Transcript Health Reform in Kazakhstan: problems and solutions

Health Reform in Kazakhstan:
problems and solutions
Meruert Rakhimova, MD, MPH
UNFPA 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
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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
12
10
8
8,1
9,2 9,5
10,2 10,4 10,1 9,8 9,7 10,1 10 10,2 10,5 10,2
8
6
4
2
0
19911992 19931994 19951996 19971998 19992000 20012002 20032004
Major Causes of Mortality
(1992-2004, per 100,000 persons)
600
500
400
300
200
100
0
Infectious
diseases
Oncologic
diseases
Corona
ry heart
disease
Respirat
ory tract
diseases
1992 2004
GI
tract
diseas
es
Accidents,
poisoning,
traumatism
other
Health System in KZ
Policy
Administration
Control
MINISTRY OF HEALTH
64 medical
institutions of
national scale
$
Province
Municipality
14
PROVINCE HEALTH
DEPARTMENTS
16
City
municipality
CITY HEALTH
DEPARTMENTS
Province medical
institutions
City medical
institutions
Health System Generic Functions
1.
2.
3.
4.
Management/monitoring
Financing
Service provision
Resources mobilization
Challenges to Health Systems:
Conceptual Framework
Means A
Intermediate Goals B
Equity &
Access
Changes in:
•Regulation
•Financing-Pooling
•Purchasing
•Delivery Models
Final Goals
C
Health
Status
Effectiveness &
Quality
Financial
sustainability
Financial
Risk Protection
Efficiency &
Productivity
Satisfaction
Social
responsiveness
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
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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
1,9
1999
2,1
2000
1,9
2001
1,97
2002
1.93
2003
2.08
2004
2.63
2005
2.4
2006
3.3
International Comparison
as % GDP on Health
Total health expenditure as % of gross domestic product GDP
Switzerland
Germany
France
Greece
Portugal
Malta
Netherlands
EU average
Israel
Sweden
Denmark
Italy
Norway
Nordic average
Slovenia
United Kingdom
Spain
Czech Republic
Finland
Hungary
Ireland
EUROPE
CSEC average
Slovakia
Lithuania
Estonia
Latvia
Belarus
Ukraine
CIS average
Republic of Moldova
Uzbekistan
Kyrgyzstan
Kazakhstan
Azerbaijan
0
5
10
2001
15
Health System in KZ before 2005
Services
Fragmented Primary
Health Care (PHC)
 Complicated
organizational structure of
hospitals and specialized
care facilities
 Access and quality of
services

Health System in KZ before 2005
Resources
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 costeffectiveness analysis
 Accountability status often unclear
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What was Good
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Academic training capacity in place
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Regulations (de juro) in place
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Decentralized structure of health sector
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Private practice allowed
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Private health insurance companies on the market
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Drug safety – rigorous drug registration; development of the
National Pharmacopoeia
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Critical mass of PHC providers trained and practicing
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Legal status conducive for practicing family medicine
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Family medicine recognized as specialty
The 2005-2010 Health Reform
Objectives:
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“Towards competitive Kazakhstan,
competitive economy, competitive
nation!” (N. Nazarbaev, 2004)
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.
The 2005-2010 Health Reform
2-stage process
Stage 1 – 2005-2007 – building a ground for long term
development of the health sector

setting up minimum standards for the guaranteed benefits
package;
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working with the population to promote healthy lifestyle;
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transferring focus from in-patient to primary health care;
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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 Reform
Stage 2 – 2008-2010 scaling up of stage 1.
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Introducing fundamental reform of the medical
education system;

Transforming PHC by strengthening the general
practice;
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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
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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
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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;
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78 children infected via (unnecessary) blood transfusion;
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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;
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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
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Delineation of functions and
authorities
Central executive body:
MoH
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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)
Local health management
bodies: Province Health
Departments
Control over providing
direct general services to
the population, licensing
of most types of medical
and pharmaceutical
activities, procurement of
drugs excluding vaccines

Health
organizations:
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
Guaranteed Basic Benefit Package
Prevention:
Promotion of
healthy lifestyle;
vaccinations;
medical
examinations
Diagnostics
Treatment of
patients in inpatient
replacement
facilities
Medical
rehabilitation
Dispensary of
chronic patients
Special care at
referral by PHC
staff
Ль го тн о е/Бе с п лBeneficial
атно е леdrug
кар provision
с тве н н оtoе patients
о бе с п е че ни е б о л ьн ых
Primary Health Care
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
For emergency care
In-Patient Care
(emergency and planned)
Referral by PHC staff
Drug provision under the list of essential drugs
Regulation of length of stay
Children
Able population
(18-63 years-old)
Socially
vulnerable
groups
Except
Treatment of diseases related to: unhealthy lifestyles,
irresponsible attitude towards preventive medical examinations
and dispensary.
Highly specialized and rehabilitation care; emergency care,
medical rehabilitation, medical care in disasters, health care for
HIV/AIDS patients
Health Care Quality Control
2005 – 2010
2004
•
•
•
•
•
•
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
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
Health Financing
Main findings on the financing
and budgeting study
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Resource allocation rules are not oriented to
population health needs and risk of illness.

Spending is not allocated to most cost-effective
interventions.
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No clear budgeting rules across provinces.
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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
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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.
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Spending on drugs is not standardized to a unique
formula and drug prices are not referenced.
Improvement of Funding System
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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)
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Why Push for PHC?
Scope of Primary Care Practice
Diagnostic & Therapeutic Care
 Acute care
 24 hr coverage
 Chronic disease management
 Prescriptions
 Psycho-social care
 Specialty referrals
 Worker health
 Home-based care
Preventive
Palliative
 Pain management
 Other symptoms
 Coordination/Referrals
 Nursing home care
 Hospice
Dx and
Therapeutic
25
Rehab
25
Preventive Services
 Screening
 Risk factor identification & mgt.
 Immunization
 Well child care
 Prevention counseling
 Family Planning
25
Rehabilitation
25
Palliative
o
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
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Coordination/Referrals
Alcohol and drug
Physical therapy
Occupational therapy
Specialty referrals
Convalescent care
PHC Reform
2004
As percentage of the
health services financing
In-patient care
83%
PHC
17%
PHC
40%
Стационар
ПМСП
In-patient care
60%
2010
Challenges to Health Systems:
Conceptual Framework
Means A
Intermediate Goals B
Equity &
Access
Changes in:
•Regulation
•Financing-Pooling
•Purchasing
•Delivery Models
Final Goals
C
Health
Status
Effectiveness &
Quality
Financial
sustainability
Financial
Risk Protection
Efficiency &
Productivity
Satisfaction
Social
responsiveness
Assessing overall performance
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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-ofpocket 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.
Equity and
Access
Assessing overall performance
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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.
Effectiveness
and Quality
Assessing overall performance
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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.
Financing and
sustainability
Assessing overall performance

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.
Efficiency and
productivity
Assessing overall performance

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.
Satisfaction and
community
participation
Recommendations
Towards Strengthening PHC
Challenges to Health Systems:
Conceptual Framework
Means A
Intermediate Goals B
Equity &
Access
Changes in:
•Regulation
•Financing-Pooling
•Purchasing
•Delivery Models
Final Goals
C
Health
Status
Effectiveness &
Quality
Financial
sustainability
Financial
Risk Protection
Efficiency &
Productivity
Satisfaction
Social
responsiveness
Towards strengthening PHC

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.
Regulation
policy
Towards strengthening PHC

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.
Financing
Towards strengthening PHC

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.
Delivery Model
Bibliography
1.
2.
3.
4.
5.
6.
7.
8.
State program on health reform 2005-2010, MoH, Astana,
2004.
MICS, 2006
MDGR, 2005
Mortality study, 2005
Kazakhstan InfoBase: national indicators
Access and quality of care in Kazakhstan, UNICEF,
UNFPA, 2005
The Dutch Model, N. Klazinga, D. Delnoij, I.K. Glasgow,
Univ. of Amsterdam, Dec. 2001, p.44
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