Health personnel and the reform of primary health care in Montenegro

Introduction: Universal health coverage reform activities in primary health care in Montenegro were conducted in the period between 2004 and 2012, with the aim of increasing the efficiency of the health care system by ensuring rational use and availability of resources.

Aim: The purpose of this study is to describe the health personnel during and after the reform activities in Montenegro.

Materials and methods: We adapted the four-dimensional World Health Organization framework to examine availability, accessibility, acceptability and quality of the health personnel in public primary health care facilities, in Montenegro, during and after the reform. Availability, accessibility, acceptability and quality of health personnel were examined using a defined set of proxies. In addition, the latest available data on density rates of health personnel were presented, in order to examine the sustainability of the implemented reforms. The data used included primary health care information system data, data published by the Institute of Public Health of Montenegro, as well as data from a number of official and expert reports by relevant experts and institutions.

Results: The total number of physicians employed in primary health care was reduced during the reform by 5%, while the number of nurses was decreased by 35%. At the same time, the number of GPs (chosen doctors for adults) increased, which improved their availability (54.4 in 2015 vs. 36.3 in 2004, per 100,000). Accessibility showed great variations among municipalities. The utilization of health care services, at the national level, increased by 25% in adult health care services. The reduction of the number of nurses was tailored to meet set norms in health care services for adults, women, and children. Reform activities improved the professional competencies of primary health care teams.

Conclusion: Primary health care reform improved the availability and accessibility of health personnel and implemented activities that improved their acceptability and quality. It is recommended to establish a permanent body which would continuously monitor the functioning of the primary health care (PHC) system, as well as the changes that occur in PHC, thus ensuring that reform results are maintained and further improved.

INTRODUCTION

The evaluations of the health care reforms conducted across Europe, in the period after the 1980s and the 1990s, have highlighted the complexity of reform processes, the achievements, and the challenges which countries have faced during the implementation of reforms [1],[2],[3]. The health workforce development, deployment, and performance are sensitive issues which were not easily solved with the health care reforms. With regard to universal health coverage, the World Health Organization AAAQ framework for governance of health personnel availability, accessibility, acceptability and quality is gaining significance globally and nationally [4],[5],[6],[7]. Primary health care reform preceded the COVID-19 pandemic in many countries, calling into question the benefits of health staff rationalization in relation to the sustainability of primary health care, in the context of crisis [8],[9],[10].

Montenegro is one of the countries in Southeast Europe investing considerable efforts into strengthening primary health care (PHC), at the beginning of the 21^st century [11],[12]. The Montenegrin health system was facing sustainability issues, mostly due to broad rights to health care services and a large number of health care personnel. In addition, efficiency in the use and management of resources was not prioritized [13]. Improvement of health system efficiency in the reformed model of PHC organization required the appropriate knowledge and skills of the chosen doctors (CDs), in order to fulfil the majority of patient needs at the level of PHC.

The adopted legislative framework [14] defined that PHC services are provided by chosen doctors (and chosen dentists). In the new organizational framework of PHC, chosen doctors provide health care services as GPs for the adult population (including specialists in the fields of general medicine, emergency medicine, internal medicine, occupational medicine, as well as family medicine), chosen gynecologists for women, and chosen pediatricians for children.

This study provides a brief overview of the primary health care reform process in Montenegro, describes changes of health personnel during and after the reform, and concludes whether the reform has improved the delivery of PHC, in terms of the availability, accessibility, acceptability and quality dimensions of health personnel, in the mid- and long-term period.

MATERIALS AND METHODS

A report issued by the Global Health Workforce Alliance (GHWA) and the World Health Organization (WHO) [4] was used to explore health personnel governance in Montenegro, during the reform period (2004 – 2012), as well as in the years after the reform, until 2015.

Using the AAAQ framework, the health personnel in Montenegro was described with 18 indicators, and their values were compared for 2004, 2015, and the latest available. The 18 indicators are: total population of Montenegro; population under 15 years as a percentage of the total population; population aged 65 years and above as a percentage of the total population; population living in urban areas; annual rate of population changes; gross national income per capita; population living on less than $1 a day; total health expenditure as a percentage of GDP; Government health spending as a percentage of health spending; external resources for health as a percentage of total health expenditure; life expectancy at birth, per sex and in total; total fertility rate (per woman); early neonatal mortality rate (per 1,000 live births); infant mortality rate (per 1,000 live births); under-five mortality rate (per 1,000 live births); maternal mortality ratio per 100,000 live births (estimate); births attended by skilled health personnel; antenatal care coverage, with at least one visit.

The indicator of health personnel availability was the rate of health workers per 100,000 municipality inhabitants. Variations of health personnel accessibility across municipalities were indicated by the ratio of the highest and the lowest municipal densities of health workforce and compared to the national average and the utilization of health services in PHC (number of visits of adults per general practitioner). The indicator of health personnel acceptability was the ratio of nurses to physicians, given that it highlights the skill mix as a factor of acceptability, which influences the users’ decision regarding whether the capacity of the health workforce can meet their expectations [4]. The quality of the health personnel in Montenegro was described trough evidence on implemented national mechanisms of accrediting educational institutions, regulating health professions, and licensing health professionals [4].

In addition, we have presented the latest available data regarding availability indicators: density rates (per 100,000) of medical doctors, dentists, pharmacists, chosen doctors and nurses, in public primary health care centers, in order to examine the sustainability of the implemented reforms.

The data holder was the Institute of Public Health of Montenegro, including the primary health care database and published official statistics data, as well as a number of official and expert reports from relevant institutions (the World Bank, the Government of Montenegro, Health Insurance Fund of Montenegro, the Ministry of Health of Montenegro, and other ministries).

RESULTS

The ongoing population dynamics in Montenegro reflects the trends of aging and migrating towards urban areas (Table 1). The population under 15 years of age decreased by 2%, while the percentage of the elderly rose by 1% [15]. The rise in population numbers was limited by lower fertility levels and extended longevity [16],[17]. The early neonatal mortality rate, infant mortality rate, under-five mortality rate, as well as the estimated maternal mortality ratio, decreased in the observed period [18],[19],[20],[21]. Antenatal care coverage rose, as well as the number of births attended by skilled health personnel. The gross national income per capita in Montenegro increased [22], with a decrease of population living in households whose income is below the international poverty line [23]. However, the total expenditure on health as a percentage of gross domestic product remained at the same level as estimated in 2004 [24],[25], while Government spending as a share in health spending decreased. Cardiovascular diseases were the leading cause of morbidity in Montenegro [28]. Ischemic heart disease, stroke, cardiomyopathy and lung cancer were the leading causes of premature death in 2010 [28]. Lung cancer hospitalizations of men rose by 18% (2005 – 2015), while diabetes related hospitalizations of women increased from 1% to 1.9% (per 1,000), in the same period [29].

Table 1. Socio-demographic and health status indicators of the population, in Montenegro, in 2004, 2015 and 2021 (or latest available data)

Availability, accessibility, acceptability and quality of health personnel in public primary health care centers in Montenegro

The total number of physicians employed in public sector primary health care (including emergency units) decreased by approximately 5% during the reform period (2004 – 2012), and the decrease was the greatest in years 2009 and 2010. In the first years after the reform, the density rate of physician per 100,000 remained relatively stable, with an increase in 2019 (Table 2.a).

Table 2.a. Medical doctors, dentists and pharmacists (rates per 100,000) in public PHC centers, in Montenegro, 2004 – 2015 and 2019

As of 2008, dentists were completely removed from public PHC. The number of pharmacists was negligible in the observed period (0.2 per 100,000, in 2015).

The total number of chosen doctors increased by 28 %, during the reform period (2004 – 2012), and continued to rise in subsequent years (Table 2.b). The density rate of CDs per 100,000, in the 2004 – 2015 period, increased from 48.6 to 64.8, while the density of CDs working as GPs for the adult population rose from 36.3 to 54.4 (per 100,000). The total number of nurses in PHC decreased by 35%, in the observed period.

Table 2.b. Number and density rates (per 100,000) of chosen doctors and nurses in public PHC centers, in Montenegro, 2004 – 2015

Figure 1. Visits made to GPs by adult patients (per 1,000), Montenegro, 2004 – 2015
Source: Institute of Public Health of Montenegro

The availability of health workers in PHC varied by municipalities and reached the highest density in the Mojkovac Municipality (62.63 per 10,000), in 2015. The largest municipalities, Nikšić and Podgorica, had the lowest density at the PHC level (20.43 and 22.32 per 10,000).

Municipal accessibility of health personnel (per 100,000) was lower in 2015 (35.18) than in 2004 (46.74). Compared to the national average, in 2015, accessibility ranged from -42% to +78% (Table 3).

Table 3. Variations of health personnel accessibility (rate per 100,000) across municipalities, in Montenegro, in 2004 and 2015, and deviations from the national average

Utilization of health services in PHC, measured by the rate of visits of adults to GPs (per 1,000), increased by 25% (7.4 in 2015, as compared to 5.9 in 2004).

The proxy measure of health personnel acceptability, measured by the national average ratio of nurses to physicians in PHC, decreased in the observed period, from 5.7 in 2004 to 2.7 in 2015. The reduction of the number of nurses was the most radical in the primary health care services for adults, where the number of nurses per CD was 1.1 in 2015. The ratio of nurses per CD for children declined to 1.5, while the ratio of nurses per CD for women was stable during the reform period – 1.3 nurses per CD (Graph 2).

Figure 2. National ratio of nurses to physicians and the ratio in the health care services for adults, children and women, as a proxy measure of health personnel acceptability, in Montenegro, in the period 2004 – 2015

Reform activities strongly influenced health personnel development. In the 20^th century, primary health care in Montenegro was based on the ideas of community oriented primary care, and as such, primary health care centers remained the predominant providers of health care services at the primary level [30]. Reforms in the new millennium kept the former orientation and “aimed to provide better quality health care at the local level, focused on family needs” [31]. The reform succeeded in developing an adapted and unique approach to the education of PHC health personnel, tailoring education to their specific needs [32]. One of the results was the inclusion of family medicine in the curriculum for undergraduate studies, the introduction of the specialization in family medicine, as well as a number of courses in this field. The specialization in family medicine was introduced at the Medical Faculty of the University of Montenegro in 2012, with 101 doctors enrolled in this specialization program [33]. A detailed description and evaluation of the program was published elsewhere [34],[35]. In addition, PHC teams (274 teams) were retrained in the area of family medicine [33].

Currently, the Faculty of Medicine in Podgorica, which is a part of the state-owned University of Montenegro, provides tertiary education in the fields of medicine, dentistry, pharmacy, applied physiotherapy and nursing. It also offers PhD studies in medicine and dentistry, as well as specializations in the area of radiology and family medicine [36]. Secondary medical education in Montenegro is organized at seven vocational high schools (4-year program) that enroll approximately 600 students every year [37]. Health workers who have completed their studies are obliged to complete an internship and pass the professional exam before the committee appointed by the Ministry of Health [38]. Health workers who have graduated in the fields of medicine, dentistry and pharmacy, in addition to attaining the appropriate qualification and passing the professional exam, are obliged to have a license to practice [38]. The competent professional chamber issues a license for a seven-year period. Apart from the Ministry of Education of Montenegro, the Council for Higher Education, appointed by the Parliament of Montenegro, also plays a very important role in tertiary education development. In keeping with the law, the quality assurance activities in tertiary education are performed by the Agency for Control and Quality Assurance of Higher Education of Montenegro [39]. Ensuring and improving the quality of higher education is achieved through the processes of accreditation, self-evaluation, and re-accreditation. The professional development of health workers, according to the law [38], includes specialization, sub-specialization and continuous education.

DISCUSSION

Montenegro is a small country, whose population, just like in most EU countries, is aging. At the time of the PHC reform, the economic crisis (2008) influenced the reduction of health budgets in many EU countries, and they struggled to increase efficiency and the rational use of resources. At the time, the total expenditure on health as a percentage of gross domestic product was relatively low (as in the Czech Republic, Bulgaria, Cyprus) [25]. Maternal and child health indicators improved in the observed period reaching the levels of developed EU countries (Italy, Germany) [18],[19],[20],[21]. Major causes of disability adjusted life years, as well as life expectancy, were mostly at the levels matching those in the region (Romania, Macedonia) [40].

A reduction of the number of PHC doctors and other health professionals in Montenegro occurred in the period after 2008, when a number of countries (Ireland, Portugal) introduced cost containment measures, including the reduction of the number of health professionals and recruitment moratoriums [6],[8]. The experience of Greece in implementing ambitious health system strengthening reforms at the time of the economic crisis (2008) may serve as a warning, as it resulted in reduced coverage, which affected the country’s population [10]. It is obvious that Montenegro did not introduce the recruitment moratorium at the time, as the number of CDs constantly grew, from 2008 onwards. The rise in the density of CDs improved their availability, which is considered to be a prerequisite of effective coverage [4], but, at the same time, it may have undermined the “do more with less” reform concept [46]. However, it is obvious that, by the time of the COVID-19 pandemic, in 2020, Montenegro had strengthened the availability of health personnel, especially CDs working as GPs for adults, which probably increased the overall health system resilience.

In Montenegro, in 2015, the reported density rate of GPs per 100,000 was among the lowest in Europe [34]. The rate referred to doctors by their medical specialty (and not by their place of work). As already pointed out, in Montenegro, in the reformed model, doctors of different medical specialties can work as CDs for the adult population (such as doctors specializing in emergency medicine, internal medicine, occupational medicine, family medicine, etc.). Therefore, if observed by the place of work, the density of CDs working as GPs for the adult population in Montenegro is expected to be higher than reported, which explains the rate obtained in this study.

Apart from an insufficient size of the workforce, inequity in its distribution has been identified as a barrier to achieving universal health coverage (UHC) [7]. The inequalities in the availability of health workers were the greatest in the biggest municipalities in the central region of Montenegro (Podgorica, Nikšić), which, among other factors, might have been influenced by internal migrations. Positive net migration is the highest in the central region, especially in the capital – Podgorica [35]. Furthermore, the reduction in the number of health personnel during the reform may have influenced additional geographical imbalances. Lately, internal migration has been observed from the public to the private sector [11], however, there is no data to support this observation or to get more detailed insight into the profile of health professionals leaving the public sector.

Municipal accessibility was not compromised by the reduction of health personnel during the reform period, however, there were great variations between municipalities. Unlike our results, other studies found that larger and wealthier urban areas had higher health personnel accessibility, as compared to rural areas [7],[36]. The rural – urban accessibility issues, in terms of both providers and services, have been noted in other countries [7], with strong political commitment needed for changes (resources, legislation, etc.). Utilization of health services reflected the changes and the reduction in the number of health personnel in 2008 (mostly pharmacists and dentists), as well as in the following years. As of 2009, utilization of health services was stable and constantly rising, indicating positive changes in terms of PHC accessibility, provision of services, and cost containment. Increased utilization can partly be explained by the benefits of reform, in terms of the following: new model of organization at the PHC level, reduced waiting times, renewed facilities, an introduced wider scope of PHC services, etc. Additional research is needed to explore whether the new model generated more short visits (prescriptions for chronic patients, sick leave forms, etc.), which might have additionally increased the overall utilization.

Health personnel acceptability in the reform period decreased, as a result of health personnel reduction, and in 2015, it reached the set norm in the departments for adults and children, while the ratio for women was somewhat higher [33]. Due to scarce data, it was not possible to determine whether the set skill mix was maintained in the years after 2015.

The development of an adapted and unique approach to the education of PHC health workers, tailored to their specific needs, is one of the major accomplishments of the reform. Legislation changes in the early stage of the reform (eleven new laws were adopted or amended) supported the implementation of national mechanisms regarding the regulation of health professions, licensing mechanisms of health professionals, and quality. Consequently, “the project had particular impact on the quality and reliability of primary care” [5].

As for the sustainability of the reform, the model of providing PHC services founded on CDs at the PHC level remains in place, as well as the legal framework defining national staffing. While there was a reduction in the total number of doctors, between 2008 and 2012 (transfer of dentists from the public sector to the private, early retirement schemes, etc.), at the same time there was an increase in the number of CDs, so that the greatest part of health care needs could be met at the PHC level. Fluctuations of the density rates for both doctors and nurses, during the reform years and later, reflected the challenges in maintaining the total number of health care personnel (potentially: external migrations, inadequate planning of human resources, migrations from the public to the private sector). Bearing this in mind, in addition to the low density of GPs in Montenegro, human resources at the PHC level also require special attention of the health authorities, so that the provision of services at this level should not be compromised. With regard to the newly available data, we can see that, in the post-reform period, the growing density of health personnel (both CDs and nurses) has constantly increased their availability and, probably, their acceptability. The experience of the recent health crisis points out the need for providing sufficient human resources that would be able to act and ensure rapid response in crisis situations [10]. However, we could ask the difficult question as to whether the health workforce will be “fit for purpose”, i.e., capable of meeting the rising needs of an aging population. Certain changes, in terms of PHC organization and further quality improvement of the health personnel, would be necessary, such as task shifting, redefining of the role of nurses [11], continuous medical education, etc.

This study examined four dimensions of health personnel, only in PHC facilities, although the private sector was relatively undeveloped at the time. It is assumed that health professionals in the public sector were working full time at their place of employment, with no data on being multi-employed. The examination of the health workforce at the national level did not capture all the health personnel structures. In addition, the Registry of Human Resources for Health in Montenegro has not been established, which has made research more demanding. Data sets and reporting have not been modified after the reform, in keeping with the new organizational model. Additional research is needed to further examine changes in the availability of doctors in PHC departments for children and for women, in the context of coverage of the most vulnerable groups. The study would benefit from further research exploring the real experiences of users of health care services during the reform process and after the reform was completed.

CONCLUSION

Reform of the PHC in Montenegro radically changed health care staffing, organization and competencies. The reform responded to uncontrolled employment of health personnel from the previous period and introduced national staffing norms in new organizational units. New organization and the introduction of the CD model resulted, among other things, in a rise in the availability of GPs and in higher utilization of health services for adults, in upgraded professional competencies of CDs, as well as in maintaining the PHC as the dominant provider of health services at the primary level of health care. The reform resulted in strengthened availability of health personnel before the COVID-19 pandemic, in 2020, which most probably increased the overall health system resilience in Montenegro. Inequalities in accessibility are evident across municipalities and demand constant monitoring due to strong migratory movements of the population, within the country and abroad. Bearing in mind the rising needs of the aging population, changes in terms of the organization of PHC, as well as further quality improvement of health personnel, would be necessary. Human resources at the PHC level require special attention of the health authorities, so that provision of services at this level should not be compromised. It is recommended that a permanent body should be established to continuously monitor the functioning of primary health care, as well as the changes occurring within the PHC.