Cover_WHO_nr35_Mise en page 1 7/10/14 09:30 Page 1 35 After the break-up of the Soviet Union in 1991, the countries that emerged from it faced myriad TRENDS IN HEALTH SYSTEMS IN THE FORMER SOVIET COUNTRIES SOVIET THE FORMER IN SYSTEMS TRENDS IN HEALTH challenges, including the need to reorganize the organization, financing and provision of health and Martin McKee Erica Richardson Bernd Rechel, services. Over two decades later, this book analyses the progress that twelve of these countries Trends in health 35 (Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Kyrgyzstan, the Republic of Moldova, the Russian Federation, Tajikistan, Turkmenistan, Ukraine and Uzbekistan) have made in reforming their health systems. systems in the former Building on the health system reviews of the European Observatory on Health Systems and Policies Observatory Observatory (the HiT series), it illustrates the benefits of international comparisons of health systems, Soviet countries Studies Series describing the often markedly different paths taken and evaluating the consequences of these choices. This book will be an important resource for those with an interest in health systems and policies Edited by in the post-Soviet countries, but also for those interested in health systems in general. It will be Bernd Rechel of particular use to governments in central and eastern Europe and the former Soviet countries Erica Richardson (and those advising them), to international and non-governmental organizations active in the Martin McKee region, and to researchers of health systems and policies. The authors Bernd Rechel is Researcher at the European Observatory on Health Systems and Policies and Honorary Senior Lecturer at the London School of Hygiene &Tropical Medicine, United Kingdom. Erica Richardson is Research Officer at the European Observatory on Health Systems and Policies, specializing in health systems monitoring for Eastern Europe and the countries of the former Soviet Union. Martin McKee is Professor of European Public Health at the London School of Hygiene & Tropical Medicine, United Kingdom, and Director of Research Policy at the European Observatory on Health Systems and Policies. 9 7 Observatory Studies Series No. 35 8 ISBN 9289050289 9 2 8 9 0 5 0 2 8 9 Trends in health systems in the former Soviet countries The European Observatory on Health Systems and Policies supports and promotes evidence- based health policy-making through comprehensive and rigorous analysis of health systems in Europe. It brings together a wide range of policy-makers, academics and practitioners to analyse trends in health reform, drawing on experience from across Europe to illuminate policy issues. The European Observatory on Health Systems and Policies is a partnership, hosted by the WHO Regional Office for Europe, which includes the Governments of Austria, Belgium, Finland, Ireland, Norway, Slovenia, Sweden, the United Kingdom and the Veneto Region of Italy; the European Commission; the World Bank; UNCAM (French National Union of Health Insurance Funds); the London School of Economics and Political Science; and the London School of Hygiene & Tropical Medicine. Trends in health systems in the former Soviet countries Edited by Bernd Rechel, Erica Richardson, Martin McKee Keywords: DELIVERY OF HEALTH CARE HEALTH FINANCING HEALTH SYSTEMS PLANS HEALTH WORKFORCE PRIMARY HEALTH CARE PUBLIC HEALTH © World Health Organization 2014 (acting as the host organization for, and secretariat of, the European Observatory on Health Systems and Policies) All rights reserved. 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ISBN 978 92 890 5028 9 Printed in the United Kingdom Cover design by M2M Contents Foreword vii Acknowledgements ix List of abbreviations xi List of tables and figures xiii About the authors xvii Chapter 1 Introduction 1 Bernd Rechel, Erica Richardson, Martin McKee Chapter 2 Health trends 9 Bayard Roberts, Marina Karanikolos, Bernd Rechel Chapter 3 Organization and governance 29 Katharine Footman, Erica Richardson Chapter 4 Health financing 51 Erica Richardson Chapter 5 Health workforce 77 Marina Karanikolos, Charlotte Kühlbrandt, Erica Richardson Chapter 6 Public health 91 Bernd Rechel Chapter 7 Primary health care 111 Charlotte Kühlbrandt Chapter 8 Specialized and inpatient services 129 Ketevan Glonti Chapter 9 Pharmaceutical care 145 Erica Richardson, Nina Sautenkova, Ganna Bolokhovets Chapter 10 Mental health care 159 Ionela Petrea, Milou Haggenburg Chapter 11 Health system performance 173 Bernd Rechel, Marina Karanikolos Chapter 12 Conclusions 205 Bernd Rechel, Erica Richardson, Martin McKee Foreword The countries of the former Soviet Union (FSU) over the last 20 years have experienced an impressive transformation. Fundamental change has occurred in almost all aspects of political, economic and social spheres. The market economy and new freedoms have generally positively impacted citizens’ lives but access and financial protection within the national health systems as well as health status of the population more generally have not kept pace and are still considerably worse than in other countries of similar economic performance. Health and social protection systems were slow to adapt to the rapid epidemiological and demographic change, characterized by a preponderance of noncommunicable diseases, health issues linked to lifestyle choices and challenges related to an ageing population. At the same time, as in most countries of the former Soviet Union, once the economy opened and information started to flow more freely, consumer expectations started to rise across the board. In the health sector, this resulted in high growth rates of private health expenditure, mostly related to high-end tertiary care services, branded pharmaceuticals and the use of expensive medical technology – often with a limited evidence base. Those who could not afford high formal and informal out-of-pocket (OOP) expenditure were increasingly at risk to either forego or postpone necessary medical interventions. When confronted with a catastrophic health event, the middle classes and the poor often experienced the impoverishing effects of a health system lacking social solidarity, such as proper mechanisms of risk pooling and strong regulation as part of functioning health insurance mechanisms. The public health domain also suffered a significant deterioration during the transition years. Lack of funding, the adherence to an outdated paradigm of infectious disease control and limited opportunities for modern public health training and research undermined the effectiveness of population-based interventions. In many countries of the FSU the notion of individual and population health is still seen through the lens of medical care for diseases only, hence missing opportunities for leveraging cross-sectoral interventions to improve health status. Political leaders are often not cognizant of the importance of social determinants of health when considering policy and are often reluctant to use a Health in All Policies approach to harness the contribution of other viii Trends in health systems in the former Soviet countries sectors of the economy to improve population health. The growing influence of powerful lobbies often combined with corrupt and unclear practices also contributed to a lack of progress with reforming and modernizing the health sector. This latest book of the European Observatory series is an important tool for policy-makers as it attempts to systematically assess the health systems performance of 12 FSU countries using the time tested framework established by the