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.  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 Life Expectancy at Birth unit199519961997199819992000200120022003 Total years63.563.66464.565.6665.565.86665.83 Female years69.469.769.970.470.7 71.1 - Male years58 58.55960.359.760.160.6-

7. Crude death rate per 1,000 persons 9,5 10,2 10,4 10,1 9,8 9,7 10,1 10 10,2 10,5 10,2 9,2 8 8,1 0 2 4 6 8 10 12 19911992199319941995199619971998199920002001200220032004

8. Major Causes of Mortality (1992-2004, per 100,000 persons)

9. Health System in KZ Province Municipality MINISTRY OF HEALTH 14 PROVINCE HEALTH DEPARTMENTS 16 CITY HEALTH DEPARTMENTS Province medical institutions 64 medical institutions of national scale City municipality City medical institutions $ Policy Administration Control

10. Health System Generic Functions 1. Management/monitoring 2. Financing 3. Service provision 4. Resources mobilization

11. Challenges to Health Systems: Conceptual Framework Changes in: Regulation Financing-Pooling Purchasing Delivery Models Health Status Equity & Access Effectiveness & Quality Financial sustainability Efficiency & Productivity Satisfaction Financial Risk Protection Social responsiveness Intermediate GoalsFinal GoalsMeans ABC

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

16. 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

17. 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

18. 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

19. 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

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

21. 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.

24. 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 children’s hospital, first clinical/research center for treatment of HIV/AIDS.

25. Health Care Management

26. 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

27. Delineation of functions and authorities  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) Central executive body: MoH Local health management bodies: Province Health Departments 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

28. Primary Health CareIn-Patient Care (emergency and planned) Treatment of diseases related to: unhealthy lifestyles, irresponsible attitude towards preventive medical examinations and dispensary. Children Able population (18-63 years-old) Socially vulnerable groups Except Prevention: Promotion of healthy lifestyle; vaccinations; medical examinations Diagnostics Treatment of patients in in- patient replacement facilities Medical rehabilitation Dispensary of chronic patients Special care at referral by PHC staff 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 Referral by PHC staff Drug provision under the list of essential drugs Regulation of length of stay Highly specialized and rehabilitation care; emergency care, medical rehabilitation, medical care in disasters, health care for HIV/AIDS patients Guaranteed Basic Benefit Package For emergency care Beneficial drug provision to patients

29. 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 doctor’s responsibility 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

30. Health Financing

31. 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.

32. 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.

33. 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)

34. Why Push for PHC?

35. Scope of Primary Care Practice Palliative Rehab Dx and Therapeutic Preventive Palliative Pain management Other symptoms Coordination/Referrals Nursing home care Hospice Rehabilitation oCoordination/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 Diagnostic & Therapeutic Care Acute care 24 hr coverage Chronic disease management Prescriptions Psycho-social care Specialty referrals Worker health Home-based care

36. PHC Reform As percentage of the health services financing 2004 2010 In-patient care PHC In-patient care PHC

37. Challenges to Health Systems: Conceptual Framework Changes in: Regulation Financing-Pooling Purchasing Delivery Models Health Status Equity & Access Effectiveness & Quality Financial sustainability Efficiency & Productivity Satisfaction Financial Risk Protection Social responsiveness Intermediate GoalsFinal GoalsMeans ABC

38. Assessing overall performance Equity and Access  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-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.

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 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.  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.

41. 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).  Staff productivity is limited by low salary, lack of equipment, drugs and supplies.

42. 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).  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.

43. Recommendations Towards Strengthening PHC

44. Challenges to Health Systems: Conceptual Framework Changes in: Regulation Financing-Pooling Purchasing Delivery Models Health Status Equity & Access Effectiveness & Quality Financial sustainability Efficiency & Productivity Satisfaction Financial Risk Protection Social responsiveness Intermediate GoalsFinal GoalsMeans ABC

45. Towards strengthening PHC Regulation policy  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.

46. Towards strengthening PHC Financing  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.

47. Towards strengthening PHC Purchasing  The introduction of the purchasing function critical to orient resources and actions in the sector.  Purchasing orients funds towards the population’s 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.

48. Towards strengthening PHC Delivery Model  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.

49. Bibliography 1. State program on health reform 2005-2010, MoH, Astana, 2004. 2. MICS, 2006 3. MDGR, 2005 4. Mortality study, 2005 5. Kazakhstan InfoBase: national indicators 6. Access and quality of care in Kazakhstan, UNICEF, UNFPA, 2005 7. The Dutch Model, N. Klazinga, D. Delnoij, I.K. Glasgow, Univ. of Amsterdam, Dec. 2001, p.44 8. 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