Health insurance as a catalyst to change in former communist countries?

A large number of former communist countries are currently undergoing a process of insurance led health sector change. Social health insurance is seen as a major source of income for the health sector, as a way of inducing fundamental restructuring of provision and of encouraging greater individual awareness of the costs (and benefits) of publicly financed health care. Attempts to introduce social medical insurance have generally been criticized by western policy analysts yet continue to have much appeal in each country. Obtaining additional revenue for the health sector is clearly a major motivation for these reforms. Yet available evidence suggests that many countries will obtain revenue that is lower and less stable than envisaged. For some countries other reasons for insurance may be as important. One of the most important is the greater autonomy given to the national Ministry of Health and local health departments over expenditure allocation. Recent experience of voluntary insurance in Turkmenistan confirms many of the fears about the feasibility and impact of social health insurance. Yet establishing an attractive but contained benefits package has been popular with the population and offers a potentially useful approach for inducing more fundamental reform.