Stakeholders' Involvement in Health Technology Assessment in Kazakhstan, Poland and Bulgaria.

Background: In recent years, involvement of healthcare stakeholders in health technology assessment (HTA) has been discussed as helping the inclusion of social values in the decision-making process. The aim of our research was to identify and compare details from Kazakhstan, Poland and Bulgaria on their stakeholders' involvement in the HTA process. Information was sought on their identification, responsibilities, and regulation. Methods: We conducted a survey of seven types of stakeholders in the healthcare systems of Kazakhstan, Poland, and Bulgaria. They included patients and the public, providers, purchasers, payers, policy makers, product makers, and principal investigators. They were questioned on their involvement in the HTA process, and on the objectives of their participation. Results: Levels of involvement of different kinds of stakeholder varied between countries, reflecting political and administrative developments. There was full or partial agreement on the objectives of stakeholder participation. All respondents agreed that representatives of the ministry of health should be involved in selection of stakeholders for HTA. Conclusion: Progress has been made in the involvement of stakeholders, with interest in further development in all three countries.

Kazakhstan: health system review

Since becoming independent, Kazakhstan has undertaken major efforts in reforming its post-Soviet health system. Two comprehensive reform programmes were developed in the 2000s: the National Programme for Health Care and Development 2005–2010 and the State Health Care Development Programme for 2011–2015 “Salamatty Kazakhstan”. Changes in health service provision included a reduction of the hospital sector and an increased emphasis on primary health care. However, inpatient facilities continue to consume the bulk of health financing. Partly resulting from changing perspectives on decentralization, levels of pooling kept changing. After a spell of devolving health financing to the rayon level in 2000–2003, beginning in 2004 a new health financing system was set up that included pooling of funds at the oblast level, establishing the oblast health department as the single-payer of health services. Since 2010, resources for hospital services under the State Guaranteed Benefits Package have been pooled at the national level within the framework of implementing the Concept on the Unified National Health Care System. Kazakhstan has also embarked on promoting evidence-based medicine and developing and introducing new clinical practice guidelines, as well as facility-level quality improvements. However, key aspects of health system performance are still in dire need of improvement. One of the key challenges is regional inequities in health financing, health care utilization and health outcomes, although some improvements have been achieved in recent years. Despite recent investments and reforms, however, population health has not yet improved substantially.

Kazakhstan: health system review

The Health Systems in Transition (HiT) profiles are country-based reports that provide a detailed description of a health system and of policyinitiatives in progress or under development. HiTs examine different approaches to the organization, financing and delivery of health services and therole of the main actors in health systems; describe the institutional framework, process, content and implementation of health and health care policies; and highlight challenges and areas that require more in-depth analysis. When Kazakhstan became independent in 1991, it faced many of the same challenges as other countries from the former Soviet Union, including an oversized and inpatient-oriented system of health facilities and a drop in health financing in the early transition years. Although the country embarked on several major health reforms in the second half of the 1990s, these often lacked consistency and clear direction. In the wake of the economic upswing fuelled by oil revenues in recent years, in 2004 Kazakhstan initiated a comprehensive National Programme of Health Care Reform and Development for the period 2005–2010. One of the key challenges addressed by the reform programme is the considerable inequities in terms of health financing per capita between the country’s oblasts (regions) and between urban and rural areas. Another major challenge is out-of-pocket payments for health services and pharmaceuticals, although the magnitude of these payments remains unknown. Despite an increased emphasis on primary care, the inpatient sector continues to consume the bulk of health funding, and the question of specialized and parallel health services has so far not been addressed by the reform programme. Overall, more attention will need to be paid to the quality and efficiency of health services. A system of monitoring and evaluation, as well as the establishment of clinical practice guidelines, could play an important role in achieving these aims.Many rural areas are lacking sufficient numbers of health care workers, while an oversupply exists in the major cities. A comprehensive system of human resources planning and the introduction of incentives for health care workers in rural areas might present an avenue for addressing this challenge.