Financing Access Quality and Outcomes in Primary Health Care The case of the Republic of Kazakhstan. Part II

Financing PHC in Kazakhstan Switzerland Germany France Greece Portugal Malta Netherlands EU average Israel Sweden Denmark Italy Norway Nordic average Slovenia United Kingdom Czech Republic Spain Finland Hungary Ireland EUROPE CSEC average Slovakia Lithuania Estonia Latvia Belarus Ukraine CIS average Moldova Uzbekistan Kyrgyzstan Kazakhstan Azerbaijan 5 10 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 Per Capita Spending (US$) MCH Per Capita Spending (US$) South National Kazakhstan Estimate Regional Variation in Per capita spending (US$) 30 25 +/- from Mean P.C. Spending 20 15 10 5 Dif from Mean 0 -5 -10 -15 -20 Area Structure of current local budget inЫегксегку ща текущих расходов In Akmola Oblast, health care, 2002, in % 25,9 Salary Nutrition 49,1 Drugs Supplies инвентарь, Utilities Building maintenance 4,7 5,2 2,6 10,9 3,8 Others Main findings on the financing and budgeting study • Resource allocation rules are not oriented to population health needs and risk of illness. • Spending is not allocated to most costeffective interventions. • No clear budgeting rules across oblasts. • Budget structure does not allow for the clear separation of primary care expenditures, versus secondary and hospital care. Main findings on the financing and budgeting study • No common budget structure across oblasts leads to difficulty in comparing spending. • Capital spending is very low and is crowded out by spending on salaries and other spending. • Spending on drugs is not standardized to a unique formulary and drug prices are not referenced. What drives outcomes? Spending per capita is not allocated according to need but has a small, positive impact on IMR. 45 IMR and Spending IMR vs. Per Capita Spending 40 Spending per capita 35 30 25 R= 0.0029 2 20 15 10 5 0 5 10 15 20 25 30 IMR MMR and Spending …with similar results in terms of MMR and… MMR v. Per Capita Spending (US$) 45 Per Capita Spending (US$) 40 35 30 25 20 15 10 5 0 20 40 60 80 100 120 MMR per 100,000 Does infrastructure matter? 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 R = 0.1688 100 2 0 0 5 10 15 20 25 30 IMR IMR and Medical/Obstetric Units 700 600 500 # Units 400 300 200 R2= 0.1637 100 0 0 5 10 15 20 25 30 IMR IMR vs. Beds per 10,000 120 100 Bed / 10,000 80 R 2 = 0.0422 60 40 20 0 0 5 10 15 IMR 20 25 30 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. Challenges to Health Systems: Conceptual Framework Means Intermediate Goals A Final Goals C Changes in: •Regulation •FinancingPooling •Purchasing •Delivery Models Equity & Access Effectiveness Quality B Health Status Financial Risk Protection Social responsive ness Financial sustainability Efficiency & Productivity Satisfaction • 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. Equity and Access Assessing overall performance 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. Assessing overall performance • 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. Financing and sustainability 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. 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. Recommendations Towards Strengthening PHC Challenges to Health Systems: Conceptual Framework Means A Intermediate Goals B Final Goals C Equity & Access Changes in: •Regulation •Financing-Pooling •Purchasing •Delivery Models Effectiveness Quality Financial sustainability Efficiency & Productivity Satisfaction Health Status Financial Risk Protection Social responsiveness 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. 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. 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. 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.