Gatekeeping model central to primary care across region

The gatekeeping model was a common theme among the presentations of Datin Dr. Noraslinah of the Ministry of Health in Brunei Darussalam, Dr. Zorayda Leopando of the Department of Family and Community Medicine at the University of the Philippines College of Medicine and Dr. Somjit Prueksaritanond of the Royal College of Family Physicians of Thailand regarding their respective countries’ experiences at implementing primary care during the conference.

The gatekeeper was described as the entry point to or the first contact with health care. The gatekeeper physician facilitates the relationship between the health care team and the patient as well as participates in health decision-making. He or she also has the opportunity to engage in disease prevention and health promotion activities and employs a team of health professionals with specific biomedical and social skills. As such, the primary care provider requires adequate resources and investment to fulfill its role in the health care system.

The gatekeeper is tasked to manage conditions the primary care facility is equipped to handle as well as triage such cases that require further outpatient, inpatient or emergent care to various specialist clinics or secondary and tertiary institutions.

Philippine experience: growth of the specialty
Leopando traced the progress of universal health care (UHC) in the Philippines in parallel to the growth of family medicine as a specialty. She pointed out that in 2008, at the 30^th anniversary of the Alma Ata Declaration, family physicians were central to the reforms in universal coverage, service delivery, public policy and leadership.

“Advocacy number one is about the role of family medicine in the health care system. But the focus, really, is the family and how we are going to prepare our family physicians to take care of the patient in the context of the family as well as how to take care of the family as a patient,” explained Leopando.

It was in the 1970s when family medicine was recognized as a specialty by various organizations in the Philippines. Since then the Philippine Academy of Family Physicians has administered its diplomate exam and enforced continuing medical education requirements among its fellows. A formal family medicine residency program was also instituted.

In the 1980s, standards of training and accreditation were formalized and the Philippine Society of Teachers of Family Medicine was formed, which forged international links to elevate the quality of training. In a 1996 workshop, they mandated that gatekeeping physicians should be able to address the majority of problems patients bring to their attention and computerization should be employed for the purpose of administrative efficiency.

Brunei experience: decentralizing health care
Noraslinah described Brunei as a small, young state achieving independence only in 1984 and with a relatively small population of 393,162 people. Since then, Brunei was declared malaria-free in 1987 and polio-free in 2000. They have had a low prevalence of the human immunodeficiency virus and has incorporated an extended program of immunization in its child and school health services. The private insurance market in Brunei is limited and even most foreign nationals in the country get public health insurance.

“In order to ascertain the sustainability of health care, the Ministry of Health has focused on the implementation of interventions that are cost-effective such as enhancing preventive steps and enhancing health promotion activities and screening,” Noraslinah reported.

Primary care is provided through a network of health centers and clinics that offer outpatient, maternal and child health and school health. It also includes a flying medical service, which is a four-times-a-month effort to target communities not easily accessible by road. As part of the National Health Care Plan from 2001 to 2010, they have promoted primary health care through decentralization and postgraduate medical training.

She reported that in Brunei, decentralization led to better organization and resource utilization. One-hour sessions for continuing professional development and continuing medical education (CME) are held weekly consisting of updates, master classes, symposia and workshops. Sessions would have 30 to 40 attendees at the time and physicians are required to attain at least 30 CME points to receive their annual practicing certificate.

General practitioners are urged to undergo a vocational training scheme that includes two years of hospital work and a one-year placement in a health center. Brunei is also the second center to administer the Member of the Royal College of General Practitioners (MRCGP) International qualifying examination after Oman. A three- to four-member total quality management committee also conducts audits per subdivision observing the three pillars of risk management, clinical effectiveness and clinical improvement.

Thailand experience: increasing health coverage
Prueksaritanond presented the example of Thailand as a low middle income country with good health status thanks to efforts toward UHC.

“The wisdom said [sic] that universal health care cannot be managed, that it cannot reach its goal, but now universal health care is in the United States agenda for millennium development goals,” she related, reflecting on how the perception of UHC has gone from a fantasy to a realistic target. She pointed out that Thailand is pursuing a universal coverage agenda while racking up only 4.2 percent of gross domestic product in health expenditures compared with the United States at 16.9 percent. She estimated that 76 percent of health expenditure came from government funds, 18 percent came out of pocket and 0.05 percent from donors.

Plotting them against a decreasing under-five mortality rate per 1,000 live births, she highlighted historical milestones such as institution of a three-year mandatory rural practice for doctors and a national expanded program of immunization in the 1970s, the Civil Servant Medical Benefit Scheme in 1980, the Voluntary Health Card in 1983, the Social Security Scheme in 1991 and legislative reform paving the way to universal health coverage in 2002.

Presently, the Thai population of 62.5 million as of 2008 is covered via three schemes: the Civil Servant Benefit covers 8 percent, the Social Security Scheme covers 16 percent and the Universal Coverage (UHC) extends to 76 percent. Generally, financing is sourced from general tax revenue and capitation. Beneficiaries are required to visit a registered primary care facility as their first contact point, which refers them to public or private hospitals for secondary or tertiary care if necessary. Similar to Leopando, Prueksaritanond also mentions the central role of the family physician by expressing preference that a primary care unit physician should be trained in family medicine.

Since the UHC was instituted, the percentage of GDP used for health has not increased much, says Prueksaritanond. From 1977 to 2010, primary care service utilization has increased from 29 percent to 54 percent, whereas tertiary care utilization has decreased from 46 percent to 12.6 percent. Outpatient utilization has also increased from 111.95 million visits in 2003 to 149.58 million visits in 2012.

They utilize a pay-for-performance system that they hope would stimulate management capabilities, maintenance of comprehensive individual and family continuous electronic records and engagement in preventive activities and chronic disease management.

Overcoming challenges for universal health care
Speakers cited different challenges for their countries’ primary care aspirations.

Noraslinah listed manpower, service expansion, increasing patient expectations, health promotion and education and health system sustainability as Brunei’s most important challenges in implementing primary care reform. On the other hand, for Leopando, the anchor of UHC in strong primary care is still in its infancy. Modernization, globalization and labor migration all impose consequences on the Philippine health care system. She felt that a dearth of research on families and health is a challenge in our country.