"To have and have not"
Equity and access in the health sector in Eastern Europe and Central Asia
Von Guy Hutton / Schweizerisches Tropen- und Public-Health Institut (Swiss TPH)
During 2002 a study was conducted examining issues of access to health care services, and related indicators, in five countries from this region - Kyrgyzstan, Tajikistan, Ukraine, Bulgaria, and Romania. The study drew principally on grey as well as published literature, identifying data available on key indicators that reflect access and equity of health systems in these countries.
Since the late 1980s, countries of Eastern Europe and Central Asia have experienced unprecedented social and economic transformation. The economic decline that ensued in these countries following the fall of the communist regimes was severe and drawn out, with particularly disastrous consequences for the public sector, whose ministries suffered severe budget cuts. Not surprisingly, the health systems suffered for many years as the health sector reforms and the removal of excess capacity could not be achieved overnight. With the cuts in public spending, the slow pace of reform, as well as the ethnic diversity, there was considerable potential for declines in access to health services for some groups as well as a declining quality of public health services, leading to a widening gap between the "haves" of the new system, and the "have-nots".
Although Kyrgyzstan, Tajikistan, Ukraine, Bulgaria and Romania are going (or have gone) through similar experiences in the health sectors, the diversity within and between these countries should not be overlooked - in terms of geography, ethnic composition, income, and health status. Such diversity has important implications for each of the three main components of health care access: economic access, physical access and cultural access. Indicators discussed below cover health status, health care financing and resource allocation, and utilisation and quality of care.
Overall health system attainment and performance for all countries in the world has been presented previously in the World Health Report (2000). Among the five countries, the health system attainment ranged between 80% in Ukraine (ranked 60th in the world) down to 67% in Kyrgyzstan (ranked 135th). Health distribution, judged on the basis of child survival, was highest in Ukraine (90%) and again lowest in Kyrgyzstan (70%). Bulgaria had the highest male life expectancy at 61 years, compared to 53 years in Kyrgyzstan.
In terms of health care financing and resource allocation, Romania has the highest expenditure per capita (US$238), which is around 13% of the European Union average. Tajikistan has the lowest expenditure (US$37), followed by Kyrgyzstan (US$105). Health spending as a percentage of Gross Domestic Product varies between 2.3% (Tajikistan) and 5.0% (Ukraine), compared to an EU average of 8.5%. In terms of the main sources of finances, in all countries the largest expenditures in the health sector were from public sources, and most of this was from tax revenues. Within countries, there has been reported a considerable inter-regional variation in the per capita government spending on health. In terms of private expenditure, out-of-pocket accounted for between 20% of total health sector expenditure in Bulgaria and 43% in Romania. Unofficial payments to health care providers have also been reported widely.
Geographical access to health care is not considered to be a major concern in former communist countries. However, during the 1990s post-Soviet systems were characterised by over capacity in terms of infrastructure, and at the same time rapidly falling quality of care and inability to support recurrent costs such as staff salaries. The number of acute hospital beds per 1'000 population varies from 6.2 in Tajikistan to 7.6 in Bulgaria. Romania has among the lowest levels of health care staff per population, while Tajikistan and Kyrgyzstan have among the highest. In Ukraine, considerable restructuring and rationalisation of health services have taken place since 1990, with reductions in hospitals and number of beds of 35%. There is also significant variation by region in health care resources, with wide rural/urban disparities. For example, in Bulgaria the number of beds vary by region from 45.7 to 99.7 per 10'000 population (average 74.3), and physicians vary by region between 17.0 and 50.2 per 10'000 population (average 33.8).
Health care utilisation is considered to be a good indicator of the impact of the health sector. In all five countries, the number of outpatient visits per person per year is reasonably high, at between 3.4 in Tajikistan and 8.5 in the Ukraine, compared to an EU average of 7.4. In Tajikistan, the richest income groups have higher rates of self-reported acute and chronic morbidity than the lower income groups, and correspondingly higher health service use rates. For women who did not seek antenatal care during pregnancy, 44% said it was due to the cost. In Bulgaria, groups that are judged to use health services marginally less than others include village dwellers, those with secondary vocational qualifications, and families with more than three children. The acute hospital admission rate is also high in all countries, at between 9.7 in Tajikistan and 17.9 in Ukraine per 100 population. Once admitted, the average length of stay is over 10 days per person in all countries. Immunisation rates for measles are high, with at least 94% in all countries. Contraceptive prevalence rate between 60% in Kyrgyzstan and 86% in Bulgaria.
In terms of health outcomes, it has been reported widely that since the fall of communist regimes and transition to market economies, health indicators have deteriorated until the present day. Some health indicators are finally improving again. In Ukraine childhood diseases increased by 18% between 1990 and 1999, with 1.6 cases of morbidity per child. Also, tuberculosis rates and HIV/AIDS are increasing from year to year in Ukraine. Infant mortality varies between 13 (Bulgaria) and 57 (Tajikistan) per 1'000 live births. The maternal mortality rate varies between 27 (Bulgaria) and 130 (Romania, Tajikistan) per 100'000 live births. For Bulgaria, infant mortality varies by region between 5.4 and 24.3 per 1'000 live births, with greater differences between rural and urban areas within each region.
Following international experience in defining and measuring populations' access to health services, it is clear that there are no single indicators that allow judgements about how accessible health services are, nor how much equity is being achieved. Therefore this article has reported briefly a variety of indicators that reflect access and equity. It should be noted that different data sources give different impressions of the situation in these countries, and also many indicators are inflated due to a culture of falsifying official reports.
Health inequalities need to be addressed
The main conclusion of the study: Due to the decline in performance of these health systems during the 1990s, health inequalities within these countries are increasing, and need to be addressed as a matter of urgency.
The health systems are in great need of the reform measures currently being applied. How these reforms are defined, and whose needs they are targeted at, are both critical issues in ensuring they have a positive impact on the populations who most need publicly-provided health services.
Due to the large size of most of these countries, the dispersed populations and income inequalities, decisions about the health care infrastructure (and how populations are to be reached efficiently) and the health care financing mechanisms are crucial in the current health sector reforms. These reforms should be accompanied by a careful process of planning that involves the appropriate stakeholders. Better quality statistics are needed to ensure health planning is based on reliable data.
Different health initiatives should be supported, especially targeting those diseases that have emerged or re-emerged in the last decade (tuberculosis, HIV/AIDS, alcohol-related). Such support should preferably be channelled through the lower levels of the health system as opposed to vertical programmes and hospitals, to improve the overall performance of the health system and promote disease prevention. There should be a renewed focus on basic immunization, management of sick children, maternal and perinatal care, and the promotion of healthy life-styles.
*Guy Hutton, MSc, PhD, works as Health Economist for the Swiss Centre for International Health in the Swiss Tropical Institute, Basel. Contact: firstname.lastname@example.org. The original study was supported by the Social Development Division of the Swiss Agency for Development and Cooperation SDC. Full versions of this article can be obtained from the author.