世界経済・社会統計 = World development indicators

http://hsrii.org/wp-content/uploads/2014/07/AP681-GHLC-Lancet.pdf

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

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

https://www.who.int/bulletin/volumes/91/10/12-115931.pdf

Hospital payment systems based on diagnosis-related groups: experiences in low- and middle-income countries

Research on what has been termed global health is geographically uneven. Much of the published literature can be divided into two categories; that addressing issues which are truly global, such as climate change, pandemic influenza, and global health institutions and that addressing issues affecting low-income countries, especially those in sub-Saharan Africa and South Asia. By contrast, there is remarkably little on regions containing middle-income countries, such as the former Soviet Union, the Middle East and North Africa, and the Pacific Islands. Among middle- and low-income countries, a few, such as Bangladesh, Thailand, and Uganda, have been the subject of intensive research while others are almost absent from the literature.

In this study, we examine access to care and its determinants in the context of rapid and diverse change in the funding and delivery of health care in one of these neglected regions, the former Soviet Union, two decades after these countries gained independence. Each country has followed a different trajectory of health system change, and we seek to take a snapshot of access to services for those who believe they need care.

Now is an appropriate time to take stock. The first decade following independence involved a process of state building, as politicians struggled with a new reality in which the old political and economic dogma no longer applied. They all faced catastrophic financial problems and, in some, gross domestic product per capita has not yet returned to 1989 levels. Others recovered more rapidly, but this was often as a consequence of profits from oil, gas, and minerals that were concentrated in the hands of a few. Within the available resources countries varied in how much governments were willing to allocate to public budgets and, in turn, the priority they gave to the health budget (Kutzin, Cashin, and Jakab 2010) (Table 1). In those newly independent states most affected, the Semashko health system inherited from the Soviet Union virtually collapsed, as they were unable to raise the necessary funds, skilled health workers left, and pharmaceuticals and technology, now at world prices (or often higher, as the newly privatized distributors took their cut) became unaffordable (Rechel and McKee 2009). Some sought, with varying degrees of success, to implement new financing systems based on health insurance, while Azerbaijan, Belarus, Tajikistan, Turkmenistan, Ukraine, and Uzbekistan essentially retained many of the features of the Soviet health system, although in the face of growing economic pressures (Figueras et al. 2004; Kutzin 2010). In many, out-of-pocket payments expanded to fill the space left by drastic reductions of state funds.



Table 1

Key Health System Indicators of the Study Countries (Various Sources, Most Recent Data Available)



They have also struggled to reform health care delivery, with health professionals coming to terms with new roles (Healy and McKee 1997) during the reconfiguration of an inefficient and increasingly obsolete health care estate (Healy and McKee 2002). There were many failures but also some successes, with a few countries managing to implement effective policies and achieve good results despite severe economic and institutional constraints (Kutzin, Jakab, and Cashin 2010; Rechel et al. 2011).

This period was extremely traumatic for those living in the region; they were plunged into uncertainty as the paradigm they had grown up with was abandoned (Field and Twigg 2000). New and unfamiliar institutional frameworks were put in place and those interacting with them had to learn the new rules (Lewis 2000). This was especially difficult for many users of health care, who inevitably include many of the most vulnerable in society who have the fewest economic and social resources.

A series of household surveys we conducted in eight former Soviet countries in 2001 as part of the Living Conditions, Lifestyles, and Health (LLH) project revealed the impact on ordinary people (Balabanova et al. 2004). In Belarus, which had rejected rapid economic reforms, people were still able to obtain health care without great difficulty (although it was clear even then that the same lack of reform was also causing the country increasingly to fall behind economically, raising questions about the sustainability of the system). By contrast, for those living in Armenia and Georgia, which in addition to more severe economic collapse had experienced major armed conflicts, the systems were clearly failing. Those who needed care were unable to obtain it and, when they were, largely paid out of pocket. Those who were already disadvantaged were experiencing the greatest problems.

In this study, we report the findings from a new wave of surveys undertaken in countries in this region in early 2010. Since our earlier surveys, things have changed considerably, although not in a consistent way. Most of the economies are growing, in some cases rapidly as a consequence of exploiting natural resources. However, the benefits have not been shared by all and while the share of households with income below the poverty line ($1.25 and $3) has fallen since the early 1990s, incomes are now much more unequal and inequalities continue to grow (World Bank 2010).

Many of the new institutions and practices introduced during the transition from socialism are now embedded in their societies, but reforms to health care financing have proven difficult to implement. Kyrgyzstan and Moldova (Kutzin, Jakab, and Shishkin 2009) have managed to introduce insurance systems with individual enrollment, risk pooling, and output-based payments, although some of these elements can be found in other countries (Kutzin 2010). People in the region now have much greater understanding about how their reconfigured health systems work, although the persistence of informal payments continues to create considerable uncertainty. Populations that were once isolated now have access to developments in the rest of the world, although not necessarily to the democratic systems they see elsewhere. Thus, we were unable to undertake surveys in Turkmenistan, where the government actively suppresses information on the health of its population (Rechel and McKee 2007), or Uzbekistan, which also seeks to control what is reported about it. Finally, the overall stability that has come about in the region remains susceptible to disruption, exemplified by our need to postpone our survey in Kyrgyzstan because of the civil disorder that erupted in early 2010 while the field work in Georgia was complicated in the aftermath of the conflict with Russia over South Ossetia and Abkhazia.

Our approach draws on the WHO framework that identifies the goals of a health system as not only to improve health but also to ensure responsiveness, fairness, and financial protection (WHO 2007). Access to necessary services is a core element of this concept and this is what we focus upon here. It is not possible, with only two studies only a decade apart, to attribute particular findings to specific reforms with any degree of certainty. Hence, our article is of necessity primarily descriptive.

Our focus is on a region of the world that has a number of specificities, in particular the historical legacy of communist rule for most of the 20th century, ending in political, social, and economic collapse. Nonetheless, we believe that some of our findings do have implications for countries elsewhere, including those emerging from major conflicts or large-scale political change.

/pdf/health-care-reform-in-the-former-soviet-union-beyond-the-ff9u8ud6m3.pdf

Health Care Reform in the Former Soviet Union: Beyond the Transition

A Framework for Health System Comparisons: the Health Systems in Transition (HiT) Series of the European Observatory on Health Systems and Policies

Since becoming independent at the break-up of the Soviet Union in 1991, the countries of Central Asia have made profound changes to their health systems, affecting organization and governance, financing and delivery of care. The changes took place in a context of adversity, with major political transition, economic recession, and, in the case of Tajikistan, civil war, and with varying degrees of success. In this paper we review these experiences in this rarely studied part of the world to identify what has worked. This includes effective governance, the co-ordination of donor activities, linkage of health care restructuring to new economic instruments, and the importance of pilot projects as precursors to national implementation, as well as gathering support among both health workers and the public.

A Katsaga

Papers

Lessons from two decades of health reform in Central Asia.

Finally on track? Health reforms in Kazakhstan