Health Reform in Kazakhstan: problems and solutions Meruert Rakhimova, MD, MPH UNFPA Kazakhstan 02.11.2006
Dec 23, 2015
Health Reform in Kazakhstan: problems and solutions
Meruert Rakhimova, MD, MPHUNFPA Kazakhstan
02.11.2006
Presentation Outline
1. About Kazakhstan
2. Health system overview: ‘pros & cons’
3. Health reform: a menu for solutions – Policy & management– Health economics & financing – Services - primary health care (PHC)
4. Research interest
The Republic of Kazakhstan
The Republic of Kazakhstan
Territory - 2,724,900 km2 Population - 15,233,244 (July 2006 est.) Population density – 5.4 person / 1 km2 GDP (purchasing power parity) - $124.3 billion
(2005 est.) GDP (real growth rate) - 9.2% (2005 est.) GDP (per capita (PPP) - $8,200 (2005 est.)
The Republic of Kazakhstan
Life expectancy at birth (2006 est.) -total population: 66.89 years male: 61.56 years female: 72.52 years
Infant mortality rate – 33.5/1,000 life births
Maternal mortality rate – 80/100,000 life births
Life Expectancy at Birth, 1995 - 2003
Life Expectancy at Birth unit 1995 1996 1997 1998 1999 2000 2001 2002 2003
Total years 63.5 63.6 64 64.5 65.66 65.5 65.8 66 65.83
Female years 69.4 69.7 69.9 70.4 70.7 70.7 71.1 71.1 -
Male years 58 58 58.5 59 60.3 59.7 60.1 60.6 -
Crude death rate per 1,000 persons
9,510,2 10,4 10,1 9,8 9,7 10,1 10 10,2 10,5 10,2
9,28 8,1
0
2
4
6
8
10
12
19911992 19931994 19951996 19971998 19992000 20012002 20032004
Major Causes of Mortality(1992-2004, per 100,000 persons)
0
100
200
300
400
500
600
Infectious diseases
Oncologic diseases
Coronary heart disease
Respiratory tract diseases
GI tract diseases
Accidents, poisoning, traumatism
other
1992 2004
Health System in KZ
Province Municipality
MINISTRY OF HEALTH
14
PROVINCE HEALTH DEPARTMENTS
16
CITY HEALTH DEPARTMENTS
Province medical institutions
64 medical institutions of national scale
City municipality
City medical institutions
$
Policy Administration
Control
Health System Generic Functions
1. Management/monitoring
2. Financing
3. Service provision
4. Resources mobilization
Challenges to Health Systems: Conceptual Framework
Changes in:
•Regulation•Financing-Pooling•Purchasing•Delivery Models
Health Status
Equity &Access
Effectiveness &Quality
Financialsustainability
Efficiency &Productivity
Satisfaction
FinancialRisk Protection
Social responsiveness
Intermediate Goals Final GoalsMeans AA BB CC
Health System in KZ before 2005 Management/monitoring
Lack of strategic vision of how system should develop
Unclear delegation of authority in /centralization – decentralization/ system
Fragmented and controversial legislation Vertical control hinders integration of
services Complicated heterogeneous infrastructure Poor capacity of health care managers
Health System in KZ before 2005 Financing and assignations
Low financing of sector – as % of GDP and % of state budget subsidy (7.3%)
Irrational (not needs based) allocations Dubious criteria for allotment – package of
universally covered health services undefined Asymmetry in funding of different provinces –
poor provinces get low budgetary appropriation; Significant amount of direct cash payment –
burden for people, limiting access to services
Total Health expenditure as % of GDP
Goal – 4% of GDP by 2010
1998 1999 2000 2001 2002 2003 2004 2005 20061,9 2,1 1,9 1,97 1.93 2.08 2.63 2.4 3.3
International Comparison as % GDP on Health
0 5 10 15
SwitzerlandGermany
FranceGreece
PortugalMalta
NetherlandsEU average
IsraelSweden
DenmarkItaly
NorwayNordic average
SloveniaUnited Kingdom
SpainCzech Republic
FinlandHungary
IrelandEUROPE
CSEC average SlovakiaLithuania
EstoniaLatvia
BelarusUkraine
CIS averageRepublic of Moldova
UzbekistanKyrgyzstanKazakhstan
Azerbaijan
Total health expenditure as % of gross domestic product GDP
2001
Health System in KZ before 2005Services
Fragmented Primary Health Care (PHC)
Complicated organizational structure of hospitals and specialized care facilities
Access and quality of services
Health System in KZ before 2005Resources
Poor planning of health institution staffing Disastrous condition of health premises and
utility supply in many provinces Obsoleteness of medical equipment and
inadequate maintenance General scarcity of medications in hospitals Standard clinical practice -
protocols/guidelines not in use
At a Glance
Drugs are too expensive, sporadically available
General over-medicalization of care Changes in use of inputs not always
linked to long-term policy reforms
Eg. Medical equipment is often purchased without any needs assessment or cost-effectiveness analysis
Accountability status often unclear
What was Good
Academic training capacity in place Regulations (de juro) in place Decentralized structure of health sector Private practice allowed Private health insurance companies on the market Drug safety – rigorous drug registration; development of the
National Pharmacopoeia Critical mass of PHC providers trained and practicing Legal status conducive for practicing family medicine Family medicine recognized as specialty
The 2005-2010 Health Reform
Objectives:
To share responsibility for health between state and patient;
To shift health care delivery to PHC; To introduce new model of health management
and health information system (HIS); To strengthen maternal and child health; To control spread of socially significant
diseases; To reform medical education system.
“Towards competitive Kazakhstan, competitive economy, competitive nation!” (N. Nazarbaev, 2004)
The 2005-2010 Health Reform2-stage processStage 1 – 2005-2007 – building a ground for long term
development of the health sector setting up minimum standards for the guaranteed benefits
package; working with the population to promote healthy lifestyle; transferring focus from in-patient to primary health care; separating PHC from in-patient services both financially and
administratively; strengthening material/technical base of health facilities,
primarily PHC; establishing a system of independent audit to ensure quality
medical care
The 2005-2010 Health ReformStage 2 – 2008-2010 scaling up of stage 1. Introducing fundamental reform of the medical
education system; Transforming PHC by strengthening the general
practice;
A complete basic modernization of the health care system, staff trainings, implementation of new technologies, a management and quality control system and a unified information system
The improvement of coordination in health sector, and building a solid foundation for competitiveness in the health care system
Inter-sectoral approach to public health protection
National Coordination Council under the Government of Kazakhstan – multisectoral multidisciplinary body;
Wide use of mass media for promotion information on disease prevention and healthy lifestyles;
Involvement of civil society organizations (health organization associations, professional associations of physicians, patients) - feedback on quality of care and patient satisfaction, provision of independent expertise of health services, certification of specialists, accreditation.
The case to study – the lesson to learn
Nosocomial pediatric HIV outbreak in South Kazakhstan – march 2006;
78 children infected via (unnecessary) blood transfusion;
Fired – Minister of Health, head of Quality Control Committee, head of Rep. AIDS Center, head of local health department, mayor of SK province, head of local QCC;
New Blood Bank, new children’s hospital, first clinical/research center for treatment of HIV/AIDS.
Health Care Management
Improvement in Health Care Management System
Rational delineation of functions and authority
Improvement of health care quality control
Improvement of health financing system Drug provision Health Information System (HIS) Training of pool of health care managers
Delineation of functions and authorities
Implementation of national policy
Executive functions (implementation of actions ensuring equal access to basic services all over the country, setting up the standards of their provision, planning sector development, development of a regulatory framework)
Regulatory functions (control of policy implementation, control of implementation of national, sector programs, accreditation of health organizations, enforcement functions)
Central executive body: MoH
Local health management bodies: Province Health
Departments
Health organizations:
Control over providing direct general services to the population, licensing of most types of medical and pharmaceutical activities, procurement of drugs excluding vaccines
Independence in the issues of:
Material and technical base strengthening
Distribution of funds saved by health facilities
Differentiated staff remuneration to ensure motivation and others
Primary Health Care In-Patient Care (emergency and planned)
Treatment of diseases related to: unhealthy lifestyles,
irresponsible attitude towards preventive medical examinations and dispensary.
ChildrenAble population(18-63 years-old)
Socially vulnerable
groups
Except
Prevention:Promotion of healthy lifestyle;vaccinations;medical examinations
Diagnostics
Treatment of patients in in-patient replacement facilities
Medical rehabilitation
Dispensary of chronic patients
Special care at referral by PHC
staff
with some social diseases (TB, cancer, necrology, psychiatry, diabetes etc.)
Children under 5
with some chronic diseases recorded in D registrar (50%)
pregnant with anemia and iodine deficiencies
Referral by PHC staff
Drug provision under the list of essential drugs
Regulation of length of stay
Highly specialized and rehabilitation care; emergency care, medical rehabilitation, medical care in disasters, health care for
HIV/AIDS patients
Guaranteed Basic Benefit Package
For emergency care
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Health Care Quality Control
2005 – 20102004
1. National control
- quality indicators- standards- accreditation- overall monitoring (PHC, in-patient, polyclinics,
emergency care)
2. Internal control
- Standard quality provision of medical services- Ensuring compliance of medical services with
common protocols- Equipment of health facilities with the
automated management system under IIS
3. Independent expertise (NGO)- establishment of NGO network- involvement in certification of medical staff - increased doctor’s responsibility
• Review and evaluation of the quality of medical services and a study of people’s satisfaction with medical services
• Determination of compliance with services provided by the treatment standards used in the facility
• Medical services quality evaluation is restricted to medical facilities
• Proposals for rectification of defects of medical services are of advise character
• Internal quality control is not systematized and is not applied everywhere
• Coverage of quality control is limited to the in-patient level
Health Financing
Main findings on the financing and budgeting study
Resource allocation rules are not oriented to population health needs and risk of illness.
Spending is not allocated to most cost-effective interventions.
No clear budgeting rules across provinces.
Budget structure does not allow for the clear separation of primary care expenditures, versus secondary and hospital care.
Main findings on the financing and budgeting study
No common budget structure across provinces leads to difficulty in comparing spending.
Capital spending is very low and is crowded out by spending on salaries and other expenses.
Spending on drugs is not standardized to a unique formula and drug prices are not referenced.
Improvement of Funding System
Introduction of single payer in the face of local (province) authority
Providers – public and private health facilities Base salary increase for medical staff Introduction of national system of quality monitoring
and resource use efficiency Stimulation of voluntary health insurance Increasing attractiveness of the sector to private
investment Wide use of financial leasing Leveling of tariffs for similar medical services between
regions Payment per case treated (outcome based)
Why Push for PHC?
Scope of Primary Care Practice
25
25
25
25
Palliative
Rehab
Dx and Therapeutic
Preventive
PalliativePain managementOther symptomsCoordination/ReferralsNursing home care Hospice
Rehabilitation
o Coordination/Referrals Alcohol and drug Physical therapy Occupational therapy Specialty referrals Convalescent care
Preventive ServicesScreeningRisk factor identification & mgt. ImmunizationWell child carePrevention counselingFamily Planning
Diagnostic & Therapeutic CareAcute care24 hr coverageChronic disease managementPrescriptionsPsycho-social careSpecialty referralsWorker healthHome-based care
40%
60%
17%
83%
Стационар
ПМСП
PHC Reform As percentage of the health services financing
2004
2010
In-patient care
PHC
In-patient care
PHC
Challenges to Health Systems: Conceptual Framework
Changes in:•Regulation•Financing-Pooling•Purchasing•Delivery Models
Health Status
Equity &Access
Effectiveness &Quality
Financialsustainability
Efficiency &Productivity
Satisfaction
FinancialRisk Protection
Social responsiveness
Intermediate Goals Final GoalsMeans AA BB CC
Assessing overall performance
Equity and Access
Distribution of funds not allocated according to population needs.
In general people have access to health services…but…
Geographic access to well developed PHC is limited and forces many rural people into hospitals as first line provider.
Financial access is a problem. Out-of-pocket payments, many times in excess of a monthly salary, keep 20% of all patients from obtaining required medical care.
Access to quality medical services in rural areas is impeded as years of under investment have eroded the technical capacity of providers.
Assessing overall performance
Effectiveness and Quality
Observance of treatment protocols is limited. For example, only 50 % of all suspected cases of eclampsia had blood pressure taken.
No monitoring system in place to track adherence to standard CPP/CPG
Over 50 percent of the 62 percent of neonatal deaths could be prevented.
Many of the neonatal deaths are due to a problems in management of high risk births, lack of EmOC or lack of timely access to PHC.
Very little activity related to promotion. PHC focused on minor palliative care.
Assessing overall performance
Financing and sustainability
Overall level of financing health care in Kazakhstan is nearly the lowest in CAR and European countries. Most countries are spending over 5 percent of GDP
Maternal child health care services receive limited resources for true PHC.
Problems with risk pooling create a serious financial burden for the population. While majority of the population pays only a small amount per visit, hospitalization is a catastrophic risk.
Assessing overall performance
Efficiency and productivity
Overall trends in health status are not improving.
Hospitals do not appear to be operating efficiently in terms of producing maximum output with minimum input.
PHC services are not capturing patients in rural areas (at least 25% went directly to hospitals).
Staff productivity is limited by low salary, lack of equipment, drugs and supplies.
Assessing overall performance
Satisfaction and community participation
Satisfaction levels with care received are high (over 75% of all people very satisfied or satisfied with the doctor).
Very limited community participation in the oversight and planning associated with local government.
Need to introduce more outreach programs—school health—to improve information and education.
RecommendationsTowards Strengthening PHC
Challenges to Health Systems: Conceptual Framework
Changes in:•Regulation•Financing-Pooling•Purchasing•Delivery Models
Health Status
Equity &Access
Effectiveness &Quality
Financialsustainability
Efficiency &Productivity
Satisfaction
FinancialRisk Protection
Social responsiveness
Intermediate Goals Final GoalsMeans AA BB CC
Towards strengthening PHC
Regulationpolicy
MOH has to strengthen regulation on quality of care.
Strengthen influence of local governments
Important to standardize performance indicators across provinces
Encourage benchmarking among providers and provinces
Need to strengthen health education and promotion.
Towards strengthening PHC
Financing
Introduce resource allocation formula that reflects the population’s health needs and risks
Attempt to strengthen the capacity of PHC and increase the per capita financing PHC
Link transfer of funds and introduce performance based payment mechanisms that link funds to results
Reduce the financial burden for a basic benefit package.
Risk pooling at the national level is highly desirable.
Towards strengthening PHC
Delivery Model Orient PHC services to priority health
problems and based on the top needs of population
Expand PHC package to other services - counseling, information sharing, promotion of healthy lifestyles, and not just palliative and curative care.
Standardize clinical care and encourage wide use of CPP/CPG at all levels of service delivery.
Training in key areas to fill the knowledge gap.
Bibliography
1. State program on health reform 2005-2010, MoH, Astana, 2004.
2. MICS, 20063. MDGR, 20054. Mortality study, 20055. Kazakhstan InfoBase: national indicators6. Access and quality of care in Kazakhstan, UNICEF,
UNFPA, 20057. The Dutch Model, N. Klazinga, D. Delnoij, I.K. Glasgow,
Univ. of Amsterdam, Dec. 2001, p.44 8. Towards a sound system of medical insurance? Consumer
driven health care reform in the Netherlands: the relaxation of supply side restrictions and greater role of market forces, 2002