ORDER OF THE GOVERNMENT OF THE REPUBLIC OF KAZAKHSTAN

of October 15, 2018 No. 634

About approval of the State program of development of health care of the Republic of Kazakhstan of Densaulyk for 2016 - 2019

The government of the Republic of Kazakhstan DECIDES:

1. Approve the enclosed State program of development of health care of the Republic of Kazakhstan of Densaulyk for 2016 - 2019 (further - the Program).

2. To the central and local executive bodies, other organizations (under approval), responsible for program implementation:

1) to take measures for program implementation;

2) to provide in the Government of the Republic of Kazakhstan information on course of execution of the Program according to the procedure and the terms determined by the order of the Government of the Republic of Kazakhstan of November 29, 2017 No. 790 "About approval of System of state planning in the Republic of Kazakhstan".

3. Declare invalid the order of the Government of the Republic of Kazakhstan of March 16, 2016 No. 143 "About approval of the Actions plan on implementation of the State program of development of health care of the Republic of Kazakhstan of Densaulyk for 2016 - 2019".

4. To impose control of execution of this resolution on the Ministry of Health of the Republic of Kazakhstan.

5. This resolution becomes effective from the date of its signing and is subject to official publication.

Approved by the Order of the Government of the Republic of Kazakhstan of October 15, 2018 No. 634

The state program of development of health care of the Republic of Kazakhstan of Densaulyk for 2016 - 2019

Content

1. Passport of the Program

2. Introduction

3. Analysis of the current situation

4. Purposes, tasks, target indicators and indicators of results of program implementation

5. Main directions, ways of achievement of effective objectives of the Program and adequate measures

6. Necessary resources

1. Passport of the Program

Name of the program		The state program of development of health care of the Republic of Kazakhstan of Densaulyk for 2016-2019
Bases for development		The presidential decree of the Republic of Kazakhstan of February 15, 2018 No. 636 "About approval of the Strategic plan of development of the Republic of Kazakhstan till 2025 and recognition voided some presidential decrees of the Republic of Kazakhstan"; President's letter of the Republic of Kazakhstan of Nazarbayev N. A. to the people of Kazakhstan of December 14, 2012 "Strategy Kazakhstan-2050: new political policy of the taken place state"; President's letter of the Republic of Kazakhstan of Nazarbayev N. A. to the people of Kazakhstan of November 11, 2014 "Nurla жол - way to the future"; President's letter of the Republic of Kazakhstan of Nazarbayev N. A. to the people of Kazakhstan of January 10, 2018 "New opportunities of development in the conditions of the fourth industrial revolution"; National plan of the President of the Republic of Kazakhstan Nazarbayev N. A. "100 specific steps on realization of five institutional reforms"
State body responsible for development of the Program		Ministry of Health of the Republic of Kazakhstan
State bodies responsible for program implementation		Ministry of Health of the Republic of Kazakhstan, Ministry of Internal Affairs of the Republic of Kazakhstan, Ministry of Culture and sport of the Republic of Kazakhstan, Ministry of national economy of the Republic of Kazakhstan, Ministry of Defence of the Republic of Kazakhstan, Ministry of Education and Science of the Republic of Kazakhstan, Ministry for Investments and Development of the Republic of Kazakhstan, Ministry of Agriculture of the Republic of Kazakhstan, Ministry of Finance of the Republic of Kazakhstan, Department of Energy of the Republic of Kazakhstan, Ministry of information and communications of the Republic of Kazakhstan, Ministry of Labour and Social Protection of the population of the Republic of Kazakhstan, Ministry of Justice of the Republic of Kazakhstan, Ministry of social development of the Republic of Kazakhstan, akimats of areas, cities of Astana, Almaty and Shymkent
Program purposes		- Strengthening of health of the population for ensuring sustainable social and economic development of the country; - Implementation of new policy on health protection of society on the basis of integrated approach to prevention and management of diseases. - Upgrade of the national health care system oriented to efficiency, financial stability and support of social and economic growth
Tasks		Development of system of public health care; enhancement of prevention and management of diseases; increase in management efficiency and financing of health care system increase in efficiency of use of resources and enhancement of infrastructure of industry
Realization terms		2016-2019
Target indicators		By 2020: - the remaining life expectancy in case of the birth will reach 73,13 of years; - the index of health will constitute 0,815; - level of satisfaction of the population with quality of medical care will constitute 48%.
Sources and amounts of financing		Funds of the government budget and fund of compulsory social medical insurance, and also other means which are not prohibited by the legislation of the Republic of Kazakhstan will be allocated for program implementation in 2016-2019. Total costs from the government budget on program implementation will constitute the 944th 998, 8 million tenges.
By years	In total	Republican budget	Local budget	Other sources (FSMS, NF)
2016.	128 034,8		92 389,3	34 945,5	700,0
2017.	408 080,9		69 309,9	19 035,9	319 735,0
2018.	207 276,4		196 079,0	11 197,4	0
2019.	201 606,8		192733,9	8 872,9	0
Total:	944 998,8		550 512,1	74 051,7	320 435,0

The amount of financing of the State program of development of health care of the Republic of Kazakhstan of Densaulyk for 2016-2019 (further - the current State program) will be specified in case of approval republican and local budgets for the corresponding financial years according to the legislation of the Republic of Kazakhstan and proceeding from possibility of revenues republican and local budgets, Fund of social medical insurance, and also with attraction of other alternative sources.

2. Introduction

For achievement of the strategic objective set by the Head of state Nazarbayev N. A. in the Message to the people of Kazakhstan of December 14, 2012 "Strategy Kazakhstan-2050: new political policy of the taken place state", on further development of the country and entry into number of 30 most developed countries of the world by 2050 it is necessary to overcome gap in development between the countries of Organization for Economic Cooperation and Development (further - OECD) and Kazakhstan.

In this regard the state shall provide step-by-step implementation of standards of the countries of OECD directed to improvement of quality and availability of the provided medical services, increase in system effectiveness of management and financing of health care system, and also rational use of the available resources.

During implementation of the previous state programs the potential of health care system of Kazakhstan was strengthened, elements of market mechanisms are implemented and the transfer of modern medical technologies is performed.

The current State program will be directed to fixing and development of the achieved results and the problem resolution in questions of health protection according to new challenges, and also will become basis for systematic development of industry till 2050.

Implementation of the current State program will promote stability and dynamic development of socially oriented national health care system with respect for the principles of general scope of the population, social justice, providing with high-quality medical care and joint liability for health according to the key principles of policy of the World Health Organization (further - WHO) "Health-2020".

3. Analysis of the current situation

According to the report of the Global index of competitiveness (further - City Elections Commission) for 2017 on the "Health and Primary Education" indicator Kazakhstan took the 59th place from 137 countries (in 2016 - 2017 - the 94th place from 138 countries). So Kazakhstan improved indicators in the social sector: quantity of cases of tuberculosis (2016 - the 92nd place, 2017 - the 90th place), the HIV illness rate - the first place in 2016 - 2017, child mortality (2016 - 71 place, 2017 - the 70th place), life expectancy (2016 - the 90th place, 2017 - the 88th place).

Meanwhile, essential decrease in line items in comparison with 2015 when the country took the 42nd place among 140 countries is noted.

On the index of human development in 2015-2016 published in March, 2017, the republic is included into group of the countries with the high level of development and takes the 56th place from 187 countries, having risen to 14 places in comparison with 2014 (in 2014 - the 70th place from 187 countries).

medico-demographic situation and incidence

For 2016-2017 implementation of the current State program is noted:

1) increase in population in the republic with 17 417,7 (for January 1, 2015) to 18 157,0 thousand people (for January 1, 2018);

2) growth of remaining life expectancy in comparison with 2015 (71,62 of years) increased about for 8 months and constituted 72,41 of years in 2017;

3) decrease in general death rate of the population on 4, % (2015 - 7,47 for 1000 the populations, 2017 - 7,15);

4) decrease in infantile death rate on % 15,3 (2015 - 9, 37 on 1000 been born live, 2017 - 7,93);

5) decrease in population morbidity tuberculosis on 10, % (2015 - 58,5 on 100 000 populations, 2017 - 52,2) and death rates more than in time 1,3 (2015 - 4,1 for 1000 the populations, 2017 - 3,0);

6) deduction of prevalence of virus of immunodeficiency of person/acquired immunodeficiency syndrome (further - HIV/AIDS) at the concentrated stage (2015 - 0,22, 2017 - 0,212).

Decrease in indicators of maternal, infantile and child mortality on confirmation of Interdepartmental group of the agencies of the United Nations (further - the UN) allowed Kazakhstan to reach the 4th and 5th (child and maternal mortality) Sustainable development goals.

Despite positive dynamics of indicators of health of the population, the remaining life expectancy of Kazakhstan citizens is nearly 10 years less, than in member countries of OECD. The considerable difference between remaining life expectancy of men and women remains (2015 - 9,15 of year), death rate at men at working-age is 24% higher, than at women.

In structure of general death rate blood circulatory system diseases (% 22,3), the most frequent - coronary heart disease, vascular damage of brain of which about 30 thousand people annually die are the leading reason. Growth of primary incidence of diseases of the blood circulatory system constitutes almost on % 16,4 (2015 - 2429,7).

Death rate from malignant new growths (% 12,1) of which about 17 thousand people annually die is the second reason, from them 16,9 of % constitutes lung cancer. The indicator of incidence of malignant new growths increased by 18% (2015 - 207,7, 2017 - 253,4).

On the third place - death rate from accidents, injuries and poisonings (% 11,3) of which about 16 thousand people annually die (2015 - 82,5 on 100 000 populations, 2017 - 69,38 on 100 000 populations). Annually over 3000 people perish from deliberate self-damage, advancing death rate from the road accidents (further - road accident).

The injury rate remains to one of the most important medico-social problems of the present not only for Kazakhstan, but also for the majority of the countries of the world. In Kazakhstan injuries in structure of population morbidity, temporary disability and death rate take the second place, on primary exit to disability - the third place. Along with it system approach on rehabilitation and recovery of working capacity of persons who got different injuries no.

In recent years there was adverse dynamics of level of primary disability (the intensive indicator of primary exit to disability in the republic in 2014 constituted 28,1, in 2015 - 28,1, in 2016 - 29,4, in 2017 - 28,9 on 10 thousand population) that indicates the need of strict observance of measures of safe engineering of work on workplace.

At the same time, the high level of maternal and infantile death rate remains. So, following the results of 2017 exceeding of indicator of maternal death rate of planned values for 2017 according to the current State program is noted (the plan - 11,4; the fact - 12,5 on 100 thousand which were born live).

Level of infantile death rate in the republic continues to decrease and following the results of 2017 constituted 7,93 on 1000 been born live. However the level of this indicator is higher than the average level in the countries of OECD (following the results of 2015 average value over the countries of OECD - 3,71).

At the same time, in general the high level of maternal and infantile death rate remains. For the last three years target measure values of maternal death rate were not reached, were at the 12,5 level at 100 thousand live-birth in 2015 (in case of the plan of 12,4), in 2016 - 12,7 (in case of the plan of 11,5), in 2017 - 12,5 (in case of the plan in 11,4 respectively).

Such situation is caused by number of the following reasons:

1) decrease in birth rate (in 2014 - 23,14 on 1000 people of the population, 2015 - 22,69, 2016 - 22,52, 2017 - 21,64) that is connected with the introduction in reproductive age of generation of the 1990th years which were born in the period of "the second demographic hole" when the low level of birth rate was observed.

Decrease will continue till 2026 then again noticeable increase in number of births is expected.

As measure calculation of maternal death rate is made on 100 thousand live-birth, it is influenced directly by birth rate indicator.

At the same time, in recent years the absolute number of cases of maternal death rate remains approximately at one level: in 2013 - 51 women, in 2014 - 47, 2015 - 50, 2016 - 51, in 2017 - 49;

2) growth of level of external migration.

Since 2013 the number of labor migrants increased by 44% (with 25566 - 2013 year, to 36792 - 2016 year).

Among the arrived many women with the low social status and index of health of which the late request for medical care is characteristic;

3) the low index of health of the women who entered pregnancy promotes increase in risk of exacerbation of chronic diseases and development of heavy complications of pregnancy and childbirth.

In 2017 from all pregnant women who arrived under observation, the share of healthy constituted 42%. Respectively ekstragenitalny pathology during pregnancy suffered from 58%. From them anemia - 32% of pregnant women, diseases of urinogenital system - 10%, bodies of blood circulation - 6%, diseases of endocrine system - 3,7 of %, respiratory organs - % 3,2, diseases of digestive organs - % 1,7.

In recent years there was negative dynamics of level of primary disability (the intensive indicator of primary exit to disability in the republic in 2014 constituted 28,1, in 2015 - 28,1, in 2016 - 29,4 on 10 thousand population) that is also the certificate of non-compliance with safe engineering of work on workplace.

Among the reasons of burden of chronic diseases in 87,5 of % 4 risk factors (high arterial pressure, the increased cholesterol level, tobacco smoking and alcohol intake) are.

According to WHO data annual level of consumption of alcohol in Kazakhstan (in equivalent of liters of net alcohol / smothering of the population in year) decreased slightly: with 7,1 in 2007 to 6,6 in 2012.

By results of Global survey of the population about consumption of the tobacco conducted in 2014, prevalence of tobacco smoking in Kazakhstan (the % of tobacco smoking is aged more senior than 15 years), constituted % 22,4 (in the countries of OECD - % 20,65).

From 2012 to 2014 the number of the registered consumers of drugs decreased by 15%.

The Management program is implemented by chronic diseases (further - PUZ). It is based on active maintaining patients with such diseases as diabetes, arterial hypertension, chronic heart failure (further - HSN). At the same time the patient signs the contribution agreement in PUZ, he is invited on periodic basis by the supervising general practitioner and specially trained nurse for carrying out clinic - diagnostic actions, control of drug intake and scheduling of dynamic observation. The patient keeps the diary on control of health and drug intake. Thus, pro-active approach in treatment of diseases and the prevention of complications both the doctor, and the patient takes root.

In 2017 the project is realized in all 16 regions, twice from 3 the number of the patients participating in the project increased to 7 thousand. As a result, at 75% of participants arterial pressure was stabilized, at 65% of patients with diabetes blood indicators improved. Hospitalization of patients with HSN decreased twice.

According to the 6th national research (2015) prevalence of obesity among adult population of Kazakhstan made % 9,2, prevalence of excessive body weight - % 33,3.

According to forecasts of Committee according to the statistics of the Ministry of national economy of the Republic of Kazakhstan population of the country by 2030 will exceed 21 million people, the share of elderly people will increase with % 7,7 approximate to 11-13% (OECD - % 15,5). Change of demographic situation with growth of chronic diseases will affect demand of medical services.

In the republic the stable epidemiological situation on the majority of infectious diseases is noted. The scope immunization against 11 vaktsinoupravlyaemy infections of all subject of the children's population is reached by 95%. In 2012 WHO was recertified by Kazakhstan the country, free from poliomyelitis and malaria.

Ongoing efforts allowed to constrain HIV infection epidemic in the Republic of Kazakhstan at the concentrated stage. In City Elections Commission on indicator "Prevalence of HIV in age group of 15-49 years" Kazakhstan was included into group of the countries with low indicator taking the 1st place.

Despite considerable decrease in incidence and death rate from tuberculosis (decrease in incidence more than for 9% annually, death rates - more than in time 2,5 in 5 years), according to 2015 Kazakhstan among 18 countries of the European region with the high level of prevalence of tuberculosis takes the 7th place, on the level of primary steady tuberculosis - the 2nd, and in City Elections Commission on prevalence of tuberculosis - the 102nd place.

In sanitary and epidemiologic service the system of forecasting, assessment and risk management is implemented, 5 zone virologic laboratories are organized, the specialized laboratories on control of safety of food products meeting the requirements of the World Trade Organization are created, vaccination of children against pnevmokokkovy infection is brought in calendar of inoculations.

At the same time, the concept of further development and enhancement of system of risks assessment assuming creation of evidence-based assessment of negative impact of factors of the environment on the state of health of the population and the potential medicobiological and economic effects connected with it is not determined.

The existing information systems do not provide operational data exchange with other databases of the interested state bodies, departments and the international organizations. There is no possibility of carrying out monitoring of sanitary and epidemiologic situation in the online mode.

The existing system of laboratory control taking into account development of technologies and the solution of tasks in ensuring sanitary and epidemiologic wellbeing of the population requires continuous improvement and retrofitting.

Health protection and health care system

For the period the current Gosprogramma's realization certain work on forming of single national policy on issues of health protection, strengthening of intersectoral and interdepartmental interaction is carried out.

In structure of authorized body and its territorial subdivisions structural divisions on protection of public health are created.

The National center of public health care which began the functioning will promote creation of available and effective mechanisms on prevention of diseases and strengthening of health.

The Algorithm of interaction of the central and local executive bodies concerning strengthening of public health is developed for ensuring effective intersectoral cooperation.

Bases of protection of public health are regulated by the Code of the Republic of Kazakhstan "About health of the people and health care system" and are implemented by the organizations of health care, including the centers of forming of healthy lifestyle, the organizations of primary health care (further - PHC), services of infectious control in the medical organizations, and also other state bodies and the organizations within interdepartmental interaction.

The implementation of actions on ensuring sanitary and epidemiologic wellbeing of the population proceeds. Measures for reducing administrative barriers, improvement of conditions for business activity are taken. Issue of the sanitary and epidemiologic conclusions with four to one type is optimized. For the first time in Kazakhstan mechanisms of alternative to checks are implemented (audit, HACCP (risk analysis and critical control points), monitoring of safety of products by means of sampling and cameral control). The training Central Asian center for food safety is created and functions.

Together with responsible state bodies the implementation of actions on providing food of school students, instilling of skills of maintaining healthy lifestyle, reducing death rate from road accident and injury rate, to delivery of health care by the TB patient in organizations of criminal executive system, to the prevention and decrease in effects of emergency situations, ensuring medical care in case of emergency situations and to development of sanitary aircraft proceeds. Also together with local executive bodies events for promotion of healthy lifestyle and prevention of especially dangerous infections are held.

Joint efforts for regulation of behavioural factors in the republic perform total ban of advertizing, the regulation of restriction of sale of tobacco products and alcohol, smoking and alcohol intake in public places is entered. Step-by-step increase in excises on alcoholic and tobacco products is carried out. The age qualification is increased by sale of alcoholic products to persons till 21 year and ban on alcohol sale is imposed at night.

Programs for prevention of drug addiction and behavioural diseases in educational institutions, including by training of children's officers in technologies of early identification of risk groups on narcological profile among children and teenagers, and also by training of staff of the Ministry of Internal Affairs of the Republic of Kazakhstan (police, local police inspectors) in skills of determination of degree of intoxication are implemented (alcoholic, narcotic, toxic).

At the same time actions for timeliness of accomplishment of obligations by participants of interdepartmental and intersectoral interaction are ineffective, the coordinating role of National coordination council is insufficient, there is no effective interaction of sectors at primary level. Not enough attention is paid to management of determinants of the reasons of noninfectious diseases. Efficiency of preventive and improving actions among school students is reduced. In insufficient amount fortification of flour on prevention of deficit of iron and folic acid is carried out.

For the purpose of strengthening of preventive orientation at the level of primary link the following events are held:

1) within integration of specialized services with primary link, in polyclinics antitubercular, oncological, mammology offices were in addition open, offices of mental health are open;

2) the institute of social workers is created (2014 - 1,2 on 10 thousand of the population, in 2017 - 7,4 on 10 thousand population);

3) the number of general practitioners (further - VOP) with 3 101 persons in 2014 to 5 382 in 2017, i.e. more than increased by 70%;

4) since 2014 the complex per capita standard rate (further - KPN) which in 2017 constituted 683 tenges and grew, in comparison with 2014, on % 29,3 is implemented. Financing of primary health care in total amount of financing of the guaranteed amount of free medical care (further - GOBMP) increased from 33% in 2014 to 37% in 2017. Vyravnen the level of financing of PHC between regions with increase in rate counting on 1 inhabitant (from 169 to 683 tenges).

For the purpose of enhancement of rendering emergency medical service (further - SMP) since 2017 implements the two-level model combining the regional centers of emergency aid and the national center of coordination of rendering SMP in single network.

The international training programs of employees of ambulance and emergency medical service are implemented (BLS, ACLS standards). Redesign of the hospital transport, specialized clothes of staff of service SMP is carried out. 259 units of the hospital transport, scope by GPS navigation - 76% are acquired. The new format of receptions (Emergency department) of multi-profile hospitals is implemented.

The new format of receptions of multi-profile hospitals (triazh-system, patsiyentooriyentirovanny approach, review of personnel and material equipment of receptions) is tested in pilot the mode in Astana, Almaty. On the basis of positive results of pilot project this model is broadcast on all regions of Kazakhstan.

The new model of urgentny telemedicine which will be realized in case of the corresponding financing is developed (presumably within financing of the World Bank).

Thanks to the taken measures decrease in growth rate of demand for stationary services, more differentiated direction of patients on additional inspections and consultations is noted.

However the PHC priority regarding financing is not reached. The amount of financing of PHC on 1 inhabitant constituted in Kazakhstan 95 US dollars, Estonia - 231, Slovenia - 369, OECD - 558. Slow rate of transition of the PHC organizations to the principle of family medicine is observed. The motivation for forming of service VOP is not fully provided. Mechanisms of economic motivation of management of the state of health of the attached population at the level of PHC are not developed, work on informing the population on new model with wider competences and functionality of VOP is insufficient.

Integration of PHC and vertical profile services (tuberculosis, oncology, HIV/AIDS, etc.) is also insufficient. Questions of improvement of succession between the out-patient and polyclinic, stationary level and service of emergency medical service require the solution. Reconsumption of consulting and diagnostic services remains. Potential of hospitals is insufficiently used for these purposes that causes dissatisfaction of the population in availability and quality of medical services.

With implementation of the Single national health care system (further - ENSZ) at the stationary level carries out consolidation of means of GOBMP at the level of the republican budget, the difference in financing between regions as a result decreased, the principle "is implemented money follows the patient", financing on kliniko-costly groups (further - KZG). It promoted intensification of use of resources of hospital and development of hospital-replacing technologies, implementation and development of high medical technologies in regions (in comparison with 2010 the average duration of stay in hospital was reduced by 27%, the number of the treated patients in the conditions of day hospital increased by % 23,5, the number of cardiac interventions increased with 7000 to 85000 in year).

However, despite reducing bed fund on 14 thousand units, in Kazakhstan indicators of security with hospital beds are higher, than in the countries of OECD for 20% more long average duration of stay in hospital (9,2 of koyko-days (2015) against 6,0 in the countries of OECD), differentiation of bed fund for the level of intensity of treatment is insufficient that creates financial load of the budget of health care: more than 60% of the budget of health care system fall to the share of hospitals.

The low performance of their work became result of insufficient level of differentiation, shortage of beds of recovery treatment, rehabilitation and long leaving. Hospitals at home and patronage service are not developed. Over 20% of the hospitalized patients could receive treatment at the out-patient level.

The most widespread groups of diseases (sharp myocardial infarction, sharp violation of brain blood circulation (stroke), malignant new growths, injuries, childbirth) are the most frequent reasons of hospitalization and death rate. At the same time the interaction and integration at all levels of route of the patient based on single algorithms of actions are not enough.

For the purpose of implementation of the integrated model under authorized body 5 Coordination councils on increase in efficiency of maternity obstetric service and the childhood, delivery of health care in case of sharp myocardial infarction are created and to management of acute strokes, management of oncological diseases, delivery of health care in case of injuries; their structures, Road maps on implementation of the integrated model in 5 directions are approved; from among the republican centers the profile medical organizations for each of 5 directions are determined.

In industry the competitive environment among suppliers of private and state pattern of ownership of medical services with providing equal conditions when rendering GOBMP is created:

- new rules of purchase taking into account equal conditions for private suppliers are developed;

- 29 SanPiNs are cancelled;

- are reviewed - 8 SanPiNs;

- the number of checks of business is reduced twice;

- are exempted from checks of 34,5 of one thousand objects.

All this allowed to provide growth of share of private suppliers in rendering GOBMP. In 2014 this indicator constituted % 27,4. In 2017 - grew to 40%, in 2018 reached 43%. At the same time, for the period 2017-2018 growth of share of participation of private suppliers in terms of money grew by 5% (from 8% in 2017 to 14% in 2018).

The state medical organizations expanded independence by transition to the status of the organizations on the right of economic maintaining (further - PHV) with the supervisory boards. The new payment methods oriented to resulting effect in out-patient and stationary sectors, in oncological service and the medical organizations of the village - the global budget are implemented.

The amount of financing of industry grew by 19% with 867, of 8 billion tenges in 2015 to 1 trillion 030 billion tenges in 2017.

At the same time, the analysis of macroeconomic indicators revealed essential lagging of the sizes of budget investments in health care in Kazakhstan from the level of developed countries. So, in 2016 the share of the public expenditures on health care in GDP in Kazakhstan constituted % 3,4 (in the countries of OECD - 9%).

In Kazakhstan the high level of private expenses on receipt of medical care remains (the republic - 41%). According to WHO data the population expense level over 20% are sign of low financial stability of health care system and characterizes the increased risk for the population connected with their approach to poverty line owing to diseases which, in turn, can affect all spheres (capability to get education, economic productivity, reduction of demand for medical services), and also to lead to deterioration in health and demographic indicators.

Besides, the operating funding mechanisms, tariff policy in health care system are insufficiently effective, issues of financing of updating of fixed assets are not resolved. Mechanisms of efficiency of use of means of GOBMP require further enhancement. So, the low performance of the National screening program (detectability makes % 3,4 among adult population, % 16,4 - among children's) is noted, efficiency of screenings does not monitorirutsya on the basis of recommendations about efficiency of early detection of cancer tumors and their successful treatment.

The existing system of financing of GOBMP does not realize the main principle of all health care system of joint liability of the state, employer and citizen for the health.

Within development of system of compulsory social medical insurance the Fund of social medical insurance (further - FSMS) and its 16 regional branches is created. FSMS accumulates assignments and fees on compulsory medical insurance from participants of system and acts as the single payer for rendering medical services.

Taking into account emergence of new technologies the modern medicine becomes more and more resource-intensive.

Work on standardization according to the international requirements is continued: protocols of diagnostics and treatment, algorithms, standards of profile services are enhanced. Consistently quality management components began to take root: accreditation system of the medical organizations, internal audit, independent assessment of knowledge and skills.

At the same time, quality management of medical services is based more on the control system, process of standardization in health care is not complete, public organizations and professional communities in quality management process are not attracted. The system of certification of health workers poorly motivates quality assurance of medical services. Process of doakcreditatsionny preparation of the medical organizations is not developed.

Creation of advisory advisory body under the Ministry of Health of the Republic of Kazakhstan - to the Joint commission on quality of medical services (further - OKK) which activities are directed to development of recommendations about enhancement of clinical protocols, standards of medical education, provision of medicines, standards of quality control system and availability of services in the field of health care became the new institutional mechanism on improvement of quality of medical services.

Within work on quality assurance of medical services the Joint commission on quality of medical services is created. The number of representatives of non-governmental organizations in OKK made 43%.

For 2016-2017 36 meetings of OKK at which 462 clinical protocols of diagnostics and treatment are approved are held, 95 new medical technologies are considered, from them 75 are approved.

Further accreditation of the medical organizations continues. For 2016 there underwent national accreditation the 169th medical organizations, for 2017 - 152.

For the first time the Center of accreditation of the Republikansky center of development of health care gained the international recognition on the main activities. Based on compliance audit of accreditation system of Kazakhstan to requirements of the supreme body in the world on quality and safety in health care - International Society for Quality in Health Care (International society on Quality in Health care (further - ISQua), the Commission on accreditation in case of the Board of directors of ISQua made the decision on accreditation for a period of four years till January, 2021.

Following the results of work in 2017 in the republic performed activities of 247 thousand health workers, including doctors - 72 134 people, average health workers (further - SMR) - 175 246 people (all departments). From them in health care system work only 209 161 persons (doctors - 56 570 and SMR - the 152nd 591).

Security with medical personnel on 10 thousand of the population averaged on the republic - 39,7 (2016 - 41,6); SMR - 96,5 (2016 - 95,3).

General security with doctors and average medical personnel per 10 thousand of the population in general is stable.

Despite it, the need for doctors on separate specialties remains. By regions uneven distribution of personnel resources - interregional difference more than in time 3,8 is observed.

Annual level of need for medical personnel develops proceeding from:

natural reasons (% 2,8): decrease (retirement, death and other), migration, social migration, overflow in private structures, etc.;

growth of the population, expansion of network of the medical organizations, at the expense of new;

heterogeneities of structure of need for personnel by specialties;

availability of unoccupied established posts (vacancies) consisting of difference of the provided established posts and busy established posts.

Completeness medical personnel in health care system in general for 2017 made 95% that is sufficient for ensuring high-quality medical care to the population. The average coefficient of combining jobs made 1,32, at the same time the maximum permissible coefficient of combining jobs is determined as 1,5.

For providing industry with medical personnel:

1. The regulation of obligatory working off of the graduates who studied at the expense of the state educational order on medical specialties is entered.

2. The annual personified monitoring of fixing of graduates on places is conducted.

3. The National policy of management of personnel resources of health care is approved.

4. Memorandums with akims of areas, cities of Astana, Almaty for 2016-2018 on achievement of indicator "decrease in deficit of medical personnel" are concluded.

5. Target orders with local executive bodies (further - MIO) are selected for training.

6. Corporate politicians on management of personnel reserve of health care and HR technology in the regional medical organizations take root.

7. The technique of the statistical recording of personnel is updated (it is harmonized with standards of WHO, Eurostat); provisions according to the admission of graduates of internship (pediatrics, obstetrics and gynecology) and graduates of internship after retraining are enshrined (neurology (adult), neurology (children's), professional pathology, phthisiology, including children's, medical rehabilitology, including children's, clinical pharmacology, anesthesiology and resuscitation (adult) at the level of out-patient and polyclinic link and in rural health care to work without passing of residency.

Deficit on clinical unoccupied established posts by clinical specialties in 2017 made 2840 established posts. At the same time, taking into account normative coefficient of combining jobs of 1,5, that physical persons will be required less, on average about 1893 people.

Despite implementation of the stimulating component of the per capita standard rate, ratio of the average salary of VOP in Kazakhstan to the average monthly salary in economy constitutes 1,0. This indicator in Great Britain - 1,9; Turkey - 2,0; Slovenia - 2,5; Hungary - 1,4; Estonia - 1,7.

In this regard work on transition until the end of 2018 of the medical organizations in the companies on the right of economic maintaining is conducted (further - PHV). Comparative analysis shows that the average salary of doctors in the medical organizations which passed one PHV above than at colleagues in the public medical institutions and constitutes 157 thousand tenges, average personnel - 101 thousand tenges.

For the purpose of quality assurance of training of medical students upgrade of medical education through strategic partnership of medical schools of the country with 6 leading foreign universities is begun: КазНМУ of S. Asfendiyarov and Duke University (USA), the Karaganda state medical university and University of Lund (Sweden), the State medical university Semey and University of St. Louis (USA), Medical university Astana and University of Rome "La Sapiyentsa" (Italy), the Southern Kazakhstan state pharmaceutical academy and the Gdansk medical university (Poland), the West Kazakhstan state medical university of M. Ospanov and the Poznan medical university (Poland). The model of university clinic where the medical organizations are integrated into structure of universities is developed.

Work on upgrade of sisterly education on the basis of the Finnish model of applied bachelor degree on which 312 people in 6 pilot colleges study is continued.

However there are low practical orientation of training, imperfection of educational programs, especially in the directions clinical pharmacology, management, economy.

Questions of low competitiveness of scientific research, their unsatisfactory practical importance, insufficient financing of applied scientific research in the field of health care and staff deficit with academic degree (more than 650 specialists) continue to remain urgent.

On the basis of the international experience the Single system of distribution of medicines is created. International standards of quality take root (GMP, GDP, GPP, etc.), are created фарминспекторат and state body in the field of drug circulation. For ensuring physical availability of the medicinal help to residents of the village realization of medicines through objects of PHC in more than 3000 rural settlements which do not have the pharmaceutical organizations is organized.

Development and enhancement of form system by implementation and maintenance of the Kazakhstan national medicinal form are continued (further - KNF).

Medicinal forms of the organizations of health care are created on the basis of KNF, constantly enhanced on the basis of regular carrying out monitoring and efficiency evaluation of application concerning separate, most expensive medicines.

In expense structure on provision of medicines within GOBMP the share of stationary provision of medicines constitutes 45%, share of out-patient provision of medicines - 55%. At the out-patient level more 2,5 of one million citizens of the republic receive medicines more than according to 400 names of medicines free of charge at the expense of the state.

The Republic of Kazakhstan became the official observer of the Commission of the European pharmacopeia and the full member country of the International program of WHO for monitoring of side effects of medicines. Within the Eurasian Economic Union agreements of state members of the Eurasian Economic Union (Belarus, Kazakhstan, the Russian Federation, Kyrgyzstan, Armenia) on the single principles and rules of drug circulation and medical products are signed.

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