Governance of hospitals and accessibility of health care in post-semashko health care systems
Date
2014
Authors
Sowa, Przemyslaw Marcin
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This thesis comprises an overview of health care transition in post-communist countries and two original contributions to the subject's literature. The background chapter establishes the meaning of post-communist transformation by presenting key socio-economic changes and characterising health care systems emerging from transition. The first of the two original studies develops, substantiates and statistically applies a model of hospital governance transition. Going beyond the public-private delineation, the model identifies five stages of hospital governance transformation: (1) the integrated Semashko model, (2) decentralised hospital management, (3) devolved hospital ownership, (4) corporatisation, and (5) privatisation of hospitals. Each stage corresponds to a distinct distribution of decision powers, financial risks and residual claims between the sector participants; moreover, it reflects efficiency factors associated with decentralisation. Building on previous studies primarily concerned with financing arrangements, this model constitutes a more complete picture of economic incentives and the managerial capacity in the sector. The econometric analysis of 22 countries over the 22-year period 1989-2010 is based on a random trend model. Notable findings include devolution of ownership leading to increases in acute care lengths of stay, numbers of admissions, and selected measures of mortality attributable to hospital care. Corporatisation of hospitals is found to be associated with increased acute lengths of stay and bed occupancy rates. The findings suggest that decentralisation and autonomisation, as introduced in the region, did not contribute to the intended de-emphasising of inpatient care. Higher utilisation rates coinciding with increased mortality may imply that territorial governments trade-off quality for quantity of care when they are given authority over hospital care provision. Reform design features and resource constraints persistent in the transition systems offer possible explanations of this. The second study examines health care accessibility in seven countries of Central and Eastern Europe, over the five years 2005-2009, through the lens of individual-level unmet needs for examination or treatment. Investigated are the magnitude and nature of access barriers as well as the structure of inequality. The study design based on logit and multinomial logit models of individual socio-economic characteristics permits the interpretation of findings in absolute and comparative terms and shows the problem dynamics. Health care is most easily accessible in the Czech Republic and Slovakia. Affordability issues and prohibitive waiting times are prevalent in Poland and the Baltic States. Mobility and information represent relatively minor access barriers. The poorest households, the unemployed, working age cohorts, and women are more exposed than the population at large to problems in accessing health care. Over the analysed period access conditions generally improved. The outcomes show that substantial differences exist between the countries that constitute an arguably homogenous group of post-communist, new EU member states. This suggests there are policy lessons to be learned from peer transition countries. The nature of access barriers is indicative of gaps in coverage and inadequacy of public sector resources relative to need, which call for systemic solutions.
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