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Hanh TTD, Ngoc LB, Hoa LN, Gong E, Tao X, Yan LL, Minh HV. Improving prevention of cardiovascular diseases: Barriers and facilitators in primary care services in Vietnam. INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 2021. [DOI: 10.1080/20479700.2020.1757858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
| | - Le Bich Ngoc
- Hanoi University of Public Health, Hanoi, Vietnam
| | - Lam Ngoc Hoa
- Hanoi University of Public Health, Hanoi, Vietnam
| | - Enying Gong
- Global Health Research Center, Duke Kunshan University, Kunshan, People’s Republic of China
| | - Xuanchen Tao
- Global Health Research Center, Duke Kunshan University, Kunshan, People’s Republic of China
| | - Lijing L. Yan
- Global Health Research Center, Duke Kunshan University, Kunshan, People’s Republic of China
- Global Health Institute, Duke University, Durham, NC, USA
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How Different Motivations for Making Informal Out-Of-Pocket Payments Vary in Their Influence on Users' Satisfaction with Healthcare, Local and National Government, and Satisfaction with Life? BIOMED RESEARCH INTERNATIONAL 2021; 2021:5763003. [PMID: 34485519 PMCID: PMC8416363 DOI: 10.1155/2021/5763003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 07/22/2021] [Accepted: 07/28/2021] [Indexed: 11/17/2022]
Abstract
Background The dominant view in the literature is that informal payments in healthcare universally are a negative phenomenon. By contrast, we theorize that the motivation healthcare users for making informal payments (IP) can be classified into three categories: (1) a cultural norm, (2) “grease the wheels” payments if users offered to pay to get better services, and (3) “sand the wheels” payments if users were asked to pay by healthcare personnel or felt that payments were expected. We further hypothesize that these three categories of payments are differently associated with a user's outcomes, namely, satisfaction with healthcare, local and national government, satisfaction with life, and satisfaction with life of children in the future. Methods We used microdata from the 2016 Life-in-Transition survey. Multivariate regression analysis is used to quantify relationships between these categories of payments and users' outcomes. Results Payments that are the result of cultural norms are associated with better outcomes. On the contrary, “sand the wheel” payments are associated with worse outcomes. We find no association between making “grease the wheels” payments and outcomes. Conclusions This is the first paper which evaluates association between three different categories of informal payments with a wide range of users' outcomes on a diverse sample of countries. Focusing on informal payments in general, rather than explicitly examining specific motivations, obscures the true outcomes of making IP. It is important to distinguish between three different motivations for informal payment, namely, cultural norms, “grease the wheels,” and “sand the wheels” since they have varying associations with user outcomes. From a policy making standpoint, variation in the links between different motivations for making IP and measures of satisfaction suggest that decision-makers should put their primary focus on situations where IP are explicitly asked for or are implied by the situation and that they should differentiate this from cases of gratitude payments. If such measures are not implemented, then policy makers may unintentionally ban the behaviour that is linked with increased satisfaction with healthcare, government, and life (i.e., paying gratitude).
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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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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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El-Jardali F, Fadlallah R, Daouk A, Rizk R, Hemadi N, El Kebbi O, Farha A, Akl EA. Barriers and facilitators to implementation of essential health benefits package within primary health care settings in low-income and middle-income countries: A systematic review. Int J Health Plann Manage 2018; 34:15-41. [PMID: 30132987 DOI: 10.1002/hpm.2625] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 07/18/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND One of the key requirements for achieving universal health coverage is the proper design and implementation of essential health benefits package (EHPs). We systematically reviewed the evidence on barriers and facilitators to the implementation of EHPs within primary health care settings in low-income and middle-income countries. METHODS We searched multiple databases and the gray literature. Two reviewers completed independently and in duplicate data selection, data extraction, and quality assessment. We synthesized the findings according to the following health systems arrangement levels: governance, financial, and delivery arrangements. RESULTS Ten studies met the eligibility criteria. At the governance level, key reported barriers were insufficient policymaker-implementer interactions, limited involvement of consumers and stakeholders, sub-optimal primary health care network arrangement, poor marketing and promotion of package, and insufficient coordination with community network. The key reported facilitator was the presence of a legal policy framework for package implementation. At the financial level, barriers included delays and inadequate remunerations to health care providers while facilitators included government and donor commitments to financing of package and flexibility in exploring new funding mechanisms. At the delivery level, barriers included inadequate supervision, poor facility infrastructure, limited availability of equipment and supplies, and shortages of workers. Facilitators included proper training and management of workforce, availability of female health workers, presence of clearly defined packages, and continuum of care, including referrals to promote comprehensive service delivery. CONCLUSION We identified a set of barriers and facilitators that need to be addressed to ensure proper implementation of EHPs within primary health care settings.
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Affiliation(s)
- Fadi El-Jardali
- Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon.,Center for Systematic Review in Health Policy and Systems Research (SPARK), American University of Beirut, Beirut, Lebanon.,Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Racha Fadlallah
- Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon.,Center for Systematic Review in Health Policy and Systems Research (SPARK), American University of Beirut, Beirut, Lebanon
| | - Aref Daouk
- Center for Systematic Review in Health Policy and Systems Research (SPARK), American University of Beirut, Beirut, Lebanon.,Staten Island University Hospital, New York, New York, USA
| | - Rana Rizk
- Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands.,Institut National de Santé Publique, d'Épidémiologie Clinique et de Toxicologie (INSPECT-LB), Faculty of Public Health, Lebanese University, Lebanon
| | - Nour Hemadi
- Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon.,Center for Systematic Review in Health Policy and Systems Research (SPARK), American University of Beirut, Beirut, Lebanon
| | - Ola El Kebbi
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Aida Farha
- Saab Medical Library, American University of Beirut, Beirut, Lebanon
| | - Elie A Akl
- Center for Systematic Review in Health Policy and Systems Research (SPARK), American University of Beirut, Beirut, Lebanon.,Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada.,Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
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Akl EA, El-Jardali F, Bou Karroum L, El-Eid J, Brax H, Akik C, Osman M, Hassan G, Itani M, Farha A, Pottie K, Oliver S. Effectiveness of Mechanisms and Models of Coordination between Organizations, Agencies and Bodies Providing or Financing Health Services in Humanitarian Crises: A Systematic Review. PLoS One 2015; 10:e0137159. [PMID: 26332670 PMCID: PMC4558048 DOI: 10.1371/journal.pone.0137159] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 08/13/2015] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Effective coordination between organizations, agencies and bodies providing or financing health services in humanitarian crises is required to ensure efficiency of services, avoid duplication, and improve equity. The objective of this review was to assess how, during and after humanitarian crises, different mechanisms and models of coordination between organizations, agencies and bodies providing or financing health services compare in terms of access to health services and health outcomes. METHODS We registered a protocol for this review in PROSPERO International prospective register of systematic reviews under number PROSPERO2014:CRD42014009267. Eligible studies included randomized and nonrandomized designs, process evaluations and qualitative methods. We electronically searched Medline, PubMed, EMBASE, Cochrane Central Register of Controlled Trials, CINAHL, PsycINFO, and the WHO Global Health Library and websites of relevant organizations. We followed standard systematic review methodology for the selection, data abstraction, and risk of bias assessment. We assessed the quality of evidence using the GRADE approach. RESULTS Of 14,309 identified citations from databases and organizations' websites, we identified four eligible studies. Two studies used mixed-methods, one used quantitative methods, and one used qualitative methods. The available evidence suggests that information coordination between bodies providing health services in humanitarian crises settings may be effective in improving health systems inputs. There is additional evidence suggesting that management/directive coordination such as the cluster model may improve health system inputs in addition to access to health services. None of the included studies assessed coordination through common representation and framework coordination. The evidence was judged to be of very low quality. CONCLUSION This systematic review provides evidence of possible effectiveness of information coordination and management/directive coordination between organizations, agencies and bodies providing or financing health services in humanitarian crises. Our findings can inform the research agenda and highlight the need for improving conduct and reporting of research in this field.
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Affiliation(s)
- Elie A. Akl
- Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Fadi El-Jardali
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Department of Health Management and Policy, American University of Beirut, Beirut, Lebanon
- McMaster Health Forum, McMaster University, Hamilton, Ontario, Canada
- Research, Advocacy and Public Policy-making Program, Issam Fares Institute for Public Policy and International Affairs, American University of Beirut, Beirut, Lebanon
| | - Lama Bou Karroum
- Department of Health Management and Policy, American University of Beirut, Beirut, Lebanon
| | - Jamale El-Eid
- VP of Medical Affairs, American University of Beirut, Beirut, Lebanon
| | - Hneine Brax
- Faculty of Medicine, Université Saint Joseph, Beirut, Lebanon
| | - Chaza Akik
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Mona Osman
- Department of Family Medicine, American University of Beirut, Beirut, Lebanon
| | - Ghayda Hassan
- Department of Psychology, University of Québec, Montreal, Québec, Canada
| | - Mira Itani
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Aida Farha
- Saab Medical Library, American University of Beirut, Beirut, Lebanon
| | - Kevin Pottie
- Department of Epidemiology and Community Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Sandy Oliver
- Department of Childhood, Families and Health, Social Science Research Unit, Institute of Education, University of London, London, United Kingdom
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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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Ancker S, Rechel B. HIV/AIDS policy-making in Kyrgyzstan: a stakeholder analysis. Health Policy Plan 2013; 30:8-18. [PMID: 24342741 DOI: 10.1093/heapol/czt092] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Kyrgyzstan has adopted a number of policy initiatives to deal with an accelerating HIV/AIDS epidemic. This article explores the main actors in HIV/AIDS policy-making, their interests, support and involvement and their current ability to set the agenda and influence the policy-making process. Fifty-four semi-structured interviews were conducted in the autumn of 2011, complemented by a review of policy documents and secondary sources on HIV/AIDS in Kyrgyzstan. We found that most stakeholders were supportive of progressive HIV/AIDS policies, but that their influence levels varied considerably. Worryingly, several major state agencies exhibited some resistance or lack of initiative towards HIV/AIDS policies, often prompting international agencies and local NGOs to conceptualize and drive appropriate policies. We conclude that, without clear vision and leadership by the state, the sustainability of the national response will be in question.
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Affiliation(s)
- Svetlana Ancker
- Faculty of Public Health and Policy, Department of Health Services Research and Policy London School of Hygiene & Tropical Medicine, London, UK and Faculty of Public Health and Policy, Department of Health Services Research and Policy, European Observatory on Health Systems and Policies, London School of Hygiene & Tropical Medicine, London, UK
| | - Bernd Rechel
- Faculty of Public Health and Policy, Department of Health Services Research and Policy London School of Hygiene & Tropical Medicine, London, UK and Faculty of Public Health and Policy, Department of Health Services Research and Policy, European Observatory on Health Systems and Policies, London School of Hygiene & Tropical Medicine, London, UK
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Steinmann P, Baimatova M, Wyss K. Patient referral patterns by family doctors and to selected specialists in Tajikistan. Int Health 2013; 4:268-76. [PMID: 24029672 DOI: 10.1016/j.inhe.2012.09.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
Referral rates are a key measure for the functioning of a healthcare system. The objective of this study was to assess referral patterns from family doctors (FD) and selected specialists to other specialists and hospitals in two rayons (districts) of Tajikistan. Quantitative data on referral decisions and self-referral was collected among FDs and selected specialists over a 10-workday period in 2008. For comparison, the collected information was contrasted to routinely recorded data and figures from the national health information system (HIS). The mean referral rate of FDs was 20.0% while the referral rate according to the HIS was 4.5%. In one rayon, the majority of the referred patients were sent to hospitals (65.6%) while in the other rayon, 65.9% were advised to see a specialist. Technical diagnostic tests not available at the primary healthcare level triggered the majority of all referrals. A need for diagnosis and treatment by specialists accounted for 19.2% of the referrals. Self-referral was common among patients seen by ophthalmologists and otorhinolaryngologists (76.0%). We conclude that referral rates among Tajik FD patients are high and self-referral of patients to a specialist is the norm. The routine HIS fails to provide accurate data.
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Affiliation(s)
- Peter Steinmann
- Swiss Center for International Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
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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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11
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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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Teutsch S, Rechel B. Ethics of Resource Allocation and Rationing Medical Care in a Time of Fiscal Restraint - US and Europe. Public Health Rev 2012. [DOI: 10.1007/bf03391667] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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13
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Rechel B, Ahmedov M, Akkazieva B, Katsaga A, Khodjamurodov G, McKee M. Lessons from two decades of health reform in Central Asia. Health Policy Plan 2011; 27:281-7. [PMID: 21609971 DOI: 10.1093/heapol/czr040] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
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.
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Affiliation(s)
- B Rechel
- European Observatory on Health Systems and Policies, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK.
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