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

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Financing, Access, Quality and Outcomes in Primary Health Care: The case of the Republic of Kazakhstan

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Financing access quality and outcomes in primary health care the case of the republic of kazakhstan l.jpg

Financing, Access, Quality and Outcomes in Primary Health Care:The case of the Republic of Kazakhstan

Mr. Aikan Akanov,

Director of the Healthy Lifestyle Promotion Centre

VII CARK MCH Forum

Almaty, Kazakhstan

5 - 7 November 2003


Agenda l.jpg

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?


Slide3 l.jpg

Challenges to Health Systems:

Conceptual Framework

Means

Intermediate Goals

Final 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


Is health sector contributing to achievement of mdg goals l.jpg

Is Health Sector Contributing to Achievement of MDG Goals?


Reaching the millennium development goals l.jpg

Reaching the Millennium Development Goals?


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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.


Under 5 mortality l.jpg

Probability of dying before

age

5

years per

1000

live births

60

50

Azerbaijan

40

Bulgaria

Czech Republic

France

Hungary

Kazakhstan

30

Russian Federation

Ukraine

United Kingdom

EU average

CARK average

EUROPE

20

10

0

Last Available

Under 5 mortality


Under five mortality structure l.jpg

Under Five Mortality Structure


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Deaths from injuries in childhood(age 0-14)

Death rate/100,000

60

55

50

45

Kazakhstan

40

Russia

35

Uzbekistan

30

Ukraine

25

Lithuania

20

Source: WHO

1980

1985

1990

1995

2000


Slide11 l.jpg

12

Lithuania

11

10

9

8

Ukraine

7

Russia

6

5

4

3

EU average

2

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

Preventive and Diagnostic Services Are Limited

Age standardised death rate, cancer of the cervix, age 0-64, per 100,000

Cervical cancer – a combination of factors

  • Probable increase in incidence, reflecting rise in STDs

  • Failure of screening programmes

  • Lots of Pap smears

    • Inadequate training

    • Inadequate quality control

    • Inadequate follow up

Kazakhstan


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Scope of Primary Care Practice

  • Diagnostic & Therapeutic Care

  • Acute care

  • 24 hr coverage

  • Chronic disease management

  • Prescriptions

  • Psycho-social care

  • Specialty referrals

  • Worker health

  • Home-based care

  • Palliative

  • Pain management

  • Other symptoms

  • Coordination/Referrals

  • Nursing home care

  • Hospice

Dx and Therapeutic

Palliative

Rehab

Preventive

  • Rehabilitation

  • Coordination/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


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Access and Quality of PHC


Objectives of the study on access to and quality of phc services l.jpg

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?


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Geographic Access to PHC


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Geographic Access


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Financial Access


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Percent of patients paid for the treatment

PHC

Hospital

Average payment – 2,011 KZT

Average payment – 6,630 KZT


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Average Cost of Hospital Treatment Compared to Percent of People’s Monthly Income

% of income

Average monthly income


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Average Cost of PHC Treatment Compared to Percent of People’s Monthly Income

% of income

Average monthly income


Slide21 l.jpg

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


Referral l.jpg

Referral


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Readiness to Pay for Services


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Readiness to Pay for Services


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Attitude Toward Health Insurance


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Pregnant woman who received antenatal care


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…and how does this compare with protocol

6 or more = 47%


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


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


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Quality of Care: Use of Protocols

q321-eclampsia

Q-321 Referral

37

30.1

Count

Column %

procedures

hospital/women's clinic

Q-321 Medicines to

24

19.5

lower blood pressure

Q-321 Diuretics provided

37

30.1

Q-321 Management

44

35.8

strategy

Q-321 Blood pressure

60

48.8

taken

Q-321 Pulse taken

44

35.8

Q-321 Diuresis

34

27.6

Q-321 Deep tendon

11

8.9

reflexes

Total

123

100.0


Slide32 l.jpg

Knowledge of STIs/HIV prevention methods?


Imci knowledge l.jpg

IMCI knowledge


Financing phc in kazakhstan l.jpg

Financing PHC in Kazakhstan


International comparison as gdp on health l.jpg

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

Slovakia

Lithuania

Estonia

Latvia

Belarus

Ukraine

CIS average

Republic of Moldova

Uzbekistan

Kyrgyzstan

Kazakhstan

Azerbaijan

0

5

10

15

2001

International Comparison as % GDP on Health


Total and per capita spending l.jpg

Total and Per Capita Spending


Differences in per capita spending l.jpg

Differences in Per Capita Spending


Main findings on the financing and budgeting study l.jpg

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.

Main findings on the financing and budgeting study


Main findings on the financing and budgeting study40 l.jpg

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.

Main findings on the financing and budgeting study


What drives outcomes l.jpg

What drives outcomes?


Imr and spending l.jpg

IMR and Spending

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


Mmr and spending l.jpg

MMR and Spending

…with similar results in terms of MMR and…


Does infrastructure matter l.jpg

Does infrastructure matter?


Infrastructure and imr l.jpg

Infrastructure and IMR

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


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IMR and Medical/Obstetric Units

…similar results in terms of medical/obstetric units---better access means fewer infant deaths.


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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


Conclusions l.jpg

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.


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Challenges to Health Systems:

Conceptual Framework

Means

Intermediate Goals

Final 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


Assessing overall performance l.jpg

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.

Assessing overall performance


Assessing overall performance51 l.jpg

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.

Assessing overall performance


Assessing overall performance52 l.jpg

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.

Assessing overall performance


Assessing overall performance53 l.jpg

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.

Assessing overall performance


Assessing overall performance54 l.jpg

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.

Assessing overall performance


Recommendations towards strengthening phc l.jpg

RecommendationsTowards Strengthening PHC


Slide56 l.jpg

Challenges to Health Systems:

Conceptual Framework

Means

Intermediate Goals

Final 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


Towards strengthening phc l.jpg

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.

Towards strengthening PHC


Towards strengthening phc58 l.jpg

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.

Towards strengthening PHC


Towards strengthening phc59 l.jpg

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.

Towards strengthening PHC


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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.

Towards strengthening PHC


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