1. Mr. Aikan Akanov, Director of the Healthy Lifestyle Promotion Centre VII CARK MCH Forum Almaty, Kazakhstan 5 - 7 November 2003 Financing, Access, Quality and Outcomes in Primary Health Care: The case of the Republic of Kazakhstan

2. Agenda Overview of trends in health status: Kazakhstan and FSU countries Access and Quality in PHC Kazakhstan Financing primary health care in Kazakhstan What drives outcomes? Where do we go from here?

3. 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

4. Is Health Sector Contributing to Achievement of MDG Goals?

5. Reaching the Millennium Development Goals?

7. Discrepancy of IMR Data: Official and Independent Studies Official Statistics indicates the Infant Mortality Rate at 18 per 1,000 live births. While the Demographic and Health Survey indicates 62 per 1,000 live births. This could be explained by use of different live birth definitions.

8. Under 5 mortality

9. Under Five Mortality Structure

10. Deaths from injuries in childhood (age 0-14) Source: WHO Kazakhstan Lithuania Russia Ukraine Uzbekistan Death rate/100,000 20 25 30 35 40 45 50 55 60 19801985199019952000

11. Preventive and Diagnostic Services Are Limited Probable increase in incidence, reflecting rise in STDs Failure of screening programmes Lots of Pap smears –Inadequate training –Inadequate quality control –Inadequate follow up Age standardised death rate, cancer of the cervix, age 0-64, per 100,000 Kazakhstan Cervical cancer – a combination of factors

12. Scope of Primary Care Practice Palliative Rehab Dx and Therapeutic Preventive Palliative Pain management Pain management Other symptoms Other symptoms Coordination/Referrals Coordination/Referrals Nursing home care Nursing home care Hospice Hospice RehabilitationCoordination/Referrals Alcohol and drug Alcohol and drug Physical therapy Physical therapy Occupational therapy Occupational therapy Specialty referrals Specialty referrals Convalescent care Convalescent care Preventive Services Screening Screening Risk factor identification & mgt. Risk factor identification & mgt. Immunization Immunization Well child care Well child care Prevention counseling Prevention counseling Family Planning Family Planning Diagnostic & Therapeutic Care Acute care Acute care 24 hr coverage 24 hr coverage Chronic disease management Chronic disease management Prescriptions Prescriptions Psycho-social care Psycho-social care Specialty referrals Specialty referrals Worker health Worker health Home-based care Home-based care

13. Access and Quality of PHC

14. Objectives of the Study on Access to and Quality of PHC Services How do patients use the network of facilities, including the evaluation of the capacity of primary health care facilities? Is the use of appropriate treatment protocols and the knowledge of providers and patients adequate to contribute to reductions in infant and maternal mortality? Does the need to pay for pharmaceuticals and other out- of-pocket payments contribute to problems with access to appropriate services?

15. Geographic Access to PHC

16. Geographic Access

17. Financial Access

18. Percent of patients paid for the treatment PHCHospital Average payment – 2,011 KZTAverage payment – 6,630 KZT

19. Average Cost of Hospital Treatment Compared to Percent of People’s Monthly Income % of income Average monthly income

20. Average Cost of PHC Treatment Compared to Percent of People’s Monthly Income % of income Average monthly income

21. % of patients that paid for treatment in the hospital (hospital, consult, medications, analysis and other)

22. Referral

24. Readiness to Pay for Services

26. Attitude Toward Health Insurance

27. Pregnant woman who received antenatal care

28. …and how does this compare with protocol 6 or more = 47%

29. During the pregnancy, were you given or did you buy iron tablets/ injections?

30. % Procedures been done at least once to all adult members of your household by level of income

31. 3730.1 2419.5 3730.1 4435.8 6048.8 4435.8 3427.6 118.9 123100.0 Q-321 Referral hospital/women's clinic Q-321 Medicines to lower blood pressure Q-321 Diuretics provided Q-321 Management strategy Q-321 Blood pressure taken Q-321 Pulse taken Q-321 Diuresis Q-321 Deep tendon reflexes q321-eclampsia procedures Total CountColumn % Quality of Care: Use of Protocols

32. Knowledge of STIs/HIV prevention methods?

33. IMCI knowledge

34. Financing PHC in Kazakhstan

35. International Comparison as % GDP on Health

36. Total and Per Capita Spending

37. Differences in Per Capita Spending

39. 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.

40. 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.

41. What drives outcomes?

42. IMR and Spending Spending per capita is not allocated according to need but has a small, positive impact on IMR.

43. MMR and Spending …with similar results in terms of MMR and…

44. Does infrastructure matter?

45. Infrastructure and IMR Total number of FAPs is positively associated with lower levels of IMR and …

46. IMR and Medical/Obstetric Units …similar results in terms of medical/obstetric units---better access means fewer infant deaths.

47. IMR vs. Beds per 10,000 IMR is negatively correlated with beds per 10,000. This means that more beds is associated with a higher IMR

48. 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.

49. 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

50. 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 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.

51. 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.

52. 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.

53. 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.

54. 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 programs—school health—to improve information and education.

55. Recommendations Towards Strengthening PHC

56. 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

57. 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.

58. 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/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.

59. 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. Holds Oblasts and providers accountable for improvements in results. Introduces performance based payments. Strong monitoring and evaluation function related to productivity, quality and satisfaction.

60. Towards strengthening PHC Delivery Model Need to orient PHC services to priority health problems and to design package of services that meets the population’s 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.