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Transcript of ARMENIA IMPROVING HEALTH CARE SYSTEM - …siteresources.worldbank.org/INTARMENIA/News and...
ARMENIAIMPROVING HEALTH CARE SYSTEM
HD Learning Week
March 9, 2011
Susanna Hayrapetyan
ECSHD
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COMMON BACKGROUNDcharacteristics of previous system
• CENTRALIZED PLANNING (budgeting, hospitals, staffing)
• FREE OF CHARGE HEALTH SERVICES• UNBALANCED FOCUS ON SPECIALISED
HOSPITAL CARE(overstaffed and oversized)• UNDERDEVELOPED PRIMARY HEALH CARE• INPUT BASED FINANICNG OF HOSPITALS
(capacity greatly exceeded demand)
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CHALLENGES OF POST-SOVIET TRANSIION
DISINTEGRATION OF THE FORMER SOCIAL SAFETY NET
SHARP DECLINE IN AVAILABLE FINANICAL RESOURSES (5.6% of total expdt. in 1999)
DETERIORATED ACSESS TO QUALITY HEALTH SERVICES (the utilization rate dropped 2 times for the three poorest income groups 1996-1998)
EXESSIVE INFORMAL PAYMENT
OVERSUPPLY AND OUT OF BALANCE SKILLS MIX (89 specialties vs 33 recognized in Europe, doctors without specialty qualification were providing PHC services, low quality of nurse staff, 36/1000 0population)
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HEALTH CARE REFORMS OPTIONSGOALS
• ESTABLISHING A SENSIBLE BALANCE OF HOSPITAL AND PRIMARY HEALTH CARE
• MAKING SUCH CARE ACCESIBLE-ENSURING ACCESS TO ESNEITAL SERVICES PARTICULARLY FOR VULNARABLE
• REIGNING IN EXESSIVE INFORMAL PAYMENT 4
HEALTH CARE REFORMS DIRECTIONS (since mid 1990s)
STRENGHTHENING PRIMARY HEALTH CARE (the GOA approved first PHC strategy in 1997)
improving the qualifications and skills of PHC providers through retraining,
developing and introducing practice guidelines, inclusion of prevention and outreach activities, improvement of PHC infrastructure in rural areas Introduction of per-capita financing , performance
based reimbursement in 2010 Increasing share of public expenditures going to
PHC WB’s support to PHC reforms through 3
investment programs, SACs, PRCs, DPO
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AMBULATORY IN KANACHUT VILLAGE
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AMBULATRORY IN KAPAN
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HEALTH CARE REFORMS DIRECTIONS (since mid 1990s) ctd
HOSPITAL SECTOR OPTIMIZATION BYConsolidation of hospitals to smaller number of
hospital networks
Reduction of excess building and staff capacity
Introducing outcome oriented financing: case-based financing, global budget contracting
Improving management capacity
Introducing new financial management systems and accounting methodologies
Modernizing/upgrading physical conditions and equipment provision
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HRAZDAN HOSPITAL
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LITTLE GEVORG AT OFTALMOLOGIST
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NEW OPERATING ROOM AT HRAZDAN HOSPITAL
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HEALTH CARE REFORMS DIRECTIONS (since mid 1990s) ctd
HEALTH FINANCING REFORMS
Establishment of separate financing agency-SHA
Shifting from line-item financing to contract based payment for a defined package of health services- BBP
Case-based reimbursement for hospital care (within a capped budget) and capitation based financing for PHC
Increasing public expenditures on health 12
ULTIMATE GOAL OF HEALTH SYTEM: TO WHAT EXTEND THE HEALTH REFOMS HELPED TO REACH
THE DEFINED GOAL OF IMPROVING HEALTH STATUS OF POPULATION?
INTEMEDIARY OBJECTIVIES: HOW THE HEALH REFORMS IMPROVED ACSESS, COVERAGE,
QUALITY AND EFFICINCY OF HEALTH?
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EFFICIENCY
Whether health system resources are used productively to deliver better health outcomes to the people of Armenia?
What progress has been made in implementing a health system that is based on PHC
What progress has been made in optimizing the hospital network in Yerevan and regions (marzes)
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PROGRESS OF HOSPITAL SECTOR OPTIMIZATIONassessed by
• The total number of hospital facilities
• Actual hospital beds compared to target bed numbers
• Hospital beds per 10 000 population
• Hospital bed occupancy rate and average length of stay
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ACCESS TO HEALTH CARE SERVICES
ARE HEALTH SERVICES ACCESIBLE TO EVERYONE, WHO NEED THEM, ESPECIALLY THE MOST VULNARABLE?
Indicators: related to utilization and of the financial barriers to access services
ARE PHARMACEUTICALS BECOMING MORE ACCESSIBLE TO THOSE WHO NEED THEM THROUGH A COMBINAION OF STATE INVESTMENT IN DRUG BENEFITS AND THE CAPACITY OF POPULATION TO PAY
Indicators: share of the state and private of pharmaceutical expenditures , availability of generic drugs
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Hospitalizations
13.1
7.5
9.5
8.9
8.4
7.97.3
6.9
6.1
4.9
5.0
0
2
4
6
8
10
12
14
1990 1995 2000 2001 2002 2003 2004 2005 2006 2007 2008
Ho
sp
ita
liza
tio
ns p
er
10
0 p
op
ula
tio
n
Hospitalization rate per 100 population , 1990, 1995 and 2000-2008
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Percent of population aged 20 and older not seeking medical care when needed, 2007 and 2009
25%
19%
0%
10%
20%
30%
40%
50%
2007 2009
Pe
rce
nt
of
po
pu
latio
n
Source: HSPA 2007 and 2009
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Percent of those not seeking care by reason, 2007 and 2009
43%
47%
78%
11%
11%10%
0%
20%
40%
60%
80%
100%
2007 2009
Pe
rce
nt
of
tho
se
no
t se
ekin
g c
are
Financial reasons Cured myself Other
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Armenia is among most vulnerable in Eastern Europe and Central Asia region
-20
-15
-10
-5
0
5
10
0% 10% 20% 30% 40% 50% 60% 70% 80%
2009 GDP growth(IMF)
OOP as share of total health expenditure (2006)
Most vulnerable
Least vulnerable
Armenia
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Percent
87% 86% 82%
12% 16% 13% 14% 18%
85%88%
0%
20%
40%
60%
80%
100%
2004 2005 2006 2007 2008
Pe
rce
nt
of
tota
l sp
en
din
g
Private expenditures Government expenditures
Private and government expenditures on medicines, AMD billions and percent of total, 2004-2008
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QUALITY AND SAFETY OF HEALTH SERVICES
ARE THE HEALTH CARE SERVICES THAT THE HEALTH SYTEM PROVIDES TO THE POPULATION OF ARMENIA OF ACCPTABLE QUALITY?
ARE THE HEALTH CARE SERVICESA THAT THE HEALTH SYSTEM PROVIDES TO WOMEN AND CHILDREN SAFE AND OF ACCEPTABLE QUALITY, AND DO THEY LEAD TO ACCEPTABLE OUTCOMES?
HOW WELL DO THESE SERVICES REFLECT THE
STRATEGY FOR IMPROVEMENT MATERNAL AND CHILED HEALTH CARE AND MDGs
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Percent of malignant neoplasms detected by stage of the disease, all cancer, 2003-2008
44% 43% 42% 44% 40% 43%
26%22% 19% 18%
20% 18%
31% 35% 39% 38% 40% 40%
0%
20%
40%
60%
80%
100%
2003 2004 2005 2006 2007 2008
Pe
rce
nta
ge
of
all
ca
se
s
I-II III IV
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5 years following breast cancer diagnosis - females only
41%
33%
47%46%46%43%40%39%
0%
10%
20%
30%
40%
50%
1996-2001
1997-2002
1998-2003
1999-2004
2000-2005
2001-2006
2002-2007
2003-2008
Pro
ba
bili
ty o
f su
rviv
al
Probability of survival following diagnosis of cancer, 2001-2008
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Hospital mortality per 100 admissions, all cases, 1990, 1995 and 2000-2008
1.51.51.61.61.61.61.5
1.1
1.81.91.9
0
1
2
3
4
5
1990 1995 2000 2001 2002 2003 2004 2005 2006 2007 2008
Ho
sp
ita
l m
ort
alit
y p
er
10
0 a
dm
issio
ns
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Percent of expectant mothers with early coverage of prenatal care (prior to 12 weeks), 1995 and 2000-2008
56%
53%
50%
48%
49%
47%
48%48%
43%
55%
0%
20%
40%
60%
80%
100%
1995 2000 2001 2002 2003 2004 2005 2006 2007 2008
Pe
rce
nt
of
exp
ecta
nt
mo
the
rs
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Overall policy environment: Armenia has undertaken many good reforms
• Key reforms over last 10-15 years:• Reform Agenda Accomplishments • Purchaser-provider split• √ - Created a state purchaser, SHA• Provider payment reform• √ - GPs paid via capitation plus performance incentive;
hospitals paid case-based with global budgets; piloting case-mix payments
• Strengthen PHC• √ - Established family medicine, trained nearly 100% of GPs• Downsize hospitals• √ - Steady progress with mergers (40% reduction in public
hospitals 2004-08); hospitals have substantial autonomy• Target the poor• √ - Modest attempt at targeting of poor through BBP 35
Improve Health Outcomes Not much progress in reducing mortality since 1970
0
20
40
60
80
100
120
140
160
180
1970 1990 2010
Ad
ult
mo
rtal
ity
(15
-60
), p
er
10
00
Armenia Western EuropeSource: Rajaratnam et al. (2010)
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Why so little progress in reducing adult mortality in Armenia?
• Currently very low access/coverage/implementation of the five specific interventions that have had the biggest impact in West
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Five interventions that have had largest impact in West
Assessment of implementation in Armenia
Anti-tobacco policies (cigarette taxes, smoking bans, etc.)
X – Cigarette tax (as % of price) much lower in Armenia than Europe, Turkey, or Georgia
Cardiovascular disease drugs (ACE-inhibitors, beta-blockers, statins, etc.)
X – About 93% of total drug spending is out-of-pocket; coverage of these cardiovascular drugs is low
Cardiac surgeries (angioplasty, bypass) X – Only about 250 people covered in 2009: a very small fraction of total ‘need’
Early diagnosis and treatment of breast and colon cancer
X – No coverage of diagnostic tests in basic benefit package
Neo-natal intensive care X – Few hospitals have capability to provide; high OOP is typically required
CHALLENGES AHEAD
Developing standards and key indicators for the quality and safety of health care services
Continuing implementation of PHC reforms and hospital optimization
Reforming the basic benefit package in terms of its content, the depth of its financial protection, the population group it covers
Addressing prevalence of behavior risk factors, particularly smoking among males, and focusing on those in lower-income households
Increasing capacity for health system information management through implementation of the HIS strategic plan, and through improved access to data and information
Strengthen SHA, move towards case-based payments/DRGs, and make better use of data to measure hospital performance
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