МОДЕЛІ: ТӘЖІРИБЕ МЕН ПЕРСПЕКТИВАЛАРЫДенис В. Панченко1,https://orcid.org/0000-0002-0947-1074
Асия К. Тургамбаева2,https://orcid.org/0000-0002-2300-0105 Зайтуна А. Хисметова3,https://orcid.org/0000-0001-5937-3045
1 Мемлекеттік мекеме «Нұр-Сұлтан қаласының денсаулық сақтау басқармасы», Нұр-Сұлтан қ., Қазақстан Республикасы;
2 КеАҚ «Астана медицина университеті», Нұр-Сұлтан қ., Қазақстан Республикасы;
3 КеАҚ «Семей медицина университеті», Семей қ., Қазақстан Республикасы.
Өзектілігі. Отандық денсаулық сақтауды қаржыландырудың қазақстандық жолы мәселесін әзірлеудің өзектілігі мен бастапқы кезеңі, оның теориялық және практикалық маңыздылығы осы зерттеудің тақырыбын, мақсаттары мен міндеттерін таңдау кезінде шешуші болды.
Мақсаты. Міндетті әлеуметтік медициналық сақтандыруды енгізуге байланысты Қазақстан Республикасының Денсаулық сақтау жүйесін қаржыландыру моделін өзгертудің негізділігі мен қажеттілігін бағалау.
Материалдары мен әдістері. Тұрақтылық, тиімділік және әлеуметтік-экономикалық өсуге бағытталған денсаулық сақтау жүйесіне жаңа тәсілдерді қалыптастырудың қаржылық аспектілері. Зерттеудің теориялық және әдіснамалық негізі денсаулық сақтау жүйесін, оның ішінде отандық денсаулық сақтау жүйесін қаржыландыру мәселелері бойынша қазақстандық және шетелдік авторлардың ғылыми жұмыстары болды. Теориялық (талдау және синтез, индукция және дедукция), эмпирикалық (салыстыру) зерттеу, сондай-ақ деректерді статистикалық өңдеу әдістері қолданылды.
Нәтижелер және тұжырымдар. Бүгінгі модельді толығымен сақтандырудан бұрын, керісінше бюджеттік және сақтандыру деп атауға болады. Ол бүкіл халықты қамтымайды: 2020 жылдың соңында сақтандырылмаған адамдардың үлесі елдің жалпы халқының 16,2% құрады, басқаша айтқанда, де-юре міндетті болып табылатын медициналық сақтандыру іс жүзінде жоқ. Сонымен қатар мемлекет тегін медициналық көмектің кепілдік берілген көлемін қамтамасыз ету бойынша елеулі шығыстарды көтеруді жалғастыруда, олардың үлесі 2020 жылы қаржыландырудың жалпы көлемінің 66,6% - ын құрады, ал он бес жеңілдікті санаттағы адамдарды сақтандыру- барлық түсімдердің 54% - ын мемлекеттік жарналарға тиесілі болды.
Түйінді сөздер: медициналық сақтандыру, қоғамдық денсаулық сақтау, қаржыландыру моделі.
Panchenko D.V.,Turgambayeva A.K.,Khismetova Z.A. Kazakhstan model of healthcare financing through public health principle: experience and prospects // Nauka i Zdravookhranenie [Science & Healthcare]. 2022. (Vol.24) 1, pp. 79-89. doi 10.34689/SH.2022.21.1.010
Панченко Д.В., Тургамбаева А.К., Хисметова З.А. Казахстанская модель финансирования здравоохранения по принципу общественного здравоохранения: опыт и перспективы // Наука и Здравоохранение. 2022. 1(Т.24). С. 79-89 doi 10.34689/SH.2022.24.1.010
Панченко Д.В., Тургамбаева А.К., Хисметова З.А. Қоғамдық денсаулық сақтау қағидаты бойынша денсаулық сақтауды қаржыландырудың қазақстандық моделі: тәжірибе мен перспективалары // Ғылым және Денсаулық сақтау. 2022. 1 (Т.24). Б. 79-89. doi 10.34689/SH.2022.24.1.010
The national health system is an integral part of the social policy of any country. Its reforming in modern conditions and taking into account international trends is an extremely important issue, since it is not only about what should correspond to the prevailing realities, but also about the need to meet the needs of the entire population.
In other words, health care is one of the most important sectors contributing to the development of the economy, since the availability and quality of human resources depends on it [1,2,3].
The degree of scientific elaboration: theoretical and methodological issues of the formation and reform of the health care system in Kazakhstan, including its financing, at certain stages have already been analyzed by research scientists. These include the works of A.A. Akanov, M.A.
Aliev, M.K. Kulzhanov, O.T. Zhuzzhanov, T.Sh. Sharmanov, V.N. Devyatko. Ilyasova K.K., Tuseeva M.Kh., Kim S.M., Isakhova P.B. paid special attention to the financing of health care.
Thus, despite the contribution of researchers to the development of the model of financing the health care system
in our country, all of them were carried out at various stages of its reform, in other words, the issues of the practical implementation of the next attempt to introduce compulsory health insurance at the present stage have not yet been analyzed in detail. The population in reality felt the changes only six months after its official introduction. In this regard, there are no in-depth scientific studies reflecting the positive and negative aspects of the ongoing processes, primarily related to the timeliness of receiving the necessary treatment and the adequacy of funding for medical organizations, including the proportionality of tariffs to real costs.
The relevance and the initial stage of the development of the issue of the Kazakhstani way of financing domestic health care, its theoretical and practical significance became decisive in choosing the topic, goal and objectives of this study.
Aim of the study: Assessment of the feasibility and necessity of changing the model of financing the health care system of the Republic of Kazakhstan, due to the introduction of compulsory social health insurance.
To achieve this goal, we are supposed to solve the following tasks:
1) study the previous experience of introducing compulsory health insurance and the prerequisites for the current actions of the state;
2) identify the risks requiring revision and changes in the implemented financing model;
3) develop practical recommendations on tariff policy aimed at further successful implementation of health insurance.
Materials and methods. Financial aspects of the formation of new approaches to the health care system aimed at sustainability, efficiency and socio-economic growth.
The theoretical and methodological basis of the study was the scientific works of Kazakhstani and foreign authors on the financing of health care systems, including domestic.
The methods of theoretical (analysis and synthesis, induction and deduction), empirical (comparison) research, as well as statistical data processing were used.
The information base of the study was made up of scientific literature on the available global models of financing health systems, scientific articles, normative legal acts of the Republic of Kazakhstan that are in force earlier and at the present time, statistical data, materials of periodicals and reports, as well as practical developments of the Ministry of Health of the Republic of Kazakhstan, the Fund social insurance and the Republican Center for Healthcare Development.
Theoretical significance: the study made it possible to summarize and systematize at a sufficient level a large amount of material related to the main stages in the development of the model of financing the health care system in Kazakhstan.
Practical relevance: lies in the development of a number of recommendations aimed at further successful implementation of health insurance, including in tariff policy.
The assessment of socio-economic processes that determine the use of financing mechanisms for the health care system in Kazakhstan, the principles of medical care provided within this framework, as well as the trend of modernization of the industry.
The state funding model to a greater extent guarantees the observance of the principle of social justice, since it provides predominantly the entire population with equal access to medical care. In contrast to the private model, it is based on the principle of allocating funds not according to citizens' ability to pay, but according to their needs .
Most often, the budget model surpasses the private model in terms of the efficiency of spending, since reliance on private funding can lead to an excessively sharp increase in health care costs . Moreover, this tendency also takes place when using the insurance model, subject to the active development of the voluntary health insurance mechanism.
In the insurance model, informal employment can also develop, and as a result, the shortfall in funds due to the concealment of income by the employed and self- employed. It is also susceptible to the effects of an aging population, provided that the contributions for this category are fully paid by the government.
As noted above, the budget model is extremely sensitive to financial crises and related tax shortfalls.
Thus, the choice of this or that model depends on many factors, which should be based on an analysis of the available opportunities to ensure adaptation to changing priorities as soon as possible. That is why, in its pure form, none of these models is found in any country.
Until the beginning of the 20th century, the population living in the territory of modern Kazakhstan, for the treatment of diseases, resorted mainly to the services of the so-called traditional healers. Taking into account the fact that officially the great sanitary awakening in the world began at the beginning of the 19th century, the imperial government sought to organize medical care for ethnic Russian settlers, creating medical centers and hospitals.
However, a large-scale fight against infectious diseases began only in the early 1920s, with the establishment of Soviet power - in October 1920, the People's Commissariat of Health of the Kazakh Autonomous Socialist Soviet Republic was created, and primary health care institutions began to be created in rural settlements. Each person had an assignment to a certain city clinic or rural medical assistant's point.
In the postwar 1950s, there was a shift in priorities towards specialized medical care and hospitals. By the late 1970s, funding for primary health care had declined, and many polyclinics and hospitals were built . It was during this period that key mistakes were made, based on the principles of the Semashko model - an increase in the number of hospital beds and doctors, which does not take into account the effectiveness of medical care, in other words, the financing of the system, which does not depend either on its quality or on the volume of services provided by it.
Budget funds were allocated on the basis of expenditures for the previous year, the number of beds and the number of medical personnel, which deprived any interest in their rational use, leading to an artificial increase in the number of beds and staff.
The shortcomings of the existing system became apparent already in the 80s and were associated with the deterioration of the health care situation. Its funding has significantly decreased, contributing to the fact that the volume of medical services provided has ceased to meet
the needs of the population, in other words, the norms have ceased to be observed . The centralized management made it impossible to take the initiative. All this favored the emergence of the shadow economy, when medical institutions became illegal, but forced, to charge fees for the services provided.
At the end of the Soviet regime, a number of reforms were undertaken, which could no longer correct the current situation. So, in 1989, an experiment was launched in five medical institutions to introduce a new economic mechanism, which was curtailed a year later, leaving only one of the directions of health policy.
Thus, the Kazakh health care system was formed during the Soviet era and was centralized, medical services were generally available and provided to the population free of charge.
The Ministry of Health of the Kazakh Soviet Socialist Republic implemented exclusively the policy of the union ministry.
After Kazakhstan gained independence, there were no significant changes in the health care system; priorities were sharply shifted to the area of economic and political transformations. At the same time, the socio-economic conditions in the country worsened, and there were not enough funds to improve the quality of medical services and improve the material and technical base. In early 1992, the Ministry of Health of the Republic of Kazakhstan was formed.
Against the background of this situation, an experiment was carried out in a number of regions of the country, during which methods of financing medical institutions through health insurance, reorganization of primary health care and the introduction of paid medical services were tested .
After the first major unsuccessful attempt to introduce compulsory health insurance since 1996, the pace of reform in the industry accelerated. Since this period, the Ministry of Health has been repeatedly reorganized, in 1997 into the Ministry of Education, Culture and Health of the Republic of Kazakhstan, and since 1999 into the Ministry of Health, Education and Sports of the Republic of Kazakhstan. In November 1999, the Agency of the Republic of Kazakhstan for Healthcare was established, which, a few years later, again received the status of a ministry. From the second half of 2014, his responsibilities also included social development. The ministry has been operating in its current format since January 2017.
The further terms of the introduction of compulsory health insurance in our country have been repeatedly shifted, another practical attempt, which was preceded by a long preparatory period, has been made since 2020.
Participants in the medical services market were: the state, the Mandatory Medical Insurance Fund, policyholders, insured persons, medical organizations and individuals engaged in private medical practice .
In the period from 1996 to 1998, the share of state budget expenditures on health care decreased from 88% to 55%, while the fund, on the contrary, increased from 12% to 40%, the difference over the past two years was citizens' own funds for paid services .
Paid medical services continued to limit the availability of medical care. First of all, citizens had to pay for
medicines, prostheses and other devices at the outpatient clinic level, as well as dental services and plastic surgery.
However, there were no clear criteria for identifying insured and uninsured persons.
Thus, over three years, an attempt was made in the republic to create a unified system of compulsory health insurance covering the entire population of the country, with the exception of military structures.
However, the Mandatory Health Insurance Fund failed to accumulate the planned volume of insurance premiums in its assets; at the end of 1996, their share in the health care budget was only 15%, while the plan was 25%, and in 1998 it was about 40%, it should be noted that half of these funds made up state contributions for non-working categories of persons .
At the same time, by the end of the same 1998, the regions' accounts payable to the fund amounted to 27 billion tenge .
All this led to the formation of indebtedness to medical institutions, which the fund subsequently abandoned in 1998. He was also accused of embezzlement of the collected funds and corruption.
Ultimately, in December 1998, the compulsory health insurance project was phased out. The reasons for this were the economic crisis, which affected the fact that many enterprises were not able to pay insurance premiums due to existing arrears, there was also a system of payment in kind for insurance payments, private entrepreneurs, small farmers and self-employed practically did not make contributions to health care. insurance, payment for medical services was carried out in the regions at different rates and methods, the country experienced an increase in unemployment, which increased the burden on local budgets, which simply did not have the ability to transfer the required amount of funds as contributions for this category of citizens.
In 1999, the Mandatory Health Insurance Fund was reorganized into the Center for Payment for Medical Services. The guaranteed set of medical care began to be funded by the state through the Health Committee of the Ministry of Health, Education and Sports of the Republic of Kazakhstan, medical services related to the basic set were financed from local budgets: regional, city, and since 2001 also regional budgets, as well as under contracts with the said center . Decentralization of the system to the district level negatively affected its overall efficiency and the availability of health care. Paid medical services were also preserved, their lists were developed, in addition, fees were charged for visiting narrow specialists without a referral from a general practitioner. Medicines provided on an outpatient basis remained the main type of paid medical services, with the exception of some of the most vulnerable groups of the population and a number of categories of patients, in particular those with cancer.
The goal of all the reforms was the need to strengthen state control over the collection and spending of funds.
At the same time, starting from 2000, the republic again continued to study the issue of re-introduction of compulsory health insurance from the beginning of 2005 .
To this end, in the first half of 2000, and then in the second half of 2002, concepts were approved both for the
further development of health care and for improving its financing, the latter envisaged three stages of introducing an insurance model up to 2007 .
In 2004, the country adopted a program for the reform and development of health care, designed for 2005-2010, aimed mainly at further implementation of the budget financing model, within the framework of the provision of a free guaranteed package of medical services, as well as in addition to it in the voluntary health insurance system.
primarily at the expense of employers. Responsibility for financing within the framework of the implementation of the new mechanism, the management of health care delivery and the ownership of most of the health facilities are consolidated at the level of regional authorities as single payers. Consideration of the issue of introducing compulsory health insurance was postponed to 2008 .
Since 2005, preparations have been under way for the implementation of the national health accounts planned for 2006-2007. This issue was implemented in 2010. Currently, they allow obtaining information and assessing the share of total, current, public and private expenditures on health care to the gross domestic product, in other words, on financial flows of the entire sector, and also provide an opportunity to assess the quality of health services provided.
In 2010, financing of most of the medical organizations in the country began to be carried out centrally from the republican budget by the Ministry of Health of the Republic of Kazakhstan through its department - the Committee for Payment for Medical Services .
Thus, the issue of transforming the model of financing the health care system, in terms of the introduction of insurance mechanisms, was worked out almost continuously a year after the first large-scale unsuccessful attempt to implement them. The greatest successes were achieved in the middle and end of the second decade of this century, which were reflected in the state program
"Densaulyk", designed for 2016-2019 .
The World Health Organization has recommended a minimum level of health spending when using a budgetary financing model, which for developed countries should be in the range from 6% to 8% of gross domestic product and at least 5% in developing countries .
At the end of 2018, the share of healthcare expenditures in Kazakhstan was within 3% of the gross domestic product , in other words, the minimum recommended level was not met, the funds allocated by the state were not able to cover all existing needs.
The reasons for this were both demographic - an increase in life expectancy, and epidemiological changes - an increase in the number of major chronic non- communicable diseases, as well as an increase in the cost of treated cases, all of them subsequently became prerequisites for the transformation of the principles of healthcare financing in the republic.
The World Bank and independent international experts assisted in studying the world experience, primarily German, post-Soviet countries such as Russia and Lithuania, as well as the post-socialist camp in Eastern Europe - Poland, Czech Republic and Slovakia, based on the principle of the most similar health systems. including taking into account the experience of the first unsuccessful attempt to introduce compulsory health insurance. By the
end of 2015, a basic law was adopted that regulates the basic principles of the functioning of the compulsory insurance part of the current model of health care financing in our country, and already in the middle of next year, the Social Health Insurance Fund was formed .
Mechanisms have been developed to guarantee its financial stability, namely, a non-commercial principle of operation, as in European states, non-return of made targeted contributions and deductions, audit of financial activities, ensuring separate accounting for assets and own funds: contributions, penalties, investment income and deductions , the use of these assets only in settlements with health care providers, as well as placement in financial instruments determined by the government, the formation of liabilities in strict accordance with income and a reserve to cover unexpected costs .
In general, the financial support of the health care system consists of the following eight sources  (Figure 1).
It should be noted that the population of the republic is actually deprived of the opportunity to choose between insurance funds. The sole founder and shareholder of the operating fund in the organizational and legal form of a joint stock company is the Government of the Republic of Kazakhstan. Thus, there is no competitive environment with all the ensuing consequences in the form of a flexible tariff policy, promotions, bonuses, etc., but at the same time, at the initial stage, the fund, although lacking autonomy, seems to create a certain financial stability. At the same time, a large number of insurance funds are also not typical for European countries.
In the period from July 2017 to 2019, the fund managed to collect 246.9 billion tenge in the assets of the fund, of which 3.7% came as contributions from persons working under civil law contracts, as well as individual entrepreneurs, and 96.3% were deductions from employers [7,14,15].
Medical care in the voluntary insurance system is currently undergoing a stage of its formation with the aim of achieving universal coverage and ensuring the improvement of mechanisms for this type of insurance, primarily for labor migrants and foreign students studying in the Republic of Kazakhstan. Voluntary insurance mechanisms will allow them to receive not only the services included in the two main packages, but also will cover additional programs, the costs of which will be compensated by the insurance company.
To date, the minimum volume of the insurance product provided within the framework of voluntary medical insurance has not been established, the list of medical services is established by the insurance company (insurer) in agreement with the insured.
Currently, work is underway to improve the coverage mechanisms for this type of insurance, primarily to determine the volume of insurance products and the procedure for the provision of medical services.
In 2020, 1,549.3 billion tenge were allocated to medical organizations of the republic, including within the guaranteed volume - 1,031.1 billion tenge (66.6%), in the compulsory insurance system - 518.2 billion tenge (33.4%) . Thus, the amount of financing increased by 49%, in 2019 it amounted to 1,039.4 billion tenge (Figure 2).