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New methods of financing the health system in
Republic of Albania
Elvana HANAGeneral Director
Health Insurance Institute
Tirana on 09 June 2008
THE STRUCTURE OF PRESENTATION
An overview of Health System and Health Financing Systems
Changes at Primary Health Care financing (achievements and problems)
Changes at hospital care financing. Study case – Durres Hospital – as a model for further developments.
Pharmaceutical services – Totally private but it remain too far from European standards. The Project of electronic control of pharmacies and drugs.
Short term efforts of Health Insurance Institute to further increasing of financing health services efficiency.
GENERAL FRAMEWORK
Health services in Albania are provided by a mix public and private services providers
Hospital services are provided by MoH and other public institutions.
PHC is provided through a general practitioners and private network well developed at this sector.
Pharmacies, dentists, and other supported health services are totally private.
Ministry of Health remain the main actor at policy making and the regulator of health system.
Local Governance is another actor in allocation of public funds for health sector at regional level.
THE SOURCES OF PUBLIC FINANCING FOR HEALTH
State budget Ministry of Health Ministry of Defense (Military hospital) Ministry of Justice (Prisons)
The obligatory contribution of health insurance Are gathered by Tax Office – HII
Directly payments / co-payments Other donors
Public expenditures for health share only 2.7% of GDP
Albania’s health delivery and financing structure – note the fragmentation of the funds
PHC Centres, GPs
Insurance Contributions
Patient Out-Of-PocketPayments (co-pay)
Taxation Authority
Health Insurance Fund/ Institute
MOH Budget
MOF Budget for Health
Municipal Councils
Hospitals
Health funds according to services (Total 2008 - 30 348 milion lek)
Primary Health Care 42%
Hospital care 52%
Planing, management administration
3%Public Health
3%
THE PROBLEMS AT PRIMARY HEALTH
CARE SERVICES
Administration of PHC Health Centers
Dual independence, institutional and financial (HII - MoH)
Fragmented financing of primary health care Payments from HII, only for Family doctors –
discouraged for team work – indifferent to the quality
Lack of Autonomy for HC Low deposits of secondary incomes – main reason
of informal payments
THE PROBLEMS AT PRIMARY HEALTH CARE SERVICES
Providing of health services and their quality
Lack of standard packages of health services for providers of services
Partly standard for health services level and norms of coverage the population within ambulatory care (the rapport (doctors/nurses and norms of coverage for nurses staff)
Lack of measures and evaluations indicators for quality of health services
Standards not completed for protocols of ambulatory treats from GFP
Lack of basic equipments for services
REFORM AT PHC
Based on: Law No. 7870, dt. 13.10.1994 “For Health Insurance in Republic of
Albania” changed DCM. No. 857, dt. 20.12.2006 “For financing of PHC services from
obligatory scheme of Health Insurance”
After January 2007, HII / RDHI has contracted with almost 420 Health Centers (HC) all over the country
Any of Health Center – juridical entity with their own account The Director of HC – representatives of HC for health insurance
relations The contracts are based at the offered packages of services 1625 General / Family Practitioners and 6636 nurses contracted to
provide general services at HC.
REFORM AT PHC
Move to a single purchaser financing for health services.
Autonomy on Management, organization and operation of HC
Definition of actors role on the system.
Development of new method of payment for HC. - Application of a mix payment formula:
- 85% fix budget, - 10% monthly added payment based on the
activities of the HC - 5% bonus payment 3 month based for HC
which fulfils the quality indicators.
Increasing of payment level for services providers.
REFORM AT PHC
Setting up the necessary framework for health services market function.
- Opportunity to exercise their profession as individual contractor / or private
Installation and using an unique system of information for all HC.
Setting up the necessary framework for HC to manage the allocated funds.
- New opportunity for increasing and using second incomes
HOSPITAL SERVICES
The hospital care in Republic of Albania is public service.
Actually there are 36 hospitals. Number of beds - 9586 beds which means an average of 1 bed for 322 habitants or 3.1 beds for 1000 habitants. This figure its quite high considering the actual economic situation in Albania as well as low utilization of the bed, with an average during last years, 50-55%.
Number of the beds has been continually decreasing due to strengthening of the primary health care.
HOSPITAL SERVICE
Physical structure of the hospital is under the desired level due to problems related with objective lack of infrastructure at the regional level as well as periodicities of investments provided by Ministry of Health especially for medical equipment, maintain and consume facilities.
Some serius problems which reflcts at the quality and effectivenes of the hospitals are related with lack of norms of, medical and supported staff as well as standard protocols of treatment.
The information system for the identification and evaluation of hospital activities its missing.
All those factors as well as low level of financing and weak management have their negative impact on the services ofered by them.
DURRES HOSPITAL EXPERIENCE
Goal:
Preparing the organizational, administrative and financial situation for including the hospitals at health insurance scheme
ACHIEVEMENT OF THE PROJECT
Hospital as juridical entity: Administrative independence
Management – Board
Financial independence Financing from HII – own decisions for using of
secondary incomes funds.
More efficiency in using the health insurance funds through: Setting up an coherent information system Processing of payment method for DRG Compiling of hospital treatment protocols
PHARMACEUTICAL SERVICES
Open pharmaceutical services, totally privatized.
Monitored from Ministry of Health and National Center of Drugs Control.
Over 80 wholesalers and 900 pharmacies and agencies.
The Basic List of Reimbursement Drugs (374 drugs) is compiled by “Commission of Compiling and Reviewing of Reimbursement List of Drugs” and from “Commission of Drugs Prices” setting up with order of Minister of Health and approved by Council of Ministers with proposal of Minister of Health once a year.
Policies at pharmaceutical sector: rational usage of a number of effective drugs, safe and with high quality, as well as available and with a reasonable price for all the population.
ACHIEVEMENTS AND PROBLEMS
The reforms at the sector and implementation of the pharmaceutical policies have positive results on some directions such as: furnishing of the market with a mix kind of drugs (3500 registered drugs), re-activate of domestic production, registration of the drugs, expanding of drugs delivery, setting up of the new information base for drugs.
Problems: Lack of transparency at prices of the drugs Circulation of contraband drugs as well as registration of
ineffective drugs, which are appealing from patients, doctors and pharmacists.
Lack at the information system, which need to include all the units such as inspection, registration, information about drugs, etc.
PROBLEMS WITH REIMBURSEMENT LIST OF DRUGS
The reimbursed drugs and the cost of reimbursement are not managed by HII
Albania pay higher price for some drugs compare with other countries in the region such as Slovenia – some time 89% higher.
The priority and cost-effectively are not the critters for compiling the list of drugs
The new entry at the list of drugs are not accompanied by financial support for HII.
The physicians prescriptions consist in more drugs and of drugs with higher cost. (due to mentality and professional education)
OBJECTIVES OF HII ON THE FUTURE
The reimbursement list of drugs consist on:
Part I – include drugs 100% reimbursed of the drug price
Part II – include drugs with co-payment for the drug price
IMPROVEMENT OF THE GOVERNANCE ON THE HEALTH SYSTEM
Compiling of basic legislation for health care as well as for obligatory scheme of health insurance
Reviewing of licenses and accreditation procedures for public and private system
Regulation of contractual relation for strategic purchaser.
IMPROVING THE HEALTH SYSTEM FINANCING
Reinforcement of HII role as strategic purchaser of health services in public and private system
Improvement of collecting contribution system Efficiency at collecting contribution from salaries Consolidation of contributions from obligatory
insurance for inactive population, from state budget
Reconsideration of the contribution rate Decreasing of informality
Presentation of co-payment Identifying the insured population through health
card Utilization of secondary incomes
ENCREASING OF MANAGERIAL CAPACITIES AT HEALTH SERVICES
Expanding of partnership public-private Encouragement of special service
privatization at all the levels of health care
Reposition of manager role at public health institutions
Setting up the standards, norms and clinical protocols in management of health services.
Consolidation of quality approach system and security of health system
INCREASING OF ACCESS AT EFFECTIVE HEALTH SERVICES
Define of basic package of health services and its monitoring
Re construction of health service providers network Restricted due to geographical, demographic
and privatization policies conditions
Improvement of refer system
Maintaining and developing of programs for public health