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

Ль

готн

ое/

Бе

сп

ла

тно

е л

ек

ар

ств

ен

но

е о

бе

сп

еч

ен

ие

бо

ль

ны

хB

enef

icia

l dru

g p

rovi

sion

to

pat

ien

ts

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