, district and regional levels, including the regional offices of the Ministry of Health and the Health Insurance Institute in Berat. The primary health care delivery system in the pilot areas had had no experience with modern health information systems. Data was collected in each facility using a system of ledgers and reports are sent forward to the Ministry of Health. There was no feedback of the data to the clinics. As a result, the clinic staff had only subjective impressions of the type of service delivery that occurred in the clinics and of the volume of service over time.
During the project, a scannable patient encounter form was designed and implemented in the pilot sites. A technical assistance team reviewed the patient encounter data collected with clinic staff and local stakeholders and worked with them to refine their information needs, based on preliminary views of their own encounter data. All levels of stakeholders were engaged in the task of defining information that provided the evidence required to manage and improve primary health care in the pilot areas. After the completion of the pilot in April 2004, the local stakeholders piloted a revised encounter form, which was implemented in ten sites in the city of Berat in June, and then implemented in three sites in the city of Kucova in July. Two sites in the district of Skrapar were added in August, and in September all the health centers in the three-district area will participate.
Additional activities that provided information to be included in a community health information data repository were: the baseline survey of households, facilities and providers and the information on financing and costs of the primary health care system in the pilot areas. Technical assistance is being provided to design computer systems that allow access and various views of these data. In this way, local stakeholders are provided with better evidence to guide their decisions on primary health care delivery.
4. Primary Health Care Financing, Planning and Budgeting
To sustain improvements in service delivery and quality of care, PHRplus is working with health authorities at national and regional levels to improve budgeting, planning and financing of primary health care. PHRplus provided technical assistance in its pilot sites to implement an expenditure tracking system, allowing facility managers to relate costs to volume of patients, to measure the cost of different services offered at the visits, and to simulate results under various assumptions. The cost data already has provided useful information for improving primary health care efficiency including productivity of doctors, cost per visit, and proportions of budget funds spent on personnel and medications.
Two technical reports were produced as a result of initial assessment of primary health care organization, financing and costs. The reports can be found at the following links:
In addition to the costing exercise, PHRplus is working with the Ministry of Health and the Health Insurance Institute to design a pilot to improve financing of primary health care. The pilot hopes to demonstrate the effectiveness of unifying fragmented sources of financing, improving management of primary health care at district and regional levels and introducing incentives to improve quality and performance. The project objectives regarding financing reform were impeded by the lack of government action in authorizing pilot activities. There is currently a government initiative to pass laws to allow for single source financing in all the country, with implementation expected to occur first in the Berat Region, with PHRplus technical assistance. Aspects of the reform include direct contracting between primary health care facilities and the Health Insurance Institute, and the implementation of provider incentives for stimulating improved performance.
The focus of financing reforms in 2004-2005 include:
- Assist and support direct contracting of selected primary health care facilities with the Health Insurance Institute
- Introduce incentives for improved quality and performance.
- Develop planning and budgeting capacities, including tracking costs at the primary health care facility level.