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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15

16

17

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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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20

21

22

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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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