1. Approaches to developing the master-plan for the development of the outpatient service network Ministry of Health and Social Development of the Republic of Kazakhstan RSE «Republican Center for Health Development» Deputy Director General Nagima M. Issatayeva

2. Social development trends (WHO) Environmental changes, influence of hazardous factors Growing expectations: provision of greater accessibility, quality improvement of medical service delivery, advancement of education, development of information support Discrepancy between the problems and the medical service delivery models Overuse, underuse and misuse of medical services The limitations of the healthcare system’s structure and functions, which lead to inefficiency and inequality of medical service delivery Demographic shift towards “ageing”, increasing life expectancy Growth of non-communicable diseases (coronary, oncological, etc, which are the causes of mortality in 87% of cases) Emergence of new infectious diseases (HIV/AIDS, Ebola and other viral infections), caused by environmental changes, population migration Uncoordinated medical service delivery schemes Focus on inpatient care Neglecting preventive and social care 2

3. Government’s and society’s approaches, modern management Coordination and integration of medical service delivery Financial protection Regulation of incentives Generating resources finances management medical service delivery resource strengthening POPULATION Strengthening the focus on the person at the center of the system by 2020 (WHO) 3

4. Why is PHC in need of updating and why is it relevant nowadays more than ever?. PHC Efficiency requirements of the modern healthcare system Cost-intensive inpatient care Globalisation produces social tension Disease and risk factor prevention 4

5. Only 1/3 of all medical care is provided at the PHC level, 2/3 are provided in the hospital sector Overspecialisation: around 50% of physicians at outpatient clinics are specialised doctors Patients are referred to specialised doctors in 30-40% of all cases (compared to 10-12% in international practice)  insufficient attention towards the actual needs of the population;  irrational use of resources (human, financial, materials and equipment);  inadequate labour process arrangement;  insufficient qualifications of PHC doctors;  tendency towards high specialisation of doctors in outpatient clinics;  lack of accountability for patient outcomes  lack of motivation for continuing professional development: low wages and other socioeconomic issues PHC specifics and limitations in Kazakhstan 5

6. International trends in medical services planning  transition from cost-intensive inpatient care to outpatient care  fulfilling the population’s needs for accessibility of medical care  enhancing general medical practice  transition from focusing on the volume of medical services to focusing on their quality  continuing professional development of doctors, leading to improvement of quality of their work  expanding the focus on prevention in healthcare 6

7. The following issues need resolving prior to planning The role of specialised care in PHC based on developing family medicine; Specifying which specialist services are to be provided in hospitals, consultation & diagnostic clinics, PHC/general medical practice; Strengthening the role of general practitioners as the coordinators of care and the first contact in the PHC system; Increasing the competency of general medical practitioners: improving the education and conversion training for general medical practice and general medical practice nursing; PHC in rural areas: motivation, salaries’ appeal 7

8. The principles of planning An approach based on the needs of population: a patient-oriented approach instead of a delivery-oriented one; Timely access to medical care for all; Focus on improving access to medical care for rural population in the context of ageing and chronic diseases; Safe and high-quality PHC services, provided in accordance with international standards of medical care; Equitable distribution of resources between PHC and the hospital sector; Stable financing terms, regulating the provision of services according to existing resources. 8

9. The components of planning The network of medical organizations GEOGRAPHICAL ACCESSIBILITY OF MEDICAL SERVICES Travelling time THE NEEDS OF THE POPULATION Morbidity and mortality SERVICE PACKAGE Clinical guidelines and standards Efficiency New technology PERSONNEL Number of personnel and distribution of authority 9

10. The approach to planning the PHC network Population according to 1999, 2009 and 2013 Censuses Analysis of existing infrastructure according to the typology and performance indicators: year built, % of depreciation 2030 Population projection according to the official projections by the Committee on Statistics Planning the service areas of outpatient care organisations: Medical stations (MS), Feldsher & Midwife stations (FMS), Medical Ambulatories (MA), Family Medicine Centers (FMC), Rural Polyclinics (RP), District (“Rayon”) Polyclinics (DP), City Polyclinics (CP) - using district maps for estimating distances, geographic specifics and the location of existing infrastructure preserving the existing type of organisation expanding or merging outpatient care organisations Attracting investments in the public-private partnership, trust management and privatisation instruments usage planning the renovation, reconstruction or construction of a new building 10

11. Assessment of the PHC infrastructure Proposed area of new PHC organisations based on the best international standards GP service area Locality Existing medical organisation Year built Type of building % of depreciation Population 2030 Proposed type of medical organisation Recommended investments Period Priority 1ZhanakorganFMC\D P 1970Adapted6030,51 0 DFMCConstructi on Medium- term High 2 TutiskenMA1983Adapted76,145,291CFMCReconstruc tion Medium- term High AkkumMS2003Adapted3,33717MSRenovatio n Long- term High KauykMS2003Adapted3,3384-- 3 BirlikMA1967Standardi sed 03,386CFMC Reconstruc tion Medium- term High Birlik/Kyras h FMS Kyzylmaktas hy 1,338MS Constructio n Short- term High 4 BesarykMA2009Standardi sed 0,072,491MA RenovationLong- term Medi um Apapkak 5ZhanarykMA1983Standardi sed 72,886MA Reconstruc tion Medium- term Medi um 6KelintobeMA1981Standardi sed 425,201CFMC Reconstruc tion Medium- term High 7BapspakkolMA1985Adapted1002,504MA Constructio n Short- term High 8KozhakentMA1988Standardi sed 44,974,364CFMC Reconstruc tion Medium- term High 9AbdigaparMA1980Standardi sed 02,933MA Reconstruc tion Medium- term Medi um Korasan-- 10SunakataMA1994Adapted9,912,473CFMC Reconstruc tion Medium- term High YekpindyFMS1988Standardi sed 801,393MS Constructio n Short- term High YenbekMS2002Adapted11,053MS RenovationLong- term High 11TakyrkolMA1970Adapted102,947MA Reconstruc tion Medium- term Medi um Type of organisaton Population min. Population max. Area min., km2 Area max., km2 MS 3001,50077125 MA 1,2013,000144187 FMC 3,00115,00 0 4121,001 District FMC+FMPC 30,00 0 100,0 00 1,0403,385 City FMC+FMPC 30,00 0 150,0 00 1,0114,910 11

12. Conditions of proper functioning of PHC 1. Priority allocation of human, material and financial resources to PHC 2. Development and implementation of a dedicated system of training of physicians, nurses and social care workers for PHC organisations 3. Provision of effective measures aimed at promoting the profile of the service and selected workers, as well as building confidence in PHC among the wider population 4. Actively involving individuals and parts of the population in the PHC activity 12

13. Proportion of localities with population under 100 residents and under 300 residents 13 Proportion of population residing in under-100 and under-300 localities Examples

14. Planning the PHC structure on the basis of the standard rate of 1500 per 1 doctor as exemplified by the Osakar district 14 Examples

15. Proposed structure of the PHC network DenominationStandard rateTravelling time Medical station300-100015-30 minutes on foot GP office1500-2000 15-30 minutes by car (longer if above 2000) GP center/Medical ambulatory4 000-30 000 15-30 minutes within the locality, 15-30 minutes in other localities District GP center/District polyclinic (outpatient clinic) 30 000 - 50000 The distance – 60-80 kilometers or an hour of travelling by car; for longer distances – more than one center, if possible City polyclinic/City GP center/City GP clinic/type 1 30000 – 5000015-30 minutes on foot or by transport City polyclinic/City GP center/City GP clinic/type 2 50000 – 150000 15-30 minutes on foot or by transport 15

16. Success factors of the PHC reforms  legislation  arrangement of medical services (including trust management and privatisation)  improving the material assets (buildings and equipment)  implementing new treatment methods through clinical guidelines based on evidence-based medicine  increasing the human resources potential (doctors, nurses), specifying the service package provided by PHC 16

17. Thank you for your attention!