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Ainur Ayipkhanova: The population is against health insurance, because medical services are cheap in Kazakhstan

25 Августа 2017 Almaty. August 25. KazTAG - Vladimir Radionov. Kazakhstan has been living in the conditions of medical insurance for the second months, but so far only employers and self-employed citizens are investing  into the Fund of Compulsory Social Health Insurance (FCSHI Fund). Ainur Ayipkhanova,  General Director of the Republican Healthcare Center, admits that the insurance system is not ideal, but there is only one chance for today to significantly improve two positions: to increase the flow of funds into the health system and encourage the population to take more responsible approach to their health. Meanwhile, according to her, the Government to some extend relieves its responsibility for the health of population. She commended on the advantages and disadvantages of the system.

- Ainur, so the main advantage of the medical insurance is a person's concern for his or her own health. Is it true that without this, people cared less about themselves?

- Indeed, medical insurance is the basis of the introduction of joint responsibility of people for their health. When medicine is free, there is not enough incentive to take care after health. The solidary responsibility is when a relatively small amount of income, 1%, will be deducted for one's health care, and he or she will have higher expectations from the health care system. At the same time, starting to pay, a person begins to take more responsibility for his own health. The reason for introducing social health insurance is to increase the responsibility for the health care not only by the Government, but also by business, and by individuals.

In the countries where an employer transfers the funds, one begins to take more careful approach to the health of staff: they tend to introduce elements of maintaining a healthy lifestyle, for example, partially pay for the cards in the fitness centers. In countries where the insurance medicine has existed for more than a decade, it is noted that an employer investing in the health of employees, tends to replace the machines selling chocolate and carbonated drinks in their offices with the machines selling fruit. Even the food, which is provided by an employer on a paid basis, becomes healthier. It is proved that investing in the health of employees an employer saves more money than if he invested in their treatment.

Next - the insurance introduction will increase funding for the health sector. Today Kazakhstan is on the final positions in terms of finance of this sphere among the countries with similar incomes. Only 3.5% of GDP falls on health care in Kazakhstan, while the state’s share is 2%. At the same time, we want to have good hospitals with first-class equipment, highly-qualified doctors. But we do not want to invest.

Moreover, the state in this system is as valuable a payer. We can not say that we completely switch to an insurance model. It will have a mixed type. Out of 17 million people, the expenses of 10.5 million citizens will continue to be covered from the budget and targeted transfers. Less than 7 million economically active citizens will be participants of the insurance system. And the World Health Organization (WHO) believes that even the budgetary health system is insurance: citizens are insured from paying large sums for treatment, because they pay taxes, and the state pays for medical services from these taxes. Even in the US, 55% of the population enjoys state insurance, and the state pays for people aged over 65 and for socially vulnerable groups of citizens.

One more thing. Foreign experts, answering the question why so few people in Kazakhstan understand the value of health insurance, note that this is due to the affordable cost of medical services. That is, Kazakhstan has relatively cheap medical services. For example, it costs about $600 in Israel to treat a sick tooth, in Kazakhstan it makes about $ 30. In Kazakhstan, treatment in a hospital with an operation costs about 200 thousand tenge - a relatively reasonable sum. But why are the services so cheap? Due to cheap labor - low salaries of doctors, nurses. Medications are the same as they are abroad, medical equipment is also bought at the exchange rate of foreign currency. Once the salaries of doctors go up in the globalization of the labor market - medical services will become more expensive. Then most people will realize the value of insurance - that it is better to pay each month a little sum, than to pay once completely.

- So, how much will the financing of the health system increase through the health insurance? Interest payments are low and hardly can cover any expensive services.

- Yes, for one employer, one employee the interest is really small. But in fact, the management of the Fund already reports that in the first month of work (employers and self-employed started depositing in the fund since July 1 of this year - KazTAG), the fees amounted to 800 million tenge.

Indeed,  1% (the amount of the employer's investment for employee today makes 1% of the salary - KazTAG), creates a resonance. Meanwhile, even in the countries of Eastern Europe, the post-Soviet states, this percentage is much higher. For instance, in Slovakia, the solidarity deposit of the employer and employee is 14% of the salary, in Estonia - 13%, in Lithuania and Poland - 9%. The highest rate is in Germany - 15.5%. In our country only by 2022 it will make 5%.

- Let's get back to the main thing, in your opinion, the advantage of the medical insurance: they say, the system will start encouraging citizens to take care of their health. For instance, I do not see this incentive: whether I am healthy or sick - the percentage of this deposit does not change ...

- The main plus is solidarity: we will not take big money from those who are sick, and less from those who are healthy. To some extend you are right: the system has a single rate of deposit, independently from the individual's health. Meanwhile, if a person pays, he has the right to demand the quality of medical services. The competition between medical organizations is developing. The Russian experience can be an example. In Russia there is no single fund, they have independent funds in each subject of the federation. And there patients tend  to choose where, in which city they treat better. And the funds flow after the patient in the appropriate regional fund, and the quality has improved in certain organizations that have become points of attraction of domestic medical tourism. This effect was seen in the third or fourth year of medical insurance. I was in Kazan on a business trip, and specialists from one of the clinics noted that they had recently increased their income by almost 30%, and the hospital made additional efforts to receive patients. In this case the competition has improved the quality.

-However, I'm still talking about real incentives. For instance, in Germany, which you referred to as a state with the most expensive insurance, there is a real incentive: for example, if a person goes to the dentist twice a year for prophylaxis, when an insured event occurs, it is covered, say, not 50%, but 70-80 % of the cost of treatment ...

- We are still making the first steps in the insurance system, and we are working on specific mechanisms to stimulate health care, so that healthier people paid less or received more benefits. Over time, perhaps it will appear. Any insurance system - life, property - looks unfair: it's not for nothing that compensation for damage, say, from a fire, is covered by the deposits of all clients of the insurance company. But this is the meaning of insurance. Everyone understands that in the event of an insured case, the amounts will be so high that it is better to insure the house for the case a fire, a car from an accident, and health for the case of expensive medical services. Obligation of medical insurance is conditioned by the task of overall coverage of population.

- However, with the overall coverage there are problems too. What will happen in the system, say, with the self-employed, who generally fall out of the economy?

- For them, the lowest rate is planned - about 15 thousand tenge per year, which they can deposit monthly dividing this amount for 12 months. I must say that they will get emergency assistance in any case- one feels bad, calls an ambulance,  taken to hospital, operated in an emergency order - it will be available free of charge within the framework of the state guaranteed medical aid. However, planned (non-urgent) operations will be available only to the insured. Such complex operations can cost up to 4 million tenge. Therefore, insurance gives access to such services.

- But the self-employed do not even transfer pension deposits. What can make them get the insurance?

- Health status. For example, medications stop being effective, they may need a planned operation. And a self-employed  person can at any time join the system of medical insurance, pay his fee and get this planned service.

- By the way, as for the cheapness of medical services. Will the insurance affect the level of salaries of medical personnel?

- I think not right away. The Ministry of Health Care believes that better qualified doctor should be paid higher salary, and relies on healthy competition among medical workers and among the medical organizations. Each chief doctor has the ability to determine allowances for employees in the framework of differentiated wages for the achieved performance indicators.

- You’ve mentioned that the insured patient has every right to demand quality of medical services. How will the question of accessibility and quality of services be settled in the medical insurance system?

- Accessibility will increase as follows: the insured will have guaranteed access to a larger volume of services. Since 2019, for example, it is planned to expand the package of medicines provided free of charge. Why in two years? Because in the early years it is necessary to provide coverage of what is promised now. With the increase of the funding, the range of services will also increase, so that accessibility will improve over the years.

As for the quality, the fund will monitor the quality of medical services  by the providers of health care services. The parameters of the quality will be fixed as indicators for the monitoring.

- Another important point, which the Ministry of Health had claimed, it is involvement of private clinics in the system of medical insurance. But the main obstacle here is the tariff policy: private traders do not like the sums that the state offers. How are you going to settle this problem?

- We plan to review the majority of tariffs for medical services within two years. For example, the tariffs in cardiosurgery, neurosurgery, hemodialysis look attractive - clinics want to engage in the provision of this type of services. At the same time, there are a number of less high-tech services, whose tariffs are very low and unattractive either for the state organizations or for private ones. Here we rely on the activity of the medical community - they should signalize such tariff distortions to the Ministry of Health Care.

How is the tariff formed? For example, 10 hospitals are taken, and for the last 6 months it is considered how much was spent on the treatment of a particular disease, including the cost of medicines,  salary of staff, amenities, and so on. Then they get an average sum and the tariff is approved. But times change, the cost of medicines and supplies changes. Therefore, they need to be reviewed from time to time.

- At the very beginning of our conversation you noted that the system of medical insurance is not ideal and needs corrections. Recently, the Ministry of Health Care signed a memorandum with the analytical center "Talap" on cooperation in this direction. In your opinion, what can civil society offer to improve it? What are you waiting for?

- The Ministry of Health Care today has become the most open institution for people - we want to be closer to the patients and directly hear about the problems and solve them together. Therefore, we expect from civil society to recognize the achievements of the national medicine. Of course, there are and there will be problems, but it's wrong to water all the doctors and medical personnel with mud. We are for the culture of coverage in the media of both problems and achievements, we are for fair analysis of how the health care system is changing.

Secondly, we call on the active part of civil society to inform about innovations in the health care system, in particular, about  medical insurance. For example, to inform self-employed villagers that they can pay their insurance through the offices of Kazpost. It would seem an elementary question, but many people do not know about it. The lack of information generates an overwhelming part of discontent and complaints.

- As far as I know, the introduction of a medical insurance system is just one of 10 projects to improve the healthcare system at the present stage. Could you tell us what other innovations are planned in this important branch?

- Yes, for the effective implementation of the Densauly state program, the Ministry of Health Care has developed 10 sectoral projects, among them is creation of the public health service, the national medicines policy (prescribing regulation of drug prices), modernization of medical education and science, and others. Unlike the routine work of state bodies, the project approach implies clear targets, fully involved project team, regular monitoring and horizontal interaction with all stakeholders. Therefore, the goal of implementing ten projects in the Ministry of Health Care is to make a breakthrough in the health system through clear lines of work.

- Thanks for the interview!