Availability and quality of primary health care in the compulsory health insurance system in Kazakhstan

doi:10.21203/rs.3.rs-3403945/v1

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Availability and quality of primary health care in the compulsory health insurance system in Kazakhstan

https://doi.org/10.21203/rs.3.rs-3403945/v1

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Background

The study aimed to assess the satisfaction of patients with primary health care services and to determine indicators of the effectiveness of medical care in the compulsory health insurance system in Kazakhstan.

Methods

It was an analytical observational study with cross-examination. This study was conducted in primary health care (PHC) organizations in Kazakhstan. Patient satisfaction was measured using a questionnaire consisting of 35 closed questions. The analysis of the indicators of the results of the stimulating component of the per capita standard for financing PHC organizations for the achieved results of activities is carried out.

Results

54.0% (1.80 ± 1.108) of the surveyed patients were completely satisfied with medical care, and 59.4% (1.82 ± 1.269) considered laboratory tests available. Men were completely satisfied with the medical care and availability of laboratory tests compared to women. Indicators of the final result were achieved in the city polyclinics № 3 and № 14 of the city of Almaty Kazakhstan and there was an increase in the amount of incentive component of per capita funding by 1.1 times.

Conclusions

In the system of compulsory medical insurance, medical care in PHC organizations is affordable and effective according to the estimates of the interviewed patients and an indicator of the final result of the polyclinics.

Patient satisfaction

Primary health care

Health Insurance

Medical Insurance

National Health Insurance database

Universal health coverage (UHC) implies improving access to health services and financial protection through voluntary health insurance, especially in low and middle-income countries. A country's socioeconomic system has the greatest impact on the population's access to specialists and general practitioners under the compulsory health insurance (CHI) system. A study on the introduction of contributory National Health Insurance in Saudi Arabia showed that the number of individuals aged 30–39 years were more willing to pay for National Health Insurance compared to participants aged 50 years and older.¹

In Switzerland, there is universal compulsory health insurance, to which it is possible to purchase additional insurance for the hospital sector, independent of factors related to the social and economic status of the population, such as education, social status and income.² Household wealth was found to be positively correlated with the likelihood of going to formal health care providers. In addition, urban residents were statistically and significantly more likely than rural residents to seek medical care, indicating the need to abolish health care fees for low-income populations.³ The study of the role of risk preferences depending on the status of the participant insured and uninsured in the voluntary health insurance system oriented to the informal sector showed that, on average, respondents have a high degree of risk aversion, and the insured are more risk averse than the don’t insured.⁴ The role of private insurance system is of particular relevance and importance among the population of the Commonwealth of Independent States (CIS) compared to the state social health insurance program in the private hospital sector. This is due to the fact that patients with private insurance received timely and comprehensive access to treatment.⁵ The main factors are poor quality of medical care and shortages of medical personnel, medicines and technology. Identifying unscrupulous spending in the health insurance sector has become an important measure to ensure the efficient use of public funds in the context of rapid growth of health care services.⁶ The study found that the educational attainment of the poor influences the decision to become members of the National Insurance Scheme than those with less or no education.⁷ In order to control and improve the efficiency of insurers' data management, a unified information system in healthcare organizations is important, which should expand cooperation with the medical industry to further develop the application processes of big healthcare data and eliminate privacy risks.⁸ There are problems in the CIS countries that hinder the coverage of the population with compulsory health insurance. Lack of funds, poor quality of care, shortage of medicines and medical supplies, poor attitude of health workers, long waiting times and lack of trust are the main reasons for low coverage of compulsory health insurance in low-income countries. In addition, it was found that the less educated are willing to pay less than the highly educated, men are willing to pay more than women, young people are willing to pay more than older people and larger households are willing to pay more than households with fewer members. ⁹ Despite differences between countries, important challenges include inadequate funding, sub-optimal pooling of funds and unmet expectations in strategic procurement.¹⁰ An analysis of the utilization of 13 allied health services provided through the Medicare Chronic Disease Management program and related general practitioner (GP) care planning initiatives showed disparities in the availability of care for patients with chronic conditions and the need for an in-depth study of program satisfaction according to GP needs. ¹¹

The purpose of the legislation of the Republic of Kazakhstan in the field of health care is to ensure that citizens realize their right to health protection, including accessible and quality medical care, in order to protect and promote the health of the population of the Republic of Kazakhstan. The task of the legislation of the Republic of Kazakhstan in the field of health care is to create legal conditions aimed at improving the health of the citizens of the Republic of Kazakhstan. Primary health care is an integral part of the socio-economic development of society and the national health care system of the Republic of Kazakhstan.

Design and study population

This analytical cross-sectional studyis one-time sociological research using the survey method with questionnaires and in-depth interviewing method. The study involved 556 patients aged 18 and 60 years and older, who applied for primary health care in the City Polyclinics of Almaty city of the Republic of Kazakhstan. The portal is a tool for automated calculation of the incentive component of the comprehensive per capita rate of primary health care based on the achieved outcome indicators in accordance with the procedure defined by the Order No. 52 of February 7, 2018.

Ethical considerations

To comply with all ethical principles and rules during the sociological research, the project received ethical approval from the Kazakh Medical University "KSPH". The study was conducted in accordance with the Declaration of Helsinki and approved by theEthics committee of the Local Ethical Committee of the Kazakhstan Medical University “KSPH” (IRB –15-2023 from 17 May 2023).

Consent for publication

Informed consent was obtained from all subjects involved in the study.

Statistical methods

Statistical analysis of the results was carried out using SPSS ver. 25.0 (IBM, Armonk, NY, USA), according to descriptive statistics, the average and standard deviations are calculated, P value <0.05 was considered statistically significant. In this study, the statistical significance of differences in mean values for all categories of variables was determined using the Student's t-test (P-value <0.05).

In this study 556 respondents participated in the survey, of which 27.3% (n=153) were male and 72.7% (n=403) were female (table 1). Analysis of the results of the age breakdown of the respondents showed that the highest number of respondents were aged 18-29 years (37.8%), aged 40-49 years (18.1%) and aged 30-39 years (17.0%). The majority of respondents had higher education -54.7%, secondary vocational education -24.8% and secondary education - 17.3%. In terms of marital status, married or married respondents - 50.5%, and 36.0% were single or unmarried. The level of accessibility of laboratory tests and medical care in the attached polyclinic showed that more than half were satisfied (laboratory tests - 59.4%, medical care - 54.0%) and partially satisfied with the accessibility of laboratory tests and medical care.

Table 1. Socio-demographic characteristics of the respondents

Characteristic		Total	Percentage	Mean	Standard deviation	Р-value
Gender	Male Female	153 403	27.3% 72.7%	1.72	0.447	0.000
Age	18-29 30-39 40-49 50-59 60 and older	209 95 101 76 75	37.8% 17.0% 18.1% 13.7% 13.4%	2.48	1.445	0.000
Education	Secondary Secondary vocational Incomplete secondary Higher	96 138 18 304	17.3% 24.8% 3.24% 54.7%	2.95	1.219	0.000
Marital status	Single/unmarried Married/married Divorced Widow/widower Unregistered marriage	200 281 30 25 20	36.0% 50.5% 5.4% 4.5% 3.6%	1.89	0.952	0.000
Assessment of the availability of laboratory tests	Completely satisfied Satisfied, but partially satisfied Rather unsatisfied Not satisfied Difficult to answer	330 120 31 25 50	59.4% 21.6% 5.6% 4.5% 9.0%	1.82	1.269	0.000
Accessibility of medical care	Completely satisfied Satisfied, but partially satisfied Rather unsatisfied Not satisfied Difficult to answer	300 150 50 30 26	54.0% 27.0% 9.0% 5.4% 4.7%	1.80	1.108	0.000

In order to determine the accessibility of laboratory tests and medical care among both men and women in primary health care, the answers of respondents were analyzed, which are presented in figures 1 and 2.

Figure 1. Opinion of respondents about availability of laboratory tests by gender

Figure 2. Opinion of respondents about availability of medical care in polyclinics by gender

According to the results of the study, laboratory tests and medical care are fully considered accessible by the majority of men (100.0%), compared to women (laboratory tests - 43.92%, medical care - 36.48%). 29.78% of women were partially satisfied with the accessibility of laboratory tests and 37.22% of women - with medical care.

The results of the study of respondents' answers regarding the duration of waiting time for certain services in medical organizations showed that half of 294 citizens (53.3%) waited in line at the registration desk for less than 15 minutes, and 251 (48.3%) waited for a doctor for less than 1 hour (table 2). Having made an appointment with a doctor, the majority of 460 patients (83.8%) got an appointment at the first call to the medical organization, and almost the same number of 470 (85.9%) were seen by a doctor at the appointed time, while the waiting time for a district doctor was up to 30 minutes for 373 (68.2%). The answer to the question about waiting time for a specialist doctor for 221 (41.1%) was more than an hour, and 169 (31.5%) respondents did not get an appointment on the day of application.

Table 2. Duration of waiting in the queue of a medical organization

The duration of waiting for certain services in medical organizations	The largest number of selected answers	Minimum time	Maximum time
How long have you been waiting in line at the reception?	up to 15 minutes	there was no queue	more than 1 hour
The waiting time for the doctor to whom you made an appointment (called to the house) from the moment of the appointment was?	less than 1 hour	less than 1 hour	24 hours or more
How much time did you spend, on average, waiting for the appointment of a district doctor (therapist, pediatrician, family doctor, in organizations?	up to 15 minutes	there was no queue	more than 1 hour
How much time has passed since the call was made to the district doctor (therapist, pediatrician, family doctor) before he came to your house?	not called	less than 3 hours	came the next day
How much time did you spend, on average, waiting for an appointment with a specialist doctor (neurologist, surgeon, ophthalmologist, otolaryngologist)?	more than 1 hour	more than 1 hour	More than 10 days
How much time did you spend waiting for the diagnostic tests assigned to you?	1 day	1 day	over 3 days

The results of the analysis of data on performance indicators of City Polyclinics #3 and #14 of the Almaty City Health Department of the Republic of Kazakhstan for 2022 are presented in table 3. To determine the incentive component of the complex per capita norm for financing of PHC organizations for the achieved final results of activity, PHC medical workers receive financial incentives and referral to professional training.

In the city polyclinic #3 in 2022 according to the plan was allocated - 838,362.50 thousand tenge, but as the data showed the actual amount increased. 1 times and amounted to 966,057.95 thousand tenge on the following indicators: maternal mortality, preventable at the PHC level, child mortality from 7 days to 5 years, for the first time detected cases of malignant neoplasm visual localizations 1-2 stage, the level of hospitalization of patients with complications of diseases of the cardiovascular system (myocardial infarction, stroke), the proportion of children under 5 years of age hospitalized with complicated acute respiratory infections, the coverage of patronage visits to newborns in the first 3 days after discharge from the maternity hospital, and substantiated complaints.

The obtained results of the analysis indicate the achievement of indicators of the result and will be directed to financial incentives and professional training of employees of the city polyclinics № 3 and №14 of Almaty (table.3)

Table 3. Outcome indicators of the Incentive component of the per capita standard (PPCS) in City Polyclinics #3 and #14 of the Almaty City in 2022

Indicator	City polyclinic #3			City polyclinic #14
	Amount PPCS thousands of tenge			Amount PPCS thousands of tenge
	Plan	Fact	Deviation (actual-plan)	Plan	Fact	Deviation (actual-plan)
Maternal mortality preventable at PHC level	838 362,50	966 057,95	127 695,45	438 337,50	442 829,78	4 492,28
Child mortality from 7 days to 5 years preventable at PHC level	838 362,50	966 057,95	127 695,45	438 337,50	442 829,78	4 492,28
Timely diagnosis of pulmonary tuberculosis	838 362,50	966 057,95	127 695,45	438 337,50	442 829,34	4 491,84
First detected cases of malignant neoplasm of visual localization 1-2 stages	838 362,50	966 057,95	127 695,45	438 337,50	442 829,78	4 492,28
Rate of hospitalization of patients with complications of cardiovascular diseases (myocardial infarction, stroke)	838 362,50	966 057,95	127 695,45	438 337,50	442 829,78	4 492,28
Justified complaints	838 362,50	966 057,95	127 695,45	438 337,50	442 829,78	4 492,28
Share of children under 5 years of age hospitalized with complicated acute respiratory infections	838 362,50	966 057,95	127 695,45	438 337,50	442 829,78	4 492,28
Coverage of patronage visits to newborns in the first 3 days after discharge from the maternity hospital	838 362,50	965 767,51	127 405,01	438 337,50	442 696,65	4 359,15

In order to study the availability and quality of primary health care in the OSMS system, a sociological survey was conducted among patients in primary health care. Within the framework of reforms carried out in the Republic of Kazakhstan, the state has provided the population with the opportunity to freely choose a polyclinic and a doctor, and to ensure the quality of medical care, incentive components of per capita norms were introduced to encourage primary care physicians to provide timely, affordable medical care.

There are many interrelated factors at the individual, interpersonal, societal and system levels that determine the implementation, utilization and sustainability of community health insurance programs.¹²

Taken together, the results suggest that voluntary health insurance in Sweden provides benefits primarily to healthy and well-off people.¹³ A study in Finland found that socio-demographic characteristics explained voluntary private health insurance coverage more than public or private health care coverage.¹⁴

Budgetary transfers to health insurance schemes have helped to deepen universal health coverage or maintain the gains made in compulsory health insurance in these low-income European countries, as they cover those not in the formal sector and particularly vulnerable groups.¹⁵

Patients who were frequent users of public health services and on low incomes were unlikely to switch to private health care or recommend private services.¹⁶ In addition, research is needed on best practices for including vulnerable groups in health insurance schemes.¹⁷^,¹⁸

Flexible payment plans where the poor can pay in installments, subsidizing premiums for the poor, and eliminating co-payments are measures that can increase enrolment and utilization among the poor.¹⁹^,²⁰ Countries that rely heavily on out-of-pocket payments, including informal payments, to finance total health expenditures are unlikely to achieve universal coverage. Reforms should include reducing drug prices and rational use, strengthening administrative controls and increasing incentives for quality care.²¹^,²²^,²³

The strengths of this study are a comprehensive assessment of the activities of medical organizations in the system of compulsory health insurance through comparative analysis based on outcome indicators and sociological survey of patients about satisfaction with medical care in primary health care. The limitations of the study are the inability to obtain data on all polyclinics in Almaty, the Republic of Kazakhstan.

The findings of the study reflect the true views of patients on primary health care in the compulsory health insurance system and can be used as a scientific and sound basis for operational and strategic management decisions, as well as for future research.

Availability of data and materials

The authors confirm that the data supporting the findings of this study are available within the article.

Transparency declaration

The corresponding author on behalf of the other authors guarantee the accuracy, transparency and honesty of the data and information contained in the study, that no relevant information has been omitted and that all discrepancies between authors have been adequately resolved and described.

Authorship contributions

Study design: M. Shurenova, K. Kurakbayev. Methodology: M. Shurenova, K. Kurakbayev, T. Abildaev. Literature review: M. Shurenova. Data collection and clean-up: M. Shurenova, K. Kurakbayev, T. Abildaev. Data analysis and interpretation: M. Shurenova, K. Kurakbayev, T. Abildaev. Writing the manuscrite: M. Shurenova, K. Kurakbayev, T. Abildaev. Critical review: M. Shurenova, K. Kurakbayev, T. Abildaev. Final version approval: M. Shurenova, K. Kurakbayev, T. Abildaev

Conflicts of Interest

The author reports no conflicts of interest in this work.

Funding

None. This research was done within the frame of doctoral program at Kazakhstan’s Medical University Kazakh School of Public Health “KSPH”.

Ethical clearance

Consent for publication

Informed consent was obtained from all subjects involved in the study.

Acknowledgements

The authors say thank to the National Research Center for Health Development named after Salidat Kairbekova, Astana, Kazakhstan for their contributions to the investigation.

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No competing interests reported.

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Availability and quality of primary health care in the compulsory health insurance system in Kazakhstan

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