# Compulsory health insurance in the Central and Eastern European countries: the similarity and the difference with Social Health Insurance

## TL;DR

This paper examines health insurance models in Central and Eastern Europe, comparing them to Social Health Insurance and identifying key differences in regulation and financing.

## Contribution

The paper introduces a new conceptual framework to distinguish compulsory health insurance models from government health financing schemes and identifies four SHI model types.

## Key findings

- State regulation dominates in collection and pooling functions in most CEE countries.
- A variety of regulation types are observed in the purchasing of medical services.
- Four SHI model types (State, Etatist, Bismarckian, Quasi-Market) are identified based on regulatory characteristics.

## Abstract

According to the conventional point of view, compulsory health insurance (CHI) models in the Central and Eastern European (CEE) countries are classified as Social Health Insurance (SHI) schemes. However, the absolute dominance of the state in their regulation in many CEE countries calls into question such a qualification. The existing approaches to the definition of SHI are insufficient to clearly distinguish existing CHI models from government health financing schemes as well as to identify their exact similarities and differences with SHI models in Western Europe (WE).

The new conceptual framework is used to compare the similarities and differences between the SHI models in CEE and WE countries. The characteristics of financial flows regulation are considered to distinguish SHI from government healthcare financing schemes. Different CHI models are compared by using three different types of regulation (state, societal, market) of the three main functions of health financing system (collection, pooling, purchasing), and by types of financing agents. A qualitative, cross-country analysis is implemented with use the data from the WHO Health system reviews Health Systems in Transition.

In almost all countries considered, state regulation is dominant in the implementation of collection and pooling functions. A variety of combinations of state, societal, and market regulation is observed in the purchasing of medical services. State regulation dominates in most CEE countries, societal regulation dominates in some of them and in almost all WE countries. In most CEE countries and in some WE countries state regulation of purchasing is complemented by market regulation. Based on these characteristics, four types of SHI models are identified (State, Etatist, Bismarckian, and Quasi-Market).

The dominance of state regulation in the CHI models in almost all CEE countries is not a sufficient reason to qualify these models as hybrid financing systems. They retain fundamental differences from government financing schemes: the systems of financial flows are separated from state budgets and operate according to the rules set specifically for these systems.