We searched PubMed and Medline with the search terms “health system”, “health reform”, “financing reform”, or “primary care reform”, in combination with “central and eastern Europe” for the years 1995–2009. We gave preference to reports published in the past 5 years, but also included older relevant publications. We also searched the reference lists of the selected reports. This search was complemented by a search of Google with the same terms, and a review of country profiles, Health Systems
ReviewHealth reform in central and eastern Europe and the former Soviet Union
Introduction
In the past two decades, governments in the former communist countries of central and eastern Europe have embarked on far-reaching reforms of financing, organisation, and delivery of health care. Communist health systems were centrally planned and administered, funded mainly by general government revenues, and delivered by state employees working from government-owned facilities.1, 2 Coverage was universal and health-care services were formally free at point of use, but this system had many weaknesses.
Problems were greatest in the Union of Soviet Socialist Republics (USSR),3, 4 where resources were most scarce and health professionals most isolated, with few if any incentives for efficiency and provision of high-quality care.1, 2, 5, 6, 7, 8 Health care was generally delivered by physicians with little training who were working in narrow, specialised areas.7 Wages were kept artificially low, access to labour-saving technology was poor, numbers of staff were high, and delivery of care was inefficient. The system was dominated by hospital provision8, 9, 10 and primary care was underdeveloped, especially in facilities that provided care for non-working mothers and children (workers often benefited from cross-subsidies provided to work-based facilities).
Furthermore, the Soviet notion of evidence rejected empiricism and deemed all knowledge to flow from statements made by the fathers of communism, such as Marx, Engels, or Lenin, or from leaders of individual disciplines, such as Pavlov in psychology or Michurin in biology.11 Even nowadays health professionals only partly accept the idea of evidence as understood in developed countries.12, 13 Many problems were present in countries of central Europe such as Hungary, Poland, and Czechoslovakia, but generally they were much less severe than in the former Soviet Union, especially in relation to understanding evidence. We explore health reform in this region since the collapse of communism and the lessons that can be learnt from this reform.
Section snippets
Reform context
Despite sharing the challenge of transition from communism to democracy and market economies, the countries of central and eastern Europe display great diversity in socioeconomic development, culture, and politics, extending to their health systems and capacity for and direction of reforms. Per head expenditure on health ranged from US$25 in Tajikistan in 2007, to $1607 in Slovenia in 2006 (figure 1), and infant mortality in 2007 was 56·6 deaths per 1000 livebirths in Tajikistan, compared with
Health insurance systems
In the communist period, government was the almost exclusive provider and purchaser of health services, with financing derived predominantly from its revenues. Yugoslavia was an exception, with a mandatory health insurance system based on contributions from employers and employees.19 Since 1989, many countries in central and eastern Europe have diversified sources of funding, including adoption of some form of health insurance (table). This diversification often included establishment of
Out-of-pocket payments
Another source of revenue that has grown in importance is private out-of-pocket expenditure, including both formal co-payments and informal, under-the-table payments.58 The economic downturn that came after the transition from communism to market economy in many countries, which was compounded by conflict in some cases,60 meant that public expenditure on health fell, leaving private health expenditure to fill the gap—mainly with out-of-pocket payments.8
Almost all health care was to be provided
Primary health-care reform
The Soviet system emphasised hospital care.34 Primary care in urban areas was provided in polyclinics, with employees obtaining care at work, whereas others (mainly non-working mothers and children) accessed care at community facilities, often of poor quality.71, 72 Rural areas were served by ambulatory facilities, feldsher-midwifery posts, staffed by feldshers (paramedical workers), nurses, and midwives. Yugoslavia was different, having created a well developed network of primary health care
Future directions
Many issues in the health-care reform of central and eastern Europe warrant separate study, such as the reform of hospital sectors, an increasing private sector, the challenge of improving public health and quality of care, countries' experience of decentralisation, and new purchasing practices. Many countries have faced frequent unforeseen difficulties, with results falling short of expectations.20 These drawbacks of policy implementation were not unique to central and eastern Europe,88 but in
Conclusions
One of the key conclusions emerging from our analysis of health reform in central and eastern Europe over the past two decades is that, as in the rest of the world, many decisions were made on the basis of politics rather than evidence. This finding should not be a surprise in view of the scarce evidence base that was available.90, 91 The rush to establish health insurance systems and general practice was motivated by a political desire to create distance from the communist system.25 In all
Search strategy and selection criteria
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