Voir page 1052 le resume en francais. En la pagina 1052 figura un resumen en espanol.
The financing of health care in countries of the former Soviet Union has undergone many changes and is now showing signs of maturing. Soon after the political transition in these countries, the development of insurance systems and fee-for-service payment systems dominated the discussions on health reform (1, 2). Often it appeared as if anything was preferable to whatever had been the existing system. As a result, many countries were faced with demands to provide more treatment than was really necessary, funded by new insurance systems that were not properly accountable, and appeared to produce more costs (e.g. in extra administration) than benefits (e.g. from improved efficiency). The process of cost escalation in the Czech Republic (3) and the less well-known instances in other countries, such as Estonia (4), serve as a warning that new payment systems can impose significant costs on impoverished systems.
Changing the payment method to a system of case-based remuneration or global budgets has the potential to moderate these escalating costs and provide the basis for a modern payment system. On their own, however, these methods are unable to bring about the fundamental restructuring required of the health care system (5). Business plans, agreed between purchaser and provider, offer a way of developing a process of global budgeting or case-based payment which is transparent and accountable. These plans can be used as a basis for fundamental restructuring in a way that even quite sophisticated payment systems alone cannot.
This article describes the process of creating a business plan to establish and monitor a global budget in a rural area of Turkmenistan. The general process of economic and health care transition in Turkmenistan are described first, while subsequent sections describe the business planning process. Although the final product is not revolutionary, the process involved reveals a considerable amount of information about the way in which the health services function and the implied objectives of the providers, Subsequent plans must build upon this process in order to develop a workable system of population-led service planning.
Health care and economic transition
Turkmenistan, the most southerly of the Central Asian republics of the former Soviet Union, has a population of about 4.6 million, most of whom live in the south around the capital of Ashkhabat. The country has borders with Iran, Afghanistan, Kazakhstan and Uzbekistan, and is largely desert in the central part.
The health status of the population in Turkmenistan compares unfavourably with other countries in the WHO European Region (EUR) (Table 1). The infant mortality rate is three times the EUR average and exceeds the rate in all the other countries in Central Asia. Maternal mortality is similar to that in other countries of the former Soviet Union, but is far higher than the European average. Although the accuracy of these data and their comparability with those from Western Europe have been questioned (6), the picture of (at best) a stagnating health situation or (at worst) serious decline over the last ten years is broadly accepted. Female life expectancy fell from around 70 years in 1989 to 66 years in 1995, while that for males fell from around 63 years to 61 years over a similar period (7). The indicators are usually significantly worse in the rural areas. In the capital Ashkhabat, for example, life expectancy at birth is eight years higher than for the country as a whole.
Table 1. Health status in Turkmenistan and regional comparator countries, 1994(a)
Turkmenistan Kazakhstan Fereration
Infant mortality rate 42.9 27.4 18.6
Maternal mortality rate 42. …