The attitudes of health care system stakeholders towards official patient charges have not been studied in Ukraine although both the central and local governments have several times considered to introduce such charges. Instead, informal patient payments are widespread and wellestablished. Ukrainian patients pay either unofficially or quasi-officially (i.e. charitable contributions) to health care institutions. The reasonable solution for dealing with these types of payments would be the introduction of official patient charges. However, the legal base for such reform in Ukraine is ambiguous. The Constitution declares that health care provision is free-of-charge. Nevertheless, in our study,  representatives of stakeholders groups appear keen not only on discussing official charges but are also favor their introduction. The expectations regarding the possible objectives of these charges expressed by different  stakeholders are the focus of this paper.

The topic of informal patient payments is rather new in policy discussions although the phenomenon has existed for decades. These payments are a threat to public health since they jeopardise efficiency, equity and quality of health care provision. Most importantly, those who  cannot afford to pay might not seek or delay seeking treatment. Before attempting to deal with informal patient payments, it is necessary to understand the reasons for their existence and their role in health care provision. This could indicate the mechanisms through which these payments can be influenced by policy, as well as relevant strategies for dealing with these payments. This paper outlines a mixture of strategies as a plausible solution to informal patient payments. The successful implementation of these strategies depends on the particular setting and the overall conditions in the country (e.g. prevalence of corruption, and attitudes of health system stakeholders towards informal payments).

Informal patient payments are a common phenomenon for the formersocialist countries, though they are reported in other European countries as well. There are various definitions of informal patient payments as well as theories which explain this phenomenon (including fee for service theory, donation hypothesis, governance hypothesis and ethics hypothesis). The definitions of informal patient payments and the theories applied for their explanation determine the measures which are taken in order to eradicate informal patient payments.

The topic of informal patient payments in Poland was discussed within a corruption debate which was neglected for a long time. Since the end of 90s, due to the pressure of the international organizations, presence of corruption generally and informal patient payments particularly have been acknowledged. It resulted in various studies on informal patient payments as well as actions undertaken by governmental and nongovernmental organisations in order to eliminate these forms of payments.

This paper presents the review of empirical studies on informal patient payments and actions which have been carried out in Poland during last two decades. The types, scope and levels of informal patient payments as well as opinions on informal patient payments are analyzed. Time series data allow to study also a dynamics of informal patient payments and to draw some conclusions on the effects of measures which have been implemented by the Polish government to deal with informal patient payments.

This study is carried out under Project ASSPRO CEE 2007 funded by the European Commission under the 7th Framework Programme, Theme 8 Socio-economic Sciences and Humanities, Project ASSPRO CEE 2007 (Grant Agreement no. 217431). The views expressed in this publication are the sole responsibility of the authors and do not necessarily reflect the views of the European Commission or its services

Policy-makers assign various objectives to the implementation of patient charges for public health care services. These charges impose prices on health care consumption and as such, they are expected to affect the quantities of health care service demanded, and to generate revenues. The actual ability of patient charges to achieve these objectives depends to a great extent on the patient payment mechanism implemented in a country, as well as on the health care system and context-specific factors. This paper reviews and discusses the theoretical and empirical evidence on the effectiveness of patient payment policies. The paper suggests that patient charges can be a successful policy tool for controlling the pattern of health care utilisation and improving the quality of health care provision. However, an additional condition for success is the appropriateness of the design of patient charges with respect to efficiency and equity in the public health care sector

The introduction of co-payments for using health care services is a relatively new issue for most of the Central-Eastern European (CEE) countries. Some CEE countries, like Slovakia, Hungary and Czech Republic have similar experiences with the introduction of such co-payments. These fees were met with a cold reception by the population and also political resistance, which led to the abolishment of these payments in Slovakia as well as in Hungary.
Our paper focuses on the experiences of Hungary, where co-payments for health care services were introduced in February, 2007 and abolished one year later as a result of a population referendum. Hungarian experiences can serve as a lesson for policy makers from other CEE countries to develop sustainable patient payment policies.

During the past decade, the reform in the Bulgarian health care sector was in the focus of policy and research discussions at national and international level. In spite of the great expectations after the introduction of social health insurance in 2000, efficiency, equity and quality problems in health care provision in Bulgaria continue to exist. The unequal start of the reform in outpatient and hospital care (namely the delay in restructuring the hospital sector) is one of the causes of these problems. Among other issues, the reform also included the implementation of formal patient charges. At present, formal patient charges are applied to all levels of medical services with the exception of emergency care. Nevertheless, informal patient payments continue to exist. The aim of this paper is to present the attitudes of health care stakeholders toward patient charges from the perspective of the state of the Bulgarian health care system. The data are collected via focus group discussions and in-depth interviews carried out in Bulgaria in May-June 2009. The results are used to out-line recommendations for policy related to patient payments

During the last decades many European governments have introduced patient payments in their public health care system with the aim to improve efficiency of health care provision, contain overall health care expenditure, and also to generate additional resources. In Poland, since 1999 patients have met formal payment obligations when they use dental services. Though introduction of formal patient payments for primary care services, out-patient specialists’ services and hospital services has been discussed, such payments do not exist. Empirical evidence suggests that the successful implementation of patient payments, to a large extent, depends upon public acceptance and political consensus. The paper presents the results of study on attitudes towards formal patient payments for publicly financed health care services, among different groups of Polish health care system’s stakeholders (health care consumers, providers, insurers and policy makers). The data are collected via focus group discussions and in-depth interviews carried out in Poland in June–October 2009 as part of project ASSPRO CEE 2007. The results are used to out-line policy recommendations.

Patient payments are considered to be a significant issue in health policy in Lithuania. Despite the unclear legislative framework, health care institutions are asking patients to co-pay (contribute) for services provided to them. Thus, patients and providers are facing challenging situation in legal, ethical and financial terms. The aim of the study was to evaluate the opinions and attitudes towards patient payments in Lithuania. Qualitative and quantitative research methods were applied in the study – focus group discussions and in-depth interviews combined with a self-administrated questionnaire filled in by each participant. The results suggest that there is no consistent policy on patient payments in Lithuania. Health care consumers are rather resistant towards the introduction of payments (they support fees only in case of services with better quality). Health care providers sustain patient payments considering the needs of health professionals and health care institutions. Health policy makers and health insurance representatives remain dispersal in their opinions. More conceptual and strategic thinking in defining the aims of patient payment policies in Lithuania and its governance is needed.

Concept of Health Impact Assessment and its application in European Union. Private sector dimension

According to the WHO definition Health Impact Assessment (HIA) refers to “procedures, methods and tools by which a policy, programme  or project may be judged as to its potential effects on the health of the population and the distribution of those effects within the population”. HIA has emerged from weather forecasts and is founding much  broader use. It helps to identify the factors, which have a potential impact on health. HIA may be relevant for all sectors to determine the effects, also unintentional, of their policies and actions on health and it has the potential to bring greater transparency to the decision-making process. Usually, it is very important to be able to foresee future health related effects, also by clarifying the nature of trade-offs in policy. Comparing and judging wanted and unwanted results is essential to choose a possibly best alternative and avoid harm.
In European Union where modern tools to rationalize decision making process are broadly accepted HIA has been welcomed, at least in declarations. Although some approaches to assess actions targeted at environment have been formalized and are binding, but others, including HIA, still depend on good will of partners involved. Both member countries and institutions are a bit reserved to use HIA. Insufficient popularity of HIA may result from scarce educational opportunities but also from deficit in well grounded scientific evidence.

Private health insurance exists alongside to the statutory health system in most of the European countries. The reason to introduce PHI in health care system, among other, is limiting public health care expenditures by involving private insurers and individuals. Moreover it is believed that increase in competition between public and private insurers would expand consumers’ choice in health care. Despite all similarities in terms of main goals and general structure of health care system, PHI institutions in European countries vary.
The aim of the article is to present classification and examples of private health insurance solutions. More focus is put on French PHI system as an instance of existence of many types of PHI under specific regulations. The article also shows characteristics of PHI types. Furthermore the EU Third Non-Life Insurance Directive is presented as a main regulatory framework for PHI. PHI market basic information is included.

In 2006 the Netherlands commenced a major reform of its health care system. The main elements of the reform were: 1) replacement of the existing system of social health insurance for people with below average income and private health insurance for people with above average income by a universal private health insurance with the identical entitlements and contributions for all 2) the gradual introduction of elements of managed competition in hospital markets. The main aims of the reforms were to improve the so-called “public interests” in health care which were defined as quality, access, efficiency and cost containment in health care.
This paper describes the reforms that have been enacted in the Dutch health care system and evaluates the impact of these reforms on the “public interests” in health care. The health care reforms have had positive effects on most of “public interests”, though still much needs to be done e.g. development of quality standards, curbing the rapid rising costs of health care. Nevertheless, the reforms are still a work in progress, and there is still a great deal of  room for further improvement in ‘public interest’ in the Dutch health care system.

In 2009, following the election of Barack Obama to the Presidency of the United States, the American public entered into a fierce debate on how to reform its health care system. The intense debate on health care reform, however, is not a new phenomenon in American political life. Debate over health care has cycled its way into the American political discourse every twenty-years or so. History suggests that forceful opposition has prevailed against most major efforts to alter the health system in the United States. Yet, once again the Democratically-controlled Congress and Presidency in the United States aspire to break this cycle of history. With both houses in Congress passing a bill with significant reforms, it seems that this time may be different. While it is very likely some reforms will pass in 2010, no law has been signed yet56. In the end, only time will dictate the outcome of this round of health reform debates.
Through a thorough literature review, this article provides the Polish reader a sense of health care reform efforts in the U.S. from the historical perspective and discusses the current proposed reforms. Particular attention is paid to the evolution of the American health insurance system, failed efforts of past health reform initiatives, their contrast with today’s efforts, and current health and economic indicators that could lead to reform in 2010.

The purpose of the paper is to investigate the relationship between ownership structure of health care providers and technical efficiency of health care in the regions of Poland. A model built with the use of data envelopment analysis methodology is used for the estimation of efficiency of the health care production process in the regions. The inputs of the process are densities of doctors and nurses as well as per capita expenditures for health care in each of the regions; the outputs are numbers of ambulatory and stationary care services produced. Generally, the results show that the regions with a higher proportion of non-public providers are characterized by a higher technical efficiency, however the results are not unambiguous. The correlation between efficiency and the development of the non-public sector is statistically significant only in the case of ambulatory care providers, while it is insignificant when the proportion of non-public hospitals is considered.

Non-public hospitals in the Malopolska region – functioning profile and participation in the in-patient services delivery and their participation in the in-patient services delivery.

As the process of privatization of the Polish health care sector, launched in 90. is progressing (especially in the out-patient sector), the hospitals remain dominantly public area – in 2008 about 93% of the hospital beds belonged to the public sector. Additionally, according to the Polish law, the non-public hospitals group includes both the private owned hospitals, as well as those owned by the local governments units, but run in a form of companies (mainly limited liability and joint stock companies). The private hospitals functioning in Malopolska region are usually small units, specialized in narrow disciplines – mainly: gynaecology and obstetrics, surgery, nefrology (dialysis units), and rehabilitation. In 2009 majority of them signed contracts with the National Health Fund (public health insurance payer) and delivered services for the public health insurance patients. Specific for hospital services – high costs of both delivery and equipment maintenance are the main reasons for significantly smaller than in out-patient services, contribution of the private sector.