Problem: Vertical, disease-oriented arrangement of health service delivery; weak gatekeeping at the primary level; outdated health system infrastructure due to limited public investment; inefficient use of health system resources and high out-of-pocket expenditures for patients; low population health literacy and limited patient decision-making in care.
Solution highlights: A health sector reform project was launched by the Government of Azerbaijan with the financial and technical support of the World Bank, leading to the adoption of a comprehensive National Master Plan for health in 2008; a strong understanding of the political context and environment proved important in determining an acceptable pace for proposed reforms; top-down leadership from the Ministry of Health ensured national ownership over internationally-supported reforms; strengthening the stewardship capacity of the Ministry was important; investment in human resources, including formalizing medical training and developing new medical specializations, was critical to driving sustainable change.
Description of practice
Between the mid-1990s and early 2000s, Azerbaijan experienced fluctuations in basic population health outcomes and life expectancy tracked below the WHO European Regional average. Effectively addressing suboptimal health outcomes was hindered by the vertical, disease-oriented arrangement of the health system. Gatekeeping at the primary level was weak and care delivery was concentrated in specialized settings. Health system resources were limited and out-of-pocket expenditures accounted for the majority of total health spending, causing patients to face financial barriers in accessing care. Low patient compliance rates in treatment plans and inappropriate use of prescription medications were also of concern and signalled a need for more people-centred care.
In 2006, a national health sector reform project was launched by the Government of Azerbaijan in partnership with the World Bank. This led to the development, and subsequent adoption, of a comprehensive National Master Plan to guide health reforms. Officially enacted in 2008, the Plan served to guide capital investments in health infrastructure, support the reorganization of health and human resources, strengthen the health information system, and design a new national health insurance model. A basic package of health services – free at the point of use – was defined and nearly 100 care guidelines were developed to support service delivery. Primary care facilities were constructed and family medicine became a medical speciality, contributing to primary care strengthening. Hospital beds were reduced by approximately 50% and underperforming hospitals were closed, increasing hospital occupancy rates three-fold to more optimal levels. A national information centre was established to introduce e-health cards for the population and several health registries were developed to support data collection for health system planning. The Ministry of Health conducted several assessments examining population health outcomes and services delivered under the Plan, including the demographic health survey and WHO STEPwise approach to surveillance (STEPS) assessment in 2011. Patient satisfaction with health services was also surveyed. When project funding from the World Bank came to a close in 2012, the Ministry of Health developed the Strategic Plan 2014–2020 to continue health system improvements and guide future reforms. Current priorities include addressing noncommunicable disease, continuing work on maternal and child health, strengthening referral systems, and improving monitoring and evaluation.
Implementation of practice
What stage is the practice currently in?
Who was/is responsible for the implementation of the practice?
The Government of Azerbaijani worked closely with the World Bank and other international partners to design the reform project. Creating government ownership over reforms helped secure continued political commitment to health. Collaborating with international agencies infused needed technical expertise into the project. Implementation was steered by the Ministry of Health, in partnership with the Ministry of Finance and international actors, with top-down government leadership supporting reform activities. The Ministry of Health has continued to guide health system improvements since the project’s completion.
Public expenditure on health increased from 162 million Azerbaijani manats in 2005 to 725 million manats in 2014. Investments in health infrastructure and technology are expected to increase service quality over the long term. An evaluation conducted by the World Bank showed that the National Master Plan increased access to primary care, improved delivery of care at the appropriate level and slightly decreased out-of-pocket expenditures.
This case was prepared as part of a larger effort by the WHO Regional Office for Europe and published (2016) in the document, "Lessons from transforming health services delivery: Compendium of initiatives in the WHO European Region".
© Copyright World Health Organization (WHO), 2016
The methodology used for the development of this case is slightly different from the templates used on the IntegratedCare4People web platform, in particular in the analysis of enabling factors and barriers to change.
Please click on the link below for more information about this practice.
- Tohfa Jamilova
- Ministry of Health