Health Reform in Kazakhstan: problems and solutions

1
Health Reform in Kazakhstan problems and
solutions

• Meruert Rakhimova, MD, MPH
• UNFPA Kazakhstan
• 02.11.2006

2
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

3
The Republic of Kazakhstan
4
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.)

5
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

6
Life Expectancy at Birth, 1995 - 2003
7
Crude death rate per 1,000 persons
10,5
10,4
10,2
10,2
10,2
12
10,1
10,1
10
9,8
9,7
9,5
9,2
10
8,1
8
8
6
4
2
0
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
8
Major Causes of Mortality(1992-2004, per 100,000
persons)
9
Health System in KZ
Policy Administration Control


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Health System Generic Functions

• Management/monitoring
• Financing
• Service provision
• Resources mobilization

11
Challenges to Health Systems Conceptual
Framework
Intermediate Goals
Final 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
12
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

13
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

14
Total Health expenditure as of GDP

• Goal 4 of GDP by 2010

15
International Comparison as GDP on Health
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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

17
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

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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

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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

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The 2005-2010 Health Reform
Towards competitive Kazakhstan, competitive
economy, competitive nation! (N. Nazarbaev, 2004)

• 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.

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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
• 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

22
The 2005-2010 Health Reform

• Stage 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  

23
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.

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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 childrens hospital, first
  clinical/research center for treatment of
  HIV/AIDS.

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Health Care Management
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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
Local health management bodies Province Health
Departments

• 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)

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

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Guaranteed Basic Benefit Package
Primary Health Care
In-Patient Care (emergency and planned)
Prevention Promotion of healthy
lifestyle vaccinations medical examinations
with some social diseases (TB, cancer, necrology,
psychiatry, diabetes etc.)
Referral by PHC staff
Drug provision under the list of essential drugs
Regulation of length of stay
Able population (18-63 years-old)
Children
Socially vulnerable groups
Diagnostics
Children under 5
Treatment of patients in in-patient replacement
facilities
  Except
with some chronic diseases recorded in D
registrar (50)
Beneficial drug provision to patients
Medical rehabilitation
Treatment of diseases related to unhealthy
lifestyles, irresponsible attitude towards
preventive medical examinations and dispensary.
Dispensary of chronic patients
pregnant with anemia and iodine deficiencies
Special care at referral by PHC staff
Highly specialized and rehabilitation care
emergency care, medical rehabilitation, medical
care in disasters, health care for HIV/AIDS
patients
For emergency care
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Health Care Quality Control
2005 2010
2004

• 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 doctors responsibility

• Review and evaluation of the quality of medical
  services and a study of peoples 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

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Health Financing
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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 provinces.
• 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 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.

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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)

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Why Push for PHC?
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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

• Palliative
• Pain management
• Other symptoms
• Coordination/Referrals
• Nursing home care
• Hospice

Dx and Therapeutic
Rehab
Preventive

• Rehabilitation
• Coordination/Referrals
• Alcohol and drug
• Physical therapy
• Occupational therapy
• Specialty referrals
• Convalescent care

• Preventive Services
• Screening
• Risk factor identification mgt.
• Immunization
• Well child care
• Prevention counseling
• Family Planning

Palliative
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PHC Reform
As percentage of the health services financing
2004
In-patient care
PHC
PHC
In-patient care
2010
37
Challenges to Health Systems Conceptual
Framework
Intermediate Goals
Final 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
38
Assessing overall performance

• Distribution of funds not allocated according to
  population needs.
• 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.

• Equity and Access

39
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.

40
Assessing overall performance

• 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

41
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

42
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 programsschool
  healthto improve information and education.

• Satisfaction and community participation

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RecommendationsTowards Strengthening PHC
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Challenges to Health Systems Conceptual
Framework
Intermediate Goals
Final 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
45
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

46
Towards strengthening PHC

• 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
• 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

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Towards strengthening PHC

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

• Purchasing

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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

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Bibliography

• 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