Europe and Central Asia Knowledge Brief
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Restructuring Regional Health Systems In Russia
The delivery of health services in Russia is a federal, regional and municipal responsibility. Reform of the regional health systems, which suffer from over-reliance on curative and inpatient care, deteriorating infrastructure and equipment, and poor quality of services, is a major challenge for the country. From 2003-2008, the World Bank helped strengthen the stewardship capacity of Russia's Federal Ministry of Health and Social Development (MOHSD) and restructure health systems in two pilot regions: the Chuvash Republic and Voronezh oblast. In both regions, hospital bed numbers were reduced while simultaneously increasing service delivery capacity at the primary care, specialized ambulatory, and long-term care facility levels through the introduction of new technologies, clinical protocols, and resource allocation mechanisms that link payments to performance.
Redesigning Health Care in ECA : Some Lessons from the UK
The countries in Europe and Central Asia (ECA) have been struggling to deliver good, affordable health care to their populations. Indeed, life expectancy gains in the region have been significantly lower than in other middle or high-income countries, and in some ECA countries the relative low level of public sector funding to cover the cost of free medical care that is already promised by the governments to their citizens has consistently hindered access to quality services and led to a significant increase in out-of-pocket spending by patients for healthcare. The main challenge now is to redesign health systems to effectively address the changing health needs of the population, chiefly the increase in non-communicable diseases such as cardiovascular diseases, cancer, and injuries, as the leading causes of ill-health, premature mortality and disability.
Tajik Child Health : All Hands on Deck
Promoting and protecting the health of their families is a high priority of households in Tajikistan-half of all households identify health as the aspect of life that is of greatest concern to them. Thirty five percent, or 2.5 million of the total estimated population of 7.2 million people in the country, are under 15 years of age. The median age of the population is just 21.6 years (UN, 2008). Although fertility has fallen in recent years, the total fertility rate remains above three. Thus, policies to improve maternal and child health (MCH) outcomes are central to improving the health of the nation. Tajikistan faces considerable challenges in its quest to achieving the Millennium Development Goals (MDGs) for MCH over the next six years. The fourth MDG target of a two-thirds reduction in child mortality calls for Tajikistan to decrease its current under-five mortality rate (U5MR) of 79 deaths per 1000 live births to less than 30 per 1000, and the current Infant Mortality Rate (IMR) of 65 deaths per 1000 to under 25 per 1000. Countries with GDP levels similar to Tajikistan have made significantly better progress towards reaching their MDG targets. For instance, IMRs in the Lao People's Democratic Republic and Cambodia stand at 52 and 59 deaths per 1000 live births, respectively, compared to 65 per 1000 in Tajikistan. IMRs in neighboring Uzbekistan and the Kyrgyz Republic are 38 and 36 per 1000 live births, respectively. Similarly, with child mortality rates of 69 and 41 per 1000 live births respectively, Lao and the Kyrgyz Republic are in a better position than Tajikistan.
Competition in Health Insurance
This knowledge brief presents the key findings of a recent World Bank report on, 'health insurance and competition'. The report examines whether competition helps multiple insurers better manage health expenditures by, for example, contracting with more efficient providers or directing consumers towards less costly care (i.e. consumers who use generic drugs pay lower premiums or co-payments). The Netherlands, Switzerland, Slovakia, and the Czech Republic are some of the countries that already have multiple and competing insurance systems in place.
Battle Against Tuberculosis : Some Gains in Russia
Across Russia, the deep socio-economic crisis of the 1990s and early 2000s provided fertile ground for the spread of Tuberculosis (TB). Indeed, as noted, 'people who were already living very precariously saw their real incomes drop by 25 percent to 30 percent at a time when government spending was also falling.' As a result, social and health conditions deteriorated, and TB spread rapidly. Russia also had one of the highest rates of imprisonment in the world that, coupled with adverse conditions in prisons, increased the risk of TB, HIV and other infectious diseases among prisoners. The Project was designed in accordance with the federal targeted social disease prevention and control program (2002-2006). About 80 percent of project funds were allocated for TB control with the goal of contributing to a leveling-off or reduction in morbidity, mortality and transmission of TB. The project covered 79 of the 83 regions across the vast Russian territory - from the Baltic Sea to the Pacific Ocean, strengthening both the civilian and prison health systems.
Action Needed : Spiraling Drug Prices Empty Russian Pockets
In large measure, this is due to the relatively low level of public health spending in the country (about 3.6 percent of gross domestic product (GDP) in 2008) that underlines the significant gap between the constitutional commitment to a range of medical care services and the actual funding to pay for them. While drugs are supposed to be provided to hospital patients free of charge, an estimated 80 percent of inpatients still have to pay part of the costs of their medicines and most outpatients must purchase them from pharmacies. The outpatient drug program under mandatory health insurance covers only around 16 million people (11 percent of the total population in the country), with more than half of them opting to receive cash rather than in-kind benefits under the 2005 'monetization' of prescription drug benefits. Those who continue with the in-kind benefits appear to be the ones greatest in need of drugs. The situation is further aggravated by the country's ineffective enforcement of controls on wholesale and retail mark-ups for medicines. Household expenditure on drugs accounted for about 30 percent of total health expenditure in Russia, as compared to 12 percent in Organization for Economic Co-operation and Development (OECD) countries in 2008.
Health Systems Strengthening Lessons from the Turkish Experience
In 2003, the Government of Turkey launched an Health Systems Strengthening (HSS) reform called the 'Health Transformation Program' (HTP). The HTP was designed to address these health system challenges. It was recognized at the outset that without system-wide reforms, significant and sustainable changes in health system performance could not take place. The overall objective of the HTP was to make the health system more effective by improving governance, efficiency, user and provider satisfaction, and long-term sustainability. The main elements of the HTP are: (i) establishment of a single purchaser in the health system; (ii) focusing the Ministry of Health (MoH) on stewardship functions; (iii) making the public sector health services delivery network autonomous; and (iv) strengthening human resources management and information systems in the health system. In its technical focus and paradigm, the HTP represents a classic 'textbook' approach to HSS which many Bank clients are trying to implement.
Setting Incentives for Health Care Providers in Serbia
The Serbian Government plans to reform its provider payment system for health care by setting incentives for providers to improve the quality and efficiency of care. Funds for health care are currently allocated on the basis of the number of staff and beds at health facilities. This encourages health care providers to use more staff and beds to define their budgets but does not reward improvements in productivity, quality of care or health outcomes.
Combating Ukraine’s Health Crisis : Lessons from Europe
This knowledge brief synthesizes the important findings of a recent study. It spotlights key issues and challenges facing Ukraine's health sector and suggests strategies for improvement. To combat the current health crisis, Ukraine could look at the lessons learned by other European countries that have faced similar health crises.
Mitigating the Impact of the Global Economic Crisis on Household Health Spending
The ongoing financial and economic crisis has hit hard the lives of citizens in Eastern Europe and Central Asian (ECA) countries. Economic growth has started to dip, unemployment is rising and government revenues are expected to fall. The crisis is having a direct impact on the ability of households to pay for health care, a situation that will likely be exacerbated as real government spending on health care declines in many countries due to reduced revenues from the general government budget and payroll-funded health insurance. Patients may have to pay higher prices for health care, make do with reduced access to necessary health services and medicines, and face other health-related financial hardships as well. This brief draws on the experience of countries (outside ECA) in coping with public financing shortfalls, to provide suggestions for mitigating the impact on ECA households of reduced public health spending. First, however, it is important to examine private health spending patterns in the ECA region.