Rationalizing rural hospital services in Kazakstan.

The Soviet health care system placed great emphasis on specialist hospitalization. Primary care, in contrast, was viewed primarily as prophylactic and also identified patients for admission to hospital. This led to long lengths of stays, since patients were provided with outpatient type care in hospital, and unnecessary admissions. The reduction in funding for the health system has exacerbated the top heavy nature of the system and made restructuring of the sector essential. Rural areas in Kazakstan follow a similar structure to other parts of the former Soviet Union. In 1996 a project was undertaken to review the provision of hospital services in one rural rayon (district) just outside Almaty. The approach taken was to emphasize the relationship between activity and financial data. It did this by analysing the link between clinical decisions taken to reduce lengths of stay, management decisions to modify staffing and costs of care. It was shown that substantial savings could be made together with improvements in the quality of care, through a programme of planned restructuring. Some success in inducing change is reported but without a major change in approach to local level management. In order to achieve changes it is important that short and long term alternatives to hospitalization are developed.