HEALTH PERSONNEL AND THE REFORM OF PRIMARY HEALTH CARE IN MONTENEGRO
Abstract
Introduction: Universal health coverage reform activities in primary health care in Montenegro were conducted in the period between 2004 and 2012, with the aim of increasing the efficiency of the health care system by ensuring rational use and availability of resources. The purpose of this study is to describe the health personnel during and after the reform activities in Montenegro.
Materials and methods: We adapted the four-dimensional World Health Organization framework to examine availability, accessibility, acceptability and quality of the health personnel in public primary health care facilities, in Montenegro, during and after the reform. Availability, accessibility, acceptability and quality of health personnel were examined using a defined set of proxies. In addition, the latest available data on density rates of health personnel were presented, in order to examine the sustainability of the implemented reforms. The data used included primary health care information system data, data published by the Institute of Public Health of Montenegro, as well as data from a number of official and expert reports by relevant experts and institutions.
Results: The total number of physicians employed in primary health care was reduced during the reform by 5%, while the number of nurses was decreased by 35%. At the same time, the number of GPs (chosen doctors for adults) increased, which improved their availability (54.4 in 2015 vs. 36.3 in 2004, per 100,000). Accessibility showed great variations among municipalities. The utilization of health care services, at the national level, increased by 25% in adult health care services. The reduction of the number of nurses was tailored to meet set norms in health care services for adults, women, and children. Reform activities improved the professional competencies of primary health care teams.
Conclusion: Primary health care reform improved the availability and accessibility of health personnel and implemented activities that improved their acceptability and quality. It is recommended to establish a permanent body which would continuously monitor the functioning of the primary health care (PHC) system, as well as the changes that occur in PHC, thus ensuring that reform results are maintained and further improved.
References
1. Figueras J, McKee M. editors. Health systems, health, wealth and societal well-being: assessing the case for investing in health systems. Maidenhead: Open University Press, 2012.
2. Saltman BR, Figueras J, Sakellarides C. Critical challenges for health care reform in Europe. Buckingham: Maidenhead, Open University Press, 1998
3. Saltman RB, Figueras J. Analyzing the evidence on European health care reforms. Health Aff (Millwood). 1998 Mar-Apr;17(2):85-108. doi: 10.1377/hlthaff.17.2.85.
4. Campbell J, Dussault G, Buchan J, Pozo-Martin F, Guerra Arias M, Leone C, et al. A universal truth: no health without a workforce. Forum Report, Third Global Forum on Human Resources for Health, Recife, Brazil. Geneva: Global Health Workforce Alliance and World Health Organization; 2013.
5. Dubey S, Vasa J, Zadey S. Do health policies address the availability, accessibility, acceptability, and quality of human resources for health? Analysis over three decades of National Health Policy of India. Hum Resour Health. 2021 Nov 13;19(1):139. doi: 10.1186/s12960-021-00681-1.
6. Correia T, Gomes I, Nunes P, Dussault G. Health workforce monitoring in Portugal: Does it support strategic planning and policy-making? Health Policy. 2020 Mar;124(3):303-310. doi: 10.1016/j.healthpol.2019.12.014.
7. Homer CSE, Castro Lopes S, Nove A, Michel-Schuldt M, McConville F, Moyo NT, et al. Barriers to and strategies for addressing the availability, accessibility, acceptability and quality of the sexual, reproductive, maternal, newborn and adolescent health workforce: addressing the post-2015 agenda. BMC Pregnancy Childbirth. 2018 Feb 20;18(1):55. doi: 10.1186/s12884-018-1686-4.
8. Fleming P, Thomas S, Williams D, Kennedy J, Burke S. Implications for health system reform, workforce recovery and rebuilding in the context of the Great Recession and COVID-19: a case study of workforce trends in Ireland 2008-2021. Hum Resour Health. 2022 May 26;20(1):48. doi: 10.1186/s12960-022-00747-8.
9. Burke S, Parker S, Fleming P, Barry S, Thomas S. Building health system resilience through policy development in response to COVID-19 in Ireland: From shock to reform. Lancet Reg Health Eur. 2021 Oct;9:100223. doi: 10.1016/j.lanepe.2021.100223.
10. Thomas S, Sagan A, Larkin J, Cylus J, Figueras J, Karanikolos M. Strengthening health systems resilience: Key concepts and strategies [Internet]. Copenhagen (Denmark): European Observatory on Health Systems and Policies; 2020.
11. WHO European Framework for Action and Integrated Health Service Delivery. Montenegro - WHO European Primary Health Care Impact, Performance and Capacity Tool (PHC-IMPACT) Copenhagen: World Health Organization 2020. [Internet]. Dostupno: https://www.who.int/europe/publications/m/item/montenegro---who-european-primary-health-care-impact--performance-and-capacity-tool-(phc-impact)-(2020).
12. World Bank. The Montenegro health system improvement project. Project ID: P082223. [Internet]. [Pristupljeno: 7. 3. 2020.]. Dostupno: http://web.worldbank.org/.
13. Ministry of Health of the Republic of Montenegro, Government of the Republic of Montenegro, Master plan 2005-2010.
14. Ministry of Health of the Republic of Montenegro, Government of the Republic of Montenegro, Law on Health care (Official Gazette Republic of Montenegro No. 39/04 from April 9, 2004, 14/10 from March 17, 2010).
15. World Bank. Population, total; annual change; urban population – Montenegro. [Internet]. [Pristupljeno: 15. 1. 2020.].
16. World Bank. Fertility rate, total (births per woman) – Montenegro. [Internet]. [Pristupljeno: 15. 1. 2020.]. Dostupno: https://data.worldbank.org/indicator/SP.DYN.TFRT.IN?end=2015&locations=ME&start=1960
17. World Bank. Life expectancy at birth, Montenegro. [Internet]. [Pristupljeno: 15. 1. 2020.]. Dostupno: https://data.worldbank.org/indicator/SP.DYN.LE00.IN?end=2015&locations=ME&start=1960
18. World Bank. Mortality rate, neonatal (per 1,000 live births). [Internet]. [Pristupljeno: 15. 1. 2020.]. Dostupno: https://data.worldbank.org/indicator/SH.DYN.NMRT?locations=ME
19. World Bank. Mortality rate, infant (per 1,000 live births). [Internet]. [Pristupljeno: 15. 1. 2020.]. Dostupno: https://data.worldbank.org/indicator/SP.DYN.IMRT.IN?locations=ME
20. World Bank. Mortality rate, under-5 (per 1,000 live births) – Montenegro. [Internet]. [Pristupljeno: 15. 1. 2020.]. Dostupno: https://data.worldbank.org/indicator/SH.DYN.MORT?locations=ME
21. World Bank. Maternal mortality ratio (modeled estimate, per 100,000 live births) – Montenegro. [Internet]. [Pristupljeno: 15. 1. 2020.]. Dostupno: https://data.worldbank.org/indicator/SH.STA.MMRT?locations=ME
22. World Bank. GNI per capita, PPP (current international $) – Montenegro; Current health expenditure (% of GDP). [Internet]. [Pristupljeno: 15. 1. 2020.]. Dostupno: https://data.worldbank.org/indicator/NY.GNP.PCAP.PP.CD?locations=ME
23. UNECE. Population living on below $1 (PPP) per day – Montenegro. [Internet]. [Pristupljeno: 15. 1. 2020.]. Dostupno: https://w3.unece.org/PXWeb/en/Charts?IndicatorCode=200
24. WHO Regional Office for Europe. “Total health expenditure as percentage of GDP in 2004,2015(Montenegro); Government spending as percentage of health expenditure in 2004,2015 (Montenegro), WHO estimates” European Health for All explorer. [Internet]. [Pristupljeno: 15. 1. 2020.].
25. OECD (2022), Health spending (indicator) 2019. [Internet]. [Pristupljeno: 3. 9. 2022.]. doi: 10.1787/8643de7e-en.
26. WHO Global health expenditure database. External health expenditure as percentage of current health expenditure (indicator). [Internet]. [Pristupljeno: 3. 9. 2022.].
27. World Bank (indicator). Births attended by skilled health personnel (%), Montenegro. [Internet]. [Pristupljeno: 3. 9. 2022.]. Dostupno: https://data.worldbank.org/indicator/SH.STA.BRTC.ZS?locations=ME
28. Institute for Health Metrics and Evaluation. GBD Profile Montenegro. [Internet]. Dostupno: http://www.healthdata.org/sites/default/files/files/country_profiles/GBD/ihme_gbd_country_report_montenegro.pdf
29. Institute of Public Health of Montenegro. “Hospital morbidity in Montenegro in the period 2010-2015”. [Internet]. [Pristupljeno: 21. 1. 2020.]. Dostupno: https://s3.eu-central-1.amazonaws.com/web.repository/ijzcg-media/files/1574195600-analiza-bolnickog-morbiditeta-u-crnoj-gori-2010-2015.pdf
30. Klančar D, Svab I. Primary care principles and community health centers in the countries of former Yugoslavia Health Policy Health Policy. 2014 Nov;118(2):166-72.
31. Ministry of Health of the Republic of Montenegro, Government of the Republic of Montenegro, Health Development Strategy of Montenegro, 2003.
32. Drecun M. “Specialization of Family Medicine – implementation project”, Ministry of Health and Social Wellfare of Montenegro, 2009. In print.
33. World Bank. The Montenegro health system improvement project. Project ID: P082223. [Internet]. [Pristupljeno: 7. 3. 2020.]. Dostupno: http://web.worldbank.org/.
34. Šter MP, Kezunović LC, Cojić M, Petek D, Švab I. Specialty Training in Family Medicine in Montenegro – an Evaluation of The Programme by the First Generation of Trainees. Zdr Varst. 2018 Apr 6;57(2):96-105.
35. Cvejanov Kezunović L, Drecun M, Švab I. Primary care reform in Montenegro Zdr Var 2013; 52: 247-254.
36. Medical faculty Podgorica, Basic information. [Internet]. [Pristupljeno: 23. 1. 2020.]. Dostupno: https://www.ucg.ac.me/objava/org/18/poz/info
37. Ministry of education of Montenegro. Public announcement for enrolment in high schools in Montenegro. [Internet]. [Pristupljeno: 23. 1. 2020.]. Dostupno: http://www.mps.gov.me/vijesti/185873/KONKURS-ZA-UPIS-UcENIKA-U-I-RAZRED-SREDNJIH-sKOLA-U-CRNOJ-GORI-ZA-sKOLSKU-2018-2019-GODINU.html
38. Law on Health Care. Off Gazette CG 003- corr. 2016; 039, 2016; 002, 2017.
39. Law on University Education. Off Gazette CG 2014, 044, 052- corr. 2014; 047, 2015; 040, 2016; 042, 2017; 071, 2017; 055, 2018; 003, 19; 017,19.
40. Institute of Health Metrics. Global Burden of disease 2019 data. [Internet]. Dostupno: https://www.healthdata.org/gbd/2019
41. Health at a Glance: Europe 2014 – OECD. Dostupno: https://www.oecd-ilibrary.org/social-issues-migration-health/health-at-a-glance-europe-2014_health_glance_eur-2014-en
42. Rule book on detailed conditions regarding standards and methods of achieving primary health care through the chosen doctor team or chosen doctor. [Internet]. [Pristupljeno: 18. 5. 2020.]. Dostupno: http://www.mzdravlja.gov.me/ResourceManager/FileDownload.aspx?rid=222998&rType=2&file=Pravilnik%20o%20bli%C5%BEim%20uslovima%20u%20pogledu%20standarda,%20normativa%20i%20na%C4%8Dina%20ostvarivanja%20primarne%20zdr.za%C5%A1tite%20preko%20ITD%20ili%20ID.pdf
43. Eurostat database. Physicians by medical specialty data 2015. [Internet]. Dostupno: https://ec.europa.eu/eurostat/web/health/data/database
44. Statistical Office of Montenegro. Release Internal Migration in Montenegro in 2015. [Internet]. Dostupno: https://www.monstat.org/userfiles/file/migracije/Migracije%20unutar%20Crne%20Gore%20u%202015_%20godini%20-%20eng_n.pdf
45. Santric Milicevic M, Vasic M, Edwards M. Mapping the governance of human resources for health in Serbia. Health Policy (2015). [Internet]. [Pristupljeno: 30. 8. 2022.]. Dostupno: http://dx.doi.org/10.1016/j.healthpol.2015.08.016
46. Burke S, Thomas S, Barry S, Keegan C. Indicators of health system coverage and activity in Ireland during the economic crisis 2008–2014—from ‘more with less’ to ‘less with less.’ Health Policy. 2014;117(3):275–8.
