1. 1 The 1st Summer School and Discussion Forum of the PERC Budapest, 1-3 September 2008 ____________________________________________ Enisa Salimović, ITUC-PERC SEE Office Sarajevo “HEALTH CARE REFORMS IN SEE COUNTRIES- The Trade Union Perspective”

2. 2 Reform of health care system is one of the most important reforms in each country 1. Health is one of the main human rights for fulfilling all other human rights. Every human beeing has right to enjoy the highest possible standards of health, what made it possible for decent life of each individual

3. 3 There are 3 main models of health care system financing 1. So called Model of social insurance/ Bismark/ in many continental countries, and in the SEE. Financing from obligatory contributions, which employers and workers need to pay

4. 4 2. Model of national health insurance/ England, Sweden, Canada-financing from the taxes 3. Liberal-market model / America- workers and their families are insured in the private insurance companies

5. 5 These three models started to overlap

6. 6 Principles for managing change Develop health policy Listen to citizen’s voice and choice Reshape health care delivery Reorient human resources for health care Strengthen management Learn from experience

7. 7 Major reform strategies: Restructuring Splitting of purchaser – provider roles Separation policy / financing functions from operational functions Reorientation of service delivery Decentralization Deconcentration; delegation; devolution; privatization Privatization of ownership; responsibility; service provision; finance Introduction of market mechanisms

8. 8 Efficiency Quality Equity Responsiveness Sustainability Reform objectives:

9. 9 Fundamental principels Within the European context, health care systems need to be Driven by values Targeted on health Centred on people Focused on quality Based on sound financing

10. 10 Activities for TUs so far: ETUI and ITUC-PERC organized two events: 1. Zagreb / April 2007/ and 2. Brussels / December 2007/ SEE TU Network for helath reforms has been set up

11. 11 The following topics were discussed: SEE Health network, past, present, future Social health insurance and mutual health associations in Belgium Reforms and their impact on health personnel Issues affecting the Sustainability of Health financing in SEE SEE Reform Policies- a view from the West, Belgian system of health care Health financing reforms in Hungary The migration of labour force from health systems in Romania

12. 12 Socail reforms started in all Balkan countries Five countries of the Western Balkans: Serbia, BiH, Croatia, Montenegro and Macedonia have a common history and a similar starting base Reforms in three phases: Initial changes, 1990 -91 Interruption / due to wars Speed continuation of reforms, from1996

13. 13 Caracteristic of social transformation in the Balkan countries: Reforms of health care system started paralelly with other social reforms International Financial institutions, particularly the World Bank, make strong influence on these processes National trade unions, are practically eliminated from the strategic decisions on the reforms and the selection of solution variants. Governments are implementing reforms without consenzus with other social partners

14. 14 There are some main issues to be discussed: 1. Future model of Health care system 2. Public healthcare 3. Quality of healthcare 4. Financing

15. 15 There are concerns about financial sustainability of the present system…. / According to the WB Financial sustainability Relatively high payroll taxes for Social Health Insurance High dependency ratio (paying as non-paying beneficiaries) Insurance benefit package not defined Fiscal pressure caused by insurance arrears and need to pay for care of uninsured population Lack of coordinated investment planning in high-cost infrastructure and technology

16. 16 … as well as efficiency and equity Efficiency No strategic purchasing to improve provider performance Overcapacities and low productivity in hospital sector Advances in medical technology, inter alia, will generate pressures for higher spending Price distortion for specialist care leading to more high-cost services Inefficient pharmaceutical procurement Equity Inequity in utilization and financing caused by out-of-pocket payments Widespread informal payment charged by health workers

17. 17 High insurance contribution rates put pressure on labor markets and result in low collection rates

18. 18 High income inequality within countries makes it difficult to reach adequate financing for health

19. 19 Steps on the way forward TU need to be active partner in the process of reforms / Social dialogue for consensus building TUs need to be realistic Need to integrate health workforce aspects into reform policies- industrial democracy in the sector Issues to be followed: trends in employment in the health sector, the financing and quality of the health care system- public finansing; privatization; patient’s contributions; under funding; accessibility; quality of services; safety and health at work Challenge for authorities: Successful reforms balance health workforce interests with population interests and service performance Successful reforms balance health workforce interests with population interests and service performance

20. 20 What is the trade union perspective: The social dialog should be diverted from a formal procedure into real Trade union organizations and employers should be encouraged by the national and European institutions to increase their administrative and expert capacity There is also a need for better cooperation /exchange of information, expertise and practices/ among the national confederations at sub-region level

21. 21 Thank you for your atention! I wish you a good health !