Reforming health care in the CIS

By Dmitriy Belyanin

Take $2 billion just before bedtime and call me in the morning…

Introduction

The goals of providing quick and reliable health care, making it affordable, paying doctors enough, keeping up with new drugs, and avoiding useless expenses, often conflict. How the dilemmas are resolved depends on who owns the medical facility.

Kazakhstan is switching from a Soviet system of health care to one that includes private clinics. Today one must often pay a fee for health care. Total spending on health care has fallen, and services have become more costly and less efficient.

The government’s first attempt at comprehensive health insurance, undertaken in the mid-1990s, failed. It plans another, and for good reason. With health insurance, clinics can pay the doctor more, make her more accountable to patients, and encourage healthy habits. Clinics can also buy up-to-date equipment without relying on the state budget. Kazakhstan must automate health care if it wants to become one of the 30 most competitive economies. This means retraining doctors of the Soviet generations as well as improving clinical equipment.

Kazakhstan also needs safer drugs. Many are sold over the counter and thus are ripe for abused. Counterfeit drugs abound. But requiring a prescription would raise the cost of treatment.

Birth of a quagmire

Ironically, Soviet health care was one of the few systems of the Union of Soviet Socialist Republics that the West admired. The USSR was the first country to pledge comprehensive health care to all, from cradle to grave. 

This system was founded by the doctor and party leader Nikolai Semashko, a companion of Lenin in exile. It drew upon the ideas of the German hygienists of the 19th century, who linked socioeconomic conditions to illness. Also vital were the ideas of the French socialists and Marxists, particularly Friedrich Engels’ The condition of the working class in England. By eliminating poverty, socialism would build decent housing and preventive facilities. Clinical services would matter less. 

But Stalin’s industrialization and collectivization created the very conditions that Engels had blamed for disease. The Man of Steel dismissed the health commissar and centralized care. The Kremlin belittled medical research and accented immediate problems. It assigned each resident to a polyclinic, based on the district of residence, and to a physician; citizens could not choose for themselves. Each large enterprise had a medical facility. The elite had their own polyclinics and hospitals, according to the European Observatory on Health Care Systems.     

Long before the October Revolution of 1917, state clinics in Russia outnumbered private ones and were preferred by doctors in epidemics. Despite collectivization, repressions and wars, average life expectancy at birth in the USSR increased by 26 years from 1926 to 1972.

As the World Health Organization recommended, many countries drew upon Soviet experience. The waiting time in Soviet poly-clinics tripled that of German private clinics, but the number of visits per Soviet citizen more than doubled that of the average Western European. The number of home visits by European doctors quintupled the Soviet one. Many Soviets went to clinics just to get medical certificates for sick leave. While doctors’ qualifications were comparable to those of western doctors, Soviet clinics in the 1980s were poorly equipped. Their number of beds per person exceeded that in Western Europe by about 150%, but the Soviets sometimes placed beds in corridors and storage rooms, and they often were short on medicine. 

Given the Soviet emphasis on quantity rather than quality, one is not surprised that during Perestroika the doctors lost prestige. The average salary of doctors, 70% of whom were women, did not exceed 70% of the average wage. Unofficial payments, in cash and in-kind benefits, were common, reports Oleg Bobrov in Medical and Pharmaceutical News.      

    

Kazakhstan’s statistical lags

 

We can evaluate the quality of health care by looking at how much people are willing to spend on it and at life expectancy. Kazakhstan’s total expenditure on health care, relative to GDP, is low even by the standards of the Commonwealth of Independent States (Tables 1.1 and 1.2). But its public health expenditure is average for the CIS (Tables 2.1 and 2.2).  Perhaps Astana should encourage private health care. Life expectancy is average by CIS standards for males and somewhat above average for females (Tables 3.1 and 3.2). But it should be improved, given President Nazarbayev’s goal of making Kazakhstan a developed country.

Country	Expenditure as a percent of GDP
Kazakhstan	4.35
Russia	7.07
Kyrgyzstan	6.48
Uzbekistan	5.83
Tajikistan	6.88
Belarus	5.68
Azerbaijan	6.03
Armenia	4.48
Georgia	7.41
Moldova	10.32
Turkmenistan	2.07
Ukraine	7.09

Table 1.1: Total health expenditure as a percent of GDP for CIS countries (2014)

Country	Expenditure as a percent of GDP
United States	17.14
United Kingdom	9.11
Japan	10.22
France	11.54
Germany	11.3
Canada	10.45
Italy	9.24

Table 1.2: Total health expenditure as a percent of GDP for G7 countries (2014)

Country	Expenditure as a percent of GDP
Kazakhstan	54.36
Russia	52.2
Kyrgyzstan	56.13
Uzbekistan	53.28
Turkmenistan	65.22
Tajikistan	28.8
Belarus	65.79
Azerbaijan	20.39
Armenia	42.98
Georgia	20.39
Moldova	51.37
Ukraine	50.8

Table 2.1: Public health expenditure as a percent of total health expenditure for CIS countries (2014)

Country	Expenditure as a percent of GDP
United States	48.29
United Kingdom	83.14
Japan	83.58
France	78.2
Germany	76.99
Canada	70.93
Italy	75.61

Table 2.2: Public health expenditure as a percent of total health expenditure for G7 countries (2014)

 

Country	Life expectancy at birth, male	Life expectancy at birth, female
Kazakhstan	67	76
Russia	65	76
Kyrgyzstan	67	75
Uzbekistan	65	72
Turkmenistan	62	70
Tajikistan	66	73
Belarus	68	78
Azerbaijan	68	74
Armenia	71	79
Georgia	71	78
Moldova	67	76
Ukraine	66	76

Table 3.1: Average life expectancy at birth, CIS countries (2014)

Country	Life expectancy at birth, male	Life expectancy at birth, female
United States	77	81
United Kingdom	79	83
Japan	81	87
France	79	86
Germany	79	83
Canada	80	84
Italy	80	85

Table 3.2: Average life expectancy at birth, G7 countries (2014)

Kazakhstan does not lack doctors. About 60,000 physicians with diplomas and 120,000 other medical staffers (nurses, etc.) work here, according to the Ministry of Health Care and Social Development. Since 2005, state institutions have added 5,000 doctors.

About 3,000 specialists graduate from medical schools annually. But most end up working outside their specializations. Doctors in the private sector sometimes can vacation at any time, which is not the case in the state sector; but state doctors enjoy a short workday. Village doctors receive housing and food for cattle, reports Nur.kz.

In 2010, the 3,500 medical organizations included 2,133 independent clinics, 524 public hospitals, and 134 private hospital-type institutions. There were 756 hospital beds per 100,000 people, over 378 doctors per 100,000 people, and 9,500 pharmacies.

Though the number of hospitals and their beds fell in the 1990s, hospitals still dominate health care. Most medical specialists work in large cities, so the shortage of personnel -- estimated at 5,000 -- is especially severe in villages, reports Saltanat Orynbasarova on Vestnik of KazNU. The number of hospital beds and specialists fell sharply in the 1990s but rose in the 2000s (Table 4).

	Number of doctors of all specializations, Th. people	Number of mid-level medical personnel, Th. people	Number of hospital organizations	Number of hospital beds, Th.	Number of hospital beds for ill children, Th.
1991	65.1	198.9	1805	230.4	46.1
1992	66.4	196.3	1821	228.4	47.4
1993	64.5	189.5	1899	225.4	46
1994	61.1	177.7	1651	205.7	40.9
1995	60.1	168.4	1518	192.6	37.4
1996	57.1	150.1	1244	164.4	31.4
1997	54.5	129.5	1006	136.4	25
1998	53.2	120.4	991	123.5	72.7
1999	50.6	110.4	917	108.2	18.9
2000	49	106.6	938	106.9	18.6
2001	51.3	109.4	981	110.2	18.4
2002	53.7	113.4	1005	111.9	18.4
2003	54.6	115	1029	114.8	20.3
2004	54.8	117	1042	116.6	19.4
2005	55.5	119.6	1063	117.6	20
2006	57.3	125.2	1086	119	20
2007	59.4	130	1055	119.6	19.6
2008	58.9	131.7	1041	120.8	20.4

Source: Statistical Journal of the Agency on Statistics of the Republic of Kazakhstan, as reported on Vestnik KazNU.

Table 4: Medical personnel and hospitals in Kazakhstan (1991-2008)

Can health insurance survive in Kazakhstan?

The government is bolstering the role of the private sector. To make treatment in private clinics more affordable, Astana tried to introduce mandatory health insurance in 1996. But in 1998, Talapker Imanbayev, head of the Mandatory Health Insurance Fund, embezzled $3 million from the fund and fled to the United States, said officials. The mandatory insurance program died. Most health care is now financed by the budget or by voluntary insurance, reports Svetlana Gribanova, of Expert Online.

The government plans to reintroduce mandatory insurance in a few years. Kazakhstanis will be able to choose between basic insurance, financed by the state budget, and insurance created from the new Mandatory Health Insurance Fund. The basic package will include vaccination, ambulance and sanitary aviation, and medical aid for the so-called socially significant diseases as well as for emergencies. Socially significant diseases, reported Zakon.kz, include tuberculosis, AIDS and related diseases, hepatitis B and C, malignant tumors, diabetes mellitus, mental and behavioral diseases, cerebral palsy, heart attacks (during the first six months), rheumatism, systematic connective tissue diseases, hereditary, sexually transmitted diseases, and demyelinating central nervous system diseases (which destroy the myelin sheaths of nerve fibers. “Myelin” is a white, fatty substance). Subsistence farmers working their own land -- are entitled to medicines and clinical aid, at state expense, until 2020. 

The insurance package will include aid in the clinics and hospitals, rehabilitation, nursing care, high-tech care, and palliative care (which ameliorates the symptoms of a disease but does not cure it). The government will help non-workers, and employers will help employees. The self-employed will pay for themselves. The government will own the Fund.

Having been burned once, this time Astana is expanding health care cautiously. Its aid for non-workers will not rise to 7% of the average monthly wage until 2024, starting at a base of 4% next year.

Employers will contribute 5% by 2020, starting at 2% in 2017. Since the difference will be deducted from corporate income tax payments, the net burden on the employer will rise from 1.6% in 2017 to 4% in 2020. 

Employees will pay 1% of their income in 2019 and 2% starting in 2020.  Self-employed citizens will pay 7% by 2020, starting at 2% next year.

Exempted from paying are: Children and mothers with many offspring; World War II veterans; the disabled; registered unemployed citizens; full-time students; nonworking, pregnant women; those who are on maternity leave or are raising a child until the age of three; retirees; military persons; civil servants of special state bodies; police officers; and prisoners, reports Zakon.kz.

Experiences of Georgia and Moldova

    

One measure of the lack or failure of health insurance is in-pocket spending by households on medical and pharmaceutical institutions, including gratuities and in-kind payments. The poor and the uninsured pay more.

Where in the post-Soviet space is insurance most successful? Moldova and Georgia have the lowest shares of in-pocket spending in private expenditures. In 2014, they were 79% and 74% respectively, says the World Bank. Compare these statistics to 99% for Kazakhstan. Health insurance is far weaker here than there.

 

Their insurance coverage is also more extensive. In Georgia, a fourth of the population is insured. The state picks insurers by taking bids, arguing that otherwise the 15 insurers would compete unfairly.

In fact, Georgians submitted 10,000 complaints about insurance to the Mediation Health Care Service of the Ministry of Health Care in the first six months of its existence, in 2011. Of these complaints, 66 concerned violations by private insurers. For example, the government limits waiting time for surgery to six months, but insurers may refuse to pay if the contract expires before then. In this case, the patient is entitled to compensation. The Service paid 12 million Georgian lair to medical institutions, reports Nino Kharadze of Radio Azadlyg.

The reform in Georgia was a solution to the trifecta of fiscal nightmares: A growing budget deficit, pension arrears, and rampant corruption. In 2004, bribes accounted for 70% of medical payments. Services are now bought through cash registers or insurance companies. State medical institutions are still open in 12 regions out of 68, but free health care is almost nonexistent. Ambulances are free and state-owned, but insurance pays for diagnosis and first aid. The patient can choose where to go for treatment. Reform benefited doctors: In 2014, their salaries averaged $1,000-$1,500, as compared to the national average of $500, reports Irina Kovalchuk of Segodnya.ua.

Neighboring Moldova has mandated insurance since 1998. The government spends 2 billion lieu ($103 million) on insurance for special groups. Insurance covers 90% of all medical services for Moldovans. There is one Mandatory Insurance Fund and one national insurer. Free services include contacting ambulances and family doctors, some medicines, and treatment of tumors and tuberculosis. Individuals pay 7% of their income for insurance, almost entirely for services from medical institutions. Informal payments to doctors still occur, but one can complain about it to a special service.

Mandatory health insurance enabled paying medical workers regularly and with periodic increases. Another 2% is spent by the Development Fund on equipment and repairs.  Administration accounts for 1% of spending; preventive works, for another 1%; and reserve funds for epidemics, another 1%. In 2010, the government set up a fund to buy equipment for transplanting marrow, kidneys and livers, which had been unavailable, reports Yekaterina Kozhukhar of Argumenti i Facti in Moldova.

In February 2016, Parliament deputies proposed to exempt the unemployed from medical insurance payments. The state can fine or imprison any citizen who doesn’t pay, reports Forinsurer, a Ukraine-based journal on insurance.

Health insurance in other Eurasian Union and Central Asian countries

In general, other CIS countries offer more generous medical benefits than Central Asian nations.

All Russians, and foreigners living in Russia, must have insurance for an unlimited term. Every Russian receives the same amount of medical aid, reported Rosgosstrakh.

To pay for mandatory health insurance in Russia, employers pay a unified social tax of 3.6%. The government supports the jobless. Each citizen can choose her own insurer. Basic insurance includes free treatment for infections and contagious diseases, except sexually transmitted diseases, tuberculosis and AIDS. It also covers diseases related to tumors; the endocrinal, nervous, cardiovascular, respiratory, digestive, urinary, blood and immune systems; nutrition and metabolism; eyes, ears, skin, muscles and bones; and trauma, pregnancy and birth. While mandatory health insurance varies with the region, and side payments to doctors are not unknown, the government provides many more free services than in Kazakhstan.    

Kyrgyzstan also introduced mandatory health insurance in the 1990s, although public spending on health fell from 3.7% of GDP in 1991 to 1.9% in 2001. Since then, the state has accounted for 60% of health expenditures, including free care for children younger than 5, pregnant women, and retirees older than 70. The insured get a 50% discount on drug prices. The Fund of Mandatory Health Insurance is responsible for quality control. 

An insurance policy covers only a year; you must then buy another. The policy partly covers: Hospital treatment referred by a doctor; urgent aid; vital medicines and injections; lab research; vaccination and other preventive measures; basic diagnosis; and immobilization.

In Armenia and Belarus, all health insurance is voluntary, and the state pays for most treatments. In 2013, the Armenian parliament rejected mandatory health insurance after a similar law on accumulated pensions proved unpopular. Supporters of mandatory insurance argue that it would help people immediately, unlike accumulated pensions. But a 2014 survey by News.am Medicine showed that 65% of the respondents were not willing to pay for such insurance.

In Belarus, the budget pays for most health care. Increasing health spending, due to expensive modern equipment, aging of the population, and inflation, may induce the legislature to ponder mandatory insurance. But this would require at least 7,000 more insurance employees, according to Yuriy Sharabchiyev of Meditsinskiye Novosti [Medical News], a Minsk-based specialized journal.         

       

Medicine safety

Counterfeit medicines are common in Kazakhstan.  For the period from 2004 to 2014, the health ministry has identified over 90 cases of selling 40 fake medicines of internationally recognized brands, which led to fines totaling 2.5 million tenge. About 1,450 drugs, one-fifth of all registered medicines, failed quality and safety assessments.  The government plans to make medical counterfeiting a crime.

Though selling medicines online is illegal, Kazakhstanis still contact international websites. Half of medicines being sold online lack quality certification, reports Kazinform.

In January, the Eurasian Economic Union (EAEU) started a common market of drugs and medical equipment, using European Union law as the benchmark, reports the Kapital newspaper.

Another issue is mandating prescriptions for medicines that had been available over the counter. In Kazakhstan and other CIS countries, many more drugs are sold without prescription than is the case in developed countries. As of January, 7,713 medicine brands were registered, of which 76% should require a prescription. (In practice, the law is ill enforced.) The corresponding figure in Germany is 80%. Aссording to a survey by the health ministry of Astana residents, 51% consult pharmacists, 18% rely on the advice of friends and relatives, 12% make the choice independently, and only 19% contact doctors, reports Kazinform. 

Initially, the government had meant to permit antibiotics only by prescription. In principle, over-the-counter sales face fines as high as 2.1 million tenge, reports Municipal TV and Radio Channel, a local channel of Petropavlovsk and the North Kazakhstan Oblast. But the government may permit these sales until October, reports Anelya Kassymova of Kazinform. 

While the new measure avoids dangers of self-medication, doctors may not always prescribe in time. The waiting line for prescriptions is long in the flu season. But you can apply for a prescription online, according to Vyacheslav Lozhkin, head of the Association of Pharmaceutical Producers. Bakhyt Tumenova, president of the Aman-Saulyk Social Fund, a legal protection organization in health care, favors small dispensaries in each district, instead of the large poly-clinics inherited from the Soviets.

Doctors may collude with distributors and pharmacies to prescribe unnecessary medication, sharing the revenues. While such pacts are illegal, low salaries make them likely. Lozhkin believes that a doctor in Kazakhstan should earn at least $2,000 per month, reports Kapital. 

Modernizing health care

The government of Kazakhstan plans an online database of state medical institutions informing the health ministry about all patients. This would help patients avoid repetition of procedures. Each patient would have her own online account informing her about her health, reports Profit.kz.

Another project is distance medicine, providing rural patients with remote consultations, according to Deputy Prime Minister Dariga Nazarbayeva, the president’s daughter.    

Analysis

Kazakhstan will rely on private medical services. Since the state will still finance health insurance for the unemployed, the system will be more equitable than Moldova’s. But the list of “socially significant diseases” is far from full; many contagions impose spillover costs that could be internalized through free treatment. If the current regime continues for a few years – perhaps redistributing some functions to the Parliament, which is under Nur Otan’s thumb – it might reform health care soon. Corruption is likely, but the government will conceal it. Corruption will not destroy mandatory health insurance.

Unlike Georgia, Kazakhstan is sparsely populated. Rural regions demand few clinics, so few will be built. Seekers of health care will migrate to cities. To avoid an imbalance of the population, the state may spend more on rural doctors.

Enforcing mandatory insurance will also be a challenge, especially in towns and rural areas. But urban doctors will benefit from reform, due to increased demand. Their pay raises will depend on administrative barriers to the entry of private facilities – barriers which must be low. 

The government can build elite medical universities, but they won’t attract applicants until it restores the profession’s reputation. In the long run, this would decrease the number of rich people going abroad for treatment.

Linking medical facilities to the Internet will spur controversy. Older medical professionals are computer-illiterate and must vie with youths who know more about software than health care. On the other hand, evasion of military service because of alleged illness, or receiving disability benefits because of fake diagnoses, will become harder.  

Conclusion

Reforming health care in Kazakhstan has been painful but unavoidable. While the Soviet system overcame epidemics and raised life expectancy, its clinics lacked equipment and space, and its underpaid doctors got little respect.

Health expenditure in Kazakhstan is low even by CIS standards, thanks to a lack of private investment. Life expectancy is just average. Many medical graduates work outside their specializations. The counterfeiting of medicines is severe, but Kazakhstan is mulling criminal liability.

Most private health expenditures are out-of-pocket, since voluntary insurance is measly. A mandatory insurance fund failed in the late 1990s, but the government says it will soon attempt another. Employees and employers will contribute, the self-employed will pay on their own, and the state will pay for the “socially vulnerable.”

In the CIS, only Georgia and Moldova have much private health insurance. This reform was particularly successful in Georgia. Doctors’ salaries rose and bribes waned. Health care expanded and improved, but few services are free.

In the Eurasian Economic Union, Russia and Kyrgyzstan have mandatory health insurance, but it is largely welfare. In Russia, employers and employees pay to prolong the insurance policy, while in Kyrgyzstan a fee buys a 12-month policy. In Kyrgyzstan, the insurance fund, being legally independent from the Ministry of Health Care, can manage quality. But political instability may stymie care. 

Automation of the health care system in Kazakhstan may make it more efficient – and it is inevitable, if Astana wants to keep up with global trends.  Kazakhstani care is not in critical condition, but it’s serious enough.           

     

Dmitriy Belyanin has a Master’s degree of Business Administration in Finance and a Bachelor of Arts degree in Economics from KIMEP University. Since 2007, he has been writing on issues ranging from stock markets to environmental economics. He is the associate editor of this blog.

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