Introducing a complex health innovation - Primary health care reforms in Estonia (multimethods evaluation)
Introducing a complex health innovation - Primary health care reforms in Estonia (multimethods evaluation)
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DOI：
10.1016/j.healthpol.2005.12.005
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发表时间：
2006-11-01
期刊：
影响因子：
3.3
通讯作者：
Habicht, Jarno
中科院分区：
文献类型：
--
作者：
Atun, Rifat Ali;Menabde, Nata;Habicht, Jarno
所有后苏联国家都在努力改革其初级卫生保健系统。迄今为止的成功是不平衡的。我们评估了在爱沙尼亚的初级保健改革，采用多方法评价：包括回顾性分析的常规卫生服务数据从爱沙尼亚健康保险基金和健康相关的调查;政策报告，法律和法规的文件分析;关键线人访谈。我们分析了爱沙尼亚初级保健系统在组织结构、法规、融资和服务提供方面的变化，以及关键知情人对影响改革引入因素的看法。爱沙尼亚成功实施并扩大了多方面的初级保健改革，包括新的组织结构、用户选择家庭医生（FP）、新的支付方式、家庭医学专家培训、FP服务合同、扩大服务范围和循证指南。这些变化已经制度化。初级保健的有效性得到了提高，这体现在初级保健机构中的FP对关键慢性病的管理得到了改善，并减少了因这些疾病而住院的人数。实行初级保健改革是一项复杂的创新，但由于强有力的领导、政策和业务层面之间的良好协调、强调干预措施简单易行、易于被潜在采用者理解的实际执行方法、避免与狭隘的专家和首都塔林对立的利益攸关方直接对抗的环绕式推广战略，谨慎的变革管理战略，避免卫生改革在进程中过早政治化，并及早投资于培训，以建立足够数量的卫生专业人员，使政策能够迅速运作。最重要的是，一个多方面的和协调的改革方法包括法律的变化;组织结构的调整;对融资和提供者支付系统的修改;创造激励措施以加强服务创新;对人力资源开发的投资对改革的成功至关重要。(c)2005爱思唯尔爱尔兰有限公司保留所有权利。
All post-Soviet countries are trying to reform their primary health care (PHC) systems. The success to date has been uneven. We evaluated PHC reforms in Estonia, using multimethods evaluation: comprising retrospective analysis of routine health service data from Estonian Health Insurance Fund and health-related surveys; documentary analysis of policy reports, laws and regulations; key informant interviews. We analysed changes in organisational structure, regulations, financing and service provision in Estonian PHC system as well as key informant perceptions on factors influencing introduction of reforms.Estonia has successfully implemented and scaled-up multifaceted PHC reforms, including new organisational structures, user choice of family physicians (FPs), new payment methods, specialist training for family medicine, service contracts for FPs, broadened scope of services and evidence-based guidelines. These changes have been institutionalised. PHC effectiveness has been enhanced, as evidenced by improved management of key chronic conditions by FPs in PHC setting and reduced hospital admissions for these conditions. Introduction of PHC reforms-a complex innovation-was enhanced by strong leadership, good co-ordination between policy and operational level, practical approach to implementation emphasizing simplicity of interventions to be easily understood by potential adopters, an encircling strategy to roll-out which avoided direct confrontations with narrow specialists and opposing stakeholders in capital Tallinn, careful change-management strategy to avoid health reforms being politicized too early in the process, and early investment in training to establish a critical mass of health professionals to enable rapid operationalisation of policies. Most importantly, a multifaceted and coordinated approach to reform-with changes in laws; organisational restructuring; modifications to financing and provider payment systems; creation of incentives to enhance service innovations; investment in human resource development-was critical to the reform success. (c) 2005 Elsevier Ireland Ltd. All rights reserved.