Evaluation of NSRF Health Care Development Projects

1. Evaluation of NSRF Health Care Development Projects Norbert Kiss Hétfa Research Institute – Corvinus University of Budapest Balázs VáradiBudapest Institute – Eötvös Loránd University 30 April 2013

2. Contents • General overview and evaluation of health care developments • Geographic targeting of health care development projects • Evaluation of developments of outpatient care providers • Modernisation of the central medical equipment register • Evaluation of lifestyle development programmes Evaluation of NSRF Health Care Development Projects

3. Overview of health care development • Methodology: • Inclusion of health care constructions (from SMIS) • Health care providers as beneficiaries (from SMIS) • Assignment of current funding of the National Health Insurance Fund (OEP) to levels of health care • Main conclusions: • Large share of health care constructions in total funding • Smaller amounts from ROPs (accessibility for the disabled, medical tourism), EEOP, EAOP (e.g. e-health) • EDOP, ROPs, SROP (lifestyle development): private providers were also eligible (app. HUF 11.5 billion) • Connections between SIOP and ROPs (statistical regions and „health care planning and management areas”) • Public providers were typically supported from one source only • HR developments (HUF 8,5 billion): only a fraction of the wages in the health care sector, longer term impacts can only be achived at very specific areas Evaluation of NSRF Health Care Development Projects

4. Targeting of the development programs (by progressivity – levels of health care) Evaluation of NSRF Health Care Development Projects

5. Evaluation of geographical targeting • Methodology: • Health care development projects (from SMIS database) • Assignment to progressivity levels and to the population of microregions (LAU1) (at institutional level) • Current („regular”) OEP funding • Assignment to progressivity levels • Assignment to microregions (by using OEP data) • Avoidable mortality by microregions (J. Vitrai & M. Bakacs) • Assessment of the targeting of regular and development funds in terms of avoidable mortality and the complex developmental indicator, using Lorenz curves • What percentage of the sources were allocated to the microregions with greatest needs Evaluation of NSRF Health Care Development Projects

6. Avoidable mortality by microregion (J. Vitrai & M. Bakacs) Evaluation of NSRF Health Care Development Projects

7. Development projects are better targeted than regular funding Evaluation of NSRF Health Care Development Projects

8. Primary care projects are the best targeted Evaluation of NSRF Health Care Development Projects

9. However, outpatient care targeting is not bad either Evaluation of NSRF Health Care Development Projects

10. Targeting of inpatient care development projects Evaluation of NSRF Health Care Development Projects

11. Geographical targeting of development projects: quantitative indicators Evaluation of NSRF Health Care Development Projects

12. Positioning of the outpatient care development projects Did the development projects meet the local needs? • Methodology: document analysis, statistical analysis • Key findings: • Feasibility studies for the tender used different methodologies. • Short run-up period • Accessibility in terms of time improved: • App. 310,000 people got access to basic level outpatient care in 20 minutes • App. 150,000 people got access to advanced level outpatient care in 25 minutes (4 basic specialities + cardiology, traumatology) • Results are similar when accessibility is defined by either car or bus • Bus timetables are not in harmonised with office hours • Low scale of economy, modest capacity utilisation Evaluation of NSRF Health Care Development Projects

13. Improvement in the accessability of basic level outpatient care Evaluation of NSRF Health Care Development Projects

14. Changes in the utilisation of services How have the projects affected the utilisation of health care services? • Methodology: comparing the number of cases between the population of the developed microregions (= „treated microregions”) vs. the population of control regions • Matching methods, combined with difference in differences • Panel data analysis with fixed effect estimation • Key findings (SIOP 2.1.2): • Solid increase (25-30%) of utilisation in almost each medical specialities regardless of the estimation methodology • Rise in utilisation is 36-43% among people above 60, while 13-23% among younger people • Standardized number of cases has increased to the level of similar regions Evaluation of NSRF Health Care Development Projects

15. Short term health impacts Has the improved access to outpatient care improved the care of chronic patients (e.g. identifying chronic conditions, utilisation of necessary tests and consultations)? Have the additional outpatient care capacities contributed to the reduction of sick leave days? • Methodology: statistical analysis • Key findings: • Sick leave days and number of cases dropped by 4-6% (SIOP 2.1.2-3) • Annual eye screening of diabetic patients: 8% increase (no significant effects on other types of screenings and laboratory tests) Evaluation of NSRF Health Care Development Projects

16. Economic sustainability Are the developed outpatient care centers in microregions sustainable on the long term? • Methodology: case studies, expert interviews • Key findings: • The original business plans and sustainability calculations became practically outdated at the time of contracting • No common responsibility of the microregion for the sustainment of the center in several cases • Problems with additional revenue creating services • The utilisation of the physical infrastructure cannot be efficient due to the low scale of economy • It is a consequence of the financing system that these centers cannot break even – or only with great difficulties • Aspects of equity Evaluation of NSRF Health Care Development Projects

17. Modernisation of the central medical equipment register: the IT system • Adequate hardware and software environment for the central system • Data collection methodology uses up-to-date technology • Automatic uploading + web-based interface • Client side interface development was also initiated, 2 major IT system suppliers implemented it • Preliminary interviews with data suppliers and users • The content of reporting has been expanded (compulsory+optional) • Information gathering processes of data suppliers have not been modelled and analysed • Problems with the nomenclature and master data Evaluation of NSRF Health Care Development Projects

18. Modernisation of the medical equipment register: Efficiency and effectiveness • „Accurate” reporting practices would lead to increase of administrative burden • Thus few providers thrive to report „accordingly” • No legal consequences, and there is a conflict of interests • Data migration between the old and new systems • Validation with sampling • No change in the number of providers with accurate reports (app. 10%) • Limited number of users of the database • Recommendation: • Analysing data gathering processes of providers • Connection to the licensing of providers Evaluation of NSRF Health Care Development Projects

19. Lifestyle development programmes in 2009: overview of applications • App. 250.000 participants (SMIS-monitoring) Source: SMIS-reporting (10th Jan 2013) Evaluation of NSRF Health Care Development Projects

20. Geographic targeting of the lifestyle development projects Evaluation of NSRF Health Care Development Projects

21. Adequateness of content and impact of lifestyle development projects • Motivation for individual and/or community level lifestyle changes were in the focus • Capacity building, changes in the local environment to promote healthy lifestyle were given lower priority • Difficulties with identifying and following the real professional content of the projects – assessing whether the content has met the needs is also difficult • Quality assurance of the professional content was missing from the selection procedure (except for LAMR applications) • Non-LAMR health plans were often only formally adequate • Recommendations and resources of the (central) research and methodological development institutions were rarely used • „Copy-paste” type content was typical in communication materials • Long lasting impacts are not achievable (according to expert opinions) • Low value of grants – high administrative burden Evaluation of NSRF Health Care Development Projects

22. Contribution to improvement of local conditions • Not clearly demostrated how the health plans are connected to the local needs and demands • Health plans, prepared during the projects, have not become a central part of local health development planning • Methodological support was provided for LAMRs • Inclusion of partners: mostly from the social sector • Partnership agreements were typically made for the duration of the projects • Occasionally „simple and inexpensive” solutions were less preferred („this is the time when we have the money…”) • Equal opportunity appeared as a horizontal objective • The practice of „one size fits all” was strong • A large part of the experiences have been incorporated into the newer calls in 2011-2012 Evaluation of NSRF Health Care Development Projects

23. Thank you for your attention!