Елизаров В.В., Архангельский В.Н. (ред) Политика народонаселения: настоящее и будущее. Четвертые Валентеевские чтения: Сборник докладов (книга 2)

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ской оценки домашнего труда переносятся на домохозяйство и

применяются для анализа домашних работ. Методика применяется

в отношении отдельного конкретного домохозяйства, она содержит

обширное исследование из 11 этапов и стоимостную оценку рабо-

чих процессов в домохозяйстве.

В расчет принимаются:

– ситуация в домохозяйстве, включая ограничивающие факто-

ры и специфические черты домохозяйства;

– целевые установки и запросы семьи;

– описание того, как выполняются работы, и их группировка по

секторам работ, взвешивание требований (в отдельных секторах

работ) по методике REFA, включая знания, умения, ответствен-

ность, умственные нагрузки, мускульные нагрузки, влияние окру-

жающей среды;

– расчет количественных показателей труда;

– вычисление справедливого вознаграждения.

Для вычисления вознаграждения в качестве базового значения

берется тарифный оклад социального работника, который на основе

количественных показателей труда корректируется с учетом вре-

менных затрат в семейном домохозяйстве.

Главными целями аналитической стоимостной оценки домаш-

него труда по методике REFA являются:

– поиск объективного масштаба для оценки домашнего труда и

труда по уходу и воспитанию детей;

– обеспечение возможности сравнения домохозяйств между собой.

Особая значимость аналитической стоимостной оценки домаш-

него труда заключается в том, что условия труда и результаты труда

в домохозяйстве формулируются по стандартам, принятым в про-

мышленности, и тем самым делаются в какой-то мере сравнимыми с

рабочим местом в профессиональном труде. Безусловно, есть и не-

достатки, заключающиеся в трудоемкости методики, результаты

применения которой – данные по отдельным домохозяйствам; в ог-

раниченной применимости переноса аналитических и оценочных

критериев из профессиональной сферы в сферу домашнего труда.

Также не могут быть учтены психологическая нагрузка, возникаю-

щая, например, при конфликте целей или при работе по построению

отношений; такие признаки домашнего труда, как одновременное

выполнение нескольких дел или многомерность работ, которые име-

ют как материальные, так и эмоциональные характеристики и др.

Методика получила широкое распространение и признание.

Так, расчеты по ней начали проводиться с 1970-х годов. О призна-

нии их объективности свидетельствует тот факт, что результаты

расчетов принимаются, например, в судебной практике, а сама ме-

тодика нашла применение и в других странах Европы. Развитие и

совершенствование методики продолжается и в настоящее время.

Анализ и оценка произведенной в домохозяйстве работы пред-

ставляет не только идеологический интерес, как это часто представ-

ляется. Уже сегодня такие стоимостные оценки домашнего труда

используются в практике судебного возмещения понесенного

ущерба. Свою традицию имеет и анализ конкретных домохозяйств

для целей консультирования и просвещения в области домохозяй-

ства. Результаты таких аналитических исследований могут быть

использованы как инструмент самооценки домашнего труда, как

основа для изменений и перестановок для более рациональной ор-

ганизации и распределения работ. Анализ и стоимостная оценка

домашнего труда также необходимы для теоретического обоснова-

ния требований большего общественного признания домашнего и

семейного труда. В качестве основы для системного обучения насе-

ления, и в первую очередь, молодежи, методам ответственного и

компетентного ведения домохозяйства необходимы знания о том,

что представляет собой хорошее, качественное ведение домохозяй-

ства в современных условиях, с учетом происходящих в мире пере-

мен, и о том, какая квалификация для этого требуется. Например,

это проблемы влияния домохозяйств на экологию и их вклад в за-

щиту окружающей среды, и поиск альтернативных моделей потре-

бительского поведения, которые уменьшают потребление природ-

ных ресурсов. Анализ и стоимостная оценка домашнего труда

должны помочь лучше понять внутридомохозяйственные и семей-

ные реалии и процессы, обосновать альтернативы, включая все по-

следствия.

ПОЛИТИКА В ОБЛАСТИ УКРЕПЛЕНИЯ ЗДОРОВЬЯ И

ПОВЫШЕНИЯ ПРОДОЛЖИТЕЛЬНОСТИ ЖИЗНИ

Catherine Gourbin* and Guillaume Wunsch**

(*University Center of General Practice and Institute of Demography; ** In-

stitute of Demography University of Louvain (UcL)

From prevention to cure: which policies for primary care?

Introduction

Though mortality has decreased dramatically in most of the indus-

trialized countries, leading to life expectancies of over 80 years of age

for females and slightly less for males, one cannot conclude that all pub-

lic health problems are progressively being solved. Actually, as one

knows, due to the increasing length of life and very low fertility levels,

all populations in the developed countries are growing older and older.

As health often deteriorates with age, as medical technology is growing

both in quality and quantity but also in cost, and as our expectations for

guaranteeing a healthy life are rising, health costs are soaring in all the

developed world. Governments in Europe are trying to contain the costs

by taking various measures, such as rationing of health-care interven-

tions and reducing the coverage of the insurance funds to more basic

services, increased co-payment or direct out-of-pocket payment by pa-

tients to providers, stimulating additional voluntary contributions to pri-

vate health insurance funds, favoring competition among insurance

funds, and more generally trying to improve the health system’s per-

formance.

Among this set of more or less ad hoc policies, one of the goals of

policy makers in the health field is to develop better preventive medicine

and its coverage for the whole population, as healthy behaviors and early

detection of diseases can significantly keep the health costs down (CDC,

2004). General practitioners (GPs) or family doctors, being in the first

line of medical intervention, are the obvious channel through which pre-

vention and early detection can occur. As the WHO has stated, a major

focus of public health interventions should therefore be to develop pri-

mary health care systems “that emphasize health promotion, disease pre-

vention and the provision of cost-effective, equitable and dignified long-

term care” (WHO, 2002). The same report stresses that “primary care

should be the lynchpin of a well designed and performance-focused

health care system”.

As an example of policies developing in the health field, this paper

aims at describing for Belgium the present situation of primary care in

the broader framework of the general health system and the measures

taken by governments

for reorganizing the system. The Belgian system

will then be compared to the one in Great Britain, as a case of a country

with a quite different health system. Finally, the situation of primary care

in Central and Eastern Europe will be briefly considered.

Primary care in Belgium

General practitioners

Up till the governmental decree of 1997, the number of physicians

was not regulated in Belgium. Once his/her degree in medicine obtained

at the university, the GP could decide to work in the municipality of his

choice. At the present time, a physician can still freely choose the area

where (s)he will practice medicine but the number of doctors produced

each year by the universities is legally fixed by a quota system, both for

general practitioners and for specialists. For the population of Belgium

of ten million inhabitants, only 700 new doctors are allowed each year,

the number of new specialists allowed being 400 maximum and the

number of GPs 300.

In Belgium, the choice of a GP by a patient is entirely free and he

may change his GP at will. The patient may also consult several GPs

during a same period, or directly consult a specialist as there is no obli-

gation of referral by a GP. GPs are self-employed and paid on a fee-for-

service basis, with co-payment by the patient

In view of limiting the number of consultations of multiple GPs by a

patient and the direct recourse to a specialist, the Ministry of Health has

initiated in 2002 the system of a global medical file (GMF) per patient.

The latter would freely choose his one and only family doctor and agree

to consult the latter (with some exceptions) for having access to a spe-

cialist. The purpose is to improve the efficiency of care and to reduce the

social security costs. The GMF should also improve communication

among the physicians themselves. The file is held by the GP and con-

Belgium being a federation of two communities, the Flemish-speaking population and

the French-speaking one, measures can be taken either by the federal government or the

community governments depending on the type of measure.

The amount depends upon one’s socio-economic situation, normally 4.7 euros (8.75

euros for an ordinary home visit) after reimbursement from the fund to only 1.21 euros

(1.99 euros for a home visit) for those of low economic status.

tains the results of the medical tests and exams for the patient, including

those possibly performed by a specialist and communicated by him. Vice

versa, the GP informs the specialist upon request of all the information

needed concerning the patient.

The global medical file is presently not legally compulsory but if a

patient accepts it and its constraints, he will benefit from a 30% reduc-

tion of his co-payment at each consultation of his family doctor. Patients

over 75 or suffering from a chronic disease retain this benefit also when

the GP performs a visit at home; contrary to some other countries, GPs

still make home visits in Belgium. As to the GP, he receives 750 euros

per year from the social security system, covering the software cost, if he

accepts to computerize his files with such a system. The general objec-

tive of the Health Ministry is to hierarchize the recourse to care and to

ensure a progressive access to health care with a view of reducing costs.

The GMF is a first step in this direction. It is hoped it will lead to better

exchange of information and harmonization of care through improved

complementarity among care providers and institutions.

Financing health costs

Belgium has a compulsory health care system based on the social

health insurance model. With very minor exceptions, the whole popula-

tion is covered. Health care is publicly funded and mainly privately pro-

vided. In Belgium, health care insurance is part of the global social secu-

rity network. Since 1995, financing is globalised: all means are put to-

gether under a common management before being distributed to the

various branches of social security such as health care, pensions, family

allowances, unemployment benefits, etc. Before 1995, employers and

employees paid specific contributions for each of these branches. Nowa-

days, the employer transfers more or less 35% of the gross salary of his

employees to the national social security fund while the employee trans-

fers slightly more than 13% of his gross salary to the same fund. These

social contributions from employers and employees represent the largest

part of the means of the fund (74%) but in addition the fund receives

subsidies from the State (12%) and 14% of its budget comes from alter-

native resources, mainly from VAT receipts but also from taxes on to-

bacco consumption, etc. Health care costs represent 35% (in 2005) of all

social security expenditures in Belgium.

Integrated health care

Though the GP is in the front line of medical intervention and as

such has a major role to play, as we have stressed in the introduction,

efficiency of the health care system requires a structured organization of

the system itself in which each care provider works in collaboration with

others, each respecting the other’s own field of action. Ideally, the GP

should be responsible for the integration and coordination of health care

as he ensures global and continuous care for his patient, in contrast to the

specialist. Structures for improving coordination of home care were set

up in Belgium in the early 1980s, though some partial initiatives were

much older. The purpose was to regroup various existing services such

as social care, nursing, family help, household aide, etc, under a common

management usually dependent upon the municipal social protection

center (CPAS) or the mutual insurance companies (i.e. sickness funds

called “mutualités”) redistributing health care benefits to the patients.

Some coordination structures were set up by the GPs themselves, inde-

pendently from the social protection centers and sickness funds.

In 1989, a governmental decree has been adopted for approving and

financing these coordination centers, but problems remain. Firstly, the

existing structures are very different among themselves, taking account

of the type of work performed, the training of their personnel, their

modes of financing, etc. Secondly, many GPs do not collaborate with

these centers, fearing the ‘sharing’ of their patients with outside actors.

Moreover, the GP is often not fully aware of the formal network caring

for the patient and does not clearly envisage his role in this network.

Emergency department attendance of hospitals

As pointed out before, in Belgium the patient may freely choose and

change his GP, consult several GPs, or directly access a specialist. He

may also go freely to the emergency department of a hospital for prob-

lems which normally should be addressed to a GP. The Belgian govern-

ment has taken measures to avoid inappropriate use of emergency de-

partments. Since March 2003, the federal government has introduced a

fixed co-payment of 12.5 euros for the patient, for a visit in an emer-

gency department if the patient was not referred by a general practitio-

ner. The patient can be dispensed of this co-payment if e.g. he is brought

in by an ambulance, by a medical intervention unit, referred by a GP or

by the police. The purpose is to stimulate the patient to visit a GP or a

primary care center instead.

An international literature review conducted by one of the present

authors (C. Gourbin et al.., 2004 ) leads however to the conclusion that

there is no evidence demonstrating the impact of co-payment on changes

in emergency department use. Moreover, it seems that patients attend an

emergency department in Belgium because they have difficulty access-

ing a primary care provider (during holidays or during the night, for ex-

ample). In addition, they consider that hospitals are much better

equipped in case of need than are general practitioners. The solution to

the problem seems to be a better organization of primary care providers

to cope with the needs of their patients (such as out-of-hours primary

clinics).

Primary care in the United Kingdom

The information in the following paragraph is taken from the WHO

country highlights on health (2005), themselves derived from publica-

tions of the European Observatory on Health Care Systems and Policies.

The United Kingdom has devolved responsibility for health care to

its constituent countries: England, Scotland, Wales, and Northern Ire-

land. They mainly fund health care through national taxation, deliver

services through public providers and have devolved purchasing respon-

sibilities to local bodies: primary care trusts in England, primary care

partnerships in Northern Ireland, health boards in Scotland and local

health boards in Wales. As is more or less the case in Belgium, the Brit-

ish health care system is mainly funded through general taxation: direct

taxes, value-added tax and employee income contributions. General

practitioners are self employed. On 1 April 2004, remuneration of their

services moved from a system mainly based on capitation

and fixed

allowances to one that combines capitation and quality points. In contrast

to Belgium, GPs in group practices (with an average of three per prac-

tice) provide primary care. To register with a GP, a patient must be a

resident of the designated practice area. There are also a small number of

NHS walk-in clinics. GPs act as gatekeepers in the system, and a referral

is required to gain access to specialist services, in contrast once again to

the Belgian situation. The whole population is covered by the system and

services are mostly free of charge at the point of use.

Under capitation, a doctor receives a flat fee every month for taking care of a regis-

tered patient, regardless of the cost of that individual's care.

Health expenditure in the United Kingdom has remained quite low

relative to the European average (8% less per capita), contrary to Bel-

gium where the level is above the European average (7% more). How-

ever, satisfaction with the British system is also low: waiting times for

care are long

, especially for gaining access to a specialist and even

more for being treated in a hospital, though the system does provide

ready access to care without regard to income (Blendon et al., 2002). A

major plan for reform has been adopted by the NHS, in particular to re-

duce waiting time for surgery and improve the quality of hospital care,

but devolution to the constituent countries is increasingly leading to re-

forms taking quite different directions across the United Kingdom.

Primary care in central and eastern Europe

We briefly present below the situation of some central and eastern

European countries concerning the current situation of GPs, their choice

by the patient, the recourse to a specialist, the cost of primary care to the

patient.

Bulgaria

Since July 2000, general practice is private. One can choose his/her

GP and can change twice a year. When the patient has a health insur-

ance, consulting GPs is without cost. In order to have access to a special-

ist physician, it is necessary to consult the GP who provides a referral

form. In the absence of a referral form, the patient must pay himself his

visit to the specialist.

Czech Republic

General practice is private. Persons with health insurance may

choose his/her doctor among those who have a contract with the patient’s

insurer for the provision of health care. In that case, there is no cost for

the patient. The GP can refer the patient to a specialist having a contract

with the patient’s insurer but the patient may visit a specialist without

recommendation from the GP. Primary health care covers both general

practitioners and paediatricians, gynaecologists, and stomatolgists.

Estonia

General practice is private. However, as GPs have a contract with

the health insurance, they may also be regarded as part of the state health

system. The patient can choose his family doctor. Consultation is with-

Waiting lists generally tend to be found in countries which combine public health in-

surance with zero or low patient cost sharing, and constraints on surgical capacity. These

prevent supply from matching demand (Siciliani and Hurst, 2005).

out cost except for home visit for which the cost is 3 euros. It is neces-

sary to consult a GP to have access to a specialist. There are also a very

limited number of private GPs without contract with the health insurance

system.

Hungary

General practice is private but GPs have a contract with the local au-

thorities that are responsible for primary care. Choice of the doctor by

the patient is free but people have to declare their choice leaving their

patient card with the doctor chosen. The local authorities are obliged to

provide family doctor care free of charge. They make a contract with the

family doctors, who are financed by the National Health Insurance Fund

according to the number of patient's cards. However, there are also pri-

vate doctors, clinics, and hospitals that are not financed by the National

Health Insurance Fund. It is possible to visit such doctors paying all the

cost of the care. Referral depends upon the specialization. Some special-

ists can be visited without a family doctor’s referral (e.g. gynaecologist,

ophthalmologist, otolaryngologist). The others can be accessed only with

a family doctor's assignment.

Latvia

Family doctors are either part of the state health system or are in

private practice. Choice of GP is free and one can change one’s physi-

cian once or twice a year. There are fixed rates of medical treatment

which do not depend upon the type of practice, state or private. A mini-

mum cost does not have to be covered by the patient if he/she is insured.

It is also possible to get tax refund for defined medical treatment. Some

specialists can be visited without referral, such as psychiatrists, gyne-

cologists, endocrinologists. The others need a referral form from the GP.

Lithuania

Family doctors are either part of the state health system or are in

private practice. In both cases, there is no cost to the patient. Choice of

GP is free. Referral by a GP is needed to have access to a specialist.

Poland

Family doctors are either part of the state health system or are in

private practice. Choice of GP is free. Care is free of charge to the pa-

tient for GPs who are part of the state health system but otherwise has to

be paid. Referral by a GP is needed to have access to a specialist except

for ophthalmologists, gynecologists, dermatologists, psychiatrists.

Romania

Family doctors are either part of the state health system or are in

private practice. In the former case, they have a contract with the na-

tional health insurance fund and are paid according to the number of pa-

tients and consultations. Choice of GP is free and one can change the

choice after 3 months. It is necessary to be referred by a GP in order to

visit a specialist. For doctors in the state health system, consultation is

generally free of charge; private doctors are paid by out-of-pocket

money.

Russia

In the state system, one can consult a GP in a polyclinic according to

one’s place of residence or one’s company. GPs in private practice are also

available in private clinics. In the fist case, care is free of charge to the pa-

tient; in the second case, it is not. In principle, one can choose another GP

in the same polyclinic. In the state sector, referral is required to have ac-

cess to a specialist. If one accepts to pay, a patient may go directly to a

specialist in the private sector or to the specialized state clinic.

Conclusions

Primary care in Europe is devolved more and more to the private

sector, both East and West, even in the countries having a National

Health Insurance System. Free choice of the GP has become the general

rule though in some countries this choice is constrained. But this relative

liberty is however accompanied in the West by an increasing influence

of the State, due principally to the fact that governments want to curb

health costs. This regulation can be seen in various sectors:

– a rationing of the number of general practitioners (and also of den-

tists, nurses, physiotherapists, etc.) . This numerus clausus was taken

quite some time ago already in France for example and is of more recent

origin in Belgium;

– the establishment of structures such as coordination centers, in

view of improving the continuity of care, a better communication and

interdisciplinarity among care providers in the first line of medical inter-

vention;

– a policy favoring referral from the front line to the specialist, in ef-

fect since many years in Central and Eastern Europe but also in the UK,

very recently in France, and under discussion in Belgium;

– the progressive establishment of a data collection system (such as

the computerized medical file) recording the activities of the first line in