1. REFORMS IN THE HEALTH CARE FINANCING The development OF health insurance system in albania ELVANA HANA GENERAL DIRECTOR III Balkanic Forum, Montenegro – September 2009 REPUBLIC OF ALBANIA INSTITUTE OF HEALTH INSURANCE

2. Page  2 Financing fields:  Primary Health Care: 414 General and Specialized HC.  Hospital Health Care: 4 University Hospitals 12 Regional Hospitals 23 Municipal Hospitals  11 Unique tertiary examinations.  Drugs reimbursement from the Reimbursement List. 377 drugs or 944 trading alternatives.

3. Page  3 Main Issues I.Deepening in the Financial Reform of the Primary Health Care. Achievements and challenges. II.The extension of the financing scheme in the hospital health care. III.Strengthen of HII role as a main purchaser of the health services.

4. Page  4 BENEFITS FROM THE REFORM ON PHC Service Providers  Financial  Experience –Financial management –Management of H. Resources –Organization  Medications/medical stuff  Increase of service quality  Conditions for following C.M.E  Strengthen of HC role as gatekeeper. Insured persons  A better access to obtain health services;  Improvement of conditions to obtain better quality from the services.  Standardized services (Package of services)  Better monitoring regarding the chronic diseases.

5. Page  5 Reforms achievements in PHC  More founds were allocated to the HC as a consequence of the improvement of their performance and quality indicators.  The HC have a better conceptions regarding the management of the allocated founds.  The level of autonomy of the HC has increased. The contracts with HC have improved and the Boards function.  There have been improvement in the collection of the secondary incomes and better possibilities to manage them by the HC.  Improvement of the information technology  It is in process of implementation, supportive supervision, as a new methodology applied to help in solving the HC problems and improve their performance  HII has provided adequate support in the implementation of professional training programs for the service providers.

6. Page  6 The budget allocated to the HC in 2009 was 13% larger than in 2008

7. Page  7 Performance indicator (no of vizits / day) 2006 - 2009

8. Page  8 The Health Centers that have benefited over 80% of the financing for the realized performance indicator: In 2007 — 24 HC; in 2008 — 170 HC and on the first 6 m 2009 — 217 HC

9. Page  9 Quality indicators - Bonus 5%

10. Page  10 Health Centers that have benefited over 70% of the financing for the realized quality indicators: In 2008 — no HC and in the first 6 m of 2009 — 64 HC

11. Page  11 The Information Technology achieved:  The application of the standard form for the visits and medical procedures by the medical staff of the HC, which helps in: - reporting, monitoring and financing the Performance and Services quality - decision-making to increase the service quality  The electronic registration of the population and the application of the effective payments per capita (still in process)

12. Page  12 The extension of the financing reform in the hospital service What do we aim by the reforms in the hospital health care :  Change the method of financing. HII as an active purchaser  Autonomy of Hospitals, which consist of: –financial: existence of a separate budget, the right to propose it and to manage it financially. –organizational : relative independence to be self-organized –normative: the power to issue self-regulatory norms. –contractual freedom : the possibility to enter in relations freely with the others.

13. Page  13 Hospital legal status  The hospital is a legal person,  public,  un-budgetary,  non-profitable,  with a separate bank account,  provides medical services approved by the Ministry of Health.

14. Page  14 Funding of Hospitals by the Health Insurance HII Contributions of the active population Ministry of Health ISS – GDT (General Directory of Taxation) RDHCI (Branches of HII) Regional hospital District hospital Contracts Investments Transfers from the State Budget (non-Active ) Board

15. Page  15 The start of the reform in Hospital care in the January 2009 enabled:  Singing of the bilateral contracts with 39 hospitals : - 4 University hospitals - 12 Regional hospitals - 23 Municipal hospitals  Signing of individual contracts between director – staff (in process)  Financing by budgeting according to a Services List  Application of a new method of reporting for the hospital performance: - Clinical - Economic and financial

16. Page  16 (continuation)  Working for the calculation of the actual cost for each hospital according to the clinical services  Defining the cost structure according to the elements of expenditure  Working for the issuance of the actual cost per day/stay for each hospital  Defining of some elements for measuring the hospitals performance like bed utilization etc.

17. Page  17 Increase of HII role as an active purchaser requires: I. In the Primary Healthcare  Improvement of the level of autonomy of the HC. Deepening in the process of decentralization.  Efficiency on the information system utilization (the informatization of the HC across the country which is still in process of conclusion  pplication of a system with differential reward for differential work within the HC, depending on the individual fulfillment of the quantitative and qualitative indicators of the job.  Improvement of the method of HC financing to increase the level of their utilization and quality service. (Revision on the actual form of payment 85/ 10 / 5 of the HC’s budget)

18. Page  18 (continuation)  The cost calculation of the primary service.  Support in the process of drafting guidelines for clinical practice regarding the family doctors.  Implementation of incentive financial policies regarding the health coverage of the vulnerable categories of the population.

19. Page  19 II. In the hospital healthcare:  Improving the legal framework.  Improving the level of autonomy in the hospitals  Setting the standards for the costs calculation: - per service, - per diagnose case and diagnose group (DRG).  Approving standards for quality and performance indicators  Implementing a unique informative system  Approving of hospital treatment protocols.  Improving and implementing rigorously a referral system in all the health services levels.

20. Page  20 ( continuation )  Implementing a flexible payment system based on the performance of each provider.  Trainings of the hospital managers and hospital staff regarding the organizational, financial and technical issues.  Increase of access by the population to benefit services.  Reducing the level of informality in the services.  Promote privatization of specific services at all levels of health care.

21. Page  21 THANK YOU