The introduction of market mechanisms into the public health sphere necessitates a clear distinction of the roles of main participants in medical service accomplishing. The processes of contracting between vendors and customers of health services are based on this distinction. This communication presents the end product of seminars supported by the "H+" Swiss hospital association in Bulgaria entitled "A contract for providing primary health care for the citizens of municipality X". The basic and secondary elements of the contract contents as well as the essence and importance of the contracting as a component of public health reform in Bulgaria are discussed. It is emphasized that the introduction of contracting relations into the public health system will ensure a better control on the amount and quality of the health services and on financial means` movement. The contracting will favourably influence on the public and private health sectors thus representing an important component of introducing the market economics, especially in the health sphere

Dokova, K.

Feschieva, N.

Kostadinova, T.

Popova, S.

English

Varna Medical University Press: Journals

Scripta Scientifica Medica, vol 31 (199% pp. 99-102 Copyright © Medical University, Varna DIVISION OF T H E R O L E S AND CONTRACTING IN PRIMARY HEALTH C A R E S. Popova, N. Feschieva, T. Kostadinova*, K. Dokova Department of Social Medicine and Biostatistics and ^Department of Health Management, Medical University of Varna, Varna The introduction of market mechanisms into the public health sphere necessitates a clear distinction of the roles of main participants in medical service accomplishing. The processes of contracting between vendors and customers of health services are based on this distinction. This communication presents the end product of seminars supported by the "H+" Swiss hospital association in Bulgaria entitled "A contract for providing primary health care for the citizens of municipality X". The basic and secondary elements of the contract contents as well as the essence and importance of the contracting as a component of public health reform in Bulgaria are discussed. It is emphasized that the introduction of contracting relations into the public health system will ensure a better control on the amount and quality of the health services and on financial means1 movement. The contracting will favourably influence on the public and private health sectors thus representing an impor­tant component of introducing the market economics, especially in the health sphere. Key-words: Contracting, primary health care, health insurance, general practitio­ner, Bulgaria Health strategy has two key el­ements - decision on the final goal and defining the means for its achievement. The main task for the Bulgarian health policy is to stop the process of further deterioration of the health status of the population and to turn it in a positive direction. In order to achieve this goal • fundamental reform in the existing health care system is required, a reform Hf the financing and delivering of re-Address for correspondence: S. Popova, Dept. of Social Medicine and Biostatistics, Medical University, 55 Marin Drinov St, BG-9002 Varna, BULGARIA E-mail: pubhealth @ mbox.digsys. bg sources. Taking in consideration that every type of health system is deter­mined by the position of the five main players in the field of health care, i . е., patient, primary health care (PHC) , spe­cialized and hospital care, payer for ser­vices, and state, the health reform should develop a new model by chang­ing the position, function, responsibili­ties, and relations between these par­ticipants (4). In the center of the system we can place the patient - consumer of health care. According to Act No 3 of the Ministry of Health on P H C organi-S. Popova et al. zation (1) and the law of health insur­ance (2), the position of the patient is changing from one asking for services into a consumer with right to choose his own doctor. The W H O ' s declaration in Alma Ata (1978) and the Strategy for P H C in Bulgaria both give a priority to P H C as the main instrument for achiev­ing "Health for A l l by the year 2000". According to this strategy, the key fig­ure in P H C is the general practitioner (GP) , and in the transitional period - the personal physician in internal medicine, paediatrician, and obstetrician-gyne­cologist. The answer of the question what type of G P we want to establish - a gate­keeper (as the one in the Netherlands), or a free access to specialized care (as in France and Belgium) wi l l be possible wil l define the relations between patient and P H C , specialized and hospital care. With the adoption of the law for health insurance a new player comes in the field - the third party payer of health services, i . е., the health insurance fund - national and regional. Among the ex­isting several types of health insurance our country has chosen the contract model. It suggests that the insured does not have to pay directly when using health services. Providers are paid di­rectly by the insurer - "the third party" based on a contract. The contract model implies that when paying for health services of the insured members the Health Insurance Fund is performing an agency function: acting as prudent buyer of care on be­half of the consumers. According to the law of compulsory health insurance "it is based on the principle of contracting the relations between the Health Insur­ance Fund and the health services' pro­vider". The law for health insurance determines the place of the insurance fund on one of the sides in the negotia­tion process. On the other side there are health institutions acting as providers of health services, selling and receiv­ing finances according to the amount and quality of the services. It is possible for a health organization from P H C to be at the same time a provider and pur­chaser of health services for the popu­lation served (e. g, the general practi­tioners' fund holders in Great Britain) (3). Where is the place for the state in this scheme? It is in the role of man­aging the competition on the market of health services. Management and con­trol of costs has been shifted away from the centralized administration towards the players in the system. Fundamental to the process of contracting between the third party and provider of health services is the division of roles among participants in health care with its legal and organizational aspects. According to article No 45 of the law of health in­surance, terms for delivery and con­tent of different types of health care are defined in the National Framework Contract (2). The details wi l l be matter of further negotiation between the re-100 Division of the roles and contracting ... ar tc о ional health insurance funds and indi-idual and collective providers. Partici­pation in the process of negotiation is a thoroughly new activity for the health institutions and health workers, respec­tively. Decisions for buying wi l l be based on the criteria "value for money". The perfect contract wi l l guarantee bet­ter control on the volume and quality f services and the transfer of finances 'or the benefit of the provider and lostly for the consumer of health ser-ices. The participants in the process of negotiation should be familiar with е kind of this activity beforehand be-use of its utmost importance. To prepare management cadre г the secrets of negotiation (the same eed exists for the private providers of ealth services as well) was the aim of minars held with the support of the "H+" Swiss hospital association in Oc­tober 1997, in Varna, in August 1998, n Bourgas, and October 1998, in argovishte. Topics of the discussions were the following basic problems: 1. The nature of negotiation as n element of the health reform in B u l ­garia; 2. The art of negotiation and basic principles for successful negotia-ion. The topic for negotiation should be clear. One should be able to define the starting position (what aims I want o achieve), the starting position of the ther side (the aims they want to achieve). Beides one has to be ready with secondary possibilities in case the first can not be achieved as well as to be sure: you have prepared key words; you are well-acquainted with your documentation; you know well your possibilities; you have attracted col­leagues well-acquainted with the mat­ter; you are able to create atmosphere of good wi l l , to be on the same wave as your partner, and to be interested in his intentions/interests. 3. Content of the contract: a) basic elements: defining the basic ben­efit package; the population served; defining the partners; setting the prices; b) secondary elements: methods of pay­ing; control for quality of services, and right for cancel. As an end product " A contract for providing P H C for the citizens of municipality X " was suggested. The contract included the following parts: aims, subject, time, right and responsi­bilities of consumers, rights and re­sponsibilities of the providers, and ways of payment. The work on the prepara­tion of the contract gave a chance to the participants to feel the atmosphere of contracting, to clarify its elements and roles in the process of negotiation. At the same time some other problems emerged and were discussed: a) professional profile of the G P and package of services which he is obliged to provide; the right for addi­tional services; b) limits for the served popula­tion and way for providing a 24-hour care for the patients; 101 S. Popova et al. c) what is the level for regional adaptation of prices according to local features; cesses and results in P H C , etc. These questions have not received any answer yet and thus need a broader discussion, indeed. Such discussions along with the common agreement of these issues rep­resent a necessary precondition for the excellence of the contracts in a health insurance setting. d) ways of payment and for which services it is possible to intro­duce "fee for service"; e) development of criteria and standards for quality of structure, pro-R E F E R E N C E S 1. Държ. в-к, бр. 20/1996 г.- 2. Държ. в-к, бр. 70/1998 г.- 3. An International Perspective. Е . Van D о or s a l er, ed. New York, etc., Oxford Medical Publishers, 1993.-4. R e i s , V. P . , R . P. С a r v a l ho. The reform of health care systems: A review of seven OECD countries. Paris, EOCD, Chapter 2. Разпределение на ролите и договарянето в условията на извънболничната медицинска помощ С. Попова, Н. Фесчиева, Т. Костадинова*, К. Докова Катедра по социална медицина и биостатистика и *Катедра по здравен мениджмънт, Медицински университет-Варна Резюме: Въвеждането на пазарните механизми в сферата на здравеопазването доведе до необходимостта от ясно разграничаване на ролите на основните участници в осъществяването на медицински грижи. Това разграничаване заляга в основата на процесите на договаряне между продавачи и купувачи на здравни услуги. Настоящото съобщение представя крайния продукт от семинари в България, подпомогнат от Швейцарската болнична асоциация "Н+" и озаглавен "Договор за предоставяне на доболнични услуги за населението от община " X " . Дискутират се първичните и вторични елементи от съдържанието на договора, както и същността и значението на договарянето като елемент на здравеопазната реформа в България. Подчертава се, че въвеждането на договорните отношения в здравеопазването ще даде възможност за по-добър контрол върху обема и качеството на извършваните дейности и движението на финансовите средства. Договарянето ще благоприятства равнопоставеността между обществения и частен сектор, което е важен елемент на въвеждането на пазарната икономика и в частност - в здравеопазването. 102 

DIVISION OF THE ROLES AND CONTRACTING IN PRIMARY HEALTH CARE

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DIVISION OF THE ROLES AND CONTRACTING IN PRIMARY HEALTH CARE

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