KAZAKHSTAN S PRIMARY HEALTH CARE: WHERE DO THE REFORMS LEAD US?

Nailya Almagambetova Northern Illinois University Kazakhstan October 2011 KAZAKHSTAN S PRIMARY HEALTH CARE: WHERE DO THE REFORMS LEAD US? The purpose of this research is to assess the impact of introduced health care reforms/programs on the population s health and health services utilization throughout the years of Kazakhstan s independence. The focus is on primary health care and reforms/programs related to maternal and child health as well as the establishment of small family practices. Although the analysis demonstrated a considerable improvement in population health during the last thirteen years, not all populations benefited from the improvements equally. The analysis revealed a significant disparity in population health among the regions, which increased in some health aspects during the studied years. The current research will assist in better understanding the challenges and threats for the population s health in Kazakhstan, as well as opportunities and shortcomings of health care reforms/programs. The following opinions, recommendations, and conclusions of the author are his/her own and do not necessarily reflect the views or policies of IREX or the US Department of State.

WWW.IREX.ORG RESEARCH IN CONTEXT Kazakhstan s health care system was developed during the seventy years of Soviet power. It was financed by the government and provided universal, free, and portable health care. After gaining its independence from the collapsed USSR in 1991, the country underwent a deep recession, characterized by a decline in GDP and health expenditures, which decreased to 1.5% of GDP, resulting in a 37% reduction in the health budget (WHO, 2005). The economic and social disruptions led to a deterioration of the population s health and a reduction in access to health services. Thus, life expectancy hit the lowest levels in 1995 (with only 58.4 years for men) and only recently started approaching the level of the 1990s (68.4 years for men). Although recent years showed a slight improvement in the population s health, many indicators have yet to reach the levels observed in 1990 (WB, 2005). In attempts to provide effective and efficient care under the constrained health budget, the country has implemented various health care reforms/programs in health finance and delivery since its independence. Many pilot programs were introduced in the selected regions in the country. The overall impact of implemented reforms on population health and health services has yet to be thoroughly studied. Among all reforms, those related to both introduction of family practices (FP) and maternal and child health present the main Of all the forms of inequality, injustice in health is the most shocking and the most inhumane Dr. Martin Luther King interest for this research. In the 1990s, the move toward establishing small FPs started in the country by introducing them in several pilot areas. Traditionally, city residents were served by polyclinics that provided thousands of people with primary care, various outpatient specialist services, minor surgeries, lab and other diagnostic procedures, rehabilitation care, and pharmacy service. Replacing polyclinics by small FPs in cities, in the researcher s opinion, contradicts the related international experience. For example, Great Britain moved from solo FPs to large groups of 10 or more physicians specialized in various areas. In other countries, including the US, multispecialty clinics integrating services of up to 60 physicians under one administration also became prevalent lately (Sloan, 2008). Some studies showed a significant positive correlation between practice size and efficiency/quality of care (Casalino, 2003). 1

RESEARCH PROCESS AND RESULTS The research is planned as a part of the continuing research agenda for assessing the impact of introduced health care reforms/programs on population health and health services utilization throughout the years of Kazakhstan s independence. The focus of the research is on primary health care, and the main objective is to evaluate the impact of reforms in primary care. In order to do that, the trends in population s health in all regions need to be evaluated and understood. Many reforms and programs in Kazakhstan s health care were implemented only in a few pilot regions; this provides an opportunity for studying the changes in population s health in the intervention and regions in comparison with intact (control) locations. The data on primary care indicators was obtained for the last 13 years, with the earliest available years being 1998-1999. The current system of administrative division of the country, which is important for defining the units of observation of the study, was introduced in 1997, when the borders of the regions were changed. Therefore, the earlier data would not be comparable to the data of later years. The preliminary analysis of this ecological study was done by using the Statistical Package for the Social Sciences, SPSS, and is based on the data for the years 1999 and 2010. During that period, health care was undergoing numerous reforms and policy changes; to name a few of them: the attempts to introduce a mandatory health insurance; expanded privatization of medical and healthrelated facilities; introduction of family practices; rationalization of the hospital sector with closing many, primarily rural, hospitals; introduction of IMCI (Integrated Management of Childhood Illness); and Support for Maternal and Child Health. During the years 1999-2010, many health indicators were considerably improved. The data demonstrated statistically significant decrease in infant mortality rate, IMR, (from 20.2 to 16.5 per 1,000 live births) and maternal mortality rate (from 65.3 to 22.7 per 100,000 live births). In spite of remarkable improvement, these numbers are still much higher than those in developed countries; for example, the IMR was 6.7 and maternal mortality was 12.7 in the US in 2007 (Healthy People 2020). The data also showed the decline in incidence of infectious diseases among the entire population (by 29%) as well as among infants (from 92.1 to 45.9 per 1,000 infants). Infant death from such preventable causes as respiratory diseases and infections also declined considerably (from 56.8 to 14.9 per 10,000 live births, and from 18.4 to 5.2 per 10,000 live births, respectively). Visible progress was reached in mental health, both in the general population and among teenagers. A statistically significant decrease was noticed in 2

the incidence of and death from tuberculosis. Larger populations became involved in preventive TB screening, which resulted in a slightly increased proportion of TB cases diagnosed during the screening among all diagnosed TB cases. Early enrollment in prenatal care (during the first trimester of pregnancy) only slightly increased and showed a negative correlation with both infant mortality rate and maternal mortality rate and no correlation with availability of obstetricians in the area. A low early prenatal care enrollment (64.8%) and its correlation with above-mentioned mortality rates indicate a need in educating women about the benefits of prenatal care. Another area of needed education among population is related to abortions and use of contraceptives. Although the number of abortions somewhat decreased (from 34.1 to 23.0 per 1,000 women of reproductive age), the number of abortions that are neither spontaneous nor due to medical reasons increased. At the same time the use of contraceptives (as a percent of women of reproductive age using them) has not changed drastically. The number of abortions has a high positive correlation with the number of obstetricians/gynecologists in the area, which could possibly illustrate an example of physician-induced demand for this procedure. There was no correlation between abortions and contraceptive use. Along with the above mentioned improvements, some conditions still present a huge concern, such as an escalating incidence of congenital disorders, neoplasms, endocrine, and immune disorders. One of the reasons, partially causing the growing rates of these conditions, is the improved diagnostics of those diseases. However, all these conditions require further thorough investigation. In spite of overall improvement in population health status, not all population groups benefited from the improvements equally. The data reveal a striking difference in health indicators across regions. The index of disparity (ID) was used for the data analysis as a tool for analyzing the differences across various indicators, population consisting of multiple groups, geographic areas, or changes in disparity over time. Presented here are a few selected findings in population s health disparity in different regions and its trends over the explored years. In 1999, IMR in regions ranged from 15.6 to 31.5 per 1000 live births. As was shown above, IMR of the overall Kazakhstan s population was noticeably improved in 2010. However, while some regions had this indicator as low as 11.9, other regions had it higher than the average number for the country more than a decade ago, and even higher than their own numbers in 1999. The index of disparity has actually increased from 12% to 15.2% in 2010. A similar situation was observed in maternal mortality: ID increased from 27.7% in 1999 to 44.3% in 2010. Again, the degree of improvement varied 3

considerably among regions. It is clear that some differences in health outcomes can be partially explained by small area practice variation theory (variation of medical practice across the geographic regions and medical facilities). However, when the range of, for example, maternal mortality rate among different regions varies from 15 to 111 per 100,000 live births, we need to study those disparities more closely. Increased disparity was observed, among other indicators, also in incidence of congenital diseases among infants, TB mortality, mortality from respiratory diseases and infections among infants, incidence of infectious diseases and neoplasm in the entire population, mental disorders among teens, and use of contraceptives. When a region has the worst indicators in the country, which is twothree times higher than the country s average, for a number of consecutive years, thorough needs assessment in those regions should take place. Some of those disparities can be partially explained by some environmental problems that exist in various regions. They are inherited from the era of Soviet Power, when a lot of ecologically hostile enterprises were launched in vast and relatively low-populated Kazakh steppes. Some of these environmental concerns include nuclear bombs testing area; a number of sites of uranium mining; extensive development of virgin lands with severe irrigation that resulted in disastrous shrinking of the Aral Sea; intensive oil drilling. These environmental problems obviously cannot be fixed in those particular regions over just a couple of years, even a decade. However, what can be done is revising some standards of health care delivery in those needy regions and introducing more health promotion and health education programs. For example, the medical manpower can be strengthened according to the disease profile (diseases/conditions that present the biggest problem in the area, as compared to other regions) of that particular region. According to the reviewed data, the highest incidence of diseases, as compared to other regions, which was persisting for several years in certain locations, did not result in increase in a number of corresponding specialists in those regions. 4

CONTINUING RESEARCH RELEVANCE TO POLICY COMMUNITY As mentioned, the current project is a part of a research agenda to study the impact of main health care reforms in Kazakhstan on population health. For the purpose of this report, a brief analysis was done over two years, 1999 and 2010. The data obtained for the 13 years will be thoroughly analyzed in a time-series study in order to determine the effect of interventions/reforms. Besides regional variations, rural/urban disparity in health indicators and health services utilization will be examined. The rural areas are very different from urban areas by their infrastructure, conditions for health services delivery, and availability of resources. The population density in rural areas is very low, and there is a constant shortage of medical personnel. All of these factors require a careful tailoring of the reform implementation approaches. The disparity between regions and rural/urban areas and its changes across the geographic areas and time will be examined. Coming reforms in medical education with higher emphasis on general/family practice will be also studied in the future. Although not presented in the current report, some initial preliminary qualitative data, including informal unstructured/semistructured interviews with practitioners and academicians, were gathered and are going to be expanded. One of the Unites States foreign policy missions is to create a more secure, democratic, and prosperous world for the benefit of the American people and the international community" (USDS). Health of a nation is one of the major factors that contribute to its prosperity and stability. Some studies demonstrated strong correlation between population health and democracy and inequality (Franco, 2004). The current analysis revealed a significant disparity in population health across regions through the reviewed period. The society that considers itself democratic should not tolerate the disparity among its citizens, especially in such an essential matter as health. The current research will assist in better understanding the challenges and threats for the population health, as well as opportunities and shortcomings of health care reforms. The results will be presented to policy makers, disseminated through publications and presentations, and used in the courses that the researcher is teaching. Discussions on health care reforms in various world regions and their impact on population s health and health services will enable students to think critically about policy changes and potential consequences, and will help them to develop analytical skills necessary for future leaders and public health decision-makers. 5

REFERENCES Casalino, L., Gillies, R., Shortell, S., Schmittdiel, J., Bodenheimer, T., Robinson, J., et al. (2003). External incentives, information technology, and organized processes to improve health care quality for patients with chronic diseases. Journal of the American Medical Association, 289: 434-441. Franco, A., Alvarez-Dardet, C., & Ruiz, M.T. (2004). Effect of democracy on health: Ecological study. British Medical Journal, 329 (7480), 1421-22. International Monetary Fund. (January, 2001). Republic of Kazakhstan: Selected issues. IMF Country Report 01/20. Washington, D.C. Sloane, P.D., Slatt, L.M., Ebell, M.H. (2008). Essentials of family medicine. Lippincott Williams & Wilkins United States Department of State. Mission and values. Retrieved from www.state.gov/documents/organization/59163.pdf World Bank. (2005). World development indicators 2005. Washington, D.C.: World Bank WHO Regional Office for Europe. (2005). European Health for All database. Copenhagen, Denmark: WHO Regional Office for Europe. Retrieved from http://www.euro.who.int/hfadb 6

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