Аскар Р. Ескалиев 1,
Наталья Е. Глушкова 2, https://orcid.org/0000-0003-1400-8436 Алмагуль А. Кауышева 2, https://orcid.org/0000-0002-5341-3189 Асель А. Наурызбаева3,
Салтанат С. Кырыкбаева4,https://orcid.org/0000-0001-6151-6025
1 «Қазақстан Республикасы Президентінің іс Басқармасы Медициналық орталығының ауруханасы»
ШЖҚ РМК, Нұр-Сұлтан қ., Қазақстан Республикасы;
2 «ҚДЖМ Қазақ медициналық университеті» ЖШС, Алматы қ., Қазақстан Республикасы;
3 Қазақстан Республикасы Денсаулық сақтау министрлігі, Нұр-Сұлтан қ., Қазақстан Республикасы;
4 «Семей медицина университеті» КеАҚ, Семей қ., Қазақстан Республикасы.
Өзектілігі: Қазақстандағы медициналық қызметтер нарығының негізгі мәселелері денсаулық сақтауға жұмсалатын мемлекеттік шығындардың төмендігі, соның салдарынан медициналық қызметтерге арналған тарифтердің төмендігі, білікті кадрлардың жетіспеушілігі болып табылады, бұл медициналық көмекті мемлекеттік және жеке денсаулық сақтау секторлары арасында қайта бөлу сипатына әсер етеді. Міндетті әлеуметтік медициналық сақтандырудың енгізілуіне байланысты медициналық көрсетілетін қызметтер нарығы құрылымдық өзгерістерге ұшырауда, бұл ағымдағы жай-күйді барабар бағалауды талап етеді
Зерттеудің мақсаты реттеу тәсілдерін айқындау, нарық теңгерімін құру және медициналық көрсетілетін қызметтердің сапасын арттыру үшін міндетті медициналық сақтандыру жағдайындағы денсаулық сақтау секторы қызметінің үрдістері мен мәселелерін зерделеу болып табылады.
Материалдар мен тәсілдер: Зерттеу нысаны медициналық қызметтерді жеткізушілер - жеке және мемлекеттік денсаулық сақтау секторы болды. Зерттеу Міндетті әлеуметтік медициналық сақтандыру жағдайында медициналық
қызмет көрсететін жеке медициналық ұйымдардың көрсеткіштерін зерделеу кезеңінде зерттелетін объектілер тобы үшін обсервациялық, кросс-секциялық, тұтас болып табылады; 2015 жылдан бастап 2019 жылға дейінгі кезеңдегі денсаулық сақтау жүйесінің статистикалық көрсеткіштері, сондай-ақ құқықтық және салалық ақпараттың ресми көздері зерделенді.
Нәтижелер: Денсаулық сақтауға арналған ағымдағы шығындар серпінін талдау мемлекеттік шығындардың 2,8 есе, сондай – ақ жеке меншік шығындардың 4,1 есе өсуін көрсетеді. 2015 жылдан бастап 2019 жылға дейінгі кезеңде жеке секторда көрсетілетін қызметтерді тұтынудың орташа есеппен 23,6%-ға өсуі, сондай-ақ жеке сектордың алғашқы медициналық-санитариялық көмекке интеграциялануының жоғары қарқыны байқалады. Бұл денсаулық сақтаудың жеке секторын Қазақстан Республикасындағы медициналық қызметтер нарығының толық құқықты қатысушысы деп санауға болады, бұл денсаулық сақтау жүйесіне жеке инвестицияларды тартуға мүмкіндік береді.
Қорытынды: Міндетті әлеуметтік медициналық сақтандыру жағдайында мемлекеттік тапсырысты орындауға және кедергісіз ортаны қамтамасыз ету саясаты сақталған жағдайда жеке сектордың одан әрі өсу қабілеті жоғары болады. Міндетті әлеуметтік медициналық сақтандыруды енгізу және МӘМС шеңберінде барлық медициналық қызмет көрсетушілердің сапасын бағалауға біріздендірілген тәсілді қамтамасыз ету бәсекелестік үшін тең жағдайларды қамтамасыз етуге мүмкіндік береді.
Түйінді сөздер: медициналық қызмет, жеке Денсаулық сақтау, міндетті әлеуметтік медициналық сақтандыру.
Bibliographic citation:
Eskaliev A.R., Glushkova N.E., Kauysheva A.A., Nauryzbaeva A.A., Kyrykbaeva S.S. The market of medical services for compulsory medical insurance: current state, opportunities and risks of medical organizations // Nauka i Zdravookhranenie [Science & Healthcare]. 2021, (Vol.23) 4, pp. 180-189. doi 10.34689/SH.2021.23.4.020
Ескалиев А.Р., Глушкова Н.Е., Кауышева А.А., Наурызбаева А.А., Кырыкбаева С.С. Рынок медицинских услуг в условиях обязательного медицинского страхования: современное состояние, возможности и риски медицинских организаций // Наука и Здравоохранение. 2021. 4(Т.23). С. 180-189. doi 10.34689/SH.2021.23.4.020
Ескалиев А.Р., Глушкова Н.Е., Кауышева А.А., Наурызбаева А.А., Кырыкбаева С.С. Міндетті медициналық сақтандыру жағдайында медициналық көрсету рыногі: медициналық ұйымдардың заманауи жағдайы, мүмкіндіктері мен тәуекелдері // Ғылым және Денсаулық сақтау. 2021. 4 (Т.23). Б. 180-189. doi 10.34689/SH.2021.23.4.020
Relevance
Access to health care is an important issue that has an influence on shaping the political image of most countries.
In many high, middle, and low income countries, the provision of affordable health care is one of the crucial issues. It is of critical importance, given that a large number of people in different countries do not have sufficient financial resources to access healthcare services.
The Republic of Kazakhstan, like many other foreign countries, responsibly assumes the obligations of the provider of social guarantees for the population and is considering ways to improve this situation in the country.
On November 16, 2015, the law “On Compulsory Social Health Insurance” was adopted. This law is intended to regulate public relations after the introduction of the norms of the system of compulsory social health insurance (hereinafter referred to as the CSHI), which protects the rights of patients in healthcare, indicated in the Constitution of the Republic of Kazakhstan (hereinafter referred to as the RK), as one of the basic rights.
The main issues of the medical services market in Kazakhstan are low government spending on healthcare, a shortage of qualified personnel, low tariffs for medical services for both public and private medical organizations, which affects the redistribution of medical care between the public and private healthcare sectors. Identifying trends and problems in both health sectors will help determine ways to regulate the balance of the market to improve the quality of medical services under compulsory health insurance (CHI).
Objective
Identify trends in the formation of the modern market for medical services in the Republic of Kazakhstan for the period of 2010-2019 and to determine the probabilistic trends of its further development for the prospective period in the context of CHI.
Materials and methods
The object of the research is the providers of medical services – the private and public health sectors. The subject of the research is medical services in the private and public health sector of the Republic of Kazakhstan.
The study is observational, cross-sectional, continuous for the study group of objects at the stage of studying the indicators of private medical organizations providing medical services under CHI, as well as retrospective when studying statistical indicators for the period from 2015-2019.
At various stages of the research, the following methods were used: content analysis; statistical; analytical; method of mathematical modeling.
The data were processed using Microsoft Excel and SPSS Statistics (version 23). p = 0.05 was taken as statistical significance value. Descriptive statistics (frequencies, percentages) and graphs were used to evaluate the results and draw conclusions.
Descriptive statistics for quantitative data are presented using the sample mean and standard deviation. The values of qualitative features are presented as frequency characteristics. To analyze the results obtained, contingency tables were used. All data used for the analysis
were verified by us for compliance with the law of normal distribution.
Results
During the study, we carried out a comprehensive analysis on the integration of the private sector into the healthcare of the Republic of Kazakhstan during the formation of the modern market of medical services. We determined its contribution to the main indicators of healthcare in the Republic of Kazakhstan. We also analyzed the main performance indicators of health care providers participating in the CHI in outpatient care.
When analyzing the dynamics of finances in Kazakhstan, it was revealed that for the period from 2010 to 2019, the gross domestic product (hereinafter – GDP) in Kazakhstan increased by 3.2 times. Total spending on health care also shows an increase in absolute terms by 2.3 times. Since 2010 in terms of the GDP, there has been a decrease in basic financing of health care by 25%, which in 2019 took up 3% of GDP.
The structure of current expenditures on health care consists of private and government expenditures (Figure 1).
Figure 1. Current expenditure on health care.
Analysis of the dynamics of current spending on health care shows an increase in both public spending by 2.8 times, and private – by 4.1 times. The average growth rate of private health spending from 2010 to 2019 was 119%.
The average growth rate of government spending over this period was 113%, which is 1.5 times lower than the growth rate of private spending. In 2010, private expenses took up 31% of current expenses and in 2019 - 40%, which is 30%
more than the base indicator.
Private spending on health care has also undergone some changes during this period. Over the period from 2010 to 2019, there has been an increase in private payments by 4 times in absolute terms. The proportion of deductions from enterprises and voluntary health insurance at the beginning of the period (in 2010) was 13.3%, by 2019 the figure increased by 37%, amounting to 18.2%. In absolute terms, the indicator has grown 5.5 times over 10 years. The dynamics of direct payments (private spending on health care) for the same period shows an increase in absolute terms by 4 times, the proportion of direct payments at the end of the study period was 84%, having decreased by 3.5% (Figure 2).
Currently there are more than 1,500 private clinics of various profiles in Kazakhstan, where 15263 doctors and 21392 nurses are working as of the beginning of 2020 (statistical collection of the Ministry of Health of the
Republic of Kazakhstan 2019). In total, at the beginning of 2020, outpatient and polyclinic care was provided by 3204 medical organizations, of which 1178 are private. We have calculated the dynamics of development of the private health sector over 10 years (the period from 2012 to 2019).
The main indicators characterizing the absolute and relative changes in the series of dynamics are: absolute increase / decrease, growth rate, growth rate, absolute value of one percent increase / decrease. We calculated the indicators of dynamic changes for the period from 2012 to 2019 for private medical organizations of the Republic of Kazakhstan, which show the intensity of the change in their number in relation to the initial value (for 2012). For the calculation, both chain and basic methods were used. In 2019, the number of private medical organizations increased by 16, or 1.4%, compared to 2018. The minimum growth was recorded in 2014 (-9). The maximum growth and growth rate is observed in 2017 – 158 more private medical organizations. For the period from 2012 to 2019, the number of private medical organizations in the Republic of Kazakhstan increased by 266 units, or by 29.2%. During the study period, there is an increase in the growth rate and increment as well as the content of 1% increase throughout the study period, which characterizes the process as developing.
Figure 2. Voluntary health insurance and direct payments (dynamics).
To analyze the dynamics of visits to private medical services in certain specialties and the provision of medical services, we have identified medical services that are most in demand in regions. An analysis of visits to private medical organizations for the period from 2015 to 2019 (Form 30) was carried out, after which the most visited specialties in the private health sector were identified.
With this analysis we were able to determine a list of
specialties that have considerable statistically significant differences from the average indicator in regions of the Republic of Kazakhstan. In this regard, a number of specialties have been identified that are potentially suitable for expanding the range of services provided by private medical organizations in the medical services market in each individual region (Figure 3).
Figure 3. Patient visits, by major specialties for 2015-2019.
Content analysis of the available information resources showed that the normative regulation of the liberalization of the medical services market has been maintained for a decade, and has received special attention in the last 5 years, starting in 2016. In the state program for the development of health care for the period 2016-2019, the section "Development of infrastructure and public-private partnership (PPP)" was highlighted, which means that the Ministry of Health of the Republic of Kazakhstan is purposefully prioritizing the possibilities of liberalizing the market for medical services and developing the private sector in health care. Private medical organizations providing primary healthcare (PHC) in 2019 took up 36.2% of all providers. To support the liberalization of the medical services market, the Roadmap
"Deregulation, Reducing Barriers to Business and the Development of the Private Healthcare Sector" [10] was developed for the growth of PPP in the healthcare system for the next period until 2022.
Ministry of Health of the Republic of Kazakhstan supports the active participation of the private sector in health care. As of today, health care organizations and individuals engaged in private medical practice and pharmaceutical activities are identified by the Order of the Ministry of Health of the Republic of Kazakhstan dated December 8, 2020 No. RoK DSM-242/2020 "On approval of the rules for the procurement of services from healthcare entities for the provision of medical care within the guaranteed volume of free medical care and (or) under compulsory social health insurance". Furthermore, definition GP Therapist Obstetrician-gynecologist Podiatrist Ophthalmologist Neuropathist Otolaryngologist
of a legal entity performing activities in the field of health care for a "health care organization" is given.
Analysis of the main performance indicators of medical service providers participating in compulsory social health insurance (CSHI) in outpatient care, revealed the following:
as of 2020, the Fund concluded contracts with 1,258 service providers, of which 657 medical organizations are state-owned (52%) and 601 private (48%). There is a tendency for the growth of private medical organizations interested in cooperation with the Fund and the provision of services within the framework of the compulsory health insurance [12]. At the end of 2020 and as of 02/01/2021, 77 medical organizations were identified in the database of excluded entities, of which 38 state utilities on the right of economic management of the regions, as well as 39 private medical organizations. According to the data of the Compulsory Health Insurance Fund, non-governmental organizations providing medical services are most widely represented in cities of Republican significance: Astana (20 out of 35 (57.1%)), Almaty (36 out of 73 municipalities (49.3%), and Shymkent (14 out of 25 (64.1%)), providing the private sector from 50 to 65% of the need for medical facilities. In the regions, medical care is provided mainly by
state clinics. The largest percentage of private medical organizations in the regions is noted in Kyzylorda (8 out of 21 (38.1%)), Mangistau (10 out of 22 (45.5%)), and Turkestan (19 out of 41 (46.3%)) regions. The lowest proportion of private medical clinics is presented in North Kazakhstan (1 out of 17 (5.9%)), West Kazakhstan (3 out of 24 (12.5%)), and Kostanay (5 out of 31 (16.1%)) regions.
The ratio of public to private medical healthcare organizations in the regions of the Republic of Kazakhstan is 1: 1.6. Analysis on private sector services shows a slightly different picture compared to the analysis on the number of medical organizations. According to the Social Health Insurance Fund, 19,182,344 people are attached to medical organizations providing primary health care in 2021, of which 15,801,699 people (82.4%) are served in state clinics in primary organizations. Accordingly, 3,380,645 patients (17.6%) are assigned to private clinics.
The ratio of the number of patients attached to private clinics to that in public ones is 1: 6. The public sector serves 82.8% of the population of the Republic of Kazakhstan, while the private sector serves 17.2% of the total population of the Republic of Kazakhstan (1 out of 6) (Figure 4).
Figure 4. Participation of medical organizations in the Mandatory Social Health Insurance of the Republic of Kazakhstan.
* According to Social Health Insurance Fund data as of 01.02.2021 Discussion
When analyzing the main factors in providing the population with equal access to medical services, the following main components were studied: health care financing and expenditure. Regarding the first aspect, it should be noted that more than 70% of health care expenditures are financed by government, primarily tax revenues and social security contributions. Throughout the world, medical care is provided through both public and private providers. In countries where healthcare financing comes from government budgets, out-of-pocket expenses are usually low. Similarly, “pocket money” is usually low in countries where health care is largely financed by private funds in the form of private voluntary insurance (for example, in the USA). It should be noted that out-of-pocket health expenditure is high in countries with underfunded public health and low levels of private voluntary health insurance (e.g. India, Afghanistan, Sudan). The second aspect relates directly to the consumable part. Statistics have shown that high-income countries spend 1.5-2 times more on health care than low-income countries. In low- and middle- income countries, the share of funding allocated by the government is much lower and the rise in individual
spending is much higher (over 50% of total spending in many countries). In 2019, the average health expenditure per capita around the world was $ 1,099. However, in low- income countries, the average was only $ 40 per person, while in high-income countries it was $ 3,313 per person, which is more than 80 times higher. Private health care spending by 2019 was US $ 3.4 trillion, or 41% of global health care expenditure, most of which came from out-of- pocket household spending, while health spending (from external assistance) was only 0.2 % of global expenses. It should be noted that health care spending remains unequal across countries, and the impact of the COVID-19 pandemic on healthcare spending is catastrophic given its devastating impact on health and economies around the world.
Regarding health care financing system of the Republic of Kazakhstan, it is worth noting that according to the International Monetary Fund (IMF), our country is included in the group of successful countries with transitional economy. However, an increase in social spending in recent years has led to a further reduction in the share of health care in the country's budget.
Figure 5. The number of medical organizations in outpatient care participating
in the provision of medical care within the framework of the compulsory health insurance for 2020.
Source: Social Health Insurance Fund data This is well reflected by the indicators in 2009-2018,
when budget expenditures on health care increased by 2.6 times, and general expenditures – by 2.1 times. These figures show how difficult it is for the government of Kazakhstan to finance medical care on their own, without the participation of private organisations and the population.
To ease the situation, an insurance program has been introduced in Kazakhstan, based on the joint responsibility of citizens for their own health. In 2015, the legislative act of the Republic of Kazakhstan "On compulsory social health insurance" was adopted, which determined that public and private clinics can compete for patients on equal terms, interacting with a single purchaser of medical services, which also controls the quality of service. After the introduction of amendments to this law, the Social Health Insurance Fund was created. That is, the innovation in the strategy of this policy lies in the mandatory collection of insurance premiums from both employers and citizens. It should be noted that from 2018 to 2020, only employers and entrepreneurs paid contributions in the amount of 1.5%
of wages, and in 2021, employees are charged 1%. Next year (2022) employers and workers will pay 3% and 2 %, respectively. However, according to experts’ analysis, the proportion of people who can afford this is not sufficient to successfully maintain this model. Of the 18.5 million people, the government will have to pay for 11 million, mainly children and the elderly, whose numbers are growing due to high birth rates and increased life expectancy. The government supports 15 groups of people, such as pensioners, children, people with disabilities, the unemployed, pregnant women and families raising children with disabilities, and others. In 2020, the state's contribution was 1.4%, in 2021 – 1.6%, and in 2022 – 1.8%.
An analysis of the integration of the private sector into healthcare in the Republic of Kazakhstan over the 10 years, preceding the mandatory social health insurance (MSHI),
revealed that the maximum growth and rate of increase is observed from 2016 to 2018, showing an increasing trend.
Analysis of indicators by region allows us to draw the following conclusions:
Analysis of indicators by region allows us to draw the following conclusions:
1) The average growth rate of the number of private medical organizations in the Republic of Kazakhstan compared to the base period for 10 years was 114%. The highest average growth rate is observed in the city of Nur- Sultan (280%), Pavlodar region (145%) and West Kazakhstan region (136%).
2) The highest average growth rate is observed in the same regions.
3) In the Mangistau region, since 2013, there has been a significant decrease in the rate of liberalization of the medical services market, as evidenced by the stagnation and regression of the average growth rate and the minimum recorded value of the growth rate and a decrease in the indicator value by an average of 45% compared to the base period.
4) Similar trends are observed in the North Kazakhstan, Turkestan and Akmola regions, where there is a decrease in the growth rate and increase in the number of private medical organizations.
5) The rate of increase in the indicator for the ten-year period during the study shows an increasing trend in the statistical series, which indicates the acceleration of the process of liberalization of the medical services market with the development of private medical organizations.
As for the structure, it should be noted that for the period from 2015 to 2019, in the private sector, there is a 4-fold increase in family practitioner visits and 18.7%
increase in visits to pediatricians, a decrease in the proportion of visits to a general practitioner and obstetrician-gynecologists, by 23.1% and 13.3%,