Kutzin Joseph, Jakab Melitta, Shishkin Sergey
WHO Europe, Office for Health Systems Strengthening, Barcelona, Spain.
Adv Health Econ Health Serv Res. 2009;21:291-312.
The aim of the paper is to bring evidence and lessons from two low- and middle-income countries (LMIs) of the former USSR into the global debate on health financing in poor countries. In particular, we analyze the introduction of social health insurance (SHI) in Kyrgyzstan and Moldova. To some extent, the intent of SHI introduction in these countries was similar to that in LMIs elsewhere: increase prepaid revenues for health and incorporate the entire population into the new system. But the approach taken to universality was different. In particular, the SHI fund in each country was used as the key instrument in a comprehensive reform of the health financing system, with the new revenues from payroll taxation used in an explicitly complementary manner to general budget revenues. From a functional perspective, the reforms in these countries involved not only the introduction of a new source of funds, but also the centralization of pooling, a shift from input- to output-based provider payment methods, specification of a benefit package, and greater autonomy for public sector health care providers. Hence, their reforms were not simply the introduction of an SHI scheme, but rather the use of an SHI fund as an instrument to transform the entire system of health financing.
METHODOLOGY/APPROACH: The study uses administrative and household data to demonstrate the impact of the reforms on regional inequality and household financial burden.
The approach used in these two countries led to improved equity in the geographic distribution of government health spending, improved financial protection, and reduced informal payments.
The comprehensive approach taken to reform in these two countries, and particularly the redirection of general budget revenues to the new SHI funds, explain much of the success that was achieved. This experience offers potentially useful lessons for LMIs elsewhere in the world, and for shifting the global debate away from what we see as a false dichotomy between SHI and general revenue-funded systems. By demonstrating that sources are not systems, these cases illustrate how, in particular by careful design of pooling and coverage arrangements, the introduction of SHI in an LMI context can avoid the fragmentation problem often associated with this reform instrument.
本文旨在将前苏联两个低收入和中等收入国家（LMIs）的证据和经验教训引入全球关于贫困国家卫生筹资的辩论中。特别是，我们分析了吉尔吉斯斯坦和摩尔多瓦引入社会医疗保险（SHI）的情况。在某种程度上，这两个国家引入社会医疗保险的意图与其他低收入和中等收入国家相似：增加卫生方面的预付收入，并将全体人口纳入新体系。但实现全民覆盖的方式有所不同。特别是，每个国家的社会医疗保险基金被用作卫生筹资体系全面改革的关键工具，工资税产生的新收入以明确互补的方式用于补充一般预算收入。从功能角度看，这些国家的改革不仅涉及引入新的资金来源，还包括集中统筹、从基于投入的提供者支付方式向基于产出的支付方式转变、确定福利包以及赋予公共部门医疗服务提供者更大自主权。因此，它们的改革不仅仅是引入一个社会医疗保险计划，而是利用社会医疗保险基金作为工具来转变整个卫生筹资体系。
方法/途径：该研究使用行政和家庭数据来证明改革对地区不平等和家庭经济负担的影响。
这两个国家采用的方法使政府卫生支出的地理分布更加公平，增强了经济保障，并减少了非正规支付。
这两个国家在改革中采取的综合方法，特别是将一般预算收入重新导向新的社会医疗保险基金，很大程度上解释了所取得的成功。这一经验为世界其他低收入和中等收入国家提供了潜在的有益教训，并有助于将全球辩论从我们所认为的社会医疗保险体系与一般税收资助体系之间的错误二分法中转移出来。通过表明资金来源并非体系，这些案例说明了如何通过精心设计统筹和覆盖安排，特别是在低收入和中等收入国家引入社会医疗保险时，避免通常与这一改革工具相关的碎片化问题。
