Financing PHC in Kazakhstan

5 10 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 International Comparison as % GDP on Health Slovakia Lithuania Estonia Latvia Belarus Ukraine CIS average Moldova Uzbekistan Kyrgyzstan Kazakhstan 5 10 Azerbaijan 15 2001

Total and Per Capita Spending 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 Kazakhstan National Estimate Per Capita Spending (US$) MCH Per Capita Spending (US$)

Differences in Per Capita Spending Regional Variation in Per capita spending (US$) 30 25 20 15 +/- from Mean P.C. Spending 10 Dif from Mean 5 Kostanai Akmola Atyrau Mangistau Almaty City Pavlodar Aktobe Zhambyl Almaty Astana City Kyzyl-Orda Karaganda -5 West Kazakhstan East Kazakhstan North Kazakhstan Sout Kazakhstan Republic of Kazakhstan -10 -15 -20 Area

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. IMR vs. Per Capita Spending 45 40 35 30 Spending per capita 2 25 R = 0.0029 20 15 10 5 - 5 10 15 20 25 30 IMR

MMR and Spending …with similar results in terms of MMR and… MMR v. Per Capita Spending (US$) 45 40 35 Per Capita Spending (US$) 30 25 20 15 10 5 - 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 5 10 15 20 25 30 IMR

IMR and Medical/Obstetric Units 700 600 500 400 # Units 300 …similar results in terms of medical/obstetric units---better access means fewer infant deaths. 200 2 R = 0.1637 100 5 10 15 20 25 30 IMR

IMR vs. Beds per 10,000 R Bed / 10,000 IMR 2 120 100 2 R = 0.0422 80 Bed / 10,000 60 IMR is negatively correlated with beds per 10,000. This means that more beds is associated with a higher IMR 40 20 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 Final Goals Intermediate Goals Means A B C Equity & Access Health Status Changes in: Regulation Financing- Pooling Purchasing Delivery Models Effectiveness Quality Financial Risk Protection Financial sustainability Efficiency & Productivity Social responsive ness Satisfaction

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 Final Goals Means Intermediate 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 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.