( )

- 2004

.
,
, :
- ,
-
-

,


.
,


.
,
,
.

SUMMARY
In the frames of this paper there is an effort of a systematic presentation and
comparative evaluation of selected

Primary Health Care

systems in Europe

aiming mainly at the export of conclusions and proposals on the prospect of

development of Greek Primary Health Care system .
European countries, what were selected in the base of criteria of organisation and
operational principles, are the following:
- Denmark, Great Britain and Finland
- Germany and Netherlands
- Switzerland
Initially, the systematic presentation of the main structural characteristics of the
Primary Health Care systems is attempted, systems of organisation and their
financing, reforming efforts and action for the quality and the rights of patients and
there is a relatively short evaluation of practical applications for all the countries
that have been selected.
Then, follows the comparative evaluation of systems of countries in the base of
characteristics that was described and is shaped the table of comparative
presentation and evaluation as methodological tool for their depiction.
Finally, are formulated the conclusions that result with regard to the prospects
of development of Greek Primary Health Care system, which are also the central
objective of this paper.





-



out-of-pocket


: , . , , , ,
.
NHS- Primary Health Care Groups PCG New NHS
Promoting Better Health Gatekeeping out-of-pocket kosts fee-for-patient .

.......... 4
1. ...... 9
1.1 ......................................................................... 9
1.2 .......................................................... 13
1.3 ............................................................................................. 17
1.4 ........................................... 19
1.5 ........................................................................................ 19
2.
B.... 21
2.1 ....................................................................... 21
2.2 .......................................................... 24
2.3 ............................................................................................. 29
2.4 .......................................... 31
2.5 ........................................................................................ 33
3.
. . 35
3.1 ........................................................................ 35
3.2 .......................................................... 40
3.3 ............................................................................................. 43
3.4 ........................................... 47
3.5 ........................................................................................ 48
4.
.. .... 50
1

4.1 ....................................................................... 50
4.2 .......................................................... 53
4.3 ........................................... 58
4.4 ............................................................................................. 60
4.5 ........................................................................................ 62
5.
64
5.1 ....................................................................... 64
5.2 .......................................................... 69
5.3 ............................................................................................. 74
5.4 .......................................... 79
5.5 ........................................................................................ 80
6.
82
6.1 ....................................................................... 82
6.2 .......................................................... 86
6.3 ........................................... 89
6.4 .............................................................................................. 90
6.5 ......................................................................................... 94
7.
..... 96
7.1 .................... 96
7.2
.............. 97
2

8. -
. 108
8.1 ......................... 108
8.2
..................................................................................... 113

.
.
,
,
. ,
, 2000 9.4%

(, 2004). ,

,
. ,


, , .

.
,


,
. ( Bcken, 2001)
,
, ,
, (
70)

4

,
. (, 1996)
, ,

,
,
, .
.


.

-
gatekeeper
.
,
, .
.


,
.

,
5

,
,
. ,

. , ,
,

(, 2003).

,

.

Beveridge ( . , , ),

Bismark ( )
( ). (, 2003)
, ,
,
, .
:

,

, .
6

:
- ,
, , ,
,

. ,
, ,
.
,

.
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.
?
?

?
,
,

.
7

- , ,

.

.

.
-

.
- ,

.
( Bcken, 2001)
, ,
:

,
,


.
,


.

,

, .

1.

1.1

,
:

/
.

( ,
, ).

( ).

,
,
275 . ( Vallgarda, et al., 2001)

( 83%) .
9

( Health Promotion Program ).
, 14 (
Copenhagen Frederiksberg) ,
.
, .
273
, .

.
,

18 .

(
,

).

(
, , )
. , ,
.
,
.

.
.
10

, 17%
( ).
( General
Practitioners ) .


.

.

.


(Association of County Councils ).

,
.
80% (
) 20%
.

.

.
80

11

.
1997 $2,042.
,
.
90 .

.
1980.
8% 1997.

. 1984 1994
117 83. 1996
1000 .
, 80,
. ,

,
.
, 7% 1997
.
1997, 87
1998, 73 .
.
,
(
- )
. ,
1996 ,

12

.
,
. 90%
.

, ,
.
35 64
.
. (Bcken et al., 2001)
1.2

, .
.
( National Health Agency )
( National Medical Council )
. ,
14

.

273

municipalities.
,

, ,
.
13

.
.


.
,
,
.
. 2
- 1.7% ,
.

.
, Danmark, 99%
.


.


.


.
1993
,

14

. ,



.

.

.
.

.


.
, 24 .
,

. (
Vallgarda, et al., 2001)


1325. 1

10 km ( 5 km ).
2096 . 1998
1507 1610 , Bornholm
1317 .
, .
15

(
).


.
gatekeeper,


.
2 ( 1.7%
)


.
, ,
.
1 .


.
1993
.
,

(Sygesikring)
.
,
16

.
, 60
,

.

1
(, , , .).
,

.

. ,
,
.
(
)
. , ,
.
1.3
1990.
, 1991,


.

17

standards.

,
1993.

. ,



.
,
11
.
,

.

2000.
.

.
,
1997.

, ,
.
18

1.4
1973
. 1993

, ,
1994,

.
,
,
.
,


, ,

(
), DRGs (1999),
(90/10), (20002002) ( 1993, 1995, 1999
2002).

. (Vallgarda, 2002)
1.5

. , , ,
.
19

.

.
,
,
,

. ,

. , ,

.
,

.

.
,
.

, .
, ,
,
,
.


. ,

20

10 km. ( Bcken,
et al., 2001)
2.

2.1

(National Health Service - NHS) 1948.
-
- .
,
. NHS .
.


,
. NHS

, .

.
,

. , ,
(National Institute for
Clinical Excellence -

NICE ).

, ,

21

. . ,
.
(Prevention program ) NHS
, ,

.

( Minister for

Public Health )

.
out-of-pocket ,
,

( National Insurance Fund )

NHS.

,
NHS.
. ,
, .
NHS
.

1,2%

.

1998.
,
22

, ( Primary
Care Groups PCGs )

.
, , ( NHS
Trusts) .
Community Service facilities

NHS .
$1,391 per capita 1997, 6,8%
.
.
1980 1990
.
, .
.
,
1000 , .
.

NHS
: 1996,
5,9 ,
5,6 . 1996, 21.4%
, 17.8%.
.
.
23

,
.

.
1993, , 12
, .
,
.
,

.
, 56% , 1996
. 27,4%
14,6%
NHS. .
.
NHS

. 79.5
74.3 .
.
1980
1990, 1992 1996
1995
1996 0.1 1000 6.1 1000.
2.2
1999, ( PCGs )
.
. PCG 50

24

250,000 .

. PCG
NHS.
PCG :
,
,
, .
2000,

NHS Trusts .

.
PCG (
Health Improvement Plans HIPs ),

.


.
( Medical Practices Committee MPC )
( General Practitioners - GPs )
. MPC
.
. ,

.
25

. (Bcken et al., 2001) .
99%
, 24

.
).
90%
.
, .

.
.

. gatekeeping
. ,

, .

,

.
1998 27392 8994
. .
. 10%
, 50% 1952.
1998,
1866 . 7% .

26

10000 .


. ( Robinson et al., 1999 )

, PCG
.
.

.
,
.
,
, ,
75% GP

.
,

5000

( 4000 ),

.
-


.

,
,

27

, ,
.
5,000 pounts

.



,
. (Bcken et al., 2001)
A NHS, 1948, NHS
. .

.
, 1990,
.

,

. (Robinson et al., 1999)
NHS,


. gatekeepers
.
,
. ( Bcken et al., 2001)
28

,
:

( practice nurses , district nurses ) ,

.

. ,
,

.
, 1998
10358

NHS.

, (district nurses),

. 10000 district nurses .
,

.
28
. 5000 .
,

.
.
12600 . . (Robinson, 1999)
2.3
NHS ( New NHS )
29

:
1. ,
standards .
- ( National
Service Frameworks) National Institute for Clinical Excellence (
NICE ) .

,
. NICE


.
NHS.
2. , PCG

NHS
.

. 1990

.
.
3. ( Commission for Health
Improvement CHI )

.
30

National Framework for Assessing Performance. ,

.

,
,
. (Bcken et
al., 2001)
2.4

NHS. 1987 ,
Promoting Better Health,
.
, 1990,
, .

Developing NHS Purchasing and GP
Fundholding, 1994. :
( Towards a primary care-led
NHS ).

. ,
( , )
(
31

,
).
1997 NHS,

.
1999 481 (
PCGs ), .
,



. ( Robinson et al.,
1999)
. ,

80% . ,
, , ,
NHS,

.

2000 2002.

.

,

,
.
,

32

,
,
,
.
,

48% . ,
,
NHS,
,
. ,
.
,
. ,
NHS. ( Health Policy Monitor, 2004).
2.5
( S )

:
,
,

.
, ,

, NHS
33

.
,
, ,

.
()

,
NHS.
,
,
PCG
NHS,
, ,

.


, .

.

standards .

.
.
,
. .

34

.
.

.

. ( Bcken et al., 2001)
,

.
( Robinson et al., 1999)
3.

3.1

70
( Primary Health Care Act ) 1972.

.

, , ,
. ( Jrvelin, 2002)

.

35

( National State Sickness Insurance NSSI )

. ,
13% .

, . ( )


. NSSI
, ,
.

.

, (
1956 ).
25%
out-of-pocket,
, .

. 50%
.

36

455
.
. 1993,
,
.
1993-1994
, ,
, , ,
.
25% 60% ,
. ,

( .
).

.

,
,
. (Bcken et al., 2001)

,
.

,
. ,

.

37

,
.
. ( Jrvelin, 2002)


,

. ,
,
.
,

.
1997 7.4% ,
$1.525. , .
.
1990,


.

, , .
15
,
. ,
.

38

,
.


.
,

(outpatient

clinics).

. 3,7
1000 5
( 40% 10 ),
.
2002.

.

. ,
.
, . , ,

.

.

, .
, .

39

3.2

.
.
270 ,
.
10000 .
22800 (
).

. ,

.
,
( ) , ,
, , , ,
. ,
( 30 60 )
. ( Bcken
et al., 2001).
.

,
, , , .. ,
gatekeepers .

40

(public health nurses),
. ,
, ,

. ( Jrvelin, 2002)

,
, ,
.
,
.
, , ,

.
16
.
,

.
,
. ( Bcken et al., 2001)

, .


( ).
41

, .
,
,


.
.
, , .
,
, .

,
. (Jrvelin. 2002)
.
(
, )
.

. ,
(
60% ), ( 20%), (
15% ) (5%). ( Bcken et al., 2001)
management , .
,
.

,
/ . (Jrvelin, 2002)

42

.

. ,


. gatekeeping.

.
(
38 ).

. .
(Bcken et al., 2001)
1999 8%
.
( National Health Insurance),

(NHI ). ( Jrvelin, 2002)
3.3

.
:
1000 ,
.
.

43

,
.

,
.
1995 , ,
.

,
. ,
,
( .. ).

, .

.
, .

:
1. ,
: .
,

.
44

2.

,
.

.
3.

.
.
( Patient Injury Law )
1986

.
,
,


.
1992 ,
( Medical Ombudsman )
.
,
.
.(
Bcken et al., 2001)
,
,

45

. (population responsibility
model),
.
,
.
, , .
,


. 5%
. 56%
65%
.

. 30-40%

. ,


.
,
. , ,
. ,
. ,
,
.

46

.


.

( , ). (
Jrvelin, 2002)
3.4
,
1972,
.

. ,

. , ,

, .
80,
,
,
. ,
, 2 6 .
,
.



.

47

,
80.
. ,
.
,
1988 1993, 17
, 1600
3100 , 40000 ( ).
,
, ,
.
,
. , ,
(
),
.
.
.

,
. , 4.4
8.3 , .
90%
. ( Jrvelin, 2002)
3.5

.

48

, ,
.
. ,
, , ,
. ,

.
,

. ,


. (Bcken et
al., 2001)

.

vestvastuu, .

:

1500-5000 .
,
,
. .

. ,

49

. , 55%

,
2500 .

.
. ,
,

, ,

.
,
. (Jrvelin, 2002)
4.

4.1

Bismark ( ).

. ,
.
, ( Health
Insurance Law KVG ) 1994.

50

.
,

100
.

,
.
,
.
( , , , . )

.

. ,
1998 95SFr,
382SFr. , 100%,
.

,
( cantons ).
10%
.

, ,
51

. ,
.
,
,

.).

( Federal
Commission for Health Insurance Services )
.
230SFr
, 10% ,
850SFr.
, ,
.

.

.

,
.
.
,
( ).
.

)
,
.

52

.

.
10%
$2,611,
.

.
:
, ,
, .
1990,
40%
50% .

,
,

.

.

.
4.2

, , ,
. , ,
, .,

53

.
.

. ,

. (
Bcken et al., 2001).

. 23679
1998, 13357 ( 56%)
. 36% 46% .
(Minder et al., 2000)
,
,
,

.

.
( TARMED )
.
.
.

,
.
.

. tiers garant ,

54

. tier payant
.
,


.

(
).

.


. , ,
,
.

.
, 50%
.

.
.
:
, ,
, .
.

,

55

.

.
,
, ,
. ,

. LORAS ( Service
Oriented Resource Allocation in Hospitals )
641 .
.

.

,

.
. ,
,

.

.
, ,

.
,

.

56

.

.

10

.

,
, .
,
,
.
( )

.

57

4.3
1994

,
-
.

.
,
:

(managed care plans),

gatekeeper
.

( gatekeeping ).

, :
-- HMOs ( HMOs Health Maintenance
Organizations). ( Bcken et al., 2001). HMOs

, ,
. 140
HMOs 98400 .
, 3792 350000
. ( Minder et al., 2000)
58

-- .
,
,
.

, 20%

(managed care plans ),


.
HMOs
.

.
. HMOs

.

HMOs

.
.
HMOs

20% .
HMOs
( .
)
59

30 35% . ,
.

,
. ,

gatekeepers
.
.

.

.


gatekeeping .
.
4.4
, 56 ,
.
77

.

60

standards
. ,
,
.


1 1998,
. ,
.

,

:
LORAS Project ,

HMOs.
,
,
.
FMH

. FMH

.
. FMH 80
61

40-60 (
).
( , )
,

.

.
4.5
1994,
.
, ,
,
,
. ,
, .
100
.
managed care plans.

. ,
,
. ,

.

.

62

.

.
. ,


. ( Bcken et al., 2001)

:

, .

. 1993 1994,
,
HMOs
:
2040 ( 1040
)
.

63

.
13.1%

45.2%

23.3% 18.2%
. ( Minder et al., 2000)
5.

5.1
.
,
,

. ,
.
80,


Dekker-Simons Plan.
,

.
,
.

. (
Health Insurance Funds Council ), 45 ,

64

(
, , , , ,
) 50 . 1999
( Health Care Insurance
Council CVZ) .
: ( General Insurance for
Special Disease Costs AWBZ )
,
, , .. AWBZ
40%

.
,
( statutory
health insurance - ZFW), (private health
insurance ), . ZFW 365
,
.
18 ,
.
, , ,

.

,
.
(75%)
(

65

out-of-pocket

. , ,
(
)
.

, , .
,
.
.
,
, , , .,

.
,

.
standard ,
.

, . , ,
,
().
,
( supplemental insurance ),

. 90%
.
66

,
,
, ,
,
. out-of-pocket
200 guilders
. , 100
guilders (1997).
( )
.
gatekeepers

,
.

.

.

, , .
.


.
,
.
.

67

80.
$1.933 , , NHS
, . .
8.5% ,
.
( Social Welfare System ).

.

15 , 3.8 1000
. ,
,
.

,

10.2%, . 8%
.
, 10 ,
2 ,
.

.
.
80 90
.
,
68

, .
,
,
.

.

,

.
.
,
.
5.2

. ,
,

.
.
.
,
.
,

. ,
69

. 1995,
2.5%
. 1997,
27% 65%.

,

, .
30
50 . ,
, ,

,
.
,
. ,

. 15%

. 40%
, 1997 1998, 100 guilders
.
,
,
, .
(CVZ),
,

70

, , .
1994,

.
.
.
, ,
.
( ) 1998
.

.
, 90%
, . .
1992 .
7000
.
.
gatekeepers
,
,
.

.
.

.
. ,
1600 .

71

, ,
.
,
. ( Bcken et
al., 2001)

( 2002)
-

8107

- 4631 , 61.7% .
- : 2408
- 43% part-time.
- : 1005
: 74.5%

1825

- 448
- : 465
- (15 39 ), :
2275

- 5500

7623

72

- : 78.5%
Dental hygienists
,

2205
13254

- 4747
- : 12250
- :
17.2%
- : 1213
( 2001)

2536

1476

2670

- 1602
- 597
- : 6088

.

91562

(www.Ministry of Health, Welfare and Sport.)

73

5.3
.
, 70,


. Dekker 80s
90s .
, standards
,
.
,
1996
.

standards
( ),
.


( Health Care Inspectorate ).
, ,
.
,
,

(

Center for Quality of Care

Research WOK ) Nijmegan Maastricht.

74

( peer
review) .
6
12 , ,
,
. , 800
80%
.
60 70% ,
,
. ,
. 1997,
70
. 16 ,
.
,

, .
18 . ,
.
. WOK

70%, 80%
( ).
.
, WOK

75

( monitoring procedures ),

.
,
,
.
,
.
.

.
,
.


. , WOK
, , ,
40%
.
- ,
. 1996,

40

, 5 ,

,
.
, . ,
-,
76

.

. 1990,
,
, 1998.
,
, , ,
.
30 ( 150 5
).
H ( General Insurance for
Special

Disease

Costs

AWBZ

,
.
( ZFW ) 1992
.
,
.
.
.

,

.

.
gatekeeper

77

,

.
,
.

1995. ,

,
.

, , .,
.
,

.
,
,
.

.
, 1994
,
.

. , ,

. ( Bcken et al., 2001)

78

5.4
,
AWBZ, .
.
,
.

.


. ,
.
:
- .
- ,
.
- .

, .

.

.
,

79

.
. , ,
,
.
,
. , ,
,
, .
, ,
.

. ,

.
,
,
. ( usse et al.,
2004)
5.5
Dekker
,
. , ,
,
.

80

. ,

, ,
.

, gatekeeper

.

.
, ,
.
, ,

.
standards , ,
.
,
,
, -

.

.

.

81

6.

6.1

. ,
, , ( Krankenkassen ),
100.000 1995.
,
,
.
, .
.
,
,

. ,

. (, 1995)
90%
( Statutory Health Insurance Programm GKV
). To GKV
, (
50-65% ), , ,
, ,
. , ,

,
, AIDS, .

82

, ,
.
GKV
.
, spa,
, , ,
. ,
( out-of-pocket )
1%
.
. GKV
. ,
50% . GKV
.
,
GKV
6,450 DM 5,325 DM
,
.
GKV
.

, ,
. ,

GKV.

,
.
83

,
.

.
,
.
,


.
,
, .


.

. ,
,

, 2003 , ,
, ,
.
1997 10.7% .

. $2,364
.
84

1989 1992 ,
. 1993 1997

,
.
1000
.

.
90s,
.


. ,

. , ,
.
.
, ,

,

. (Saltman, et al., 1997)

85

6.2


. ,

,
. , ,
,

.
90%
( statutory health insurance funds ). ,
,
,
. , ,
,
1996. ,
500
, .

, .

,
1994
.

86

,

. GKV
,

, ,

1999
.

. ,
,
.
GKV
,
, .
6,450 DM 5,325 DM

, GKV
.

GKV. 9% .
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230
.
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,
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-
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,

50%
50%

, 1993

, 270

,
gatekeeping

75%

.
,
1992, 1998.

1991,Patient
Charter,

, 3

,
Medical
Ombudsman

,
gatekeepers

,
gatekeepres

Fee-for-patient,

fee-for-service

GP

fee-for-service

feefor-service,

, PGRs,

, feefor-service,

, outpatient
clinics

, .

,


,

, 8%.

, 6.8%

7.4%

, 10%.

8.5%

, 10.7%

,

1993

,
,
Commission For
Health
Improvement.

,
LORAS Project

: Reforming the Health Sector, J.

Bcken, M. Butzlaff, A. Esche, Bertelsmann Foundation Publishers, Gutersloh 2001

10

11

12

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Busse R., Schlette S. (eds.) (2004): Health Policy Developments, Issue 2:

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