K.M. Kozhabek –PhD
candidate
Kazakh National
University named after Al Farabi, Kazakhstan
To the question of healthcare
development trends in Kazakhstan
In modern history
of Kazakhstan the issues concerning public health play important role. Healthy population
is accurate indicator and reliable guarantee of country’s prosperity.
Scientists treat public health issues as an important indicator of human
development and country’s development capacity. Accordingly public health is priority area of national security.
According to the Article 29 of the Constitution of the Republic of
Kazakhstan the citizens have the certain rights relating health care, i.e.:
“The citizens of the Republic of Kazakhstan have the rights to health
protection. The citizens of the Republic of Kazakhstan have a right to free
medical services legislatively guaranteed by the legislation. Commercial medical services in the public and private centers and privately
engaged professionals are available under and in accordance with the rules and order
set by the legislation». [1].
By providing
constitutional rights to health protection the state undertakes responsibility
to carry out measures related to rehabilitation of health deterioration,
epidemic and other diseases prevention, quality medical treatment, and to
provide conditions where every citizen may live long lasting and active life.
So it is worthy
to join the scientists who argue that health protection is “the set of measures
of political, economical, legal, social, cultural, scientific, medical, sanitary and epidemiological
nature, aimed to every man physical and mental health maintenance and promotion,
long lasting active life support, medical aid in case of loss of health.» [2, p.
207].
However the healthcare reform is implemented through several stages and
has long term period.
Upon its sovereignty Kazakhstan inherited unmanageable healthcare
system funded residually, and clinics and polyclinics with out-of-date
equipment, but material and workforce capacity that is used nowadays still.
From 1991
to 1996healthcare sphere was under specially established the Ministry of Health,
that endeavored during financially hard times, lack of appropriate funding, and
emigration of best professionals to provide the population with healthcare
services even of low quality, therefore these period of time recorded with the
highest index of child and adult mortality. That time the policy to improve the
healthcare system adopted the principle of market mechanism.
Back in
1996 the country started the insurance system reform that affected healthcare
system as well. 1996-1998 are remarkable for transition to budgetary-insurance
system. Statutory order On medical care insurance issued by the President of
the Republic of Kazakhstan dated 15 June 1995 #2339 warranted compulsory and
optional insurance through the state non-commercial institution, i.e. Fund of
compulsory health insurance that provided Basic program on compulsory health
insurance, created by the Ministry of Health. But the program failed due to
corruption schemes; meanwhile the core idea played certain positive role in
financial stabilization and creation of new insurance institutions. It should
be noted that today the state resurrected the idea of compulsory medical
insurance as important tool of medical institutions subsidization.
In 1999 The Ministry of Health Sport
and Education of the Republic of Kazakhstan developed and implemented the first
state program “Public health” within the Strategy “Kazakhstan -2030” that
contained provisions on public health maintenance and citizens welfare.
Public health maintenance
and welfare, development and realization of short, mid and long-term
initiatives that will contribute to speedy grow of healthcare services to new
quality level was the aim of the program “Public health”. It was scheduled for
1998-2008 and consisted of three basic stages. The program included the
following principles: 1. Economical, legal, organizational
measures aimed to maintain and support existing level of public medical
services and adapt the healthcare system to optimum performance in market
environment. 2. Economic and legal predetermination of domestic medical services
market development. 3. Medical
institutions effective performance assurance, improvement of medical aid
quality. 4. Responsibility of the state, participation of the employers and
citizens in formation, promotion and maintenance of public health. [3].
Implementation of the program revealed
many challenging problems not only in healthcare but in associated areas as
well, e.g. water supply, export-import food quality control, environment
monitoring, etc. Hereupon the number of projects
was developed, as “immunization”, “maternal health”, “HIV control”,
“performance of asepsis and antisepsis measures in both general health and
obstetrical institutions”, “environment and public health”, “family planning”,
“childhood nutrition”, etc. To solve the issues the special system was developed
but finally it was concluded that none of these subprogram achieved its goals. At
the same time the fact of implementing such long-term program was worth
noticing.
Development of State
program related to reform and development of healthcare in Kazakhstan 2005-2010
by the Ministry of Health of the Republic of Kazakhstan was the next stage of
healthcare system renewal. It supposed program financing
that allowed targeting eventual results depending on funding. Package of free
medical services provided by the medical institutions was defined within the
program, and this principle remains as of today. At the same time as analysis
revealed the reform was not aimed to significant changes, was not accomplished
to its logical end and could not change healthcare system fundamentally. But it
created turning point in national healthcare system as gave direction to create
new managing model based on sharing responsibility between the state and a
person. [4].
The program
allowed introducing new mechanisms of material support of the healthcare system
by financing of contractual patients per capita. Capitation standard rate for
such institutions was determined based on sufficient volume of medical aid on
certain level, population according to sex and age and other factors that
reflected peculiarities by region. It meant that the more patients were
registered in a polyclinic the more funding, equipment and medicaments were
provided from the state budget, though funding could be used for professional
staff wage raise. The program continued
implementation of medical care quality assessment system. Tools to control
medical aid quality, penalty scheme, and different indicators of medical care assessment
were developed upon introducing compulsory healthcare insurance.
Eventually
due to external reasons the penalty scheme, medical aid quality control was replaced
by medical aid analysis and quality assessment by the following criteria:
compliance of medical aid rendered with medical standards, medical aid quality
assessment, patients questioning.
Among
the results achieved in medical aid quality management shall be noted implementation
of quality assessment and guaranteed free medical services, quality review program
maintenance elements, methodology basis preparation to develop criteria of
quality assessment aligned with international practice’.
State program 2005-2010
significantly contributed into development of healthcare of Kazakhstan. It was
stated in the message “Strategy “Kazakhstan – 2050” by the President of the
Republic of Kazakhstan – Nation’s Leader Nursultan Nazarbayev that: “We are
managed to achieve notable progress in improving health of a nation. In order
to improve efficiency in healthcare the reforms in organizing, managing and
funding were introduced.”[5]. The Message contains among arguments yearly
increasing funding, introducing of free and preferential provision of
medicines, increase of life expectancy, introduction of cluster system
including childhood rehabilitation center, child guidance and family counseling
center, neurosurgery, emergency care, and cardiology center. Also the
construction of a number of medicine-purpose designed centers, and yearly
running program of assignment in IVF shall be noted as well as corrections into
the system of forced treatment of socially dangerous diseases, etc.
Also serious changes
were introduced into the legislation related to healthcare. The Code of the
Republic of Kazakhstan “On the health of a nation and system of healthcare” was
adopted, and it statutory regulates the public relations in healthcare allowing
people to exercise constitutional rights on health protection. This
code regulates full range of issues related to healthcare in the country,
including government control in the sphere.
Public health issues are not ones of
a person being solved solely. The principle of “joint and several
responsibility of the state, employer and citizen to maintain and promote
solidary and public health” is enshrined in art.4 of the Code of the Republic of Kazakhstan “On the health of a nation
and system of healthcare”. Moreover the Code directly sets that
“Citizens are obliged to care and promote safety of health” (art. 90) and
“Citizens obliged to take measures to maintain and promote own health” (art.
92) [6]. It shall be noted that this document stipulating the responsibility of
citizens of own health defines the role of a state and other institutions in
public health promotion.
It is important to note that the
Code for the first time ever obligated innovation of health technology in
medical centers and healthcare education centers of Kazakhstan, and for this
purpose the National healthcare holding was established. Besides, for the first
time ever the order of licensing, accreditation and attestation in healthcare
was legislatively set.
The President specifies
the new tasks in the Strategy “Kazakhstan -2050”: delivery of proficient and
accessible healthcare services; diagnosticating and treatment of possibly wide
range of diseases; preventive medicine development; “smart-medicine” service
implementation, distance prophylaxis and treatment; providing all health
services for children aged up to 16 years; legislatively defined minimum
standards of living.
Since 2011 there is the Unified
national healthcare system. The state program “Salamatty Kazakhstan” 2011-2015
was developed and under implementation. The system uses two key indicators
showing high standards of healthcare development such as: quality and
accessibility that are corresponding with the indicators of human development
concept.
The program is carried out within
the Unified national healthcare system (UNHS). Total expenditures of the state
program “Salamatty Kazakhstan” amount to 300 bln. KZT (approx.2400 mln.USD).
These funds are aimed to achieve target indicators such as increase in population
life expectancy, reduction in the infant, general mortality rates, reduction of
tuberculosis, and other socially dangerous diseases, HIV infection spread
retention.
Quality and accessibility are not
the indicators of medical aid only but also indicative of human, therefore the
attention of medical staff is focused on accessibility of medical aid for
remote non-urban areas within the state program “Salamatty Kazakhstan”, so
today there are 6000 objects (feldsher’s station, feldsher-midwife stations,
ambulatory), but it does not solve the problem of access due to low density of
population. So the transport medicine is evolving.
As a result of social reforms in
healthcare of Kazakhstan might be pointed increase of birth rate by 25%,
decrease of mortality rate by 11%, natural increase by 1,7 times, life
expectancy was 69,61 in 2012 and 70 in 2013. [7].
The Ministry of Healthcare and
social development works to create the unified agency for medicine services
quality. This work is under going to execute the task of the President within
the Plan of nation - 100 steps to implement five institutional reforms (82
step) [8]. The main aim was to implement leading standards
of health services by improving treatment regimen, medicine education
standards, pharmaceutical benefits, quality control, and accessibility of
medicine services.
According to the
MHSD of RK “Today there are 911 hospitals and 3164 outpatient clinics, among
which 729 state hospitals and 2175 state outpatient clinics. There are about
229 thous. healthcare professionals in the country, among which 70 thous. doctors
and 160 thous. mid-level health professionals. During the years of independence
life expectancy at birth in the republic increased by 8 years making 71,61
years. Circulation diseases mortality rate decreased by 2,3 times, tuberculosis
by 5, maternal mortality by 6,6, infant mortality by 2,8, malignancy maternity by
1,5. [9].
Public and
private partnership development in the sphere is the important line of
healthcare reforming in Kazakhstan.
Currently the
public and private partnership is governed by the Law of the Republic of
Kazakhstan “On concessions” dated 7.07.2006 #167-III (as amended by 4.07.2013
#131-V), and Government Resolution of the Republic of Kazakhstan “Concerning
approval of the Rules for submission, revision and selection of concession
projects, concessionary selection procedure, concession contracts monitoring, budgetary
co-financing concession contracts assessment and monitoring, concession
contracts selection for providing or increasing the state sponsorship amount”
dated 10 December 2010 #1343.
Among the program
documents the medicine sphere is considered as one of the attractive for public
and private partnership. In particular, it is anticipated that the private
sector co-financed by the state will undertake construction development of the
clinics, medical centers, education centers, etc. Besides it is worth to note that the healthcare sector is also
attractive to private investments, besides there is flexible mechanism of
permissions and control in the country.
Today the
tremendous amounts of funds are spent to advance the healthcare system.
Since the
program “Salamatty Kazakhstan” 2011-2015 is over the Ministry of Health launched
the State program of healthcare development for 2016-2020.
The main directions of the program
are:
- development of emergency aid,
access to it for any region or place. It is anticipated to spend 40% of total
funds;
- implementation of diseases
management system covering prophylaxis, disease detection and treatment at early
stage as unified process of medical treatment;
- development of talent density in
healthcare. Modernization of personnel training, retraining, continuing
development system that shall correspond with the National system of
qualification implemented in Kazakhstan since 2009.
- maintenance of
financial strength.
Economic recession in
Kazakhstan required significant sequestering of state budget expenditures,
since the budget income dropped by 870 bln.KZT (minus 12,9%). Budget spending was cut by 610 bln.KZT (minus
7,8%) – to 7 trln.244,5bln. KZT. Additionally
686,7 bln.KZT were optimized. Due to these all new programs for the 2015 were
postponed. Expenses for cost demanding and long lasting projects were also
postponed, administrative and capital costs of the state bodies were cut as
well. At the same time by the order of the President the scheduled costs for
social sector shall not be subject to any alterations. So the costs for the
healthcare sector shall amount to 2,084 trln. KZT in 2015-2017. Costs for
healthcare sector development shall amount to 2 trln.84bln.KZT in 2015-2017. [10].
In this case we shall
join the opinion of A.Marat saying that: “State policy in healthcare and the
mechanisms of healthcare funding will be aimed to increase the level of managing
the system with adequate financial support, and will help to achieve the high
results in healthcare of Kazakhstan. Based on the above said it may be
concluded that any sector of the economy, including healthcare may not exist
and develop effectively without well functioning financial system and source of
financing. Therefore, the effective system of financing in healthcare is based
on the study of state’s funds allocation into healthcare sector in the developed
countries” [11].
Besides
it worth noting other innovations in healthcare sector, i.e. since 2015
Kazakhstan introduced compulsory medicine insurance of 3% from wages fund to
ease financial burden on the budget. CMI means that the employer will pay
medical tax into special fund to cover treatment expenses.
Alongside
with that, the healthcare system suffers serious problems and weaknesses. Among
those problems the ones are of “growth” while the others of system. Absence of
comprehensive competitive relations between the public and private polyclinics
within one population serving area could be an example of
system problem. So public polyclinics, upon the receipt of quotas per each registered
person disregard their duties to such citizen. The district doctor and narrow
specialist will not call the citizens for preventive examination unless the
citizen will not demand the services at polyclinic himself/herself. So it means
that the doctors adhere to the principle “No need to feed not crying child”.
The second issue of the system is
low level of doctors’ and mid-level health professionals qualification. Though
the model itself is aimed to continuous professional development, the specialists
prefer bonus payments instead of trips to obtain enhanced trainings. Commonly this
is explained by the shortage of personnel as hospital chief executives say, and
it is obvious since hospitals and polyclinics seriously suffer under manning
yet.
Third negative side is that the
government servants of medicine on behalf of the state funds the construction
of new polyclinics, hospitals and aid posts and purchases the latest equipment and
techniques for millions of USD. The training of the personnel is often not
provided or the medicaments’ date of expiry is not observed these finally bring
difficulties to the patients. In the meantime it should be noted that the crime
detection rate of medical delinquency almost at zero level, it means that
culprit goes unpunished.
Alongside with that there are wide ranges of outstanding issues in healthcare
sphere such as:
- shortage of qualified personnel in rural areas;
- low level of medical education;
- low level of wages of medical staff, weak social support;
- lack of proper equipment and techniques in rural medical centers;
- corruption of state bodies. Among
other things failure of vivid distinction between guaranteed volume of free and
for pay medical services contributes to commitment of financial manipulations;
- low level of responsibility among the medical profession for the
medical errors, difficulties to prove presence of those and prosecution of
liable;
- budget model of funding to healthcare does not supply needs to cover all
legislatively guaranteed volume of free medical services;
- disparity in volume and quality of medical services due to different possibilities
of local budgets;
- free medical services are not available for citizens away from
permanent residence;
- no unified tariff policy for
medical services.
Literature:
1. Constitutaion of the Republic of
Kazakhstan dated 30 August 1995 [Electronic recource] – Accessed at:<http://law.ucoz.kz/load/zakony_respubliki_kazakhstan/skachat_besplatno_konstitucija_respubliki_kazakhstan/1-1-0-391>.
2. A.N.Golovistkova, L.Y.Gruditzina.
Human rights. Text book. ÎÎÎ “Eksmo” Publishing house”, 2008. – 448 p.
3. Decree of the President «On the
state program “Health of a nation” dated 16.11.1998 #4153. [Electronic resource]
– Accessed at: <http://kazakhstan.news-city.info/docs/sistemsb/dok_oeqgzi/>.
4. Decree of the President of the Republic of Kazakhstan State program
of healthcare reforming and development for 2005-2010 dated 13 September 2004 1438.
[Electronic resource] – Accessed at: < http://do.gendocs.ru/docs/index-279252.html>.
5. Message of the President – the
Nation’s Leader “Strategy “Kazakhstan- 2005”. [Electronic resource] – Accessed
at: <http://www.bnews.kz/ru/videonews/post/115508/>.
6. The Code of the Republic of
Kazakhstan “On the health of a nation and system of healthcare” dated 18 September
2009. [Electronic resource] – Accessed at:
7. Average expectancy of life in
Kazakhstan in 2012 increased by 6 months.
[Electronic resource] – Accessed at: <http://news.mail.ru/inworld/kazakhstan/society/11781411/>.
8. «100 certain steps» are defined
to implement 5 institutional reforms. [Electronic resource] – Accessed at:
<http://www.zakon.kz/4713070-sto-konkretnykh-shagov-prezidenta.html>.
9. Speech of the Ministry of Health and
Social development of Kazakhstan on joint meeting of “Nur Otan” party and Mazhilis
Committee on social and culture development. [Electronic resource] – Accessed
at: < http://www.mzsr.gov.kz/taxonomy/term/30>.
10. How the state budget revenue
dropped. [Electronic resource] – Accessed at: <http://www.caravan.kz/article/103423 >.
11. A.Marat. State policy of healthcare funding. [Electronic
resource ] – Accessed at: < http://www.articlekz.com/article/11227 >.