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Semenova Y, Lim L, Salpynov Z, Gaipov A, Jakovljevic M. Historical evolution of healthcare systems of post-soviet Russia, Belarus, Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan, Uzbekistan, Armenia, and Azerbaijan: A scoping review. Heliyon 2024; 10:e29550. [PMID: 38655295 PMCID: PMC11036062 DOI: 10.1016/j.heliyon.2024.e29550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 03/31/2024] [Accepted: 04/09/2024] [Indexed: 04/26/2024] Open
Abstract
This scoping review addresses the transformation and development of new healthcare systems in nine countries -Armenia, Azerbaijan, Belarus, Kazakhstan, Kyrgyzstan, Russia, Tajikistan, Turkmenistan, and Uzbekistan over the period following the collapse of the Soviet Union from 1991 to the present. This assessment focuses on maternal and child health, mental health, communicable diseases, and non-communicable diseases in an effort to highlight the changes in the healthcare status of these nine countries under scrutiny. Considering that all the post-Soviet nations are officially recognized members of the World Health Organization (WHO) and have demonstrated their commitment to attaining the WHO's objectives, the evaluation of healthcare system progress and improvement was carried out utilizing indicators provided by the WHO. This review reveals that the evolution of healthcare systems could be considered sustainable, given that average life expectancy has returned to the level it was in 1991- the year of the USSR's breakup, and people's health has improved since the turn of the twenty-first century. To enhance the potential success of future healthcare reforms, however, governments must monitor implementation of the reform process, evaluate the achievement of objectives, and make necessary adjustments. The success of future healthcare changes will depend on the active involvement of the government, medical community, and patient community, as well as obtaining the support of local health authorities. This study may help identify successful and failed strategies, guiding future healthcare changes and investments.
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Affiliation(s)
- Yuliya Semenova
- Nazarbayev University, School of Medicine, Astana, Kazakhstan
| | - Lisa Lim
- Nazarbayev University, Graduate School of Public Policy, Astana, Kazakhstan
| | | | | | - Mihajlo Jakovljevic
- UNESCO-TWAS, Trieste, Italy
- Shaanxi University of Technology, Hanzhong, China
- Department of Global Health Economics and Policy, University of Kragujevac, 34000, Kragujevac, Serbia
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Ndayishimiye C, Tambor M, Dubas-Jakóbczyk K. Barriers and Facilitators to Health-Care Provider Payment Reform - A Scoping Literature Review. Risk Manag Healthc Policy 2023; 16:1755-1779. [PMID: 37701321 PMCID: PMC10494919 DOI: 10.2147/rmhp.s420529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 08/04/2023] [Indexed: 09/14/2023] Open
Abstract
Background Changes to provider payment systems are among the most common reforms in health care. They are important levers for policymakers to influence the health system performance. The aim of this study was to identify, systematize, and map the existing literature on the factors that influence health-care provider payment reforms. Methods A scoping review was conducted. Literature published in English between 2000 and 2022 was systematically searched in five databases, relevant organizations, and journals. Academic publications and grey literature on health-care provider payment reform and the factors influencing reform were considered. An inductive thematic analysis was applied to map the barriers and facilitators that influence payment reforms. Results The study included 51 publications. They were divided into four categories: empirical studies (n=17), literature reviews (n=6), discussion/policy papers (n=18), and technical reports/policy briefs (n=9). Most of the studies were conducted in developed economy countries (n=36). The most frequently reformed payment method was fee-for-service (n=37), and the newly implemented methods included bundled payments (n=16), pay-for-performance (n=15), and diagnosis-related groups (n=11). This study identified 43 sub-themes on barriers to provider payment reforms, which were grouped into eight main themes. It identified 51 sub-themes on facilitators, which were grouped into six themes. Barriers include stakeholder opposition, challenges related to reform design, hurdles in implementation structures, insufficient resources, challenges related to market structures, legal barriers, knowledge and information gaps, and negative publicity. Facilitators include stakeholder involvement, complementary reforms/policies, relevant prior experience, good leadership and management of change, sufficient resources, and external pressure to introduce reform. Conclusion The factors that influence health-care payment reforms are often contextual and interrelated, and encompass a variety of perspectives, including those of patients, providers, insurers, and policymakers. When planning reforms, one should anticipate potential barriers and devise appropriate interventions. Registration The study was registered with the Open Science Framework.
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Affiliation(s)
- Costase Ndayishimiye
- Doctoral School of Medical and Health Sciences, Jagiellonian University Medical College, Krakow, Poland
- Health Economics and Social Security Department, Institute of Public Health, Jagiellonian University Medical College, Krakow, Poland
| | - Marzena Tambor
- Health Economics and Social Security Department, Institute of Public Health, Jagiellonian University Medical College, Krakow, Poland
| | - Katarzyna Dubas-Jakóbczyk
- Health Economics and Social Security Department, Institute of Public Health, Jagiellonian University Medical College, Krakow, Poland
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Zhamantayev O, Kayupova G, Nukeshtayeva K, Yerdessov N, Bolatova Z, Turmukhambetova A. COVID-19 Pandemic Impact on the Maternal Mortality in Kazakhstan and Comparison with the Countries in Central Asia. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:2184. [PMID: 36767550 PMCID: PMC9914964 DOI: 10.3390/ijerph20032184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 01/18/2023] [Accepted: 01/23/2023] [Indexed: 06/18/2023]
Abstract
Maternal mortality ratio is one of the sensitive indicators that can characterize the performance of healthcare systems. In our study we aimed to compare the maternal mortality ratio in the Central Asia region from 2000 to 2020, determine its trends and evaluate the association between the maternal mortality ratio and Central Asia countries' total health expenditures. We also compared the maternal mortality causes before and during the pandemic in Kazakhstan. The data were derived from the public statistical collections of each Central Asian country. During the pre-pandemic period, Central Asian nations had a downward trend of maternal mortality. Maternal mortality ratio in Central Asian countries decreased by 38% from 47.3 per 100,000 live births in 2000 to 29.5 per 100,000 live births in 2020. Except for Uzbekistan, where this indicator decreased, all Central Asian countries experienced a sharp increase in maternal mortality ratio in 2020. The proportion of indirect causes of maternal deaths in Kazakhstan reached 76.3% in 2020. There is an association between the maternal mortality ratio in Central Asian countries and their total health expenditures expressed in national currency units (r max = -0.89 and min = -0.66, p < 0.01). The study revealed an issue in the health data availability and accessibility for research in the region. The findings suggest that there must be additional efforts from the local authorities to enhance the preparedness of Central Asian healthcare systems for the new public health challenges and to improve health data accessibility.
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Affiliation(s)
| | | | | | | | - Zhanerke Bolatova
- School of Public Health, Karaganda Medical University, Gogol Street 40, Karaganda 100008, Kazakhstan
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Aliev AA, Roberts T, Magzumova S, Panteleeva L, Yeshimbetova S, Krupchanka D, Sartorius N, Thornicroft G, Winkler P. Widespread collapse, glimpses of revival: a scoping review of mental health policy and service development in Central Asia. Soc Psychiatry Psychiatr Epidemiol 2021; 56:1329-1340. [PMID: 33738529 DOI: 10.1007/s00127-021-02064-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 03/10/2021] [Indexed: 01/17/2023]
Abstract
PURPOSE We aimed to map evidence on the development of mental health care in Central Asia after 1991. METHOD We conducted a scoping review complemented by an expert review. We searched five databases for peer-reviewed journal articles and conducted grey literature searching. The reference lists of included articles were screened for additional relevant publications. RESULTS We included 53 articles (Kazakhstan: 13, Kyrgyzstan: 14, Tajikistan: 10, Uzbekistan: 9, Turkmenistan: 2, Multinational: 5). Only 9 were published in internationally recognised journals. In the 1990's mental health services collapsed following a sharp decline in funding, and historically popular folk services re-emerged as an alternative. Currently, modernised mental health policies exist but remain largely unimplemented due to lack of investment and low prioritisation by governments. Psychiatric treatment is still concentrated in hospitals, and community-based and psycho-social services are almost entirely unavailable. Stigma is reportedly high throughout the region, psychiatric myths are widespread, and societal awareness of human rights is low. With the exception of Kyrgyzstan, user involvement is virtually absent. After many years of stagnation, however, political interest in mental health is beginning to show, along with some promising service developments. CONCLUSIONS There is a substantial knowledge gap in the region. Informed decision-making and collaboration with stakeholders is necessary to facilitate future reform implementation.
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Affiliation(s)
- Akmal-Alikhan Aliev
- Department of Public Mental Health, National Institute of Mental Health, Topolová 748, 256 01, Klecany, Czech Republic
| | - Tessa Roberts
- Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- Centre for Society and Mental Health, King's College London, London, UK
| | - Shakhnoza Magzumova
- Department of Psychiatry and Narcology, Tashkent Medical Academy, Tashkent, Uzbekistan
| | - Liliia Panteleeva
- Department of Medical Psychology, Psychiatry and Psychotherapy, Kyrgyz-Russian Slavic University Named After B. N. Yeltsin, Bishkek, Chuy Province, Kyrgyzstan
| | - Saida Yeshimbetova
- Department of Psychiatry, Narcology and Neurology, Kazakh-Russian Medical University, Almaty, Kazakhstan
| | - Dzmitry Krupchanka
- Department of Mental Health and Substance Use, World Health Organization, Geneva, Switzerland
| | - Norman Sartorius
- Association for the Improvement of Mental Health Programmes, CH, Geneva, Switzerland
| | - Graham Thornicroft
- Centre for Global Mental Health and Centre for Implementation Science, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Petr Winkler
- Department of Public Mental Health, National Institute of Mental Health, Topolová 748, 256 01, Klecany, Czech Republic.
- Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
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Klassen AC, Milliron BJ, Reynolds L, Bakhtibekova Z, Mamadraimov S, Bahruddinov M, Shokamolova S, Shuster M, Mukhtar S, Gafurova M, Iskandari M, Majidian R, Job-Johnson B. Formative research to address vaccine hesitancy in Tajikistan. Vaccine 2021; 39:1516-1527. [PMID: 33487469 DOI: 10.1016/j.vaccine.2021.01.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 01/10/2021] [Accepted: 01/11/2021] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Incomplete childhood vaccination is associated with caregiver vaccine hesitancy, conceptualized by "3 Cs": high complacency, low confidence, and low convenience. To expand on existing evidence drawn primarily from the Americas and Europe, and develop culturally appropriate interventions, this research explored drivers of vaccine hesitancy in the Central Asian country of Tajikistan. METHODS In twelve diverse districts, clinic-based immunization record abstraction identified purposive samples of children who were up-to-date (N = 300) or not (N = 300) on all first year vaccines. Using a modified case-control design, the structured face-to-face in-home survey of 600 caregivers compared knowledge, attitudes and practices regarding childhood vaccination by up-to-date status. Socio-demographic and psychological factors associated with hesitancy were identified, using a 22-item vaccine hesitancy scale, with subscales measuring complacency, confidence, and convenience. Overall contribution of vaccine hesitancy to up-to-date status was modeled, adjusting for other significant covariates. RESULTS Caregivers of not up-to-date children were more likely to report their child's health as poor, and report many logistical barriers to vaccination. Knowledge of vaccine-preventable illnesses was low, and complacency regarding vaccination was high among not up-to-date caregivers. In final multivariable models of predisposing, enabling and reinforcing influences on vaccination status, urban children, those with transportation and employed mothers were more likely to be up-to-date, while not up-to-date children included those born at home, seen as having fair or poor health, or reportedly told by clinicians to avoid immunization. Reinforcing factors included having a "vaccine passport", receiving useful information from medical providers, and believing that vaccine-preventable illnesses are serious and that most in their community are vaccinated. Additionally, vaccine hesitancy was negatively associated with up-to-date status (odds ratio 0.15, 95% C.I. 0.08, 0.26). CONCLUSIONS Results confirm that in this traditional culture, there is a strong need for tailored communication campaigns to address vaccine hesitancy, while continuing to address systems-level barriers.
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Affiliation(s)
- Ann Carroll Klassen
- Department of Community Health and Prevention, Drexel University Dornsife School of Public Health, Philadelphia, PA 19104, USA.
| | - Brandy-Joe Milliron
- Department of Nutrition Sciences, Drexel University College of Nursing and Health Professions, Philadelphia, PA 19101, USA
| | - Leslie Reynolds
- Department of Community Health and Prevention, Drexel University Dornsife School of Public Health, Philadelphia, PA 19104, USA
| | | | | | | | | | - Michelle Shuster
- Department of Community Health and Prevention, Drexel University Dornsife School of Public Health, Philadelphia, PA 19104, USA
| | - Sarah Mukhtar
- Department of Community Health and Prevention, Drexel University Dornsife School of Public Health, Philadelphia, PA 19104, USA
| | - Maftuna Gafurova
- Department of Community Health and Prevention, Drexel University Dornsife School of Public Health, Philadelphia, PA 19104, USA
| | - Malika Iskandari
- Department of Community Health and Prevention, Drexel University Dornsife School of Public Health, Philadelphia, PA 19104, USA
| | - Rauf Majidian
- Department of Community Health and Prevention, Drexel University Dornsife School of Public Health, Philadelphia, PA 19104, USA
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Abstract
In Tajikistan, dermatologic services are available across the country. Yet, the most experienced dermatologists work at the National Republic Center for Dermatology and Venereology (NRCDV). Patients from across the country bypass local dermatologists and self-refer to NRCDV. Furthermore, no formal mechanisms exist for dermatologists in different cities to consult with experts at NRCDV. The authors designed a teledermatology program linking dermatologists across Tajikistan to NRCDV. They used the World Health Organization health systems framework to plan this program and define objectives. To date, 228 teledermatology consultations have taken place. The authors find that good governance is key to program implementation.
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Jacobs E, Baez Camargo C. Local health governance in Tajikistan: accountability and power relations at the district level. Int J Equity Health 2020; 19:30. [PMID: 32122333 PMCID: PMC7053113 DOI: 10.1186/s12939-020-1143-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 02/10/2020] [Indexed: 11/10/2022] Open
Abstract
Background Relationships of power, responsibility and accountability between health systems actors are considered central to health governance. Despite increasing attention to the role of accountability in health governance a gap remains in understanding how local accountability relations function within the health system in Central Asia. This study addresses this gap by exploring local health governance in two districts of Tajikistan using principal-agent theory. Methods This comparative case study uses a qualitative research methodology, relying on key informant interviews and focus group discussions with local stakeholders. Data analysis was guided by a framework that conceptualises governance as a series of principal-agent relations between state actors, citizens and health providers. Special attention is paid to voice, answerability and enforceability as crucial components of accountability. Results The analysis has provided insight into the challenges to different components making up an effective accountability relationship, such as an unclear mandate, the lack of channels for voice or insufficient resources to carry out a mandate. The findings highlight the weak position of health providers and citizens towards state actors and development agents in the under-resourced health system and authoritarian political context. Contestation over resources among local government actors, and informal tools for answerability and enforceability were found to play an important role in shaping actual accountability relations. These accountability relationships form a complex institutional web in which agents are subject to various accountability demands. Particularly health providers find themselves to be in this role, being held accountable by state actors, citizens and development agencies. The latter were found to have established parallel principal-agent relationships with health providers without much attention to the role of local state actors, or strengthening the short accountability route from citizens to providers. Conclusion The study has provided insight into the complexity of local governance relations and constraints to formal accountability processes. This has underlined the importance of informal accountability tools and the political-economic context in shaping principal-agent relations. The study has served to demonstrate the use and limitations of agency theory in health governance analysis, and points to the importance of entrenched positions of power in local health systems.
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Affiliation(s)
- Eelco Jacobs
- University of Basel, Petersplatz 1, 4001, Basel, Switzerland. .,KIT Royal Tropical Institute, Mauritskade 63, Amsterdam, 1092 AD, The Netherlands.
| | - Claudia Baez Camargo
- University of Basel, Petersplatz 1, 4001, Basel, Switzerland.,Basel Institute on Governance, Steinenring 60, 4051, Basel, Switzerland
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The Effects of Healthcare Quality on the Willingness to Pay More Taxes to Improve Public Healthcare: Testing Two Alternative Hypotheses from the Research Literature. Ann Glob Health 2019; 85:131. [PMID: 31750080 PMCID: PMC6838763 DOI: 10.5334/aogh.2462] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The research literature discusses two opposite hypotheses regarding the possible effects of healthcare quality on the willingness to pay more taxes to improve public healthcare. One hypothesis theorizes that a lower quality of public healthcare may weaken the willingness to pay more taxes towards improving it. Another hypothesis posits that a low quality of public healthcare may strengthen the willingness to pay more taxes towards improving it. We tested both hypotheses on a diverse sample of 27 post-communist countries within Eurasia and Southern and Eastern Europe over a period of five years. We apply a binary logistic model for each country under investigation. The model is estimated by regressing the willingness to pay more taxes on six dimensions of quality, while controlling for covariates and the dummy for 2016. We found empirical support for both hypotheses, and hence none of the hypotheses gleaned from the literature is a clear "winner." However, we also found that the situation is less straightforward and more nuanced than is usually acknowledged within the literature. Our findings also suggest the effect is specific with respect to both a quality dimension and a country tested.
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Vogler S, Schneider P, Dedet G, Bak Pedersen H. Affordable and equitable access to subsidised outpatient medicines? Analysis of co-payments under the Additional Drug Package in Kyrgyzstan. Int J Equity Health 2019; 18:89. [PMID: 31196109 PMCID: PMC6567501 DOI: 10.1186/s12939-019-0990-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 05/23/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Out-of-pocket (OOP) payments can constitute a major barrier for affordable and equitable access to essential medicines. Household surveys in Kyrgyzstan pointed to a perceived growth in OOP payments for outpatient medicines, including those covered by the benefits package scheme (the Additional Drug Package, ADP). The study aimed to explore the extent of co-payments for ADP-listed medicines and to explain the reasons for developments. METHODS A descriptive statistical analysis was performed on prices and volumes of prescribed ADP-listed medicines dispensed in pharmacies during 2013-2015 (1,041,777 prescriptions claimed, data provided by the Mandatory Health Insurance Fund). Additionally, data on the value and volume of imported medicines in 2013-2015 (obtained from the National Medicines Regulatory Agency) were analysed. RESULTS In 2013-2015, co-payments for medicines dispensed under the ADP grew, on average, by 22.8%. Co-payments for ADP-listed medicines amounted to around 50% of a reimbursed baseline price, but as pharmacy retail prices were not regulated, co-payments tended to be higher in practice. The increase in co-payments coincided with a reduction in the number of prescriptions dispensed (by 14%) and an increase in average amounts reimbursed per prescription in nearly all therapeutic groups (by 22%) in the study period. While the decrease in prescriptions suggests possible underuse, as patients might forego filling prescriptions due to financial restraints, the growth in average amounts reimbursed could be an indication of inefficiencies in public funding. Variation between the regions suggests regional inequity. Devaluation of the national currency was observed, and the value of imported medicines increased by nearly 20%, whereas volumes of imports remained at around the same level in 2013-2015. Thus, patients and public procurers had to pay more for the same amount of medicines. CONCLUSIONS The findings suggest an increase in pharmacy retail prices as the major driver for higher co-payments. The national currency devaluation contributed to the price increases, and the absence of medicine price regulation aggravated the effects of the depreciation. It is recommended that Kyrgyzstan should introduce medicine price regulation and exemptions for low-income people from co-payments to ensure a more affordable and equitable access to medicines.
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Affiliation(s)
- Sabine Vogler
- WHO Collaborating Centre for Pharmaceutical Pricing and Reimbursement Policies, Pharmacoeconomics Department, Gesundheit Österreich GmbH (GÖG / Austrian Public Health Institute), Vienna, Austria
| | - Peter Schneider
- WHO Collaborating Centre for Pharmaceutical Pricing and Reimbursement Policies, Pharmacoeconomics Department, Gesundheit Österreich GmbH (GÖG / Austrian Public Health Institute), Vienna, Austria
| | - Guillaume Dedet
- Organisation for Economic Co-operation and Development (OECD), Paris, France
| | - Hanne Bak Pedersen
- World Health Organization, Regional Office for Europe, Copenhagen, Denmark
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Jacobs E. The politics of the basic benefit package health reforms in Tajikistan. Glob Health Res Policy 2019; 4:14. [PMID: 31143840 PMCID: PMC6532152 DOI: 10.1186/s41256-019-0104-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 05/06/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Health reform is a fundamentally political process. Yet, evidence on the interplay between domestic politics, international aid and the technical dimensions of health systems, particularly in the former Soviet Union and Central Asia, remains limited. Little regard has been given to the political dimensions of Tajikistan's Basic Benefit Package (BBP) reforms that regulate entitlements to a guaranteed set of healthcare services while introducing co-payments. The objective of this paper is therefore to explore the governance constraints to the introduction and implementation of the BBP and associated health management changes. METHODS This qualitative study draws on literature review and key informant interviews. Data analysis was guided by a political economy framework exploring the interplay between structural and institutional features on the one hand and agency dynamics on the other. Building on that the article presents the main themes that emerged on structure-agency dynamics, forming the key governance constraints to the BBP reform and implementation. RESULTS Policy incoherence, parallel and competing central government mandates, and regulatory fragmentation, have emerged as dominant drivers of most other constraints to effective design and implementation of the BBP and associated health reforms in Tajikistan: overcharging and informal payments, a weak link between budgeting and policymaking, a practice of non-transparent budget bargaining instead of a rationalisation of health expenditure, little donor harmonisation, and weak accountability to citizens. CONCLUSION This study suggests that policy incoherence and regulatory fragmentation can be linked to the neo-patrimonial character of the regime and donor behaviour, with detrimental consequences for the health system.. These findings raise questions on the unintended effects of non-harmonised piloting of health reforms, and the interaction of health financing and management interventions with entrenched power relations. Ultimately these insights serve to underline the relevance of contextualising health programmes and addressing policy incoherence with long horizon planning as a priority.
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Affiliation(s)
- Eelco Jacobs
- University of Basel, Basel, Switzerland
- KIT Royal Tropical Institute, Amsterdam, The Netherlands
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Horodnic AV, Williams CC. Informal payments by patients for health services: prevalence and determinants. SERVICE INDUSTRIES JOURNAL 2018. [DOI: 10.1080/02642069.2018.1450870] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Adrian V. Horodnic
- Faculty of Medicine, ‘Grigore T. Popa’ University of Medicine and Pharmacy, Iasi, Romania
| | - Colin C. Williams
- Sheffield University Management School (SUMS), University of Sheffield, Sheffield, UK
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Williams CC, Horodnic AV. Rethinking informal payments by patients in Europe: An institutional approach. Health Policy 2017; 121:1053-1062. [PMID: 28867153 DOI: 10.1016/j.healthpol.2017.08.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 07/12/2017] [Accepted: 08/18/2017] [Indexed: 10/19/2022]
Abstract
The aim of this paper is to explain informal payments by patients to healthcare professionals for the first time through the lens of institutional theory as arising when there are formal institutional imperfections and asymmetry between norms, values and practices and the codified formal laws and regulations. Reporting a 2013 Eurobarometer survey of the prevalence of informal payments by patients in 28 European countries, a strong association is revealed between the degree to which formal and informal institutions are unaligned and the propensity to make informal payments. The association between informal payments and formal institutional imperfections is then explored to evaluate which structural conditions might reduce this institutional asymmetry, and thus the propensity to make informal payments. The paper concludes by exploring the implications for tackling such informal practices.
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Affiliation(s)
- Colin C Williams
- Sheffield University Management School (SUMS), University of Sheffield, Conduit Road, Sheffield S10 1FL, Room: D038.a, United Kingdom.
| | - Adrian V Horodnic
- Sheffield University Management School (SUMS), University of Sheffield, Conduit Road, Sheffield S10 1FL, Room: D038.a, United Kingdom
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Beauvais W, Coker R, Nurtazina G, Guitian J. Policies and Livestock Systems Driving Brucellosis Re-emergence in Kazakhstan. ECOHEALTH 2017; 14:399-407. [PMID: 25925340 DOI: 10.1007/s10393-015-1030-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Revised: 02/09/2015] [Accepted: 03/26/2015] [Indexed: 06/04/2023]
Abstract
Brucellosis is a considerable public health and economic burden in many areas of the world including sub-Saharan Africa, the Middle East and former USSR countries. The collapse of the USSR has been cited as a driver for re-emergence of diseases including brucellosis, and human incidence rates in the former Soviet republics have been estimated as high as 88 per 100,000 per year. The aim of this paper is to examine the historical trends in brucellosis in Kazakhstan and to explore how livestock systems, veterinary services and control policies may have influenced them. In conclusion, a brucellosis epidemic most likely began before the collapse of the USSR and high livestock densities may have played an important role. Changes to the livestock systems in Kazakhstan, as well as other factors, are likely to have an impact on the success of brucellosis policies in the future. Incentives and practicalities of different policies in smallholder settings should be considered. However, the lack of reliable estimates of brucellosis prevalence and difficulties in understanding exactly how policy is being applied in Kazakhstan, which is a vast country with low population density, prevent firm conclusions from being drawn.
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Affiliation(s)
- Wendy Beauvais
- Royal Veterinary College, Hawkshead Lane, North Mymms, Hertfordshire, AL9 7TA, UK.
| | - Richard Coker
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - Javier Guitian
- Royal Veterinary College, Hawkshead Lane, North Mymms, Hertfordshire, AL9 7TA, UK
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Mihailovic NM, Kocic SS, Trajkovic G, Jakovljevic M. Satisfaction with Health Services among the Citizens of Serbia. Front Pharmacol 2017; 8:50. [PMID: 28232799 PMCID: PMC5299022 DOI: 10.3389/fphar.2017.00050] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 01/23/2017] [Indexed: 01/26/2023] Open
Affiliation(s)
- Natasa M Mihailovic
- Department of Social Medicine, Institute of Public Health Kragujevac Kragujevac, Serbia
| | - Sanja S Kocic
- Department of Social Medicine, Institute of Public Health KragujevacKragujevac, Serbia; Department of Social Medicine, Faculty of Medical Sciences, University of KragujevacKragujevac, Serbia
| | - Goran Trajkovic
- Faculty of Medicine, Institute for Medical Statistics and Informatics, University of Belgrade Belgrade, Serbia
| | - Mihajlo Jakovljevic
- Health Economics and Pharmacoeconomics, Faculty of Medical Sciences, University of Kragujevac Kragujevac, Serbia
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Ekawati FM, Claramita M, Hort K, Furler J, Licqurish S, Gunn J. Patients' experience of using primary care services in the context of Indonesian universal health coverage reforms. ASIA PACIFIC FAMILY MEDICINE 2017; 16:4. [PMID: 28344507 PMCID: PMC5360086 DOI: 10.1186/s12930-017-0034-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 02/16/2017] [Indexed: 05/11/2023]
Abstract
BACKGROUND The World Health Organization (WHO) recommendation on universal coverage has been implemented in Indonesia as Jaminan Kesehatan Nasional (JKN). It was designed to provide people with equitable and high-quality health care by strengthening primary care as the gate-keeper to hospitals. However, during its first year of implementation, recruitment of JKN members was slow, and the referral rates from primary to secondary care remained high. Little is known about how the public views the introduction of JKN or the factors that influence their decision to enroll in JKN. AIM This research aimed to explore patients' views on the implementation of JKN and factors that influence a person's decision to enroll in the JKN scheme. METHODS This study was informed by interpretative phenomenological analysis (IPA) methodology to understand patients' views. The interview participants were purposively recruited using maximum variation criteria. The data were gathered using in-depth interviews and was conducted in Yogyakarta from October to December 2014. The interviews were transcribed, translated and analyzed using IPA analysis. RESULT Twenty three participants were interviewed from eight primary care clinics. Three superordinate themes: access, trust, and separation anxiety were identified which impacted on the uptake of JKN. Participants acknowledged that whilst primary care clinics were conveniently located, access was often complicated by long waiting times and short opening hours. Participants also expressed lower levels of trust with primary care doctors compared to hospital and specialist care. They also reported a sense of anxiety that the current JKN regulation might limit their ability to access the hospital service guaranteed in the past. DISCUSSION This study identified patients' views that could challenge the implementation of the gate-keeper role of primary care in Indonesia. While the patients valued the availability of medical care close to home, their lack of trust in primary care doctors and fear that they might lost the hospital care in the future appears to have impacted on the uptake of JKN. Unless targeted efforts are made to address these views through sustained public education and further capacity building in primary care, it is unlikely that the full potential of the JKN scheme in primary care will be realized.
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Affiliation(s)
- Fitriana Murriya Ekawati
- Department of Family and Community Medicine, Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia
- Department of General Practice and Primary Health Care, University of Melbourne, Melbourne, Australia
| | - Mora Claramita
- Department of Family and Community Medicine, Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia
- Department of Medical Education, Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Krishna Hort
- Nossal Institute of Global Health, University of Melbourne, Melbourne, Australia
| | - John Furler
- Department of General Practice and Primary Health Care, University of Melbourne, Melbourne, Australia
| | - Sharon Licqurish
- Department of General Practice and Primary Health Care, University of Melbourne, Melbourne, Australia
| | - Jane Gunn
- Department of General Practice and Primary Health Care, University of Melbourne, Melbourne, Australia
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Kohler S, Asadov DA, Bründer A, Healy S, Khamraev AK, Sergeeva N, Tinnemann P. Health system support and health system strengthening: two key facilitators to the implementation of ambulatory tuberculosis treatment in Uzbekistan. HEALTH ECONOMICS REVIEW 2016; 6:28. [PMID: 27406392 PMCID: PMC4942444 DOI: 10.1186/s13561-016-0100-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Accepted: 05/28/2016] [Indexed: 06/06/2023]
Abstract
Uzbekistan inherited a hospital-based health system from the Soviet Union. We explore the health system-related challenges faced during the scale-up of ambulatory (outpatient) treatment for drug-susceptible and drug-resistant tuberculosis (TB) in Karakalpakstan in Uzbekistan. Semi-structured interviews were conducted with key informants of the TB services, the ministries of health and finance, and their TB control partners. Structural challenges and resource needs were both discussed as obstacles to the expansion of ambulatory TB treatment. Respondents stated need for revising the financing mechanisms of the TB services to incentivize referral to ambulatory TB treatment. An increased workload and need for transportation in ambulatory TB care were also pointed out by respondents, given the quickly rising outpatient numbers but per capita financing of outpatient care. Policy makers showed strong interest in good practice examples for financing ambulatory-based management of TB in comparable contexts and in guidance for revising the financing of the TB services in a way that strengthens ambulatory TB treatment. To facilitate changing the model of care, TB control strategies emphasizing ambulatory care in hospital-oriented health systems should anticipate health system support and strengthening needs, and provide a plan of action to resolve both. Addressing both types of needs may require not only involving TB control and health financing actors, but also increasing knowledge about viable and tested financing mechanisms that incentivize the adoption of new models of care for TB.
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Affiliation(s)
- Stefan Kohler
- Institute of Public Health, Heidelberg University, Heidelberg, Germany.
- Institute for Social Medicine, Epidemiology and Health Economics, Charité - Universitätsmedizin Berlin, Berlin, Germany.
- Médecins Sans Frontières, Nukus and Tashkent, Uzbekistan.
| | - Damin Abdurakhimovich Asadov
- Department of Health Management, Evidence-based Medicine Centre, Tashkent Institute of Postgraduate Medical Education, Tashkent, Uzbekistan
| | | | - Sean Healy
- Médecins Sans Frontières, Nukus and Tashkent, Uzbekistan
| | | | | | - Peter Tinnemann
- Institute for Social Medicine, Epidemiology and Health Economics, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Park K, Park J, Kwon YD, Kang Y, Noh JW. Public satisfaction with the healthcare system performance in South Korea: Universal healthcare system. Health Policy 2016; 120:621-9. [PMID: 26831040 DOI: 10.1016/j.healthpol.2016.01.017] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Revised: 12/31/2015] [Accepted: 01/13/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND An awareness of the public's level of satisfaction with health professionals is becoming more important as steps are being taken to improve quality, reduce costs, and implement reform. The purpose of this study is to assess public satisfaction with the healthcare system and to examine the relationship between satisfaction and socio-demographic factors in the context of the health care environment in the Republic of Korea. METHODS The data were obtained from 1573 adults aged 20-69 in three major areas - Seoul, Gyeonggi, and Busan - by the Ministry of Health and Welfare during June and July 2011 in South Korea. Satisfaction with the healthcare system was evaluated by using 13 items in three sections: access to care, cost of care, and quality of care. A confirmatory factor analysis (CFA) was conducted to examine the validity of satisfaction with a healthcare system performance questionnaire. A structural equation model (SEM) was estimated to assess the relative impact of demographic and socio-economic variables on satisfaction. RESULTS The study proposed a comprehensive three-factor model of healthcare system performance satisfaction. Among the three factors, the quality of care had the largest impact on satisfaction with the healthcare system, suggesting that is the most important determinant of consumers' satisfaction with their healthcare system. Regarding the relationships between public satisfaction and demographic and socio-economic variables, residence and marital status were significant predictors of the satisfaction level. CONCLUSIONS It is important to be aware of the potential significance of background variables in determining satisfaction with the healthcare system. An understanding of the characteristics of the sample enables healthcare managers and/or policymakers to inform targeted follow-up actions.
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Affiliation(s)
- Kisoo Park
- Department of Healthcare Management, University of Korea, Seoul, South Korea
| | - Jumin Park
- National Institutes of Health Clinical Center, Bethesda, MD, USA
| | - Young Dae Kwon
- Department of Humanities and Social Medicine, College of Medicine and Catholic Institute for Healthcare Management, the Catholic University of Korea, Seoul, South Korea
| | | | - Jin-Won Noh
- Department of Healthcare Management and Institute of Global Healthcare Research, Eulji University, Seongnam, South Korea.
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Damrongplasit K, Melnick G. Funding, coverage, and access under Thailand's universal health insurance program: an update after ten years. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2015; 13:157-166. [PMID: 25566748 DOI: 10.1007/s40258-014-0148-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND In 2001, Thailand implemented a universal coverage program by expanding government-funded health coverage to uninsured citizens and limited their out-of-pocket payments to 30 Baht per encounter and, in 2006, eliminated out-of-pocket payments entirely. Prior research covering the early years of the program showed that the program effectively expanded coverage while a more recent paper of the early effects of the program found that improved access from the program led to a reduction in infant mortality. OBJECTIVE We expand and update previous analyses of the effects of the 30 Baht program on access and out-of-pocket payments. DATA AND METHODS We analyze national survey and governmental budgeting data through 2011 to examine trends in health care financing, coverage and access, including out-of-pocket payments. RESULTS By 2011, only 1.64 % of the population remained uninsured in Thailand (down from 2.61 % in 2009). While government funding increased 75 % between 2005 and 2010, budgetary requests by health care providers exceeded approved amounts in many years. The 30 Baht program beneficiaries paid zero out-of-pocket payments for both outpatient and inpatient care. Inpatient and outpatient contact rates across all insurance categories fell slightly over time. CONCLUSIONS Overall, the statistical results suggest that the program is continuing to achieve its goals after 10 years of operation. Insurance coverage is now virtually universal, access has been more or less maintained, government funding has continued to grow, though at rates below requested levels and 30 Baht patients are still guaranteed access to care with limited or no out-of-pocket costs. Important issues going forward are the ability of the government to sustain continued funding increases while minimizing cost sharing.
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Affiliation(s)
- Kannika Damrongplasit
- Faculty of Economics, Chulalongkorn University, Phayathai Road, Bangkok, 10330, Thailand,
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Ulikpan A, Mirzoev T, Jimenez E, Malik A, Hill PS. Central Asian Post-Soviet health systems in transition: has different aid engagement produced different outcomes? Glob Health Action 2014; 7:24978. [PMID: 25231098 PMCID: PMC4166545 DOI: 10.3402/gha.v7.24978] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Revised: 07/27/2014] [Accepted: 08/07/2014] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The collapse of the Soviet Union in 1991 resulted in a transition from centrally planned socialist systems to largely free-market systems for post-Soviet states. The health systems of Central Asian Post-Soviet (CAPS) countries (Kyrgyzstan, Mongolia, Tajikistan, Turkmenistan, and Uzbekistan) have undergone a profound revolution. External development partners have been crucial to this reorientation through financial and technical support, though both relationships and outcomes have varied. This research provides a comparative review of the development assistance provided in the health systems of CAPS countries and proposes future policy options to improve the effectiveness of development. DESIGN Extensive documentary review was conducted using Pubmed, Medline/Ovid, Scopus, and Google scholar search engines, local websites, donor reports, and grey literature. The review was supplemented by key informant interviews and participant observation. FINDINGS The collapse of the Soviet dominance of the region brought many health system challenges. Donors have played an essential role in the reform of health systems. However, as new aid beneficiaries, neither CAPS countries' governments nor the donors had the experience of development collaboration in this context.The scale of development assistance for health in CAPS countries has been limited compared to other countries with similar income, partly due to their limited history with the donor community, lack of experience in managing donors, and a limited history of transparency in international dealings. Despite commonalities at the start, two distinctive trajectories formed in CAPS countries, due to their differing politics and governance context. CONCLUSIONS The influence of donors, both financially and technically, remains crucial to health sector reform, despite their relatively small contribution to overall health budgets. Kyrgyzstan, Mongolia, and Tajikistan have demonstrated more effective development cooperation and improved health outcomes; arguably, Uzbekistan and Turkmenistan have made slower progress in their health and socio-economic indices because of their resistance to open and accountable development relationships.
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Affiliation(s)
- Anar Ulikpan
- School of Population Health, The University of Queensland, Herston, QLD, Australia;
| | - Tolib Mirzoev
- Nuffield Centre for International Health & Development, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Eliana Jimenez
- School of Population Health, The University of Queensland, Herston, QLD, Australia
| | - Asmat Malik
- Integrated Health Services, Islamabad, Pakistan
| | - Peter S Hill
- School of Population Health, The University of Queensland, Herston, QLD, Australia
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Supiyev A, Nurgozhin T, Zhumadilov Z, Sharman A, Marmot M, Bobak M. Levels and distribution of self-rated health in the Kazakh population: results from the Kazakhstan household health survey 2012. BMC Public Health 2014; 14:768. [PMID: 25073469 PMCID: PMC4131021 DOI: 10.1186/1471-2458-14-768] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Accepted: 07/17/2014] [Indexed: 11/08/2023] Open
Abstract
BACKGROUND The high and fluctuating mortality and rising health inequalities in post-Soviet countries have attracted considerable attention. However, there are very few individual-level data on distribution of health outcomes in Central Asian countries of the former Soviet Union. We analysed socioeconomic predictors of two self-rated health outcomes in a national survey in Kazakhstan. METHODS We used data from the 2012 Kazakhstan Household Health Survey on 12,560 respondents aged 15+. Self-rated health, self-reported worsening of health, and a range of socio-demographic variables were collected in an interview. The self-rated health outcomes were dichotomized and logistic regression was used to estimate their associations with education, income, ownership of a car, second house and computer, marital status, ethnicity and urban/rural residence. RESULTS The prevalence of poor/very poor self-rated health was 5.3%, and 11.0% of participants reported worse health compared to 1 year ago. After controlling for age, sex and region, all socio-demographic factors were related to self-rated health. After adjusting for all variables, education and car ownership showed the most consistent effects; the odds ratio of poor health and worsening of health were 0.43 (95% confidence interval 0.32-0.58) and 0.54 (0.44-0.68) for university vs. primary education, respectively, and 0.64 (0.51-0.82) and 0.68 (0.58-0.80) for car ownership, respectively. Unmarried persons, ethnic Russians and urban residents also had increased prevalence of poor health in multivariable models. CONCLUSIONS Despite the limitations of using subjective health measures, these data suggest strong associations between two measures of self-rated health and a number of socioeconomic characteristics. Future studies and health policy initiatives in Kazakhstan and other Central Asian countries should take social determinants of health into account.
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Affiliation(s)
- Adil Supiyev
- />Centre for Life Sciences, Nazarbayev University, 53 Kabanbay batyr ave., Astana, 010000 Kazakhstan
- />Department of Epidemiology and Public Health, University College London, London, UK
| | - Talgat Nurgozhin
- />Centre for Life Sciences, Nazarbayev University, 53 Kabanbay batyr ave., Astana, 010000 Kazakhstan
| | - Zhaxybay Zhumadilov
- />Centre for Life Sciences, Nazarbayev University, 53 Kabanbay batyr ave., Astana, 010000 Kazakhstan
| | - Almaz Sharman
- />Academy of Preventive Medicine, Almaty, Kazakhstan
| | - Michael Marmot
- />Department of Epidemiology and Public Health, University College London, London, UK
| | - Martin Bobak
- />Department of Epidemiology and Public Health, University College London, London, UK
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Mirzoev TN, Green A, Van Kalliecharan R. Framework for assessing the capacity of a health ministry to conduct health policy processes--a case study from Tajikistan. Int J Health Plann Manage 2014; 30:173-85. [PMID: 24677036 DOI: 10.1002/hpm.2222] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2012] [Revised: 02/06/2013] [Accepted: 09/27/2013] [Indexed: 11/06/2022] Open
Abstract
An adequate capacity of ministries of health (MOH) to develop and implement policies is essential. However, no frameworks were found assessing MOH capacity to conduct health policy processes within developing countries. This paper presents a conceptual framework for assessing MOH capacity to conduct policy processes based on a study from Tajikistan, a former Soviet republic where independence highlighted capacity challenges. The data collection for this qualitative study included in-depth interviews, document reviews and observations of policy events. Framework approach for analysis was used. The conceptual framework was informed by existing literature, guided the data collection and analysis, and was subsequently refined following insights from the study. The Tajik MOH capacity, while gradually improving, remains weak. There is poor recognition of wider contextual influences, ineffective leadership and governance as reflected in centralised decision-making, limited use of evidence, inadequate actors' participation and ineffective use of resources to conduct policy processes. However, the question is whether this is a reflection of lack of MOH ability or evidence of constraining environment or both. The conceptual framework identifies five determinants of robust policy processes, each with specific capacity needs: policy context, MOH leadership and governance, involvement of policy actors, the role of evidence and effective resource use for policy processes. Three underlying considerations are important for applying the capacity to policy processes: the need for clear focus, recognition of capacity levels and elements, and both ability and enabling environment. The proposed framework can be used in assessing and strengthening of the capacity of different policy actors.
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Affiliation(s)
- Tolib N Mirzoev
- University of Leeds, Nuffield Centre for International Health and Development, Leeds, UK
| | - Andrew Green
- University of Leeds, Nuffield Centre for International Health and Development, Leeds, UK
| | - Ricky Van Kalliecharan
- University of Leeds, Nuffield Centre for International Health and Development, Leeds, UK
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Bachireddy C, Soule MC, Izenberg JM, Dvoryak S, Dumchev K, Altice FL. Integration of health services improves multiple healthcare outcomes among HIV-infected people who inject drugs in Ukraine. Drug Alcohol Depend 2014; 134:106-114. [PMID: 24128379 PMCID: PMC3865106 DOI: 10.1016/j.drugalcdep.2013.09.020] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Revised: 09/16/2013] [Accepted: 09/17/2013] [Indexed: 12/18/2022]
Abstract
BACKGROUND People who inject drugs (PWID) experience poor outcomes and fuel HIV epidemics in middle-income countries in Eastern Europe and Central Asia. We assess integrated/co-located (ICL) healthcare for HIV-infected PWID, which despite international recommendations, is neither widely available nor empirically examined. METHODS A 2010 cross-sectional study randomly sampled 296 HIV-infected opioid-dependent PWID from two representative HIV-endemic regions in Ukraine where ICL, non-co-located (NCL) and harm reduction/outreach (HRO) settings are available. ICL settings provide onsite HIV, addiction, and tuberculosis services, NCLs only treat addiction, and HROs provide counseling, needles/syringes, and referrals, but no opioid substitution therapy (OST). The primary outcome was receipt of quality healthcare, measured using a quality healthcare indicator (QHI) composite score representing percentage of eight guidelines-based recommended indicators met for HIV, addiction and tuberculosis treatment. The secondary outcomes were individual QHIs and health-related quality-of-life (HRQoL). RESULTS On average, ICL-participants had significantly higher QHI composite scores compared to NCL- and HRO-participants (71.9% versus 54.8% versus 37.0%, p<0.001) even after controlling for potential confounders. Compared to NCL-participants, ICL-participants were significantly more likely to receive antiretroviral therapy (49.5% versus 19.2%, p<0.001), especially if CD4 ≤ 200 (93.8% versus 62.5% p<0.05); guideline-recommended OST dosage (57.3% versus 41.4%, p<0.05); and isoniazid preventive therapy (42.3% versus 11.2%, p<0.001). Subjects receiving OST had significantly higher HRQoL than those not receiving it (p<0.001); however, HRQoL did not differ significantly between ICL- and NCL-participants. CONCLUSIONS These findings suggest that OST alone improves quality-of-life, while receiving care in integrated settings collectively and individually improves healthcare quality indicators for PWID.
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Affiliation(s)
- Chethan Bachireddy
- Yale University School of Medicine, Department of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, USA
| | - Michael C. Soule
- Massachussetts General Hospital, Department of Psychiatry, Boston, USA
| | - Jacob M. Izenberg
- Yale University School of Medicine, Department of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, USA
| | - Sergey Dvoryak
- Ukrainian Institute on Public Health Policy, Kyiv, Ukraine
| | | | - Frederick L. Altice
- Yale University School of Medicine, Department of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, USA,Yale University School of Public Health, Division of Epidemiology of Microbial Diseases, New Haven, USA
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Mathauer I, Wittenbecher F. Hospital payment systems based on diagnosis-related groups: experiences in low- and middle-income countries. Bull World Health Organ 2013; 91:746-756A. [PMID: 24115798 PMCID: PMC3791650 DOI: 10.2471/blt.12.115931] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Revised: 06/03/2013] [Accepted: 06/06/2013] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE This paper provides a comprehensive overview of hospital payment systems based on diagnosis-related groups (DRGs) in low- and middle-income countries. It also explores design and implementation issues and the related challenges countries face. METHODS A literature research for papers on DRG-based payment systems in low- and middle-income countries was conducted in English, French and Spanish through Pubmed, the Pan American Health Organization's Regional Library of Medicine and Google. FINDINGS Twelve low- and middle-income countries have DRG-based payment systems and another 17 are in the piloting or exploratory stage. Countries have chosen from a wide range of imported and self-developed DRG models and most have adapted such models to their specific contexts. All countries have set expenditure ceilings. In general, systems were piloted before being implemented. The need to meet certain requirements in terms of coding standardization, data availability and information technology made implementation difficult. Private sector providers have not been fully integrated, but most countries have managed to delink hospital financing from public finance budgeting. CONCLUSION Although more evidence on the impact of DRG-based payment systems is needed, our findings suggest that (i) the greater portion of health-care financing should be public rather than private; (ii) it is advisable to pilot systems first and to establish expenditure ceilings; (iii) countries that import an existing variant of a DRG-based system should be mindful of the need for adaptation; and (iv) countries should promote the cooperation of providers for appropriate data generation and claims management.
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Affiliation(s)
- Inke Mathauer
- Department of Health Systems Financing, World Health Organization, 20 avenue Appia, 1211 Geneva, 27, Switzerland
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Footman K, Roberts B, Mills A, Richardson E, McKee M. Public satisfaction as a measure of health system performance: A study of nine countries in the former Soviet Union. Health Policy 2013; 112:62-9. [DOI: 10.1016/j.healthpol.2013.03.004] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2012] [Revised: 02/26/2013] [Accepted: 03/09/2013] [Indexed: 11/16/2022]
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Balabanova D, Mills A, Conteh L, Akkazieva B, Banteyerga H, Dash U, Gilson L, Harmer A, Ibraimova A, Islam Z, Kidanu A, Koehlmoos TP, Limwattananon S, Muraleedharan VR, Murzalieva G, Palafox B, Panichkriangkrai W, Patcharanarumol W, Penn-Kekana L, Powell-Jackson T, Tangcharoensathien V, McKee M. Good Health at Low Cost 25 years on: lessons for the future of health systems strengthening. Lancet 2013; 381:2118-33. [PMID: 23574803 DOI: 10.1016/s0140-6736(12)62000-5] [Citation(s) in RCA: 177] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- Dina Balabanova
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK.
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Rechel B, Roberts B, Richardson E, Shishkin S, Shkolnikov VM, Leon DA, Bobak M, Karanikolos M, McKee M. Health and health systems in the Commonwealth of Independent States. Lancet 2013; 381:1145-55. [PMID: 23541055 DOI: 10.1016/s0140-6736(12)62084-4] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The countries of the Commonwealth of Independent States differ substantially in their post-Soviet economic development but face many of the same challenges to health and health systems. Life expectancies dropped steeply in the 1990s, and several countries have yet to recover the levels noted before the dissolution of the Soviet Union. Cardiovascular disease is a much bigger killer in the Commonwealth of Independent States than in western Europe because of hazardous alcohol consumption and high smoking rates in men, the breakdown of social safety nets, rising social inequality, and inadequate health services. These former Soviet countries have embarked on reforms to their health systems, often aiming to strengthen primary care, scale back hospital capacities, reform mechanisms for paying providers and pooling funds, and address the overall shortage of public funding for health. However, major challenges remain, such as frequent private out-of-pocket payments for health care and underdeveloped systems for improvement of quality of care.
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Affiliation(s)
- Bernd Rechel
- European Observatory on Health Systems and Policies, London School of Hygiene & Tropical Medicine, London, UK.
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Schwarz J, Wyss K, Gulyamova ZM, Sharipov S. Out-of-pocket expenditures for primary health care in Tajikistan: a time-trend analysis. BMC Health Serv Res 2013; 13:103. [PMID: 23505990 PMCID: PMC3614449 DOI: 10.1186/1472-6963-13-103] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2012] [Accepted: 03/08/2013] [Indexed: 11/26/2022] Open
Abstract
Background Aligned with the international call for universal coverage of affordable and quality health care, the government of Tajikistan is undertaking reforms of its health system aiming amongst others at reducing the out-of-pocket expenditures (OPE) of patients seeking care. Household surveys were conducted in 2005, 2007, 2008 and 2011 to explore the scale and determinants of OPE of users in four district of Tajikistan, where health care is legally free of charge at the primary level. Methods Using the data from four cross-sectional household surveys conducted between 2005 and 2011, time trends in OPE for consultation fees, drugs and transport costs of adult users of family medicine services were analysed. To investigate differences along the economic status, an asset index was constructed using principal component analysis. Results Adjusted for inflation, OPE for primary care have substantially increased in the period 2005 to 2011. While the proportion of patients reporting the payment of informal consultation fees to providers and their amount were constant over time, the proportion of patients reporting expenditures for drugs has increased, and the median amounts have doubled from 5.3 US$ to 10.7 US$. Thus, the expenditures on medicine represent the biggest financial burden for patients accessing a primary care facility. Regression models showed that in 2011 patients from the most remote district with spread-out villages reported significant higher expenditures on medicine. Besides the steady increase in the median amount for OPE, the proportion of patients reporting making an informal payment to their care provider showed great variations across district of residence (between 20% and 73%) and economic status (between 33% among the ‘worst-off’ group and 68% among the ‘better-off’ group). Conclusions In a context of limited governmental funds allocated to health and financing reforms aiming to improve financial access to primary care, the present paper indicates that in Tajikistan OPE – especially in relation to expenditures for drugs – have increased over time, and vary substantially across geographical areas and economic status. The fact that better-off households report disbursing more and in higher proportions hints towards a discrimination along the capacity to pay from providers. Increased public investments in the health sector, incentives for family doctors to provide PHC services free of charge and a strengthened drug control and supply system are necessary strategies to improve access of patients to services.
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Affiliation(s)
- Joëlle Schwarz
- Swiss Centre for International Health, Swiss Tropical and Public Health Institute, Socinstr 57, Basel 4002, Switzerland.
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Janevic T, Sarah PW, Leyla I, Elizabeth BH. Individual and community level socioeconomic inequalities in contraceptive use in 10 Newly Independent States: a multilevel cross-sectional analysis. Int J Equity Health 2012; 11:69. [PMID: 23158261 PMCID: PMC3520858 DOI: 10.1186/1475-9276-11-69] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Accepted: 11/08/2012] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Little is known regarding the association between socioeconomic factors and contraceptive use in the Newly Independent States (NIS), countries that have experienced profound changes in reproductive health services during the transition from socialism to a market economy. METHODS Using 2005-2006 data from Demographic Health Surveys (Armenia, Azerbaijan, and Moldova) and Multiple Indicator Cluster Surveys (Belarus, Georgia, Kazakhstan, Kyrgyzstan, Tajikistan, Ukraine, and Uzbekistan), we examined associations between individual and community socioeconomic status with current modern contraceptive use (MCU) among N = 55,204 women aged 15-49 married or in a union. Individual socioeconomic status was measured using quintiles of wealth index and education level (higher than secondary school, secondary school or less). Community socioeconomic status was measured as the percentage of households in the poorest quintile of the nationals household wealth index (0%, 0-25%, or greater than 25%). We used multilevel logistic regression to estimate associations adjusted for age, number of children, urban/rural, and socioeconomic variables. RESULTS MCU varied by country from 14% (in Azerbaijan) to 62% (in Belarus). Overall, women living in the poorest communities were less likely than those in the richest to use modern contraceptives (adjusted odds ratio (aOR) = 0.82, 95% Confidence Interval = 0.76, 0.89). Similarly, there was an increasing odds of MCU with increasing individual-level wealth. Women with a lower level of education also had lower odds of MCU than those with a higher level of education (aOR = .75, 95%CI = 0.71, 0.79). In country-specific analyses, community-level socioeconomic inequalities were apparent in 4 of 10 countries; in contrast, inequalities by individual-level wealth were apparent in 7 countries and by education in 8 countries. All countries in which community-level socioeconomic status was associated with MCU were in Central Asia, whereas at the individual-level inequalities of the largest magnitude were found in the Caucasus. There were no distinct patterns found in Eastern European countries. CONCLUSIONS Community-level socioeconomic inequalities in MCU were most pronounced in Central Asian countries, whereas individual-level socioeconomic inequalities in MCU were most pronounced in the Caucasus. It is important to consider multilevel contextual determinants of modern contraceptive use in the development of reproductive health and family planning programs.
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Affiliation(s)
- Teresa Janevic
- Department of Epidemiology, UMDNJ School of Public Health, 683 Hoes Lane West, Piscataway, NJ, 08854, USA
| | - Pallas W Sarah
- Department of Health Policy and Management, Yale School of Public Health, 60 College Street, New Haven, CT, 06520, USA
| | - Ismayilova Leyla
- School of Social Service Administration, University of Chicago, 969 East 60th Street, Chicago, IL, 60637, USA
| | - Bradley H Elizabeth
- Department of Health Policy and Management, Yale School of Public Health, 60 College Street, New Haven, CT, 06520, USA
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Aringazina A, Gulis G, Allegrante JP. Public Health Challenges and Priorities for Kazakhstan. Cent Asian J Glob Health 2012; 1:30. [PMID: 29755863 PMCID: PMC5927750 DOI: 10.5195/cajgh.2012.30] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The Republic of Kazakhstan is one of the largest and fastest growing post-Soviet economies in Central Asia. Despite recent improvements in health care in response to Kazakhstan 2030 and other state-mandated policy reforms, Kazakhstan still lags behind other members of the Commonwealth of Independent States of the European Region on key indicators of health and economic development. Although cardiovascular diseases are the leading cause of mortality among adults, HIV/AIDS, tuberculosis, and blood-borne infectious diseases are of increasing public health concern. Recent data suggest that while Kazakhstan has improved on some measures of population health status, many environmental and public health challenges remain. These include the need to improve public health infrastructure, address the social determinants of health, and implement better health impact assessments to inform health policies and public health practice. In addition, more than three decades after the Declaration of Alma-Ata, which was adopted at the International Conference on Primary Health Care convened in Kazakhstan in 1978, facilitating population-wide lifestyle and behavioral change to reduce risk factors for chronic and communicable diseases, as well as injuries, remains a high priority for emerging health care reforms and the new public health. This paper reviews the current public health challenges in Kazakhstan and describes five priorities for building public health capacity that are now being developed and undertaken at the Kazakhstan School of Public Health to strengthen population health in the country and the Central Asian Region.
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Affiliation(s)
- Altyn Aringazina
- Department of Population Health and Social Sciences, Kazakhstan School of Public Health, Almaty, Republic of Kazakhstan
| | - Gabriel Gulis
- Unit for Health Promotion Research, University of Southern Denmark, Esbjerg, Denmark
| | - John P Allegrante
- Department of Health and Behavior Studies, Teachers College, and Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY USA
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Beran D, Abdraimova A, Akkazieva B, McKee M, Balabanova D, Yudkin JS. Diabetes in Kyrgyzstan: changes between 2002 and 2009. Int J Health Plann Manage 2012; 28:e121-37. [DOI: 10.1002/hpm.2145] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2011] [Revised: 04/30/2012] [Accepted: 09/13/2012] [Indexed: 11/09/2022] Open
Affiliation(s)
| | | | | | - Martin McKee
- London School of Hygiene and Tropical Medicine; London; UK
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Balabanova D, Roberts B, Richardson E, Haerpfer C, McKee M. Health care reform in the former Soviet Union: beyond the transition. Health Serv Res 2011; 47:840-64. [PMID: 22092004 DOI: 10.1111/j.1475-6773.2011.01323.x] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To assess accessibility and affordability of health care in eight countries of the former Soviet Union. DATA SOURCES/STUDY SETTING Primary data collection conducted in 2010 in Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Moldova, Russia, and Ukraine. STUDY DESIGN Cross-sectional household survey using multistage stratified random sampling. DATA COLLECTION/EXTRACTION METHODS Data were collected using standardized questionnaires with subjects aged 18+ on demographic, socioeconomic, and health care access characteristics. Descriptive and multivariate regression analyses were used. PRINCIPAL FINDINGS Almost half of respondents who had a health problem in the previous month which they viewed as needing care had not sought care. Respondents significantly less likely to seek care included those living in Armenia, Georgia, or Ukraine, in rural areas, aged 35-49, with a poor household economic situation, and high alcohol consumption. Cost was most often cited as the reason for not seeking health care. Most respondents who did obtain care made out-of-pocket payments, with median amounts varying from $13 in Belarus to $100 in Azerbaijan. CONCLUSIONS Access to health care and within-country inequalities appear to have improved over the past decade. However, considerable problems remain, including out-of-pocket payments and unaffordability despite efforts to improve financial protection.
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Affiliation(s)
- Dina Balabanova
- London School of Hygiene and Tropical Medicine, Faculty of Public Health and Policy, 15-17 Tavistock Place, London, WC1H 9SH, UK.
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