Tackling the problem of Tackling the problem of informal payments for informal payments for maternity care in Eastern maternity care in Eastern European context European context The cases of Russia & The cases of Russia & Armenia Armenia Presenter: Daria Ukhova (MEEECIS Regional Research Officer, Oxfam GB) 11 th International Women’s Health Meeting – 2011 Women’s Health & Human Rights. Let us build the Future, Brussels, 13-17 September 2011 Panel 10: Struggles for the right to health and universal healthcare: Perspectives form the women’s movement
Transcript
Tackling the problem of Tackling the problem of informal payments for informal payments for
maternity care in Eastern maternity care in Eastern European contextEuropean context
The cases of Russia & The cases of Russia & ArmeniaArmenia
Presenter: Daria Ukhova (MEEECIS Regional Research Officer, Oxfam GB)
11th International Women’s Health Meeting – 2011 Women’s Health & Human Rights. Let us build the Future, Brussels, 13-17 September 2011
Panel 10: Struggles for the right to health and universal healthcare: Perspectives form the women’s movement
Background - 1Background - 1
• Comparatively high maternal mortality rates in the region (old EU - 5.68/100,000; new EU - 10.2/100,000; CIS - 28.62/100,000)•Informal payments for publicly funded maternity care present in a range of CEE/CIS countries • Maternity care - the area of health care where informal payments appear to be most common• Russia & Armenia – first in the region to introduce policies targeting specifically informal payments for maternity care
Background - 2Background - 2
In both countries, maternity care certificate represents a document which all pregnant women legally residing in the country are entitled to receive, and which they subsequently are expected to hand over to those maternity care facilities where they receive maternity care services. The certificates are publicly funded and are meant to serve as a source of additional funding for maternity care services, thus substituting informal payments.
Background - 3Background - 3
• The Childbirth Certificate (introduced in Russia in 2006) - no reduction in informal payments for maternity care after the first year of the programme’s implementation; ‘dissolution’ of the policy objective.
• The Obstetric Care State Certificate (introduced in Armenia in 2008) - sharp decline in the incidence of informal payments after the first year of the programme’s implementation. Sources: Shishkin et al., 2004; Chernets et al., 2008; Muharyamova et
al., 2008; Mkrtchyan & Sacci, 2009; Truzyan et al., 2010
Research questions - 1Research questions - 1
Why has the Armenian Obstetric Care State Certificate programme been more effective than the Russian Childbirth Certificate programme in the reduction of the informal payments for maternity services?
Research questions - 2Research questions - 2
• What were the differences and similarities in the policy contexts in the two countries? • What are the differences and similarities in the two policy programmes (policy contents and policy implementation)?
‘[...] a direct contribution, which is made in addition to any contribution determined by terms of entitlement, in cash or in-kind, by patients or others acting on their behalf, to health care providers for services that the patients are entitled to.’ (Gaal et al., 2006)
IP – theoretical approachesIP – theoretical approaches
• Socio-cultural theories
• Legal-ethical theories
• Economic theories
• Theory of inxit (Gaal &McKee, 2004)
Theory of INXIT - 1Theory of INXIT - 1
• Shortage
• Exit
• Voice
• Inxit (informal exit)
Theory of INXIT - 2Theory of INXIT - 2
• Availability of the option
• Individual’s ability to use the option
• Individual’s willingness to use the option
MethodologyMethodology
• Case studies/MSSD
• Method of structured focused comparison (George & Benett, 2005)
• Types of data: Policy-related documents; evaluation reports; scholarly publications; media reports; consumer internet forums
Policy context – State socialismPolicy context – State socialism
• Shortage (maternity houses as “slaughter houses”; underpaid medical staff)• Blocked exit (no market; residential principle of care provision)• Blocked voice (no patient organisations; no mechanisms of complaint)• Informal payments (non-monetary forms such as, for example, the system of blat )
Sources: Holland & McKevitt, 1985; Bucher, 2000; Rivkin-Fish, 2005
• Increased shortage (OMI)• Blocked exit (persisting residential principle of care provision; very slow development of private sector)• Blocked voice (no patient organisations; no mechanisms of complaint)• Informal payments (monetary forms prevailing; highest incidence when compared with other health services)
• Increased shortage (BBP)• Blocked exit (persisting residential principle of care provision; development of ‘quasi’ private sector)• Slightly increased availability of voice option (appearing of the practice of patient surveys)• Informal payments (monetary forms prevailing; extremely high incidence – 91%)
• Additional funding for public facilities at all levels of the maternity care system (60% spent on salaries of the medical staff; 40% - on equipment & medicines)
• ‘Money follow the patient’ principle + payments depend on outcomes
• Serve as a ‘confirmation’ of the users’ right to choose facilities
Sources: Muharyamova et al., 2008; Sharapova et al., 2008; Guseva et al., 2010
Policy content – Obstetric Care Policy content – Obstetric Care State Certificate (Armenia)State Certificate (Armenia)
• Additional funding for maternity hospitals (85+% spent on salaries of the medical staff; 15% - on equipment & laboratory costs)
• ‘Money follow the patient’ principle + payments depend on outcomes & type of services provided
• Serve as a ‘confirmation’ of the users’ right to choose facilities & physicians
Sources: Muharyamova et al., 2008; Sharapova et al., 2008; Guseva et al., 2010
•Problem of shortage only partially solved (medical staff still unhappy with salary increases)
• Exit remains blocked (no real choice between public facilities; exit to the market remains open only to those able to pay out-of-pocket)
• ‘Overlooked’ possibility of making the certificate a tool of voice expression
Sources: Chagin, 2008; Muharyamova et al., 2008; Mishkina & Gabbasova, 2009; Borozdina, 2010; Guseva et al., 2010
Sources: Muharyamova et al., 2008; Sharapova et al., 2008; Guseva et al., 2010
Policy implementation & impact – Policy implementation & impact – Obstetric Care State Certificate Obstetric Care State Certificate (Armenia) (Armenia)
• Problem of shortage only partially solved (material conditions of facilities remain poor; decrease of the actual income of providers)• Increased availability of and users’ ability to exit (choice between facilities and physicians)• Increased availability of voice option through introduction of monitoring mechanisms (hotline for complaints), but users reluctant to use it• Doctors less willing to inxit due to introduction of punishment mechanisms
Sources: Harutyunyan, 2008 ; Helsinki Committee of Armenia, 2009; Truzyan et al., 2010
Sources: Muharyamova et al., 2008; Sharapova et al., 2008; Guseva et al., 2010
Childbirth Certificate vs. Obstetric Childbirth Certificate vs. Obstetric Care State Certificate Care State Certificate
Childbirth Certificate
Obstetric Care State Certificate
Shortage in the maternity care system
Has not been completely eliminated
Has not been completely eliminated
Inxit Has not been blocked Has been partially blocked
• Even when the problem of underfunding cannot be solved completely, the real opening of exit and voice options supported by a proper control of inxit could have substantial positive impact on the reduction of informal payments
• Further research needed to understand the extent to which each of the identified contributing causes has been important for the programme’s success/failure and how their impact may/would change over time
