HEALTH CARE FINANCING REFORM AND THE ROLE OF HII

1. REPUBLIC OF ALBANIA THE HEALTH CARE INSURANCE INSTITUTE HEALTH CARE FINANCING REFORM AND THE ROLE OF HII Mag. Elvana HANA General Director of HII Ohrid 31 May – 01 June 2010

2. What was the aim of the financing reform in the primary health care? • Reforms in the manner of financing and managing of the health centers • Restructuring of the primary health care institutions • Reforms in the manner of motivating the health’s employers according to their performance’s quality • Contracts based on the health services package provided from the HC and improvement of the accountability • The measurement of the performance and services quality provided from the HC Main aim: “Improving the patient’s health state”

3. How did the primary health care reform develop? Through the restructuring of the primary institutions we achieved: • Increase of the HC autonomy in the managing of the human and financial resources • By the reforms in the manner of financing and contracting, the financing of the HC were focused on the improvement of the health services at 85% - payments, insurances and goods and services, 10% for the performance and 5% bonus for the quality • The contracts were based on the basic package of services by aiming the services standardization of the services in all the HC all over the country • The motivation of the HC’s employers” from the beginning of the reform the payments of the nurses increased with 60% and the general and family doctors with 40% At the center of the realization of the performance and quality indicators the employers of the HC have been financed up to two rewarding wages

4. What did this reform bring? • There have been a significant improvement of the population access to the primary care • With the realization of the performance and quality indicators from the HC, they managed to absorb more funds • The improvement of the HC management in accordance to the financial and human resources related to the changing needs of the inhabitants • The implementation of the supervising process of the HC brought the identification and the rapid solution of the problems, improvement of the accountability • Improvement of the information technology, in order to implement the information system in the primary care • Increase of the expenditures transparence for the primary care

5. The Contracting process in the Primary care It has been an essential process for the reform in the primary care, which consisted of: • During 2009 – 2010 have been singed contracts regarding the financing in order to provide health services in the primary health care for 419 HC • The services provided were based on the basic services package, which were significantly improved in 2009 • The improvement of the quality indicators (5% bonus), increasing it from 6 in 2008 to 9 in 2010, by introducing the results indicators for the first time in the Albanian primary health services, like: chronic patients with HTA and Mellitus Diabetes that have clinic parameters within norms, follow-up of the children from 0-1 years old • No. of differentiated visits according to the areas, in order to easy the access to the health services in the remote mountainous area

6. Contracts with the HC • Implementation of the information system in the primary care • Implementationof the supervising process • Implementationof the referential system • Improvement regarding the implementation of choosing freely the doctor • Improvements in the process of negotiation with the HC for the reimbursement expenditures planning, based on evidence • Improvement in the manner of reporting, accountability and financial control in the primary care • Giving more tasks to the RDHII (Regional authorities), as a direct authority in the contracting process with the HC

7. The evolution of the financing based on the performance The performance of the HC have improved from year to year, and in the third year of the reform it was almost doubled the level of the payment per performance, from 49.8% to 81.4%.

8. The performance’s evolution During 2009 the HC have absorbed financial sources per performance 31% more that it was in 2007 and 7% more than in 2008. 240 HC have realized over 80% of the indicators in 2009 compared to 170 that it was in 2008.

9. Average no. of visits as indicator of performance During 2009 have been effectuated 4.95 million visits from the doctors of the primary health care centers, while in 2008 have been effectuated 4 million visits. The increasing of the average number of visits per doctor per day, from 7.9 to 9.9.

10. Financing the quality indicators (5%) In 2009 the HC have been financed 23.4% more than it was in 2008; over 321 HC have profited over 60% of the bonus, from 17 that it was in 2008;

11. Contacting for the first time the patients In 2009 the contact for the first time (PVHP) with the patient have increased up to 17% more than it was before the reform; and 10% more than in 2007. The most important indicators as: tracking of pregnant women and the children’s vaccination, as indicators that show a direct relation to the diseases prevention, it have been realized over 95%.

12. The increasing number of people which become eligible to profit from scheme During 2009 the number of people that become eligible to profit health services financed by the scheme have doubled compared to 2007 and tripled compared to year before the reform. During the first 3-Months we have an increase of 86% more than in the first 3-Months of 2009 of the people who ask for insurance booklet.

13. The performance of drugs’ reimbursement financing

14. 226,818 200,261 171,088 250,000 200,000 150,000 100,000 50,000 0 2007 2008 2009 The financing of the reimbursable chronic diseases Chronic diseases The yearly average of cases in years About 98% of the reimbursement expenditures is occupied by the chronic diseases

15. Increase of the new cases during the last 3 years The reimbursment expenditures for the new cases of the last 3 years 44,700 43,506 60,000,000 45,000 32,660 40,000 50,000,000 35,000 30,000 40,000,000 25,000 30,000,000 20,000 15,000 20,000,000 10,000 10,000,000 5,000 0 0 2007 2008 2009 2007 2008 2009 Increase of the new chronic cases during the years During 2009 have been treated 13% of new chronic cases more than in 2008 and 33% more than in 2007.

16. 45 40 35 30 25 20 15 10 5 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Ease of the population’s access in the PC services The No of catchment areas with difficulties to cover with GP in Years The coverage of the population by the medical personnel have always been in improvement, the number of the problematic areas have been reduced up to a minimum, from 40 that they were before the reform to 6 areas in 2009

17. The exact registration of the population from the HC Registering the active inhabitants that are covered by the HC with service have been a very important process during 2009, which aimed: • The exact illustration of the number of people enrolled nearby each HC • The exact illustration of the chronic disases diagnosticated according to the FD of the HC • The exact illustration of the resident and non- resident people for which the FD is paid, also by taking into consideration that the a major part of the Albanian citizens have emigrated • The creation of an electronic data base for the registered population according to each FD/HC, which will help HII to have a better planning of the respective budget and improvement of the payments scheme for the FD

18. The Health Information System in the Primary Care The informatization of the HC performance for the services in the primary health was one of the aims of the health reform • Through the HIS we are going to digitalize the whole performance effectuated by the FD and the nurses of the HC • A better monitoring of the performance performed in the HCs, the type of performance effectuated, the job attendance from the health personnel, the bugdet planning per performance as well as the financing based in the indicators realization • HIS is going to help HII and the Ministry of Health in the decision-making based on evidence

19. The HII challenges for the Primary Care • Improvement of the financing system, focusing on increasing the performance and quality of the services (changing the financing report); • Concluding the electronic registration of the population and the improvement of the payment system per capita. • Improvement of the quality and performance standards • Perfecting the supervising system regarding the financial managment, human resources and performance. • Supporting the process of Drafting the clinical practise guidance and give support in the training programs of the Continual Medical Education. • The functioning of a unique informative system. • Cooperating with the Ministry of Health for the fulfillment of the Standards in the primary health services

20. The start of the reform in Hospital care in 2009 enabled: • Hospital legal status (public, non-budgetary, non-profitable, provides medical services approved by the Ministry of Health) • Contracts with 39 hospitals : - 4 University hospitals - 12 Regional hospitals - 23 Municipal hospitals • Individual contracts between director – staff • Financing by historical budgeting based on a service list • Application of a new method of reporting • Clinical activities • Economic and financial activities

21. What have been observed by monitoring the contracts during the first year? • There are absences of the Specialist Doctors and this is more visible in the hospitals of the municipal level • Lack of provision of the defined services in the services packages • Not good indicators of the medical performance • The medical equipments in some hospitals are not of the appropriate standards • Inadequacy according to the type of service that should be provided • Inappropriate level of qualification regarding the hospital management and the frequent changing of the leading staff • Not appropiate informative system regarding download of the data and the results’ extration.

22. 42% 33%

23. What are going to bring the proposed changes? • Improvement of the population access • Improvement of the cost – effectiveness report • Better services quality • Increase of the services security: • The patient deserves a safer and qualitative service • The standardization of services • Drafting the guidance and medical protocols, the services costs and changing in the manner of financing, dictates the need of hospitals’ reconfiguration • A better relation with the primary health care services • The increase of the diagnostics role with prevention effects • The strengthen of the out-patient service

24. Options for the changesThe first option Maintaining of the status quo • 39 hospitals with services according to the CMD 39 contracts with HII This requires: • Fulfillment of the standards in 39 hospitals • Fulfillment with human resources (especially Specialist Doctors) equipments, devices, etc • Larger investments in the infrastructure Advantages: Maximal possible access Disadvantages: Unaffordable financial costs Impossibility for real resources and mainly with specialists Can not respond to the level of the country development

25. The second option • District level: 11 District hospitals that have to provide 19 obligatory services based on DCM • I Level 5 Municipality hospitals with a level of services between the district hospitals and the municipality existing ones • II Level 11 Municipality hospitals. The possibility to fully provide eight basic services according to the DCM • III Level 8 Municipality hospitals are going to be transformed into centers which will provide these services: Emergency 24 hours, micro-surgery, radiology, lab clinical/biochemical. Advantages: Better access compared to the existing one in the 5 mentioned municipalities Services’ standardization Disadvantages: absence of the flexibility in the provision of the specialized services; contracting in three levels and inappropriate management; social costs

26. The third option Regionalism of the services Reconfiguration of the hospital services in the District level • 11 Hospitals in the districts which manage all the services within the District • 16 Municipality hospitals of the I level • With the necessary basic services according to D.C.M (8 + 1) services • By adding the out-patient as a separate service In the cases of absence this service will be provided from the regional hospital • 8 Municipality hospitals of the II level The conversion of these hospitals in daily hospitals with a limited number of beds for: emergency services, general medicine, micro-surgery services, labs, radiology services, pharmaceutical services, obstetric and gynecological services, the consolatory ambulatory services (out-patient) The tendency of this daily hospitals, according to the results and efficiency, is going to be turning them into primary health care facilities.

27. Advantages & disadvantages of the III option Advantages: • Contacting only with 11 District Hospitals • Providing 19 (+1) basic services in the district hospitals by outlining the service out-patient as a separated and measurable service • The efficiency and flexibility in the usage of the human resources, financial and technological, etc • This enables the providing of the basic services, absent in 16 municipality Hospitals • Enables the contracting of the SD with more attractive payments • Improvement of the access and increase the quality of the services • Standardization of the services and provision of the services according to the needs of the community and make people trust in the hospital services • Disadvantages: - Absence of managers of this reconfiguration - Not appropriate infrastructure regarding the human resources

28. Photos from ALBANIA THANK YOU ! Mag. Elvana HANA General Director of HII Ohrid 01/06/2010