Snapshots

This page provides a preliminary brief on some of the key elements concerning healthcare reforms in CEE countries. We welcome any comments and suggestions for revisions.

At the onset of their transition to democracy and market economics, Central and Eastern European (CEE) countries started with very similar healthcare systems. Inherited from socialist times, these were organised in a command-style as the rest of the economy had been. All healthcare was funded and provided by the state. The state owned hospitals, clinics, GP surgeries, pharmacies and pharmaceutical companies. Access to health services was, in theory, universal and free of charge. The medical landscapes were characterised by a strong centralisation and concentration. Large clinical centres, for example, were given favour over doctor’s surgeries.

As was characteristic of the socialist economic model, there was a large emphasis on output quantities, but very little attention was paid to productivity and customer responsiveness. For the relatively simple infectious diseases that were prevalent in the post-war era, this top-down mode of organisation proved relatively efficient. In fact, looking at primary figures, CEE healthcare systems appeared relatively advanced. They generally had more doctors, nurses and hospital beds per 1,000 inhabitants than other nations with comparable income levels. Eventually, however, these systems began to stagnate in terms of productivity and medical innovation, and found themselves unable to adapt to a changing morbidity spectrum with its need for more diversified and individualised forms of care. Waiting lists and other shortages led to ‘informal payments’ and medical black markets. 

Since 1991, CEE countries have taken very different approaches to healthcare reform. Some countries moved to a multiple insurance system diversifying funding and included private insurance and/or patient co-payments, while others retained a largely state-funded system. Some diversified the provider side and included the private sector in activities like the running of hospitals, while elsewhere the state remained the major provider. Some countries adopted a ‘medical federalism’ and delegated funding and provision to sub-national levels, others left responsibilities with the central government.

However, some similarities between CEE countries’ health systems remain. With regard to measures like solvency guarantees for clinics and hospitals, most countries have shielded the medical provider side from the pressures for structural adjustment. Provision is still strongly concentrated, with a large emphasis on clinical centres and a relative neglect of GP surgeries and other ways of providing routine treatment. CEE countries sometimes afford more medical staff, hospital beds, and hospitalisation days per citizen than Western countries. While there was a general tendency to move towards multiple insurance systems, no country has gone the whole way. Sickness funds were often established, but large parts of healthcare financing still come from general taxation, not from the sickness funds. Another common characteristic has been that the opportunities linked to insurance-based systems have seldom been fully exploited. It was expected that if insurance funds contracted with providers on the basis of performance, it would instil competition and result in higher standards. However, performance could often not be properly monitored, because assessment requires large amounts of medical data which was often unavailable. Lastly, most of the CEE countries are also dealing with problems like ageing populations, high informal payments and doctor migration to better paying countries.

CEE countries cannot easily be grouped into ‘reformers’ and ‘conservers’.  Many of them have mixed records, with a strong reform effort in one area of healthcare and inertia in others. There are neither obvious reform ‘success stories’ or reform ‘failures’. Countries with good health outcomes may owe their positive results to the greater funding made available by economic growth, although today’s dire economic circumstances are now likely to halt this past progress. At the same time, successful healthcare reform may not produce the best health outcomes due to lack of funding in countries that have experienced lower levels of growth.

The following section will provide a snapshot of selected CEE countries’ reform stories so far.