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 v v v Territory - 2, 724, 900 km 2 Population - 15, 233, 244 (July 2006 est. ) Population density – 5. 4 person / 1 km 2 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 v Life expectancy at birth (2006 est. ) total population: 66. 89 years male: 61. 56 years female: 72. 52 years v Infant mortality rate – 33. 5/1, 000 life births v 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 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)
Health System in KZ Policy Administration Control MINISTRY OF HEALTH 64 medical institutions of national scale $ Province Municipality City municipality 14 PROVINCE HEALTH DEPARTMENTS 16 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 v Unclear delegation of authority in /centralization – decentralization/ system v Fragmented and controversial legislation v Vertical control hinders integration of services v Complicated heterogeneous infrastructure v Poor capacity of health care managers v
Health System in KZ before 2005 Financing and assignations v v v 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
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 2001 10 15
Health System in KZ before 2005 Services Fragmented Primary Health Care (PHC) v Complicated organizational structure of hospitals and specialized care facilities v Access and quality of services v
Health System in KZ before 2005 Resources Poor planning of health institution staffing v Disastrous condition of health premises and utility supply in many provinces v Obsoleteness of medical equipment and inadequate maintenance v General scarcity of medications in hospitals v Standard clinical practice - protocols/guidelines not in use v
At a Glance Drugs are too expensive, sporadically available v General over-medicalization of care v 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 v Accountability status often unclear v
What was Good v Academic training capacity in place v Regulations (de juro) in place v Decentralized structure of health sector v Private practice allowed v Private health insurance companies on the market v Drug safety – rigorous drug registration; development of the National Pharmacopoeia v Critical mass of PHC providers trained and practicing v Legal status conducive for practicing family medicine v Family medicine recognized as specialty
The 2005 -2010 Health Reform Objectives: v v v “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 v setting up minimum standards for the guaranteed benefits package; v working with the population to promote healthy lifestyle; v transferring focus from in-patient to primary health care; v separating PHC from in-patient services both financially and administratively; v strengthening material/technical base of health facilities, primarily PHC; v 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. v Introducing fundamental reform of the medical education system; v Transforming PHC by strengthening the general practice; v 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 v 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 v v v 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 v Nosocomial pediatric HIV outbreak in South Kazakhstan – march 2006; v 78 children infected via (unnecessary) blood transfusion; v 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; v 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 v Improvement of health care quality control v Improvement of health financing system v Drug provision v Health Information System (HIS) v Training of pool of health care managers v
Delineation of functions and authorities Central executive body: Mo. H v v v 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 v 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: v Material and technical base strengthening v Distribution of funds saved by health facilities v Differentiated staff remuneration to ensure motivation and others
Guaranteed Basic Benefit Package Primary Health Care Prevention: Promotion of healthy lifestyle; vaccinations; medical examinations with some social diseases (TB, cancer, necrology, psychiatry, diabetes etc. ) In-Patient Care (emergency and planned) Referral by PHC staff Drug provision under the list of essential drugs Regulation of length of stay Able population (18 -63 years-old) Treatment of patients in inpatient replacement facilities Medical rehabilitation Dispensary of chronic patients Special care at referral by PHC staff Beneficial drug provision to patients Diagnostics Children under 5 Children Socially vulnerable groups with some chronic diseases recorded in D registrar (50%) pregnant with anemia and iodine deficiencies For emergency care 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 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 2005 – 2010 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 v Resource allocation rules are not oriented to population health needs and risk of illness. v Spending is not allocated to most cost-effective interventions. v No clear budgeting rules across provinces. v 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 v No common budget structure across provinces leads to difficulty in comparing spending. v Capital spending is very low and is crowded out by spending on salaries and other expenses. v Spending on drugs is not standardized to a unique formula and drug prices are not referenced.
Improvement of Funding System v Introduction of single payer in the face of local (province) authority v 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) v v v v
Why Push for PHC?
Scope of Primary Care Practice Diagnostic & Therapeutic Care l Acute care l 24 hr coverage l Chronic disease management l Prescriptions l Psycho-social care l Specialty referrals l Worker health l Home-based care Dx and Therapeutic Palliative l Pain management l Other symptoms l Coordination/Referrals l Nursing home care l Hospice Rehab Preventive Services l Screening l Risk factor identification & mgt. l Immunization l Well child care l Prevention counseling l Family Planning Rehabilitation Palliative o l l l 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 PHC In-patient care 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 v v v 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 v v v 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 Em. OC 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 v v v 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 v Overall trends in health status are not improving. v Hospitals do not appear to be operating efficiently in terms of producing maximum output with minimum input. v PHC services are not capturing patients in rural areas (at least 25% went directly to hospitals). v Staff productivity is limited by low salary, lack of equipment, drugs and supplies. Efficiency and productivity
Assessing overall performance v Satisfaction levels with care received are high (over 75% of all people very satisfied or satisfied with the doctor). v Very limited community participation in the oversight and planning associated with local government. v 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 v MOH has to strengthen regulation on quality of care. v Strengthen influence of local governments v Important to standardize performance indicators across provinces v Encourage benchmarking among providers and provinces v Need to strengthen health education and promotion. Regulation policy
Towards strengthening PHC v Introduce resource allocation formula that reflects the population’s health needs and risks v Attempt to strengthen the capacity of PHC and increase the per capita financing PHC v Link transfer of funds and introduce performance based payment mechanisms that link funds to results v Reduce the financial burden for a basic benefit package. v Risk pooling at the national level is highly desirable. Financing
Towards strengthening PHC v Orient PHC services to priority health problems and based on the top needs of population v Expand PHC package to other services - counseling, information sharing, promotion of healthy lifestyles, and not just palliative and curative care. v Standardize clinical care and encourage wide use of CPP/CPG at all levels of service delivery. v 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, Mo. H, Astana, 2004. MICS, 2006 MDGR, 2005 Mortality study, 2005 Kazakhstan Info. Base: 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
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