The subsequent variations across the health-care systems of countries in the region reflect diverse political and economic trajectories. Generally, health-care systems have experienced difficulties since the 1980s, exacerbated by their countries’ shift to market economies (McKee et al., 2002). The political and economic transition as well as declining government financing and support for reform has led to dramatic depletion of resources in the health-care systems across the region. While health-care spending in Russia has remained relatively stable, in Georgia and Armenia it was in the range of 1–2% of GDP throughout the 1990s. In particular, public health expenditure experienced profound declines. With the collapse in public funding, reliance on out-of-pocket payments by users to access care and pharmaceuticals has grown. Formal and informal out-of-pocket payments to obtain good-quality health care have become increasingly common across the region, although to different degrees (Lewis, 2002; Falkingham, 2004). For the poor, out-of-pocket expenditures often represent a barrier to care, thus restricting demand (Balabanova et al., 2004). With limited investment in infrastructure maintenance, this pattern looks set.
Unlike the situation in many other parts of the world, where reduced access to the health-care system has arisen following often donor-driven policies to implement user charges, in the FSU region it is a consequence of dramatically reduced resources, in systems formerly reliant on extensive growth. Wider policies of economic liberalization, the introduction of market mechanisms replacing traditional state functions, deregulation, and decentralization have also influenced the architecture of reforms. Despite official commitment to guarantee universal coverage (with most insurance packages covering virtually all medical conditions apart from cosmetic surgery and dentistry), the reality is that profound barriers to access exist for substantial populations.
Despite changes in funding in recent years, from taxation to insurance, most health-care facilities continue to receive budgets allocated according to number of beds and staff, rather than volume or quality of services (Danishevski et al., 2006a). Moreover, public health systems remain heavily dependent on parallel vertical programs. Medical associations are still not in a position to act as self-regulatory bodies. In addition, because of an underdeveloped civil society and low awareness of public sector entitlements, patients have limited opportunities to question clinical decisions and cost of care. There has been some, though variable penetration of the principles of evidence-based health care that were previously rejected by the traditional Russian scientific orthodoxy.
Health-care staff-to-population ratios continue to be high, with wide variation across the region, a paradoxical position of overcapacity and ineffective function. For example, in Russia, formally little reduction in maternal facilities capacity has been observed despite a large decline in the birth rate (WHO, 2006), although capacity is not used as intended. The skill mix, especially in urban settings, remains in favor of training and retaining physicians, rather than midwives, nurses, and auxiliary staff, or developing new, innovative approaches through training and employment of nurse practitioners. In contrast, in rural areas, due to a decline in personnel and skills, in practice, unsupported staff with narrow skills are often taking on significant responsibilities (Danishevski et al., 2006b). Despite high staff capacity, health services continue to be unresponsive to user needs.
Health System Reform
Over the past 15 years, all countries in the region have implemented wide-ranging reform programs of healthcare financing and delivery of care models. Some countries have implemented comprehensive reform programs with monitoring and evaluation components (e.g., MANAS in Kyrgyzstan), while others have adopted a piecemeal approach (Russia, Ukraine). Despite differences between countries, given the similarities in the pretransition health systems, most countries have faced similar challenges. Several major reforms have taken place in the region.
- The first radical health financing reform was a move from tax-based to social insurance systems, seeking to cover the whole population with a comprehensive package of services. The compulsory social insurance model (based on the Bismarckian sickness funds system) has formally upheld the principle of universal access to care, while seeking to mobilize resources given the narrow tax base, to safeguard health-care funding flows, and promote strategic purchasing. However, its most explicit objectives were to improve transparency and accountability of health sector financing and its dependence on short-term political priorities. The shift from central government budgets to compulsory health insurance has involved varying degrees of competition and state subsidy, as well as expansion of out-of-pocket payments (Lewis, 2002). In most countries, there is a separation of purchasing and provision, often with health insurance funds acting as third-party insurers contracting care.
However, the shift to a social insurance model requires complex systems, and this has been hampered by poor administrative capacity and information systems, and high transaction costs. It also failed to significantly increase resources for health care, as shown by the example of Kyrgyzstan and Georgia (Bonilla-Chacin et al., 2005). Moreover, sustaining funding levels has relied on budget subsidies. In many cases, an employment-based health insurance has been incompatible with patterns of informal employment, rural poverty, and non-cash economies, and certain vulnerable or marginalized groups have been consistently excluded. The ability of the governments to back insurance systems deficits has been limited because of macroeconomic shocks.
The countries in the Caucasus (Armenia, Georgia, and Azerbaijan) have implemented microinsurance schemes for rural, isolated populations – which are difficult to cover in a formal insurance system – relying on community management and solidarity. While these schemes have provided a vital first-line service, the scope and quality of care is basic (e.g., excluding care for common chronic conditions), participation remains low, and scaling-up is proving a challenge (Poletti et al., 2007). The schemes also suffer from generic problems with insurance, such as small risk pools, lack of cohesive communities, poor administrative capacity, and poor ability to attract subsidies.
- Changes to delivery of primary care across the region include development of general practice (family medicine) to replace the former polyclinic-based model. Reform also included introducing new types of clinical training and primary care financing, usually capitation-based. However, despite efforts to shift the health system orientation toward primary care with a gatekeeping function, in reality progress has been slow. In Russia, where efforts to recruit and train generalists has been considerable, newly trained professionals commonly return to practice in polyclinics where they are not provided with resources or incentives and often revert to old models of practice, or they face unemployment (Rese et al., 2005). Professional demarcations persist. For example, in Kyrgyzstan and Georgia, despite physicians receiving training in managing diabetes and other complex chronic diseases prevalent among the population they serve, in practice all care continues to be provided by specialists (Hopkinson et al., 2004).
- Management training for administrators remains limited and systems of resource allocation and reporting inherited from the Semashko model are still in place, with important implications for the sustainability of reform models and the introduction of incentives to engineer change (Danishevski et al., 2006a). Managerial autonomy is very restricted. Policy making in the health sector remains heavily influenced by political power.
- Efforts to create a private sector or liberalize existing provision have largely been limited to the pharmaceutical sector and out-patient care in urban settings, where the ability to pay is greater. The private sector remains limited in most countries due to deficiencies in voluntary health insurance such as narrow coverage, limited capacity, unaffordable premiums, and a lack of trust.
- Most countries have sought to decentralize their health-care systems. Within Russia, there has been a process of decentralization (Danishevski et al., 2006a), allowing regional and municipal administrations to fund and deliver health care while still formally observing the norms established by the Ministry of Health. There are also numerous local, often donordriven, initiatives. The move to decentralization and regional autonomy, with the intention of creating more locally responsive, although less coordinated systems, led to declining stewardship of the national institutions, such as the Ministries of Health and public health authorities. Duplication of functions at different levels of the system has resulted as facilities are financed and managed by different principals, resulting on occasion in a lack of coordinated policies and practice. Linkages between the multiple horizontal and vertical (disease-specific) services have been further weakened, with the effect particularly visible in the area of infectious disease control (HIV and TB), where concerted action between the specialized facilities and the general system has been particularly difficult to achieve.
- Professional organizations of physicians have been reestablished and have begun to play a role in training, licensing, and quality control as well as becoming partners in health sector reform through setting clinical guidelines and advising on contracts of packages of care. Associations of nurses and other mid-level staff have been less influential. Patient organizations have also emerged, but they play a marginal role in national policy making and mostly provide health information, education, and small-scale service delivery to particular constituencies.
Despite ambitious and in many cases donor-financed reform, in most of the post-Soviet Union, the health systems retain much of their previous orientation, structures, and ethos. With some exceptions (rationalization of hospitals in Kyrgyzstan), reforms have done little to address inefficiencies in the inherited system and improve provider incentives. Radical reform initiatives are often placed in the context of old resource allocation patterns, institutions, and attitudes, such as with the attempts to implement general practice in Russia, without addressing working conditions and support at the system level (Rese et al., 2005).
In many countries, however, it is not the planned changes that have had greatest impact but those that were unplanned. In particular, many have seen large increases in informal payments (Lewis, 2002). In some, social safety nets have been eroded with catastrophic illness bringing long-term impoverishment for whole families.
Access To Health Care: The User’s Perspective
There is significant evidence that since the transition, people living in this region have experienced barriers to effective health care. A study in eight of the former Soviet countries demonstrated the extent to which the principles of universal access that underlined the former Soviet health systems have eroded (Balabanova et al., 2004). One in five of those who had experienced an episode of illness that they felt would have justified seeking health care did not seek it. This percentage was lowest in Belarus, at 9%, a country where change has been less radical, and was highest in Armenia (42%) and Georgia (49%), both countries that have experienced dramatic economic declines as well as civil conflict, and where the healthcare systems effectively collapsed during the 1990s. Even symptoms such as chest and severe abdominal pain would often be self-treated using either traditional remedies, for example herbal and alcohol-based remedies, or by direct purchase of pharmaceuticals. There is little standardized and comparable data in the CEE/FSU region on the use of traditional (nonbiomedical) healing systems, and these usually vary between and within countries. Prior to transition, these were mainly used to supplement biomedical treatments and were not perceived to be credible substitutes. However, evidence (as cited above) suggests that traditional remedies are increasingly chosen as a more affordable option. Self-medication, both with traditional remedies and with biomedical drugs, is often a strategy to bypass the mainstream health services, which tend to be associated with high access costs.
Informal out-of-pocket payment is frequent. Almost one-third of people had paid or given a gift at their most recent consultation. Again, this varied among countries. In Georgia and Armenia, 65% and 56%, respectively, had paid out of pocket, while in Belarus and in Russia the figures were 8% and 19%, respectively. Informal coping strategies, for example, for urgent hospitalization, such as use of connections (37%) or offering money to doctors or nursing staff (29%), were seen as acceptable strategies. Those who needed care but did not receive it were most often older, typically over 65, with lower education. This was a group that was disadvantaged in other ways, with worries about their financial situation and fewer household assets. They were also least likely to have family support networks in place. Those living in cities were better off, being 20% more likely to obtain care after taking account of their socioeconomic circumstances.
Access to care varies across many of the countries that emerged from the USSR. Access to even quite basic care is highly variable depending on the socioeconomic circumstances of individuals, public sector resources, reform programs, and government support.
During the Soviet period, it was impossible to study socioeconomic inequalities in health status and expenditure. Although such research is now possible, it remains rare, with the notable exception of Russia. In contrast to the media attention devoted to political and economic changes in this region, the impact of the transition on the health of individuals and families remains poorly recognized. Yet what evidence exists paints an alarming picture. In a single year, one in every 160 households in Kyrgyzstan and one in 25 in Ukraine faced catastrophic expenditure due to health costs (Xu et al., 2003). In Tajikistan and Turkmenistan, substantial inequalities have been documented in access to care as services become unaffordable for the poor (Falkingham, 2004; Rechel and McKee, 2005).
Survey data on health-care use and the expenditure involved are increasingly available (data from the Russian Longitudinal Monitoring Survey is available from 12 series of consecutive surveys, the World Bank Living Standards Measurement Study in Central Asia, etc.). However, these surveys often exclude the experiences of the most disadvantaged populations (Hopkinson et al., 2004). The case of abortion also demonstrates how gaps in access to care can occur even where overall utilization is high (Parkhurst et al., 2005). Abortions have been widely used as a method for contraception in the former Soviet Union and remain at high levels. Although abortion is legal and generally accessible, abortion complications account for approximately 25% of maternal deaths, with two-thirds of this reportedly resulting from illegal abortions. Certain groups such as migrants and those without a permanent address are particularly at risk and may face barriers in accessing care due to bureaucratic obstacles and informal pressure to pay. Mothers under 18 remain under the care of pediatric services, which have poor links to sexually transmitted infections (STI), maternal, and reproductive services. Awareness of contraception is high, but in practice it is often inaccessible, resulting in high rates of abortion.
The understanding of the health systems in the FSU, the impact of reform, and the ability to draw lessons and inform future policy direction remain in their infancy. For no population groups is this more apparent than for the poorest sections of these changing societies.