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We don’t know if health system changes in eastern Europe have improved quality

BMJ 2012; 344 doi: (Published 25 June 2012) Cite this as: BMJ 2012;344:e3923
  1. Tomasz Tomasik, chair of internal medicine and gerontology, Department of Family Medicine, Jagiellonian University Medical College, 31-061 Krakow, Poland
  1. mmtomasi{at}

Twenty years have passed since the countries of eastern and central Europe began the substantial reorganisation of their health systems. The Soviet model had been centrally planned, government run, and oriented to hospital care. Universal coverage was an ideological priority, and the phrase “quality of care” was hardly used.

Central to the reforms was the implementation of family medicine. In countries such as Estonia, Lithuania, and Poland, district internists and paediatricians were retrained to become family physicians; in countries such as Slovakia and the Czech Republic they changed their titles to general practitioners for adults and general practitioners for children. This accompanied privatisation in healthcare provision and the disintegration of polyclinics into separate, smaller outpatient clinics. These changes seemed to the public to be well planned, and the objective of improving quality of care was commonly cited.

However, it is unclear whether this reorganisation has resulted in any improvement in quality in primary care. The international literature, according to a report by Polish researcher Małgorzata Bala1 on a European Commission Leonardo da Vinci vocational education and training project2 to improve the competencies of family physicians in quality improvement, has no examples of any successful quality improvement projects related to cardiovascular diseases from eastern and central European countries. The report focused on cardiovascular diseases because they are the major cause of morbidity and mortality (about half of deaths) in central and eastern European countries—which have higher rates than western European countries or the United States. Bala searched PubMed, EMBASE, journal websites, and the internet to find any quality improvement programmes concerning cardiovascular diseases in primary care in Europe. The search was limited to the English language. She identified no examples from former communist countries.

There are other sources of relevant information, such as the European Society for Quality and Safety in Family Practice (EQuiP)—a network organisation within the World Organization of Family Doctors (WONCA), European Region. Seven central and eastern European countries provide brief information about quality improvement activities in primary care,3 but this information relates only to topics such as accreditation, clinical guidelines, quality criteria in the management of type 2 diabetes mellitus, and educational activities. The European Observatory on Health Systems and Policies provides a comprehensive and rigorous analysis describing the mechanisms to improve quality of care and highlights the considerable variation within and between EU member states.4 Although this publication presents several initiatives in central and eastern European countries, they relate mainly to policy or to health systems, and it does not mention any specific projects, such as cardiovascular diseases, in primary care.

Searching the published literature in languages other than English is complex and costly. In Poland, medical journals do not publish much on quality improvement; a recent article by Pajak is an exception.5 Papers, reports, and descriptions of non-research activities are not often formally published, so searching the grey literature may be fruitful. The Leonardo da Vinci project mentioned above gives extensive case studies of quality improvement projects in Poland, Slovenia, and the Czech Republic.6 If reports of projects are published in English, more readers would have the opportunity to gain insight and to assess and comment on them.

Twenty years is too short a time for family physicians from central and eastern Europe to publish internationally on examples of quality improvement projects, whether or not these projects have been successful. Currently, after two decades of primary care transformation, only every third Polish citizen is under the care of his or her own family doctor. The remaining two thirds of the population still seek treatment by regional internists and paediatricians. No one knows how long it will take to finish the reorganisation in Poland.

General practitioners in central and eastern European countries should be aware of the importance of continuous improvement in the quality of care that they deliver to patients. The European community of family doctors supports the efforts of central and eastern European countries in the development of high quality primary care: the WONCA-Europe conference in September 2011 was held in Warsaw and the WONCA-World Conference in 2013 will be held in Prague. I hope that during international events, as well as in journals, successful quality improvement projects will be presented, and not only from western European countries, the United States, or Australia.


Cite this as: BMJ 2012;344:e3923


  • Competing interests: the author has completed the ICMJE uniform disclosure form at (available on request from the corresponding author) and declares: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years, no other relationships or activities that could appear to have influenced the submitted work.

  • Provenance and peer review: Not commissioned; externally peer reviewed.


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