Health Reforms in Central and Eastern Europe: Options, obstacles, limited outcomes, James Warner Björkman and Juraj Nemec (editors). Eleven International Publishing. June 2013.

This title offers timely insight into the emerging patterns in health reforms in Central and Eastern European countries since the fall of the Berlin Wall, writes Anna Raphael. Authors present conclusions that can be used to guide future policy, and the book will be of interest to policy makers, professional practitioners and students.

Following the dissolution of the Soviet Union, health reforms in some countries of Central and Eastern Europe (CEE) were mainly ‘panic policies’. They were driven by external pressure, partly from international donors, and mostly the desire to move away from the communist legacy towards the establishment of market-based system.

This book explores these reforms, presenting a comparative study of health care reform systems by providing information and data at five-year intervals since 1990.

Based on case-study countries, this title illustrates that the transition from the pre-Soviet healthcare system – which provided access to health care ‘free at point of use’ – to the introduction of health insurance systems proved to be more difficult than firstly envisaged. The authors illustrate the weaknesses, obstacles and the limited outcomes that governments faced with the introduction of health reforms.

The main objective of implementing large-sale health reforms in all CEE countries was a desire to convert the old ‘socialist’ system to a ‘modern’ health care system that would be more responsive to patients’ needs. The move was towards implementing a market-based system by introducing health insurance, privatization and the introduction of private payments and co-payments.

High expectations were met with relative failure in fulfilling expected goals, due to failure in raising adequate funds, low contribution tax, lack of health policy implementation, weak capacity and poor coordination among different actors.

All these factors prompted many CEE countries to continue to rely on general government revenues and out-of-pocket expenditure. These drawbacks were particularly prominent in Armenia, Russia and Bulgaria. Major contrast can also be drawn from health reforms in Armenia, Russia and Slovenia based on differences in their socioeconomic development, demographic variety in terms of population size and urbanization as well as life expectancy rates of maternal mortality (tables 1.1 & 1.2).

While Slovenia can be considered the most successful model of health reform within the CEE due to having inherited a ‘relatively sound system’ and developed it further by introducing compulsory and voluntary health insurance.

Cooperation between privatisation and key partners played key role in promoting the reform. Armenia, on the other hand, had a comparatively limited success in implementing health care changes due to unavailability of public financing not only for the new health expenditure but for sustaining the inherited system as well.

Adding a severe economic crisis and socio-political problems, the population became impoverished and this led to a decline in the utilization of health services and ultimately damaged the health status of the population by increasing mortality and morbidity rates.

The example of Russia, although not unexpected, remains interesting. Russia is in a great transition period, and this extended to developing and improving the health situation by redesigning its healthcare model from ‘collective to individual responsibility’. The trend which started in 1990s continued to switch from budget to social insurance model by promoting individual responsibility and private insurance.

However, the author argues that this shift may contribute to widen the inequality between the poor and the rich by contributing to the creation of two separate “sub-systems”, one for the rich who can afford to pay and another for the poor, free of charge. The Russian health care system therefore remains ‘sustainably underfinanced’ and the main threat is that Russia may likely to enter what is called the ‘health expenditure growth trap’ because of the spiralling growth of health expenditures.

It is thus suggested that it would be more advisable to allocate more money to the budget model rather than changing the model to the social insurance which will inevitably invite increase in budget spending.

Countries case studies indicated that the structure of health care systems adopted two directions. ‘Private medicine’ and ‘mixed systems’ of public-private cooperation. The former gives access to health care services based on the ability to pay and is available in the less developed countries, while the latter is dominant in more developed countries and financed by public and private sources.

Although the analysis of heath care reforms in CEE shows some improvements, however, these transitions have demonstrated a ‘chronic gap’ between proclamation and implementation due to fiscal problems and the need for effective cost-containment systems to cope with limited resources.

The book shows that implementation of health reforms was more complex than expected. Based on country chapters and existing knowledge, potential positive reform outcome is based on economic and health resources; dimensions of health policy-making and implementation, and the positions and strategies of main actors ready to support the changes needed.

The publication of this book is timely, offering insight into the emerging patterns in health reforms in the CEE. Authors presented conclusions that can guide future directions. The book will be of interest to policy makers, professional practitioners and students.