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Health Care Reform in the Former Soviet Union: Beyond the Transition
Abstract
To assess accessibility and affordability of health care in eight countries of the former Soviet Union.
Primary data collection conducted in 2010 in Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Moldova, Russia, and Ukraine.
Cross-sectional household survey using multistage stratified random sampling.
Data were collected using standardized questionnaires with subjects aged 18+ on demographic, socioeconomic, and health care access characteristics. Descriptive and multivariate regression analyses were used.
Almost half of respondents who had a health problem in the previous month which they viewed as needing care had not sought care. Respondents significantly less likely to seek care included those living in Armenia, Georgia, or Ukraine, in rural areas, aged 35-49, with a poor household economic situation, and high alcohol consumption. Cost was most often cited as the reason for not seeking health care. Most respondents who did obtain care made out-of-pocket payments, with median amounts varying from $13 in Belarus to $100 in Azerbaijan.
Access to health care and within-country inequalities appear to have improved over the past decade. However, considerable problems remain, including out-of-pocket payments and unaffordability despite efforts to improve financial protection.
... While many services are free for Russians, they pay for them officially or unofficially because the national public health system is underfunded (Popovich et al., 2011;Sheiman et al., 2018) and cannot offer service at the desired level. Finally, patients can informally pay for healthcare as a form of 'gratitude' which is a tradition rooted in the Soviet Union (Aarva et al., 2009;Balabanova et al., 2012;Feeley et al., 1999;Sheiman et al., 2018) . ...
... For example, the survey conducted in 2014 showed that 22.2% of patients paid for outpatient care while 37.5% of patients paid for inpatient care officially or unofficially (Zasimova 2016). In study (Balabanova et al., 2012) the survey data for 2010 showed that 19% of Russians taking outpatient care had to pay for it and 5.7% of patients had to pay for inpatient care. The studies stress that medication is the main health expense for Russians: 70.4% have to pay for drugs in (Balabanova et al., 2012) or 92.1% in (Balbuena et al., 2009) and this expenditure takes 85% of the total volume of health spending in (Shishkin et al., 2014). ...
... In study (Balabanova et al., 2012) the survey data for 2010 showed that 19% of Russians taking outpatient care had to pay for it and 5.7% of patients had to pay for inpatient care. The studies stress that medication is the main health expense for Russians: 70.4% have to pay for drugs in (Balabanova et al., 2012) or 92.1% in (Balbuena et al., 2009) and this expenditure takes 85% of the total volume of health spending in (Shishkin et al., 2014). ...
The studies on the demand for healthcare in low- and middle-income countries rarely take into consideration the fact that many people spend their income on self-treatment and professional treatment. The estimation of the income elasticity of demand for self-treatment and professional treatment can show a more precise picture of the affordability of professional care. This paper contributes to the discussion around estimates of income elasticity of health spending and discussion whether professional care and self-treatment are close to a luxury good and inferior good respectively in a middle-income country. We apply the switching regression model to explain the choice between self-treatment and professional healthcare via estimates of the income elasticity. Estimates are made with the use of the Russian Longitudinal Monitoring Survey — Higher School of Economics (RLMS-HSE), a nationally representative survey. While individual expenditure on professional treatment is higher than that on self-treatment, our estimates show that expenses on professional treatment can be income inelastic except when spending on medicines prescribed by a physician that are elastic. The results also indicate that cost of self-treatment is income elastic. In all cases, the considered income elasticities are statistically insignificant between professional and self-treatment.
... In the Commonwealth of Independent States (CIS) (), NCDs are estimated to account from 62% to 92% of total deaths (WHO, 2014). When CIS countries were part of the Union of Soviet Socialistic Republic (USSR), the health system, Semashko system, was characterised by a centralised (state-run model) healthcare system with strong emphasis on specialists and hospital care (Balabanova et al., 2012). The Soviet Polyclinics (outpatient facilities) were represented by narrow specialists only, while paediatricians and 2 E Muratalieva et al. ...
... From health financing point of view, health care was free for the patients, but very expensive for the Government of the USSR (Birn and Krementsov, 2018). Therefore, after collapse of the USSR, the Soviet Republics were unable to maintain this model which resulted in a crisis for the newly independent ex-Soviet states in the delivery of health care (Balabanova et al., 2012). ...
... These articles identified for this building block can be divided into two groups: firstly, articles describing the intentions of CIS countries to develop family medicine (Asadov and Aripov, 2009;Akhmedov and Jarylkasynova, 2010;Balabanova et al., 2012;Peabody et al., 2017;Blake et al., 2019). In most of these articles, authors are documenting shift from soviet system of polyclinics to family medicine/general practice without appropriate financing and human resources reforms (Gazizov, 2010;Balabanova et al., 2012). ...
Aim:
The aim of this study is to review the literature in Commonwealth of Independent States (CIS) countries with regard to their response to non-communicable diseases (NCDs) and the implementation of the World Health Organization (WHO) Package of Essential Non-communicable (PEN) disease interventions for primary health care.
Background:
NCDs are estimated to account from 62% to 92% of total deaths in CIS countries. Current management of NCDs in CIS countries is focused on specialists and hospital care versus primary health care (PHC) as recommended by the WHO.
Methods:
This paper uses a scoping review of published and grey literature focusing on diabetes and hypertension in CIS countries. These two conditions are chosen as they represent a large burden in CIS countries and are included in the responses proposed by the WHO PEN.
Findings:
A total of 96 documents were identified and analysed with the results presented using the WHO Health System Building Blocks. Most of the publications identified focused on the service delivery (41) and human resources (20) components, while few addressed information and research (17), and only one publication was related to medical products. As for their disease of focus, most studies focused on hypertension (14) and much less on diabetes (3). The most studies came from Russia (18), followed by Ukraine (21) and then Kazakhstan (12). Only two countries Moldova and Kyrgyzstan have piloted the WHO PEN. Overall, the studies identified highlight the importance of the PHC system to better control and manage NCDs in CIS countries. However, these present only strategies versus concrete interventions. One of the main challenges is that NCD care at PHC in CIS countries continues to be predominantly provided by specialists in addition to focusing on treatment versus preventative services.
... The collapse of the political system is associated with more than just economic hardship: it also represents a lost system of values and a lost ideology that had provided the sense and meaning of life for decades and across the generations, especially within the Soviet states. The loss of ideology, along with economic crisis, may trigger higher consumption of alcohol, and an increase in the suicide rate and in participation in risky behavior, among other issues (Balabanova et al., 2012;Rechel & McKee, 2009;Shishkin, 2013;Walberg et al., 1998). Some studies have specifically analyzed the decline in public health during the early 1990s (1990)(1991)(1992)(1993)(1994), looking at how and why socio-economic changes led to a decline in life expectancy (Walberg et al., 1998). ...
... Previous studies also point out that the populations of non-democracies do not search for medical care even if they need it, mainly because it is not affordable (Balabanova et al., 2012) but also because of low trust to medical personal (along with general lower social and institution trust-trust to people and to services). The later was argued to be one of the pronounced historical legacies of Communism, among many others (Pop-Eleches & Tucker, 2017;Beissinger & Kotkin 2014;Lankina et. ...
... along with general lower social and institution trust-trust to people and to services). The later was argued to be one of the pronounced historical legacies of Communism, among many others (Pop-Eleches & Tucker, 2017;Beissinger & Kotkin 2014;Lankina et. al 2016b; The same group of people exhibit risky behavior, thus reducing their life expectancy. Balabanova et. al (2012), for example, discovered, that people from such transition states as Armenia, Georgia, and Ukraine are significantly less likely to seek medical care, especially those living in rural areas and within age group of 35-49. The post-Soviet non-democratic states contrast with the more successful achievers among the post-communist states in ...
Democracy is generally associated with governmental accountability, better public policy choices and public health. However, there is limited evidence about how political regime transition impacts public health. We use two samples of the states around the world to trace the impact of regime transition on public health: the first sample comprises 29 post-communist states, along with 20 consolidated democracies, for the period of 1970–2014; the second sample is a subsample of the same 29 post-communist states but only for the period of transition, 1990–2014. We find that the post-communist states experienced some decline in life expectancy in the first few years of transition (1990–1995). Yet, with a steady increase in the measure of democracy from 1995 onwards, life expectancy significantly improved and infant mortality decreased. Therefore, in the long run, democratization has had a positive impact on both the life expectancy and infant mortality of citizens of the post-communist states.
... Global efforts to address chronic malnutrition among infants and children have contributed to drastic improvements in child stunting, as the prevalence of stunting among children has decreased by 42% worldwide, between 1990 and 2017, from 39.3% to 22.2% (1). The Kyrgyz Republic is a landlocked country in Central Asia, with an estimated population of 6.39 million (2), with the majority of the population living in rural areas ( Figure 1A). ...
... Similarly, Kyrgyz Republic economy (GDP/capita) improved rapidly between 2000 and 2006 (21). These improvements may be due to national cash transfer programs, poverty reduction frameworks (22) and land privatization. Land privatization was associated with 13% of the variation in child HAZ outcome in one study (23). ...
... A supportive policy environment and the introduction of comprehensive, multifaceted and multilevel health sector reforms and policy efforts improved the cost-effectiveness of the health system, and the accessibility, affordability, and quality of health services (80). Top-down reforms transformed health financing and increased the financial protection, efficiency, and transparency of the health system (18,22), whereas bottom-up approaches improved the local coverage and provision of health services, particularly for rural and hard-to-reach populations in the Kyrgyz Republic (22,54). Evidence on improvements in maternal, newborn, and child health and universal health coverage and primary care (18,76,81) highlight the enabling role of the health sector reforms to improve the equity, quality, and efficiency of health services in the Kyrgyz Republic. ...
Background:
Chronic malnutrition among infants and children continues to represent a global public health concern. The Kyrgyz Republic has achieved rapid declines in stunting over the last 20 y, despite modest increases in gross domestic product per capita.
Objective:
This study aimed to conduct a systematic, in-depth assessment of national, community, household, and individual drivers of nutrition change and stunting reduction, as well as nutrition-specific and -sensitive policies and programs, in the Kyrgyz Republic.
Methods:
This mixed methods study employed 4 inquiry methods, including: 1) a systematic scoping literature review; 2) retrospective quantitative data analyses, including linear regression multivariable hierarchical modeling, difference-in-difference analysis, and Oaxaca-Blinder decomposition; 3) qualitative data collection and analysis; and 4) analysis of key nutrition-specific and -sensitive policies and programs.
Results:
Stunting prevalence has decreased in the Kyrgyz Republic, however, subnational variations and inequities persist. Child growth Victora curves show improvements in height-for-age z-scores (HAZ) for children in the Kyrgyz Republic between 1997 and 2014, indicating increased intrauterine growth and population health improvements. The decomposition analysis explained 88.9% (0.637 SD increase) of the predicted change in HAZ for children under 3 y (1997-2012). Key factors included poverty (61%), maternal nutrition (14%), paternal education (6%), fertility (6%), maternal age (3%), and wealth accumulation (2%). Qualitative analysis revealed poverty reduction, increased migration and remittances, food security, and maternal nutrition as key drivers of stunting decline. Systematic scoping literature review findings supported quantitative and qualitative results, and indicated that land reforms and improved food security represented important factors. Key nutrition-specific and -sensitive policies and programs implemented involved breastfeeding promotion, social protection schemes, and land and health sector reforms.
Conclusions:
Improvements in stunting were achieved amidst political and economic changes. Multilevel enablers, including poverty reduction, improved food security, and introduction of land and health reforms have contributed to improvements in health, nutrition, and stunting among children in the Kyrgyz Republic.
... 22 Together with vanishing social welfare, a deficient health care system with subsequent mass privatization of health facilities and proliferation of direct out-of-pocket payments for health services and pharmaceuticals likely interacted with cultural and economic factors to magnify the effects of transition on mortality. 23,24 In 2012, public spending on healthcare represented 1.7% of GDP, suggesting a significant mismatch between the very limited government resources devoted to health and existing needs. 21 In the same year, only 8% of the population was insured in private insurance, while 36% were covered by state insurance and 56% were uninsured. ...
... This pattern receives more support from previous studies in Georgia, identifying that over half (61%) of adults aged 18 and over, notably at ages 34-49, with long-term illnesses did not seek care when needed primarily owing to unaffordability (70%), but not geographical inaccessibility. 23,24 There is also evidence that the share of households that incurred catastrophic out-of-pocket health expenditures, predominantly due to chronic diseases, increased from 2.8% to 11.7% during 2000-2007. 87 Such a trend seems to be commonplace in the FSU, 23 as in LMICs in general, bearing a disproportionate detrimental economic burden of NCDs, which in turn precipitates impoverishment and poorer careseeking behavior. ...
... 23,24 There is also evidence that the share of households that incurred catastrophic out-of-pocket health expenditures, predominantly due to chronic diseases, increased from 2.8% to 11.7% during 2000-2007. 87 Such a trend seems to be commonplace in the FSU, 23 as in LMICs in general, bearing a disproportionate detrimental economic burden of NCDs, which in turn precipitates impoverishment and poorer careseeking behavior. 88 All the above may, in large part, explain the other noteworthy finding of our study regarding the absence of NCD mortality gradient by the place of death as a proxy of the access and utilization of care during the terminal illness. ...
Purpose:
Worldwide, noncommunicable diseases (NCDs) are the leading cause of premature death of women, taking the highest toll in developing countries. This study aimed to identify key socio-demographic determinants of NCD mortality in reproductive-aged women (15-49 years) in Georgia.
Materials and methods:
The study employed the verbal autopsy data from the second National Reproductive Age Mortality Survey 2014. Univariate and multivariate logistic regression models were fitted to explore the association between each risk factor and NCD mortality, measured by crude and adjusted odds ratio (AOR) with respective 95% confidence intervals (95% CI).
Results:
In the final sample of 843 women, 586 (69.5%) deaths were attributed to NCDs, the majority of which occurred outside a hospital (72.7%) and among women aged 45-49 years (46.8%), ethnic Georgians (85.2%), urban residents (60.1%), those being married (60.6%), unemployed (75.1%) or having secondary and higher education (69.5%), but with nearly equal distribution across the wealth quintiles. After multivariate adjustment, the odds of dying from NCDs were significantly higher in women aged 45-49 years (AOR=17.69, 95% CI= 9.35 to 33.50), those being least educated (AOR=1.55, 95% CI= 1.01 to 2.37) and unemployed (AOR=1.47, 95% CI= 1.01 to 2.14) compared, respectively, to their youngest (15-24 years), more educated and employed counterparts. Strikingly, the adjusted odds were significantly lower in "other" ethnic minorities (AOR=0.29, 95% CI= 0.14 to 0.61) relative to ethnic Georgians. Contrariwise, there were no significant associations between NCD mortality and women's marital or wealth status, place of residence (rural/urban) or place of death.
Conclusion:
Age, ethnicity, education, and employment were found to be strong independent predictors of young women's NCD mortality in Georgia. Further research on root causes of inequalities in mortality across the socioeconomic spectrum is warranted to inform equity- and life course-based multisectoral, integrated policy responses that would be conducive to enhancing women's survival during and beyond reproduction.
... Each viloyat exists out of smaller districts: cities or rural areas that are called tumanlar. The different hierarchical levels have different responsibilities in terms of regulation and financing of health services [25]. ...
... Although most health care is public, the private sector is gradually growing. The MoH has had to limit the private sector in the past due to unnecessary and unsafe care practices [4,25]. However, the government has started to encourage private practices and clinics to mobilise resources and improve quality and efficiency. ...
Over the past twenty years, Uzbekistan’s health system changed drastically from the inherited Soviet health system. This research aims to examine the main aspects of the Uzbek health financing system and policy process that led to out-of-pocket (OOP) health care expenditures by using a mixed-method case study approach. Qualitative findings reveal that the covered basic benefit package is limited. Health care evaluation methods and accessible information on health quality are lacking. This leads to inefficient use of resources and a risk of using unnecessary or low-quality health services. Quantitative findings reveal that especially the chronically ill have high OOP. Furthermore, alcohol use, health status of the household head, money saved in the past and place of residence proved to be significant factors. This research showed that the limited benefit package, lacking evaluation methods, and inaccessible information on health care led to high OOP. Policies remain inefficient at addressing OOP due to limited civilian participation, lack of data, and limited evidence-based decision making. This research suggests that the benefit package should be expanded to cover the chronically ill.
... In Thailand, VHVs emphasize the need for a health working group to interact, collaborate, and coordinate actions in the primary care system. They are an important group of people who facilitate effective health activities that increase awareness, motivation, and involvement and monitor the health status within a community [12,13]. VHVs within local villages and PCUs are the first point of contact with primary care and the broader health system. ...
... Of the 15 ULISS items, more VHVs had incorrect rather than correct understandings of item numbers 6,8,9,12,13, and 15. Unlike VHVs from H-RDVs, those from L-RDVs correctly responded to four items (1, 2, 11, and 14); this difference in response was statistically significant (p < 0.05). ...
Background
Successful dengue solutions require community collaboration between agencies engaged in human health, vector control and the environment. In Thailand, village health volunteers emphasize the need for a health working group to interact, collaborate, and coordinate actions. The objectives of this study were to acquire an understanding of dengue solutions, as well as the larval indices surveillance system of village health volunteers in high- and low-risk dengue villages.
Methods
After 12 months of training in dengue prevention and setting larval indices surveillance systems, an analytical cross-sectional survey was conducted. A total of 117 villages were included in the 18 primary care facilities within one district in southern Thailand, and they were divided into 71 high-risk and 46 low-risk dengue villages. Sample size was determined using the G*power formula. The content validity index and reliability values of Cronbach's alpha coefficient for the questionnaires were 0.91 and 0.83, respectively. A random sampling approach was used to acquire data. The chi-square test, t-test, and odds ratio were used to assess the sample's level of understanding.
Results
The study included 1302 village health volunteers, including 895 and 407 from high- and low-risk dengue communities, respectively. In total, 87.9% were female, 51.6% were 20–35 years old, 48.8% had worked as a village health volunteer for 11–20 years, 27.1% had an upper elementary education, and 59.1% had dengue in the previous 12 months. Understanding of the dengue solution and larval indices surveillance system varied across high- and low-risk dengue villages. Village health volunteers with a high level of understanding of the dengue solution and larval indies surveillance system were 1.064 and 1.504 times more likely to stay in high-risk dengue villages, respectively (odds ratio [OR] = 1.064, 95% confidence interval [CI]:0.798–1.419, p = 0.672 and OR = 1.504, 95% CI:1.044–2.167, p = 0.028).
Conclusions
Village health volunteers require ongoing training to understand the prevention and control of dengue and larval indices surveillance systems, promote awareness, and monitor dengue in both high- and low-risk dengue villages.
... Due to a lack of studies on the poverty effects of out-of-pocket payments in Russia, we can only compare our findings on forgoing healthcare use to the results for Russia published in two previous studies Balabanova et al., 2012 If we use the results of the same study as a comparator, estimations for Russia in 2001 are lower than those for most of the other ex-Soviet countries. In particular, as report, the number of households that had to constantly do without medical services and pharmaceuticals was as follows: Armenia (38.0% and 31.6%), ...
... In 2007, 12% of Georgian respondents had to forgo the purchase of pharmaceuticals as they were too expensive, while an equal share of Serbian households had to forgo healthcare use due to payments (Gotsadze et al., 2009;Arsenijevic et al. 2013). Even higher estimations are reported for six former socialist countries for both outpatient and inpatient care: in Bulgaria (30.6% and 6%), Hungary (24.8% and 2.8%), Lithuania Azerbaijan (58.1%) (Balabanova et al., 2012). Based on results from the same study, self-treatment remained to be the main reason of not consulting health professionals in Russia (45.1%), while unaffordability of services reduced to 3.5%, unaffordability of drugs to 2.5%, and unaffordability of either services or drugs to 4.6% of respondents. ...
... N otable improvement has been made in the International Society of Nephrology (ISN) region of the Newly Independent States (NIS) and Russia, in access to healthcare and reduction of within-country inequalities during the past 2 decades. 1 Socioeconomic development and growth have been associated with an overall increase in the prevalence of treated kidney failure (KF), greater accessibility and affordability of kidney replacement therapy (KRT), and improvement of the quality of delivered medical services. 2 However, the ongoing war in parts of the region has had a serious impact on the lives of people with chronic diseases, destroying infrastructure and interfering with opportunities to gain access to life-saving therapies. ...
... Still, in recent years, most of these initiatives have reduced their spectrum and programs have been discontinued due to a lack of governmental support. Attempting to navigate between the internal political tensions as a transitional state and its aspirational Westernization, the country continues to face social policy reform challenges (Balabanova et al. 2012;Sayfutdinova 2015). The lack of attention to healthcare has been linked to corruptive systems in many post-Soviet states (Habibov & Cheung 2017). ...
... Likewise, 16.8% of respondents reported that they were never able to obtain medications and 32.0% reported that they could not obtain them sometimes. 34 In a follow-up study, Balabanova et al 35 reported that Russians were less likely to forgo healthcare than were inhabitants of countries that emerged from the former Soviet Union (Amernia, Azerbaijan, Georgia, Kazakhstan, Moldova and Ukraine); these findings echoed results from several studies that had focused exclusively on Russia. 36 Nonetheless, although the proportion of individuals has decreased over time, the poor and rural populations of the Russian Federation continue to forgo medications. ...
Introduction Unmet need for healthcare is a proxy indicator used to assess the performance of healthcare systems throughout the world. While the Russian Federation is committed to improving healthcare for its citizens, barriers to access remain.
Methods Using data from a region-level survey, we document and analyse the extent of the unmet need for healthcare at both national and subnational levels in the Russian Federation for the years 2014–2018. We used a panel fixed effects modelling approach to examine the link between unmet need and its correlates at the subnational level. We also used data from various sources that addressed the reasons underlying unmet need to interpret the findings from the modelling analysis.
Results Approximately one-third of the Russian population (34.7% in 2018) reported that healthcare was not received when it was needed with little change observed between 2014 and 2018. We observed significant variation across the various regions in Russia. The prevalence of unmet need was substantially higher in the regions of the Volga, Siberia and Far East Federal Districts. Our analysis revealed that the density of hospital beds and economic development across regions were correlated with the prevalence of unmet need. Dissatisfaction with healthcare services, perceived lack of effective treatments and financial constraints were the main reasons offered for forgoing healthcare when needed.
Conclusions An unanticipated positive link between unmet need and hospital bed density might be attributed to the low accessibility and quality of primary healthcare. High demand and supply of inpatient care do not compensate for the structural imbalances of the current healthcare model. Strengthening and improving the quality of primary care might significantly reduce the prevalence of unmet need.
... A longitudinal study conducted in the Netherlands found that 7.0% and 6.4% of Dutch people cancelled primary care appointments and hospital outpatient appointments during COVID-19 pandemic, respectively [35]. The lower rate of avoidance or delay found in our study could be explained, at least partially, by the low healthcare utilization rates in Armenia which have been documented even prior to COVID-19 pandemic [36,37]. At the same time, this finding might suggests that Armenians have not been heavily restricted in their use of health-care services specifically due to COVID-19 compared to the residents of other more developed countries. ...
Background
The coronavirus disease 2019 (COVID-19) pandemic has disrupted healthcare systems throughout the world. Many patients faced delays and cancellation of care due to scaled back services, mobility restrictions, and concerns related to the risk of infection. The present study aimed to assess the prevalence of and risk factors associated with the avoidance or delay of medical care due to COVID-19 in Armenia.
Methods
We conducted a cross-sectional telephone survey of 3,483 adults across Armenia. We used stratified two-stage cluster sampling to select the participants from different age groups proportionate to their size in the population. Logistic regression analysis assessed the association of risk factors with avoidance/delay of routine, urgent/emergency, and any medical care.
Results
The mean age of the sample was 49.5 (SD = 14.8), ranging from 18 to 90. About 9.9% of the respondents avoided/delayed any type of medical care; whereas 5.5% avoided/delayed urgent/emergency care and 6.6% routine care. In the adjusted analysis, female gender and higher monthly expenditures were associated with avoidance/delay of routine medical care. Factors associated with delay/avoidance of urgent/emergency care included female gender and higher perceived threat of COVID-19. Younger age, female gender, higher perceived threat and not being vaccinated against COVID-19 were associated with avoidance/delay of any medical care in the adjusted analysis.
Conclusion
Since avoiding or delaying care might increase morbidity and mortality associated with conditions not related to COVID-19, identifying population groups that are more likely to avoid care is important. Targeting such groups with educational interventions focusing on the risks of using versus not using medical care in times of pandemic might be crucial. Ensuring the provision of in-home healthcare services for high-risk groups might help to address important medical care needs during the pandemic.
... These three critical social themes that Koch originally found surrounding TB care in Georgia, we argue, are also present in Ukraine due to the two nations shared historical context. For example, the value of personalisation of care helps explains the well-documented distrust many Ukrainians have toward biomedicine (Balabanova et al. 2012). In Kołodziejska-Degórska's analysis (2016) of the rural Ukrainian medicoscape, she noted that many Ukrainians believe each body reacts differently to clinically standardised biomedicines, and, therefore, they must 'check' if a medicine will work for their body. ...
This research article seeks to understand how the cultural context of tuberculosis (TB) care in Ukraine influences healthcare workers’ perception of their patients and the choices they make in offering TB treatment. Specifically, we aim to explore healthcare workers’ predilection towards inpatient treatment of TB in Ukraine in lieu of other, evidence-based treatment approaches. Based on qualitative research with TB care providers in Ukraine, we argue that a preference for inpatient treatment instead of the standard outpatient regimen is rooted in the care workers’ assessment of the patient’s desire to get well. In other words, the preferred treatment modality is not based on any biological characteristic of TB infection; instead, it is based on the perceived strengths and weaknesses of patients’ psychology.
... Since the collapse of the former Soviet Union in 1991, changes in the healthcare and social welfare system of Azerbaijan have been slow. Attempting to navigate between the internal political tensions as a transitional state and its aspirational Westernization, the country continues to face healthcare reform challenges (Balabanova et al., 2012;Sayfutdinova, 2015). In general, the lack of attention to healthcare has been linked to corruptive systems in many post-Soviet states including Azerbaijan (Habibov et al., 2017). ...
What is recovery? Is recovery a process of individual transformation, an endpoint, or a part of drug use? How do people ‘do’ recovery and how can research trace this? How do different drug policies and national drug discourses understand and enforce recovery? This book explores these questions and offers personal accounts of recovery that shed light on differences, contexts, relations, and meanings. It aims to expand research into individual, communal, and political roles of recovery and take the use of the concept beyond the discourse of free will, reintegration, and formal treatment. It is also the aim of this book to address the questions on what makes recovery a contested concept, how can we better approach it, and whether there is a need to talk about recovery at all, especially in semiotic, sociomaterial, and relational forms.
... [26] Due to excessive out-of- which results in poor health outcomes. [27][28][29][30] Cost-sharing is typically seen in patients with chronic ailments, the elderly and patients who are poor. [30][31][32][33][34][35][36] According to the NSS 71 st round, the average out-of-pocket expenditure in India has doubled from the similar survey conducted in 2004-2005. ...
Objectives
Palliative care involves providing symptomatic relief from the pain and stress of a severe illness to markedly improve the quality of life for both the patients and their families. It imposes high indirect costs on the patients. The study was conducted at SGPGIMS, which caters to 500 head-and-neck cancer patients annually. Out of these, 30–40% of cases require dedicated palliative care. Unfortunately, often, when patients reach the stage of palliative care, they have exhausted their all financial reserves. Therefore, a cost analysis of total cost incurred (including out-of-pocket expenditure and social cost) during palliative care in cases of head-and-neck cancer at a Government Regional Cancer Centre was undertaken.
Material and Methods
The study is a descriptive study and the study sample consisted of (a) patients who had undergone surgery, chemotherapy, or radiotherapy and had recurred/relapsed and were now candidates for palliative care and (b) patients who presented de novo to the Regional Cancer Centre, SGPGIMS with advanced-stage disease, where the cure was not possible. The expenditure incurred was obtained retrospectively and prospectively from the study samples.
Results
The out-of-pocket expenditure per patient per day was INR 2044.21. The social cost per patient per day was INR 518.21. Out of the total expenditure of INR 2562.42/patient/day, 80% of the cost was out-of-pocket expenditure and the remaining 20% was social cost borne by the patient.
Conclusion
The study thus added to perspective on the average expenditure on out-of-pocket expenses and social costs being incurred as of date, while getting palliative care for head-and-neck cancer at a Regional Cancer Centre.
... The reorganization of the healthcare system, launched i n 1995, was focused on the model of preventive healthcare 3,4 . The role of public health is especially critical, as it serves for disease prevention, health promotion, management and analysis of the epidemiological situation, and establishment of a healthy lifestyle. ...
... Inequalities and access to health care appear to have improved since the Soviet era and the turbulent years of change. However, significant problems still remain, including the practice of informal payments for health care, and the Russian health care system lags far behind those considered the best in the world (GBD 2019 Universal Health Coverage Collaborators 2020; Aarva et al., 2009;Balabanova et al., 2012). ...
Research has documented both lower and higher cancer incidence among migrants. Evidence among the large Russian-born migrant population, however, is scarce. We examined cervical cancer incidence and screening participation among Russian-born immigrant women in Finland, a country with complete cancer registration and universal public health care including organized cancer screening. Our study population included all the women that resided in Finland during 1970–2017 and was formed linking individual-level data from four nationwide registries. The linked data sets on cancer and cancer screening were analysed separately using different statistical models. Russian-born immigrant women had increased (+62%) incidence of cervical cancer compared to the general Finnish female population, and they participated in cervical cancer screening slightly less than other women. Our findings showed no consistent transition pattern in cancer incidence or screening participation rate with duration of stay. Potential explanations for the observed differences include institutional and behavioural factors. Cervical cancer is one of the most preventable cancers, and cancer screening can both prevent and reduce incidence and mortality of cervical cancer. Efforts should be made to encourage migrant populations to participate in cervical screening.
... Cette catégorie est formée de chômeurs (5,6 % de la population), de travailleurs dans le secteur informel (2,6 %) et de catégories relevant des familles pauvres qui ne bénéficient pas de l'assistance médicale. Plusieurs études en Chine, en Zambie, en Inde, en Moldavie et au Brésil (31)(32)(33)(34)(35) ont montré que les ménages sans couverture sanitaire sont les plus exposés aux dépenses catastrophiques de santé et à l'appauvrissement en raison de leurs paiements directs élevés. Le gouvernement tunisien devrait alors renforcer les mécanismes d'avancement vers la couverture sociale universelle en intégrant ces catégories dans l'assurance santé. ...
Background: In 2004, Tunisia has implemented health insurance reform in order to remedy several problems related to alarming inequity, insufficient health coverage, and exponential growth in health costs and out of pocket spending. Aims: this paper gives a critical vision and a qualitative assessment of this reform. Methods: using several sources of information such as the national health insurance fund and the national institute of statistics, we identify the major problems of the health insurance system and we make a comparison between the objectives outlined by the reform in relation to these problems, the implementation of the measures taken and the level of achievement of these objectives. Results: In general, the measures taken by the reform are not sufficiently efficient to achieve its objectives. Conclusion: We provide some recommendations that will help to achieve the reform objectives more effectively.
... For example, a new family medicine model has been established in Uzbekistan, along with human resources training, and in Kyrgyzstan, practitioners now receive direct nancial payments, and formal user fees-for-service have been authorized (Fidler et al., 2009). In Kazakhstan, the number of people utilizing the health system has increased signi cantly: in 2012, almost 60% of the population had consulted a health professional in the past 4 weeks if they thought they needed it; simultaneously, the number of informal cash payments for health services decreased (Balabanova et al., 2012). Rechel et al. (2012) have suggested that successful reforms across the region share a number of common factors. ...
... However, the number of studies on developing and former Soviet Union countries is limited. Post-Soviet countries could prove an interesting case because they inherited extensive healthcare infrastructure and universal health coverage which guaranteed easy access to healthcare (Balabanova et al., 2012;Popovich et al., 2011;Rechel et al., 2014). However, because most post-Soviet countries did not invest sufficient amounts of money in their respective public health systems, their patients could be required to make substantial out-of-pocket payments (Rechel et al., 2014;Reshetnikov et al., 2019). ...
In this study we estimate the income elasticity of spending on different healthcare services and medication in Russia, taking into account the non-linear relationship between income level and expenditure. We employ the RLMS-HSE data, 2006–2017, to estimate the elasticities at household level. Our findings show these elasticities have not changed over the years. Additionally, we show that low-income and high-income households demonstrate different levels of elasticities, which is consistent with the fact that healthcare is less affordable for the poor. The study confirms that healthcare and medication are close to luxury level for low-income households and drugs are almost income inelastic for rich households. The results could help to reveal which services are the least affordable for the population.
... Since the collapse of the former Soviet Union in 1991, changes in the healthcare and social welfare system of Azerbaijan have been slow to progress. Attempting to navigate between the internal political tensions as a transitional state and its aspirational Westernization, the country continues to face healthcare reform challenges (Balabanova et al., 2012;Sayfutdinova, 2015). In general, the lack of attention to healthcare has been linked to corruptive systems in many post-Soviet states (Habibov et al., 2017). ...
This policy paper bridges interdisciplinary research to analyze the effects of drug policy in Azerbaijan on the provision of social care and treatment for young people who use illicit drugs. Drawing on Carol Bacchi's critical policy analysis method-'what's the problem represented to be' (WPR) approach-the paper focuses on what the state's drug policy enables and/or impedes in the implementation of better protection and care for young people aged between 14 and 17. To do this, two texts are selected for the analysis to explore representations and social construction of youth through various problematizations in policy legislations. The analysis suggests that drug policy in Azerbaijan fosters certain cultural and political purposes to promote an agenda of community-based 'immunity' to drugs. As a result of this approach, the policy neglects psycho-social and medical interventions as well as individual approaches to young people's wellbeing.
... The plan has eight axes, one of the important of which is the program to promote natural childbirth and reduce cesarean section with the general goal of improving the health indicators of mothers and neonates. In this axis, reducing the rate of cesarean section, increasing the satisfaction of pregnant mothers by maintaining the privacy and optimizing the physical space, reducing the direct payment of patients, and improving the motivation of providers to increase the rate of natural childbirth are pursued as specific goals (14). Cesarean section is considered as one of the problems in the field of health and treatment due to the numerous consequences it creates for patients, including heavy costs, various complications, and reduced quality of life in patients (15). ...
Introduction: Health systems are making reforms to ensure and promote public health. Measuring the effects of reform is one way to determine its effectiveness and can lead to improved consequences. This study was aimed to investigate the effect of the Iranian Health Sector Evolution Plan (HSEP) implementation with the focus on the type of delivery on maternal and neonatal health indicators in East-Azerbaijan Province.
Material and Methods: This descriptive-analytical study was conducted in 2017. The data on a total of 800 patients were randomly selected through the dataset of 8 hospitals equally in the two time periods of before and after the HSEP implementation. A researcher-made checklist was used to data extraction. Data were analyzed by SPSS-22 software using descriptive statistics, t-test, and chi-square.
Findings: The mean age of mothers in both periods was 27 years. Most of the participants did not have a previous delivery and had a diploma or a lower level of education. The rate of natural childbirth increased from 34.5% (before the HSEP) to 44.2% (after the HSEP) (p 0.05).
Conclusion: The findings indicate a significant increase in the rate of natural childbirth after the HSEP implementation. Maternal and neonatal mortality rates have also decreased. These results can guide policy-makers in deciding whether to continue and review the reform.
... To curb IP, postcommunist countries embraced the wide range of healthcare reforms and each postcommunist country has chosen their own way for reforms with at least four main models were utilized: (1) to introduce compulsory health insurance system, (2) to implement guaranteed benefit packages for specific types of healthcare services or for specific population groups (e.g., maternal healthcare and healthcare for internally displaced people), (3) to use some combination of both above-described approaches, and (4) to remain with a traditional model of healthcare financing where healthcare funding is paid from the general budget revenue [20][21][22][23]. The fully comparable data about current characteristics of the healthcare systems in postcommunist countries is hard to find, so Table 1 provides the available information from the Global Health Expenditure database by the WHO that is the most reputable source of crosscountry comparison for healthcare [24]. ...
Background. The dominant view in the literature is that informal payments in healthcare universally are a negative phenomenon. By contrast, we theorize that the motivation healthcare users for making informal payments (IP) can be classified into three categories: (1) a cultural norm, (2) “grease the wheels” payments if users offered to pay to get better services, and (3) “sand the wheels” payments if users were asked to pay by healthcare personnel or felt that payments were expected. We further hypothesize that these three categories of payments are differently associated with a user’s outcomes, namely, satisfaction with healthcare, local and national government, satisfaction with life, and satisfaction with life of children in the future. Methods. We used microdata from the 2016 Life-in-Transition survey. Multivariate regression analysis is used to quantify relationships between these categories of payments and users’ outcomes. Results. Payments that are the result of cultural norms are associated with better outcomes. On the contrary, “sand the wheel” payments are associated with worse outcomes. We find no association between making “grease the wheels” payments and outcomes. Conclusions. This is the first paper which evaluates association between three different categories of informal payments with a wide range of users’ outcomes on a diverse sample of countries. Focusing on informal payments in general, rather than explicitly examining specific motivations, obscures the true outcomes of making IP. It is important to distinguish between three different motivations for informal payment, namely, cultural norms, “grease the wheels,” and “sand the wheels” since they have varying associations with user outcomes. From a policy making standpoint, variation in the links between different motivations for making IP and measures of satisfaction suggest that decision-makers should put their primary focus on situations where IP are explicitly asked for or are implied by the situation and that they should differentiate this from cases of gratitude payments. If such measures are not implemented, then policy makers may unintentionally ban the behaviour that is linked with increased satisfaction with healthcare, government, and life (i.e., paying gratitude).
1. Background
IP is defined as a direct contribution in cash or gifts that is in addition to any formally required contributions and which are made by users to healthcare personnel or others acting on their behalf [1, 2]. Since such payments are made out of the counter and under the table, they are not part of formal healthcare expenditures and can be made in the form of cash such as small tips and large sums of money, or through various types of gifts such as flowers and sweets, and before or after receiving services [3]. IP is a subsection of a wider category of out-of-pocket payments [4]. Thus, out-of-pocket payments represent the amount of IP and legitimate legal fees paid in the healthcare sector taken together. Legitimate fees may include copayments for compulsory and voluntary health insurance schemes and payments for healthcare services which are not covered by compulsory and voluntary health insurance schemes.
Various estimates show that IP represents the lion’s share of out-of-pocket payments [5]. For instance, the share of IP has reached 96% in Pakistan [6] and 74% in Azerbaijan [7]. Even in EU and OECD countries, incidents of IP are high, reaching 35% in Poland, 41% in Lithuania, and 17% in the Czech Republic and Slovakia [7]. From the standpoint of health policy and planning, such a large share of IP underlines a shift in healthcare funding from a solidarity approach that is based on budget-financed or insurance-financed schemes, to an individualistic approach where consumers are expected to bear the main responsibility for healthcare costs [8, 9].
Against this background, the literature highlights a lack of studies on association between different motivations for IP and user outcomes and points out that the current literature tends to evaluate overall effect of IP without considering different motivations for making IP [10, 11]. With the above evidence in mind, we theorize that the motivations for making could be grouped into three broad categories, namely, “cultural norm,” “grease the wheels,” and “sand the wheels.” We further theorize that the direction of association between IP and satisfaction is not universal and depends on the specific motivation for making IP. More specifically, we hypothesize that “cultural norm” and the “grease the wheels” conceptualization of IP may be associated with positive user outcomes, while the “sand the wheels” conceptualization will have an opposite association. To test these hypotheses, we separately analyze the effect of each of the above-discussed theoretical motivations of IP on user well-being. This approach allows us to shed light on differences in the association between the various motivations for making IP with a wide range of users’ outcomes. In this way, the study answered to the following three research questions: (1)How do each of these motivations influence satisfaction with public healthcare?(2)How do each of these motivations influence satisfaction with local and national governments?(3)How do each of these motivations influence satisfaction with one’s own life and expected satisfaction with the future life of one’s children?
The unique contribution of this study is threefold. First, as far as we know, this is the first study which tests for plausible variation in the influence of the different conceptualizations of IP on users’ outcomes on a large sample of countries. Second, we test for the influence of IP on a wide range of outcomes including satisfaction with local and national governments and satisfaction with one’s own life and expected satisfaction with the future life of one’s children.
Finally, we focused on postcommunist countries where incidents of IP are high and have a prolonged history. Historically, under the Semashko system, the state in the communist countries assumes the primary responsibility to provide universal healthcare to the citizens free at the point of utilization [12]. However, considerable shortage in the available public funding together with the nonexistence of official and legitimate mechanisms for engaging private healthcare expenditures led to widespread inequalities in access in the 1970s and IP became an important factor in ensuring access to rationed public healthcare since 1970s [13, 14]. The role of IP in providing access to public healthcare further grew through 1980 as postcommunist countries were not able to sufficiently increase public finding for healthcare and IP became widespread in forms of cash and small gifts, for instance, liquors, cigarettes, and perfume [15–17]. Collapse of communist economic system in the 1990s increased the spread of IP since the profound and protracted political and economic crisis associated with transition from communist further reduced public funding for healthcare [18, 19].
To curb IP, postcommunist countries embraced the wide range of healthcare reforms and each postcommunist country has chosen their own way for reforms with at least four main models were utilized: (1) to introduce compulsory health insurance system, (2) to implement guaranteed benefit packages for specific types of healthcare services or for specific population groups (e.g., maternal healthcare and healthcare for internally displaced people), (3) to use some combination of both above-described approaches, and (4) to remain with a traditional model of healthcare financing where healthcare funding is paid from the general budget revenue [20–23]. The fully comparable data about current characteristics of the healthcare systems in postcommunist countries is hard to find, so Table 1 provides the available information from the Global Health Expenditure database by the WHO that is the most reputable source of cross-country comparison for healthcare [24].
Government schemes and compulsory contributory health care financing schemes
Voluntary health care payment schemes
Household out-of-pocket payment
Albania
58
0
42
Armenia
18
1
81
Azerbaijan
29
0
71
Belarus
71
2
27
Bosnia and Herzegovina
71
0
29
Bulgaria
55
1
43
Croatia
83
7
11
Czech Republic
82
3
15
Estonia
76
2
23
Georgia
37
8
56
Hungary
68
4
28
Kazakhstan
60
5
36
Kyrgyzstan
42
0
57
Latvia
56
1
43
Lithuania
67
1
32
Mongolia
64
3
32
Poland
69
8
23
Romania
78
1
21
Russia
57
3
40
Serbia
58
2
40
Slovakia
81
1
18
Slovenia
73
15
12
Tajikistan
32
2
66
Ukraine
48
3
48
Uzbekistan
45
1
55
Data is from the WHO’s Global Health Expenditure database by WHO at https://apps.who.int/nha/database/Select/Indicators/en. Household out-of-pocket expenditures encompass informal payments (IP) and various legitimate fees, as detailed in Introduction.
... Following the collapse of the former Union of Soviet Socialist Republics, this region has been experiencing many socioeconomic, political, and demographic challenges, with constantly growing inequalities in access to health care and increasing diversity in provision of medical services. 1 Taking into account the historical background and its socioeconomic consequences, each country in the region is unique in terms of health care structure and policies, which has its impact on noncommunicable disease care. In this setting, chronic kidney disease (CKD) and kidney failure (KF) care remains of interest, as the strategies in disease surveillance, detection, prevention, and management vary considerably from country to country across the entire region. ...
The International Society of Nephrology Global Kidney Health Atlas analyzed the current state of kidney care in Newly Independent States and Russia. Our results demonstrated that the Newly Independent States and Russia region was not an exception and showed the same effect of chronic kidney disease on health and its outcomes, facing many difficulties and challenges in terms of improving kidney care across the countries. This work summarized and presented demographics, health information systems, statistics, and national health policy of the region, as well as characteristics of the burden of chronic kidney disease and kidney failure (KF) of participating countries. Besides significant economic advancement in the region, the collected data revealed existing shortage in KF care providers, essential medications, and health product access for KF care. Moreover, there was low reporting of kidney replacement therapy (dialysis and kidney transplantation) quality indicators and low capacity for long-term hemodialysis, peritoneal dialysis, and kidney transplantation. The financial issues and funding structures for KF care across the region needs strategic support for fundamental changes and further advancement. This article emphasizes the urgent need for further effective regional and international collaborations and partnership for establishment of universal health care systems for KF management.
... 19 Among all hypertensive members in eligible households, one will be invited to participate using a probability based method, such as the KISH, age-order or full enumeration methods. 20 A questionnaire consisting of validated instruments, including the Demographic & Health Surveys, 21 WHO STEPS, 22 World Values Survey 23 and the Living Conditions, Lifestyle and Health Survey, 24 will be administered to participants within their homes, collecting information on housing characteristics, including structure, amenities and household assets. A validated household asset-based wealth score, allowing within-country and cross-country comparisons, will be calculated. ...
Background: Cardiovascular diseases (CVDs) are the leading cause of premature mortality in the world and are a growing public health concern in low- and middle-income countries (LMICs), including those in South East Asia. Their management requires coordinated responses by a range of healthcare providers, which should preferably be based on knowledge of the national context. We systematically review evidence on the pathways followed by patients with CVD in Malaysia and the Philippines to understand patient journeys, along with the barriers at each stage.
Methods : We searched seven bibliographic databases and grey literature sources to identify material focused on the pathways followed by patients with CVD in Malaysia and the Philippines, and performed a narrative synthesis.
Results: The search yielded 25 articles, 3 focused on the Philippines and 22 on Malaysia. Most articles were quantitative analyses that focused on hypertensive patients. Three examined secondary prevention post myocardial infarction, and one each examined acute myocardial infarction, heart failure, and atrial fibrillation. Reported barriers reflected capability (knowledge of behaviours to achieve control or the capacity to conduct these behaviours), intention (attitudes or motivations toward the behaviours to achieve control), and aspects of the health care system (availability, accessibility, affordability and acceptability of services).
Conclusions: There are large gaps in our understanding of patient pathways in Malaysia and the Philippines that limit the development of evidence-based strategies to effectively address the CVD burden in South East Asian countries and in LMICs more broadly. Addressing these evidence gaps will require longitudinal mixed-methods studies following patients from initial diagnosis to long-term management.
... Health care services where available locally are often not equipped. According to Balabanova et al. (2012), rural population is also less likely to seek medical help in the event of illness. They are often less likely to go to hospital due to poverty and illiteracy and a culture of waiting for the final stage of illness before rushing to hospital. ...
The objective of this research is to identify the institutional dimensions that are the most relevant to the improvement of health outcomes in sub-Saharan Africa. To this end, institutional quality measures are integrated into a health production model. This model is estimated by the Two-stage least squares method on a panel of 45 countries observed over the period 1996-2018. The data used are from the World Bank. The results show that the most relevant institutional dimensions that improve health outcomes in the region are by order: rule of law, control of corruption, government effectiveness, voice and accountability and political stability and absence of violence. For these reasons, African decision-makers who often have limited resources can focus on a few key components of these institutional qualities or their combinations to improve health outcomes in their countries.
... IP is a key factor in explaining satisfaction with public services. The willingness to support public services is seen to be dependent on one's satisfaction with the services provided (Svallfors, 2011;Balabanova et al., 2012;Habibov et al., 2019d). Lower satisfaction with public services weakens support for the public provision of such services (Crozier et al., 1975;Kumlin, 2007;Habibov, 2016). ...
The current dominant discourse in the research literature postulates that informal payments in public education will be negatively associated with satisfaction with public education. In contrast, we theorize that informal payments can be classified into three different groups based on the motivations of the people who make such payments, namely, “sand-the-wheels”, “cultural norm”, and “grease-the-wheels” motivations. We further hypothesize that each of these motivations will have distinctly different patterns of association with satisfaction with public education. We test our hypotheses on a diverse sample of 27 post-communist countries in Eastern and Central Europe, Central Asia, and the Caucasus. Our main findings confirm our hypotheses. The “sand-the-wheels” motivation is indeed associated with lower satisfaction. However, the “cultural norm” motivation is associated with higher satisfaction. As well, the “grease-the-wheels” motivation does not have a significant association with satisfaction. These findings are true for education at the primary/secondary and vocational levels. These findings are also true for fixed effect and for random effect multilevel models. Overall, 12 % of users made informal payments in public primary/secondary education and 14 % did so in public vocational education. Most informal payments were made because users had been directly asked to do so by educational personnel or when users felt that such payments were required by educational personnel.
... After the collapse of the Soviet Union, the healthcare systems in former Soviet countries have undergone major reforms during which they have faced similar challenges in terms of affected quality and accessibility of healthcare services (Balabanova et al. 2004(Balabanova et al. , 2012. There has been limited research on adolescents' health and health services utilization across the majority of former Soviet countries, leaving a room for collective learning. ...
Objectives
The study aimed to explore potential challenges that hamper utilization of adolescent friendly health services (AFHS) in primary healthcare (PHC) facilities in Armenia.MethodsA qualitative study using in-depth interviews and focus group discussions was conducted with experts in adolescent health, PHC providers and facility managers from public PHC facilities and adolescents from the two largest cities in Armenia. We also collected data through observations in PHC facilities. We utilized a directed content analysis approach for data analysis.ResultsThe study identified various factors negatively influencing utilization of AFHS in Armenia. These factors included adolescents’ poor health literacy and awareness of health services, lack of PHPs’ professional competencies, and breaches of confidentiality. Several facility-level barriers such as lack of privacy, inconvenient operating hours and long waiting times also contributed to insufficient service utilization by adolescents.Conclusions
The study findings shed light on different perspectives related to various challenges adolescents faced in PHC facilities in Armenia. Targeted interventions needed to improve adolescents’ health literacy, to enhance the PHPs’ competencies and to create a friendly and welcoming environment in PHC facilities.
... A solid proportion of respondents who have not used health care services in the last 12 months (31.4%) mentioned the inability to pay for health services as the reason for not using them, which is quite close to the findings of previous studies conducted in 2010 and 2016 [19,22] and signifies a substantial unmet need for health care in the Armenian population. ...
Background
Few studies have examined public opinion about the health care system in the former Soviet region. The objective of our study was to evaluate the population’s satisfaction with the health care system and identify factors associated with it in Armenia.
Methods
We conducted a cross-sectional telephone survey among 576 adult residents of the capital Yerevan using Random Digit Dialing technique. Simple and multivariate logistic regression explored associations between potential determinants and satisfaction.
Results
A substantial proportion of respondents (45.5%) were dissatisfied or very dissatisfied with the health system. About 49% of respondents negatively evaluated the ability of the system to provide equal access to care. About 69% of respondents thought that the responsibility for an individual’s health should be equally shared between the individual and the government or that the government’s share should be larger. The adjusted odds of satisfaction were higher among individuals with better health status, those who positively rated equal access and respect to patients in the system, those thinking that the responsibility for health should be equally shared between the individual and the government, and those who tended to trust the government.
Conclusions
This study enriched our understanding of factors that shape the population’s satisfaction with the health care system in different cultural and political environments. We recommend further exploration of public opinion about those system attributes that are not directly linked to patient experiences with care, but might be equally important for explaining the phenomenon of satisfaction.
... This perspective suggests that people are driven by rational choice (Kumlin, 2007). It purports that citizens weigh the costs and benefits related to public services, and their willingness to support these services is seen as being dependent on their perceptions regarding the quality of the services that are provided (Svallfors, 2011;Balabanova et al., 2012). ...
Purpose
The purpose of this paper is to empirically test two opposing theoretical hypotheses from research literature: low quality of public education boosts support for public education; and low quality of public education weakens support for public education.
Design/methodology/approach
The authors use microdata from 27 post-communist countries over a period of five years. This study uses two outcome variables in order to capture the level of support for public education: the willingness to elevate investments in public education to an important policy priority; and the willingness to pay more taxes to improve public healthcare. A series of logistic regressions is used to find how the outcome variable is influenced by six dimensions of the quality of the public education system.
Findings
The main finding is that a lower quality of public education strengthens the willingness of citizens to make investments into public education by: making it a political priority for the government; and through a professed increased willingness to pay more taxes towards improving public education. These findings remain valid for both years of investigation and for both EU and non-EU samples. In contrast, the authors could not find support for the hypothesis that postulates that a lower quality of public education will reduce support for public education.
Research limitations/implications
The main implication of these findings is that despite the increases in availability of private schooling opportunities, the citizens of post-communist countries have not abandoned their support for public education. Even if citizens of post-communist countries believe that public education is no longer of an appropriately high quality, they continue to support the provision of resources to it in order to improve on the current situation.
Practical implications
The current low quality of public education can be seen as providing an impetus for encouraging support for public education.
Social implications
In terms of policy-making, the findings demonstrate the opportunity to shore up public support for further reforms in public- education in post-communist countries.
Originality/value
The current education policy research literature is silent about the direction of the effect of low quality public education on the willingness to provide support for public education. Against this background, this is the first study which empirically tested whether quality of public education affect willingness to support it. Covering a period of five years, the authors test the above-postulated hypotheses using a diverse sample of 27 post-communist countries.
... Some have pursued creative policy innovation; some have stagnated. Some launched meaningful reforms immediately after the Soviet collapse; others have progressed only in the last two or three years (Balabanova et al. 2011;Cook 2015;Merkur, Maresso, and McDaid 2015;Rechel et al. 2012;Stepanovich 2018). ...
The sudden onset of COVID-19 has challenged many social scientists to proceed without a robust theoretical and empirical foundation upon which to build. Addressing this challenge, particularly as it pertains to Eurasia, our multinational group of scholars draws on past and ongoing research to suggest a roadmap for a new pandemic politics research subfield. Key research questions include not only how states are responding to the new coronavirus, but also reciprocal interactions between the pandemic and society, political economy, regime type, center-periphery relations, and international security. The Foucauldian concept of "biopolitics" holds out particular promise as a theoretical framework.
... 7, 8 Iranian health system has also got some important issues in its history during recent decades including setting up health networks based on primary health care for accessing global goal of health for everyone up to 2000 in the 1980s. 7 It also executes family physician and rural insurance programs (2014) for the sake of general coverage of health and millennium development goals. 8 ...
... In turn, such underfunding resulted in greater official out-of-pocket expenditures and unofficial under-the-counter payments, lack of contemporary competencies, technologies, and equipment, and reductions in satisfaction with public healthcare [18,19]. Because healthcare reforms in post-communist countries will likely require additional funding [20], policy makers and healthcare planners should focus on the factors that influence the willingness to pay more to support public healthcare. ...
The research literature discusses two opposite hypotheses regarding the possible effects of healthcare quality on the willingness to pay more taxes to improve public healthcare. One hypothesis theorizes that a lower quality of public healthcare may weaken the willingness to pay more taxes towards improving it. Another hypothesis posits that a low quality of public healthcare may strengthen the willingness to pay more taxes towards improving it. We tested both hypotheses on a diverse sample of 27 post-communist countries within Eurasia and Southern and Eastern Europe over a period of five years. We apply a binary logistic model for each country under investigation. The model is estimated by regressing the willingness to pay more taxes on six dimensions of quality, while controlling for covariates and the dummy for 2016. We found empirical support for both hypotheses, and hence none of the hypotheses gleaned from the literature is a clear "winner." However, we also found that the situation is less straightforward and more nuanced than is usually acknowledged within the literature. Our findings also suggest the effect is specific with respect to both a quality dimension and a country tested.
... This plan has eight axis, one of which is promoting the rate of natural birth to improve the mothers and babies' health indexes by reducing c section and increasing natural birth. The specific goals of this axis included reducing c section, increasing contentment of pregnant women by maintaining their privacy and optimizing the physical atmosphere, and reducing direct payments (14). C section is a problem in health and medical system, which entails different consequences for patients, causes great costs, results in different complications, and finally reduces the quality of life for patients (15). ...
Background: To improve the individuals' health, reforms should be made in the health systems. As a result, assessing the impacts of reforms is a way to evaluate the effectiveness of the health system. The aim of this study was to study the relationship between the kind of delivery and the five indexes of mother and baby's health before and after implementing the health reform plan in selected hospitals of East Azerbaijan, Iran. Methods: This descriptive-analytical study was conducted in 2018. The study was conducted among eight educational, medical, and private hospitals. Before and after the program, 800 files were selected using simple random sampling method. The researcher made a check list with confirmed validity to extract the data. The data were analyzed using descriptive statistics and T-tests by SPSS-22. Results: The average age of mothers in the two intervals was 27 years. Most participants did not deliver before and their education was diploma or lower. The rate of natural delivery from 34.5% (before the plan) reached 44.2% (after the plan)(p<0.05). The rate of mothers and babies' mortality reduced from 0.3 and 0.8 to 0 and 0.5, respectively. Mothers and babies' mortality and stillbirth had no significant difference based on the kind of delivery (p>0.05). Conclusion: Findings indicated significant increase of natural delivery after the reform plan in health system. Moreover, the rate of mothers and babies' mortality decreased. These results can guide the policymakers for deciding about the course of plan and its review.
Drug treatment policies, especially the medical discourse as it is known in the West and especially in the USA (e.g., Volkow et al. in N Engl J Med 374:363–371, 2016), has different implications in the post-Soviet Azerbaijan where the medical paradigm is a relatively new phenomenon in drug treatment practice. The existing literature shows that the medical approach to drug treatment is also a relatively new phenomenon in the West with the example of Germany, where treatment was based on a full-abstinence model until the 1980s (Schmid in Drogenhilfe in Deutschland: Entstehung und Entwicklung 1970–2000. Campus Verlag, 2013).
Reorganization of healthcare system in Georgia was based on the development of public health, aiming to activate of preventive medicine and operate efficient tools of epidemiological surveillance. This paper seeks to explore the attitudes and values which underlie public health reform in Georgia, and to investigate the goals of reform and the strategies designed to achieve them. The article is based on a documentary analysis, which included official documents and non-official journal publications. Georgia was the only country (except the Baltic states) to abandon the soviet system of Sanitary-Epidemiological Service, completely reorganizing it and establishing a new public health infrastructure, built on European principles. The reorganization of the Sanitary-Epidemiological Service implied the separation of supervisory (sanitary control) and executive functions, typical of the Soviet system. As a result, the Public Health Department and the Department for Sanitary Supervision and Hygienic Regulation were established. In terms of decentralization, the funds out of four elements of healthcare system (financing, Policy Development, Standard definition, Management and Administration) were distributed at central, regional and municipal levels. The role of public health is especially increasing in the modern globalized world, when the epidemics of infectious diseases have become topical. In globalized world, the public health challenges go beyond national borders and interests, having huge global political and economic consequences. Therefore, modern public healthcare is reviewed in a global context and requires international regulations, transnational actions and solutions based on coordinated cooperation among different countries of the world. Keywords: Public health, health care reforms, prevention, healthy lifestyle. JEL Codes: H51, H75, I18
Objectives
This study aimed to estimate and analyze the effects of out-of-pocket expenditure attributed to medicine on catastrophic health expenditure (CHE) and impoverishment. Our study also explored the determinants of CHE for Tunisian households.
Methods
CHE and impoverishment were estimated using the representative sample of 25 087 households’ survey of Budget, Consumption, and Living Standards in 2015. Logistic regression was applied to determine factors associated with the CHE.
Results
The occurrence of catastrophic expenditure on health and medicine from the total population was, respectively, estimated to be 18.4% and 8.0%, whereas the impoverishment was 2.8% and 1.8%. The catastrophic expenditure was high in households having a chronic disease, disability, elderly, and children younger than 5 years and those living in a rural area. The rich and insured households are also experiencing financial hardship.
Conclusions
Out-of-pocket expenditure for medicine generates high levels of catastrophic and impoverishment in Tunisia. To achieve universal and affordable access to medicine, policy makers should remove fees at public facilities for patients with chronic diseases and disabilities, consolidate public procurement and distribution, and ensure effective reimbursement of health insurance.
The trend of the last decade is to achieve sustainable development of society. The reasons of the development of this tendency are the global processes of industrial growth, the level of consumption of products, urbanization, and the development of globalization processes, the formation of the impact of non-profit organizations in the fight against environmental problems. The problems of environmental responsibility are urgent for many researchers, as they represent a way to solve complex environmental and economic problems facing the representatives of modern business, society and the state. The article deals with the analysis of the environmental component of social responsibility and its impact on the sustainable development of European countries. The article focuses on prioritizing sustainable development goals, namely Partnership for Sustainable Development. The factors that most influence on the environmental sustainability of European countries (Lithuania, Hungary, Slovakia, France, and Ukraine) were analyzed. The correlation between GDP changes, populations and the level of environmental pollution has been proved. The definition of the concept of responsible consumption is considered and recommendations of reducing the level of influence of the agricultural sector on the environmental component were proposed. The necessity to increase environmental social responsibility in order to prevent a negative impact on the economy of European countries is substantiated. Abstract. Decisions on public funding allocation are significant challenges for any healthcare system. The Latvian health financing policy faces challenges that threaten its long-term sustainability and the values of solidarity. According to the World Health Organization, health, as a state of complete physical, mental and social well-being, is one of the fundamental rights every human, and is dependent upon the fullest cooperation of individuals and states. This also includes the task to "substantially increase health financing." Such concepts require the regular measurement of progress in order to explicate the achieved level in statics and dynamics and to make strategic decisions for the coming period, including those on public healthcare expenditure. The purpose of this article is to evaluate the necessary allocations of general government budget expenditures, ensure justification for the strategic decisions for the next planning period on healthcare expenditure, evaluate the achieved level in statics and dynamics, and provide policy recommendations for future health financing system reforms. Research methodology-To achieve the goal of the research, comparative analysis and methods of theoretical research were used. Intelligent data mining methods were employed for the discovery of and the creation of knowledge on existing regularities in health system expenditure based on mutually comparable factual cases-the declared statistical indicators of the EU27 countries. Findings-Using data mining analytical tools, the minimum of the general government health expenditure in EU countries was computed in this study: around €1,500 per capita in 2018. The optimal segmentation of general government health expenditure according to the COFOG classification was also computed. Research limitations-The minimum expenditure calculated is especially relevant for low-expenditure Central and Eastern European countries, while the total public health expenditure segmentation is applicable for any EU country. The benchmarking algorithms are well-suited for comparing aspects of the health sector, identifying leaders with the best performance and best practices, and analyzing how higher performance levels are achieved. However, it should be borne in mind that some dispersion could be caused by heterogeneous environmental conditions. Practical implications-Governments can consider making sustainable policy decisions and performing the programming process of allocating public resources. This would also help to balance cross-sectoral links between public healthcare and the economy during post-COVID-19 recovery. Originality/Value-The use of the data mining analytical tools in this study answered a question that is very important for society: What is the minimum amount an EU country should spend on health? The processing of financial data shows that the widespread assumption of the necessary general government health expenditure of 5% of the GDP is not substantiated.
According to Dante, “Limbo” is the first circle of Hell located at its edge. Unlike other residents of Hell, the Limbo population suffers no torment other than their lack of hope. We argue that a lack of hope in post-Soviet Ukraine is expressed by a lack of conditions for a better future since the past is overrepresented in the present. Therefore, every movement transforms under the past’s pressure, changing its course in order to reproduce and perpetuate ghosts of what is long gone. We argue that the current state of Ukraine can be framed as “post-Soviet limbo.” If the great stability of the Soviet regime was a result of overregulation and extensive control, or of “uncertainty avoidance,” then a post-Soviet limbo is a result of “managing uncertainty” simultaneously influenced by Soviet legacies and neoliberal promises of growth, calculability, and deregulation on the part of the State. “Soviet legacies” are dominant and represent a mix of formal overregulation explicitly presented through laws and policies and informality which, according to some authors, became even more widespread in the post-Soviet period than it used to be under the Soviet rule. We do not aim to consider the past legacies as being opposite to neoliberal features and futures, but negotiate the way the two are interrelated and mutually reinforced in the present to produce the post-Soviet limbo. Ukraine’s performance of Opioid Agonist Therapy (OAT) coverage is consistently estimated as insufficient and needing further improvement. However, we argue that that there are two modes of OAT implementation in Ukraine: state-funded (formal) and privately-funded (informal). The latter’s size does not fall into official estimates since the national reports on OAT performance never include the numbers of patients involved in informal treatment. We suggest, that the informal mode of OAT implementation appeared as a result of contrasting efforts towards intensive regulation and extensive growth. To understand how these two modes are produced in the context of post-Soviet narcology, how they differ and where their paths cross, we analyze two types of texts: legal and policy documents regulating substance use disorder (SUD) treatment, mainly OAT; and qualitative data, including interviews with OAT patients and field notes reflecting the environment of OAT programs. Finally, the presented article seeks to answer how the state’s contrasting efforts to manage the uncertainty of SUD treatment through OAT regulation and implementation reproduce the post-Soviet limbo and, thus, people with SUD as “patients of the state” who are frozen in a hopeless wait for changes.
Background:
Achieving universal health coverage (UHC) includes financial risk protection. To date, catastrophic healthcare expenditure (CHE), the impoverishing effect of out-of-pocket (OOP) healthcare payments, and unmet healthcare need are the most widely used indicators for assessing the financial risk protection of a healthcare system. This study aimed to estimate the Russian healthcare system's financial risk protection by focusing on CHE, OOP and unmet healthcare need.
Methods:
The study used eight waves of the Russia Longitudinal Monitoring Survey (RLMS) (2010-2017) to analyze the financial risk protection of the Russian healthcare system. Commonly used indicators - CHE, both incidence and intensity, the impoverishing effect of CHE and unmet need -were used.
Results:
We found low incidence and intensity of CHE in the Russian Federation. Our results are robust to various definitions of CHE (eg, as a share of total household expenditure or total household income). Furthermore, the impoverishing effect of OOP healthcare payments remains limited, despite the most recent economic slowdown (2014- 2016). This could be explained by a noticeable reduction in CHE during the crisis years, as postponing healthcare was adopted as a coping mechanism, particularly among households heavily affected by the crisis.
Conclusion:
As stressed by the UHC framework, our findings suggest that CHE only partly captures inefficiencies and inequities in coverage, because one tenth of households forwent medical care for medicines and certain services. As spending on medicines and dental care are the main drivers of CHE, policy interventions should focus on extending coverage for pharmaceutical and dental care and target financial barriers to seeking care, particularly for the poor and vulnerable.
Background
The World Health Organization predicts a striking rise in the burden of traumatic brain injury (TBI) burden in the next decades. A disproportionately large increase is predicted in low- and middle-income countries, which have brain injury rates 3 times higher than high-income countries. The aim of this study was to identify current TBI practices and treatment capacity in 3 low- and middle-income countries: Republic of Armenia, Georgia, and Republic of Moldova.
Methods
After a national inventory of hospitals treating TBI, a situational analysis was conducted in the highest volume adult and pediatric hospital in each country. The situational analysis included key informant interviews with content analysis and a quantitative checklist of treatment resources.
Results
All 3 countries follow international, national, and hospital protocols for TBI treatment, and the in-hospital management of patients with TBI is similar to international standards in all 3 countries. Although health care specialists were well trained, however, lack of proper equipment, a scant number of hospitals outside the capital region, lack of specialized personnel in regional areas, and lack of rehabilitation services were mentioned as difficulties in interviews from all 3 countries.
Conclusions
Particular gaps were found in pre-hospital and rehabilitative care, as well as national leadership and data collection. Surveillance and standardized data collection are important measures to fill treatment gaps and reduce the burden of TBI.
Objectives
To identify key factors influencing the utilisation of governmental and private primary healthcare services in Albania.
Design
A cross-sectional health facility survey using a 4-point Likert scale questionnaire to rank the importance of factors driving services utilisation.
Setting
Exit interviews with patients who consulted one of 23 primary care providers (18 public and 5 private) in Fier district of Albania from the period of July–August 2018.
Participants
Representative sample of 629 adults ≥18 years of age.
Main outcomes measures
(1) Factors influencing the decision to visit a governmental or private primary care provider and (2) the association of sociodemographic characteristics and patients’ decision to attend a given provider. Data were analysed using mixed logistic regression models.
Results
Nearly half of the participants in this study were older than 60 years (45%). The majority (63%) reported to suffer from a chronic condition. Prevailing determinants for choosing a provider were ‘quality of care’ and ‘healthcare professionals’ attitudes. Solely looking at patients using a public provider, ‘geographical proximity’ was the most important factor guiding the decision (85% vs 11%, p<0.001). For private provider’s patients, the ‘availability of diagnostic devices’ was the most important factor (69% vs 9%, p<0.001). The odds of using public facilities were significantly higher among the patients who perceived their health as poor (OR 5.59; 95% CI 2.62 to 11.92), suffered from chronic conditions (OR 3.13; 95% CI 1.36 to 7.24) or were benefiting from a socioeconomic aid scheme (OR 3.52; 95% CI 1.64 to 7.56).
Conclusion
The use of primary healthcare is strongly influenced by geographical and financial access for public facility users and availability of equipment for private users. This study found that aspects of acceptability and adequacy of services are equally valued. Additional commitment to further develop primary care through engagement of local decision-makers and professional associations is needed.
Although a great deal of attention is paid to reproductive health during violent conflicts, the literature is sparse on the consequences of conflict for abortion and miscarriage. This research provides an analysis of a recent historical case: the 1992–1997 civil war in Tajikistan, using the female questionnaire of the 2007 Tajik Living Standards Survey to examine a subsample of 1445 women surveyed who had reached menarche during or after the war and had been pregnant at least once by the time of the survey. The analysis leverages the uneven geographical scope of conflict events during the civil war to pinpoint women’s exposure to violence, measured by the Uppsala Conflict Data Program. The results show that for women who had reached menarche during or after the civil war, exposure to conflict events increases the likelihood of ever experiencing miscarriage, but not abortion. Including a spatial lag operator reveals that there were also spillover effects for abortion, in which women who were in a broader region of uncertainty were more likely to induce an abortion. These findings highlight the role of institutional changes in affecting pregnancy loss during and after civil war.
Health care systems ideally include universal access to comprehensive prepaid medical care along with health promotion and disease prevention. National health insurance and national health services of various models have evolved in the developed world and increasingly in developing countries as well. Some models, such as the Bismarckian social security model and the Bereidge National Health Service model, or National Health insurance such as in pioneered in Canada, are used by a number of countries. The common features are based on principles of national responsibility and solidarity for health, social solidarity for providing funding and searching for effective ways of providing care. Various universal systems of health coverage exist in all industrialized countries, except in the United States which has a mix of public and private insurance but with high percentages of uninsured and poorly insured. Health reform is a continuing process as all countries aspire to assure health care for all. Aging populations, increasing costs, advancing and increasing technology all require nations to modify and adapt organization and financing systems of health care, health protection and promotion.
This study aims to address the question: Why did transition countries enact laws related to social health insurance (SHI) at different times, even though they experienced dissolution of the Soviet Union at the same time in the early 1990s? We used Ragin’s fuzzy-set qualitative comparative analysis to investigate the configurations of causal conditions that affected the speed of developing SHI-related legislation in 24 post-socialist countries. The potential causal conditions were health status, economic status, level of governance, level of democracy, issue salience, and number of medical professionals. We found 3 pathways that led to the enactment of SHI-related laws and 1 pathway that inhibits enactment. The key factors impacting enactment of SHI-related laws were non-corrupt governments and realization of democracy. In addition, medical professionals’ involvement in policymaking could be the factor to enact SHI-related laws. Further research is needed for more in-depth analysis regarding what the laws specifically include, type of health insurance systems that were adopted based on the laws, and if the legislation contributed toward achieving universal health coverage.
L’objectif de ce travail est de déterminer les indicateurs de gouvernance qui améliorent la formation du capital humain en Afrique subsaharienne. Pour ce faire, des indicateurs de gouvernance sont intégrés dans un modèle de production de l’éducation d’une part et un modèle de production de la santé, d’autre part. Le modèle de production de l’éducation est estimé à l’aide de la méthode des moments généralisés en système sur un panel de 36 pays observés sur la période allant de 1996 à 2018. Le modèle de production de la santé, lui, est estimé par la méthode des doubles moindres carrés sur un panel de 45 pays observés sur la même période. Les données utilisées proviennent de la Banque mondiale. En général, les résultats montrent que l’amélioration de l’efficacité des pouvoirs publics favorise la formation du capital humain en Afrique subsaharienne. Pour l’éducation, l’amélioration de l’efficacité des pouvoirs publics favorise l’accroissement de l’accès à l’éducation primaire, secondaire et supérieure dans la région. Pour la santé, l’amélioration de la stabilité politique et absence de violence et de l’efficacité des pouvoirs publics favorise la réduction de la mortalité des enfants de moins de cinq ans, de la mortalité maternelle et l’accroissement de l’espérance de vie à la naissance. Ces résultats invitent les gouvernements africains à améliorer leur efficacité dans l’offre de services publics d’éducation et de santé pour permettre aux citoyens d’acquérir et d’accroître leur niveau d’éducation et de jouir d’une meilleure santé.
Mots-clés : Afrique subsaharienne, capital humain, éducation, gouvernance, santé
This chapter examines social protection policies under the Georgian UNM government. In focusing on developments in the pension system, health care and social assistance, the chapter identifies a pronounced gap between social protection policies and their social consequences for the elderly. The gap was affected by an ultraliberal economic policy and by serial policy changes. Informal safety nets that waned due to outward migration and urbanization increasingly failed to remedy the gap from below. The second part of the chapter turns to NGOs as gap agents. It highlights their efforts to activate informal care and the challenges they faced in advocating for systemic change.
This chapter analyzes pensions, health care, and social assistance in Armenia, and outlines a marked gap between social protection policies and ground level effects for the elderly. Family ties that once represented an important informal coping mechanism were no longer capable of closing the gap. Irrespective of official commitments for ageing, the government was unable to remedy the gap due to low levels of government capacity and societal distrust vis-à-vis public officials and institutions. The second part of the chapter examines NGOs as gap agents: In supplementing the state through service provision, the NGOs tried to remedy the gap in lieu of the state mainly by addressing symptoms, not causes. Eventually, they rather perpetuated state failure instead of prodding the government into action.
Health financing policy is one of major challenges for any health care
system. The Latvian health care system faces challenges and financial pressures that
threaten its long-term sustainability and the values of solidarity. The goal of this paper
is to conduct the review of the financing resources of the health care in Latvia, to
evaluate the development of the health care reform in Latvia and provide
recommendations for future changes. To achieve the goal of the research, comparative
analysis and methods of theoretical research, as well as for data processing and
analysis, the statistical analysis methods are used.
Keywords: health systems; healthcare financing; taxation; universal health coverage.
The Health Systems in Transition (HiT) profiles are country-based reports that provide a detailed description of a health system and of policy initiatives in progress or under development. HiTs examine different approaches to the organization, financing and delivery of health services and the role 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. Since independence, the health system in Armenia has undergone numerous changes that have effectively transformed a centrally run state system into a fragmented one that is largely financed from out-of-pocket payments. The population, especially those in need, meet with limited access to health services, and those services which are available are often of questionable quality, as health care standards and quality assessment systems are absent. Drugs on the essential drugs list are generally not affordable to those in need. Many health facilities, especially in rural areas, lack modern medical technology and what is available is not distributed efficiently. The commitment to free health care thus remains more declarative than factual, as informal payments are still expected or required in many cases. Despite significant investments in primary care, a disproportionate share of resources has been invested in secondary and tertiary care. Nevertheless, Armenia is increasingly engaged in reforming the system from one that emphasizes the treatment of disease and response to epidemics towards a system that emphasizes prevention, family care and community participation. The shift towards a primary care orientation is noticeable, with gradually increased roles for health workers to influence the determinants of health.
Since 1990, the paths of the so-called transition countries of central and eastern Europe, the Caucasus, and central Asia have diverged with regard to their social and economic policies, including the implementation of reforms in the financing of their health systems. Until now, this rich experience has not been analysed in a systematic way. The book begins with the background to health financing systems and reform in these countries, starting with the legacy of the systems in the USSR and central Europe before 1990 and the consequences (particularly fiscal) of the transition for their organization and performance. Relying on in-depth country case experiences, reforms are analysed first from a functional perspective, with chapters focusing on how policies were implemented to change mechanisms for revenue collection, pooling, purchasing and policy on benefit entitlements. Highlighted in subsequent chapters are particular reform topics, such as: • financing of capital costs • links between health financing reform and the wider public finance system • financing of public health services and programmes • role of voluntary health insurance • informal payments • accountability in health financing institutions.
This paper develops the economic impact of remittances in Armenia. There is a high propensity to save out of remittances, and thus the impact of remittances on growth is expected to be positive. Using plausible values for some of the parameters under study, we show that the Armenian economy probably grows 1.6% per year in the long run for a permanent 10% increase in the flow of remittances. Evidence also suggests that remittances have a negative impact on labor supply of adults and a positive impact on education. We find that for households receiving remittances, they constitute 80% of household income and help reduce poverty. We then suggest several strategies for increasing the reach of remittances to more remote parts of Armenia. While more research is needed, there is also a need to improve the transmission of remittances and improve linkages with the diasporan community.
Since 1990, the paths of the so-called transition countries of central and eastern Europe, the Caucasus, and central Asia have diverged with regard to their social and economic policies, including the implementation of reforms in the financing of their health systems. Until now, this rich experience has not been analysed in a systematic way. The book begins with the background to health financing systems and reform in these countries, starting with the legacy of the systems in the USSR and central Europe before 1990 and the consequences (particularly fiscal) of the transition for their organization and performance. Relying on in-depth country case experiences, reforms are analysed first from a functional perspective, with chapters focusing on how policies were implemented to change mechanisms for revenue collection, pooling, purchasing and policy on benefit entitlements. Highlighted in subsequent chapters are particular reform topics, such as: • financing of capital costs • links between health financing reform and the wider public finance system • financing of public health services and programmes • role of voluntary health insurance • informal payments • accountability in health financing institutions.
Informal payments in the health sector in Eastern Europe and Central Asia are emerging as a fundamental aspect of health care financing and a serious impediment to health care reform. Informal payments are payments to individuals or institutions in cash or in kind made outside official payment channels for services that are meant to be covered by the public health care system. Such private payments to public personnel have created an informal market for health care within the confines of the public health care service network, and are a form of corruption. Unlike gratuity payments to providers, informal payments are required, not discretionary. Part of the problem can be traced to declining revenues without commensurate downsizing of buildings, hospital beds and health personnel, which has meant reductions in salaries and in some countries chronic arrears. Informal payments compensate for lost earnings. Reforms to modernize the Region’s health systems must compete with the personal revenues from informal payments, making change difficult. The frequency of informal payments exceeds 60 percent in the CIS countries for which there are data, reaching 91 percent in Armenia, and are reported in all but a handful of Eastern European countries. Inpatient care carries the highest costs, but pharmaceuticals are the most frequently purchased health service that public providers do not finance. Informal payments have become a major impediment to health care access leading to both reduced consumption due to unaffordable cost and the selling of personal assets to finance care. Systematic reports of delayed care in Poland, 37 percent reduction in prenatal care in Tajikistan and the fact that 45 percent of rural patients sold assets to finance health care in the Kyrgyz Republic suggest rising inaccessibility and declines in equity. Options for addressing the problem include comprehensive anti-corruption policies, downsizing of the public system, paring back the set of services subsidized by government, encouraging cost sharing for those who can afford it, improving accountability, and promoting private alternatives.
Since becoming independent at the break-up of the Soviet Union in 1991, the countries of Central Asia have made profound changes
to their health systems, affecting organization and governance, financing and delivery of care. The changes took place in
a context of adversity, with major political transition, economic recession, and, in the case of Tajikistan, civil war, and
with varying degrees of success. In this paper we review these experiences in this rarely studied part of the world to identify
what has worked. This includes effective governance, the co-ordination of donor activities, linkage of health care restructuring
to new economic instruments, and the importance of pilot projects as precursors to national implementation, as well as gathering
support among both health workers and the public.
Within the countries of the former Soviet Union, the Kyrgyz Republic has been a pioneer in reforming the system of health care finance. Since the introduction of its compulsory health insurance fund in 1997, the country has gradually moved from subsidizing the supply of services to subsidizing the purchase of services through the 'single payer' of the health insurance fund. In 2002 the government introduced a new co-payment for inpatients along with a basic benefit package. A key objective of the reforms has been to replace the burgeoning system of unofficial informal payments for health care with a transparent official co-payment, thereby reducing the financial burden of health care spending for the poor. This article investigates trends in out-of-pocket payments for health care using the results of a series of nationally representative household surveys conducted over the period 2001-2007, when the reforms were being rolled out. The analysis shows that there has been a significant improvement in financial access to health care amongst the population. The proportion paying state providers for consultations fell between 2004 and 2007. As a result of the introduction of co-payments for hospital care, fewer inpatients report making payments to medical personnel, but when they are made, payments are high, especially to surgeons and anaesthetists. However, although financial access for outpatient care has improved, the burden of health care payments amongst the poor remains significant.
The aim of the paper is to bring evidence and lessons from two low- and middle-income countries (LMIs) of the former USSR into the global debate on health financing in poor countries. In particular, we analyze the introduction of social health insurance (SHI) in Kyrgyzstan and Moldova. To some extent, the intent of SHI introduction in these countries was similar to that in LMIs elsewhere: increase prepaid revenues for health and incorporate the entire population into the new system. But the approach taken to universality was different. In particular, the SHI fund in each country was used as the key instrument in a comprehensive reform of the health financing system, with the new revenues from payroll taxation used in an explicitly complementary manner to general budget revenues. From a functional perspective, the reforms in these countries involved not only the introduction of a new source of funds, but also the centralization of pooling, a shift from input- to output-based provider payment methods, specification of a benefit package, and greater autonomy for public sector health care providers. Hence, their reforms were not simply the introduction of an SHI scheme, but rather the use of an SHI fund as an instrument to transform the entire system of health financing.
The study uses administrative and household data to demonstrate the impact of the reforms on regional inequality and household financial burden.
The approach used in these two countries led to improved equity in the geographic distribution of government health spending, improved financial protection, and reduced informal payments.
The comprehensive approach taken to reform in these two countries, and particularly the redirection of general budget revenues to the new SHI funds, explain much of the success that was achieved. This experience offers potentially useful lessons for LMIs elsewhere in the world, and for shifting the global debate away from what we see as a false dichotomy between SHI and general revenue-funded systems. By demonstrating that sources are not systems, these cases illustrate how, in particular by careful design of pooling and coverage arrangements, the introduction of SHI in an LMI context can avoid the fragmentation problem often associated with this reform instrument.
Informal payments for health care services are common in many transition countries, including Russia. While the Russian government proclaims its policy goal of improving access to and quality of free-of-charge health services, it has approved regulations that give local authorities the right to provide services against payment. This paper reports the results of a population-based survey (n = 2001) examining the prevalence of the use of medical services for which people pay formally or informally in two regional capitals of different economic status. The purpose of the study was to reveal any differences in the forms of and reasons for payments between the two cities and between socio-economic groups. The results indicate that formal payments were more common in the capital of the wealthier region, Tyumen, while the prevalence of informal payments was higher in the capital of the poorer region, Lipetsk. Around 15% of respondents had made informal payments in the past 3 years. Being a female (OR = 1.57), having a chronic disease (OR = 1.62), being a pensioner (OR = 2.8) and being willing to pay for additional medical information (OR = 2.48) increased the probability of informal payments. The survey demonstrates that in Russia access to and quality of publicly funded health care services may be under serious threat due to the current unclear, non-transparent financial rules. The practice of informal payments exists along with the introduction of formal chargeable government services, which may hamper the government's efforts to enhance equality among health service users.
The success or failure of health sector reform in the countries of Central and Eastern Europe depends, to a large extent, on their health care staff. Commentators have focused on the structures to be put in place, such as mechanisms of financing or changes in ownership of facilities, but less attention has been paid to the role and status of the different groups working in health care services. This paper draws on a study of trends in staffing and working conditions throughout the region. It identifies several key issues including the traditionally lower status and pay of health sector workers compared to the West, the credibility crisis of trade unions, and the under-developed roles of professional associations. In order to implement health sector reforms and to address the deteriorating health status of the population, the health sector workforce has to be restructured and training programmes reoriented towards primary care. Finally, the paper identifies emerging issues such as the erosion of 'workplace welfare' and its adverse effects upon a predominantly female health care workforce.
This study sought to describe the evolution of the Russian compulsory health insurance system and to identify factors associated with noncoverage.
Data from successive waves of the Russian Longitudinal Monitoring Survey (1992-2000) were analyzed.
Insurance coverage grew rapidly throughout the 1990s, although 11.8% of the country's citizens were still uninsured by 2000. Coverage initiation rates were greater at first among citizens who were better off, but this gap closed over the study period. Among individuals of working age, coverage rates diminished with age and were lower for the unemployed, for the self-employed, and for those residing outside Moscow or St. Petersburg.
The growth of insurance coverage in Russia slowed toward the end of the 1990s, and gaps remain. Achievement of universal coverage will require new, targeted policies.
The transition resulting from the break-up of the Soviet Union significantly affected the health care systems and population health status in the newly independent States. The available body of evidence suggests that contraction of public resources resulting from economic slowdown has led to the proliferation of out-of-pocket payments and private spending becoming a major source of finance to health service provision to the population. Emerging financial access barriers impede adequate utilization of health care services. Most transition countries embarked on reforming health systems and health care financing in order to tackle this problem. However, little evidence is available about the impact of these reforms on improved access and health outcomes. This paper aims to contribute to the assessment of the impact of health sector reforms in Georgia. It mainly focuses on changes in the patterns of health services utilization in rural areas of the country as a function of implemented changes in health care financing on a primary health care (PHC) level. Our findings are based on a household survey which was carried out during summer 2002. Conclusions derived from the findings could be of interest to policy makers in transitional countries. The paper argues that health financing reforms on the PHC level initiated by the Government of Georgia, aimed at decreasing financial access barriers for the population in the countryside, have rendered initial positive results and improved access to essential PHC services. However, to sustain and enhance this attainments the government should ensure equity, improve the targeting mechanisms for the poor and mobilize additional public and private funds for financing primary care in the country.
There is a health crisis in Turkmenistan similar to, but more severe than, in other Central Asian countries. This paper asks whether the health crisis in Turkmenistan is attributable to the consequences of the dictatorship under president Niyazov, who died in 2006.
The basis for this paper was a series of semi-structured in-depth interviews with key informants complemented by an iterative search of internet sites, initially published as a report in April 2005, and subsequently updated with feedback on the report as well as a comprehensive search of secondary information sources and databases.
This paper describes in depth three areas in which the dictatorship in Turkmenistan had a negative impact on population health: the regime's policy of secrecy and denial, which sees the "solution" to health care problems in concealment rather than prevention; its complicity in the trafficking of drugs from Afghanistan; and the neglect of its health care system.
The paper concludes that dictatorship has contributed to the health crisis facing Turkmenistan. One of the first tests of the new regime will be whether it can address this crisis.
The political and economic transition of the 1990s in the countries of central and eastern Europe has been accompanied by wide ranging health care reform. The initial Soviet model has given way to a variety of forms of health insurance. Yet, as this paper argues, reform has too often been preoccupied with ideological imperatives, such as provider autonomy and the creation of funds separate from government, and has given much less thought to the contribution that health care can make to population health. The paper begins by examining the changing nature of health care. It recalls how the Soviet model was able to provide basic care to dispersed populations at low cost but notes how this is no longer sufficient in the face of an increasingly complex health care environment. This complexity reflects several factors, such as the growth in chronic disease, the emergence of new forms of infectious disease, and the introduction of new treatments requiring integrated delivery systems. It reviews evidence on how the former communist countries failed to keep up with developments in the west from the 1970s onwards, at a time when the complexity of health care was becoming apparent. It continues by setting out a framework for the organisation of health care based on the goal of health gain. This involves a series of activities that can be summarised as active purchasing, and which include assessment of health needs, designing effective packages of care, and monitoring outcomes. It concludes by arguing that a new relationship is needed between the state and the organisations involved in funding and delivering health care, to design a system that will tackle the considerable health needs of the people who live in this region.
After 1991, when the USSR dissolved, the ensuing sociopolitical transformation resulted in deepening poverty, increasing marginalization, and widening income inequality. Overall, compared with countries of the European Union, health indicators deteriorated markedly as did access to health care. Across the region, reforms have been dependent upon varying economic and political imperatives, but similarities exist. For the more reform-oriented countries, there has been a shift from a taxation based to an insurance-based system. All countries have sought to address the weaknesses of the inherited primary care system, usually by seeking to introduce family medicine or general practice models. However, a substantial network of vertical structures with narrowly specialized professional staff persists in most countries. Building integrated, coordinated, evidence-based, multidisciplinary, patient-centered care to respond to the chronic disease burden and (re-)emerging communicable diseases remains a challenge.
The recent sociopolitical transition of the former Soviet Union has resulted in deepening poverty, increasing marginalization, and widening income inequality. Overall, compared with Western Europe, health indicators have deteriorated markedly. Over this period, access to health care has deteriorated. Across the region, reforms have been dependent upon varying economic and political imperatives, but similarities exist. Broadly, there has been a shift from a taxation-based to an insurance-based system and some support for primary care expansion. However, a substantial network of vertical structures with highly specialized professional staff persists. Building integrated, coordinated, evidence-based, multidisciplinary, patient-centered care to respond to chronic disease and emerging communicable diseases remains a challenge.
Russia's attempt to replace the failed Soviet system and its command economy with a capitalist, democratic society has produced a health and social welfare crisis, at considerable human cost. Russia s Torn Safety Nets presents a series of essays by distinguished Russian and American scholars which describe and analyze the consequences of the collapsed socialist system, focusing on issues of health and demography, HIV/AIDS, drug addiction and abuse, the disabled, aging and pensions, education, women and sexism, and social issues in the military. The essays conclude with a section on the private and public efforts to ease the impact of the ongoing transition on the Russia people.
From its inception after the 1917 Bolshevik Revolution, the centrally controlled Soviet medical system attempted to monopolize medical practice - stigmatizing and punishing alternative practitioners who worked outside the state system. Nonetheless, alternative medical practitioners survived the seven decades of Soviet power. Ordinary people never stopped seeking them out, and since the late 1980s, the number of alternative healers in the Russian Federation has increased astronomically. The aim of this article is to analyze the forms of alternative medicine that exist in contemporary Russia and to offer an explanation for their continuing popularity in terms of popular conceptions of health and healing, the functioning of the state medical care system, and the attitudes of Russian physicians toward alternative healing.
In 2004, the Moldovan government introduced mandatory (social) health insurance (MHI) with the goals of sustainable health financing and improved access to services for poorer sections of the population. The government pays contributions for non-employed groups but the self-employed, which in Moldova include many agricultural workers, must purchase their own cover. This paper describes the extent to which the Moldovan MHI scheme has managed to achieve coverage of its population and the characteristics of those who remain without cover.
The 2008 July-October enhanced health module of the Moldovan Household Budget Survey was used. The survey uses multi-stage random sampling, identifying individuals within households within 150 primary sampling units. Numbers and characteristics of those without insurance were tabulated and the determinants of lack of cover were assessed using multivariate regression.
3760 respondents were interviewed. Seventy-eight per cent were covered by MHI. Factors associated with being uninsured include being self-employed (particularly in agriculture), unemployed, younger age and low income. Respondents who were self-employed in agriculture were over 27 times more likely to be uninsured than those who were employed. Agricultural workers in Moldova are responsible for purchasing their own cover; most respondents cited cost as the main reason for not doing so.
While being uninsured has an impact on utilization, financial barriers persist for those with insurance who seek care. The strengths and weaknesses of the MHI system in Moldova provide valuable lessons for policy makers in low- and middle-income countries addressing the challenges of achieving equitable coverage in health insurance schemes and the complex nature of financial barriers to access.
The USSR failed to establish a modern pharmaceutical industry and lacked the capacity for reliable distribution of drugs. Patients were required to pay for outpatient drugs and the successor states have inherited this legacy, so that those requiring long-term treatment face considerable barriers in receiving it. It was hypothesised that citizens of former Soviet republics requiring treatment for hypertension may not be receiving regular treatment.
To describe the regularity of treatment among those diagnosed with hypertension and prescribed treatment in eight countries of the former Soviet Union, and explore which factors are associated with not taking medication regularly.
Using data from over 18 000 respondents from eight former Soviet countries, individuals who had been told that they had hypertension by a health professional and prescribed treatment were identified. By means of multivariate logistic analysis the characteristics of those taking treatment daily and less than daily were compared.
Only 26% of those prescribed treatment took it daily. The probability of doing so varied among countries and was highest in Russia, Belarus and Georgia, and lowest in Armenia (although Georgia's apparent advantage may reflect low rates of diagnosis). Women, older people, those living in urban areas, and non-smokers and non-drinkers were more likely to take treatment daily.
A high proportion of those who have been identified by health professionals as requiring hypertension treatment are not taking it daily. These findings suggest that irregular hypertension treatment is a major problem in this region and will require an urgent response.
World Development Indicators, the World Bank's respected statistical publication presents the most current and accurate information on global development on both a national level and aggregated globally. This information allows readers to monitor the progress made toward meeting the goals endorsed by the United Nations and its member countries, the World Bank, and a host of partner organizations in September 2001 in their Millennium Development Goals. The print edition of World Development Indicators 2005 allows you to consult over 80 tables and over 800 indicators for 152 economies and 14 country groups, as well as basic indicators for a further 55 economies. There are key indicators for the latest year available, important regional data, and income group analysis. The report contains six thematic presentations of analytical commentary covering: World View, People, Environment, Economy, States and Markets, and Global Links.
Previously published as an Appendix to the World development report. Incl. users guide, list of acronyms, bibl., index. The Little data book is a pocket edition of WDI
In the two decades since the fall of the Berlin Wall, former communist countries in Europe have pursued wide-ranging changes to their health systems. We describe three key aspects of these changes-an almost universal switch to health insurance systems, a growing reliance on out-of-pocket payments (both formal and informal), and efforts to strengthen primary health care, often with a model of family medicine delivered by general practitioners. Many decisions about health policy, such as the introduction of health insurance systems or general practice, took into account political issues more than they did evidence. Evidence for whether health reforms have achieved their intended results is sparse. Of crucial importance is that lessons are learnt from experiences of countries to enable development of health systems that meet present and future health needs of populations.
The countries emerging from the Soviet sphere of influence in the early 1990s inherited Soviet style hospital-dominated health care systems. The countries that were part of the Soviet Union, in particular, had much higher levels of provision, as assessed by numbers of hospital beds, than the countries of western Europe. This capacity has been reduced, forced in large part by shrinking health budgets, but the development of a modern, co-ordinated, hospital system that is appropriate to the health needs of populations has proved difficult to achieve. A paradigm that assumed that most treatment would take place in hospital, supported by powerful vested interests in the health bureaucracy and medical profession, produced many obstacles to change. A tradition in which change took place through bureaucratic central plans took no account of the many actors in the policy process, the steps required to implement change, and the need to involve more people in the new and more pluralist context. This paper explores the experiences of attempts to restructure hospital systems in countries of central and eastern Europe and the former Soviet Union. It identifies a series of challenges that have often been addressed inadequately. These are a failure to take account of the specific context within which reform is taking place, an over reliance on market mechanisms to bring about change, insufficient recognition of the wide range of stakeholders involved, a failure to ensure that incentives and policies are aligned, and a lack of appropriate human resources to implement change.
Informal payments are known to be widespread in the post‐communist health care systems of Central and Eastern Europe. However, their role and nature remains contentious, with the debate characterized by much polemic. This paper steps back from this debate to examine the theoretical basis for understanding the persistence of informal payments.
The authors develop a cognitive behavioural model of informal payment, which draws on the theory of government failure and extends Hirschman's theory of ‘exit, voice, loyalty’, the behavioural responses to ‘decline in firms, organizations and states’. It is argued that informal payment represents another possible behavioural reaction: ‘inxit’, which becomes important when the channels of exit and voice are blocked.
The theory is applied to explain informal payments in Hungary, but can be shown to be relevant to other countries facing similar issues. The paper examines the proposed policies to tackle informal payments, and on the basis of the theory of ‘inxit’ it advocates that solutions should contain an appropriate balance between exit and voice to optimize the chances of maintaining a good standard of public services. Copyright © 2004 John Wiley & Sons, Ltd.
In the past decade, the countries that emerged from the Soviet Union have experienced major changes in the inherited Soviet model of health care, which was centrally planned and provided universal, free access to basic care. The underlying principle of universality remains, but coexists with new funding and delivery systems and growing out-of-pocket payments.
To examine patterns and determinants of health care utilization, the extent of payment for health care, and the settings in which care is obtained in Armenia, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia, and Ukraine.
Data were derived from cross-sectional surveys, representative of adults aged 18 and over in each country, conducted in 2001. Multistage random sample of 18,428 individuals, stratified by region and area, was obtained. Instrument contained extensive data on demographic, economic, and social characteristics, administered face-to-face. The analysis explored the health seeking behavior of users and nonusers (those reporting an episode of illness but not consulting).
In the preceding year, over half of all respondents visited a medical professional, ranging from 65.7 percent in Belarus to 24.4 percent in Georgia, mostly at local primary care facilities. Of those reporting an illness, 20.7 percent of all did not consult although they felt they should have done so, varying from 9.4 percent in Belarus to 42.4 percent in Armenia and 49 percent in Georgia. The main reason for not seeking care was lack of money to pay for treatment (45.2 percent), self-treatment with home-produced remedies (32.9 percent), and purchase of nonprescribed medicine (21.8 percent). There are marked differences between countries; unaffordability was a particularly common factor in Armenia, Georgia, and Moldova (78 percent, 70 percent, 54 percent), and much lower in Belarus and Russia. In Georgia and Armenia, 65 percent and 56 percent of those who had consulted paid out-of-pocket, in the form of money, gifts, or both; these figures were 8 percent and 19 percent in Belarus and Russia respectively and 31.2 percent overall. The probability of not consulting a health professional when seriously ill was significantly higher among those over age 65, and with lower education. Use of health care was markedly lower among those with fewer household assets or a shortage of money, and those dissatisfied with their material resources, factors that explained some of the effects of age. A lack of social support (formal and informal) decreases further the probability of not consulting, adding to the consequences of poor financial status. The probability of seeking care for common conditions varies widely among countries (persistent fever: 56 percent in Belarus; 16 percent in Armenia) and home remedies, alcohol, and direct purchase of pharmaceuticals are commonly used. Informal coping strategies, such as use of connections (36.7 percent) or offering money to health professionals (28.5 percent) are seen as acceptable.
This article provides the first comparative assessment of inequalities in access to health care in multiple countries of the former Soviet Union, using rigorous methodology. The emerging model across the region is extremely diverse. Some countries (Belarus, Russia) have managed to maintain access for most people, while in others the situation is near collapse (Armenia, Georgia). Access is most problematic in health systems characterized by high levels of payment for care and a breakdown of gate-keeping, although these are seen in countries facing major problems such as economic collapse and, in some, a legacy of civil war. There are substantial inequalities within each country and even where access remains adequate there are concerns about its sustainability.
To provide accurate and timely data on the determinants of smoking in countries of the former Soviet Union in order to facilitate the development of effective tobacco control policies in the region. Such data are urgently needed given the absence of accurate comparative data in the region and the recent changes experienced.
Cross-sectional surveys using standardized methods and representative samples of the adult population in eight former Soviet Union countries conducted as part of the EU-Copernicus Project Living Conditions, Lifestyle, and Health study.
Armenia, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia and Ukraine.
A total of 18 428 adults aged 18 plus; response rates 71-88%.
The association of smoking with demographic and socio-economic factors was investigated using multiple logistic regression analyses, stratifying by gender.
Age was a strong determinant of smoking in both genders, with elderly individuals being less likely to smoke. Men who were more socially disadvantaged (less educated, poorer economic situation and/or less social support) were more likely to smoke. In women, living in larger urban areas was the strongest predictor of smoking. Divorced, separated or widowed women were also more likely to smoke than married women. Muslim respondents smoked less frequently compared with other respondents.
Smoking is a major public health issue in the FSU particularly affecting socially vulnerable men and young women living in urbanized areas. These high-risk groups should be targeted in future smoking prevention and cessation strategies in the region.
Remarkably, there has been very little detailed research on clinical practice in Russia and its neighbours in what was the USSR, even though it is known that the USSR was isolated from many international developments, in particular evidence-based medicine. In this study we examine obstetric practice, an area of practice where there is an extensive body of evidence on the appropriateness of many interventions. The study is undertaken in Tula, a region 200 km south of Moscow. Building on earlier detailed analyses of data from the facilities in the region, it reports a series of structured interviews with 52 obstetricians from all 19 facilities in the region, designed to identify patterns of prescribing, supplemented by 36 more detailed re-interviews to explore reasons for the differing practices. The study demonstrates a widespread divergence from internationally accepted practice. Maternity care is extremely medicalised but many non-evidence based medicines are used. Some are heavily marketed by large pharmaceutical companies, some were widely used during the Soviet period but never evaluated, and a few are not known to be used anywhere else in the world. For several conditions, the most widely used drugs are clearly inferior to alternative products and some are used for indications quite different from those in other countries. This study contributes to the growing evidence that much of the care provided in Russian maternity units is ineffective or potentially dangerous but also begins to offer some explanations for why this is, including a lack of access to information and a lack of awareness of the concept of evidence-based practice.
Extending Population Coverage in the National Health Insurance Scheme in the Republic of Moldova. Health Financing Policy Paper 2010/1. Copenhagen: World Health Organization
- M Jowett
- S Shishkin
Jowett, M., and S. Shishkin. 2010. Extending Population Coverage in the National Health
Insurance Scheme in the Republic of Moldova. Health Financing Policy Paper 2010/1.
Copenhagen: World Health Organization, Regional Office for Europe.
Coverage Decisions: Benefit Entitlements and Patient Cost Sharing In Implementing Health Financing Reform: Lessons from Coun-tries in Transition
- G Gotsadze
Gotsadze, G., and P. Gaal. 2010. " Coverage Decisions: Benefit Entitlements and Patient Cost Sharing. " In Implementing Health Financing Reform: Lessons from Coun-tries in Transition, edited by J. Kutzin, C. Cashin, and M. Jakab, pp. 187–217.
Improving Financial Protection in Kyrgyzstan through Reducing Informal Payments. Evidence from 2001-06
- M Jakab
- J Kutzin
Jakab, M., and J. Kutzin. 2009. Improving Financial Protection in Kyrgyzstan through Reducing Informal Payments. Evidence from 2001-06. Policy Research Paper 57. Bishkek:
Health Policy Analysis Unit (DFID/WHO).
Health Systems in Transition: Learning from Experience. Copenhagen: European Observatory on Health Care Systems
- J Figueras
- M Mckee
- J Cain
- S Lessof
Figueras, J., M. McKee, J. Cain, and S. Lessof. 2004. Health Systems in Transition: Learning from Experience. Copenhagen: European Observatory on Health Care Systems.
Who Is Paying for Health Care in Eastern Europe and Central Asia? Wash-ington, DC: World Bank. Ministry of Health. 2011. Evaluation of National Health Programme " Manas Taalimi
- M Lewis
Lewis, M. 2000. Who Is Paying for Health Care in Eastern Europe and Central Asia? Wash-ington, DC: World Bank. Ministry of Health. 2011. Evaluation of National Health Programme " Manas Taalimi ". Bishkek: Ministry of Health.
In Implementing Health Financing Reform: Lessons from Countries in Transition
- G Gotsadze
- P Gaal
Gotsadze, G., and P. Gaal. 2010. "Coverage Decisions: Benefit Entitlements and
Patient Cost Sharing." In Implementing Health Financing Reform: Lessons from Countries in Transition, edited by J. Kutzin, C. Cashin, and M. Jakab, pp. 187-217.
Copenhagen: World Health Organization.
Who Is Paying for Health Care in Eastern Europe and Central Asia? Washington, DC: World Bank. Ministry of Health
- M Lewis
Lewis, M. 2000. Who Is Paying for Health Care in Eastern Europe and Central Asia? Washington, DC: World Bank.
Ministry of Health. 2011. Evaluation of National Health Programme "Manas Taalimi".
Bishkek: Ministry of Health.
Everybody's Business: Strengthening Health Systems to Improve Health Outcomes. WHO's Framework for Action
- Who
WHO. 2007. Everybody's Business: Strengthening Health Systems to Improve Health Outcomes.
WHO's Framework for Action. Geneva: World Health Organization.