Rational use of health care resources is critical to improving health service access and quality in an environment of declining government funding. At present, health systems in Central Asia suffer from chronic under-financing and inefficient use of limited available resources. One of the most profound inefficiencies in the health care system is the imbalance between the hospital and primary health care sectors. The health delivery system inherited from the former Soviet Union is like an inverted pyramid. The hospital sector at the top of the pyramid is over-developed and the primary health care sector that should serve as the broad base of the pyramid is under-developed, under-financed, and under-utilized. Hospitals consume more than 70% of the health care budget. Solving this problem requires a complete restructuring of the service delivery system, and, as a first step, strengthening the primary health care sector through the creation of new independent primary health care practices.
This component of the ZdravPlus Project improves the efficiency of resource use in Central Asia by:
ZdravPlus helps governments in Central Asia define and implement a clear vision for the future of their health delivery systems. The project's vision centers on primary health care practices that provide an expanded scope of integrated services to the entire population. The inpatient sector is consolidated to consist mainly of general hospitals with outpatient departments, and provides inpatient services to treat severely ill patients. Polyclinics are integrated into hospital outpatient departments or diagnostic centers. This new structure of the health delivery system meets the dual goals of rationalization to allocate limited resources more effectively and creating space (both physical and clinical practice space) for new primary health care practices to expand their scope of services. Whenever possible, savings generated from rationalization will be retained within the health sector.
One of the greatest obstacles to rationalizing the Central Asian health delivery system is a budgeting process that maintains separate budgets tied to separate delivery systems at every level of administration (national, oblast, city, rayon, and rural). ZdravPlus recommends pooling budget funds at the oblast level as a crucial pre-condition for rationalization, because it allows a health delivery system to be established across government units and facilities to be closed or downsized without budget funds leaving the health sector. Pooling health care resources also can empower health planning organizations instead of financing organizations to plan, manage, finance, and monitor the health service delivery system.
New ways to pay health providers are needed to provide incentives to introduce competition, encourage increased efficiency, and allow health care providers greater autonomy over their resources. ZdravPlus is introducing new provider payment systems in pilot sites throughout Central Asia, and continues to refine provider payment systems already in place. Per capita payment systems are preferred to reimburse primary health care facilities because they are simple to administer, they ensure equitable distribution of health care resources, and they support health promotion and prevention. Case-based payment systems have been chosen as the preferred method for reimbursing hospitals. These payment systems strengthen the connection between the services provided to an individual patient and the amount of financial reimbursement received by the hospital.
In addition, ZdravPlus engages in policy dialogue on health financing issues and helps health systems in analyzing and evaluating options for mobilizing additional resources for the health sector. Some of these options are: (1) privatization - developing policies to allow public funds to be directed to private health facilities, and creating non-profit status for health providers to retain tax subsidies; and (2) private health insurance - defining key regulatory issues and setting boundaries between public and private insurance benefits packages. ZdravPlus also has provided technical assistance to inform Central Asian policymakers on the benefits and pitfalls of social health insurance mechanisms based on international experiences.
In the past, health care facility budgets were disbursed by budget chapters (line items) according to strict norms. Since budgets had to be spent according to these chapter allocations, facilities could not use their resources in the most cost-effective manner. ZdravPlus works to ensure that facilities are given more autonomy and flexibility through "chapterless financing" and business planning processes, so that facilities can manage their resources more effectively to meet local health needs.
ZdravPlus provides technical assistance to improve management skills at all levels of the health care system. At the system level, ZdravPlus provides technical assistance and training to upgrade accounting systems and skills to international standards, establish internal controls and accountability, install performance management systems, develop internal and external audit functions, and develop fraud prevention capabilities. At the facility level, ZdravPlus continues efforts started under ZdravReform to strengthen financial management systems, establish health management as a profession, and develop a sustainable cadre of primary health care practice managers throughout the region. These newly trained health managers help the primary health care practice begin to function more like a business and free head physicians from administrative work so they can spend more time in clinical practice. By providing technical assistance, training, and operations manuals, ZdravPlus upgrades financial management systems and practice manager capability in the areas of general administration, health care financing, accounting standards, budgeting and business planning, human resource management, facility and inventory management, and using data for decision-making.
The Ministry of Health as a health purchaser requires health management information systems that support the design, implementation, and evaluation of new provider payment systems and quality assurance systems. ZdravPlus believes that a comprehensive health information system is sustainable in Central Asia because of the existing infrastructure devoted to accumulating health data and statistics. It is necessary to adapt the existing health statistics systems to increase their efficiency and to shift their focus from collection to analysis of data, through computerization and more effective use of human resources. Information also should be used for quality assurance purposes that move from evaluation of processes to evaluation of outcomes and to support licensing and accreditation bodies, to ensure that both public and private health providers meet minimal standards. ZdravPlus provides support to the continued development and refinement of these health information systems at the health purchaser level. At the health provider level, ZdravPlus is helping to introduce new management information systems to provide health facility managers with tools to adapt to the new environment, support decision-making and allocation of resources, and monitor quality improvements.