Approaches to developing the master-plan for the development of the outpatient service

network

Ministry of Health and Social Development of the Republic of KazakhstanRSE «Republican Center for Health Development»

Deputy Director GeneralNagima M. Issatayeva

Social development trends (WHO)

• Environmental changes, influence of hazardous factors

Growing expectations: provision of greater accessibility, quality improvement of medical service delivery, advancement of education, development of information

support

Discrepancy between the

problems and the medical service delivery models

Overuse, underuse and

misuse of medical services

The limitations of the healthcare system’s structure and functions, which lead to inefficiency and inequality of

medical service delivery

Demographic shift towards “ageing”, increasing life expectancy

Growth of non-communicable diseases (coronary, oncological, etc, which are the causes of mortality in 87% of cases)

Emergence of new infectious diseases (HIV/AIDS, Ebola and other viral infections), caused by environmental changes, population migration

Uncoordinated medical service

delivery schemes

Focus on inpatient care

Neglecting preventive and

social care

2

Government’s and society’s approaches, modern

management

Coordination and integrationof medical service delivery

Financial protection Regulation of incentives

Generating resources

finances

management

medical service delivery

resource strengthening

POPULATION

Strengthening the focus on the person at the center of the system by 2020 (WHO)

3

Why is PHC in need of updating and why is it relevant nowadays more than ever?

.

PHC

Efficiency requirements of the modern healthcare system

Cost-intensive inpatient careGlobalisation produces social

tension

Disease and risk factor prevention 4

•Only 1/3 of all medical care is provided at the PHC level, 2/3 are provided in the hospital sector •Overspecialisation: around 50% of physicians at outpatient clinics are

specialised doctors•Patients are referred to specialised doctors in 30-40% of all cases

(compared to 10-12% in international practice)

insufficient attention towards the actual needs of the population;irrational use of resources (human, financial, materials and equipment); inadequate labour process arrangement; insufficient qualifications of PHC doctors; tendency towards high specialisation of doctors in outpatient clinics; lack of accountability for patient outcomeslack of motivation for continuing professional development: low wages and

other socioeconomic issues

PHC specifics and limitations in Kazakhstan

5

International trends in medical services planning

transition from cost-intensive inpatient care to outpatient care

fulfilling the population’s needs for accessibility of medical care

enhancing general medical practice

transition from focusing on the volume of medical services to focusing on their quality

continuing professional development of doctors, leading to improvement of quality of their work

expanding the focus on prevention in healthcare

6

The following issues need resolving prior to planning

• The role of specialised care in PHC based on developing family medicine;

• Specifying which specialist services are to be provided in hospitals,

consultation & diagnostic clinics, PHC/general medical practice;

• Strengthening the role of general practitioners as the coordinators of care

and the first contact in the PHC system;

• Increasing the competency of general medical practitioners: improving

the education and conversion training for general medical practice and

general medical practice nursing;

• PHC in rural areas: motivation, salaries’ appeal

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The principles of planning

• An approach based on the needs of population: a patient-oriented approach instead of a delivery-oriented one;

• Timely access to medical care for all;

• Focus on improving access to medical care for rural population in the context of ageing and chronic diseases;

• Safe and high-quality PHC services, provided in accordance with international standards of medical care;

• Equitable distribution of resources between PHC and the hospital sector;

• Stable financing terms, regulating the provision of services according to existing resources.

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The components of planning

The network of medical

organizations

GEOGRAPHICAL ACCESSIBILITY OF

MEDICAL SERVICESTravelling time

THE NEEDS OF THE POPULATION

Morbidity and mortality

SERVICE PACKAGE• Clinical guidelines and standards

• Efficiency• New technology

PERSONNELNumber of personnel

and distribution of authority

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The approach to planning the PHC network

Population according to 1999, 2009 and 2013 Censuses

Analysis of existing infrastructure according to the typology and performance indicators: year built, % of depreciation

2030 Population projection according to the official projections by the Committee on Statistics

Planning the service areas of outpatient care organisations: Medical stations (MS), Feldsher & Midwife stations (FMS), Medical Ambulatories (MA), Family Medicine Centers (FMC), Rural Polyclinics (RP), District (“Rayon”) Polyclinics

(DP), City Polyclinics (CP) - using district maps for estimating distances, geographic specifics and the location of existing infrastructure

preserving the existing type of

organisation

expanding or merging

outpatient care organisations

Attracting investments in the public-private partnership,

trust management and privatisation instruments usage

planning the renovation,

reconstruction or construction of a

new building10

Assessment of the PHC infrastructure

Proposed area of new PHC organisations based on the best

international standards

GP service area

Locality

Existing medical organis

ation

Year built

Type of building

% of depreciatio

n

Population 2030

Proposed type of medical

organisation

Recommended

investments

PeriodPrior

ity

1 Zhanakorgan FMC\DP 1970 Adapted 60 30,510

DFMC Construction

Medium-term

High

2

Tutisken MA 1983 Adapted 76,14 5,291 CFMC Reconstruction

Medium-term

High

Akkum MS 2003 Adapted 3,33 717 MS Renovation Long-term

High

Kauyk MS 2003 Adapted 3,33 84 - -

3

Birlik MA 1967 Standardised

0 3,386 CFMC Reconstruction

Medium-term

High

Birlik/Kyrash

FMS

Kyzylmaktashy

1,338 MS Construction

Short-term

High

4

Besaryk MA 2009 Standardised

0,07 2,491 MA Renovation Long-term

Medium

Apapkak

5 Zhanaryk MA 1983 Standardised

7 2,886 MA Reconstruction

Medium-term

Medium

6 Kelintobe MA 1981 Standardised

42 5,201 CFMC Reconstruction

Medium-term

High

7 Bapspakkol MA 1985 Adapted 100 2,504 MA Construction

Short-term

High

8 Kozhakent MA 1988 Standardised

44,97 4,364 CFMC Reconstruction

Medium-term

High

9 Abdigapar MA 1980 Standardised

0 2,933 MA Reconstruction

Medium-term

Medium

Korasan - -

10 Sunakata MA 1994 Adapted 9,91 2,473 CFMC Reconstruction

Medium-term

High

Yekpindy FMS 1988 Standardised

80 1,393 MS Construction

Short-term

High

Yenbek MS 2002 Adapted 1 1,053 MS Renovation Long-term

High

11 Takyrkol MA 1970 Adapted 10 2,947 MA Reconstruction

Medium-term

Medium

Type of

organisato

n

Population min.

Population max.

Area min., km2

Area max., km2

MS 300 1,500 77 125

MA 1,201 3,000 144 187

FMC 3,001 15,000

412 1,001

District

FMC+FMPC

30,000

100,000 1,040 3,385

City FMC+FMPC

30,000

150,000 1,011 4,910

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Conditions of proper functioning of PHC

1. Priority allocation of human, material and financial resources to

PHC

2. Development and implementation of a dedicated system of training

of physicians, nurses and social care workers for PHC organisations

3. Provision of effective measures aimed at promoting the profile of

the service and selected workers, as well as building confidence in

PHC among the wider population

4. Actively involving individuals and parts of the population in the

PHC activity

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Proportion of localities with population under 100 residents and

under 300 residents

РК

ЗКО

Атырауская

Мангистауская

Актюбинская

Костанайская

СКО

Акмолинская

Астана

Карагандинская

ВКО

Алматинская

Алматы

Павлодарская

Жамбылская

ЮКО

Кызылординская

0% 20% 40% 60% 80%

15%

20%

7%

7%

16%

22%

21%

17%

50%

17%

22%

8%

0%

20%

6%

5%

16%

39%

47%

29%

17%

44%

50%

52%

45%

0%

47%

48%

24%

67%

49%

21%

14%

31% <300

<100

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Proportion of population residing in under-100 and under-300 localities

РК

ЗКО

Атырауская

Мангистауская

Актюбинская

Костанайская

СКО

Акмолинская

Астана

Карагандинская

ВКО

Алматинская

Алматы

Павлодарская

Жамбылская

ЮКО

Кызылординская

0.0% 5.0% 10.0%

2.3%

4.8%

1.4%

0.2%

3.2%

4.8%

8.4%

5.7%

2.2%

3.6%

1.8%

0.0%

3.6%

1.3%

0.7%

1.2% <300

<100

Examples

Planning the PHC structure on the basis of the standard rate of 1500 per 1 doctor as exemplified by the Osakar district

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Examples

Proposed structure of the PHC network

Denomination Standard rate Travelling time

Medical station 300-1000 15-30 minutes on foot

GP office 1500-200015-30 minutes by car

(longer if above 2000)

GP center/Medical ambulatory 4 000-30 00015-30 minutes within the locality, 15-30

minutes in other localities

District GP center/District polyclinic (outpatient clinic)

30 000 - 50000

The distance – 60-80 kilometers or an hour of travelling by car; for longer distances – more than one center, if

possible

City polyclinic/City GP center/City GP clinic/type 1

30000 – 50000 15-30 minutes on foot or by transport

City polyclinic/City GP center/City GP clinic/type 2

50000 – 150000

15-30 minutes on foot or by transport

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Success factors of the PHC reforms

legislation

arrangement of medical services (including trust management

and privatisation)

improving the material assets (buildings and equipment)

implementing new treatment methods through clinical guidelines

based on evidence-based medicine

increasing the human resources potential (doctors, nurses),

specifying the service package provided by PHC

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Thank you for your attention!