Introduction of Complex Capitation Standard Rate (CCSR) in outpatient care organizations

1. Introduction of Complex Capitation Standard Rate (CCSR) in outpatient care organizations

2. Network public MOs, rendering OPP polyclinics-361 Women’s health centres under obstetric organizations-26 Perinatalcentres-16 Maternity hospitals-10 PD of dispensary with beds -130 TB dispensary-51 Oncologic-17 Dermatovenerologic-20 Psychoneurologic-18 Endocrinological-1 Narcological-19 Cardiologic dispensary -4 CPMSH -15 OC-1086

3. Network of МОs, rendering PHC, on the situation on January 1, 2013 Total- 2206 Outpatient-polyclinic organizations– 612 PDand OC of hospital organizations – 1304 Municipal polyclinics – 119 CDC – 3 PDof city hospitals– 20 PD of CRH, RH, VH – 192 Child polyclinics – 14 CRP, RP, VP – 36 CPMSH – 17 OC – 409 CPMSH - 10 OC – 1082 Private OPO 1082 МS, village first-aid station - 4311 MWwithout rooms – 128

4. Independent organizations, rendering PHC Total number of organizations 363 City184 Village179 MP122 OC12 VH5 CRH133 CPMSH9 CDC3 RH12 RP29 CP14 MH24

5. Medical organizations, providing CDS Total- 399 Outpatient-polyclinic organizations -174 Polyclinic departments (PD) of hospital organizations - 225 Municipal polyclinics - 124 Pediatric polyclinics - 14 PD of regional hospitals - 12 PD of regional pediatric hospitals- 16 PD of city hospitals - 30 RP - 25 CDC -11 PD ofCRH, RH - 158 PD of VH - 9

6. NETWORK OF ORGANIZATIONS, PROVIDING PHC. EXAMPLE OF ZHAMBYL REGION.

7. NETWORK OF ORGANIZATIONS, PROVIDING PHC. EXAMPLE OF KARAGANDA REGION

8. Tasks and objectives Objective: Improving availability and quality of primary medical and sanitary care by introducing economic incentives Tasks: 1. Stimulating preventing direction in work of PMSC organizations 2. Expanding the range of primary medical and sanitary help services 3. Provision of rational and effective usage of means dedicated for outpatient-polyclinic and hospital care 4. Increasing payment of PMSC workers by introducing economic incentive mechanisms

9. Stimulating preventing direction in work of PMSC organizations Covering not lesser than 70% of target group of assigned population with screening assays Increasing the number of diseases detected at early stage Decreasing the number of chronic non-contagious diseases and their complications by integrating the chronic diseases management program Systematic explanatory and promotion work with population on disease preventing and forming healthy lifestyle

10. Expanding the range of primary medical and sanitary care services • 1. Delegation of consultative and practical skills on most frequent diseases from dedicated experts (subject matter experts) to the specialists of PMSC : • cardiology– hypertension, CHD • endocrinology– hypothyroidism, diabetes gastroenterology– ulcer, gastritis, duodenitis and hepatitis ophthalmology – conjunctivitis neurology – acute cerebrovascular disease, root disorders pulmonology– pneumonia,COPD, bronchial asthma obstetrics and gynecology – pregnancy follow-up 2. Expanding SMWpowers and independence : - independent admission of patients including case follow-up of dispensary patients; - being able to use basic practical skills in surgery and obstetrics and gynecology; - providing services for house-calls; - prenatal nursing, postnatal nursing, nursing of healthy children younger that 1 year, patients with chronic diseases; - consulting on disease prevention and healthy lifestyle, social and psychological help

11. Provision of rational and effective usage of means dedicated for outpatient-polyclinic and hospital care • Decreasing the number of unreasonable hospitalizations to twenty-four hour hospitals • Decreasing CDS consumption • Decreasing the number of emergency calls in PMSC organizations working hours

12. Increasing payment of PMSC workers by introducing economic incentive mechanisms • Introduction of differentiated payment for doctors’ and SMW work for: • expanding the list of consultative and diagnostic and practical skills • expanding prevention direction of work (covering not lesser than 70% of assigned population with preventive activities) • reaching basic indicators of productivity of PMSC activity

13. Primary medical and sanitary care Article 45 of Code on Health and Healthcare System Premedical, qualified medical care without twenty-four hour medical observation, including complex of available medical services, provided at the levels of person, family and society: 1) diagnostics and treatment of most common ailments, as well as of traumas, poisonings and other emergencies; 2) sanitary and anti-epidemic (preventive) activities in sites of diseases; 3) hygienic education of population, family, maternity, paternity and child welfare services; 4) explanatory work on safe water supply and nutrition

14. Capitation standard rate for 2000-2200 population Existing functions of PHC: Problems: • lack of doctors • lines in polyclinics • poor quality of medical care • premedical, qualified medical care, • examining patients for detecting ailments at an early stage, • appointment for hospitalization, • chronically ill patients for preventive medical examination, • rehabilitation treatment, • provision of medicines. assigned population using PHC Expanding functions of PHC: Solutions: Complex capitation standard rate • making requirements for doctor and SMW training stricter • SMW status reinforcement • extending the staff size of SMW and keeping the relation between them in balance • improving the level of doctor and SMW training • improving the level and the quality of care workers’ and psychologists’ work • increasing payments by integrating differentiated payment for doctors’ and SMW work for expanding their functions and achieving targeted results • decreasing the number of common chronic manageable diseases (CMD) at PHC level • systematic, explanatory, promotion work with population on disease prevention and forming healthy lifestyle • transferring focus from ill patients onto protection of healthy population • delegation of powers from dedicated expert to the specialists of PHC • expanding SMW powers and independence • strengthening social orientation of PHC assigned population using PHC, primarily with preventive purposes

15. Pilot studies results on the example of pilot MO – municipal polyclinic №8 of Аstana –general practitioners’ actual salary rose 2.2 times, therapists – 2.0 timesandpediatrists – 1.6 times, nurses actual salary rose 2.3 times; therapist nurses – 2.1 times; pediatristsnurses –1.6 times on the example of pilot MO – TaiynshynCRH, NKR –general practitioners’ actual salary rose 2.9 times, therapists – 2.5 times andpediatrists – 2.3 times, nurses actual salary rose 3 times; therapist nurses – 2.4 times; pediatristsnurses – 2.5 times (CCSR equals to 1221,12)

16. 491890 tenge– one division’s salary fund per month (1 doctor– 2-3 SMW), consists of: 215000 – base actual salary (as of today on actual basis) 276890 – additional actual salary (per 1 doctor and 2 SMW) (+) For reaching lowest acceptable level of indicators (-) In case of not reaching or partially reaching lowest acceptable level of indicators, financial means are redirected to divisions with better results (of lowest acceptable level) CCSR fund distribution (on the example ofMP №8) Additional salary fund – 276890 KZT 56% Base salary fund – 215000 KZT 44%

17. Expenses structure (on the example of pilot organization – municipal polyclinic №8, Astana)

18. Relation between PHC/CDPexpenses on the example of pilot MO MP №8 of Astana Additional 95 tenge per one assigned person per month

19. Differentiation of PHC and CDPservices, included to CCR (896 KZT) High-cost services (are limited by the local executive bodies) for certain population classes • PCR, angiography, PET, CT, medicogenetic examinations and others in accordance with the GVFMC PHC – 55 services (596 KZT) Doctor admissions General clinic examinations Biochemical examinations ECG Bacteriologic examinations Immunoprophylaxis Procedures and operations CDP – all the other services including high-cost services (300 KZT) Specialized doctors admissions Extended biochemical examinations Radiologic examinations Ultrasound Function studies Procedures and operations Primary surgical treatment of wounds, cast application/removal

20. PHC volume within the GVFMC

21. PHC volume within the GVFMC

22. Expected results • Expanding PHC availability by private PHC organizations network expansion, as well as on the base of PPP • Increasing the number of finished cases of visits for medical care at PHC level (not lesser than 70%) • Provision of PHC development priority • Transfer of focus from hospital care onto outpatient services

23. Thank you for your attention!