1. Financing PHC in Kazakhstan

2. 5 10 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
International Comparison as % GDP on Health
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
East Kazakhstan
Akmola
Kzylorda
South Kazakhstan
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
Kostanai
Akmola
Atyrau
Mangistau
Almaty City
Pavlodar
Aktobe
Zhambyl
Almaty
Astana City
Kyzyl-Orda
Karaganda -5
West Kazakhstan
East Kazakhstan
North Kazakhstan
Sout Kazakhstan
Republic of Kazakhstan
-10
-15
-20
Area

6. 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.

7. 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.

8. What drives outcomes?

9. 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 25 R = 20 15 10 5 - 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 - 20 40 60 80
100
120
MMR per 100,000

11. Does infrastructure matter?

12. Infrastructure and IMR
Total number of FAPs is positively associated with lower levels of IMR and …
IMR vs. Total # FAPS
700
600
500
# FAPS
400
300
200 2 R =
100 5 10 15 20 25 30
IMR

13. IMR and Medical/Obstetric Units
700
600
500
400
# Units
300
…similar results in terms of medical/obstetric units---better access means fewer infant deaths.
200 2 R =
100 5 10 15 20 25 30
IMR

14. IMR vs. Beds per 10,000 R Bed / 10,000 IMR 2
120
100 2 R = 80
Bed / 10,000 60
IMR is negatively correlated with beds per 10,000. This means that more beds is associated with a higher IMR 40 20 5 10 15
IMR 20 25 30

15. 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.

16. Challenges to Health Systems:
Conceptual Framework
Final Goals
Intermediate Goals
Means A B C
Equity &
Access
Health
Status
Changes in:
Regulation
Financing-
Pooling
Purchasing
Delivery
Models
Effectiveness
Quality
Financial
Risk
Protection
Financial
sustainability
Efficiency &
Productivity
Social
responsive
ness
Satisfaction

17. 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.

18. 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.

19. 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.

20. 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.

21. 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.

22. Recommendations Towards Strengthening PHC

23. Challenges to Health Systems:
Conceptual Framework
Final Goals
Means
Intermediate Goals A B C
Changes in:
Regulation
Financing-Pooling
Purchasing
Delivery Models
Equity &
Access
Health
Status
Effectiveness
Quality
Financial
Risk Protection
Financial
sustainability
Efficiency &
Productivity
Social
responsiveness
Satisfaction

24. 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.

25. 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.

26. 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.

27. 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.