How resilient is health financing policy in Europe to economic shocks? Evidence from the first year of the COVID-19 pandemic and the 2008 global financial crisis.

The COVID-19 pandemic triggered an economic shock just ten years after the shock of the 2008 global financial crisis. Economic shocks are a challenge for health systems because they reduce government revenue at the same time as they increase the need for publicly financed health care. This article explores the resilience of health financing policy to economic shocks by reviewing policy responses to the financial crisis and COVID-19 in Europe. It finds that some health systems were weakened by responses to the 2008 crisis. Responses to the pandemic show evidence of lessons learnt from the earlier crisis but also reveal weaknesses in health financing policy that limit national preparedness to face economic shocks, particularly in countries with social health insurance schemes. These weaknesses highlight where permanent changes are needed to strengthen resilience in future: countries will have to find ways to reduce cyclicality in coverage policy and revenue-raising; increase the priority given to health in allocating public spending; and ensure that resources are used to meet equity and efficiency goals. Although many health systems are likely to face budgetary pressure in the years ahead, the experience of the 2008 crisis shows that austerity is not an option because it undermines resilience and progress towards universal health coverage.

Improving clinical practice in primary care for the prevention and control of noncommunicable diseases: a multi-actor approach to two regional pilot projects in Kazakhstan.

Improving access to quality services is integral to achieving better outcomes for noncommunicable diseases (NCDs). In Kazakhstan, like other countries with historically centralized governance models, key to improving quality is instilling a common and shared understanding of the roles and responsibilities in correspondence with the multifaceted nature of quality of care. This review details the experience of two pilot projects implemented in Kazakhstan's regions of Kyzylorda and Mangystau over a three-year period with the aim to improve clinical practice through a multi-actor, multi-intervention approach. Adopting a health system perspective, the pilots, by design, introduced interventions targeting four actors: policy-makers; health facility managers; health practitioners and patients. The review draws on the following sources of data: rapid baseline assessments; implementation plans, curriculums and other pilot-related material; a mid-way joint implementation meeting; intervention-specific evaluations; and a final external evaluation. The multi-actor, multi-intervention approach to the pilot projects showed some improvements to service outputs, in particular for cardiovascular disease (CVD) risk assessment and decreases in hospitalization rates for hypertension. The pilot projects also illustrated progress in working towards a shared understanding of the different roles of actors for improving quality of care, appreciating the complementarity of individual actors working towards improved population health and in establishing a culture of learning through the exchange of ideas and practices. The importance of responsibility across health system actors for outcomes is vital for the NCD agenda. This approach offers relevant policy lessons for similar centralized governance systems.

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.

Addressing the double-burden of diabetes and tuberculosis: lessons from Kyrgyzstan.

BACKGROUND: The incidence of diabetes and tuberculosis co-morbidity is rising, yet little work has been done to understand potential implications for health systems, healthcare providers and individuals. Kyrgyzstan is a priority country for tuberculosis control and has a 5% prevalence of diabetes in adults, with many health system challenges for both conditions. METHODS: Patient exit interviews collected data on demographic and socio-economic characteristics, health spending and care seeking for people with diabetes, tuberculosis and both diabetes and tuberculosis. Qualitative data were collected through semi-structured interviews with healthcare workers involved in diabetes and tuberculosis care, to understand delivery of care and how providers view effectiveness of care. RESULTS: The experience of co-affected individuals within the health system is different than those just with tuberculosis or diabetes. Co-affected patients do not receive more care and also have different care for their tuberculosis than people with only tuberculosis. Very high levels of catastrophic spending are found among all groups despite these two conditions being included in the Kyrgyz state benefit package especially for medicines. CONCLUSIONS: This study highlights that different patterns of service provision by disease group are found. Although Kyrgyzstan has often been cited as an example in terms of health reforms and developing Primary Health Care, this study highlights the challenge of managing conditions that are viewed as "too complicated" for non-specialists and the impact this has on costs and management of individuals.

How does the introduction of patient co-payments for selected health services affect formal and informal out-of-pocket payments and utilization?: Evidence from Armenia

This report presents the findings of an evaluation of the introduction in Armenia of patient co-payments for specific services provided through the publicly financed basic benefits package (BBP) at the inpatient level. A baseline survey was conducted in July/August 2011 and a follow-up survey in December 2011 with data disaggregated in a number of ways to facilitate equity analysis. Overall, out-of-pocket payments fell as a result of the policy, with approximately 6% fewer patients nationally accessing care without making any form of out-of-pocket payment. Furthermore, nationally the number of patients making an unofficial payment fell significantly. However, this picture hides the impact of the policy on different population groups, for different services, and in different parts of the country. One significant finding is that although the number of people making an unofficial payment decreased, the average amount of each payment increased considerably.

Tajikistan: Health System Review.

The pace of health reforms in Tajikistan has been slow and in many aspects the health system is still shaped by the countrys Soviet legacy. The country has the lowest total health expenditure per capita in the WHO European Region, much of it financed privately through out-of-pocket payments. Public financing depends principally on regional and local authorities, thus compounding regional inequalities across the country. The high share of private out-of-pocket payments undermines a range of health system goals, including financial protection, equity, efficiency and quality. The efficiency of the health system is also undermined by outdated provider payment mechanisms and lack of pooling of funds. Quality of care is another major concern, due to factors such as insufficient training, lack of evidence-based clinical guidelines, underuse of generic drugs, poor infrastructure and equipment (particularly at the regional level) and perverse financial incentives for physicians in the form of out-of-pocket payments. Health reforms have aimed to strengthen primary health care, but it still suffers from underinvestment and low prestige. A basic benefit package and capitation-based financing of primary health care have been introduced as pilots but have not yet been rolled out to the rest of the country. The National Health Strategy envisages substantial reforms in health financing, including nationwide introduction of capitation-based payments for primary health care and more than doubling public expenditure on health by 2020; it remains to be seen whether this will be achieved.

Coping with the economic burden of Diabetes, TB and co-prevalence: evidence from Bishkek, Kyrgyzstan.

BACKGROUND: The increasing number of patients co-affected with Diabetes and TB may place individuals with low socio-economic status at particular risk of persistent poverty. Kyrgyz health sector reforms aim at reducing this burden, with the provision of essential health services free at the point of use through a State-Guaranteed Benefit Package (SGBP). However, despite a declining trend in out-of-pocket expenditure, there is still a considerable funding gap in the SGBP. Using data from Bishkek, Kyrgyzstan, this study aims to explore how households cope with the economic burden of Diabetes, TB and co-prevalence. METHODS: This study uses cross-sectional data collected in 2010 from Diabetes and TB patients in Bishkek, Kyrgyzstan. Quantitative questionnaires were administered to 309 individuals capturing information on patients' socioeconomic status and a range of coping strategies. Coarsened exact matching (CEM) is used to generate socio-economically balanced patient groups. Descriptive statistics and logistic regression are used for data analysis. RESULTS: TB patients are much younger than Diabetes and co-affected patients. Old age affects not only the health of the patients, but also the patient's socio-economic context. TB patients are more likely to be employed and to have higher incomes while Diabetes patients are more likely to be retired. Co-affected patients, despite being in the same age group as Diabetes patients, are less likely to receive pensions but often earn income in informal arrangements. Out-of-pocket (OOP) payments are higher for Diabetes care than for TB care. Diabetes patients cope with the economic burden by using social welfare support. TB patients are most often in a position to draw on income or savings. Co-affected patients are less likely to receive social welfare support than Diabetes patients. Catastrophic health spending is more likely in Diabetes and co-affected patients than in TB patients. CONCLUSIONS: This study shows that while OOP are moderate for TB affected patients, there are severe consequences for Diabetes affected patients. As a result of the underfunding of the SGBP, Diabetes and co-affected patients are challenged by OOP. Especially those who belong to lower socio-economic groups are challenged in coping with the economic burden.

Tajikistan: health system review

The pace of health reforms in Tajikistan has been slow and in many aspectsthe health system is still shaped by the country’s Soviet legacy. Thecountry has the lowest total health expenditure per capita in the WHOEuropean Region, much of it financed privately through out-of-pocket payments.Public financing depends principally on regional and local authorities, thuscompounding regional inequalities across the country. The high share of privateout-of-pocket payments undermines a range of health system goals, includingfinancial protection, equity, efficiency and quality. The efficiency of the healthsystem is also undermined by outdated provider payment mechanisms andlack of pooling of funds. Quality of care is another major concern, due tofactors such as insufficient training, lack of evidence-based clinical guidelines,underuse of generic drugs, poor infrastructure and equipment (particularly atthe regional level) and perverse financial incentives for physicians in the formof out-of-pocket payments. Health reforms have aimed to strengthen primaryhealth care, but it still suffers from underinvestment and low prestige. A basicbenefit package and capitation-based financing of primary health care havebeen introduced as pilots but have not yet been rolled out to the rest of thecountry. The National Health Strategy envisages substantial reforms in healthfinancing, including nationwide introduction of capitation-based payments forprimary health care and more than doubling public expenditure on health by2020; it remains to be seen whether this will be achieved.

Долгосрочные тенденции финансового бремени в ходе обращения за медицинскими услугами в Кыргызстане, 2000 – 2014 гг.

Кыргызстан взял курс на достижение всеобщего охвата медицинскими услугами и внедряет комплексные реформы, направленные на улучшение состояния здоровья населения Кыргызстана. Для того, чтобы документально зафиксировать прогресс в снижении финансового бремени населения, модуль по использованию медицинских услуг и расходам на здравоохранение был добавлен в Кыргызское интегрированное обследование бюджета домохозяйств, проводимое Национальным статистическим комитетом. Данное уникальное межсекторальное обследование для оценки финансового бремени на население и доступа населения к медицинской помощи проводится уже в течение 15 лет. Обследование свидетельствует о впечатляющем снижении финансового бремени, связанного с обращением за медицинской помощью благодаря внедрению комплексных реформ в области здравоохранения в течении 2000- 2009 гг. Однако, финансовое бремя, связанное с медицинскими услугами, вновь возросло значительно после 2009 года, в частности, для двух наиболее бедных слоев населения, а также в двух крупнейших городах Бишкек и Ош. Лекарственные средства, приобретённые на амбулаторном уровне, являются главной движущей силой в увеличении наличных расходов из кармана. Финансовые и географические барьеры для доступа к услугам здравоохранения улучшилась в течение рассматриваемого периода, но почти половина населения по-прежнему считает, что трудно найти деньги, чтобы оплатить за медицинское обслуживание. Таким образом, данные, полученные в течение последних 15 лет в Кыргызстане, свидетельствует о том, что хорошо продуманные реформы здравоохранения, приведенные в соответствии к потребностям страны, могут снизить финансовую нагрузку на население, связанную с обращениями за медицинской помощью, но поддержание этих достижений в долгосрочной перспективе может быть сложным.

Long-term trends in the financial burden of health care seeking in Kyrgyzstan, 2000–2014

Kyrgyzstan has committed itself to universal health coverage and has launched comprehensive reforms to improve the health of the Kyrgyz population. In order to document progress in reducing the financial burden of the population, a module on health care utilization and health expenditure was added to the Kyrgyz integrated household budget survey, conducted by the National Statistical Committee. This is a unique, repeated cross-sectional survey to assess financial burden on the population and access to care over a 15-year period. The survey provides evidence of impressive reduction in financial burden associated with health care seeking due to the introduction of comprehensive health reforms during 2000-2009. However, the financial burden for health care services increased again after 2009 considerably, in particular for the two poorest groups of the population and in the two largest cities, Bishkek and Osh. Outpatient medicines drive the increase in OOP expenditures. Financial and geographical barriers to accessing health services improved during the survey period, but almost half the population still finds it difficult to find the money to pay for health care. Thus, the evidence obtained over the past 15 years in Kyrgyzstan indicates that well thought-out health reforms contextualized to the country’s needs can reduce financial burden associated with health care seeking but sustaining these gains in the longer term can be a challenge.

Can reductions in informal payments be sustained?: Evidence from Kyrgyzstan, 2001–2013

Kyrgyzstan demonstrated impressive results in reducing informal payments in its health system between 2001 and 2006, particularly for medicines, medical supplies and food. This was achieved by introducing reforms to reduce inefficiencies in the health system, by strengthening primary health care, restructuring the hospital network and channelling the savings to medicines and supplies. The health financing reforms facilitated this transformation of service delivery by introducing a single-payer system, with progressive centralization of funds, pooling and introduction of population and output-based provider payment mechanisms. The findings demonstrate that policies matter and that the right mix of policies can contribute to reducing informal payments. Our results also show, however, that Kyrgyzstan could not sustain these gains in the longer run, as informal payments began to increase again after 2006, offsetting previous gains. This reversal was driven to a great extent by informal payments to medical personnel, despite a sizeable salary increase introduced in 2011, and to a lesser extent by informal payments for medicines and supplies. A number of factors contributed to the reversal of the positive trends in informal payments after 2006, including the overextended State-guaranteed benefit package, the low salaries and poor working conditions of health workers, outdated purchasing mechanisms that fuel hospitalizations, rigidity in public finance, remaining inefficiency in service delivery, inefficient public procurement of medicines and supplies and the absence of provider performance monitoring. The persistence of informal payments remains a problem because they continue to impose an unpredictable financial burden on patients and undermine the credibility of the State-guaranteed benefit package. There is no magic bullet for further reducing informal payments in the Kyrgyz health system. A comprehensive, multi-pronged approach that addresses the causes simultaneously could succeed if public funding is maintained at current levels.

Можно ли обеспечить устойчивость снижения неформальных платежей?: Результаты из Кыргызстана: 2001–2013 гг.

Кыргызстан продемонстрировал впечатляющие результаты в области снижения неформальных платежей в своей системе здравоохранения в период с 2001по 2006 годы, особенно в отношении лекарственных средств, медицинских принадлежностей и питания. Для достижения этих результатов были внедрены реформы, направленные на снижение неэффективности в системе здравоохранения посредством укрепления первичной медико-санитарной помощи, реструктуризации сети стационаров и перенаправленя сэкономленных средств на лекарственные препараты и медицинские принадлежности. Реформы финансирования здравоохранения были разработаны для того, чтобы содействовать трансформации модели предоставления услуг внедряя систему единого плательщика с прогрессивной централизацией аккумулирования средств и внедряя механизмы оплаты поставщиков основанные на население и результаты (Катцин, 2004 г.). Эти выводы демонстрируют, что политика имеет большое значение, а правильная комбинация инструментов политики может внести вклад в снижение неформальных платежей. Однако наши результаты также показывают, что Кыргызстану не удалось обеспечить устойчивость этих достижений в более долгосрочной перспективе, и неформальные платежи снова начали расти после 2006 года, нейтрализовав предыдущие достижения. Данный «поворот вспять» был обусловлен в большой степени неформальными платежами сделанными медицинским работникам, несмотря на существенное повышение заработных плат в 2001 году, и, в меньшей степени, неформальными платежами за лекарственные препараты и медицинские принадлежности. Смена ранее позитивных тенденций в неформальных платежах после 2006года была обусловлена рядом факторов, включая чрезмерное расширение Пакета государственных гарантий, низкий уровень заработных плат и плохие условия работы медицинских работников, устаревшие механизмы закупок, стимулирующие госпитализации, отсутствие гибкости государственных финансов, сохраняющаяся неэффективность конфигурации предоставления услуг, неэффективность государственных закупок лекарственных средств и медицинских принадлежностей, и отсутствие мониторинга эффективности деятельности поставщиков. Стойкая природа неформальных платежей остается проблемой политики, поскольку они являются непредсказуемым финансовым бременем для пациентов и подрывают доверие к Пакету государственных гарантий. Не существует чудодейственного средства, которое позволило бы и далее продолжить снижение неформальных платежей в системе здравоохранения Кыргызстана. Однако, комплексный и многосторонний подход, который принимает во внимание вышеприведенные причины, имеет потенциал добиться успеха, при условии, что государственное финансирование останется на прежнем уровне.

Better noncommunicable disease outcomes: challenges and opportunities for health systems: Tajikistan country assessment

Cardiovascular diseases are the predominant cause of death in Tajikistan, with a growing burden of ischaemic heart disease, strokes and cirrhosis between 1990 and 2010. Considering this, this report focuses on cardiovascular diseases and their risk factors, such as hypertension and poor nutrition; it is estimated that 40% of the Tajik population is overweight and 9% is obese. Other risk factors such as diabetes and tobacco use are also analysed. While Tajikistan has made some progress in implementing anti-smoking policies and reducing the harmful use of alcohol, opportunities such as better enforcement and monitoring of legislation exist. Significant challenges also remain for coverage of core individual services, especially in the effective diagnosis and management of key cardiovascular disease conditions, such as hypertension and diabetes. This report identifies key health system challenges that prevent greater coverage of core noncommunicable diseases interventions and services, and proposes three strategic recommendations to accelerate gains in cardiovascular diseases outcomes.

Better noncommunicable disease outcomes: challenges and opportunities for health systems: Tajikistan country assessment: focus on cardiovascular disease

Cardiovascular diseases are the predominant cause of death in Tajikistan, with a growing burden of ischaemic heart disease, strokes and cirrhosis between 1990 and 2010. Considering this, this report focuses on cardiovascular diseases and their risk factors, such as hypertension and poor nutrition; it is estimated that 40% of the Tajik population is overweight and 9% is obese. Other risk factors such as diabetes and tobacco use are also analysed. While Tajikistan has made some progress in implementing anti-smoking policies and reducing the harmful use of alcohol, opportunities such as better enforcement and monitoring of legislation exist. Significant challenges also remain for coverage of core individual services, especially in the effective diagnosis and management of key cardiovascular disease conditions, such as hypertension and diabetes. This report identifies key health system challenges that prevent greater coverage of core noncommunicable diseases interventions and services, and proposes three strategic recommendations to accelerate gains in cardiovascular diseases outcomes.

Good Health at Low Cost 25 years on: lessons for the future of health systems strengthening.

In 1985, the Rockefeller Foundation published Good health at low cost to discuss why some countries or regions achieve better health and social outcomes than do others at a similar level of income and to show the role of political will and socially progressive policies. 25 years on, the Good Health at Low Cost project revisited these places but looked anew at Bangladesh, Ethiopia, Kyrgyzstan, Thailand, and the Indian state of Tamil Nadu, which have all either achieved substantial improvements in health or access to services or implemented innovative health policies relative to their neighbours. A series of comparative case studies (2009-11) looked at how and why each region accomplished these changes. Attributes of success included good governance and political commitment, effective bureaucracies that preserve institutional memory and can learn from experience, and the ability to innovate and adapt to resource limitations. Furthermore, the capacity to respond to population needs and build resilience into health systems in the face of political unrest, economic crises, and natural disasters was important. Transport infrastructure, female empowerment, and education also played a part. Health systems are complex and no simple recipe exists for success. Yet in the countries and regions studied, progress has been assisted by institutional stability, with continuity of reforms despite political and economic turmoil, learning lessons from experience, seizing windows of opportunity, and ensuring sensitivity to context. These experiences show that improvements in health can still be achieved in countries with relatively few resources, though strategic investment is necessary to address new challenges such as complex chronic diseases and growing population expectations.

Diabetes in Kyrgyzstan: changes between 2002 and 2009.

Health system reform in Kyrgyzstan is seen as a relative success story in central Asia. Initially, most attention focused on structural changes, and it is only since 2006 that the delivery of care and the experience of health service users have risen on the agenda. One exception from the earlier period was a rapid appraisal of the management of diabetes, undertaken in 2002. Using that study as a baseline, we describe the findings of a new evaluation of diabetes management, undertaken in 2009, using the Rapid Assessment Protocol for Insulin Access, now implemented in seven countries. Access to care has improved through the creation of the Family Medical Centres and the deployment of endocrinologists to them. Another improvement is the access to insulin and related medicines, although assessment of the procurement system reveals that the government is getting very poor value for money. Looking ahead, there are grounds for optimism that the passage of the law on diabetes may progressively have a greater impact. Although the law is not yet fully implemented, it has enabled the diabetes associations to defend the rights of their members. This increased capacity is credited with some improvements in diabetes care.

Kyrgyzstan: Health system review.

Kyrgyzstan has undertaken wide-ranging reforms of its health system in a challenging socioeconomic and political context. The country has developed two major health reform programmes after becoming independent: Manas (1996 to 2006) and Manas Taalimi (2006 to 2010). These reforms introduced comprehensive structural changes to the health care delivery system with the aim of strengthening primary health care, developing family medicine and restructuring the hospital sector.Major service delivery improvements have included the introduction of new clinical practice guidelines, improvements in the provision and use of pharmaceuticals, quality improvements in the priority programmes for mother and child health, cardiovascular diseases, tuberculosis and HIV/AIDS, strengthening of public health and improvements in medical education. A Community Action for Health programme was introduced through new village health committees, enhancing health promotion and allowing individuals and communities to take more responsibility for their own health. Health financing reform consisted of the introduction of a purchaser provider split and the establishment of a single payer for health services under the state-guaranteed benefit package (SGBP). Responsibility for purchasing health services has been consolidated under the Mandatory Health Insurance Fund (MHIF), which pools general revenue and health insurance funding. Funds have been pooled at national level since 2006, replacing the previous pooling at oblast level. The transition from oblast-based pooling of funds to pooling at the national level allowed the MHIF to distribute funds more equitably for the SGBP and the Additional Drug Package. Although utilization of both primary care and hospital services declined during the 1990s and early 2000s, it is increasing again. There is increasing equality of access across regions, improved financial protection and a decline in informal payments, but more efforts will be required in these areas in the future.

Kyrgyzstan: health system review

The Health Systems in Transition (HiT) country profiles provide an analytical description of each health system and of reform initiatives in progress or under development. They aim to provide relevant comparative information to support policy-makers and analysts in the development of health systems and reforms in the countries of the WHO European Region and beyond. The HiT profiles are building blocks that can be used: to learn in detail about different approaches to the financing, organization and delivery of health services; to describe accurately the process, content and implementation of health reform programmes; to highlight common challenges and areas that require more in-depth analysis; and to provide a tool for the dissemination of information on health systems and the exchange of experiences of reform strategies between policy-makers and analysts in countries of the WHO European Region. This series is an ongoing initiative and material is updated at regular intervals.

Trends in out-of-pocket payments for health care in Kyrgyzstan, 2001-2007.

Within the countries of the former Soviet Union, the Kyrgyz Republic has been a pioneer in reforming the system of health care finance. Since the introduction of its compulsory health insurance fund in 1997, the country has gradually moved from subsidizing the supply of services to subsidizing the purchase of services through the 'single payer' of the health insurance fund. In 2002 the government introduced a new co-payment for inpatients along with a basic benefit package. A key objective of the reforms has been to replace the burgeoning system of unofficial informal payments for health care with a transparent official co-payment, thereby reducing the financial burden of health care spending for the poor. This article investigates trends in out-of-pocket payments for health care using the results of a series of nationally representative household surveys conducted over the period 2001-2007, when the reforms were being rolled out. The analysis shows that there has been a significant improvement in financial access to health care amongst the population. The proportion paying state providers for consultations fell between 2004 and 2007. As a result of the introduction of co-payments for hospital care, fewer inpatients report making payments to medical personnel, but when they are made, payments are high, especially to surgeons and anaesthetists. However, although financial access for outpatient care has improved, the burden of health care payments amongst the poor remains significant.

Who pays for health care in Asia?

We estimate the distributional incidence of health care financing in 13 Asian territories that account for 55% of the Asian population. In all territories, higher-income households contribute more to the financing of health care. The better-off contribute more as a proportion of ability to pay in most low- and lower-middle-income territories. Health care financing is slightly regressive in three high-income economies with universal social insurance. Direct taxation is the most progressive source of finance and is most so in poorer economies. In universal systems, social insurance is proportional to regressive. In high-income economies, the out-of-pocket (OOP) payments are proportional or regressive while in low-income economies the better-off spend relatively more OOP. But in most low-/middle-income countries, the better-off not only pay more, they also get more health care.