Кыргызстан: обзор системы здравоохранения

В предлагаемом анализе системы здравоохранения Кыргызстана рассматриваются процессы, происходящие в ее организации и стратегическом руководстве и предоставлении услуг, реформыздравоохранения и показатели функционирования системы здравоохранения. В стране действует система обязательного медицинского страхования, при которой Фонд обязательного медицинского страхования(ФОМС) при Министерстве здравоохранения выступает в качестве единого государственного плательщика, оплачивающего почти все услуги больниц и поставщиков первичной медико-санитарной помощи.Пакет медицинских услуг, покрываемых из государственных средств, определяется в Программе государственных гарантий по обеспечению граждан медико-санитарной помощью (ПГГ). Однако многие услуги требуют соплатежей, а в 2019 г. только 69% населения были охвачены обязательным медицинским страхованием. Показатель подушевых расходов на здравоохранение является одним из самых низких вЕвропейском регионе ВОЗ, что объясняется небольшим ВВП страны на душу населения. На долю личных расходов, почти целиком принимающих форму платежей из собственных средств и включающих неформальные платежи, в 2019 г. приходилось 46,3% расходов на здравоохранение. Финансовую защиту подрывают низкие уровни государственных расходов на здравоохранение, и это приводит к тому, что люди, пользующиеся услугами здравоохранения, сталкиваются с финансовыми трудностями. Несмотря на то, что в стране хорошо развита сеть медицинских учреждений, географическое распределение медицинских работников неравномерно и в целом наблюдается нехватка семейных врачей. Сохраняются трудности в доступе к медицинским услугам, и эти трудности усугубила пандемия COVID-19. Хотя в последние годыбыли достигнуты улучшения, инфекционные и неинфекционные заболевания по-прежнему представляют большую проблему, а ожидаемая продолжительность жизни до пандемии COVID-19 была одной из самыхнизких в Европейском регионе ВОЗ.

Barriers to access adequate maternal care in Romania, Bulgaria, and Moldova: A cross-country comparison.

BACKGROUND: Eastern European health system indicators (e.g., number of health workers and care coverage) suggest well-resourced maternity care systems, but maternal health outcomes compare poorly with those in Western Europe. Often, poor maternal health outcomes are linked to inequities in accessing adequate maternal care. This study investigates access-related barriers (availability, appropriateness, affordability, approachability, and acceptability) to maternity care in Romania, Bulgaria, and Moldova. METHODS: This cross-country study (n = 7345) is based on an online survey where women who received maternity care and gave birth in 2015-2018 in Bulgaria (n = 4951), Romania (n = 2018), and Moldova (n = 376) provided information on their experiences with the care received. We used regression analysis to identify factors associated with accessing maternity care across the three countries. RESULTS: Results show high rates of cesarean births (CB) and a low number of antenatal and postnatal care visits. Informal payments and use of personal connections are common practices. Formal and informal out-of-pocket payments create a financial burden for women with health complications. Women who had health complications, those who gave birth by cesarean, and women who gave birth in a public facility and had fewer antenatal check-ups, were more likely to describe facing access-related barriers. CONCLUSIONS: This study identifies several barriers to high-quality maternity care in Romania, Bulgaria and Moldova. More attention should be paid to the appropriateness of care provided to women with complicated pregnancies, to those who have CBs, to women who give birth in public facilities, and to those who receive fewer antenatal care visits.

Kyrgyzstan: Health System Review.

This analysis of the Kyrgyz health system reviews developments in its organization and governance, financing, provision of services, health reforms and health system performance. A mandatory health insurance is in place, with the Mandatory Health Insurance Fund (MHIF) under the Ministry of Health acting as single public payer for almost all hospitals and providers of primary care. The benefits package of publicly covered services is defined in the State-Guaranteed Benefits Programme (SGBP). However, many services require co-payments and in 2019 only 69% of the population was covered by mandatory health insurance. Health expenditure per capita is one of the lowest in the WHO European Region, due to the country's small GDP per capita. Private spending, almost entirely in the form of out-of-pocket expenditure and including informal payments, accounted for 46.3% of health expenditure in 2019. Financial protection is undermined by low levels of public spending for health, resulting in financial hardship for people using health services. While there is a well-developed network of health facilities, the geographical distribution of health workers is uneven and there is an overall shortage of family doctors. Access to health services remains a challenge, which has been exacerbated by the COVID-19 pandemic. While improvements have been made in recent years, communicable and noncommunicable diseases still pose a major problem and life expectancy prior to the COVID-19 pandemic was one of the lowest in the WHO European Region.

Croatia: Health System Review.

This analysis of the Croatian health system reviews developments in its organization and governance, financing, provision of services, health reforms and health system performance. Croatia has a mandatory social health insurance system with nearly universal population coverage and a generous benefits package. Although per capita spending is low when compared to other EU countries, the share of public spending as a proportion of current health expenditure is high and out-of-pocket payments are low. There are sufficient physical and human resources overall, but some more remote areas, such as the islands off the Adriatic coast and rural areas in central and eastern Croatia, face shortages. While the Croatian health system provides a high degree of financial protection, more can be achieved in terms of improving health outcomes. Several mortality rates are among the highest in the EU, including mortality from cancer, preventable causes (including lung cancer, alcohol-related causes and road traffic deaths) and air pollution. Quality monitoring systems are underdeveloped, but available indicators on quality of care suggest much scope for improvement. Another challenge is waiting times, which were already long in the years before 2020 and are bound to have increased as a result of the COVID-19 pandemic.

Croatia: Health system review

This analysis of the Croatian health system reviews developments in its organization and governance, financing, provision of services, health reforms and health system performance. Croatia has a mandatory social health insurance system with nearly universal population coverage and a generous benefits package. Although per capita spending is low when compared to other EU countries, the share of public spending as a proportion of current health expenditure is high and out-of-pocket payments are low. There are sufficient physical and human resources overall, but some more remote areas, such as the islands off the Adriatic coast and rural areas in central and eastern Croatia, face shortages. While the Croatian health system provides a high degree of financial protection, more can be achieved in terms of improving health outcomes. Several mortality rates are among the highest in the EU, including mortality from cancer, preventable causes (including lung cancer, alcohol-related causes and road traffic deaths) and air pollution. Quality monitoring systems are underdeveloped, but available indicators on quality of care suggest much scope for improvement. Another challenge is waiting times, which were already long in the years before 2020 and are bound to have increased as a result of the COVID-19 pandemic.

Living longer, but in better or worse health?

This policy brief in the Observatory’s Economics of Healthy and Active Ageing series explores available information on the health and disability of older people in Europe and how it relates to increases in life expectancy. It considers the main theories on health and ageing, explores the latest evidence on health and disability measures, and considers policy options to support healthy and active ageing. The policy brief argues that the health of older people is best captured by measures of disability or functional impairment. Studies using such measures have found different trends in different countries, with vast differences in the health of older people across and within countries. One overarching finding is that later cohorts of older people have much better cognitive functioning than earlier cohorts. The policy brief concludes that health systems can be important contributors to increases in life expectancies, decreases in severe disability, and better coping and functioning with chronic disease.

Finland: Health System Review.

This analysis of the Finnish health system reviews developments in its organization and governance, financing, provision of services, health reforms and health system performance. Finland is a welfare state witha high standard of social and living conditions and a low poverty rate. Its health system has a highly decentralized administration, multiple funding sources, and three provision channels for statutory services in first-contact care: the municipal system, the national health insurance system, and occupational health care. The core health system is organized by the municipalities (i.e. local authorities) which are responsible for financing primary and specialized care. Health financing arrangements are fragmented, with municipalities, the health insurance system, employers and households all contributing substantial shares. The health system performs relatively well, as health services are fairly effective, but accessibility may be an issue due to long waiting times and relatively high levels of cost sharing. For over a decade, there has been broad agreement on the need to reform the Finnish health system, but reaching a feasible policy consensus has been challenging.

Ethnic boundary-making in health care: Experiences of older Pakistani immigrant women in Norway.

Older immigrant women experience several barriers in accessing health care. In this study, we explored how older Pakistani women are met with, and respond to, barriers to health care in Norway, using an ethnic boundary-making and intersectionality approach. Our data included interviews with 23 older Pakistani women and 10 caregivers. We found that ethnic boundaries were constructed in healthcare interactions and were influenced by participants' social positions. At the micro level, the interplay of language barriers and being an immigrant fuelled the making of ethnic boundaries. At the macro level, ethnicised cultural discourse in the public sphere fuelled the making of ethnic boundaries in health care. Having encountered ethnic boundaries in health care, older Pakistani women actively coped through compensatory, de-stigmatising and boundary-modifying strategies.

Barriers to accessing adequate maternal care in Latvia: A mixed-method study among women, providers and decision-makers.

INTRODUCTION: Latvia has a high maternal mortality ratio compared to other European countries, as well as major inequities in accessing adequate maternal care. Adequacy refers to the extent to which services are safe, effective, timely, efficient, equitable and people-centred. This study aims to explore stakeholder views on access to adequate maternal care in Latvia and the extent to which there was consensus. METHODS: This mixed-method study is based on an online survey among women who recently gave birth, as well as interviews with healthcare providers and decision-makers. The data were analysed using the method of directed qualitative content analysis. The extent of stakeholder consensus was determined by studying five access-related aspects of maternal care: availability, adequacy, affordability, approachability and acceptability. FINDINGS: Our study identified barriers to accessing adequate maternal care related to availability (i.e. shortage of human resources, geographical distance) and appropriateness (i.e. inequalities in provider knowledge, care provision and use of clinical guidelines). Other challenges were related to providers' approaches towards women (i.e. communication) and, to a lesser extent, maternal care acceptance by women (i.e. health literacy). CONCLUSIONS: The barriers identified in our study highlight areas that should be addressed in future reforms of maternal care. These barriers also indicate the need for micro-level indicators that can facilitate a comprehensive evaluation of maternal care in Latvia and elsewhere.

Funding for public health in Europe in decline?

Concerns have been raised in recent years in several European countries over cutbacks to funding for public health. This article explores how widespread the problem is, bringing together available information on funding for public health in Europe and the effects of the economic crisis. It is based on a review of academic and grey literature and of available databases, detailed case studies of nine European countries (England, France, Germany, Italy, the Netherlands, Slovenia, Sweden, Poland, and the Republic of Moldova) and in-depth interviews. The findings highlight difficulties in establishing accurate estimates of spending on public health, but also point to cutbacks in many countries and an overall declining share of health expenditure going to public health. Public health seems to have been particularly vulnerable to funding cuts. However, the decline is not inevitable and there are examples of countries that have chosen to retain or increase their investment in public health.

Finland: health system review

This analysis of the Finnish health system reviews developments in its organization and governance, financing, provision of services, health reforms and health system performance. Finland is a welfare state with a high standard of social and living conditions and a low poverty rate. Its health system has a highly decentralized administration, multiple funding sources, and three provision channels for statutory services in first-contact care: the municipal system, the national health insurance system, and occupational health care. The core health system is organized by the municipalities (i.e. local authorities) which are responsible for financing primary and specialized care. Health financing arrangements are fragmented, with municipalities, the health insurance system, employers and households all contributing substantial shares. The health system performs relatively well, as health services are fairly effective, but accessibility may be an issue due to long waiting times and relatively high levels of cost sharing. For over a decade, there has been broad agreement on the need to reform the Finnish health system, but reaching a feasiblepolicy consensus has been challenging.

What are the conditions for successful health policy implementation? Lessons learnt from WHO’s regional health policy Health 2020: policy brief

This policy brief explores the conditions that need to be in place for successful health policy implementation in the context of Health 2020. It is based on a scoping review of the literature, as well as semi-structured in-depth interviews with experts in selected WHO Member States. The policy brief identifies six key conditions for successful health policy implementation in the context of Health 2020: 1) ensure contexts are appropriate and receptive; 2) get the timing right; 3) transfer appropriate policies and innovations; 4) ensure good governance; 5) work with other sectors; and 6) move from exploration to full implementation. Identifying how these conditions can be used to maximum effect in specific national contexts and policies will help health policy-makers to increase the chances of success for the policies they develop and aim to implement. Crucially, putting policies in place is only the first step towards full implementation. Successful health reforms generally take several years to prepare and adopt, and they often take far longer to implement. A certain degree of pragmatism will also be needed, using evidence as best as possible and allowing for feedback and refinements throughout the reform process. This includes sticking to principles of good governance. They fulfil a double purpose, ensuring the required leadership for the reform process and allowing for effective implementation to take place. This publication was tabled as a background document during the Sixty-ninth session of the Regional Committee for Europe, Copenhagen, 16–19 September 2019.

Family transfers and long-term care: An analysis of the WHO Study on global AGEing and adult health (SAGE).

BACKGROUND: Populations globally are ageing, resulting in increased need for long-term care. Where social welfare systems are insufficient, these costs may fall to other family members. We set out to estimate the association between long-term care needs and family transfers in selected low- and middle- income countries. METHODS: We used data from the World Health Organization's Study on global AGEing and adult health (SAGE). Using regression, we analysed the relationship between long-term care needs in older households and i) odds of receiving net positive transfers from family outside the household and ii) the amount of transfer received, controlling for relevant socio-demographic characteristics. RESULTS: The proportion of household members requiring long-term care was significantly associated with receiving net positive transfers in China (OR: 1.76; p = 0.023), Ghana (OR: 2.79; p = 0.073), Russia (OR: 3.50; p < 0.001). There was a statistically significant association with amount of transfer received only in Mexico (B: 541.62; p = 0.010). CONCLUSION: In selected LMICs, receiving family transfers is common among older households, and associated with requiring long-term care. Further research is needed to better understand drivers of observed associations and identify ways in which financial protection of older adults' long-term care needs can be improved.

Barriers to accessing adequate maternal care in Georgia: a qualitative study.

BACKGROUND: The maternal health outcomes in Georgia are linked to shortcomings in healthcare such as inequities in access to adequate maternal care. Due to the macro-level, quantitative approach applied in most previous studies, little is known about the underlying reasons that influence maternal care and care-seeking behaviour of pregnant women. METHODS: This qualitative study explores the stakeholders' perspectives on access to adequate maternal care in Georgia. Focus-group discussions are conducted with mothers who gave birth within in the past four years and in-depth interviews are conducted with decision-makers and health professionals in the field. Five access-related aspects are studied: availability, appropriateness, affordability, approachability and acceptability of maternal care. The method of direct content analysis is applied. RESULTS: Results indicate problems with maternal care standards, inequalities across population groups and drawbacks in maternal care financing. This includes gaps in clinical quality and staff skills, as well as poor communication between women and health professionals. Geographical barriers to adequate maternal care exist in rural and mountainous areas due to the weak infrastructure (poor roads and weak transportation), in addition to financial hardships. Despite improvements in the coverage of maternal care, affordability remains an access barrier. Poorer population groups are financially unprotected from the high out-of-pocket payments for maternal care services. CONCLUSION: These findings imply that micro-level indicators, such as disrespectful behaviour of health professionals and affordability of care, should be taken into account when assessing maternal care provision in Georgia. It should complement the existing macro-level indicators for a comprehensive evaluation of maternal care.

Аспекты общественного здравоохранения в Европе

За последние два столетия развитие общественного здравоохранения позволило значительно сократить распространенность инфекционных болезней и их последствий, однако ситуация с неинфекционными заболеваниями, такими как болезни сердца и рак, остается напряженной. В Европейском регионе ВОЗ наибольшая часть бремени болезней приходится в настоящее время именно на неинфекционные заболевания. Авторы данной книги рассматривают общественное здравоохранение масштабно, но вместе с тем детально, и приводят беспрецедентно полный анализ ситуации в Регионе. В книге рассматривается огромное количество ключевых тем охраны общественного здоровья, и в нее вошли главы, посвященные таким вопросам, как: скрининг; укрепление здоровья; воздействие на социальные детерминанты здоровья; оценка воздействия на здоровье; кадровые ресурсы общественного здравоохранения; научные исследования в области общественного здравоохранения. Авторы также анализируют современные структуры, возможности и услуги общественного здравоохранения в ряде европейских стран и перечисляют меры, необходимые для оптимизации деятельности и, в конечном итоге, улучшения показателей здоровья населения. Принимая во внимание огромное географическое разнообразие Европейского региона ВОЗ, авторы приводят примеры из самых разных его стран, тем самым освещая различные подходы к охране общественного здоровья. Книга может стать прекрасным подспорьем в научной работе или практической деятельности в области общественного здравоохранения, в первую очередь – в контексте Европейского региона.