Sustaining progress towards universal health coverage amidst a full-scale war: learning from Ukraine.

In the aftermath of Russia's military response to the 2014 Revolution of Dignity, the government of Ukraine implemented a package of health financing reforms underpinned by universal health coverage (UHC) principles. By the time of Russia's full-scale invasion of Ukraine in February 2022, the new systems and institutions envisaged in the reforms were largely established. In this Commentary article, we explain how these attributes strengthened the Ukrainian health system's response to the impacts of the war. Ukraine's experience highlights the role that health financing arrangements, designed in accordance with UHC principles, can play in strengthening health system resilience.

Resilience of Primary Health Care in Ukraine: Challenges of the Pandemic and War.

This commentary examines the resilience of primary health care in Ukraine amidst the ongoing war, drawing a few reflections relevant for other fragile and conflict-affected situations. Using personal observations and various published and unpublished reports, this article outlines five reflections on the strengths, challenges, and necessary adaptations of Primary Health Care (PHC) in Ukraine. It underscores the concerted efforts of the government to maintain public financing of PHC, thereby averting system collapse. The research also highlights the role of strategic adaptations during the COVID-19 pandemic in fostering resilience during the war, including the widespread use of digital communication and skills training. The commentary emphasizes the role of managerial and financial autonomy in facilitating quick and efficient organizational response to crisis. It also recognizes emerging challenges, including better access to PHC services among the internally displaced persons, shifting patient profiles and service needs, and challenges related to reliance on local government financing. Finally, the authors advocate for a coordinated approach in humanitarian response, recovery efforts, and development programs to ensure the sustainability and effectiveness of PHC in Ukraine.

Typology and implications of verified attacks on health care in Ukraine in the first 18 months of war.

Attacks on health care are part of the spectrum of threats that health care endures during conflict. Protecting health care services against attacks depends on understanding the nature and types of attacks that occur during conflict. The World Health Organisation has implemented the Surveillance System for Attacks on Health Care (SSA) in Ukraine since 2020, and the system has continued to monitor and report on attacks on health care during the war in Ukraine. This study aims to analyse the data reported through the SSA for the first 18 months of the war. This paper involves a retrospective, descriptive study based on the analysis of publicly available SSA data of all incidents of attacks on health care in Ukraine reported through the SSA between February 24th 2022 and August 24th 2023. Out of the 1503 verified attacks, 37% occurred in the initial six weeks of the war. Attacks involving violence with heavy weapons were among the most common incidents reported (83%). The reported attacks were associated with a total of 113 deaths and 211 injuries among health care workers and patients: 32 (2%) attacks were associated with a death of a health care worker or patient, and 63 (4%) were associated with an injury. Health transports facing attacks had a higher probability of experiencing casualties than other health resources (p<0.0001, RR 3.1, 95%CI 1.9-4.9). In conclusion, the burden of attacks on health care in Ukraine was high and sustained over the course of the first 18 months of the war. Reported casualties were not homogenously distributed among attack incidents, but occurred in a set of high-casualty incidents. Health transports were found to be particularly vulnerable. In addition to continued calls for a cessation of hostilities, prevention, protection, mitigation, and reconstruction strategies are urgently required.

Реформа фінансування системи охорони здоров’я в Україні: прогрес та майбутні напрями: огляд звіту

У 2015 р. український уряд ініціював трансформаційну реформу системи охорони здоров’я, метою якої було поліпшення показників здоров’я населення та забезпечення фінансового захисту від надмірних витрат на охорону здоров’я «з кишені» пацієнтів. Реформа повинна була впроваджуватися шляхом модернізації та інтеграції системи надання послуг, запровадження змін до механізмів оплати надавачам медичних послуг, які б стимулювали ефективність, а також шляхом покращення якості медичних послуг. Кульмінацією реформи став новий закон про фінансування системи охорони здоров’я—Закон України «Про державні фінансові гарантії медичного обслуговування населення» 2017 р.,—яким було запроваджено гарантований пакет медичних послуг під назвою Програма медичних гарантій (ПМГ) і створено Національну службу здоров’я України (НСЗУ) в ролі стратегічного закупівельника послуг для цієї програми. Передбачалося, що з часом ПМГ буде розширюватися і зрештою охопить всі види медичної допомоги, а фінансування охорони здоров’я перейде від кошто рисного фінансування до методів фінансування, орієнтованих на результат, що забезпечить краще узгодження надаваних медичних послуг з потребами пацієнтів.

Реформа фінансування системи охорони здоров’я в Україні: прогрес та майбутні напрями

У 2015 р. український уряд ініціював трансформаційну реформу системи охорони здоров’я, метою якої було поліпшення показників здоров’я населення та забезпечення фінансового захисту від надмірних витрат на охорону здоров’я «з кишені» пацієнтів. Реформа повинна була впроваджуватися шляхом модернізації та інтеграції системи надання послуг, запровадження змін до механізмів оплати надавачам медичних послуг, які б стимулювали ефективність, а також шляхом покращення якості медичних послуг. Кульмінацією реформи став новий закон про фінансування системи охорони здоров’я—Закон України «Про державні фінансові гарантії медичного обслуговування населення» 2017 р.,—яким було запроваджено гарантований пакет медичних послуг під назвою Програма медичних гарантій (ПМГ) і створено Національну службу здоров’я України (НСЗУ) в ролі стратегічного закупівельника послуг для цієї програми. Передбачалося, що з часом ПМГ буде розширюватися і зрештою охопить всі види медичної допомоги, а фінансування охорони здоров’я перейде від кошто рисного фінансування до методів фінансування, орієнтованих на результат, що забезпечить краще узгодження надаваних медичних послуг з потребами пацієнтів.

Estonia: health system review

The Health Systems in Transition (HiT) profiles are country-based reports that provide a detailed description of a health system and of policyinitiatives in progress or under development. HiTs examine different approaches to the organization, financing and delivery of health services and therole of the main actors in health systems; describe the institutional framework, process, content and implementation of health and health care policies; and highlight challenges and areas that require more in-depth analysis. Estonia has vigorously and quite successfully reformed its health system over the last decades. Whereas incremental changes are observed in the last five years,larger scale legislative reforms had been implemented since the early 1990s and at the beginning of this century. The current system is built on solidarity based health financing; a modern provider network based on family-medicine centred primary health care (PHC); modern hospital services and more attention for public health. This has resulted in a steadily increasing life expectancy and continuously high population satisfaction rates with access and quality. However, as in any health system, a number of challenges remain. They include reducing inequities in health status and health behaviour; improving control of and responding to the consequences of the high rates of HIV andrelated conditions; improving regulation of providers to ensure better public accountability; and sustaining health expenditures and human resources on a level that ensures timely access and high quality of care. The last challenge isparticularly important in the face of rising patient expectations and increased costs and volume of health care services. If solidarity and equity are to be maintained and guaranteed for the future, additional resources need to be found from public sources of revenue.

Can people afford to pay for health care? New evidence on financial protection in Kyrgyzstan

This review examines the extent to which people living in Kyrgyzstan experience financial hardship when using health services, it is structured as follows. Section 2 sets out the analytical approach and sources of data used to measure financial protection. Section 3 provides a brief overview of health coverage and access to health care. Sections 4 and 5 present the results of the statistical analysis of household data, with a focus on out-of-pocket payments in Section 4 and financial protection in Section 5. Section 6 provides a discussion of the results of the financial protection analysis and identifies factors that strengthen and undermine financial protection: those that affect people’s capacity to pay for health care, and health system factors. Section 7 highlights implications for policy and draws attention to areas that require further analysis. Annex 1 provides information on household budget surveys; Annex 2 the methods used; Annex 3 regional and global financial protection indicators; Annex 4 a glossary of terms; and Annex 5 the KIHBS.This review is part of a series of country-based studies generating newevidence on financial protection in European health systems.

Health care systems in transition: Estonia

The Health Systems in Transition (HiT) series provide detailed descriptions of health systems in the countries of the WHO European Region as well as some additional OECD countries. An individual health system review (HiT) examines the specific approach to the organization, financing and delivery of health services in a particular country and the role of the main actors in the health system. It describes the institutional framework, process, content, and implementation of health and health care policies. HiTs also look at reforms in progress or under development and make an assessment of the health system based on stated objectives and outcomes with respect to various dimensions (health status, equity, quality, efficiency, accountability).

Better noncommunicable disease outcomes challenges and opportunities for health systems, n°4: Republic of Moldova Country Assessment

Like many countries, the Republic of Moldova faces a growing NCD burden. This report examines the challengesand opportunities faced in the Republic of Moldova in order to accelerate improvement in NCD outcomes. Inrecent years, the Government of the Republic of Moldova has implemented a number of important reforms thathave increased effi ciency and equity in resource allocation, and have provided incentives to improve servicedelivery, including for NCDs. Challenges include further scale up and implementation of new initiatives inthe area of NCD risk factor management. Major gains can be made through relatively low-cost public healthand primary health care interventions. These include, among others, strengthening tobacco, alcohol, anddietary polices and their implementation, improving detection and treatment of risk factors for cardiovasculardisease, including hypertension and hyperlipidaemia, strengthening clinical protocols, and improving rationalprescribing practice. This report examines in depth the health system challenges and opportunities for improvedprevention and control of NCDs and concludes with policy recommendations for the consideration of policymakers in the Republic of Moldova.

Better noncommunicable disease outcomes: challenges and opportunities for health systems: Republic of Moldova: country assessment

Like many countries, the Republic of Moldova faces a growing NCD burden. This report examines the challenges and opportunities faced in the Republic of Moldova in order to accelerate improvement in NCD outcomes. In recent years, the Government of the Republic of Moldova has implemented a number of important reforms that have increased efficiency and equity in resource allocation, and have provided incentives to improve service delivery, including for NCDs. Challenges include further scale up and implementation of new initiatives in the area of NCD risk factor management. Major gains can be made through relatively low-cost public health and primary health care interventions. These include, among others, strengthening tobacco, alcohol, and dietary polices and their implementation, improving detection and treatment of risk factors for cardiovascular disease, including hypertension and hyperlipidaemia, strengthening clinical protocols, and improving rational prescribing practice. This report examines in depth the health system challenges and opportunities for improved prevention and control of NCDs and concludes with policy recommendations for the consideration of policy makers in the Republic of Moldova.

Võimalused Eesti tervisesüsteemi rahalise jätkusuutlikkuse tagamiseks: üks aasta hiljem

Käesolevas lühikeses dokumendis käsitletakse peamisi muutusi tervishoiu rahastamises alates 2009. aasta aprillist, mil alustasime algse aruande koostamist. Eesmärk ei ole hinnata 2010. aasta aru ande mõju, vaid vaadata üle areng nendes valdkondades, mille puhul aruandes leiti, et need võivad märkimisväärselt mõjutada tervisesüsteemi rahalist jätkusuutlikkust. Selline läbivaatamine on eriti vaja lik viimas tel aastatel Eestis toimunud majanduslike ja poliitiliste muutuste tõttu: Majanduskoostöö ja Arengu Organisatsiooni (OECD) liikmeks saamine, uue (kuid samas juba tuntud) valitsuse ametisse astumine ning kestvast majanduslangusest, kasvavast töötusest ja euroalaga ühinemisest tingitud eelarvesurve

Responding to the challenge of financial sustainability in Estonia’s health system: one year on

This brief document identifies the main changes to health financing policy since we began preparing the original report in April 2009. Its intention is not to measure the impact of the 2010 report, but to review progress in areas the report highlighted as likely to have a significant effect on the health system’s financial sustainability. Following up would be a useful exercise under most circumstances; in Estonia’s case it is particularly compelling due to the economic and political changes that have occurred in the last few years: joining the Organisation for Economic Cooperation and Development (OECD), the election of a new (but familiar) government and fiscal pressures created by a sustained recession, growing unemployment and entry to the Eurozone.

Võimalused Eesti tervisesüsteemi rahalise jätkusuutlikkuse tagamiseks: Kokkuvõte

Tervisesüsteemi rahaline jätkusuutlikkus on Eesti tervisepoliitika keskmes olnud alati, kuid hiljutine ¬nantskriis on tõstnud selle esmatähtsaks poliitiliseks küsimuseks mitte ainult Eestis, vaid kogu maailmas. Aruandes hinnatakse Eesti tervisesüsteemi toimivust ja selle rahalist jätkusuutlikkust. Analüüsitakse, kas praegune rahastamissüsteem on pikas perspektiivis (aastani 2030) elujõuline, ning pakutakse välja võimalusi rahastamispoliitika tõhustamiseks.

Responding to the challenge of financial sustainability in Estonia's health system

Estonia explores how to move from values to action by implementing the Tallinn Charter: Health Systems for Health and Wealth. There are many options for change, but only some will help the health system to achieve its objectives. This report brings together the views and values of stakeholders, recent data on health financing and new revenue and expenditure projections from now to 2030.

Income-related inequality in health care financing and utilization in Estonia 2000–2007: health financing technical report

This paper analyses out-of-pocket payments (OOPs), their impact on catastrophic expenditures and the distribution of the taxation burden to finance health care in Estonia from 2000 to 2007. It also looks at income-related inequality in Estonian health care utilization in 2006. We use microdata of the Estonian Household Surveys collected by Statistics Estonia, national health accounts data, detailed tax revenue structure from 2000–2007, results from the ALAN microsimulation model, statistical and econometric methods outlined in Xu (2005), Klavus (1998), Habicht et al. (2006) and van Doorslaer and Masseria (2004).The results show that out-of-pocket expenditures have increased since 2000. The socioeconomic factors that determine the relatively high household health expenditure relative to capacity to pay are those that describe income level, on the one hand, and health expenditure, on the other hand. Most affected are elderly people whose expenditure for both prescription and over-the-counter drugs increases their risk of impoverishment. The analysis of inequality in health care utilization shows that after taking into account the need for health care, the use of dental care, phone consultations and other medical specialties are positively related to income. Day treatment utilization also turns out to be highly related to income, though it is statistically insignificant due to very small number of people it in our sample who have used. The increasing share of OOPs has lead to a decline in the progressivity of overall health care financing.