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Financing PHC in Kazakhstan
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
Moldova
Uzbekistan
Kyrgyzstan
Kazakhstan 5 10
Azerbaijan
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 National
Per Capita Spending (US$) Kazakhstan Estimate
MCH Per Capita Spending (US$)
Regional Variation in Per capita spending (US$)
30
25
+/- from Mean P.C. Spending
20
15
10
Dif from Mean
5
0
-5
-10
-15
-20
Area
Structure of current local budget
inЫегксегку ща текущих расходов
In Akmola Oblast, health care, 2002, in %
25,9 Salary
Nutrition
49,1 Drugs
4,7 Supplies
инвентарь,
5,2 Utilities
2,6
Building maintenance
10,9
3,8
Others
Main findings on the financing and
budgeting study
• Resource allocation rules are not oriented to
population health needs and risk of illness.
• Spending is not allocated to most cost-
effective interventions.
• No clear budgeting rules across oblasts.
• Budget structure does not allow for the clear
separation of primary care expenditures,
versus secondary and hospital care.
Main findings on the financing and
budgeting study
• No common budget structure across oblasts
leads to difficulty in comparing spending.
• Capital spending is very low and is crowded
out by spending on salaries and other
spending.
• Spending on drugs is not standardized to a
unique formulary and drug prices are not
referenced.
What drives outcomes?
IMR and Spending
Spending per capita is not allocated according
to need but has a small, positive impact on IMR.
45
IMR vs. Per Capita Spending
40
Spending per capita
35
30
25
R= 0.0029
20
2
15
10
5
-
0 5 10 15 20 25 30
IMR
MMR and Spending
…with similar results in terms of MMR and…
MMR v. Per Capita Spending (US$)
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
2
R = 0.1688
100
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
R 2 = 0.0422
Bed / 10,000
80
60
40
20
0
0 5 10 15 20 25 30
IMR
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 Final Goals
A B C
Equity & Health
Access
Changes in: Status
•Regulation Effectiveness
•Financing- Quality Financial
Pooling Financial Risk
•Purchasing sustainability Protection
•Delivery Efficiency &
Models Productivity Social
Satisfaction
responsive
ness
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.
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
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
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 Final Goals
B C
Equity & Health
Access
Status
Changes in: Effectiveness
•Regulation Quality
•Financing-Pooling Financial Financial
•Purchasing sustainability Risk Protection
•Delivery Models
Efficiency &
Productivity
Social
Satisfaction 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.
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