Author: Nurlana GULIYEVA
Mandatory health insurance (MHI) is a widely used system in all the developed countries. Over time, the governments of other states also recognise it as an optimal solution for financing healthcare services instead of state subsidies for healthcare.
MHI is an innovation for Azerbaijan. A pilot project implemented in the country recently has demonstrated its viability. The State Agency for Mandatory Health Insurance is the body responsible for the introduction of the system in Azerbaijan. According to the decree of President Ilham Aliyev, Aghdash Region also joined the pilot project in addition to Yevlakh Region and the city of Mingachevir. In general, more than ₼17m are allocated from the state budget for these three regions.
Vugar Gurbanov, Head of Department of the State Agency for Mandatory Health Insurance, told us about the progress of the project.
What particular measures did your agency launch to introduce the MHI system in the pilot regions? What was your most difficult task?
I would like to mention that many healthcare reforms have been implemented in Azerbaijan so far. This includes the reconstruction of clinics, purchase of new technologies and equipment, as well the import of modern medicines. In fact, MHI is not going to change anything in this sector, for the changes concern the sources of financing.
Indeed, we had certain difficulties when we first started the program implementation. We had problems associated with the low level of access to medical services for the population in the regions, absence of electronic exchange system, etc.
Therefore, as a priority, we decided to start with the management of medical institutions in Yevlakh and Mingachevir covered by the pilot project. We used the experience of Turkey, where the management of hospitals is a separate body that manages the incomes and expenses of the institution, and does not treat patients. Therefore, we appointed directors to the clinics and assigned them specific tasks including the organisation of workflow in the hospital, expansion of the range of services, management of economic issues, etc. The process of medical treatment however was controlled by head physicians as before. In addition, we have improved the services of primary health care. For example, the system of family healthcare has not been developed sufficiently in Azerbaijan.
Our first task was to make medical services accessible to all residents of pilot regions as much as possible and to make sure that residents of remote villages do not need to visit city centres to get medical services. Therefore, we reshaped rural health posts into family-health centres and began providing small outpatient medical services using their potential. So, today we have five such centres in Yevlakh and two family health centres in Mingachevir that comply with the sanitary and epidemiological standards of the Ministry of Health. Currently, they provide 18 types of medical services. All centres are equipped with basic equipment such as ECG and ultrasonography devices, which make it possible to diagnose the patients and provide first aid. Family doctors should help in such circumstances and their services are included in the basic insurance package.
Where did you find the specialists, family doctors? You mentioned that this institution had not been developed enough in our country.
We chose them among district physicians and therapists. But you are right – a family doctor has a broader specialisation than a therapist. Therefore, we organised trainings for local doctors, which were conducted by specialists from Turkey, where the system of family doctors is developed quite well. The result was so successful that therapists from other regions of Azerbaijan began requesting us to help them re-qualify as a family doctor. By the way, the work of family doctors in the regions covered by our pilot project was also remunerated through the MHI in addition to their monthly salaries, which further stimulated the development of this institution.
In addition, we conducted trainings for the personnel of central clinics of the regions, primarily for surgeons and gynaecologists. We organised internships for them in Turkey and also automated the work of local laboratories.
After that, the number of healthcare applications has increased significantly. For example, the number of patients who received inpatient treatment in 2017 was 28% more than in 2016, while the number of surgeries increased by 50% and reached 8,274. Our main insurance package includes high-cost and vital medical services such as heart surgeries, operations to prevent brain aneurysms, angioplasty, etc. Last year, 300 such operations were conducted. In 2017, more than ten children with congenital heart disease were born in Mingachevir, and all of them were operated with the support of our agency.
Perhaps another important achievement is the adaptation of the local population to new rules of treatment, which concern the order of procedures from the registry in the clinic to the doctor's office. According to our data, patients are satisfied with the quality of services, and doctors are happy to have a significant extra to wages backed by the mandatory health insurance funds.
At the same time, it is worth noting that there were no insurance premiums among the population of the pilot regions and all necessary funds were allocated from the state budget in accordance with the presidential decree.
Does it mean that it will be necessary to apply the system of insurance fees if MHI covers the entire country?
Of course. Now the project is going through the test mode. We therefore need to test the system, mechanisms, and to identify drawbacks. But with the expansion of the coverage area, collection of insurance premiums will begin. In general, the countries where the MHI is financed from the state budget have serious problems. Yes, this is a social project and for certain groups of the population such as children, pensioners, unemployed, etc. the expenses will be covered from the state budget. But the employees will have to pay a part of the premium themselves, the other part will be covered by the employer. In addition, certain taxes may be applied to replenish the MHI fund. We all know that medical services require constant improvement, respectively, are becoming expensive from time to time, so good financial support is required.
So, it is going to be a system similar to the existing social insurance system?
But it is known that, despite the efforts of authorities, it was never possible to achieve full legalisation of all employees. On the other hand, additional fees that the employers must pay are the reason why they decrease the number of employees. Do not you think MHI will be another such factor?
I do not think so, because the MHI is a slightly different type of insurance. If you look globally, social insurance is an accumulation for the future, for a comfortable pension. Many people do not care much about it, or they think it is something intangible. But medical insurance is necessary at any age, always. Therefore, people themselves will be interested in paying the fee and have an official job. In addition, of course, there will be a system of administrative punishment for evading payment.
As I said, MHI is a social project. This system is based on the principle of social solidarity, when a young man pays for the elderly, healthy - for the patient. MHI is based on the universal nature of coverage. In other words, all citizens, regardless of gender, age, health status, place of residence, personal income level, are entitled to get free medical services included in the basic package of MHI services. This is the main concept of MHI.
There is another scrupulous moment. Negative facts in public health facilities are well known. For example, sometimes the medical staff request patients to pay extra fees for their work. Do not you think that the MHI will simply become an "additional" payment for doctors?
First of all, the doctors in all the three regions where the MHI system is applied are satisfied with the tariffs of services, because we have taken into account all costs including the cost of medicines, equipment, etc. So, this is not a tariff plan copied from other countries, rather it is based on our calculations. As I mentioned above, the whole system of rendering medical services in our pilot areas is automated. For example, when a surgery is required, we send an electronic request to the warehouse for a certain number of medicines, bandages, etc., and we already know the costs. Then we add up expenses for equipment, medical staff, treatment of the patient in hospital, etc. that is how the tariffs are calculated.
Moreover, there is a certain limit on the admission of patients. If the doctor exceeds this number, then he gets additional bonuses. Therefore, doctors themselves are interested in accepting more patients. And since the choice of a doctor is voluntary, then it is profitable for them to be known as a good and conscientious specialist.
When a contract is concluded with medical staff, we warn everyone that they may not request patients to pay additional fees. But I must admit that we had a few complaints from patients with this regard. Every such case was investigated in detail, and in case of significant evidence, the doctor was simply fired, and we submitted the case to law enforcement agencies.
What other difficulties did your specialists face when organising the MHI system in three regions of the country?
First and utmost, we had a shortage of qualified personnel in regions. Sometimes we had attract doctors from Baku, and they agreed to continue their work in regional hospitals. In addition, we are trying to organise the provision of new types of medical services, which currently force the patients to seek medical assistance in Baku.
MHI is a global project. It is quite complex but extremely important for all our citizens. Our main goal is to prepare all conditions for its implementation throughout the country and prevent possible difficulties. We aim to complete these works as soon as possible and provide results to the country's leadership, which is the final authority to decide if the project is applied nationwide.
At the end of the day, MHI influences not only the social component of our life. Improving the access to high-quality medical services should contribute to increasing the volume of labour pool, which will ultimately bolster Azerbaijan’s economic potential. We believe that the introduction of the mandatory health insurance system will benefit the entire population of Azerbaijan.