Health and health systems in the Commonwealth of Independent States

Historical evolution of healthcare systems of post-soviet Russia, Belarus, Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan, Uzbekistan, Armenia, and Azerbaijan: A scoping review

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.

Breast and cervical cancer screening practices in nine countries of Eastern Europe and Central Asia: A population-based survey

BACKGROUND

Eastern Europe and Central Asia (EECA) countries have higher cervical and breast cancer mortality rates and later stage at diagnosis compared with the rest of WHO European Region. The aim was to explore current early detection practices including "dispensarization" for breast and cervix cancer in the region.

METHODS

A questionnaire survey on early detection practices for breast and cervix cancer was sent to collaborators in 11 countries, differentiating services in the primary health setting, and population-based programs. Responses were received from Armenia, Belarus, Georgia, Kazakhstan, Kyrgyzstan, the Russian Federation (Arkhangelsk, Samara and Tomsk regions), Tajikistan, Ukraine, and Uzbekistan.

RESULTS

All countries but Georgia, Kyrgyzstan, and the Russian Federation had opportunistic screening by clinical breast exam within "dispensarization" program. Mammography screening programs, commonly starting from age 40, were introduced or piloted in eight of nine countries, organized at national oncology or screening centres in Armenia, Belarus and Georgia, and within primary care in others. Six countries had "dispensarization" program for cervix cancer, mostly starting from the age 18, with smears stained either by Romanowsky-Giemsa alone (Belarus, Tajikistan and Ukraine), or alternating with Papanicolaou (Kazakhstan and the Russian Federation). In parallel, screening programs using Papanicolaou or HPV test were introduced in seven countries and organized within primary care.

CONCLUSION

Our study documents that parallel screening systems for both breast and cervix cancers, as well as departures from evidence-based practices are widespread across the EECA. Within the framework of the WHO Initiatives, existing opportunistic screening should be replaced by population-based programs that include quality assurance and control.

Burden of bradycardia and barriers to accessing bradycardia therapy in underserved countries

Bradycardia, a condition characterized by an abnormally slow heart rate, poses significant challenges in terms of diagnosis and treatment. While it is a concern world-wide, low- and middle-income countries (LMICs) face substantial barriers in accessing appropriate bradycardia therapy. This article aims to explore the global aetiology and incidence of bradycardia, compare the prevalence and management of the condition in high-income countries versus LMICs, identify the key reasons behind the disparities in access to bradycardia therapy in LMICs, and emphasize the urgent need to address these disparities to ensure equitable healthcare on a global scale.

The correlation between economic fluctuation, workforce employment and health expenditure in the BRICS countries

In this paper, we use the Fourier ARDL method (data from 2000 to 2019) to examine whether there is a correlation between economic fluctuation, health expenditure, and employment rate among BRICS countries. Fourier ARDL's model, the same as Bootstrap ARDL model, is to test the long-term cointegration relationship of variables; when there is cointegration, it will test whether there is a causal relationship. When there is no cointegration, short-term Granger causality between variables is tested. Our study shows that, in the long-term, whether South Africa takes economic fluctuation, employment rate or health expenditure as the dependent variable, there is a cointegration relationship with the other two independent variables, but the causal relationship is not significant. In short-term Granger causality tests, the effects of economic fluctuation in Brazil, China, and South Africa on health expenditure lag significantly by one period. Economic fluctuation in Brazil, India and China had a negative effect on employment rate, while South Africa had a positive effect. Health expenditure in Russia and India has a negative effect on employment rate, while China has a positive effect. Employment rates in China and South Africa have a significant positive effect on economic fluctuation, while Russia has a negative effect. India's employment rate has a negative effect on health expenditure, while South Africa's has a positive effect. In short-term causality tests, different countries will exhibit different phenomena. Except for economic fluctuation, where health spending is positive, everything else is negatively correlated, and all of them are positive in South Africa. Finally, we make policy recommendations for the BRICS countries on economic fluctuation, employment rates, and health expenditure.

Current dichotomous metrics obscure trends in severe and extreme child growth failure

Historically, the prevalence of child growth failure (CGF) has been tracked dichotomously as the proportion of children more than 2 SDs below the median of the World Health Organization growth standards. However, this conventional "thresholding" approach fails to recognize child growth as a spectrum and obscures trends in populations with the highest rates of CGF. Our analysis presents the first ever estimates of entire distributions of HAZ, WHZ, and WAZ for each of 204 countries and territories from 1990 to 2020 for children less than 5 years old by age group and sex. This approach reflects the continuous nature of CGF, allows us to more comprehensively assess shrinking or widening disparities over time, and reveals otherwise hidden trends that disproportionately affect the most vulnerable populations.

Progress in reducing premature mortality from cancer and cardiovascular disease in the former Soviet Union, 2000-19

Background

A reduction in non-communicable diseases premature mortality by one-third by 2030 is one of the targets of the UN Sustainable Development Goals (SDG3.4). We examined the mortality profiles in the Newly Independent States of the former Soviet Union (NIS) and the European Union (EU) and assessed progress in reductions of premature mortality from cancer, as compared to cardiovascular disease (CVD).

Methods

We used WHO’s Global Health Estimates and GLOBOCAN 2020 to examine current mortality profiles and computed the unconditional probabilities of dying at ages 30–70 from CVD and cancer for the years 2000–19 in both sexes, using a linear extrapolation of this trend to predict whether the target of a one-third reduction, as set in 2015, would be met in 2030.

Results

CVD was the main cause of premature death in the NIS (43%), followed by cancer (23%), inversely from the EU with 42% cancer and 24% CVD deaths. The NIS achieved major reductions in premature CVD mortality, although the probabilities of death in 2019 remained about five times higher in the NIS compared to the EU. For cancer, mortality reductions in most NIS were quite modest, other than large declines seen in Kazakhstan (44%) and Kyrgyzstan (30%), with both on course to meet the 2030 target.

Conclusions

Limited progress in cancer control in the NIS calls for policy action both in terms of structural changes towards universal health coverage, and scaling up of national cancer control plans, including a shift from opportunistic to evidence-based early detection practices.

Strategies to address non-communicable diseases in the Commonwealth of Independent States countries: a scoping review

Aim:

The aim of this study is to review the literature in Commonwealth of Independent States (CIS) countries with regard to their response to non-communicable diseases (NCDs) and the implementation of the World Health Organization (WHO) Package of Essential Non-communicable (PEN) disease interventions for primary health care.

Background:

NCDs are estimated to account from 62% to 92% of total deaths in CIS countries. Current management of NCDs in CIS countries is focused on specialists and hospital care versus primary health care (PHC) as recommended by the WHO.

Methods:

This paper uses a scoping review of published and grey literature focusing on diabetes and hypertension in CIS countries. These two conditions are chosen as they represent a large burden in CIS countries and are included in the responses proposed by the WHO PEN.

Findings:

A total of 96 documents were identified and analysed with the results presented using the WHO Health System Building Blocks. Most of the publications identified focused on the service delivery (41) and human resources (20) components, while few addressed information and research (17), and only one publication was related to medical products. As for their disease of focus, most studies focused on hypertension (14) and much less on diabetes (3). The most studies came from Russia (18), followed by Ukraine (21) and then Kazakhstan (12). Only two countries Moldova and Kyrgyzstan have piloted the WHO PEN. Overall, the studies identified highlight the importance of the PHC system to better control and manage NCDs in CIS countries. However, these present only strategies versus concrete interventions. One of the main challenges is that NCD care at PHC in CIS countries continues to be predominantly provided by specialists in addition to focusing on treatment versus preventative services.

Assessing Health Data Security Risks in Global Health Partnerships: Development of a Conceptual Framework

Background

Health care databases contain a wealth of information that can be used to develop programs and mature health care systems. There is concern that the sensitive nature of health data (eg, ethnicity, reproductive health, sexually transmitted infections, and lifestyle information) can have significant impact on individuals if misused, particularly among vulnerable and marginalized populations. As academic institutions, nongovernmental organizations, and international agencies begin to collaborate with low- and middle-income countries to develop and deploy health information technology (HIT), it is important to understand the technical and practical security implications of these initiatives.

Objective

Our aim is to develop a conceptual framework for risk stratification of global health data partnerships and HIT projects. In addition to identifying key conceptual domains, we map each domain to a variety of publicly available indices that could be used to inform a quantitative model.

Methods

We conducted an overview of the literature to identify relevant publications, position statements, white papers, and reports. The research team reviewed all sources and used the framework method and conceptual framework analysis to name and categorize key concepts, integrate them into domains, and synthesize them into an overarching conceptual framework. Once key domains were identified, public international data sources were searched for relevant structured indices to generate quantitative counterparts.

Results

We identified 5 key domains to inform our conceptual framework: State of HIT, Economics of Health Care, Demographics and Equity, Societal Freedom and Safety, and Partnership and Trust. Each of these domains was mapped to a number of structured indices.

Conclusions

There is a complex relationship among the legal, economic, and social domains of health care, which affects the state of HIT in low- and middle-income countries and associated data security risks. The strength of partnership and trust among collaborating organizations is an important moderating factor. Additional work is needed to formalize the assessment of partnership and trust and to develop a quantitative model of the conceptual framework that can help support organizational decision-making.

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?

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).

Widespread collapse, glimpses of revival: a scoping review of mental health policy and service development in Central Asia

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.

Determinants of Legislation on Social Health Insurance in Transition Countries

This study aims to address the question: Why did transition countries enact laws related to social health insurance (SHI) at different times, even though they experienced dissolution of the Soviet Union at the same time in the early 1990s? We used Ragin's fuzzy-set qualitative comparative analysis to investigate the configurations of causal conditions that affected the speed of developing SHI-related legislation in 24 post-socialist countries. The potential causal conditions were health status, economic status, level of governance, level of democracy, issue salience, and number of medical professionals. We found 3 pathways that led to the enactment of SHI-related laws and 1 pathway that inhibits enactment. The key factors impacting enactment of SHI-related laws were non-corrupt governments and realization of democracy. In addition, medical professionals' involvement in policymaking could be the factor to enact SHI-related laws. Further research is needed for more in-depth analysis regarding what the laws specifically include, type of health insurance systems that were adopted based on the laws, and if the legislation contributed toward achieving universal health coverage.

The distributive fairness of out-of-pocket healthcare expenditure in the Russian Federation

This article examines the effects of socioeconomic position and urban-rural settlement on the distribution of out-of-pocket expenditure (OPE) for health in the Russian Federation. Data comes from 2005 to 2016 waves of the Russian Longitudinal Monitoring Survey. Concentration index reflects changes in the distribution of OPE between the worse-off and the better-off Russians over a 12-year period. Finally, unconditional quantile regression-a recentred influence function approach estimates differential impacts of covariates along the distribution of OPE. OPE is concentrated amongst the better-off Russians in 2016. Urban settlements contribute to top end OPE distribution for the richest and town settlements, at the median for the richest and the poorest. Our model for the analysis is unique in the context of study population, as it marginalises the effect over the distributions of other covariates used in the model.

Testing the influence of musical expertise on novel word learning across the lifespan using a cross-sectional approach in children, young adults and older adults

Word learning is a multifaceted perceptual and cognitive task that is omnipresent in everyday life. Currently, it is unclear whether this ability is influenced by age, musical expertise or both variables. Accordingly, we used EEG and compared behavioral and electrophysiological indices of word learning between older adults with and without musical expertise (older adults' perspective) as well as between musically trained and untrained children, young adults, and older adults (lifespan perspective). Results of the older adults' perspective showed that the ability to learn new words is preserved in elderly, however, without a beneficial influence of musical expertise. Otherwise, results of the lifespan perspective revealed lower error rates and faster reaction times in young adults compared to children and older adults. Furthermore, musically trained children and young adults outperformed participants without musical expertise, and this advantage was accompanied by EEG manifestations reflecting faster learning and neural facilitation in accessing lexical-semantic representations.

Quality improvement in hospitals in the Russian Federation, 2000-2016: a systematic review

We reviewed published evidence on quality improvement in hospitals in the Russian Federation since 2000. We used three data sources: MEDLINE, 'Rossiiskaia Meditsina' (Central Scientific Medical Library), and elibrary.ru using specific search terms. No language or study design restrictions were imposed. In total, 1717 articles were identified; 51 met the inclusion criteria and were thematically analysed. Russian legislation, government acts and grey literature were sourced to contextualise identified themes. Since 2010, the Federal Ministry of Health has increasingly sought to improve quality of care, providing additional resources and new initiatives across the health system. These include clinical practice guidelines, pay for performance schemes, electronic medical records, more specialist care, paraclinical care, and quality control systems. Quality of care, increasingly a concern of the Russian government, is said to be improving. Yet most initiatives have rarely been evaluated. This reflects the limited capacity for health services research in Russia. It seems likely that the full potential for improvements in quality of care in Russia is still to be realised.

Health Systems and Their Assessment: A Methodological Proposal of the Synthetic Outcome Measure

The effectiveness of health systems is an area of constant interest for public health researchers and practitioners. The varied approach to effectiveness itself has resulted in numerous methodological proposals related to its measurement. The limitations of the currently used methods lead to a constant search for better tools for the assessment of health systems. This article shows the possibilities of using the health system synthetic outcome measure (SOM) for this purpose. It is an original tool using 41 indicators referring to the epidemiological situation, health behaviors, and factors related to the health-care system, which allows a relatively quick and easy assessment of the health system in terms of its effectiveness. Construction of the measure of health system functioning in such a way allowed its presentation in dynamic perspective, i.e., assessing not only the health system itself in a given moment of time but also changes in the value of the effectiveness measures. In order to demonstrate the cognitive value of the SOM, the analysis of the effectiveness of health systems in 21 countries of Central and Eastern Europe during the transformation period was carried out. The mean SOM values calculated on the basis of the component measures allowed to differentiate countries in terms of the effectiveness of their health systems. Considering the whole period, a similar level of health system effects can be observed in Slovenia, Croatia, Czech Republic, Slovakia, Poland, Macedonia, and Albania. In the middle group, Hungary, Romania, Latvia, Lithuania, Georgia, Estonia, Bulgaria, Belarus, and Armenia were found. The third group, weakest in terms of achieved effects, was formed by health systems in countries like Ukraine, Moldova, and Russia. The presented method allows for the analysis of the health system outcomes from a comparative angle, eliminating arbitrariness of pinpointing a model solution as a potential reference point in the assessment of the systems. The measure, with the use of additional statistical tools to establish correlations with elements of the external and internal environment of a health system, allows for conducting analyses of conditions for differences in the effects of health system operation and circumstances for the effectiveness of reform processes.

Quality of radiotherapy services in post-Soviet countries: An IAEA survey

BACKGROUND

The quality of radiotherapy services in post-Soviet countries has not yet been studied following a formal methodology. The IAEA conducted a survey using two sets of validated radiation oncology quality indicators (ROIs).

METHODS

Eleven post-Soviet countries were assessed. A coordinator was designated for each country and acted as the liaison between the country and the IAEA. The methodology was a one-time cross-sectional survey using a 58-question tool in Russian. The questionnaire was based on two validated sets of ROIs: for radiotherapy centres, the indicators proposed by Cionini et al., and for data at the country level, the Australasian ROIs.

RESULTS

The overall response ratio was 66.3%, but for the Russian Federation, it was 24%. Data were updated on radiotherapy infrastructure and equipment. 256 radiotherapy centres are operating 275 linear accelerators and 337 Cobalt-60 units. 61% of teletherapy machines are older than ten years. Analysis of ROIs revealed significant differences between these countries and radiotherapy practices in the West. Naming, task profile and education programmes of radiotherapy professionals are different than in the West.

CONCLUSIONS

Most countries need modernization of their radiotherapy infrastructure coupled with adequate staffing numbers and updated education programmes focusing on evidence-based medicine, quality, and safety.

The epidemiological transition in Eastern and Western Europe: a historic natural experiment

Background

The continent of Europe has experienced remarkable changes in the past 25 years, providing scope for natural experiments that offer insight into the complex determinants of health.

Methods

We analysed trends in life expectancy at birth in three parts of Europe, those countries that were members of the European Union (EU) prior to 2004, countries that joined the European Union since then, and the twelve countries that emerged from the Soviet Union to form the Commonwealth of Independent States (CIS). The contribution of deaths at different ages to these changes was assessed using Arriaga's method of decomposing changes in life expectancy.

Results

Europe remains divided geographically, with an East-West gradient. The former Soviet countries experienced a marked initial decline in life expectancy and have only recovered after 2005. However, the situation for those of working ages is little better than in 1990. The pre-2004 EU has seen substantial gains throughout the past 25 years, although there is some evidence that this may be slowing, or even reversing, at older ages. The countries joining the EU in 2004 subsequently began to see some improvements in the early 1990s, but have experienced larger gains since 2000.

Conclusions

Europe offers a valuable natural laboratory for understanding the impact of political, economic, and social changes on health. While the historic divisions of Europe are still visible, there is also evidence that individual countries are doing better or worse than their neighbours, providing many lessons that can be learned from.

The contribution of alcohol to the East-West life expectancy gap in Europe from 1990 onward

BACKGROUND

Central and Eastern European (CEE) countries have lower life expectancies and higher alcohol-attributable mortality than Western European countries. We examine the contribution of alcohol consumption to mortality across Europe, and specifically to the East-West life expectancy gap from 1990 onward.

METHODS

We retrieved alcohol-attributable mortality rates (GBD Study 2013) and all-cause mortality rates (Human Mortality Database) by age and sex for nine CEE countries and for the EU-15 countries. We assessed country-specific potential gains in life expectancy (PGLE) by eliminating alcohol-attributable mortality using associated single decrement life tables. We decomposed the life expectancy differences between each CEE country and the EU-15 population-weighted average for 1990-2012/13 into alcohol-attributable and non-alcohol-attributable mortality.

RESULTS

In 2012/13, the PGLE for men and women were, respectively, 2.15 and 1.00 years in the CEE region and 0.90 and 0.44 years in the EU-15 region. The contribution of alcohol to the East-West gap in life expectancy was largest among men in Russia {2.88 years [uncertainty interval (UI): 1.57-4.06]}, Belarus [3.70 years (UI: 1.75-5.45)] and Ukraine [2.47 years (UI: 0.90-3.88)]. The relative contributions increased in most of the countries between 1990 and 2005 (on average, from 17.0% to 25.4% for men, and from 14.7% to 22.5% for women), and declined thereafter (20.2% for men and 20.5% for women in 2012/13).

CONCLUSIONS

Alcohol contributed substantially to the East-West life expectancy gap in Europe, and to its increase (1990-2005) and decline (2005 onward). Diminishing alcohol consumption in CEE countries to Western European levels can contribute to mortality convergence across Europe.

Role of emerging private hospitals in a post-Soviet mixed health system: a mixed methods comparative study of private and public hospital inpatient care in Mongolia

Background

The collapse of the Soviet Union in 1990 severely impacted the health sector in Mongolia. Limited public funding for the post-Soviet model public system and a rapid growth of poorly regulated private providers have been pressing issues for a government seeking to re-establish universal health coverage. However, the evidence available on the role of private providers that would inform sector management is very limited. This study analyses the current contribution of private hospitals in Mongolia for the improvement of accessibility of health care and efficiency.

Methods

We used mixed research methods. A descriptive analysis of nationally representative hospital admission records from 2013 was followed by semi-structured interviews that were carried out with purposively selected key informants (N = 45), representing the main actors in Mongolia's mixed health system.

Results

Private-for-profit hospitals are concentrated in urban areas, where their financial model is most viable. The result is the duplication of private and public inpatient services, both in terms of their geographical location and the range of services delivered. The combination of persistent inpatient-oriented care and perverse financial incentives that privilege admission over outpatient management, have created unnecessary health costs. The engagement of the private sector to improve population health outcomes is constrained by a series of issues of governance, regulation and financing and the failure of the state to manage the private sector as an integral part of its health system planning.

Discussions/Conclusion

For a mixed system like in Mongolia, a comprehensive policy and plan which defines the complementary role of private providers to optimize private public service mix is critical in the early stages of the private sector development. It further supports the importance of a system perspective that combines regulation and incentives in consistent policy, rather than an isolated approach to provide regulation.

Health Care in the Russian Federation

The Russian Federation health system has its roots in the country's complex political history. The Ministry of Health and Social Development and its associated federal services are the principal Russian institutions subserving the Russian Federation. Funding for the health system goes through 2 channels: the general revenue budget managed by federal, regional, and local health authorities, and the Mandatory Health Insurance Fund. Although the Soviet Union was the first country in the world to guarantee free medical care as a constitutional right to all its citizens, quality and accessibility are in question.

Drug prescribing patterns at primary health care level and related out-of-pocket expenditures in Tajikistan

BACKGROUND

The Government of Tajikistan is reforming its health system to make access more equitable. Nonetheless, out-of-pocket expenditures (OPE) remain a key modality for purchasing health care. Drugs remain a major driver of household expenditures for health. We conducted a household survey to investigate drug prescribing patterns at primary health care (PHC) level as well as the related OPE.

METHODS

Adult patients in eight districts who had visited a PHC facility in the period March to May 2014 were interviewed at home, using a structured questionnaire. A descriptive analysis was conducted and regression models were constructed to identify factors influencing the number of drugs provided and the types of drugs prescribed.

RESULTS

There were 1281 (80.1 %) patients who received a drug prescription after visiting a doctor at PHC level. 16.2 % of them had five or more drugs prescribed concomitantly. The number of drugs prescribed to patients ranged from 0 to 8 and was statistically different across regions (RRS region =3.3; Khatlon region = 3.1; p = 0.05), after adjusting for age and sex. In 31.1 % of cases, prescriptions included an intra-venous (IV) injection; in 45.6 % of cases, a non-IV injection; in 52.9 % of cases, an antibiotic; and in 61.0 % of cases, vitamins. Patients suffering from a respiratory disease had higher odds of being prescribed an IV injection and antibiotics. Vitamins were widely prescribed across all diseases. In 94.5 % of cases, the patients interviewed procured at least one of the prescribed drugs. Among those who received a prescription, 2.0 % were not able to procure at least one drug due to a lack of money. In 94.9 % of cases, respondents reported purchasing drugs in private pharmacies. Median expenditures for drugs procured following consultation were 45 TS (US$ 6.9) corresponding to 77.6 % of total expenditures related to the visit (58 TS, US$ 8.8).

CONCLUSIONS

In a context where OPE are important, drugs represent an important income source for health service providers. Such a situation does not favour rational prescribing nor efficient service delivery, and is potentially harmful for patients. In particular, the economic ramifications cause high levels of expenditure for patients and households with detrimental, knock-on effects in the more vulnerable segments of the population.

Overall satisfaction of health care users with the quality of and access to health care services: a cross-sectional study in six Central and Eastern European countries

Background

The measurement of consumer satisfaction is an essential part of the assessment of health care services in terms of service quality and health care system responsiveness. Studies across Europe have described various strategies health care users employ to secure services with good quality and quick access. In Central and Eastern European countries, such strategies also include informal payments to health care providers. This paper analyzes the satisfaction of health care users with the quality of and access to health care services. The study focuses on six Central and Eastern European countries (Bulgaria, Hungary, Lithuania, Poland, Romania and Ukraine).

Methods

We use data on past experience with health care use collected in 2010 through uniform national surveys in these countries. Based on these data, we carry out a multi-country analysis to investigate factors associated with the satisfaction of health care users in the six countries.

Results

The results indicate that about 10-14 % of the service users are not satisfied with the quality of, or access to health care services they used in the preceding year. However, significant differences across countries and services are observed, e.g. the highest level of dissatisfaction with access to outpatient services (16.4 %) is observed among patients in Lithuania, while in Poland, the level of dissatisfaction with quality of outpatient and inpatient services are much lower than dissatisfaction with access. The study also analyses the association of users’ satisfaction with factors such as making informal payments, inability to pay and relative importance of service attributes stated by the service users.

Conclusions

These multi-country findings provide evidence for health policy making in the Central and Eastern European countries. Although the average rates of satisfactions per country are relatively high, the results suggest that there is ample room for improvements. Specifically, many service-users still report dissatisfaction especially those who pay informally and those unable to pay. The high shares of informal payments and inability of users to deal with the health expenditures lead to doubts about the fairness of the health care provision in Central and Eastern Europe. There is an urgent need for policy makers in the region to not only acknowledge but also to effectively address this key problem.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1585-1) contains supplementary material, which is available to authorized users.

International SF-36 reference values in patients with ischemic heart disease

PURPOSE

International reference data for the SF-36 health survey (version 1) are presented based on a sample of 5508 adult patients with ischemic heart disease.

METHODS

Patients with angina, myocardial infarction and ischemic heart failure completed the SF-36. Data were analyzed by diagnosis, gender, age, region and country within region and presented as mean ± standard deviation (SD), minimum, maximum, 25th, 50th and 75th percentile of the physical (PCS) and mental component summary (MCS) measures.

RESULTS

Mean PCS scores were reported as being more than one SD below the normal range (standardized mean of 50 ± 10) by more than half of the patient subgroups (59 %) with all of the mean MCS scores falling within the normal range. Patients with angina and patients with ischemic heart failure reported the poorest mean PCS scores with both diagnoses reporting scores more than one SD below the standardized mean. Females, older patients (especially >70 years) and patients from Eastern Europe reported significantly worse mean PCS scores than male, younger and non-Eastern European patients. The cardiac diagnosis had no effect on the mean MCS scores; however, females, younger patients (especially <51 years) and patients from Eastern Europe reported significantly worse mean MCS scores than male, older and non-Eastern European patients.

CONCLUSIONS

These international reference SF-36 values for patients with IHD are useful for clinicians, researchers and health-policy makers when developing improved health services.

Regional differences in cardiovascular mortality in Kazakhstan: further evidence for the 'Russian mortality paradox'?

BACKGROUND

The role of alcohol consumption in patterns of CVD mortality in Central Asia is still largely unexplored. Previous research in Kazakhstan and Kyrgyzstan has found that ethnic Russians have higher adult mortality rates than native ethnic groups, despite their higher socio-economic status. This has been termed the 'Russian mortality paradox'.

METHODS

We calculated age-standardized CVD mortality data by gender and region of Kazakhstan, based on mortality data obtained from the Ministry of Health and population data from the State Agency for Statistics. We analysed data on self-reported alcohol consumption from the nationally representative 5th National Behavior Study.

RESULTS

We found substantial differences in CVD mortality rates across regions, as well as between males and females. With the exception of Almaty and Astana cities, mortality rates are highest in the country's North-Eastern regions and lowest in South-Western regions, despite the fact that North-Eastern regions have higher income levels. Patterns of self-reported alcohol consumption and alcohol sales follow a similar pattern. One explanation could be related to higher self-reported drinking prevalence among ethnic Russians who live predominantly in the country's North-Eastern regions.

CONCLUSIONS

Hazardous alcohol consumption seems to be highest in Kazakhstan's North-Eastern regions, which might be related to different patterns of alcohol consumption among different ethnic groups. However, more detailed analyses are required to corroborate these assumptions. The high overall rates suggest the need for population-based measures, such as increasing taxes on alcohol, in particular spirits such as vodka, and strengthening the capacity of primary health care.

How economic crises affect alcohol consumption and alcohol-related health problems: a realist systematic review

Economic crises are complex events that affect behavioral patterns (including alcohol consumption) via opposing mechanisms. With this realist systematic review, we aimed to investigate evidence from studies of previous or ongoing crises on which mechanisms (How?) play a role among which individuals (Whom?). Such evidence would help understand and predict the potential impact of economic crises on alcohol consumption. Medical, psychological, social, and economic databases were used to search for peer-reviewed qualitative or quantitative empirical evidence (published January 1, 1990-May 1, 2014) linking economic crises or stressors with alcohol consumption and alcohol-related health problems. We included 35 papers, based on defined selection criteria. From these papers, we extracted evidence on mechanism(s), determinant, outcome, country-level context, and individual context. We found 16 studies that reported evidence completely covering two behavioral mechanisms by which economic crises can influence alcohol consumption and alcohol-related health problems. The first mechanism suggests that psychological distress triggered by unemployment and income reductions can increase drinking problems. The second mechanism suggests that due to tighter budget constraints, less money is spent on alcoholic beverages. Across many countries, the psychological distress mechanism was observed mainly in men. The tighter budget constraints mechanism seems to play a role in all population subgroups across all countries. For the other three mechanisms (i.e., deterioration in the social situation, fear of losing one's job, and increased non-working time), empirical evidence was scarce or absent, or had small to moderate coverage. This was also the case for important influential contextual factors described in our initial theoretical framework. This realist systematic review suggests that among men (but not among women), the net impact of economic crises will be an increase in harmful drinking. Such a different net impact between men and women could potentially contribute to growing gender-related health inequalities during a crisis.

An assessment of progress towards universal health coverage in Brazil, Russia, India, China, and South Africa (BRICS)

Brazil, Russia, India, China, and South Africa (BRICS) represent almost half the world's population, and all five national governments recently committed to work nationally, regionally, and globally to ensure that universal health coverage (UHC) is achieved. This analysis reviews national efforts to achieve UHC. With a broad range of health indicators, life expectancy (ranging from 53 years to 73 years), and mortality rate in children younger than 5 years (ranging from 10·3 to 44·6 deaths per 1000 livebirths), a review of progress in each of the BRICS countries shows that each has some way to go before achieving UHC. The BRICS countries show substantial, and often similar, challenges in moving towards UHC. On the basis of a review of each country, the most pressing problems are: raising insufficient public spending; stewarding mixed private and public health systems; ensuring equity; meeting the demands for more human resources; managing changing demographics and disease burdens; and addressing the social determinants of health. Increases in public funding can be used to show how BRICS health ministries could accelerate progress to achieve UHC. Although all the BRICS countries have devoted increased resources to health, the biggest increase has been in China, which was probably facilitated by China's rapid economic growth. However, the BRICS country with the second highest economic growth, India, has had the least improvement in public funding for health. Future research to understand such different levels of prioritisation of the health sector in these countries could be useful. Similarly, the role of strategic purchasing in working with powerful private sectors, the effect of federal structures, and the implications of investment in primary health care as a foundation for UHC could be explored. These issues could serve as the basis on which BRICS countries focus their efforts to share ideas and strategies.

Foregoing medicines in the former Soviet Union: changes between 2001 and 2010

Pharmaceutical costs dominate out-of-pocket payments in former Soviet countries, posing a severe threat to financial equity and access to health services. Nationally representative household survey data collected in Armenia, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia and Ukraine were analysed to compare the level of population having to forego medicines in 2001 and 2010. Subgroup analysis was conducted to assess differences between populations of different economic status, and rural and urban populations. A substantial proportion of the population did forego medicines in 2010, from 29.2% in Belarus to 72.9% in Georgia. There was a decline in people foregoing medicines between 2001 and 2010; the greatest decline was seen in Moldova [rate ratio (RR)=0.67 (0.63; 0.71)] and Kyrgyzstan [RR=0.63 (0.60; 0.67)], while very little improvement took place in countries with a higher Gross National Income (GNI) per capita and greater GNI growth over the decade such as Armenia [RR=0.92 (0.87; 0.96)] and Georgia [RR=0.95 (0.92; 0.98)]. Wealthier, urban populations have benefited more than poorer, rural households in some countries. Countries experiencing the greatest improvement over the study period were those that have implemented policies such as price controls, expanded benefits packages, and encouragement of rational prescribing. Greater commitment to pharmaceutical reform is needed to ensure that people are not forced to forego medicines.

Levels and distribution of self-rated health in the Kazakh population: results from the Kazakhstan household health survey 2012

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.

Progress towards universal health coverage in BRICS: translating economic growth into better health

Brazil, the Russian Federation, India, China and South Africa--the countries known as BRICS--represent some of the world's fastest growing large economies and nearly 40% of the world's population. Over the last two decades, BRICS have undertaken health-system reforms to make progress towards universal health coverage. This paper discusses three key aspects of these reforms: the role of government in financing health; the underlying motivation behind the reforms; and the value of the lessons learnt for non-BRICS countries. Although national governments have played a prominent role in the reforms, private financing constitutes a major share of health spending in BRICS. There is a reliance on direct expenditures in China and India and a substantial presence of private insurance in Brazil and South Africa. The Brazilian health reforms resulted from a political movement that made health a constitutional right, whereas those in China, India, the Russian Federation and South Africa were an attempt to improve the performance of the public system and reduce inequities in access. The move towards universal health coverage has been slow. In China and India, the reforms have not adequately addressed the issue of out-of-pocket payments. Negotiations between national and subnational entities have often been challenging but Brazil has been able to achieve good coordination between federal and state entities via a constitutional delineation of responsibility. In the Russian Federation, poor coordination has led to the fragmented pooling and inefficient use of resources. In mixed health systems it is essential to harness both public and private sector resources.

Mentoring a health technology assessment initiative in Kazakhstan

OBJECTIVES

The aim of this study was to assist in the development of a health technology assessment (HTA) program for the Ministry of Health (MOH) of the Republic of Kazakhstan

METHODS

Mentoring of an initial HTA program in Kazakhstan was provided by the Canadian Society for International Health (CSIH) by means of a partnership with the Kazakhstan MOH. HTA materials, courses, and one-on-one support for the preparation of a series of initial HTA reports by MOH HTA staff were provided by a seven-member CSIH team over a 2.5-year project.

RESULTS

Guidance documents on HTA and institutional strengthening were prepared in response to an extensive set of deliverables developed by the MOH and the World Bank. Introductory and train-the-trainer workshops in HTA and economic evaluation were provided for MOH staff members, experts from Kazakhstan research institutes and physicians. Five short HTA reports were successfully developed by staff in the Ministry's HTA Unit with assistance from the CSIH team. Challenges that may be relevant to other emerging HTA programs included lack of familiarity with some essential underlying concepts, organization culture, and limited time for MOH staff to do HTA work.

CONCLUSIONS

The project helped to define the need for HTA and mentored MOH staff in taking the first steps to establish a program to support health policy decision making in Kazakhstan. This experience offers practical lessons for other emerging HTA programs, although these should be tailored to the specific context.

National Health Systems

Health care systems ideally include universal access to comprehensive prepaid medical care along with health promotion and disease prevention. National health insurance and national health services of various models have evolved in the developed world and increasingly in developing countries as well. Some models, such as the Bismarckian social security model and the Bereidge National Health Service model, or National Health insurance such as in pioneered in Canada, are used by a number of countries. The common features are based on principles of national responsibility and solidarity for health, social solidarity for providing funding and searching for effective ways of providing care. Various universal systems of health coverage exist in all industrialized countries, except in the United States which has a mix of public and private insurance but with high percentages of uninsured and poorly insured. Health reform is a continuing process as all countries aspire to assure health care for all. Aging populations, increasing costs, advancing and increasing technology all require nations to modify and adapt organization and financing systems of health care, health protection and promotion.

Changes in hypertension treatment in the yaroslavl region of Russia: improvements observed between 2 cross-sectional surveys

This prospective before-and-after survey of hypertensive patients visiting government-run outpatient health facilities in the Yaroslavl Region of Russia assessed blood pressure (BP)-related endpoints following initiation of a comprehensive health system improvement program for hypertension. Two cross-sectional surveys, one at baseline and the other approximately 1 year after program initiation, evaluated the primary measure of BP control rate. Secondary measures included mean BP levels and distribution, cardiovascular risk factors, and associated conditions, heart rate levels, and antihypertensive therapy. From the 2011 survey (n=1794) to the 2012 survey (n=2992), BP control rate (<140/90 mm Hg) significantly increased from 16.8% to 23.0%, reflecting a 37% relative improvement (P<.0001). Mean BP level was significantly reduced from 151/90 mm Hg to 147/88 mm Hg (P<.0001). Severe uncontrolled hypertension (systolic BP ≥180 mm Hg) was reduced from 9.7% to 6.4% (P<.0001). Implementing a guidelines-based treatment protocol with medical and patient education programs resulted in physician behavior change and improved patient BP control.

The unequal health of Europeans: successes and failures of policies

Europe, with its 53 countries and divided history, is a remarkable but inadequately exploited natural laboratory for studies of the eff ects of health policy. In this paper, the fi rst in a Series about health in Europe, we review developments in population health in Europe, with a focus on trends in mortality, and draw attention to the main successes and failures of health policy in the past four decades. In western Europe, life expectancy has improved almost continuously, but progress has been erratic in eastern Europe, and, as a result, disparities in male life expectancy between the two areas are greater now than they were four decades ago. The falls in mortality noted in western Europe are associated with many different causes of death and show the combined eff ects of economic growth, improved health care, and successful health policies (eg, tobacco control, road traffic safety). Less favourable mortality trends in eastern Europe show economic and health-care problems and a failure to implement effective health policies. The political history of Europe has left deep divisions in the health of the population. Important health challenges remain in both western and eastern Europe and signify unresolved issues in health policy (eg, alcohol, food) and rising health inequalities within countries.