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8MEDICAL SCIENCES
PRIMARY MEDICAL AID - CADRES AND FUNDING
Shopov D.G.
MD, PhD, Chief Assistant Prof. Department of Social Medicine and Public Health Medical University-Plovdiv, Bulgaria
Mihaylova V.K.
PhD,Assoc.Prof. Department of Preventive Medicine, Faculty of Public Health, Sofia; Chief Assistant Prof.
Department of Healthcare Management, Faculty of Public Health, Medical University-Plovdiv, Bulgaria
Dragusheva S.S.
Assistant Prof.Department Nursing Care, Faculty of Public Health (FPH), Medical University -Plovdiv, Bulgaria
Stoev T.S.
PhD, Assoc.Prof.Department of Health management and Economy of healthcare, Faculty of Public Health,
Medical University-Plovdiv, Bulgaria
Alakidi A.
Medical Student in fifth year, Medicine Faculty, Medical University
Sofia, Bulgaria
ABSTRACT
In the contemporary health systems the priority position and role of the primary medical aid is undisputable, officially recognized and accepted. The present article examines the dynamics in the availability of general practitioners, problems with the coverage and access of the population to medical services in statistically differentiated administrative geographic regions in the Republic of Bulgaria for a 5-year period from 2011 to 2015 inclusive. The following facts have been established:
^ The demographic structure of the population is in regression. The total number is decreasing, with increase in the percentage of elderly people (over the age of 65). In the economically developed regions there is concentration of people and depopulation of the economically undeveloped regions.
^ The number of active practices for primary medical aid decreases.
^ The medical resources are concentrated in the cities and university centres and in the rarely populated regions there is demand for general practitioners.
^ The special financial stimulae proposed by the National Health Insurance Fund are not sufficient to compensate the decreased number of patients and activities forming the monthly remuneration of the physicians.
^ NHIF does not provide funds for investment in new technologies and vocational training. This significantly restricts the general practitioners for investments in such trends and leads to some minimal threshold of equipment and qualification.
^ The contemporary primary medical aid requires a more adequate system of financial stimuli with an increased share of individual productivity and quality in determining the amount of remuneration of the general practitioners.
^ A priority of the health policy is stimulation of the prophylactic and preventive activities. General practitioners, as active participants in such activities, should be financially stimulated on the basis of their contribution and results of the performance of the national health priorities.
Key words: primary medical aid, population, administrative geographic regions, general practitioners, financial stimuli
Introduction:
In the contemporary health systems the priority position and role of the primary medical aid is undis-putable, officially recognized and accepted. This recognition finds its place in the health and political priorities and in the legal basis of the different countries in the world.[2 p.29; 3 p.13] In a historical aspect the priority of the primary medical aid was imposed after the acceptance of the concept and strategy of the World health organization in 1978 at the world conference in Alma Ata. The declaration of Alma Ata indicates that
the minimum of primary healthcare includes: health education of the population, rational feeding, environmental hygiene, prophylactic and medical care of the mothers and children, vaccinations, prophylaxis of the socially significant diseases, treatment of the most wide-spread diseases and traumas and accessibility of the most necessary medicines.[4 p.13; 5 p.3; 6 p.55]
Primary medical aid is of utmost importance because it is the most mass and close medical aid which also forms the public opinion on the condition of the health system in general. [8 p.4; 9 p.18]
Today, irrespective of the national specifications and differences, common priority trends are observed in the health policy of the European countries, one of which is re-orientation from inpatient aid to expansion of the primary (basic) medical aid. The developed European countries more and more often position primary healthcare among the leading priorities of their health systems. Vivid examples of the priority position of the primary medical aid can be seen in countries like Great Britain, Sweden, Denmark, Finland, the Netherlands, Spain, etc.[10 p.41; 11 p.23]
According to English experts, the relationship between General practitioners - specialists (consultants) influences the indices of public health. Where the physicians - general practitioners are more than the specialists, the indices of public health are better.
A central figure in the system of primary healthcare is the physician with general profile, who is an established specialist in general medicine, familiar with the medical and social problems of the patients. In some countries he is called general practitioner (GP), in other countries - doctor - generalist, family doctor or personal doctor. The main task of the general practitioner is to meet the basic, most popular health needs of the population, to reduce to a reasonable minimum the redirection of patients to the narrow specialists and hospitals. In this way the general practitioners become a positive organizational and economic factor of any national health system.[13 p.4]
In our country the general medical practice has not yet determined the necessary position of a number of important elements and aspects of primary medical aid, such as: importance of the group medical practice, of the team approach and especially of the nurse, despite the perception that the development and establishment of primary medical aid relates not only to the general practitioner but also to all members of his main team -
For better visibility in the following charts we have numbered the administrative-geographic regions in the following manner:
nurses, doctor»s assistants, midwives, psychologists, etc. Therefore the multi-sided problems in the activity of the general practitioner in our country should be subject to increased intention on the part of the health politicians, health managers and the society in general.14 p.12; 15 p.40]
Objective: of the present article is the study of the dynamics of GP staffing, problems with the coverage and access of the population to medical services provided by general practitioners in the administrative geographic regions of Bulgaria.
Material and methods:
Subject of observation are the practices of the general practitioners in the statistically differentiated regions of the Republic of Bulgaria. The study is retrospective for a 5-year period from 2011 to 2015 inclusive. Quantitative and qualitative indices have been used for the analysis. The primary information has been derived from the annual reports of the National Statistical Institute (NSI). The statistical processing of the collected primary information was carried out using variational, alternative and non-parametric analyses. The computer processing of the collected database has been performed using the statistical pack SPSS version 19 and Microsoft Excel.
Results and discussion:
The behaviour of the general practitioner, connected with the provision of high-quality medical services, is determining for the correct course of the medical treatment of patients and for the efficient spending of public funds. The existing method of payment to the general practitioners in Bulgaria does not guarantee the achievement of those two main objectives imposed before any healthcare system.
Statistically the Republic of Bulgaria is divided into six administrative-geographic regions. They comprise the areas indicated in Table 1.
Table 1
North-Western Northern Central North-Eastern South-East South-West Southern Central
Vidin Veliko Tarnovo Varna Burgas Blagoevgrad Kardzhali
Vratsa Gabrovo Dobrich Sliven Kyustendil Pazardzhik
Lovech Razgrad Targovishte Stara Zagora Pernik Plovdiv
Montana Ruse Shumen Yambol Sofia Smolyan
Pleven Silistra Sofia (capital) Haskovo
Region №
North-Western 1
Northern Central 2
North-East 3
South-East 4
South-West 5
Southern Central 6
In our country the general practitioners as an institution and function were introduced in 2000 when their
number in Bulgaria was 5146. Chart 1 provides information about the dynamics of the GP staffing in the analyzed period of time (2011-2015 inclusive). A general tendency in all regions is reduction of the number of
practices for primary medical aid, the highest being in the South-Western region, followed by the Southern central region and the lowest - in the Northern central region.
Chart 1
Number of General Practitioners
I li il II I
2011year 2012year 2013year 2014year I2015year
1 600 594 589 580 561
2 470 536 447 443 431
3 635 642 598 604 604
4 654 703 689 641 625
5
1393 1420 1358 1 371 1 341
6 945 1005 891 886 871
The number of patients per general practitioner in- region, followed by the Southern central region and the creases in dynamics, the highest being Northern central lowest - in the North-Western region. (Chart 2).
Chart 2
Number of patiens per General Practitioner
1 2 3 4 5 6
2011year 1438 1860 1595 1659 1571 1685
2012year 1420 1660 1567 1506 1497 1615
2013year 1409 1937 1706 1543 1594 1747
■ 2014year 1403 1921 1688 1667 1572 1732
■ 2015year 1441 1959 1673 1701 1577 1750
Primary medical aid is entirely provided by general practitioners who enter into individual or group contracts with the National Health Insurance Fund. All citizens with health insurance are obliged to choose their doctor and register with him.
The health fund makes a difference between patients with chronic diseases (hospitalized patients) and all the rest by age groups - over 65, below 18, and in active age between 18 and 65. For each patient NHIF pays an amount which is determined on an annual basis in the National framework agreement. Upon determination of the amounts for each group of patients the different volume of work and frequency of visits to the GP are taken into consideration. However, the necessity of such differentiation has a questionable effect because
the consumer fee should compensate the physicians for the increased volume of work with elderly people and inhouse patients. The age structure of the population of the administrative-geographic regions marks certain tendencies (Table 2):
^ The population aged 0 - 19 is around 18% of the entire population, marking a downward trend, provided that in the analyzed period of time (2011-2015 inclusive) the highest per cent was in the South-East region, followed by the Southern central and the lowest - in the Northern central region.
^ The population aged 20-64 is the biggest part, also with a downward trend. The highest percent was in the South-West region, followed by the Southern central and the lowest - in the North-Western region.
^ The population over 64 marks an upward trend. The higher per cent is in the North-West region,
The payment on the basis of activities comprises:
• Medical service of mandatorily health insured persons included in the register of the general practitioner - payment on the basis of capitation
• Prophylactic activity under programme ,,Children»s healthcare"
• Prophylactic observation under the programme „Mother»s healthcare"
• Vaccines for people up to the age of 18
• Dispensary observation
• Prophylactic medical checks of health insured individuals over the age of 18
• Examination of health insured persons from another health region
• Since 2011 funds for payment of the permanent 24-hour access to medical aid of health insured individuals, as well as vaccinations of people over 18 have been included.
Conclusions:
The number of opened and active practices for primary medical aid decreases.
The medical resources are concentrated in the cities and university centers and in the rarely populated areas characterized by low level of employment and health insurance coverage there is a deficit of general practitioners.
followed by the North central region and the lowest -in the South-West and Southern central region.
Table 2
The special financial stimulae offered by NHIF are not sufficient to compensate the lower number of patients and activities forming the monthly remuneration of the patients.
Unsolved problems with the coverage and access to medical services make the announced trends of the reform in healthcare a topical problem in terms of the bigger consumer choice and competition only in the big cities.
Currently the general practitioners receive additional financial resources in order to register more retired individuals in their lists, to pay more attention to the children and the prophylaxis during pregnancy, as well as to have more visits by patients, because of the consumer fee.
NHIF does not provide funds for investments in new technologies and professional training. This imposes significant limits on the general practitioners for investment in such aspects, especially in regions where the elasticity of demand of health services is low, i.e. wher the patients cannot replace the supplier of medical services with another. This means that only health service providers who have achieved some minimum threshold of equipment and qualification should be allowed access to the market.
Contemporary primary medical aid requiresa more adequate system of financial stimuli, with increased share in the individual productivity and
Population aged 0 - 19
Регион 2011 г. 2012 г. 2013 г. 2014 г. 2015 г.
North-West 17,22% 17,13% 16,98% 16,91% 16,89%
Northern central 16,17% 16,07% 15,98% 15,93% 15,96%
North-East 18,34% 18,22% 18,13% 18,11% 18,13%
South-East 18,99% 18,96% 18,92% 18,99% 19,10%
South-West 16,25% 16,29% 16,31% 16,47% 17,75%
Southern central 18,53% 18,42% 18,33% 18,33% 18,46%
Population aged 20 to 64
North-West 56% 55,59% 54,99% 54,42% 53,82%
Northern central 59,94% 59,49% 58,96% 58,31% 57,62%
North-East 61,60% 61,27% 60,82% 60,25% 59,68%
South-East 59,86% 59,54% 59,03% 58,49% 57,88%
South-West 63,65% 63,32% 62,90% 62,35% 63,63%
Southern central 62,63% 62,50% 62,24% 61,80% 61,23%
Population over the age of 64
North-West 26,78% 27,28% 28,03% 28,67% 29,29%
Northern central 23,89% 24,44% 25,06% 25,76% 26,42%
North-East 20,06% 20,51% 21,05% 21,64% 22,19%
South-East 21,15% 21,50% 22,05% 22,52% 23,02%
South-West 20,10% 20,39% 20,79% 21,18% 18,62%
Southern central 18,84% 19,08% 19,43% 19,87% 20,31%
achieved quality in determining the remuneration of the general practitioners.
A priority of the health policy for the purpose of improvement of the health status of the population is stimulation of the prophylactic and preventive activities. General practitioners, as active participants in such activities, should be stimulated by NHIF or the budget on the basis of their contribution and results for the performance of the national health priorities.
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СРАВНИТЕЛЬНОЕ ИЗУЧЕНИЕ ЦИРКУЛЯРНОГО КРАЯ РЕЗЕКЦИИ ПРИ РАЗЛИЧНЫХ СПОСОБАХ ТОТАЛЬНОЙ МЕЗОРЕКТУМЭКТОМИИ И АНАЛИЗ ЕГО ВЛИЯНИЯ НА ОТДАЛЕННЫЕ РЕЗУЛЬТАТЫ ЛЕЧЕНИЯ БОЛЬНЫХ
Азимов Э.Г.
Кафедра хирургических болезней I, АМУ, медицинский центр ELMED
COMPARATIVE STUDYING OF CIRCUMFERENTIAL RESECTION MARGIN IN DIFFERENT METHODS OF TOTAL MESORECTAL EXCISION AND THEIR INFLUENCE ON THE REMOTE RESULTS OF PATIENTS TREATMENT.
Azimov E.H.
Department of surgical diseases I, AMU, "ELMED" medical center
АННОТАЦИЯ
Цельюнашего исследования явилось изучение особенностей CRM-статуса при лапароскопических и открытых способах проведения резекций у больных со злокачественными новообразованиями прямой кишки.
Материалы и методы. В исследование были вовлечены 103 пациента с установленным диагнозом локачественных новообразований прямой кишки. Больные были разделены на 2 группы:1) пациенты, которым была выполнена тотальная мезоректумэктомия открытым способом (ОТМЭ) -(n=56), 2)
