ELVANA HANA General Director Health Insurance Institute

1. Challenges on financing the health care from obligatory health insurance schemeAlbania: Health System under reforms ELVANA HANAGeneral Director Health Insurance Institute IInd Balkan Forum, Ljubljana – November 2008

2. Area 28,748 km2 Population 3,622,720 Nr. of Prefectures 12 65 Municipalities, 311 Communes Religion: (Mostly; Muslims, Orthodoxies, Catholics) Life expectancy at birth 73,8 years Crude birth rate (‰):13.8 Crude death rate (‰): 5.7 Infant (♀+♂) mortality rate (‰): 14.9 GDP per Capita 5.6% (2.7% from public funds)

3. OVERVIEW - ALBANIAN HEALTH INSURANCE SYSTEM • HII presents the national health insurance model and its managed from the Board (or Administrative Council) • Restricted autonomy and report to Ministry of Health and Parliament • At administrative structure there are: Main office consist on 9 departments, 12 regional directories and … agencies …………..

4. FINANCING SOURCES AND THE ADMINISTRATION OF CONTRIBUTIONS FROM HII • The contributions of health insurance are obligatory State determine the contribution rate based on individual incomes paid directly at tax office or social insurance office. 2. Direct transfers from state budget State is responsible to cover the inactive population (such as pensioner, veterans, invalids, students, etc)

5. THE STRUCTURE OF HEALTH SERVICES FINANCED FROM HII • Primary health care Contracts with Public Health Center for services package • Drugs reimbursement Contracts with open network pharmacy (totally privatizes system) • Tertiary unikal examinations (11 expensive examinations done at university clinics) • Durres Regional Hospital

6. FINANCING OF HEALTH INSURANCE State Budget Transfer Active population contribution MoH SII - TO HII HC of primary care Co-payment Administrative expenditures and Investments Tertiary examinations Durres hospital Drug reimbursement (pharmacy with contract)

7. THE EXPENDITURES STRUCTURE YEAR 2008

8. THE PROBLEMS AT PRIMARY HEALTH CARE SERVICESshort history ….. Administration of PHC Health Centers • Dual independence, institutional and financial (HII - MoH) • Fragmented financing of primary health care • Payments from HII, only for Family doctors – discouraged for team work – indifferent to the quality • Lack of Autonomy for HC • Low deposits of secondary incomes – main reason of informal payments

9. THE PROBLEMS AT PRIMARY HEALTH CARE SERVICES : Providing of health services and their quality • Lack of standard packages of health services for providers of services • Partly standard for health services level and norms of coverage the population within ambulatory care (the rapport (doctors/nurses and norms of coverage for nurses staff) • Lack of measures and evaluations indicators for quality of health services • Standards not completed for protocols of ambulatory treats from GFP • Lack of basic equipments for services

10. SCHEME OF REFORMED PHC FINANCING

11. REFORM AT PHC • Move to a single purchaser financing for health services. • Autonomy on Management, organization and operation of HC • Definition of actors role on the system. • Development of new method of payment for HC. - Application of a mix payment formula: - 85% fix budget, - 10% monthly added payment based on the activities of the HC - 5% bonus payment 3 month based for HC which fulfils the quality indicators. • Increasing of payment level for services providers.

12. REFORM AT PHC • Setting up the necessary framework for health services market function. - Opportunity to exercise their profession as individual contractor / or private • Installation and using an unique system of information for all HC. • Setting up the necessary framework for HC to manage the allocated funds. - New opportunity for increasing and using second income

13. LIST OF INDICATORS FOR EVALUATION OF HC ACTIVITY • The performance: - number of visits for the insured persons (daily average of visits per doctor within HC) • The quality - First contacts with the patient within the year - Respecting the average/prescription cost for specified diagnoses - Monthly attendance of chronic patients (% of chronics every month) - Attendance of pregnant women (% of pregnant women for their first visit of first trimester of pregnancy) - Vaccination in the ages 0-14 years old - Participating in the Continuous Medical Education

14. SOME POSITIVE INDICATORS HC Productivity Invreasing of daily average of doctor’s visits at national level In urban areas: - 7.9 vis/day year 2006 - 10 vis/day year 2007 - 11.1 vis/day first 6 months of 2008 ; In rural areas: - 3.9 vis/day year 2006 - 6 vis/day year 2007 - 6.9 vis/day first 6 months of 2008

15. Performance: year 2007 49.8 % year 2008 72.5 % Quality: year 2007 – year 2008 – 35.5 % 80 70 60 50 performance 40 quality 30 20 10 0 2007 2008 FINANCING OF PERFORMANCE AND QUALITY INDICATORS

16. HOSPITAL SERVICES Durres Hospital Experience, Priorities, problems and challenges. Hospital as juridical entity: • Administrative independence • Management – Board • Financial independence • Financing from HII – own decisions for using of secondary incomes funds. • More efficiency in using the health insurance funds through: • Setting up an coherent information system • Processing of payment method for DRG • Compiling of hospital treatment protocols

18. THE CHALLENGES IN THE CURRENT FINANCING OF HOSPITAL SERVICE • Implementing a contemporary computer network for all the hospital activity and economic/technical one, up to services • Improving the financing method (from budgetary – to cost per case – DRG) • Financing the new services • Improving the quality of health services: - the permanent supply in medicaments and medical goods, referring cost/efficiency - privatization of supporting services (The experience in financing this regional hospital will serve to extend the scheme in all the hospital service)

19. IMPROVING THE HEALTH SYSTEM FINANCING • Reinforcement of HII role as strategic purchaser of health services in public and private system • Improvement of collecting contribution system • Efficiency at collecting contribution from salaries • Consolidation of contributions from obligatory insurance for inactive population, from state budget • Reconsideration of the contribution rate • Decreasing of informality • Presentation of co-payment • Identifying the insured population through health card • Utilization of secondary incomes

20. ENCREASING OF MANAGERIAL CAPACITIES AT HEALTH SERVICES • Expanding of partnership public-private • Encouragement of special service privatization at all the levels of health care • Reposition of manager role at public health institutions • Setting up the standards, norms and clinical protocols in management of health services. • Consolidation of quality approach system and security of health system

21. INCREASING OF ACCESS AT EFFECTIVE HEALTH SERVICES • Define of basic package of health services and its monitoring • Re construction of health service providers network • Restricted due to geographical, demographic and privatization policies conditions • Improvement of refer system • Maintaining and developing of programs for public health