Health reform in central and eastern Europe and the former Soviet Union

Review

Health reform in central and eastern Europe and the former Soviet Union Bernd Rechel, Martin McKee Lancet 2009; 374: 1186–95 See Editorial page 1120 European Observatory on Health Systems and Policies, London, UK (B Rechel PhD, Prof M McKee MD); and London School of Hygiene and Tropical Medicine, London, UK (B Rechel, Prof M McKee) Correspondence to: Dr Bernd Rechel, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK [email protected]

For more on the European Observatory on Health Systems and Policies see http://www. euro.who.int/observatory

1186

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.

Introduction In the past two decades, governments in the former communist countries of central and eastern Europe have embarked on far-reaching reforms of financing, organisation, and delivery of health care. Communist health systems were centrally planned and administered, funded mainly by general government revenues, and delivered by state employees working from governmentowned facilities.1,2 Coverage was universal and health-care services were formally free at point of use, but this system had many weaknesses. Problems were greatest in the Union of Soviet Socialist Republics (USSR),3,4 where resources were most scarce and health professionals most isolated, with few if any incentives for efficiency and provision of high-quality care.1,2,5–8 Health care was generally delivered by physicians with little training who were working in narrow, specialised areas.7 Wages were kept artificially low, access to labour-saving technology was poor, numbers of staff

were high, and delivery of care was inefficient. The system was dominated by hospital provision8–10 and primary care was underdeveloped, especially in facilities that provided care for non-working mothers and children (workers often benefited from cross-subsidies provided to work-based facilities). Furthermore, the Soviet notion of evidence rejected empiricism and deemed all knowledge to flow from statements made by the fathers of communism, such as Marx, Engels, or Lenin, or from leaders of individual disciplines, such as Pavlov in psychology or Michurin in biology.11 Even nowadays health professionals only partly accept the idea of evidence as understood in developed countries.12,13 Many problems were present in countries of central Europe such as Hungary, Poland, and Czechoslovakia, but generally they were much less severe than in the former Soviet Union, especially in relation to understanding evidence. We explore health reform in this region since the collapse of communism and the lessons that can be learnt from this reform.

Search strategy and selection criteria

Reform context

We searched PubMed and Medline with the search terms “health system”, “health reform”, “financing reform”, or “primary care reform”, in combination with “central and eastern Europe” for the years 1995–2009. We gave preference to reports published in the past 5 years, but also included older relevant publications. We also searched the reference lists of the selected reports. This search was complemented by a search of Google with the same terms, and a review of country profiles, Health Systems in Transition, produced by the European Observatory on Health Systems and Policies. We included articles deemed most relevant to the three issues examined, and modified our reference list on the basis of comments from peer reviewers. Although we have aimed to include the most relevant studies, our review was selective. The major limitation was the scarcity of published research for this region, in part because of the weak research capacity in many countries. Our search did not identify studies reported only as conference abstracts or in informal publications within countries.

Despite sharing the challenge of transition from communism to democracy and market economies, the countries of central and eastern Europe display great diversity in socioeconomic development, culture, and politics, extending to their health systems and capacity for and direction of reforms. Per head expenditure on health ranged from US$25 in Tajikistan in 2007, to $1607 in Slovenia in 2006 (figure 1), and infant mortality in 2007 was 56·6 deaths per 1000 livebirths in Tajikistan, compared with 3·2 in the Czech Republic (figure 2). In 2007, life expectancy ranged from 67·5 years at birth for women and 59·0 years for men in Turkmenistan to 81·5 years for women and 74·1 years for men in Slovenia (figure 3). Health reforms in this region have included a reduction in size of the hospital sector,9 expansion of private providers,15 decentralisation,16 a change in methods of payment for providers,16 and efforts to improve public health17 and quality of care.18 We recognise the three areas we discuss in this Review (health insurance, out-of-pocket payments, and primary health care) do not capture all www.thelancet.com Vol 374 October 3, 2009

Review

aspects of health reform, but are some of the most important challenges faced by countries in this region, and are also those for which the most empirical evidence is available. Furthermore, countries’ experiences of these three issues draw attention to many challenges that are common to other aspects of reform.

Health insurance systems In the communist period, government was the almost exclusive provider and purchaser of health services, with financing derived predominantly from its revenues. Yugoslavia was an exception, with a mandatory health insurance system based on contributions from employers and employees.19 Since 1989, many countries in central and eastern Europe have diversified sources of funding, including adoption of some form of health insurance (table). This diversification often included establishment of separate social health insurance funds with varying degrees of independence that would purchase care on behalf of members. This separation of purchase from provision was regarded as a means to improve efficiency of delivery of health care.48,49 Why did all these countries choose health insurance rather than a tax-funded model? Reasons usually owed much to politics.5,20 Reforms often took place against a background of distrust of governments that in the communist period had generally given the health sector only what resources were left after other needs were met. Hence, political desire for a separate funding stream was widespread. In many countries, a conscious decision was made, in line with predominant values and preferences of professionals, to reject institutions of the Soviet period and go “back to Bismarck”21 by re-establishment of pre-Soviet structures and institutions. Another factor was a wish to emulate the apparent success of models used in Germany and Austria,22,50 at a time when active debate was underway in the UK, which exemplified tax-funded systems, about the merits of a move to social insurance funding.51 Other reasons included an aspiration to mobilise additional funds and contain costs, a demand for increased transparency and constraints on the ability of politicians to redirect funds away from health, a desire to introduce market mechanisms that were sometimes linked to privatisation of health-care delivery, and the aim to create services that would be responsive to patients.7,20,22,24,52 International agencies and donors played a part in this process, although their contribution should not be overstated. Design of health systems formed no part of the process of acceding to the European Union (EU).16 German advisers had a role in some reforms,16 but the process was largely endogenous. WHO, although they reportedly recommended an insurance-based health system in Estonia,25 did not take an official position in the Bismarck versus Beveridge debate—ie, whether health funding should be based on general taxation or social health insurance.53 However, the World Bank www.thelancet.com Vol 374 October 3, 2009

Slovenia

1607

Croatia

996

Czech Republic

953

Hungary

929

Slovakia

735

Estonia

632

Latvia

582

Poland

555

Lithuania

547

Russian Federation

367

Montenegro

348

Serbia

336

Bulgaria

297

Bosnia and Herzegovina

296

Romania

256

TFYR Macedonia

249

Belarus

243

Kazakhstan

190

Albania

187

Ukraine

160

Georgia

147

Turkmenistan

146

Azerbaijan

102

Armenia

98

Republic of Moldova

90

Kyrgyzstan

35

Uzbekistan

30

Tajikistan

25 0

200

400

600

800

1000

1200

1400

1600

1800

US$

Figure 1: Health expenditure per head (current US$)14 TFYR Macedonia=The former Yugoslav Republic of Macedonia. Data for 2006, except Tajikistan and Croatia (2007).

expressed concerns about premature establishment of health insurance systems in countries such as Bulgaria, Kazakhstan, Kyrgyzstan, Romania,48 and Ukraine.26 Of the 28 countries in the region, 22 have introduced systems of social health insurance—although Kazakhstan42 has since abandoned their system (table). Such systems are either one national fund, as in Croatia, Hungary, Estonia, Poland, Latvia, Lithuania, Slovenia, and Bulgaria,16,21,22,24,40 or are competing funds, as in Slovakia and the Czech Republic.16,54 Timing varied greatly—Hungary introduced their system just before the regime changed in 1989,27 whereas Turkmenistan did so only in 2006.44 Contribution rates vary greatly, but are typically much lower in the former USSR than in other countries. They range from 2% in Kyrgyzstan, paid entirely by employers, to 18% of net salaries (13% paid by employees and 5% by employers) in parts of Bosnia and Herzegovina—one of the highest in Europe.55 Contributions are generally decided on the basis of income from employment (via a payroll tax), but Latvia has an earmarked tax on all sources of income.39 1187

Review

Tajikistan

56·6

Turkmenistan

44·9

Uzbekistan

35·6

Azerbaijan

34·4

Kyrgyzstan

33·5

Kazakhstan

28·0

Georgia

26·9

Armenia

21·9

Ukraine

19·7

Republic of Moldova

15·9

TFYR Macedonia

14·6

Albania

13·4

Russian Federation

12·8

Romania

12·6

Bosnia and Herzegovina

12·6

Belarus

11·9

Bulgaria

9·8

Montenegro

8·9

Latvia

7·2

Lithuania

6·7

Serbia

6·6

Slovakia

6·5

Poland

5·8

Hungary

5·5

Croatia

4·9

Estonia

4·3

Slovenia

3·3

Czech Republic

3·2 0

10

20

30

40

50

60

Deaths

Figure 2: Infant mortality rate per 1000 livebirths for 200714 TFYR Macedonia=The former Yugoslav Republic of Macedonia.

In view of the many reasons for introduction of health insurance systems, and the difficult institutional and economic environments faced by many countries when new systems were introduced, we are not surprised that implementation was more complex than was expected.17 Many countries failed to raise adequate funds,48 such as Bulgaria,36 Croatia,40 Hungary,27 and the Russian Federation.20 This outcome is not unexpected in former Soviet countries with very low contribution rates, but even countries of central and southeastern Europe with very high rates have problems.34 Thus, many countries have continued to rely on general government revenues and accumulation of deficits, negating some of the main reasons for the introduction of health insurance in the first place.48 However, the alternative, to raise funds from direct taxation, would also have been questionable because of the difficulties many governments faced in tax collection,20 which is indicated by the high share of out-of-pocket expenditure in many countries in the former Soviet Union (figure 4). 1188

Gathering contributions has been a fundamental drawback, especially in countries with low wages, large informal sectors, and widespread corruption.2,16,40,48 These three factors are most acute in much of the former USSR,48 but also in Albania,35 Bulgaria,36 and Hungary.27 A rare exception seems to be Estonia, where health insurance is thought to be the best collected tax or contribution.25 In countries such as Poland, evasion of health insurance contributions is regarded only as an administrative offence.24 A further difficulty in countries such as Bosnia and Herzegovina55 and Macedonia38 has been ensuring adequate transfers of funds from central or regional government budgets to cover the non-working population. Implementation of health insurance was generally more successful in central Europe than in countries of the former Soviet Union, but even in Slovenia22 questions have been raised about the long-term sustainability of a system of health financing that is dependent on wages. These questions have been echoed in Estonia37 and Macedonia.38 A major reason for this concern, as in western Europe, is the ageing population.22,57 Consequently, a nascent debate is underway in some countries about whether the contribution base needs to be broadened in the medium-to-long term.34 Apart from difficulties in mobilisation of funds, another factor is the implication of existing insurance systems for equity.58 Although some countries have achieved nearly universal coverage,22,24,38 others have some way to go—eg, in Moldova in 2008, 30% of the working population was uninsured.31 In Romania and Bulgaria many members of the Roma minority have been excluded from health insurance coverage.2,59 People without health insurance generally have to pay out-of-pocket charges,44 restricting their access to health services.51 Many observers have also drawn attention to the fact that high contributions to health insurance lead to increased labour costs, potentially impairing economic growth.8,34,48,51 Recognition that a new financing model does not automatically translate into increased efficiency or quality is emerging.23,34,58

Out-of-pocket payments Another source of revenue that has grown in importance is private out-of-pocket expenditure, including both formal co-payments and informal, under-the-table payments.58 The economic downturn that came after the transition from communism to market economy in many countries, which was compounded by conflict in some cases,60 meant that public expenditure on health fell, leaving private health expenditure to fill the gap—mainly with out-of-pocket payments.8 Almost all health care was to be provided free at point of use33 under the constitutions of the USSR and the countries of the former Soviet bloc—a commitment that was retained in many postcommunist constitutions.36,61 Moves to establish or formalise user fees have been met with much resistance in countries www.thelancet.com Vol 374 October 3, 2009

Review

A

B

Slovenia

Slovenia

81·5

Czech Republic Albania

79·7

Albania

Poland

79·6

Montenegro

Croatia

78·8

Slovakia

72·3 72·2

TFYR Macedonia

Montenegro

76·8

Romania

Latvia

76·8

Bulgaria

TFYR Macedonia

76·6

Hungary

Bulgaria

76·3

Armenia

Serbia

76·2

Estonia

Belarus

76·2

Georgia

Romania

76·1

Latvia

Ukraine

64·0 63·8

72·1

Kyrgyzstan

67

69

61·5

Russian Federation

60·9

Kazakhstan 59·0

Turkmenistan

67·5 65

63·5 62·5

Ukraine

69·4

Turkmenistan

64·5 64·1

Azerbaijan

70·4

Tajikistan

65·1 64·9

Uzbekistan

71·2

Uzbekistan

67·1 65·9

Tajikistan

72·5

Azerbaijan

68·4 67·3

72·2

Republic of Moldova

Kyrgyzstan

69·2 69·0

Belarus

74·2 74·0

Kazakhstan

69·2

Lithuania

74·8

Russian Federation

70·5

Republic of Moldova

75·1

Georgia

70·7

Slovakia

77·2

Armenia

70·9

Serbia

77·4

Lithuania

71·8

Poland

77·4

Bosnia and Herzegovina

73·4 72·4

Croatia

78·1

Hungary

73·7

Bosnia and Herzegovina

79·2

Estonia

74·1

Czech Republic

79·9

71

73

75

77

79

81

83

55

57

59

Years

61

63

65 Years

67

69

71

73

75

Figure 3: Life expectancy at birth for 200714 Life expectancy for females (A) and males (B) in central and eastern Europe. TFYR Macedonia=The former Yugoslav Republic of Macedonia.

such as the Czech Republic,62 Hungary,62 Poland,24 and Slovakia.39,62 However, many countries have introduced formal co-payments for health services.10,33,63 This change has led to problems beyond affordability—such payments often encourage expensive and unnecessary treatments,1,6,62 which is exacerbated by raised prices of retail pharmaceuticals.64 However, widespread under-the-table payments pose the greatest challenges. These payments are pervasive in central and eastern Europe, with the possible exception of the Czech Republic,10,65 and are a major impediment to health-care reform.10,16,63–65 Although evidence for their extent and magnitude is incomplete—an indication of their illegal status—they are especially common in some of the poorest post-Soviet countries34 where they now constitute a major source of health-care expenditure.10,58 In Armenia, these payments were estimated to be 61% of total health-care expenditure in 2003.33 The issue of informal payments is very complex. Some countries, such as Estonia,37,48 have very low rates of www.thelancet.com Vol 374 October 3, 2009

informal payments and moderate rates of formal payments, whereas others such as Latvia21 have low rates of informal payments but extensive formal payments. Countries including Russia20 and Ukraine26 have levels that are high for informal but low for formal payments, and yet both formal and informal payments are substantial in Azerbaijan,33 Bulgaria,36 Georgia,30 Republic of Moldova,31 and Romania.23 In many countries, the net result is that both types of payment now account for a major part of total health expenditure (figure 4). Physicians are the main beneficiaries of informal payments,66 with the largest payments often going to those who work in hospitals.10 Such payments create a very complex system, perhaps explaining the difficulty in their elimination.66 In some cases they provide resources for essential but otherwise unavailable treatments, and in others they supplement low salaries of health workers.67 An important factor in their persistence is the continuing low status and salaries of health-care workers, which are generally below average national incomes.7 Salaries of 1189

Review

Year of introduction

Contribution rates

% of total health expenditure in 2006

Albania

1995

3·5% of wages, split equally between employers and employees

11·3%

Armenia

No

NA

NA

Azerbaijan

No

NA

NA

Belarus

No

NA

NA

Federation of Bosnia and Herzegovina

Newly regulated in 1997

18% of net salary; 13% paid by employee and 5% by employer

51·6%

Republika Srpska

1999

15%; split equally between employers and employees

51·6%

Bulgaria

1999

6%; split equally since 2009 between employers and employees

37·0%

Croatia

1993

15%; paid entirely by employee since 2003, plus 0·5% for occupational safety

78·4%

Czech Republic

1991

13·5% of gross salaries; 9% paid by employer and 4·5% by employee

78·8%

Estonia

1992

13%; paid entirely by employee, although 61·5% in practice employers make the contributions

Georgia

1995

Employers contribute 3% and employees 1% of salary

11·1%

Hungary

1989

4% of gross income paid by employees, 4·5% plus a flat-rate contribution by employers

60·1%

Kazakhstan

Introduced in 1996, but abandoned 1998

NA

NA

Kyrgyzstan

1996

2%; paid entirely by employer

Latvia

1991

Tax-funded system with Latvian State Health Insurance Agency (established in 1994) as purchaser of services. Until 2004, earmarked payroll taxes (28·4% of personal income-tax revenue). Since 2005, general government revenues, with funds transferred to the Health Insurance Agency

Bosnia and Herzegovina

9·0% 52·2%

Lithuania

1997

6% since 2009; paid entirely by employee 59·2%

TFYR Macedonia

1991

8·6% of gross salary; paid by employer

Republic of Moldova

2004

6% since 2008; split equally

35·2%

Montenegro

1992

15%; split equally

69·7%

Poland

1997

9% since 2007; paid entirely by employee

58·7%

Romania

1998

5·2% paid by employers, 5·5% by employees

65·4%

Russian Federation

1993

3·6%; paid entirely by employers

26·7%

Serbia

1992

15%; split equally

64.8%

Slovakia

1991

10% of gross salary paid by employer and 4% by employee

63·2%

Slovenia

1992

6·36% of gross salary paid by employees, 6·56% by employer

67·1% NA

65·9%

Tajikistan

No

NA

Turkmenistan

2006

··

Ukraine

No

NA

NA

Uzbekistan

No

NA

NA

4·1%

TFYR Macedonia=The former Yugoslav Republic of Macedonia. NA=not applicable. ··=data not available.

Table: Social health insurance in central and eastern Europe by country20–48

1190

health workers have decreased in many countries in real terms since transition, and are sometimes paid only after long delays7,10 However, salaries have been increased substantially in response to emigration in some countries that are now members of the EU. Other factors include a failure of governments to enforce regulations, weak systems of accountability,61,67 and confusion of patients about which payments are official and which are not.10 Furthermore, little political commitment has been made to address the problem65,68— sometimes because politicians regard informal payments as a means to avoid a rise in salaries.34 However, the complex and deeply ingrained use of informal payments67–69 has caused difficulty in reaching agreement on what might usefully be done.48 Informal payments create major difficulties. They are highly regressive, because people on low incomes pay proportionally more than do wealthy people.10,63,64,68 Evidence has emerged from the Caucasus, central Asia, Republic of Moldova, and Ukraine70 of increased reliance on self care and traditional healers, with formal medical care as a last resort. Informal payments distort the care that is provided,63 favouring expensive but inappropriate services.64 Finally, the incentives that informal payments provide act as a major barrier to effective reform of health care because health professionals block proposals that would improve health care but damage their own ability to extract informal payments.65,67

Primary health-care reform The Soviet system emphasised hospital care.34 Primary care in urban areas was provided in polyclinics, with employees obtaining care at work, whereas others (mainly non-working mothers and children) accessed care at community facilities, often of poor quality.71,72 Rural areas were served by ambulatory facilities, feldshermidwifery posts, staffed by feldshers (paramedical workers), nurses, and midwives. Yugoslavia was different, having created a well developed network of primary health care with municipal health centres2 in the immediate postwar period, although it consequently had serious financial problems.73 Many health reforms have attempted to reduce overcapacity in the hospital sector while strengthening primary health care, with the introduction of programmes to train physicians as general practitioners.74 As with the introduction of health insurance, a major reason for the establishment of general practice was the desire to move away from the communist past—a wish that was especially strong in the Baltic states.75 Many countries wanted to converge with western European models of primary care—with the UK model one of the best known.74 In central Europe, this move built on longstanding personal ties with some leaders of British general practice. Internationals agencies, especially the World Bank, WHO, and to a lesser extent the EU and bilateral donors, www.thelancet.com Vol 374 October 3, 2009

Review

had key roles in initiatives designed to strengthen primary health care in this region.1,35,48,52,76–78 Primary care reform accounts for the largest portion of World Bank loans to the health sector.48 The family physician model of general practitioners working in solo or group practices was reportedly promoted by WHO79 and the World Bank,8,49 and was described as a “WHO-promoted ‘export article’ of countries such as the United Kingdom and the Netherlands”.53 Family medicine was not recognised as an academic discipline in the communist era75 apart from in Yugoslavia.72,75 Hence, recognition of it as a specialty and its resultant widespread introduction into medical curricula has been a major change.75,76 However, much variation in extent and quality of postgraduate training remains.76 Some countries, especially in central Europe, have made substantial progress in implementation of guidelines and recertification procedures.75,76 Outstanding concerns include an absence of academic infrastructure and underdeveloped systems for continuing professional development.76 Most of the ten former communist countries that have joined the EU have embraced a system in which primary care is provided mainly by family doctors.21,25,27,37,80 These changes were typically accompanied by new financing models, with independent contractors being paid by health insurance schemes, mostly on a capitation basis,2 as part of a broad agenda of privatisation.19,76 Encouraged by external agencies,52,81 most primary care practices and a growing number of outpatient specialist clinics in these countries are privately owned.49 In much of former Yugoslavia, primary care is still provided mainly in health centres that are government owned,35,38,55 although family doctor systems are being developed. However, this situation is changing. Care in Croatia is largely provided by private practices consisting of a doctor and a nurse,40 whereas the proportion of independent family doctors continues to increase in Macedonia.15 By contrast, throughout most of the former Soviet Union,26,30,33,33,42,75,82 the Soviet model of primary care remains in place, although the model shifted to capitation payments for recurrent expenses whereas state ownership of facilities is retained. Countries such as Kyrgyzstan41 and the Republic of Moldova31,83 have developed centres for family medicine in buildings that were previously district polyclinics, and much regional diversity exists in implementation of primary care reform throughout the Russian Federation.84 Experience of countries in implementation of primary health-care reform has differed, but few rigorous assessments have been done. Although in Latvia the creation of a family doctor system has been described as one of their most successful reforms,21 and in Estonia popular satisfaction with primary care is high,25,27 the new model seems to have been less popular in Croatia.19 Common problems include an absence of information campaigns about the role of general practitioners, as in www.thelancet.com Vol 374 October 3, 2009

76·9

Georgia Tajikistan

74·6

Azerbaijan

63·7 59·9

Armenia Albania

57·9

Kyrgyzstan

57·4

Uzbekistan

50·8

Republic of Moldova

42·9

Bosnia and Herzegovina

41·3

Ukraine

40·0

Latvia

38·6

Bulgaria

38·0

Kazakhstan

35·8

Turkmenistan

33·3

Lithuania

32·2

Russian Federation

31·3

TFYR Macedonia

29·6

Poland

26·1

Romania

25·3

Hungary

25·3

Montenegro

24·5

Serbia

24·3

Slovakia

22·6

Estonia

20·5

Croatia

17·5

Belarus

16·7

EU members before May, 2004

15·0

Slovenia

12·4 10·9

Czech Republic 0

10

20

30

40

50

60

70

80

90

Total health expenditure (%)

Figure 4: 2005 out-of-pocket payment (formal and informal) for health56 Payments are expressed as a percentage of total health expenditure. EU=European Union. TFYR Macedonia=The former Yugoslav Republic of Macedonia.

Albania35 and Armenia,33 and little clarity about general practitioner roles in the Russian Federation74,75 and elsewhere.76 Despite much progress, general practice still has low status and prestige in many countries,76 and researchers in Slovenia and Uzbekistan have concluded that further steps need to be taken to improve management of quality of primary care.85,86 One of the major challenges in implementation of family medicine was training family doctors. This training often lagged behind the introduction of new employment and payment systems.26 Many countries tried to transform specialists into generalists with short courses.33,79,83 However, this strategy has had little success, raising questions about the ability of some former specialists to provide care beyond their specialty area.48,87 In addition to concerns about the qualifications of many retrained family doctors, which have also been raised in western Europe, the new training programmes have struggled to meet demand. Countries such as Lithuania have had much success,80 but elsewhere many physicians presently working in general practice are poorly qualified.2 1191

Review

The Russian Federation managed to retrain only 2500 general practitioners by 2002,74 while in Ukraine in 2004, only about 2% of the estimated demand had been met,26 with Armenia (11% in 2006)33 and Poland (50% in 2004)24 also having much work still to do. Introduction of capitation-based payment systems has proved challenging because they provided no incentive to improve quality of care.27 Alone, these systems encouraged underprovision of services and high referral rates,15 as was noted in Armenia.33 In Poland, capitation funding for general practitioners has been blamed for a rapid rise in hospital admissions.34 Similarly, in Hungary between 1990 and 2002, referrals to specialist outpatient care for reasons other than diagnosis more than doubled, and the number of patients admitted to hospital increased by 71%.27 In response, countries such as Bulgaria87 and Croatia19 have introduced restrictions on referrals. Hungary27 is one of a few countries that has redirected resources to primary care. This redirection of resources has not happened in other countries so that hospitals continue to dominate health budgets,2,39,42,76 although this difficulty is not unique to central and eastern Europe.29 In Poland, the share of total health expenditure devoted to primary health care even decreased from 19·9% in 1999, to 11·6% in 2003.24 Primary health-care reform has achieved some of its objectives in many countries, but in others has given rise to some unintended consequences, such as a fall in preventive services for schoolchildren and students, women of reproductive age, and elderly people.19,75,87 In Croatia, numbers of home visits by general practitioners and nurses fell sharply under the reformed system because provider reimbursement for these services stopped.19 Furthermore, concerns have been raised about how reforms have affected access to health services.6 In Bulgaria, restrictions on the number of referrals to paediatricians before general practice had been properly established were linked to reduced quality of care for children.87 In Romania in 2005, an estimated 7% of the population remained unregistered with a general practitioner, affecting the Roma population the most.23 Facilities for primary care in many countries have fared poorly from a scarcity of investment,37 especially in rural areas.23,48,82

to change, and sometimes major conflict,55 was especially daunting. Difficulties were often exacerbated by frequent changes of government—eg, Macedonia had 13 different governments and ten ministers of health between 1991 and 2006,43 and was fairly typical in this region. Concerns persist about how best to collect funds in countries with low incomes, low institutional capacities, and large informal sectors.58 In other countries, some governments are questioning whether the financial basis of social insurance might be too narrow. Furthermore, concerns have been raised about whether the widely anticipated benefits of general practice will be realised.52 Benefits of high-quality primary care are well established,25,75–77,89 but in many countries of central and eastern Europe the measures put in place fall short of the ideal, and are often made up of isolated elements of reform that do not form a coherent or sustainable whole.34 Successful reform needs a comprehensive model of care delivered by trained health professionals in appropriately designed and equipped settings, in which information exchange throughout the system helps with continuity of care. Many countries still aspire to this outcome,53,76 including parts of western Europe. This situation has led some people to question the wisdom of replacement of the polyclinic model with general practice.74,79 Some researchers have suggested that polyclinics could have been adapted, with measures to enhance the skills and autonomy of health workers, placing a greater emphasis on health promotion, disease prevention, and improved integration of primary and secondary care.79 What some see as the premature dissolution of polyclinics in several countries has resulted in many solo practices, running counter to the trend in much of western Europe to establish group practices and strengthen links between primary and specialist care, long-term care, and public health.23,28,34,76 Reform of primary care has given rise to some curious transfers of ideas. Fund holding for primary care was introduced in Poland in 1999, after it had been discontinued in the UK.34,42 Polyclinics are now being introduced in the UK National Health Service, even though countries in central and eastern Europe were encouraged to abandon them.71 Moreover, polyclinics are now being reintroduced into Germany as a means to enhance cooperation between primary and secondary care.71

Future directions Many issues in the health-care reform of central and eastern Europe warrant separate study, such as the reform of hospital sectors, an increasing private sector, the challenge of improving public health and quality of care, countries’ experience of decentralisation, and new purchasing practices. Many countries have faced frequent unforeseen difficulties, with results falling short of expectations.20 These drawbacks of policy implementation were not unique to central and eastern Europe,88 but in this region the reformation of an entire sector, frequently in the context of economic recession,78 political resistance 1192

Conclusions One of the key conclusions emerging from our analysis of health reform in central and eastern Europe over the past two decades is that, as in the rest of the world, many decisions were made on the basis of politics rather than evidence. This finding should not be a surprise in view of the scarce evidence base that was available.90,91 The rush to establish health insurance systems and general practice was motivated by a political desire to create distance from the communist system.25 In all countries, health policies are grounded in values and beliefs, political issues, www.thelancet.com Vol 374 October 3, 2009

Review

interests of professional groups, and a sense of what is feasible. Furthermore the options are often constrained by the starting conditions (path dependency).1,84,90,92 In Romania, questions about the social consequences of new financing arrangements, or how unofficial payments might be reduced, were asked too late or not at all.23 In Poland in 2003, replacement of 17 decentralised sickness funds with one national fund was attributable mainly to a change of government.24 Without much evidence, a technical argument for an evolutionary approach has emerged, with new policies being piloted locally before their national introduction.1,8,48 Evidence of the effect of health reforms from the past two decades is unfortunately sparse.34,83 Moreover, little sharing of available evidence took place.20 This situation might be changing as countries become increasingly interested in assessment of their reforms. First steps in this direction include a study of the primary care model in two rayons (districts) in Moscow’s oblast (region).84 International agencies have played an important part in changes that have taken place. However, their role often concentrated on the transfer of ideas rather than on building domestic capacity for policy analysis and planning.48,78,93 Inevitably, foreign experts who had prominent roles in the early days often had little insight into local situations.75 Furthermore, assistance often bore little relation to the major health challenges faced by each country.94 Crucially, health systems need to correspond to the health needs of their populations5,8—a fundamental factor often overlooked as governments implementing reforms pursued other agendas.34,36,48,78,81 This factor includes recognition of demographic and epidemiological transitions. Although far from unique to this region, health systems are still based on an acute, episodic model of care that is ill-equipped to deal with comorbidities and chronic diseases.91 In some countries, this absence of capacity is exacerbated by reforms, such as the introduction of diagnosis-related groups to pay for hospital care.81,95,96 A study97 of panel data from 28 countries in this region reported that adoption of social health insurance increased national health spending and rates of hospital activity, but did not improve health outcomes. Although the link between systems for health financing and health outcomes is very complex, we need to understand the implications of reform initiatives for population health. Finally, there is still much work to be done to respond to the special needs of some population groups, such as the Roma minority and those with disabilities, who face substantial barriers to access to health services.81,87,98 Contributors BR and MM jointly designed the structure for the paper on the basis of a request from The Lancet. BR assembled the necessary data and wrote the first draft, which MM revised. Both authors have seen and approved the final version.

www.thelancet.com Vol 374 October 3, 2009

Conflicts of interest We declare that we have no conflicts of interest. Acknowledgments We thank Josep Figueras and Reinhard Busse for their helpful comments on an early draft. Both authors’ work on health systems in central and eastern Europe is supported by the European Observatory on Health Systems and Policies. References 1 Grielen SJ, Boerma WG, Groenewegen PP. Science in practice: can health care reform projects in central and eastern Europe be evaluated systematically? Health Policy 2000; 53: 73–89. 2 Rechel B, McKee M. Health systems and policies in South-Eastern Europe. In: WHO, ed. Health and economic development in south-eastern Europe. Paris: World Health Organization, 2006: 43–69. 3 Andreev E, Nolte E, Shkolnikov V, Varavikova E, McKee M. The evolving pattern of avoidable mortality in Russia. Int J Epidemiol 2003; 32: 437–46. 4 Balabanova D, McKee M, Pomerleau J, Rose R, Haerpfer C. Health service utilisation in the former Soviet Union: evidence from eight countries. Health Serv Res 2004; 39: 1927–50. 5 Oreskovic S. New priorities for health sector reform in central and eastern Europe. Croat Med J 1998; 39: 225–33. 6 Banoob SN. Private and public financing—health care reform in eastern and central Europe. World Health Forum 1994; 15: 329–34. 7 Healy J, McKee M. Health sector reform in central and eastern Europe: the professional dimension. Health Policy Plan 1997; 12: 286–95. 8 Staines VS. A health sector strategy for the Europe and central Asia region. Washington: World Bank, 1999. 9 Healy J, McKee M. Implementing hospital reform in central and eastern Europe. Health Policy 2002; 61: 1–19. 10 Lewis M. Who is paying for health care in eastern Europe and central Asia? Washington: World Bank, 2000. 11 McKee M. Cochrane on communism: the influence of ideology on the search for evidence. Int J Epidemiol 2007; 36: 269–73. 12 Vlassov V. Is there epidemiology in Russia? J Epidemiol Community Health 2000; 54: 740–44. 13 Danishevski K, McKee M, Balabanova D. Prescribing in maternity care in Russia: the legacy of Soviet medicine. Health Policy 2008; 85: 242–51. 14 World Bank. World development indicators, online database. Washington: World Bank, 2008. www.worldbank.org/data (accessed May 2, 2009). 15 Nordyke R, Peabody J. Market reforms and public incentives: finding a balance in the Republic of Macedonia. Soc Sci Med 2002; 54: 939–53. 16 Dubois C-A, McKee M. Health and health care in the candidate countries to the European Union: common challenges, different circumstances, diverse policies. In: McKee M, MacLehose L, Nolte E, eds. Health policy and European Union enlargement. Maidenhead: Open University Press, 2004: 43–63. 17 Figueras J, Menabde N, Busse R. The road to reform. BMJ 2005; 331: 170–71. 18 Eldar R. Activities for quality of care improvement in the countries of central eastern Europe. Croatian Med J 2001; 42: 692–95. 19 Chen MS, Mastilica M. Health care reform in Croatia: for better or for worse? Am J Public Health 1998; 88: 1156–60. 20 Tragakes E, Lessof S, eds. Health care systems in transition: Russian Federation. Copenhagen: European Observatory on Health Systems and Policies, 2003. 21 Tragakes E, Brigis G, Karaskevica J, et al. Latvia: health system review. Health systems in transition. Copenhagen: World Health Organization, on behalf of the European Observatory on Health Systems and Policies, 2008; 1–253. 22 Albreht T, Cesen M, Hindle D, et al. Health care systems in transition: Slovenia. Copenhagen: European Observatory on Health Care Systems, 2002. 23 Vladescu C, Scintee G, Olsavszky V, Allin S, Mladovsky P. Romania: Health system review. Health systems in transition. Copenhagen: World Health Organization, on behalf of the European Observatory on Health Systems and Policies, 2008: 1–172.

1193

Review

24

25

26

27

28 29

30

31

32

33

34

35 36

37

38

39

40

41

42

43

44

1194

Kuszewski K, Gericke C. Health care systems in transition: Poland. Copenhagen: WHO Regional Office for Europe on behalf of the European Observatory on Health Systems and Policies, 2005. Lember M. A policy of introducing a new contract and funding system of general practice in Estonia. Int J Health Plann Manage 2002; 17: 41–53. Lekhan V, Rudiy V, Nolte E. Health care systems in transition: Ukraine. Copenhagen: WHO Regional Office for Europe on behalf of the European Observatory on Health Systems and Policies, 2004. Gaál P. Health care systems in transition: Hungary. Copenhagen: WHO Regional Office for Europe on behalf of the European Observatory on Health Systems and Policies, 2004. Koppel A, Meiesaar K, Valtonen H, Metsa A, Lember M. Evaluation of primary health care reform in Estonia. Soc Sci Med 2003; 56: 2461–66. Boerma WGW, Dubois C-A. Mapping primary care across Europe. In: Saltman RB, Rico A, Boerma W, eds. Primary care in the driver’s seat? Organizational reform in European primary care. Maidenhead: Open University Press, 2006: 22–49. Gamkrelidze A, Atun R, Gotsadze G, MacLehose L. Health care systems in transition: Georgia. Copenhagen: European Observatory on Health Care Systems, 2002. Atun R, Richardson E, Shishkin S, et al. Moldova: health system review. Health systems in transition. Copenhagen: World Health Organization, on behalf of the European Observatory on Health Systems and Policies, 2008: 1–138. Hakobyan T, Nazaretyan M, Makarova T, Aristakesyan M, Margaryants H, Nolte E. Armenia: health system review. Health systems in transition. Copenhagen: World Health Organization, on behalf of the European Observatory on Health Systems and Policies, 2006: 1–180. Holley J, Akhundov O, Nolte E. Health care systems in transition: Azerbaijan. Copenhagen: WHO Regional Office for Europe on behalf of the European Observatory on Health Systems and Policies, 2004. Belli P. Ten years of health reforms in former socialist economies: lessons learned and options for the future. Cambridge, MA: Center for Population and Development Studies, 2001. Nuri B, Tragakes E. Health care systems in transition: Albania. Copenhagen: European Observatory on Health Care Systems, 2002. Georgieva L, Salchev P, Dimitrova S, Dimova A, Avdeeva O. Bulgaria: Health system review. Health systems in transition. Copenhagen: World Health Organization, on behalf of the European Observatory on Health Systems and Policies, 2007: 1–156. Koppel A, Kahur K, Habicht T, Saar P, Habicht J, van Ginneken E. Estonia: Health system review. Health systems in transition. Copenhagen: World Health Organization, on behalf of the European Observatory on Health Systems and Policies, 2008: 1–230. Gjorgjev D, Bacanovic A, Cicevalieva S, Sulevski Z, Grosse-Tebbe S. The former Yugoslav Republic of Macedonia: health system review. Health systems in transition. Copenhagen: World Health Organization, on behalf of the European Observatory on Health Systems and Policies, 2006: 1–98. Waters HR, Hobart J, Forrest CB, et al. Health insurance coverage in central and eastern Europe: trends and challenges. Health Aff 2008; 27: 478–86. Voncina L, Jemiai N, Merkur S, et al. Croatia: Health system review. Health Systems in Transition. Copenhagen: World Health Organization, on behalf of the European Observatory on Health Systems and Policies, 2006: 1–108. Meimanaliev A-S, Ibraimova A, Elebesov B, Rechel B. Health care systems in transition: Kyrgyzstan. Copenhagen: WHO Regional Office for Europe on behalf of the European Observatory on Health Systems and Policies, 2005. Kulzhanov M, Rechel B. Kazakhstan: health system review. Health systems in transition. Copenhagen: World Health Organization, on behalf of the European Observatory on Health Systems and Policies, 2007: 1–158. Ahmedov M, Azimov R, Alimova V, Rechel B. Uzbekistan: Health system review. Health systems in transition. Copenhagen: World Health Organization, on behalf of the European Observatory on Health Systems and Policies, 2007: 1–210. Rechel B, Sikorskaya I, McKee M. Health in Turkmenistan after Niyazov. London: London School of Hygiene & Tropical Medicine, 2009.

45

46 47

48

49 50 51

52

53

54

55

56

57

58

59

60

61 62

63 64

65

66

67

Rokosová M, Háva P, Schreyögg J, Busse R. Health care systems in transition: Czech Republic. Copenhagen: WHO Regional Office for Europe on behalf of the European Observatory on Health Systems and Policies, 2005. WHO. National health accounts, country information; 2009. http:// www.who.int/nha/country/en/index.html (accessed May 9, 2009). Pavlokova K, Prusvic D, Zapal J, et al. Health system financing in the EU. Current practices and the ageing challenge. Prague: Ministry of Health, 2009. World Bank. Health, nutrition and population in Europe and central Asia (ECA). A decade of experience: lessons learned, implications for the future. Washington: World Bank, 2003. Deppe H, Oreskovic S. Back to Europe: back to Bismarck? Int J Health Services 1996; 26: 777–802. Jacoby W. The enlargement of the European Union and NATO. Cambridge: Cambridge University Press, 2004. McKee M, Dixon A, Mossialos E. Social insurance—the right way forward for health care in the United Kingdom? Against. BMJ 2002; 325: 488–90. Mossialos E, Dixon A. Funding health care: an introduction. In: Mossialos E, Dixon A, Figueras J, Kutzin J, eds. Funding health care: options for Europe. Buckingham: Open University Press, 2002; 1–30. Delnoij DM, Klazinga NS, van der Veelden K. Building integrated health systems in central and eastern Europe: an analysis of WHO and World Bank views and their relevance to health systems in transition. Eur J Public Health 2003; 13: 240–45. Bryndova L, Pavlokova K, Roubal T, Rokosova M, Gaskins M. Czech Republic: health system review. Health systems in transition. Copenhagen: World Health Organization, on behalf of the European Observatory on Health Systems and Policies, 2009: 1–176. Cain J, Duran A, Fortis A, Jakubowski E. Health care systems in transition: Bosnia and Herzegovina. Copenhagen: European Observatory on Health Care Systems, 2002. World Health Organization. European health for all database, January 2009 edn. Copenhagen: World Health Organization Regional Office for Europe, 2009. Chawla M, Betcherman G, Banerji A. From red to gray: the third transition of aging populations in eastern Europe and the former Soviet Union. Washington, DC: World Bank, 2007. Preker AS, Jakab M, Schneider M. Health financing reforms in central and eastern Europe and the former Soviet Union. In: Mossialos E, Dixon A, Figueras J, Kutzin J, eds. Funding health care: options for Europe. Buckingham: Open University Press, 2002: 80–108. European Roma Rights Centre. Ambulance not on the way: the disgrace of health care for Roma in Europe. Budapest: European Roma Rights Centre, 2006. Rechel B, Schwalbe N, McKee M. Health in south-eastern Europe: a troubled past, an uncertain future. Bull World Health Organ 2004; 82: 539–46. Watson N. Central Europe dabbles in private health. Lancet 2004; 364: 1745–46. Kulish N. Health care fees trouble Eastern Europe. International Herald Tribune, May 26, 2008: http://nytimes.com/2008/05/26/ world/europe/26iht-czech.4.13228766.html (accessed May 8, 2009). Falkingham J. Poverty, out-of-pocket payments and access to health care: evidence from Tajikistan. Soc Sci Med 2004; 58: 247–58. Ensor T, Savelyeva L. Informal payments for health care in the Former Soviet Union: some evidence from Kazakstan. Health Policy Plan 1998; 13: 41–49. Lewis M. Informal payments in central and eastern Europe and the former Soviet Union: issues, trends and policy implications. In: Mossialos E, Dixon A, Figueras J, Kutzin J, eds. Funding health care: options for Europe. Buckingham: Open University Press, 2002: 184–205. Gaal P, McKee M. Fee-for-service or donation? Hungarian perspectives on informal payment for health care. Soc Sci Med 2005; 60: 1445–57. Ensor T. Informal payments for health care in transition economies. Soc Sci Med 2004; 58: 237–46.

www.thelancet.com Vol 374 October 3, 2009

Review

68 69

70

71 72

73

74

75

76 77

78

79

80

81

82

83

Szende A, Culyer AJ. The inequity of informal payments for health care: the case of Hungary. Health Policy 2006; 75: 262–71. Delcheva E, Balabanova D, McKee M. Under-the-counter payments for health care: evidence from Bulgaria. Health Policy 1997; 42: 89–100. Gotsadze G, Zoidze A, Vasadze O. Reform strategies in Georgia and their impact on health care provision in rural areas: evidence from a household survey. Soc Sci Med 2005; 60: 809–21. Rechel B, McKee M. Lessons from polyclinics in Central and Eastern Europe. BMJ 2008; 337: 236. Grielen SJ, Boerma WG, Groenewegen PP. Unity or diversity? Task profiles of general practitioners in Central and Eastern Europe. Eur J Public Health 2000; 10: 249–54. Saric M, Rodwin V. The once and future health system in the former Yugoslavia: myths and realities. J Public Health Policy 1993; 14: 220–37. Rese A, Balabanova D, Danishevski K, McKee M, Sheaff R. Implementing general practice in Russia: getting beyond the first steps. BMJ 2005; 331: 204–07. Švab I, Pavliè DR, Radiæ S, Vainiomäki P. General practice east of Eden: an overview of general practice in eastern Europe. Croatian Med J 2004; 45: 537–42. Seifert B, Syab I, Madis T, et al. Perspectives of family medicine in central and eastern Europe. Family Practice 2008; 25: 113–18. Atun R, Kyartsis I, Jelic G, Rados-Malicbegovic D, Gurol-Urganci I. Diffusion of complex health innovations—implementation of primary health care reforms in Bosnia and Herzegovina. Health Policy Plan 2007; 22: 28–39. Sabbat J. International assistance and health care reform in Poland: barriers to project development and implementation. Health Policy 1997; 41: 207–27. Shabarova Z. Primary health care in the NIS: history and current situation. Washington: American International Health Alliance, 2001. http://www.aiha.com/en/WhatWeDo/PrimaryCare_ ResourcesNIS.asp (accessed April 7, 2009). Liseckiene I, Boerma W, Milasauskiene Z, Valius L, Miseviciene I, Groenewegen P. Primary care in a post-communist country 10 years later: comparison of service profiles of Lithuanian primary care physicians in 1994 and GPs in 2004. Health Policy 2007; 83: 105–13. McKee M, Nolte E. Health sector reforms in central and eastern Europe: how well are health services responding to changing patterns of health? Demogr Res 2004; (April 16, 2004). http://www. demographic-research.org/special/2/7/S2-7.pdf (accessed May 2, 2009). Ahmedov M, Rechel B, Alimova V, Azimov R. Primary health care reform in Uzbekistan. Intl J Health Plann Manage 2007; 22: 301–18. Atun R, Berdaga V, Turcan L, Stefanetz S, Cibotaru E, Ibragimov A. Review of experience of family medicine in Europe and central Asia: Moldova case study. Washington: World Bank, 2005.

www.thelancet.com Vol 374 October 3, 2009

84

85

86

87

88 89

90

91

92

93

94

95

96

97

98

Kringos D, Boerma W, Spaan E, Pellny M, Son I, Korotkova A. Evaluation of the organizational model of primary care in the Russian Federation. A survey based pilot project in two rayons in Moscow oblast. Copenhagen: WHO Regional Office for Europe, 2009. Boerma W, Kringos D, Verschuuren M, Pellny M, Baymirova L. Primary care quality management in Uzbekistan. Primary care in the WHO European Region. Copenhagen: WHO Regional Office for Europe, 2008. Boerma W, Kringos D, Verschuuren M, Pellny M, Bulc M. Primary care quality management in Slovenia. Primary care in the WHO European Region. Copenhagen: WHO Regional Office for Europe, 2008. Rechel B, Spencer N, Blackburn C, Holland R, Rechel B. Impact of health reforms on child health services in Europe: the case of Bulgaria. Eur J Public Health 2009; 19: 326–30. deLeon P. The missing link revisited: contemporary implementation research. Policy Stud Rev 1999; 16: 311–38. Boerma WGW. Coordination and integration in European primary care. In: Saltman RB, Rico A, Boerma W, eds. Primary care in the driver’s seat? Organizational reform in European primary care. Maidenhead: Open University Press, 2006: 3–21. Jennings R, Legge D. The Victorian primary health care reforms. In: Lin V, Gibson B, eds. Evidence-based health policy problems and possibilities. Oxford: Oxford University Press, 2003: 181–95. Nolte E, McKee M. Caring for people with chronic conditions: an introduction. In: Nolte E, McKee M, eds. Caring for people with chronic conditions: a health system perspective. Maidenhead: Open University Press; 2008: 1–14. Lin V. Competing Rationalities: evidence-based health policy? In: Lin V, Gibson B, eds. Evidence-based health policy problems and possibilities. Oxford: Oxford University Press, 2003: 3–17. McKee M, Zwi A, Koupilova I, Sethi D, Leon D. Health policy-making in central and eastern Europe: lessons from the inaction on injuries? Health Policy Plan 2000; 15: 263–69. Suhrcke M, Rechel B, Michaud C. Development assistance for health in central and eastern European region. Bull World Health Organ 2005; 83: 920–27. Rechel B, Doyle Y, Grundy E, McKee M. How can health systems respond to population ageing? Copenhagen: World Health Organization, Regional Office for Europe, 2009. Rechel B, Wright S, Edwards N, Dowdeswell B, McKee M, eds. Investing in hospitals of the future. London: World Health Organization, on behalf of the European Observatory on Health Systems and Policies, 2009. Wagstaff A, Moreno-Serra R. Europe and central Asia’s great post-communist social health insurance experiment: aggregate impacts on health sector outcomes. J Health Econ 2009; 28: 322–40. Rechel B, Blackburn C, Spencer N, Rechel B. Access to health care for Roma children in Central and Eastern Europe: findings from a qualitative study in Bulgaria. Int J Equity Health 2009; 8: 24.

1195