HSG Europe pre-conference: Building Just, Sustainable and Resilient Health Systems in Times of Crisis

Lessons from three decades of reform in the low- and middle-income countries of Europe, the Caucasus and Central Asia.

The Thematic Working Group on Health Systems in Fragile and Conflict-Affected Settings (TWG FCAS) co-organised this pre-conference in collaboration with the HSG Europe Regional Network, which was held in Katowice, Poland on 12-13 September. The pre-conference brought together around 70 participants, including 40 people from Ukraine. It included panel discussions of relevance to all LMICs in the region, and had a specific focus on Ukraine, learning lessons from a decade of reforms undertaken amidst severe challenges created by the Russian invasion since 2014.

The conference was organised around three main topics, each discussed by a panel, and aimed to initiate formulation of a research agenda:

• Healthcare financing
• Healthcare delivery (Primary Health Care)
• Health system governance

A great video summary of the pre-conference was prepared by the organizers which you can find here.

Dr Nigel Pearson, Advisory Group member of the TWG FCAS, has worked extensively in Ukraine with International Medical Corps, focusing on health system strengthening. He represented the TWG FCAS at the pre-conference and reports below on the key take home messages under each of the topics discussed.

Finding commonalities and learning from innovation

This conference provided an important step in getting public health academics and practitioners in this country grouping (central and eastern Europe, the Caucasus and Central Asia) to look for commonalities in the region and in identifying challenges and learning from innovations in countries, while focussing on Ukraine. There is no common pattern of reform and change in this ‘region’, but there is room for much more learning and sharing of ideas, and cross-country comparisons.

There have been similar patterns of risk and exposure in many of these countries, including economic shocks, conflict, epidemiological changes (with higher rates of TB and other epidemics than in HICs, and a huge unmet NCD burden), and demographic changes, with many countries experiencing substantial outward migration and accelerated population pyramid transformation to an older population. In Bosnia Herzegovina (BIH) the population decreased substantially during and after the 1991-95 conflict; in Ukraine similarly, the population has continued to reduce since the 1990s, with a substantial outflow from 2022. Climate change is likely exacerbating natural hazards such as flooding, heat, drought but is not sufficiently mapped.

There were some key ‘lessons learned’ both from these countries and from HIC countries in the three subject areas that panels looked into.

Session 1: Health Care Financing

Research question: What health financing structures enhance health system preparedness, response and recovery from crises?

Key tactics for enhancing resilience in health financing include increasing reliance on central government revenues rather than contributory schemes, through ensuring sufficient and stable funds, and in creating stronger purchasing and flexible payment schemes that allow access to be maintained. In times of stress, richer countries can draw on reserves to maintain payments (counter-cyclical funding), can reallocate budgets and raise additional finance by borrowing, selling bonds or giving direct assistance (further subsidising care). Capital investments and investments in professionals’ skills should be protected.

Income tax is a fairer source for public services than VAT, which can be regressive, and while contributory schemes are not as fair, they are more effective if they are statutory schemes. Public Private Partnerships are often accelerated during crises, but should be reshaped to comply with good governance practices while ensuring the private sector doesn’t crowd out the public sector.

In emergencies, funds can be directed to most needed priorities. To maintain service provision, providers may need to be compensated for income loss (e.g. during the Covid pandemic or in areas of high population movement during conflict). Kazakhstan has innovated using taxes on polluting industries directed towards health via its Qazaq Halqyna fund. 

In terms of out-of-pocket payments, these are comparatively higher in these countries, but the interpretation of different metrices for OOP expenditure clouds the picture. OOP payments need to be analysed alongside poverty rates and extreme poverty to get a more complete understanding. There is a higher rate of informal payments in Central and Eastern European countries (CEE) than in the EU, with richer people paying informal payments getting added value in care, increasing inequitable access.

Ukraine focus

Ukraine illustrates many of these adaptations, with the single purchaser scheme, set up from 2018 and before the invasion of 2022, ensuring continuity of care with non-contributory entitlements, including  for displaced people who have remained eligible for services. Strong purchasing and flexible payments (via altered reimbursements within the Programme of Medical Guarantees), and contracting adjustments at regional (oblast) level helped access be maintained. 4.2 million Ukrainians displaced in the EU and UK are still on PHC lists in Ukraine, many of them still accessing remote consultation with family doctors. Development Partner assistance as budget support enabled the government to maintain health spending while having to increase its defence spending. While capitation payments to family doctors have substantially increased consultations numbers, there is not yet enough oversight on how these payments are used, and no system yet for measuring quality of care in PHC or secondary/ specialist care. The Ukrainian health system has shown resilience to the multiple threats, maintaining essential health functions during crises while continuing to reform.

Session 2: Health care delivery – PHC

Research question: How are PHC-oriented health systems better for response to crises? Elements of a resilient PHC system.

Innovations in PHC from high-income countries were presented, including successes in using multidisciplinary teams for managing patients with NCDs and multiple morbidities and in reducing admissions with upstream management of NCDs (Emilia Romagna with the Casa della Salute^[1], and UK with multidisciplinary PHC team, and in nurse-led 24hr observation centres in Norway). Living in a country with strong PHC systems is proven to be beneficial to those with chronic conditions.

The Covid pandemic exposed weaknesses and underinvestment in PHC and public health provision in many European countries, exacerbated by the initial focus of the response on hospital care which delayed diagnosis and treatment of non-Covid 19 illnesses in PHC.

Ukraine focus

Increasing focus on PHC by the single purchaser in Ukraine ensured access to PHC and essential services in Ukraine during the conflict. Monthly revenues to PHC centres have gone up by one and half times between 2017/18 and 2020/21, with 81% of these revenues coming from the PMG (compared with 27% in 2017/18. There has been no accompanying major reform of the hospital sector, and reimbursements to both PHC and secondary care are not yet connected to quality of care, and there is persisting low levels of qualification and professional capacity. There is also a challenge in retention of staff with a strong pull for health professionals towards the EU. But informal payments in PHC have gone down by 21% between 2017/18 and 2020/21 (although the average amount paid has nearly quadrupled). The prevalence of informal payments in PHC is estimated to be 10.4% in 2020/21, whereas in secondary care payments are between 60% and 70% with an average 10% reduction during the same time period (source USAID HRS).

More reform is needed to ‘turbo-charge’ PHC in Ukraine. More deliberate budget allocation will be needed to shift the current 18% spent by the NHSU on PHC to a larger share. New initiatives are needed in patient-driven competition and purchasing of specialised care by PHC partial fundholders. And the Programme of Medical Guarantees (PMG) would ideally move towards incentivising providers to provide a mandatory PHC package along with standard treatment guidelines instead of providers being able to ‘pick and choose’ services their offer along with the current self-selection of treatment guidelines.  While the Affordable Medicines Program has expanded the list of medicines family doctors can prescribe, there is still perverse selection in dispensing of higher costs brands in pharmacies which inflates OOP payments.

Session 3: Health System Governance

Research question: How can informality and corruption be addressed in the pursuit of more just, sustainable, and resilient health systems and what role do democratic institutions play in establishing these?

Politically, democracy in a country has a more pronounced effect than raised GDP on reducing mortality and morbidity of those with NCDs and transport injuries (while in autocratic political jurisdictions effective coverage of Universal Health Care decreases, and decreases more post-recession whereas in democracies it increases post-recession).

Conceptually, a framework of fair process for UHC was discussed, with substantive fairness referring to how benefits are distributed and procedural fairness considers the views and interests of the population, which is a core feature of open societies. Taking these into consideration improves trust and promotes durability of reforms.

Transparency is crucial to decrease fraud, build trust and increase acceptance and compliance with service provision reforms. Corruption reduces disease outcomes; there is an association with higher corruption rates and higher maternal mortality and under-five mortality rates, and lower immunisation rates, higher rates of infectious disease transmission and increased antimicrobial resistance. Mainstreaming accountability and transparency (ACTA) in health systems is vital, and this process can be accelerated through digitalisation and investments in reporting systems. But an ACTA platform in health is needed.

Ukraine focus

The top two priorities of the Ukrainian population in surveys are anti-corruption and health care reform. Ukraine improved 12 points on Transparency International’s Corruption Perception Index (CPI), down to 104 in 2023. The conflict has increased demand for more inclusive decision making. It has been proposed that it is more effective to invest more time and resources in engaging citizens in fair processes than in marketing reforms. Civil society organisations are being included in the governance board of the PMG.

Governance of health professionals is on a self-governance model (draft law 10392 of 2024), but because professional associations are registered as NGOs the state can’t delegate regulatory functions to them, and the governance decisions of these organisations only apply to members – and there are many associations for each profession (98 for dentists). There is no individual licensing of medical professionals, but licensing is linked to premises.

Research agenda

A number of themes emerged from presentations and discussions, in these three panel areas. While there are a number of studies cross comparing health expenditure and OOP between countries, there are fewer studies in governance and on PHC.

Health financing

• More analysis of commissioning/ purchasing comparing CEE and Central Asian models would be helpful, and in comparing insurance based contributory schemes with central budget funded provision in the region.

PHC

• More research is needed in clinical outcomes, quality of care, use of treatment guidelines, performance in PHC and secondary care
• Multidisciplinary work in PHC is still in its infancy in many CEE and Central Asian countries. Research would be welcome to capture what initiatives are already in place in these countries and to examine the effect task shifting to multidisciplinary teams and from secondary care to family doctor teams could have on efficiency and on quality of outcomes
• It would be interesting to compare training and mentoring models in the region for the PHC workforce, and also to examine models of referral to specialist/ secondary care
• More understanding of essential packages of health services/ benefits packages comparing countries in the region would be revealing.

Governance

• More cross-country learning needed on corruption, and on successful accountability (ACTA) models, participatory governance models, and in particular in engaging civil society and local communities, comparing countries in the region
• More understanding is needed comparing the region’s decentralized governance models, and the impact of decision making and budgeting at local levels of government
• More learning would be helpful on professional accreditation and regulation models in the region, and in self-governance models
• More in-depth analysis comparing the political economy of states in the region and the effect this has on governance and inclusion and on coverage and effectiveness of UHC.

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