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

1
Financing, Access, Quality and Outcomes in
Primary Health CareThe 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
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
Intermediate Goals
Final Goals
Means
A
B
C

• Changes in
• Regulation
• Financing-Pooling
• Purchasing
• Delivery Models

Health Status
Equity Access
Effectiveness Quality
Financial Risk Protection
Financial sustainability
Efficiency Productivity
Social responsiveness
Satisfaction
4
Is Health Sector Contributing to Achievement of
MDG Goals?
5
Reaching the Millennium Development Goals?
6
(No Transcript)
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)
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
11
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
12
Scope of Primary Care Practice

• Palliative
• Pain management
• Other symptoms
• Coordination/Referrals
• Nursing home care
• Hospice

• Diagnostic Therapeutic Care
• Acute care
• 24 hr coverage
• Chronic disease management
• Prescriptions
• Psycho-social care
• Specialty referrals
• Worker health
• Home-based care

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

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
PHC
Hospital
Average payment 2,011 KZT
Average payment 6,630 KZT
19
Average Cost of Hospital Treatment Compared to
Percent of Peoples Monthly Income
of income
Average monthly income
20
Average Cost of PHC Treatment Compared to Percent
of Peoples 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
23
(No Transcript)
24
Readiness to Pay for Services
25
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
Quality of Care Use of Protocols
Q-321 Referral
q321-eclampsia
37
30.1
Count
Column
hospital/women's clinic
procedures
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
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
38
(No Transcript)
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
Intermediate Goals
Final Goals
Means
A
B
C

• Changes in
• Regulation
• Financing-Pooling
• Purchasing
• Delivery Models

Health Status
Equity Access
Effectiveness Quality
Financial Risk Protection
Financial sustainability
Efficiency Productivity
Social responsiveness
Satisfaction
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
  servicesbut
• 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 programsschool
  healthto improve information and education.

55
RecommendationsTowards Strengthening PHC
56
Challenges to Health Systems Conceptual
Framework
Intermediate Goals
Final Goals
Means
A
B
C

• Changes in
• Regulation
• Financing-Pooling
• Purchasing
• Delivery Models

Health Status
Equity Access
Effectiveness Quality
Financial Risk Protection
Financial sustainability
Efficiency Productivity
Social responsiveness
Satisfaction
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 populations 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 populations
  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 populations 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.