Impact of provider payment reforms on hospital productivity in Kazakhstan

Worldwide demand for enhanced hospital productivity has propelled the implementation
of new provider payment schemes across many countries. The impact of these hospital
payment reforms on hospital productivity is, however, rather under-researched. This thesis
aims to address this evidence gap by conducting two case studies on provider payment
reforms in Kazakhstan. It aims to provide a comprehensive understanding of intended and
unintended consequences of hospital payment systems, review and address any limitations
of their evaluation methods.

A systematic literature review followed the Preferred Reporting Items for Systematic
Reviews and Meta-Analyses and was conducted to a) explore the consequences of hospital
payment reforms in the global context, b) critically assess the methods applied in studies on
hospital payment reforms. Two quasi-experimental designs, a controlled interrupted series
approach and a single interrupted time-series were used to evaluate the immediate and
delayed impacts of the newly introduced provider payment policies: diagnosis-related groups
and global budgets. The thesis employed administrative hospital data for the period of
2011-2013 provided by the Ministry of Health of the Republic of Kazakhstan. The controlled
interrupted time-series was employed for three hospital levels separately (regional, city and
district hospitals) to assess the impact of the patient-based payment system, whereas the
matching technique was performed to find the closest pair of piloted and non-piloted hospitals
to balance them on a set of baseline characteristics. The single interrupted time series was
employed to assess the introduction of the global budget payment system in district hospitals.

The studies suggest that the two hospital payment systems that were consequently
introduced in Kazakhstan had a limited effect on hospital productivity. The amount of
healthcare services is likely to increase as a result of the change of payment system
from fee-for-services to diagnosis-related groups. On the other hand, a switch from
diagnosis-related Groups to global budgets is likely to bring some reverse effects where the
amount as well as complexity of healthcare provision are decreased.