Financing PHC in Kazakhstan

1
Financing PHC in Kazakhstan
2
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
Moldova
Uzbekistan
Kyrgyzstan
Kazakhstan
5
10
Azerbaijan
15
2001
3
Total and Per Capita Spending
Total and MCH Spending Per Capita 2002
50.0
45.0
40.0
35.0
30.0
25.0
20.0
15.0
10.0
5.0
0.0
South Kazakhstan
East Kazakhstan
Akmola
Kzylorda
National Estimate
Per Capita Spending (US)
MCH Per Capita Spending (US)
4
Differences in Per Capita Spending
Regional Variation in Per capita spending (US)
30
25
20
15
/- from Mean P.C. Spending
10
Dif from Mean
5
0
Akmola
Almaty
Atyrau
Aktobe
Kostanai
Pavlodar
Zhambyl
Mangistau
Almaty City
Karaganda
Astana City
Kyzyl-Orda
-5
East Kazakhstan
Sout Kazakhstan
North Kazakhstan
West Kazakhstan
Republic of Kazakhstan
-10
-15
-20
Area
5
(No Transcript)
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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 oblasts.
• Budget structure does not allow for the clear
  separation of primary care expenditures, versus
  secondary and hospital care.

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Main findings on the financing and budgeting study

• No common budget structure across oblasts leads
  to difficulty in comparing spending.
  
• Capital spending is very low and is crowded out
  by spending on salaries and other spending.
  
• Spending on drugs is not standardized to a unique
  formulary and drug prices are not referenced.

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What drives outcomes?
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IMR and Spending
Spending per capita is not allocated according
to need but has a small,
positive impact on IMR.
IMR vs. Per Capita Spending
45
40
35
30
Spending per capita
2
0.0029
R
25
20
15
10
5
-
0
5
10
15
20
25
30
IMR
10
MMR and Spending
with similar results in terms of MMR and
MMR v. Per Capita Spending (US)
45
40
35
Per Capita Spending (US)
30
25
20
15
10
5
-
0
20
40
60
80
100
120
MMR per 100,000
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Does infrastructure matter?
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Infrastructure and IMR
Total number of FAPs is positively associated
with lower levels of IMR and

IMR vs. Total FAPS
700
600
500
400
FAPS
300
2
200
0.1688
R
100
0
0
5
10
15
20
25
30
IMR
13
IMR and Medical/Obstetric Units
700
600
500
400
Units
300
200
2
R
0.1637
100
0
0
5
10
15
20
25
30
IMR
14
IMR vs. Beds per 10,000
120
100
2
R
0.0422
80
Bed / 10,000
60
40
20
0
0
5
10
15
20
25
30
IMR
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Conclusions

• Outcomes appear to be linked to elements that
  improve access to MCH services (more FAPS and
  more obstetric units).
  
• Outcomes in IMR/MMR/Anemia are not linked to
  financing or to inputs. In some cases, outcomes
  are worse where inputs are greater.
  
• Improved outcomes depend on better access and
  quality of care.
  
• Resource allocation formulas should to take into
  account a population needs based formula.
  

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Challenges to Health Systems
Conceptual Framework
Final Goals
Intermediate Goals
Means
C
A
B
Health Status
Equity Access

• Changes in
• Regulation
• Financing-
• Pooling
• Purchasing
• Delivery
• Models

Effectiveness Quality
Financial Risk Protection
Financial sustainability
Efficiency Productivity
Social responsive ness
Satisfaction
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Assessing overall performance

• Equity and Access

• Distribution of funds not allocated according to
  population needs.
  
• Equity in outcomes is limited as a very small
  of women in lowest income groups meet standards
  of care in key protocols
  
• In general people have access to health
  servicesbut
  
• 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.
  

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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.
  
• 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 EOC or
  lack of timely access to PHC.
  
• Outcomes are limited by problems with the
  management of programs thereby limiting
  effectiveness.
  
• MOH should develop improved capacity to monitor
  and evaluate the use of protocols at all levels
  of system.
  
• Very little activity related to promotion. PHC
  focused on minor palliative care.
  

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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.
  
• At current financing levels, it will be difficult
  to ensure access to a cost effective basic
  package and improve existing technological
  stock.
• 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.
• Problems with budgetary structure and reporting
  that makes it difficult to estimate national
  health accounts and make policy decisions
  regarding allocation of funds.

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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).
  
• Lack of solidarity in the financing model is
  highly inefficient at the macro level.
  
• Staff productivity is limited by a lack of
  equipment, drugs and supplies.
  
• There is very limited production and penetration
  on the key messages of the project or the health
  insurance fund.
  

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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).
  
• Nurses receive similar rankings with respect to
  physicians.
  
• Very limited community participation in the
  oversight and planning associated with local
  government.
  
• Need to introduce more outreach programsschool
  healthto improve information and education.
  

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RecommendationsTowards Strengthening PHC
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Challenges to Health Systems
Conceptual Framework
Final Goals
Intermediate Goals
Means
A
B
C

• Changes in
• Regulation
• Financing-Pooling
• Purchasing
• Delivery Models

Health Status
Equity Access
Effectiveness Quality
Financial Risk Protection
Financial sustainability
Efficiency Productivity
Social responsiveness
Satisfaction
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Towards strengthening PHC

• Regulation/policy

• MOH has to strengthen regulation over the quality
  of care.
  
• Important role of private sector in provision of
  drugs underscores the need for stronger
  regulation
  
• Seek initiatives to strengthen influence over
  direction of local governments
  
• Important standarize indicators across oblasts
• Encourage benchmarking among providers and
  Oblasts
  
• Need to take an active role in health education.
  
  

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Towards strengthening PHC

• Financing

• Introduce resource allocation formula that
  reflects the populations health needs and risks
  
• Attempt to strengthen the capacity of PHC and
  increase the per capita financing PHC/MCH
  
• Link transfer of funds and introduce performance
  based payment mechanisms that link funds to
  results.
  
• Efforts need to be made to reduce the financial
  burden for a basic package of services. This
  means that all services required to deliver the
  package are free of charge.
• Risk pooling at the national level is highly
  desireable.
  

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Towards strengthening PHC

• Purchasing

• The introduction of the purchasing function
  critical to orient resources and actions in the
  sector.
  
• Purchasing orients funds towards the populations
  priority health needs.
  
• Holds Oblasts and providers accountable for
  improvements in results.
  
• Introduces performance based payments.
• Strong monitoring and evaluation function related
  to productivity, quality and satisfaction.
  

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Towards strengthening PHC

• Delivery Model

• Need to orient PHC services to priority health
  problems and to design package of services that
  meets the populations health needs.
  
• This includes consultation, drugs, materials and
  all services NOT just one aspect.
  
• Examples of services organized around key
  population groups.
  
• Package of services includes entire spectrum of
  PHC not just palliative and curative.
  
• Initiate disease management approach which
  integrates protocols across levels of care.
  
• Wider use of care guidelines in PHC.
• Training in key areas to fill the knowledge gap.