PUBLIC-PRIVATE MIX IN HEALTH CARE FINANCE IN SELECTED CIS MEMBERS
|
|
- Phebe Charles
- 6 years ago
- Views:
Transcription
1 Chubarova Tatiana (Russia), Grigorieva Natalia (Russia) PUBLIC-PRIVATE MIX IN HEALTH CARE FINANCE IN SELECTED CIS MEMBERS Paper prepared for the 24 st World Congress of Political Sciences, Poznan, Poland, July Abstract Problems of health care financing are at the forefront of modern health care systems development for many well-documented reasons. The limits of public funds that can be mobilized and allocated to health care in modern capitalist society give rise to the problem of how to find resources to cover raising health care needs of populations and how to use the available funds more effectively. One way is to increase the share of private finance. However, this is likely to increase inequality of access to health care. The problem of health care financing manifests in members of the Commonwealth of Independent States (CIS) in a specific way. Determined by both the common pre-transitional history of health systems development and paths of transition that each country chose, the common trend is less state participation and increased private spending. The paper analyses the existing public-private mix in health finance in selected CIS members including introduction of fee for services in state health services. Taking into account the relatively low level of public health expenditures coupled with high inequality, it is suggested that low-income people in the countries in question are likely to experience problems in receiving medical treatment. This situation provides a new role for governments to control not only public but also private health expenditures as well in the course of public sector reforms with the view of securing people's access to health care. Authors contacts: Dr. Tatiana Chubarova Institute of Economics, Russian Academe of Sciences, Moscow, Russia: t_chubarova@mail.ru Prof. Natalia Grigorieva School of Public Administration, Lomonosov Moscow State University Moscow, Russia: grigorieva@msu.spa.ru Introduction The Commonwealth of Independent States (the CIS) was formed in 1991 to unite the majority of new independent states that emerged after the collapse of the USSR. 12. Though they have always differ significantly in cultural, social and economic terms they did share important common features as before the transition started their health care was organized along the same rules as Semashko model. It was based on the strong role of the state in health care finance and provision for population. 1 Ukraine failed to ratify the CIS Charter and is not an official member of the CIS; Turkmenistan is as associate member starting from 2005; Georgia officially left the organization in August 2009 The specific position is occupaied by the former Soviet Baltic republics - Latvia, Lithuania and Estonia, that later eiond the EU. 2 The Statistical Committee of the CIS publishes data for nine countries -Azerbaijan, Armenia, Belarus, Kazakhstan, Kyrgyzstan, Moldova, Russia, Tajikistan, and Ukraine. 1
2 During the transition period all CIS members had to go thought reforms that turned out to be quite painful for people. They in fact participated in a unique experience in moving from a centrally planned to a market economy. This involved the dramatic changes in the role of the state with the emergence of both market mechanisms and market ideology together with the advent of the private sector/property. Definitely, modern health care reforms in CIS members are an integral part of the overall structural changes taking place in these countries that transform entire socio-economic system in society. The main objectives of reforms - improving health status and making health systems more responsive to the expectations of citizens, increase the level of "fairness" of financial contributions to the development and functioning of the health system - are not fully implemented. The question for this paper is to investigate the changing role of the state and private sector in health care bearing in mind the necessity to secure peoples access to health care. For the purpose of comparative studies we tried not to just describe new health reality in the countries in question, but rather highlight and explain common as well as divergent trends in formulating and implementing health reforms. Particular attention is paid on financial issues and their implications for the overall health system performance. Problems with empirical and analytical data should be mentioned. First, statistical data available is often fragmented thus creating problems for a multi-country comparative analysis. In this paper we use two main sources of statistical data, namely Statistical Committee of the CIS and WHO health indicators database. Second, there is a lack of analytical including comparative studies on CIS health reforms and practical implementation of laws, plans or programs adopted in the course of health reforms in countries in question. The most striking example is Turkmenistan, where Medecins Sans Frontieres (MSF) closed its office in 2010 after the Turkmen authorities failed to support its project proposals, thus making it impossible for the organization to carry out its work in the country. According to MSF final report, health care system in the country was not transparent and failed to provide accurate data on population health status that may in turns lead to a serious health crisis (MSF, 2010). As a result it can be speculated that some of the legal requirements might not be implemented in practice. The paper consists of two parts. The first one deals with the overview of health care systems in CIS from the point of view of identifying major important both common and divergent characteristics related to the role of the state in health care. The second part analyses in detail the role of public and private sector in health care financing with the view to identify how it might affect access to health care. And, at last, some ideas are suggested to pick up probable trends for the future based on data presented in the paper. 1. Health care systems in CIS members towards a new public-private mix? CIS members can be classified alongside two basic criteria geographical location and income (WHO-WB classification) (see Table 1). It suggests that the differences between the countries may be explained by their national traditions and attitudes, including policy making and level of economic development. Table 1. CIS members income/regional grouping-2014 Low income Low middle income Upper middle income High income European Moldova, Ukraine Belarus Russia Caucuses Armenia, Georgia Azerbaijan Central Asia Tajikistan Kyrgyzstan Uzbekistan Kazakhstan Turkmenistan 2
3 The results of more than two decades of CIS healthcare reforms are contradictory. Four main phases in the development of the post-soviet CIS countries' health systems can be selected, the current stage started about 2008, when almost all CIS members initiated strategic reform plans (modernization) reflected in relevant strategies or programmes. Kazakhstan approved the Concept of the Unified National Health System (UNHS) and the Code "On people's health and the health care system," (2009), the State Health Development Program "Salamatty Kazakhstan" for (2010).Russia adopted the new federal laws "On Mandatory Health Insurance in the Russian Federation" (2010) and "On the Basis of Public Health Protection in the Russian Federation."(2010) In December 2012, the Russian government approved the State Program of Health until Ukraine at that time only began the first major health sector reforms - health care reform program has become a subsection under "Improving the quality of social services" program of economic reforms in Ukraine for Moldova announced comprehensive health care reform as a part of the National Health Policy for health in and Health system development strategy for the period was adopted. In order to maintain links existed during the Soviet era in June 1992 CIS members (except Azerbaijan) signed an agreement on cooperation in the health field. In accordance with this document, Council on Health Cooperation was established. Its activities aim at specifying mechanisms of interaction between health and other concerted ministries of CIS members on mutully important issues of health protection 3. To improve the interaction of CIS members in health sector the Expert Council on Public Health at the Inter-Parliamentary Assembly of States - the CIS members was created in April Its task is to improve the model legislative framework in the field of health and to identify optimal ways to achieve balanced budgets, reduce costs. The problem is that the multilateral documents approved often fail to keep pace with the changes that are taking place in national health systems, so there is a need for the modernization of the regulation of inter-state relations in the health field. The common health system problems in CIS members are identified as follows: - increasing antagonism between insurance, budget and market health care model with constant growth of health care costs; - insufficient level of family, preventive and high-tech medicine and lack of public commitment to a healthy lifestyle; - increase in the cost of drugs while domestic pharmaceutical plants often fail to comply with international GMP standards; - lack of model legislation governing the general principles and approaches in the organization of the health care system, as well as the state guarantees the citizens of the CIS of affordable and quality health care in the territory of the other Commonwealth entities. Perhaps the main question that is often left beyond the discussions is what better demonstrate the CIS members in health sector today, similarities or differences. One of similarities worse noting is the changing role of the state leading to the growth of private spending. At the initial stage of health reforms, almost all countries set the task of introducing market mechanisms. But the Soviet model laid high level of state social guarantees for population and their sudden cancellation could cause large social costs. Probably because of this, the disproportion between the proclaimed goals (universality and accessibility of health care), and the mechanisms to achieve them (the reduction of public health expenditures, the commercialization of services delivery) can be observed. The use of different technologies for solving similar problems, leads to different outcomes that in fact, can be seen in CIS members. At the same time policy closure distorts the real picture of what is happening and makes it 3 For example, Interstate programme of cooperation in sanitation protection of territories of CIS members from dangiourous infectious diseases (2000). 3
4 difficult to reach correct conclusions, to build a political perspective and develop appropriate action plans. (Sinfield A. 2005) In recent years, interest in research in health policies has increased, especially in terms of the analysis of their changes (C. Clavier and E. de Leeuw 2013).There are attempts to construct a multi-dimensional classification of political systems and political regimes of modern states based on the development and application of complex methods of comparative analysis that would compare the political evolution of the post-communist countries, and changes in the development of health systems and the provision of medical services (Melvil, 2007). However, there are certain difficulties in the political interpretation of the quantitative studies. Health care reforms in the CIS countries, especially in the initial period, had a negative impact on population health status major trends being reduced life expectancy and increased mortality. At the end of the first decade of the twenty-first century, these indicators have improved slightly for selected countries. The rate of decline in mortality vary across countries and categories of settlements. A similar situation is with mortality rates by main causes. However, the data is incomplete ( no data for Turkmenistan and Uzbekistan since 1995 and 2000, incomplete data on Tajikistan; Georgia s data taken into account until 2009), which complicates the comparative analysis. Morbidity from six main classes of diseases: infectious and parasitic [1]; cancer [2]; respiratory [3]; cardiovascular [4]; digestive [5]); injury and poisoning [6]) in CIS members during the past 15 years has increased in almost all classes, except for infectious and parasitic diseases. For example, in Azerbaijan there is an increased in the incidence in the first 5 classes and reduction in the 6th class. In Armenia, the situation is similar. In Belarus, the increase is observed only in the 2,3 and 4. Kazakhstan shows the incidence rate for all classes, except the 1st. Kyrgyzstan - reduction in the incidence of 1 and 3, the remaining growth is observed. Moldova - growth in 2,3, 5. Russia - decrease in the incidence of the 1st, the remaining growth. Tajikistan shows growth in all classes of illnesses. Ukraine shows growth of only cardiovascular diseases (the 4), the rest are decreasing. Thus, there is an increase in morbidity rates for the five out of 6 main classes of diseases. However, in all CIS members number of first registered HIV cases increased, in some countries, in dozens of times: Armenia ( , ), Kyrgyzstan ( , ), Tajikistan ( , ). Not so much, but there is an increase in first registered diabetes in all CIS members in last 15 years, from thousand people in 2000 to thousand in 2014, with almost twofold growth in all countries. Against the background of increasing morbidity it is important to identify those diseases in which there is a decline in the majority of CIS members, or only a slight increase in the rest. For example, the statistic demonstrate that in Azerbaijan, Kazakhstan, Moldova, Russia, Ukraine the incidence of drug and substance abuse (the number of first registered cases) has been a decline for the period (in Russia, perhaps the most significant from thousands to 21.9 thousands) and Armenia (0.02. thousand to 0.06 thousand), Belarus (1.2 thousand and 1.4 thousand), Tajikistan (0.5 thousand and 0.6 thousand). It should be noted that the highest morbidity rates were observed at the turn of , than they began to fall. Therefore, many researchers, despite the higher level of morbidity in 2014 as compared to 2000 consider this to be a positive result. In 2014, almost all countries have improved their morbidity indicators, but it is too early to talk about sustainable trend. The all-cause mortality rates per 1000 population for the period increased in Azerbaijan, Armenia, Belarus, Tajikistan and Ukraine, decreased in Kazakhstan, Kyrgyzstan, Moldova, and Russia. Mortality rates for a wider period between 1991 to 2014 (25 years of reform) have increased in Azerbaijan, Armenia, Belarus, Kyrgyzstan, Russia, Tajikistan, Turkmenistan (most recent data 1995) and Uzbekistan (latest data 2000 ) and decreased in Georgia (most recent data 2009), Kazakhstan, Ukraine and Moldova. In other words, the larger 4
5 the period that is analysed- from the beginning of the reform and to the present day- the higher mortality rates for all CIS members as well as for individual countries. Infant mortality (under 1 year) from main causes over the past 10 years (from 2005 to 2014) decreased, growth was recorded in Azerbaijan, Kyrgyzstan and Ukraine. There have been significant changes in the availability of health services for population. Some countries are considering a universal access as a key principle of health policy, in others it is assumed, but not guaranteed. In some countries, the principle of universal access is declared, but in reality, the state is unable to provide it. In Constitutions adopted after the countries in question declared independence almost all of them fixed the right for health protection. But in three countries, namely Uzbekistan, Azerbaijan and Armenia, the right to free health care was not fixed. However in 2015 in the new constitution Armenia included free health care into constitutional guarantees. Though getting free health care is restricted by either state health services or basic package defined by law. Access is becoming more limited due to the lack of public resources devoted to health and health care. Consequently, expanding private practice, little regulated or not regulated by the state, especially in terms of establishing fee for service. All countries have intended for more efficient use of hospital beds in practice meaning a reduction in their total number. CIS members inherited a large hospital network and the number of beds is still quite high (Table 2), though constantly decreasing. But the question remains open if such a reduction is justified in terms of securing access taking into account space-geographical factor, including ratio of urban to rural population. With 35.9 % as the CIS average the share of the rural population in Central Asian CIS members is significantly high (73.4 % for Tajikistan, followed by 64.5 % for Kyrgyzstan and 63.8 % for Uzbekistan) than in European CIS countries (24.1 % for Belarus), with the exception of Moldova (55.1 %). In the current decade, there is a tendency of the numbers of doctors and nursing staff to decrease (see Table 2). This process is observed in Azerbaijan, Armenia, Belarus, Russia, at the same time, after a decline in 2011, there is a growth in the numbers of medical personnel of various qualifications in Kazakhstan, Kyrgyzstan, Tajikistan and Uzbekistan. Table 2. Medical personnel and hospital beds (end of the year). Doctors (1) Nurses Hospital beds 000 Per population 000 Per population 000 Per population Azerbaijan Armenia ,2 12, ,5 12, Belarus (2) 89 (2) Kazakhstan , Kyrgyzstan
6 Moldova ,5 77, ,4 77, , Russia Tajikistan Uzbekistan Ukraine (1) For Armenia and Moldova- dentisits are included Source: «CIS Statistics, 2014, 9 (540), С. 48, 49, 50,51 In course of transition the role of the state in society as well as in health care has changed with the emergence of strong individual ideology. (Chubarova, Grigorieva, 2013). On the crest of the democratic up tide of the late 1980's and early 1990 s the notion prevailed that the state should withdraw from direct participation in the economy by providing space for market self-regulation. General principles of market relations have been automatically transferred to the social sector, including health care. In the early years of reform hopes were high that the market will regulate the relationship between all the actors of the health system. Conceptually, this is reflected in the statement of "self-regulation in health care." that led to decreasing role of government in health care in the post-soviet states. The Soviet state was regarded as too paternalistic for the market economy, so the main course had been taken to reduce state intervention in social sector and to increase individual responsibility for well-being and health. However, health care as W. Hsiao mentioned, is a "distorted economy," ie, economy in which market forces can operate, but their influence on the "product" ( volume, prices, and quality) may differ significantly from other commodity markets (Hsiao W. 1995). Most CIS members have decentralised responsibilities for organizations and management of health system transferring them to regional (municipal) governments. Ministry of Health's role in the hierarchy of ministries was low and mostly reduced to regulation, development of clinical protocols and standards, auditing projects and programs. But in the conditions of high social and economic disparities between regions this led to widening regional disparities in access to health care and undermine equity in health financing in regions and municipalities. Though at the beginning of the current decade, there has been a process of re-centralization (new centralization) in some CIS members (Armenia, Kazakhstan, Kyrgyzstan, Russia, Moldova). However such a centralization might does not seem to changes in the role of the state in publicprivate mix in health care. Among the trend that contributed to increased individual responsibility the following should be mentioned. First, the resistance of already established organizational structures in health care, meaning the formation of new system of interests, second the changing role of medical profession that seems to be adopting quite well to modern market realities, and third, stress on behavioral factors in understanding social determinant of health and evident underestimation of such social factors as income, employment, education, housing. (Chubarova 2010). 6
7 2. Public-private mix in health care finance: towards individual financing. What consequences for access? All countries in question in 1990s experienced dramatic drop in GDP due to disintegration processes and resources devoted by the state to the public needs had decreased. This was reflected in government health financing and as a result people have to mobilize private resources. In 2000 the CIS economies started to recover- the rate of GDP growth in most of them was quite high. Did it translated into health expenditures growth? Total health expenditures as a share of GDP in CIS members differ. The lowest are in Turkmenistan (2.5 %), Kazakhstan (4,3%) and Armenia (4,5%); the biggest Moldova and Georgia, up to European standards. It should be noted that there is no strict link between income level and share of GDP devoted to health. Russia (6,5%) is the only high income level country in the group but is somewhere in the middle between CIS members closed to Tajikistan (6,3%), the country with the lowest income. Total health expenditure in CIS members, % of GDP Table Azerbaijan Armenia Belarus Georgia Kazakhstan Kyrgyzstan Moldova Russia Tajikistan Turkmenistan Uzbekistan Ukraine However, what is important for access is how total expenses are split between public and private sources. Below we will discuss in more detail data available on public and private finance in CIS members Public health expenditures The share of GDP devoted to health care from public sources is low in all countries in question according to international standards. During the transition the share of public finance dropped in all countries though to a varying degree. The decrease was the most dramatic in Georgia, Armenia, Azerbaijan and Tajikistan. By 2013 public health expenses amount to more than 50% of total health expenses in Uzbekistan 50,5%, Moldova- 50,6%, Ukraine 55,9%, Russia - 64,3% and Belarus 72,2%. In these countries except Belarus the share of public expenses increased as compared to The share of government expenditure in total health expenditure also vary greatly from 20% in Azerbaijan, 21,5% in Georgia and 30,6% in Tajikistan to 65.4 % in Belarus and 65.5 % in Turkmenistan. Table 4 General government expenditure on health as % of total health expenditure
8 Azerbaijan 24 18,1 26,8 21, Armenia Belarus Georgia 5.2 lowest Kazakhstan Kyrgyzstan ,3 54,0 48, Moldova Russia , Tajikistan , Turkmenistan Uzbekistan Ukraine Source: WHO health statistics The CIS Statistical committee provides data on social spending of consolidated budgets as % of GDP, to include health spending as well. It should be noted that health expenditures apart from being quite low - in all countries in question rank 3 rd among social expenditures after social protection that include various social cash benefits and education. Social spending, consolidated budgets, % GDP Table 5 Health Education Social protection Recreation, culture and religion Azerbaijan ,4 3,5 1,7 0, ,9 3,9 3,0 0, ,9 3,0 2,4 0, ,0 2,8 2,6 0, ,3 3,0 3,4 0,5 Armenia ,0 2,6 2,1 0, ,4 2,5 2,0 0, ,6 2,8 7,1 0, Belarus ,8 5,5 4,4 0, ,0 2 6,2 0, ,6 6,2 4,5 1, ,9 5,1 9,4 1, Kazakhstan ,0 4,5 0,8 0, ,1 3,3 6,6 0, ,4 3,4 4,5 0, ,5 3,5 4,1 1, ,1 3,3 4,2 0,7 Kyrgyzstan ,0 3,5 1,7 0, ,3 4,9 2,8 0, ,9 5,4 5,0 0, ,0 6,0 5,9 0,8 Moldova ,8 0, ,9 4,5 3,8 0, ,2 7,2 11,3 0, ,6 9,1 14,3 0, ,3 6,9 12,9 0,9 Russia ,9 2 4,0 1,5 0, ,1 2 2,9 0, ,7 2 3,7 8,7 0, ,7 2 4,1 13,3 0, ,5 3,8 12,4 1,0 Tajikistan ,9 2,3 1,8 0, ,1 3,5 3,2 0, ,4 4,0 3,5 1,2 8
9 2015 2,0 5,1 1,2 Uzbekistan ,3 6,2 1,8 0, ,8 7,2 2,2 0, ,0 7,1 1,3 0,2 Ukraine ,8 2 5,8 3 6,1 0, ,8 4,0 3,4 0, ,4 5,9 8,7 0, ,0 7,1 9,3 1, ,6 5,8 8,9 0, State budget of Azerbaijan, Armenia and Uzbekistan; in Kazakhstan until Including physical culture and sport. 4 Including basic research. Spiritual and physical development. The composition of public finance in CIS members differs significantly. Methodologically, public spending includes budget and social health insurance money. Some countries - Moldova, Russia, Geogria and Kyrgistan- introduced compulsory health insurance (CHI) and social security contributions amount to a sizeble share of public health funds. Though introduction of CHI is declared by many countries (Russian Federation, Kazakhstan, Kyrgyzstan, Ukraine, Moldova, and Azerbaijan) as aim of health reforms, it seems that most of them are still at the beginnhing of the road. Historically, the situation in the CIS members is specific in a sense that in these countries CHI replaces free services provided by the state rather than private expences as it was the case in Western Europe. Perhaps this explains to a large extent why models of CHI developed in the region might not sit well with the CIS memebrs social and economic realities. Table 6 Social security expenditures on health as % of total government expenditure on health Azerbaijan Armenia Belarus Georgia Kazakhstan 13 (1996) 19.4 (1998)- stop Kyrgyzstan (1997) Moldova (2004) Russia Tajikistan Turkmenistan 6 (1996) Uzbekistan Ukraine 0 0 0,5 (2003) Source: WHO statistics The share of health expenditures in total government expenditures is the lowest in Azerbaijan, and amounts to only 3.5% in 2013, decreasing during the whole transition period. The highest share is in Belarus (13.5%), Moldova (13.4%), Kyrgyzstan (13.2%) and Ukraine (12.2%). However, if look at the dynamics, by 2000s in most countries except Belarus, Kyrgyzstan, Russia and Turkmenistan the share of health in government expenditures decreased and later gained some momentum. It seems that fluctuation in government health expenditures were caused by the adoption of selected health programmers that led to increase in financing at certain periods of time. 9
10 Table 7. General government expenditure on health as % of total government expenditure Azerbaijan Armenia Belarus ,7 9, Georgia 2.5 2,3 4,0 7, Kazakhstan Kyrgyzstan Moldova Russia , Tajikistan Turkmenistan Uzbekistan Ukraine Source: WHO statistics Financial support for health care reform in the CIS members by international organizations is selective. In some cases it is substantial. For example, the total health reform budget in Azerbaijan in 2008 was million, of which $ 50 million - loan from the World Bank. External sources play an important role in the financing of health in Moldova, first of all from the EU. For example, the total budget of European Commission that sponsored Strategy for Health System Development of Moldova only for the period amounted to more than EUR 46 million. Under the terms of the grant a country should implement important structural changes, some of them are controversial as they are typically based on certain ideological preferences of the donor while national (objective and subjective) conditions might not be given a due account Private health expenditures After the decay of the USSR private health expenditures increased substantially in all CIS members. Especially if it is assumed that they were zero in Soviet times. Some fluctuations are observed in all countries in question for the 25 years of transition. But in general, having increased sharply immediately after the transition started, private health expenditures remain quite high in all countries. As a result by 2013 they accounted for more that 50 % of total health expenditures in Azerbaijan (79.2), Georgia (78.5), Tajikistan (69.4), Armenia (58.3), Moldova (54), Russia (51.9). A bit lagging are Uzbekistan (49), Kazakhstan (46.9) and Ukraine (45.5). The lowest share is in Belarus and Turkmenistan (about 34.5). Private expenditure on health as % of total expenditure on health Table Azerbaijan 76 81, ,8 78, Armenia ,7 55,5 47, peak Belarus , , Georgia Kazakhstan Kyrgyzstan Moldova Russia Tajikistan Turkmenistan Uzbekistan Ukraine
11 Source: WHO statistics But what is more important, private expenses in all CIS members mostly consist of out-ofpocket payments (OOP). This means that people pay cash at the moment of receiving medical treatment. What a striking similarity taking into account the fact that after the decay of the Soviet Union the countries in question developed along different paths and had to face globalisation challenges individually, relaying on their own strengths and weaknesses Their share of OOP payments is significant in private expenditure and as a result in total health expenditures as well. In 2013 in five CIS member states Armenia, Belarus, Kazakhstan, Russia, Uzbekistan and Ukraine- OOP constitute more than 90% of private health expenditures. The situation is slightly better as to total health expenditures because of the varying share of the latter in total health budget. As a result the differentiation between countries is more if OOP payments are analysed, from 31.9% in Belarus and 34.5% in Turkmenistan to 71.1% in Azerbaijan and 60.1% in Tajikistan. Table 9 Out-of-pocket expenditure on health % % % % % % % % % % % % % THE PHE THE PHE THE PHE THE PHE THE PHE THE PHE THE Azerbaijan Armenia Belarus Georgia Kazakhstan Kyrgyzstan Moldova Russia Tajikistan Turkmenistan Uzbekistan Ukraine THE total health expenditures PHE private health expenditures Source: WHO statistics At the same time voluntary private health insurance (PHI) is not a success in the region. The share of VHI in health financing is high in Russia 7 % in In the majority of countries in question it is less than 1% (Belarus, Tajikistan 0.1%, Kyrgyzstan 0.2%, Armenia 0.4 %). It should also be noted that PHI is typically provided by large foreign and domestic employers as a supplement to the state system. Table 10 Private health insurance as % of private expenditure on health Azerbaijan Armenia (2001) 0.2 0,4 1, Belarus 0.1 (1998) 0.1 0, Georgia 0.1 (1997) Kazakhstan Kyrgyzstan Moldova (2002) Russia Tajikistan Turkmenistan Uzbekistan (с 2004) % PHE
12 Ukraine 0.8 (1996) Source: WHO statistics The recent collective study analysed health spending by source for 184 countries between 2013 and 2040 to specify general trends in health expenditures, included all CIS members. (Dieleman J. et al 2016). The authors discuss the so called health transition that means that with the growth of national income the health spending also increase as well as the share of pre-paid government or private plans in health financing. The data for CIS counties is presented in table below. It shows that by 2040 the role of OOP payments in total health budget in these countries will not change much and still remain significant as in Comparing OOP projections for individual CIS members with the 2040 prognosis for WHO income groups (see also Table 1) provides information for a further discussion. Let s start with extremes. Russia is the only country in the group that is at present rated by the WB as high income. The predicted share of OOP in total health expenditures is much more higher than average for the relevant income group (42.8 versus 12.6). Tajikistan, the low income CIS member, is also considerably above the low income average (61 versus 49.7). Kyrgyzstan, on the contrary is expected to perform better than low income countries as average.( 33.7). Among upper-middle income CIS members, Belarus and Turkmenistan are likely have low (relatively to other CIS members) share of OOP and fall within the average, for Azerbaijan and Kazakhstan the estimations predict much bigger share of OOP than average. Low middle income CIS members generally comply with the average estimates of 49%- (Armenia 49, Moldova 44, Uzbekistan- 41.2, Ukraine 37.5). Table 11 Health care financing in 2040 High income (HI) Upper middle(umi) 9019 ( ) 1935 ( ) 507 ( ) Lowermiddle (LMI) Low income (LI) 1995 THE, % GDP 2013 THE, % GDP 2040 THE, % GDP ( ( ) ( ) ( ) THE per capita, US$ 164 ( ) Domestic GHE, % THE 56.9 ( ) 56.4( ) 36.6 ( ) 31.2 ( ) Prepaid, % THE 30.4 ( ) 16.5 ( ) 13.2 ( ) 7.4 ( ) OOP,% THE 12.6 ( ) 27.0 ( ) 49.0 ( ) 49.7 ( ) DAH, % THE growth in THE per capita ( ) 0.1 ( ) 1.2 ( ) 11.7 ( ) 3.4 ( ) 3.0% ( ) 2.4 ( ) Armenia (LMI) Azerbaijan (UMI) ( ) ( ) 951 ( ) 1854 ( ) 41.3 ( ) 24 2 ( ) 7.0 ( ) 6.9 ( ) 49.1 ( ) 68.8 ( ) 2.6 ( ) 0.1 ( ) 4.0 ( ) 3.2 ( ) Belarus (UMI) Georgia (LMI) Kazakhstan (UMI) ( ) ( ) ( ) 2703 ( ) 2064 ( ) 1747 ( ) 68.5 ( ) 22.5 ( ) 57.1 ( ) 4.3 ( ) 23.6( ) 0.8 ( ) 27.3 ( ) 53.0.( ) 42.1( ) 0.0 ( ) 0.9 ( ) 0.0 ( ) 3.5( ) 4.2 ( ) 2.5( ) 12
13 Kyrgyzstan (LI) Moldova (LMI) ( ) ( ) Russia (HI) (6.4 Tajikistan (LI) Turkmenistan (LMI) Ukraine (LMI) Uzbekistan (LMI) 8.8) ( ) ( ) ( ) ( ) 441 ( ) 1496 ( ) 3281 ( ) 363 ( ) 668 ( ) 1838 ( ) 849 ( ) 60.0 ( ) 52.9 ( ) 51.2 ( ) 34.4 ( ) 68.1 ( ) 57.9 ( ) 53.2 ( ) 0 1 ( ) 1.1 ( ) 6.0 ( ) 0.3 ( ) 4.9 ( ) 4.4 ( ) 5.0 ( ) 33.7 ( ) 44.0 ( ) 42.8 ( ) 61.0( ) 26.8 ( ) 37.5( ) 41.2 ( ) 6.2 ( ) 2.0 ( ) ( ) 4.3 ( ) ( ) 4.3 ( ) 0.2 ( ) 0.2 ( ) 0.5 ( ) Source: Dieleman J. et al (2016). Kurowski. National spending on health by source for 184 countries between 2013 and 2040 / Published online April 13, Individual health financing and access to health care. The increased role of private finance in health care in CIS members raises concerns about people s access to health care. The idea is that no one is pushed into poverty or kept in poverty because of expenditure on health services. In this context the WHO stresses that any form of prepayment is more equitable that individual payment in case of emerging need.(who, 2000) The basic problem is not that health care is financed privately, but the necessity to ensure that people have money to pay so this does not impede access and are equitable. Two basic concepts in health financing include fairness of financial contribution and financial risk protection. The index of fairness was developed in 2000 WHO health report. Though it is criticized still it provides useful information..the most unfair in relative terms are health systems in Russia, Armenia, Kyrgyzstan and Kazakhstan. On the other side of the spectrum are much more fair Belarus, Georgia and Tajikistan. Table 12 WHO 2000 ranking-cis members Country WHO 2000 rank Rank in CIS WHO fairness of Rank in CIS financial contribution rank 1 Kazakhstan Belarus Ukraine Moldova Armenia Azerbaijan Georgia Uzbekistan Russia Kyrgyzstan Turkmenistan Tajikistan Source: World Health Report, Health systems, improving performance. Geneva, WHO. 3 1 ( ) 3.4 ( ) 3.6( ) 3.4 ( )
14 Financial risk protection indicators are developed within the framework of WHO UHC monitoring to track the level of financial risk in health, namely the incidence of: catastrophic health expenditures (the number of households of all income levels who suffer financial hardship because of relatively large health payments in a given time period); impoverishment due to out-of-pocket health payments. Using CIS statistics we tried to look at two things, namely the household health expenditures and influence of poverty and inequality. Household expenditures on health care increased in most of CIS members quite significantly remaining relatively stable in Kazakhstan and Kirgizstan. Table 13 Household expenditures on health care, % of total consumer expenditures Azerbaijan Armenia Belarus Kazakhstan Kyrgyzstan Moldova Russia Tajikistan Ukraine Source: CIS Statistics The same dynamics can be followed in the role of health services in household expenditures on services, for which they are to pay money directly. Their share increased in 2013 as compared to 2000 in all countries for which such data is available. Table 14 Share of health in services-for-fees household expenditures, in current prices, % of total Azerbaijan Armenia Belarus Moldova Russia Tajikistan Source: CIS Statistics The situation in the CIS members seems to be in line with the results of research on health financing in low- and middle- income countries over the past decades focusing on equity in health financing and delivery that indicates the following. 1. Health care financing in such countries benefits the rich more than the poor but the burden of financing also falls more on the rich (Asante A et al 2016). 2. Poor people might not even try to search medical care if they know they have to pay for them. Thus this item of household expenditures is lower that it should be if all the health needs are to be met (unmet need). 14
15 There is a lot of literature on inequality and access to health care. It discusses social economic factors, including special reference to racial and gender inequality as well as organization of health care, for example role of universal health insurance (Davis K. 1991). It also covers CIS countries (Shalke, Kislisina). The authors generally accept that there is likely to be a link between various inequality dimensions and access to health care. Health inequalities stream documents the structural differences in health status caused by social and economic (income) status of people. It suggests that poor people generally have worse health status that relatively well off people. In 2012 considerable share of population of Tajikistan (46.7 %), Kyrgyzstan (38.0 %) and Armenia (32.4 %) lived below the national poverty line, while the corresponding shares for Kazakhstan (3.8 %), Azerbaijan (6.0 %) and Belarus (6.3 %) were significantly lower. In fact poverty in CIS members is probably the most popular comparative social policy topic, especially for the western researches. The explanation might be in the availability of quantitative data ( in health care qualitative, institutional information seems to be more important). It should be noted that in 2000s all countries recorded the decrease both in poverty rates and absolute numbers of people living in poverty. Kyrgyzstan and Russia recorded the highest levels of income inequality (42.0 in 2012) among CIS countries followed by Armenia Moldova and Azerbaijan (37, 37 and 33.0 in 2014, respectively) The levels of income equality of Ukraine (24.8), Kazakhstan (28.4) and Belarus (28.5) were lower than the EU-28 average (30.6) in 2012 (Eurostat, 2014). The high degree of polarization of income in 2014 was observed in Armenia, Kyrgyzstan, Moldova and Russia, where the share of 20% of the richest population accounted for 43-51% of the total population cash income, while the share of 20% of the least well-to-do amounted to 5-6%. This allows to suggest that taking into account the large share of OOP in health finance the latter group of population might have difficulties in access to health services. The paradox of CIS members is that the high share of private finance corresponds with a high share of population living in poverty. In Tajikistan where 75 % of population lives in poverty private expenses amount to 70.4 %. In Georgia state financing amounts to only 30.9% of total health expenses while private covers 69.1%. The need to pay out of pocket whether formally or informally- makes health services inaccessible to 30% of Georgian population. The practice of informal payments became widespread in the CIS members in early 1990s leading to formation of shadow health economy (Lewis M. 2007).They include institutional or individual payments to suppliers, in kind or in cash, which are made outside the official channels or paid for services that should be covered by the health care system. With the reduction of government spending and low wages paying medical staff directly has become almost a norm. However it changed with the official introducton of - co-payments when patients officially compensate directly a certain share of the costs of medical treatment (Armenia, Kyrgizstan); - right for state health services to charge fee for medical treatment provided extra to a guaranteed package (Russia, Belarus). This usually goes together with the introduction of a basic health package that formally includes services that are provided to the public free of charge and are funded by public means-- social security contributions or taxes. For example, in Russia all public health services especially hospitals have a special department though which a patient can pay and get services not included into free government guaranteed through CHI. However, there is a big concern- supported by evidence- that health services often make patients pay fees for services that should be provided free of charge (to overcome waiting lists, to visit a certain specialist). The situation is even more complicated as the paid services are rendered in the same facility, using the same equipment, etc. Almost all countries have accepted the possibility of open privatization in the pharmaceutical sector and specialized outpatient care. In Azerbaijan, the private practice as well as private pharmacies were legalized in However, there are significant differences between the CIS members in respect to hospital sector: for example, in Armenia, hospitals are semi- 15
16 commercial organizations while in Georgia health care institutions are independent legal entities. They operate as private enterprises or joint ventures, autonomous from the state budget and management. In Russia, private health services are developing fast in certain segments of the industry (dentistry, plastic surgery, obstetrics). Discussion The modern public-private mix in health care financing in CIS members developed from the similar financing structures in the Soviet era. Since that time health systems and health policies in these countries took seemingly divergent paths that to a large extend are routed in national peculiarities; many of them did exist when they were parts of the USSR. However certain common trends are to be stressed, namely: share of private finance in total health expenditures is significant in all countries; OOP expenditures constitute the major share of private health expenditures. Thus, it is suggested here that all countries in question rely heavily on out of pocket payments in health care finance regardless of the GDP level, total amount of health system finance and the concrete organizational structures. One can even speak about individual, rather than just private health care financing. Even more, such a big share of OOP as predicted by some research is unlikely to change dramatically in coming years. As a result, everyone pays for himself/herself and the system itself becomes individualized. An important consequesnce is that virtually no redistribution happens in health financing that in fact undermines the basis of social solidarity, when rich pays for the poor and those who are healthy pay for those who are ill. The problem in a majority of CIS members is aggravated by high levels of inequality and in some countries- poverty. Decline in the share of state financing in many countries has led to negative results for people in CIS members making it difficult for people to access healthy services. In such circumstances, the effective use of public funds is high on the health agenda in all CIS members. However, the programme-based measures that are adopted in many CIS members and aim at solving particular problems in health systems, based either on epidemiological or resource approach, does not seems to contribute much to overall health system performance (lacking systematic vision and proper sequencing, creating gaps). Lack of public resources allocated to health care in poor countries is likely not only to impede assess to health care by a large population segments but to change relevant policies. Therefore, the role of private finance seemed to be institutionalized, or deeply embedded into existing health systems. Even more, it is not just supported by existing delivery structures but such structures are likely to develop based on the notion of individual health finance. Governments seem to be ready to shift responsibilities for health care to people as a way to solve a problem of health financing. Thus, the stress on individual health responsibility based on a behavioral approach. In such a situation building health systems on basic packages opens a possibility for the state to easily change the composition of such a package to increase individual finance. It is argued here that if the modern governments in CIS members still are not prepared to expand their health responsibilities, the development of other collective forms of prepayment need to be developed if universal health coverage is to be a reality. Literature Asante A, Price J., Hayen A., Jan S., Wiseman V. (2016).. Equity in Health Care Financing in Low- and Middle-Income Countries: A Systematic Review of Evidence from Studies Using Benefit and Financing Incidence Analyses. PLoS One.Apr 11;11(4). Fierlbeck K. H. Palley (eds). (2015). Comparative Health Care Federalism. Ashgate, UK. Clavier C., E. de Leeuw (eds). (2013). Health Promotion and Policy Process. Oxford University Press. 16
Index. B Belarus health-care system, 107 Budget-based financing, 11 Bulgaria, corporatised hospitals,
Index A Age structure of population, 31 Aggregate health spending, national product and, 27 29 Albania health-care system, 106 Ambulatory care, 10 Anecdotal evidence, 18 Armenia, corporatised hospitals
More informationPoverty and Inequality in the Countries of the Commonwealth of Independent States
22 June 2016 UNITED NATIONS ECONOMIC COMMISSION FOR EUROPE CONFERENCE OF EUROPEAN STATISTICIANS Seminar on poverty measurement 12-13 July 2016, Geneva, Switzerland Item 6: Linkages between poverty, inequality
More informationAmong CIS oil exporters, only Kazakhstan will evade the risk of slowing down economy
MACROECONOMY CIS RESEARCH In 1990 2017, the economies of Azerbaijan and Kazakhstan have grown more than two-fold.......2 The Azerbaijan's potential GDP growth was based on fixed capital but it ceased to
More informationPresentation to SAMA Conference 2015
Presentation to SAMA Conference 2015 NHI MODEL, RELATIONSHIP TO FINANCE AND ITS EFFECTS ON PUBLIC AND PRIVATE MEDICAL PRACTITIONERS Date: 19 SEPTEMBER 2015 Venue: Sandton Convention Centre Dr Aquina Thulare
More informationThe Path to Integrated Insurance System in China
Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Executive Summary The Path to Integrated Insurance System in China Universal medical
More informationEastern Europe and Central Asia
Eastern Europe and Central Asia Financial Resource Flows and Revised Cost Estimates for Population Activities Twenty years ago, the landmark International Conference on Population and Development put people
More informationCountries of the CIS
Countries Socio-economic Statistics Key Publications A summary of key publications from (StatCommittee) comprising socio-economic statistics on the twelve countries of the Commonwealth of Independent States:
More informationInnovating Public Health Policy in times of the financial & economic crisis in the WHO European Region
Brussels, 21 February 2013 Innovating Public Health Policy in times of the financial & economic crisis in the WHO European Region Hans Kluge Director, Health Systems and Public Health The WHO policy Health
More informationHealthcare System Innovation for Aging Society -Issues and Direction-
Healthcare System Innovation for Aging Society -Issues and Direction- APEC Life Sciences Innovation Forum Health Financing Mechanisms & Options Sep. 19, 2010 Prof. Akira Morita University of Tokyo 2010
More informationLABOR STATISTICS LAG BEHIND CHANGES IN THE LABOR MARKET AND IN POLICIES
LABOR STATISTICS IN THE CIS COUNTRIES: A USER S PERSPECTIVE ANNA LUKYANOVA, CENTER FOR LABOR MARKET STUDIES, HIGHER SCHOOL OF ECONOMICS (MOSCOW) LABOR STATISTICS LAG BEHIND CHANGES IN THE LABOR MARKET
More informationUniversal Health Coverage Assessment. Republic of the Fiji Islands. Wayne Irava. Global Network for Health Equity (GNHE)
Universal Health Coverage Assessment Republic of the Fiji Islands Wayne Irava Global Network for Health Equity (GNHE) July 2015 1 Universal Health Coverage Assessment: Republic of the Fiji Islands Prepared
More informationHOW DO ARMENIA S TAX REVENUES COMPARE TO ITS PEERS? A. Introduction
HOW DO ARMENIA S TAX REVENUES COMPARE TO ITS PEERS? A. Introduction Armenia s revenue-to-gdp ratio is among the lowest relative to other CIS countries and selected Eastern European countries 1 (Figure
More informationRunning a Business in Belarus
Enterprise Surveys Country Note Series Belarus World Bank Group Country note no. 2 rev. 7/211 Running a Business in Belarus N ew data from Enterprise Surveys indicate that tax reforms undertaken by the
More informationACTION FICHE N 1 FOR THE KYRGYZ REPUBLIC. Total cost: EUR. DAC-code Sector SociaVWelfare Service
ACTION FICHE N 1 FOR THE KYRGYZ REPUBLIC 1. IDENTIFICATION Title/Number Total cost Sector Policy Support Programme, Social Protection and PFM - Kyrgyzstan 2007-2009 - Third allocation DCI-ASIE/2009/021-363
More informationCitizens Health Care Working Group. Greenville, Mississippi Listening Sessions. April 18, Final Report
Citizens Health Care Working Group Greenville, Mississippi Listening Sessions Final Report Greenville, Mississippi Listening Sessions Introduction Two listening sessions were held in Greenville, MS, on.
More informationAlthough a larger percentage of the world s population
Social health protection coverage 3 Although a larger percentage of the world s population has access to health-care services than to various cash benefits, nearly one-third has no access to any health
More informationUniversal Health Coverage (UHC): Myths and Challenges
Universal Health Coverage (UHC): Myths and Challenges Insight Thursday, ADB Nov 10 2016 Soonman KWON, Ph.D. Technical Advisor (Health) ADB 1. Financial Protection for UHC GOAL: Access to quality health
More informationWORLD HEALTH ORGANIZATION. Social health insurance
WORLD HEALTH ORGANIZATION EXECUTIVE BOARD 115th Session Provisional agenda item 4.5 EB115/8 2 December2004 Social health insurance Report by the Secretariat 1. Following up on the debate of the Executive
More informationZIMBABWE HEALTH FINANCING. GWATI GWATI Health Economist: Planning and Donor Coordination MOHCC Technical team leader National Health Accounts.
ZIMBABWE HEALTH FINANCING GWATI GWATI Health Economist: Planning and Donor Coordination MOHCC Technical team leader National Health Accounts. Our approach to HFP Development Key steps in the development
More informationBABEȘ-BOLYAI UNIVERSITY FACULTY OF ECONOMICS AND BUSINESS ADMINISTRATION DEPARTMENT OF MANAGEMENT. Title of thesis
BABEȘ-BOLYAI UNIVERSITY FACULTY OF ECONOMICS AND BUSINESS ADMINISTRATION DEPARTMENT OF MANAGEMENT Title of thesis PROJECT MANAGEMENT IMPLEMENTATION IN ROMANIAN PUBLIC ADMINISTRATION Scientific coordinator:
More informationTHREE WORLDS THEORY G L O B A L S T R A T I F I C A T I O N
THREE WORLDS THEORY G L O B A L S T R A T I F I C A T I O N OUTLINE Wealth and Poverty in Global Perspective Problems in Studying Global Inequality Classification of Economies by Income Measuring Global
More informationNew approaches to measuring deficits in social health protection coverage in vulnerable countries
New approaches to measuring deficits in social health protection coverage in vulnerable countries Xenia Scheil-Adlung, Florence Bonnet, Thomas Wiechers and Tolulope Ayangbayi World Health Report (2010)
More informationTHE SHARE IN PERCENTAGE OF TAXES IN GDP (COMPARATIVE ANALYSIS OF THE POST-SOVIET COUNTRIES)
THE SHARE IN PERCENTAGE OF TAXES IN GDP (COMPARATIVE ANALYSIS OF THE POST-SOVIET COUNTRIES) Mikheil CHIKVILADZE Ivane Javakhishvili Tbilisi State University, Georgia eter.kharaishvili@tsu.ge Abstract There
More informationOverview messages. Think of Universal Coverage as a direction, not a destination
Health Financing for Universal Coverage: critical challenges and lessons learned Joseph Kutzin, Coordinator Health Financing Policy, WHO Regional Forum on Health Care Financing, Phnom Penh, Cambodia Overview
More informationUniversal health coverage
EXECUTIVE BOARD 144th session 27 December 2018 Provisional agenda item 5.5 Universal health coverage Preparation for the high-level meeting of the United Nations General Assembly on universal health coverage
More informationCapital Markets Development in Southeast Europe and Eurasia An Uncertain Future
Capital Markets Development in Southeast Europe and Eurasia An Uncertain Future The Impact of the Global Financial Crisis and the Need for Engagement Presented by: Robert H. Singletary Competitiveness,
More informationCOMPARATIVE ANALYSIS OF SOCIAL PROTECTION IN GREECE AND ROMANIA, PERIOD
Scientific Bulletin Economic Sciences, Volume 16/ Special Issue EtaEc 2017 COMPARATIVE ANALYSIS OF SOCIAL PROTECTION IN GREECE AND ROMANIA, PERIOD 2007-2015 Emilia UNGUREANU 1, Florentina Cristina BÂLDAN
More informationUsing health spending to achieve fiscal consolidation objectives?
Using health spending to achieve fiscal consolidation objectives? Dr. Tamás Evetovits Senior Health Financing Specialist WHO Regional Office for Europe Outline Let s get the objectives right Dealing with
More informationCountry reviews of financial protection in Europe
Country reviews of financial protection in Europe Evidence for Universal Health Coverage WHO Barcelona Office for Health Systems Strengthening 2 The WHO Barcelona Office is a centre of excellence in health
More informationMitigating the Impact of the Global Economic Crisis on Household Health Spending
50834 Mitigating the Impact of the Global Economic Crisis on Household Health Spending Elizabeth Docteur Key Messages The economic crisis is impacting the ability of households in ECA countries to pay
More informationMANAGING LOCAL PUBLIC DEBT IN ESTONIA Public Sector Finance and Accounting Group 14 th NISPAcee Annual Conference (2006)
MANAGING LOCAL PUBLIC DEBT IN ESTONIA 2000--2005 Public Sector Finance and Accounting Group 14 th NISPAcee Annual Conference (2006) Viktor Trasberg 1 Faculty of Economics University of Tartu Estonia Abstract
More informationWorld Social Security Report 2010/11 Providing coverage in times of crisis and beyond
Executive Summary World Social Security Report 2010/11 Providing coverage in times of crisis and beyond The World Social Security Report 2010/11 is the first in a series of reports on social security coverage
More informationBackground Paper: International Comparisons of Bulgaria s Health System Performance
ADVISORY SERVICES AGREEMENT between MINISTRY OF HEALTH OF THE REPUBLIC OF BULGARIA and the INTERNATIONAL BANK FOR RECONSTRUCTION AND DEVELOPMENT Background Paper: International Comparisons of Bulgaria
More informationRegional Benchmarking Report
Financial Sector Benchmarking System Regional Benchmarking Report October 2011 About the Financial Sector Benchmarking System This Regional Benchmarking Report is part of a series of benchmarking reports
More informationRecommendations Of The High Level Expert Group (Planning Commission)
Universal Health Coverage For India Recommendations Of The High Level Expert Group (Planning Commission) Prof. K. Srinath Reddy President, Public Health Foundation of India Bernard Lown Professor of Cardiovascular
More informationETHIOPIA S FIFTH NATIONAL HEALTH ACCOUNTS, 2010/2011
Federal Democratic Republic of Ethiopia Ministry of Health ETHIOPIAN HEALTH ACCOUNTS HOUSEHOLD HEALTH SERVICE UTILIZATION AND EXPENDITURE SURVEY BRIEF ETHIOPIA S 2015/16 FIFTH NATIONAL HEALTH ACCOUNTS,
More informationGlobal Social Policy forum 4-5 November 2013 Helsinki, Finland. Directions of Social Policy in CIS+ Countries. Population Ageing. Alexandre Sidorenko
Global Social Policy forum 4-5 November 2013 Helsinki, Finland Directions of Social Policy in CIS+ Countries. Population Ageing. Alexandre Sidorenko Main Conclusion: The CIS+ countries have accumulated
More informationNew data from Enterprise Surveys indicate that tax reforms undertaken by the government of Belarus
Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized WORLD BANK GROUP COUNTRY NOTE NO. 2 29 ENTERPRISE SURVEYS COUNTRY NOTE SERIES Running
More informationReimbursable Advisory Services in Europe and Central Asia (ECA)
Reimbursable Advisory Services in Europe and Central Asia (ECA) Expanding Options for Our Clients: Global Knowledge, Strategy, and Local Solutions REIMBURSABLE ADVISORY SERVICES (RAS): What Are They? RAS
More informationABLV High Yield CIS Bond Fund Prospectus
ABLV High Yield CIS Bond Fund Prospectus Open-end mutual fund Registered in Latvia, with the Financial and Capital Market Commission: Fund registration date: 15.06.2007 Fund registration No.: 06.03.05.263/34
More informationExecutive summary. Universal social protection to achieve the Sustainable Development Goals
Executive summary Universal social protection to achieve the Sustainable Development Goals 2017 19 Universal social protection to achieve the Sustainable Development Goals Executive summary Social protection,
More informationThe ILO Social Security Inquiry SSI
Steve Brandon The ILO Social Security Inquiry SSI Florence Bonnet Social Security Department International Labour Office (ILO) The Social Security Inquiry Outline Why Main objective and rationale What
More informationPROJECT INFORMATION DOCUMENT (PID) APPRAISAL STAGE Report No.: PIDA Project Name. Region. Country
Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized PROJECT INFORMATION DOCUMENT (PID) APPRAISAL STAGE Report No.: PIDA32577 Project Name
More informationADDRESSING PUBLIC PRIVATE SECTOR INEQUALITIES PROFESSOR EMERITUS YOSUF VERIAVA
ADDRESSING PUBLIC PRIVATE SECTOR INEQUALITIES PROFESSOR EMERITUS YOSUF VERIAVA HEALTH INEQUALITY AND INEQUITY Disparity: Is there a difference in the health status rates between population groups? Inequality:
More informationHealth Care Financing: Looking Towards Kurdistan s Future
Health Care Financing: Looking Towards Kurdistan s Future Presentation for International Congress on Reform and Development of Health Care in Kurdistan Region C. Ross Anthony, Ph.D. 2-4 February 2011 Erbil
More informationIntroduction to the US Health Care System. What the Business Development Professional Should Know
Introduction to the US Health Care System What the Business Development Professional Should Know November 2006 1 Understanding of the US Health Care System Evolution of the US health care system to its
More informationPOLICY BRIEF. Figure 1: Total, general government, and private expenditures on health as percentages of GDP
POLICY BRIEF Financial Burden of Health Payments in Mongolia The World Health Report 2010 drew attention to the fact that each year 150 million people globally are facing catastrophic health expenditures,
More informationWill India Embrace UHC?
Will India Embrace UHC? Prof. K. Srinath Reddy President, Public Health Foundation of India Bernard Lown Professor of Cardiovascular Health, Harvard School of Public Health The Global Path to Universal
More informationHong He Min-Min Lyu Nari Park May 2, 2012 South Korea Health Care System South Korea formed a Universal Healthcare system in 1977 which is controlled
Hong He Min-Min Lyu Nari Park May 2, 2012 South Korea Health Care System South Korea formed a Universal Healthcare system in 1977 which is controlled by the government and managed under the NHIC (National
More informationPROJECT INFORMATION DOCUMENT (PID) APPRAISAL STAGE
Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized PROJECT INFORMATION DOCUMENT (PID) APPRAISAL STAGE Project Name Kosovo Health Project
More informationHIA implementation and health in Environmental Assessments across Europe
HIA implementation and health in Environmental Assessments across Europe Julia Nowacki WHO European Centre for Environment and Health, Bonn, Germany Reuniting planning and health: tackling the implementation
More informationExtent and Nature of Informal Payments for Health Care
Extent and Nature of Informal Payments for Health Care This section provides an overview of the frequency, patterns and levels of informal payment for inpatient care, outpatient services, and drugs. It
More informationSHOULD THE PENSION REFORM PROGRAM BE CHANGED? 1. Consequences of the 1998 crisis for the pension security system
Mikhail Egonovich Dmitriyev Doctor of Economics, Member of the Scientific Board of the Carnegie Moscow Center SHOULD THE PENSION REFORM PROGRAM BE CHANGED? 1. Consequences of the 1998 crisis for the pension
More informationThe regional analyses
The regional analyses Central Asia & Eastern Europe Central Asia & Eastern Europe has been the biggest reformer over the nine years of the study. Economies in this region have shown the largest fall in
More informationPrinciples and Main Elements of Social Strategy. E.Sh. Gontmakher, V.V. Trubin
Principles and Main Elements of Social Strategy E.Sh. Gontmakher, V.V. Trubin March 23, 2000 1. When Russia undertook systemic reforms in the 1990s, it had a quite heavy burden in the form of the people
More informationInogate Annual Meeting 22 nd October 2014 Brussels
Inogate Annual Meeting 22 nd October 2014 Brussels Global assessment of the EU support provided in the field of energy in Eastern Partnership countries and Central Asia (2007 2013) Helene Ryding Team Leader
More informationHealth care systems today account for about 9 percent of
Health Care Financing And Delivery In Developing Countries Developing countries, which contain 84 percent of the world s population, claim only 11 percent of the world s health spending. by George Schieber
More informationBy Zuzana Brixiova 1. Introduction
PROMOTING ECONOMIC TRANSITION IN BELARUS By Zuzana Brixiova 1 Introduction I would like to thank the organizers of this seminar for the opportunity to speak about how to promote economic reforms in Belarus.
More informationLong Term Reform Agenda International Perspective
Long Term Reform Agenda International Perspective Asta Zviniene Sr. Social Protection Specialist Human Development Department Europe and Central Asia Region World Bank October 28 th, 2010 We will look
More informationSocioeconomic Processes in the Cis Countries
Doi:10.5901/mjss.2014.v5n24p331 Abstract Socioeconomic Processes in the Cis Countries Battalova A.R Abdullin I.A. Kazan Federal University, Institute of Management, Economics and Finance, Kazan, 420008,
More informationUniversal health coverage roadmap Private sector engagement to improve healthcare access
Universal health coverage roadmap Private sector engagement to improve healthcare access Prepared for the World Bank February 2018 Copyright 2017 IQVIA. All rights reserved. National health coverage has
More informationTax Arrears, Tax Compliance and Tax Debt Management in Uzbekistan: Existing Issues and Possible Solutions
Tax Arrears, Tax Compliance and Tax Debt Management in Uzbekistan: Existing Issues and Possible Solutions Samariddin Elmirzaev Department of Financial Management, Tashkent Financial Institute, 60A, Amir
More informationUniversal health coverage A review of Commonwealth hybrid mixed funding models
Universal health coverage A review of Commonwealth hybrid mixed funding models Dr Ravi P. Rannan-Eliya Institute for Health Policy, Sri Lanka Global Network for Health Equity (GNHE), Asia Network for Capacity
More informationMACROECONOMY OF THE RUSSIAN REGIONS NEIGHBORING WITH THE NEW EUROPEAN UNION
THE 43 RD CONGRESS OF THE EUROPEAN REGIONAL SCIENCE ASSOCIATION 27-30 AUGUST, 2003, JYVÄSKYLÄ, FINLAND Alexander Granberg, Council for the Study of Productive Forces, Moscow, Russia, e-mail: granberg@online.ru;
More informationThe Social Sectors from Crisis to Growth in Latvia
The World Bank The Social Sectors from Crisis to Growth in Latvia March 1, 2011 Peter Harrold, Indhira Santos and Emily Sinnott, The World Bank, Brussels Overview 1. World Bank involvement in stabilization
More informationHealth Financing in Indonesia
Executive Summary In 2004, the Indonesian government committed to provide health insurance coverage to its entire population through a mandatory health insurance program. As of 2008, its public budget
More informationR & D expenditure. Statistics Explained. Main statistical findings
R & D expenditure Statistics Explained Data extracted in March 2018. Most recent data: Further Eurostat information, Main tables and Database. Planned article update: May 2019. This article presents data
More informationPosition Paper on Income and Wages Approved August 4, 2016
Position Paper on Income and Wages Approved August 4, 2016 1. The Context on Income and Wages Lack of sufficient income and household savings are the main reasons people seek help from EFAA to meet their
More informationSouth Eastern Europe BEEPS-at-a-Glance
Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Introduction The EBRD-World Bank Business Environment and Enterprise Performance Survey
More informationThe reform experience of Estonia
The reform experience of Estonia Dr. Ewout van Ginneken Department of Health Care Management Berlin University of Technology WHO Collaborating Centre for Health Systems, Research and Management European
More informationEconomic Standard of Living
DESIRED OUTCOMES New Zealand is a prosperous society, reflecting the value of both paid and unpaid work. All people have access to adequate incomes and decent, affordable housing that meets their needs.
More informationCorporate Tax Issues in the Baltics
Corporate Tax Issues in the Baltics In the last twenty years the Baltic States has gone through many historical changes. The changes have affected the political system, society, economics, capital market
More informationHealth System and Policies of China
of China Yang Cao, PhD Associate Professor China Pharmaceutical University Nanjing, China Transformation of Healthcare Delivery in China Medical insurance 1 The timeline of the medical and health system
More informationNew data from the Enterprise Surveys indicate that senior managers in Georgian firms devote only 2 percent of
Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized WORLD BANK GROUP COUNTRY NOTE NO. 6 29 ENTERPRISE SURVEYS COUNTRY NOTE SERIES Running
More informationAn Insight on Health Care Expenditure
An Insight on Health Care Expenditure Vishakha Khanolkar MBA Student The University of Findlay Simeen A. Khan MBA Student The University of Findlay Maria Gamba Associate Professor of Business The University
More informationEconomic Standard of Living
DESIRED OUTCOMES New Zealand is a prosperous society, reflecting the value of both paid and unpaid work. All people have access to adequate incomes and decent, affordable housing that meets their needs.
More informationAlbania BEEPS-at-a-Glance
THE WORLD BANK Introduction The EBRD-World Bank Business Environment and Enterprise Performance Survey (BEEPS) is a joint initiative of the European Bank for Reconstruction and Development and the World
More informationA few remarks on the case study of Poland
A few remarks on the case study of Jan Krzysztof Bielecki EY Chairman of the Partners Board 3 March 21 Political and economic transition can go hand in hand Contrary to intuition, more political turnover
More informationLabour Law & Social Security in Nepal
202 Issue of the World of Work in Nepal Labour Law & Social Security in Nepal by Umesh Upadhyaya Background Since Nepal is one of the least developed countries of the world, the process of socio-economic
More informationTHE INVERTING PYRAMID: DEMOGRAPHIC CHALLENGES TO THE PENSION SYSTEMS IN EUROPE AND CENTRAL ASIA
THE INVERTING PYRAMID: DEMOGRAPHIC CHALLENGES TO THE PENSION SYSTEMS IN EUROPE AND CENTRAL ASIA 1 Anita M. Schwarz Lead Economist Human Development Department Europe and Central Asia Region World Bank
More informationAlexander Shirov. The long-term forecast of development of the Russian economy
Alexander Shirov The long-term forecast of development of the Russian economy 2007-2030 In 2007 a number of works on long-term development of the Russian economy were published. So much interest in this
More information19th International Farm Management Congress, THE POST-SOCIALIST TRANSITION IN A COMPARATIVE PERSPECTIVE: THE LESSONS 1. Leszek Balcerowicz
THE POST-SOCIALIST TRANSITION IN A COMPARATIVE PERSPECTIVE: THE LESSONS 1 Leszek Balcerowicz Warsaw School of Economics, Poland 1. THE ANALYTICAL SCHEME: INSTITUTIONAL SYSTEMS VERSUS POLICIES (1) Propelling
More informationUniversal access to health and care services for NCDs by older men and women in Tanzania 1
Universal access to health and care services for NCDs by older men and women in Tanzania 1 1. Background Globally, developing countries are facing a double challenge number of new infections of communicable
More informationBooklet C.2: Estimating future financial resource needs
Booklet C.2: Estimating future financial resource needs This booklet describes how managers can use cost information to estimate future financial resource needs. Often health sector budgets are based on
More informationSelected World Development Indicators
Selected World Development Indicators Introduction to the Selected World Development Indicators 270 Map The World by Income 273 Tables World View Table 1 Size of the economy 274 Table 2 Quality of life
More informationWHO reform: programmes and priority setting
WHO REFORM: MEETING OF MEMBER STATES ON PROGRAMMES AND PRIORITY SETTING Document 1 27 28 February 2012 20 February 2012 WHO reform: programmes and priority setting Programmes and priority setting in WHO
More informationEUROPEAN COMMISSION EUROSTAT. Directorate F: Social statistics Unit F-5: Education, health and social protection
EUROPEAN COMMISSION EUROSTAT Directorate F: Social statistics Unit F-5: Education, health and social protection DOC 2013-PH-06 Annex 6D Towards a possible Out of Pocket (OOP) expenditure Indicator at macro-level
More informationResponding to the challenge of financial sustainability in Estonia s health system
Responding to the challenge of financial sustainability in Estonia s health system EXECUTIVE SUMMARY Sarah Thomson, Andres Võrk, Triin Habicht, Liis Rooväli, Tamás Evetovits and Jarno Habicht Keywords
More informationInvestment Performance in the Healthcare System by the Population Assessments
Investment Performance in the Healthcare System by the Population Assessments Nagimova Aysylu Mirzarifovna Doctor of Social Sciences,Associate Professor of General Management, Institute of Management,
More informationBudget Literacy Practices in PEMPAL Member Countries
Budget Literacy Practices in PEMPAL Member Countries thematic survey results BCOP Budget Literacy Working Group Deanna Aubrey, World Bank 20 May 2015 Objectives and Scope of Survey (1) This presentation
More informationT H E NA I RO B I C A L L TO A C T I O N F O R C L O S I N G T H E I M P L E M E N TA T I O N G A P I N H E A LT H P RO M O T I O N
T H E NA I RO B I C A L L TO A C T I O N F O R C L O S I N G T H E I M P L E M E N TA T I O N G A P I N H E A LT H P RO M O T I O N 1. INTRODUCTION PURPOSE The Nairobi Call to Action identifies key strategies
More informationThe Impact of Globalisation on Systems of Social Security
The Impact of Globalisation on Systems of Social Security prepared for the 9 th NISPAcee Annual Conference: Government, Market and the Civic Sector: The Search for a Productive Partnership (Working group
More informationACP-EU JOINT PARLIAMENTARY ASSEMBLY. Committee on Social Affairs and the Environment WORKING DOCUMENT
ACP-EU JOINT PARLIAMTARY ASSEMBLY ASSEMBLEE PARLEMTAIRE PARITAIRE ACP-UE Committee on Social Affairs and the Environment 20.6.2017 WORKING DOCUMT on improving access to basic health systems, notably to
More informationIndex. tax evasion ethics in tax system change in Bureaucracy 3-11 Canada
Ability to pay principle 58 Administrative burden 51-79, 73-90, 430 Albania 112 Alternative Minimum Tax (AMT) 75 Anti-capitalistic mentality 318 Appeals in Armenia 317 Argentina 281-308 Armenia 113, 309-358
More informationRegional Development Institutions in Russia
Regional Development Institutions in Russia Veronika Yu. Maslikhina Volga State University of Technology, Russian Federation Alexander V. Maslikhin Mari State University, Russian Federation Email: Maslihina_nika@mail.ru
More informationEconomic Standard of Living
DESIRED OUTCOMES New Zealand is a prosperous society where all people have access to adequate incomes and enjoy standards of living that mean they can fully participate in society and have choice about
More informationBenefits Extension of Health Insurance in South Korea: Impacts and Future Prospects
Benefits Extension of Health Insurance in South Korea: Impacts and Future Prospects Asia Health Policy Program Stanford University Jan 27, 2015 Soonman KWON (School of Public Health, Seoul Nat. Univ.)
More informationImpact of Possible Growth of Minimum Wage in Georgia
Impact of Possible Growth of Minimum Wage in Georgia DAVIT DARSAVELIDZE January 2019 Most of developed as well as developing countries regulate the Minimum Wage by law. The Minimum Wage for countries vary
More informationUniversal Basic Income
Universal Basic Income The case for UBI in Developed vs Developing Countries Maitreesh Ghatak London School of Economics November 24, 2017 Universal Basic Income Three dimensions Cash transfers (not in-kind,
More informationCzech Republic BEEPS-at-a-Glance
Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Introduction The EBRD-World Bank Business Environment and Enterprise Performance Survey
More information