Stanisława Golinowska

The inability to pay for health services in Central and Eastern Europe: evidence from six countries

Background: Out-of-pocket payments for health services constitute a major financial burden for patients in Central and Eastern European (CEE) countries. Individuals who are unable to pay use different coping strategies (e.g. borrowing money or foregoing service utilization), which can have negative consequences on their health and social welfare. This article explores patients’ inability to pay for outpatient and hospital services in six CEE countries: Bulgaria, Hungary, Lithuania, Poland, Romania and Ukraine. Methods: The analysis is based on quantitative data collected in 2010 in nationally representative surveys. Two indicators of inability to pay were considered: the need to borrow money or sell assets and foregoing service utilization. Statistical analyses were applied to investigate associations between the indicators of inability to pay and individual characteristics. Results: Patient payments are most common in Bulgaria, Ukraine, Romania and Lithuania and often include informal payments. Romanian and, particularly, Ukrainian patients most often face difficulties to pay for health services (with approximately 40% of Ukrainian payers borrowing money or selling assets to cover hospital payments and approximately 60% of respondents who need care foregoing services). Inability to pay mainly affects those with poor health and low incomes. Conclusion: Widespread patient payments constitute a major financial barrier to health service use in CEE. There is a need to formalize them where they are informal and to take measures to protect vulnerable population groups, especially those with limited possibilities to deal with payment difficulties.

Towards a stakeholders' consensus on patient payment policy: the views of health‐care consumers, providers, insurers and policy makers in six Central and Eastern European countries

Although patient charges for health‐care services may contribute to a more sustainable health‐care financing, they often raise public opposition, which impedes their introduction. Thus, a consensus among the main stakeholders on the presence and role of patient charges should be worked out to assure their successful implementation.

The System of Long-Term Care in Poland

In the field of social protection, Poland belongs to the EU group of countries with the familybased welfare model, what is extremely visible for the long-term care where family is the main care provider for elderly individuals with limitations in activities of daily living. At the same time the proportion of elderly in the coming decades is projected to be among the highest in the European Union, what raises questions on the design of the long-term care. For the moment the system is highly unregulated and disintegrated between social assistance and health care services. But it is the health sector that concentrates policy debate with a proposal of an introduction of nursing insurance. In the social sector, the significant changes that were favorable to LTC services development were introduced by the law on the social assistance (2004) and family benefits (2003) widening the scope of care available at home and in adult day care centers. But still provision of services is insufficient and a market of private services, paid out-of-pocket rapidly develops. It seems that main problems of the long-term care development in the future will be raising demand against insufficient resources and diversified priorities of the health care system.

Can European Countries Improve Sustainability of Health Care Financing through Patient Cost-Sharing?

Rising health care cost and resource constraints confront policy makers with the challenge to ensure the financial sustainability of health care systems, without jeopardizing the main health system objectives. To respond to this challenge, many European countries have introduced patient payments for publicly financed health care services (patient cost-sharing) (1–4). The potential of patient cost-sharing to contribute to the sustainability of the health care system relies on two elements. First, cost-sharing generates additional sources of funding. Hence, through cost-sharing, some of the health care cost might be shifted from public budgets to patients. Second, cost-sharing has the potential to improve efficiency in publicly financed health care, as it is expected that patients, when faced with the price of health care services, reduce the utilization of unnecessary and low-value health care (5, 6). It is also expected that this could slow the growth of health care costs. However, opponents of cost-sharing question the potential of cost-sharing to improve efficiency and instead point to its potentially negative effects on equity in health care. This is documented by evidence, among them the best known is the RAND health insurance experiment (7, 8). Whether the potential of cost-sharing can be realized without threatening equity and consumers financial protection depends on various context-specific factors as well as on the design of the cost-sharing systems applied by European countries.

Institutional analysis of health promotion for older people in Europe - concept and research tool

BackgroundEuropean societies are ageing rapidly and thus health promotion for older people (HP4OP) is becoming an increasingly relevant issue. Crucial here is not only the clinical aspect of health promotion but also its organisational and institutional dimension. The latter has been relatively neglected in research on HP4OP. This issue is addressed in this study, constituting a part of the EU project ProHealth65+, engaging ten member countries. This paper is based on two intertwining research goals: (1) exploring which institutions/organisations are performing HP4OP activities in selected European countries (including sectors involved, performed roles of these institutions, organisation of those activities); (2) developing an institutional approach to HP4OP. Thus, the paper provides a description of the analytical tools for further research in this area.MethodsThe mentioned aims were addressed through the mutual use of two complementary methods: (a) a literature review of scientific and grey literature; and (b) questionnaire survey with selected expert respondents from 10 European countries. The expert respondents, selected by the project’s collaborating partners, were asked to fill in a custom designed questionnaire concerning HP4OP institutional aspects.ResultsThe literature review provided an overview of the organisational arrangements in different HP4OP initiatives. It also enabled the development of functional institutional definitions of health promotion, health promotion activities and interventions, as well as an institutional definition adequate to the health promotion context. The distinctions between sectors were also clarified. The elaborated questionnaires provided in-depth information on countries specifically indicating the key sectors involved in HP4OP in those selected countries. These are: health care, regional/local authorities, NGO’s/voluntary institutions. The questionnaire and literature review both resulted in the indication of a significant level of cross-sectorial cooperation in HP4OP.ConclusionsThe inclusion of the institutional analysis within the study of HP4OP provides a valuable opportunity to analyse, in a systematic way, good practices in this respect, also in terms of institutional arrangements. A failure to address this aspect in policymaking might potentially cause organisational failure even in evidence-based programmes. This paper frames the perception of this problem.

Investing in Health Institutions in Transition Countries

This study presents an overview of the health care systems in postcommunist countries with its resources and operations, in addition to proposing steps that should be taken in order to overcome the health crisis associated with transition and increase the effectiveness and efficiency of health care systems. At the beginning of the 90s, the crisis of transition had a significant impact on the low level of funding in health care, declining in proportion to the fall of GDP or even faster. The continued crisis and slow recovery also affect the low political preference for funding the health care sector during the GDP allocation process. There is excessive competition from other important socio-economic goals and health care frequently loses the battle.

State Social Policy and Social Expenditure in Central and Eastern Europe

Social policy pursued in the transition period to date can be divided into two phases. The first phase covers the times of economic crisis on the onset of transition period. Social policy in that time created, on the one hand, new instruments replacing those from the period of real socialism, which were subject to liquidation or limitations. On the other hand social policy pursued then soothed new social problems caused by economic crisis. In most countries the second path of changes was followed, except for the Czech Republic, where creation of new instruments and social sphere institutions was considerably more distinct.

Health promotion targeting older people

Health is determined by behavior in many ways. The most well-known types of health-related behavior – smoking, alcohol use and exercise/eating habits – are only a selection of the behavioral aspects of health. A healthy lifestyle can be promoted by various means, ranging from educational and counseling programs to financial incentives for a healthy lifestyle. These interventions are further offered in various ways, ranging from general legislative measures to programmatic interventions. Health promotion interventions can take different forms, from small projects to large national programs. They can be funded and organized by donations from individuals or NGOs, or through taxation by national governments. In short, health promotion is typified by heterogeneity in every conceivable aspect. Health promotion is meant for the entire population. If a specific group within a population is singled out as the recipient of health promotion interventions, it is because of a valid reason, such as epidemiological concerns or preferences in social policy (e.g. measures targeting vulnerable or disadvantaged groups). This explains the focus of many health promotion activities on youth, citizens of big cities, workers in certain industries or occupations. The elderly have long been neglected as the addressee of health promotion activities. The need to promote health among older people was first highlighted in the 1990s [1]. Before that, it was commonly assumed that the older generations were not a good target for health promotion as it was thought it was too late to change their lifestyle. Requiring the elderly to radically change their diet and start exercising was perceived as disturbing to their peace and wellness. Therefore, it was only after 2001, when WHO experts unanimously stated the importance of a healthy lifestyle at every stage of life, health promotion measures targeted to the elderly started to grow in numbers. Evidence has shown that exercising, quitting smoking and limiting alcohol consumption, participating in learning activities and integrating in the community can help to inhibit the development of many diseases and prevent the loss of functional capacity, thus improving quality of life and lengthening life expectancy. Most of these health promotion activities among the elderly focus on the relatively younger seniors. Within the group of those aged 85+, the emphasis is more on appropriate medical attention from physicians and care givers rather than on their health behavior. Health promotion targeted to older people differs significantly from that addressing younger generations. This partly stems from the fact that the health of older people is generally less than perfect [2]. Seniors are more likely to be suffering from chronic conditions and multi-morbidities, and their functional capacity is frequently limited [3]. This implies that the health promotion programs for the elderly have to account for these limitations in health and daily activities, and require more involvement of professional health promoters and more individualized approaches. The prevalence of certain lifestyle issues is also higher among the elderly. Elderly people are – for example – more likely to suffer from loneliness and social isolation. Also, because of their relatively shorter remaining life expectancy, the focus is more on health promotion activities that yield immediate effects. That is why health promotion programs for older people in European countries are mainly implemented at the local level by primary health care providers and nurses, and by NGOs, self-governing public authorities and voluntary organizations. These programs sometimes lack sustainable sources of funding. Health promotion strategies for the elderly generally have three basic aims: maintaining and increasing functional capacity, maintaining or improving self-care [4], and stimulating one’s social network [5]. The idea behind these strategies is to contribute to a longer, independent and self-sufficient quality of life [6]. It should be noticed that there is an additional objective to be considered: the significance of social participation and integration of the elderly to maintain quality of life at old age [7]. There is ample evidence to support the claim that social bonds and social activities, e. g. continuing professional work, learning activities later on, participation in cultural events and social work and maintaining * Correspondence: stellag@onet.pl Faculty of Health Sciences, Department of Health Economics and Social Security, Institute of Public Health, Jagiellonian University Collegium Medicum, ul. Grzegorzecka 20, 31-531 Krakow, Poland Full list of author information is available at the end of the article

Financial incentives for a healthy life style and disease prevention among older people: a systematic literature review.

BackgroundTo motivate people to lead a healthier life and to engage in disease prevention, explicit financial incentives, such as monetary rewards for attaining health-related targets (e.g. smoking cessation, weight loss or increased physical activity) or disincentives for reverting to unhealthy habits, are applied. A review focused on financial incentives for health promotion among older people is lacking. Attention to this group is necessary because older people may respond differently to financial incentives, e.g. because of differences in opportunity costs and health perceptions. To outline how explicit financial incentives for healthy lifestyle and disease prevention work among older persons, this study reviews the recent evidence on this topic.MethodsWe applied the method of systematic literature review and we searched in PUBMED, ECONLIT and COCHRANE LIBRARY for studies focused on explicit financial incentives targeted at older adults to promote health and stimulate primary prevention as well as screening. The publications selected as relevant were analyzed based on directed (relational) content analysis. The results are presented in a narrative manner complemented with an appendix table that describes the study details. We assessed the design of the studies reported in the publications in a qualitative manner. We also checked the quality of our review using the PRISMA 2009 checklist.ResultsWe identified 15 studies on the role of explicit financial incentives in changing health-related behavior of older people. They include both, quantitative studies on the effectiveness of financial rewards as well as qualitative studies on the acceptability of financial incentives. The quantitative studies are characterized by a great diversity of designs and provide mixed results on the effects of explicit financial incentives. The results of the qualitative studies indicate limited trust of older people in the use of explicit financial incentives for health promotion and prevention.ConclusionsMore research is needed on the effects of explicit financial incentives for prevention and promotion among older people before their broader use can be recommended. Overall, the design of the financial incentive system may be a crucial element in their acceptability.

The Impact of the Economic and Financial Crisis on the Polish Pension System

In 1999, Poland introduced a radical reform of its retirement pension system. That reform rested on replacing a portion of the pay-as-you-go scheme with a fully funded capital scheme, as well as on withdrawing from a defined-benefit pension formula in favour of equivalent solutions via the introduction of a defined-contribution pension formula. When, in 2008, the global financial crisis disrupted financial markets, the rate of returns on investments from pension funds dropped dramatically. Moreover, the difficult state of public finances started to encumber the further financing of the reform’s transitional period. This brought about a discussion on “reforming the reform” in Poland and led to a reduction of the contribution rate to the funded pillar from 7.3% to 2.3% beginning in May 2011. The recent debate has both touched on and highlighted a range of issues which had not been aired to date.