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Health Reforms
in Post-Communist
Eastern Europe
The Politics of
Policy Learning
Tamara Popic
Health Reforms in Post-Communist
Eastern Europe
Health Reforms in
Post-Communist
Eastern Europe
The Politics of Policy Learning
Tamara Popic
School of Politics and International Relations
Queen Mary University of London
London, UK
© The Editor(s) (if applicable) and The Author(s), under exclusive licence to Springer
Nature Switzerland AG 2023
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To Lorenzo and David
About the Book
This book provides the first in-depth study of healthcare reform in post-
communist Eastern Europe. Combining insights from comparative poli-
tics and public policy analysis, it examines health reforms in Slovenia, the
Czech Republic, and Poland between 1989 and 2019. The book argues
that the transformation of post-communist health systems has entailed a
process of policy learning and that the pathways taken by different states
away from communist-era healthcare system have been shaped by a series
of reform initiatives aimed at adapting of market-oriented policy ideas in
healthcare provision. The success of these initiatives has been influenced
by three factors: policy legacies, political competition, and institutional
configurations. The book offers a novel and important comparison of
health reform in the region, as well as policy changes more generally. It
will appeal to scholars and students of public policy, health policy, and
European politics.
Acknowledgements
This book would not have been possible without people who provided
inspiration, encouragement or other types of support for its research and
writing. Its ‘beginnings’ date back to 2009, when I enrolled in the doc-
toral programme at the European University Institute (EUI) and was
given an opportunity to pick a topic of my choice for my PhD research.
My gratitude goes first and foremost to Sven Steinmo for his generous
support and guidance as I was developing my first ideas about the politics
of health reforms in post-communism. I am also very grateful to Ellen
Immergut, for the stimulating intellectual support and comments which
provided inspiring motivation as I worked on the book during my postdoc
period. Ellen was also incredibly generous with her advice on different
aspects of the book publishing and writing, and I feel deeply indebted to
her for helping me with the first steps in finding a balance between aca-
demia and motherhood, two worlds that I combined as I started writing
the book. I am also grateful to my colleagues from the Max Weber
Programme’s Writers Group—Bilyana Petrova, Takuya Onoda, and
Alexandru Moise—who provided highly stimulating comments on the
book’s first draft chapters and encouraged its further writing. I also thank
Diana Burlacu, my colleague and co-author, for sharp comments on
book’s contribution. At my new academic ‘home’, Queen Mary University
of London, I am very grateful to David Williams for the understanding
and time he generously provided—both were needed to finalize this book.
ix
x Acknowledgements
1 Introduction 1
3 Slovenia 59
5 Poland149
6 Conclusion197
Index 213
xi
About the Author
xiii
Abbreviations
xv
xvi ABBREVIATIONS
xvii
CHAPTER 1
Introduction
Introduction
Writing about a highly controversial health law in the Czech Republic, a
2008 article in The New York Times reported the introduction of patient
fees for medical services, including a fee of $1.85 to see a doctor. Clearly
puzzled by how such a small fee could generate so much public outrage,
the journalist suggested healthcare was a sensitive issue in the Czech
Republic and, indeed, in Eastern Europe more generally. ‘The idea of
charging anything for healthcare can generate significant controversy’, he
pointed out, ‘because many Czechs see it as a matter of principle that
healthcare should be free’ (New York Times 2008).
As this book goes on to show, the introduction of user fees during post-
communist health reforms in the Eastern Bloc countries was one of many
measures that marked a departure from the state-dominated system of
healthcare in which medical services were provided centrally and hierarchi-
cally, but also universally, at no cost to citizens. Emerging out of the com-
munist era, however, these systems had numerous problems and in the
context of the double transition to capitalism and democracy, policymak-
ers looked to private markets and competition, hoping this would improve
the efficiency and quality of healthcare provision, as well as eradicate ubiq-
uitous corruption.
Of course, post-communist countries were not alone in this: attempts
to reduce public funding for healthcare, shifting to a mix of public and
private funding and replacing state with market mechanisms in the provi-
sion of medical services, entered European governments’ health reform
agendas in the 1990s (Immergut et al. 2021a; see also Tritter et al. 2009;
Thomson et al. 2009; Gingrich 2011). Yet in the Eastern Bloc, these
market- oriented tendencies were particularly strong, as after almost
50 years of the state-dominated, socialist command-and-control systems
of healthcare based on central planning, newly democratic governments
embraced markets and privatisation with enthusiasm. Eastern European
countries, as shown in this book, essentially became laboratories testing
market-oriented ideas and their adaptation to the post-communist health
context.
Healthcare reforms in the three countries discussed in this book
(Poland, Slovenia, and Czech Republic) are interesting comparative cases
of the turn to markets. In the Czech Republic, beside the above-mentioned
user fees, the government introduced a highly market-oriented, competi-
tive insurance system and installed a reimbursement method for doctors’
services based on a competitive fee-for-service model that, far from work-
ing as planned, actually generated textbook examples of market failure. In
Slovenia, one of the main aspects of the breakdown of the socialist model
was the introduction of co-payments for healthcare and complementary
private health insurance, and these became an integral part of the new
health system. In Poland, market enthusiasm led to radical but failed mar-
ket reforms in the early transition, followed by continuous efforts to push
for further marketisation through various measures, including the trans-
formation of public hospitals into private, for-profit commercial compa-
nies. Whilst these market reforms were embraced enthusiastically by the
post-communist policymakers, they also generated criticism and inspired
heated debates revolving around substantial social values of egalitarianism,
fairness, and solidarity.
The examples of market-oriented health reforms in the Eastern Bloc are
illustrative of a much wider departure from, in principle, a very generous
‘cradle-to-grave’ system of social benefits built under socialism. This wel-
fare system developed gradually during the post-war period and was
labelled a ‘premature welfare state’, characterised by universal entitlements
out of proportion with countries’ resources and fiscal capacity (Kornai
1997). Ending socialism whilst still adhering to some of the core values of
the welfare state, such as universalism, was a notable challenge for the new
democratic leaders in the Eastern Bloc. Economic transition led to restruc-
turing, generating radical disruptions, crises, and unexpectedly high social
1 INTRODUCTION 3
1
Studies of the post-communist welfare restructuring that cover healthcare are either
restricted to very brief descriptions of some of the aspects of healthcare system transforma-
tions (see Kuitto 2016) or offer short cross-country comparisons (see Szikra and
Tomka 2009).
4 T. Popic
2
According to Hayek: ‘Whereas in the case of sickness and accident, neither the desire to
avoid such calamities nor the efforts to overcome their consequences are as a rule weakened
by the provision of assistance—where, in short, we deal with genuinely insurable risks—the
case for the state’s helping to organize a comprehensive system of social insurance is very
strong’ (Hayek 2007: 148).
6 T. Popic
between the two processes in the degree to which they attach importance
to the state. Whilst ‘economised’ health policy depends on a strong and
regulative state and involves elements of central steering, ‘marketisation’
reduces the impact of the state by initiating competition between non-
profit and for-profit providers, contracting-out certain services, or form-
ing new kinds of contracts between users and providers, without the state
(Ewert 2009: 24).
This book combines these different conceptualisations to define the
healthcare markets introduced in the post-communist context. Building
on the definition of health markets as ‘quasi-markets’ (Le Grand 2011),
instruments that combine elements of state funding of healthcare with
consumer choice and competition, it pays attention to the behavioural
dimension of markets in healthcare. As shown throughout the book, the
introduction of market mechanisms in the post-communist countries
essentially implied a shift from the ‘command-and-control’ model in
which the state as a central agency had exclusive control of the provision
of the medical services (see Gingrich 2011). In this model, healthcare
facilities belonged to the state, medical professionals were state employees
on fixed salaries and patients’ access to care was territorially determined and
hence restricted (Field 1991). Healthcare was financed according to a
main instrument of classical socialism, a ‘Five Year Plan’, with a pre-
established share of the state budget dedicated to the sector (Weinerman
1969). In this context, the post-communist shift to a ‘market-oriented’
healthcare system, the term used here, implied the introduction of new
mechanisms of healthcare provision, or ‘marketisation’, which aimed at
changing incentives for consumers and producers of health services
(Gingrich 2011), with countries taking different routes to the reduction
of the state’s role in healthcare (see Ewert 2009).
In terms of healthcare financing, the introduction of healthcare markets
meant a reduction of public funding and an increase in private ‘out-of-
pocket’ payments for health services. In terms of healthcare delivery, it
involved the conversion of public, state-owned healthcare facilities into
private, either non- or for-profit organisations, in some instances, subject
to commercial rather than public law. More essentially, however, this
reduction in the role of the state aimed to influence the behaviour of the
main actors in the sector by changing incentives for patients as consumers
and for providers as producers of health services. Patients became able to
choose their own doctors or insurance funds and change them if they were
not satisfied. Through other market measures, such as user fees or
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CHAPTER XXV
THE DISPUTE WITH SPAIN
How curiously the wheels of human action act and interact! The
outrage on British sailors on the dimly known coast of Vancouver
Island furnished French democrats with a potent motive for driving
another nail into the coffin of the old monarchy. In any case the right
of Louis XVI to declare war and make peace would have been
challenged—for how can Democracy allow a Sovereign wholly to
control its policy at the most important of all crises—but now the
need was overwhelming. If the old prerogative held good, the rusty
link that bound together the fortunes of France and Spain would
compel free Frenchmen to fight their English neighbours whenever a
Spanish captain thought fit to clap in irons British voyagers to the
Pacific.
The question aroused gusts of passion at Paris. Enormous
crowds waited outside the Tuileries while the deputies hard by were
debating this question (16th and 22nd May). To the surprise of the
people the royal prerogative was upheld by Mirabeau. The great
orator descanted forcibly on the need of energy and secrecy in the
diplomacy of a great nation, and reminded those who ascribed all
wars to the intrigues of Courts that popular assemblies had often
declared war in a fit of passion. He remarked that members had all
applauded a speaker who advocated war against England if she
attacked Spain, and the expenditure of their last man and their last
926
crown in reducing London. Few of Mirabeau’s speeches were
more convincing. Nevertheless, on coming forth from the Chamber
he was threatened with violence; and a pamphlet, “Great Treason of
Count Mirabeau” was hawked about the streets. His reasoning,
however, ensured the carrying of a compromise on 22nd May. The
right of declaring war and making peace was vested in the King: and
war was to be decided only by a decree of the Legislature, on “the
formal and necessary proposition of the King, and afterwards
927
sanctioned by him.” The position was thus left far from clear; and
Camille Desmoulins, referring to the ups and downs of the debate,
summarized it thus: “The question was decided, firstly, in favour of
the nation, secondly, in favour of the King; thirdly, in favour of both.”
The royalists were highly displeased. Their best speaker, Cazalès,
declared that nothing was now left to the monarchy—an exclamation
which probably revealed his disgust at the passing away of the
opportunity of a war with England.
Meanwhile Pitt had worked hard to array his allies, Prussia and
Holland, against Spain. In this he succeeded. In particular, he offered
to the Dutch a considerable subsidy for arming a squadron as if for
war. To this topic he referred in a letter of 18th May 1790, to
Auckland. After informing him that the tellership of the Exchequer
would be reserved for him, or one of his sons, besides a pension of
£2,000 a year on retirement, he continued thus:
The efforts which the Court of Madrid then put forth at St.
Petersburg and Vienna showed its resolve to concert a league
against England in which Denmark was to be included. This scheme,
as visionary as the grandiose dreams of Alberoni, caused our
Ministers some concern, until they found that their Allies, Prussia
and Holland, were resolved to support them. On 20th May Hertzberg
assured Ewart, that Prussia would fulfil her engagements, if Spain
931
pushed matters to extremes.
Nevertheless, for a time everything portended war. Fitzherbert,
after reaching Aranjuez on 10th June, became convinced that
Floridablanca, for all his peaceful assurances, intended to force a
rupture at the first favourable opportunity. The Spanish Court
absolutely refused to grant satisfaction for the injury done to Meares
and Colnett, because that would imply the right of British subjects to
932
be at Nootka. For the very same reason the Pitt Cabinet pressed
its preliminary demand. It also brushed aside the Spanish
pretensions of sole sovereignty on the Nootka coasts, because
British and other seamen had for some little time traded there—an
933
assertion difficult to maintain.
The deadlock was therefore complete; and, if Spain could have
looked forward to help either from France, Russia, or Austria, war
would inevitably have ensued. It is of interest to observe that, as the
crisis became acute, Pitt adopted his usual habit of writing the drafts
of the most important despatches; and they were sent off without
alteration. He thus disposed of the suggestion of Floridablanca, that
the whole matter in dispute should be settled by arbitration. “Your
Excellency will not be surprised that they are such as cannot be
adopted. The idea of an arbitration upon a subject of this nature
must be entirely out of the question; and a reservation such as that
contained in the second proposal would render the satisfaction
nugatory, as it would refer to subsequent discussion the very ground
934
on which that satisfaction is demanded.”
The outlook was not brightened by the suggestion of
Floridablanca, that Spain should keep the whole of the coast from
California up to and including Nootka; that from that inlet northwards
to 61°, British and Spaniards should have conjointly the right of
trading and forming establishments; and that British sailors should
enjoy certain fishery rights in the South Sea on uninhabited islands
935
far removed from Spanish settlements. These proposals seemed,
as they doubtless were, a device to gain time until France, Austria,
or Russia could step forth and help Spain; and Pitt refused to admit
these “chimerical claims of exclusive sovereignty over the American
Continent and the seas adjacent,” which were to Spain herself
936
“rather matter of useless pride than of actual advantage.”
Towards the end of July more peaceful counsels prevailed at Madrid,
probably because the weak and luxurious King, Charles IV, disliked
war, and dreaded contact with Revolutionary France. Further it must
have transpired that Russia and Austria, owing to their war with
Turkey, were not likely to give more than good wishes to Spain.
Either for these reasons, or because he hoped that delay would tell
in favour of Spain, Floridablanca signed with Fitzherbert on 24th July
a Declaration that Spain would give satisfaction for the seizure of
British vessels and their cargoes at Nootka. On 5th August Grenville
937
informed the King of this auspicious turn of affairs.
But now, while the Court of Madrid abated its pretensions,
French patriots began to rattle the sword in the scabbard. For
reasons which are hard to fathom, the Spanish request for armed
assistance, which reached Paris on 16th June, was not presented to
the National Assembly until 2nd August. On that day Montmorin
informed the deputies of the continuance of naval preparations in
England, and declared that, unless French aid were accorded to
Spain, she would seek an ally elsewhere. The statement was well
calculated to awaken jealousy of England; and members came to the
conclusion that the islanders were seeking, in the temporary
weakness of France, to bully the Court of Madrid out of its just rights.
Consequently the whole matter was referred to the newly appointed
Diplomatic Committee which supervised the work of the Foreign
938
Office. As this body now practically controlled French diplomacy,
everything became uncertain; and it is not surprising that Pitt and
Leeds declined to disarm now that the question of peace or war
depended on an emotional Assembly and its delegates.
At the head of this new controlling body was Mirabeau. As
Reporter of the Committee he held a commanding position, which
was enhanced by his splendid eloquence, forceful personality, and
knowledge of the shady by-paths of diplomacy. The Report which he
presented to the Assembly on 25th August was, in effect, his. While
minimizing the importance of the Nootka dispute, scoffing at the old
diplomacy, and declaring that Europe would not need any diplomacy
when there were neither despots nor slaves, he yet proposed that,
pending the advent of that glorious age, France must not abrogate
her treaties but continue to respect them until they had been
subjected to revision. Further, in place of the Family Compact of the
Kings of France and Spain, he proposed to substitute a National
Compact, based on the needs of the two nations. On the following
day he continued his speech and moved that France and Spain
should form a national treaty in the interests of peace and
conformable to “the principles of justice which will ever form the
policy of the French.” What was far more significant, he himself
added a rider for the immediate armament of forty-five sail of the line
and a proportionate number of smaller vessels. This was carried
939
immediately.
Seeing that the Assembly passed this vote at the very time when
the terrible mutiny at Nancy was at its height, the feelings of the
deputies must have been of the bellicose order which Mirabeau had
previously deprecated. Despite the pressing need for peace, France
seemed to be heading straight for war. On ordinary grounds her
conduct is inexplicable. Everywhere her troops were clamouring for
arrears of pay; her sailors could scarcely be kept together; and the
virtual bankruptcy of the State was a week later to be quaintly
revealed by the flight of Necker to Switzerland. The King and his
Ministers disapproved the arming of so large a fleet; for Montmorin
confessed to Gower his surprise and regret, adding the comforting
assurance that it would be done as slowly as possible. The mystery
deepens when we know that Floridablanca continued to speak in
peaceful tones. On 19th August he admitted to Fitzherbert that he
desired help from Russia and Austria, but felt complete indifference
as to what France might do. Aid from her, he said, would lead to the
introduction of democratic principles, which he was determined to
keep out, if need arose, by a cordon along the frontier, as one would
940
exclude the plague.
Here probably we have the key to the enigma. The recent action
of Mirabeau (for the arming of the French naval force was his
proposal, not Montmorin’s) rested on the assumption that Spain did
not mean to draw the sword. His agents at the various Courts kept
him well abreast of events, and doubtless he foresaw that Charles
IV’s hatred of democracy would bar the way to an alliance of the two
peoples such as was now projected. Why, then, should Mirabeau
have threatened England with war? His reasons seem to have been
partly of a patriotic, partly of a private, nature. He desired to restore
the prestige of the French monarchy by throwing its sword into the
wavering balances of diplomacy. As to the expense, it was justifiable,
if it tended to revive the national spirit and to quell the mutinous
feelings of the sailors. Work, especially if directed against “the
natural enemy,” would be the best restorative of order at the
dockyards, and prevent the deterioration of the navy. But apart from
these motives Mirabeau may have been swayed by others of a lower
kind. His popularity had swiftly waned during the previous debates.
He might revive it by pandering to the dislike of England now widely
prevalent. Manufacturers who suffered by English competition and
Chauvinists who dreaded her supremacy at sea were joining in a
941
hue and cry against Pitt; and Mirabeau gained credit by posing as
the national champion. Further, by holding peace and war, as it were,
in the folds of his toga, he enhanced his value in the diplomatic
market. His corruptibility was notorious. Even the sums which he
drew from the King were far from meeting the yawning gulf of his
debts.
In the present case there was much to tempt him to political
auctioneering. There were present in Paris two political agents to
whom Pitt had confided the task of humouring the French democrats
and dissolving the Family Compact. These were William Augustus
Miles and Hugh Elliot. The former was a clever but opinionated man,
half statesman, half busy-body, capable of doing good work when
kept well in hand, but apt to take the bit into his teeth and bolt. He
had already looked into the affairs of Brabant, Liége, and Frankfurt
for Pitt; and as early as 4th March the Prime Minister summoned him
to Downing Street for the purpose of sending him to Paris; but not till
the middle of July did he finally entrust to him the task of inducing
French deputies to annul the Family Compact. That this was to be
done secretly appears from the order that he was to have no
942
dealings whatever with the British Embassy. Unfortunately the
letters which passed between Pitt and Miles at this time have all
943
been destroyed. But we know from other sources that Miles was
charged to prepare the way for an Anglo-French entente. He
certainly made overtures to Talleyrand, Mirabeau, and Lafayette; he
was also elected a member of the Jacobins Club, and worked hard
to remove the prejudices against England. These he found
exceedingly strong, all the troubles in the fleet being ascribed to her.
By 11th October he had fulfilled his mission, and informed George
Rose that Pitt might, if he chose, form a close working alliance with
the French nation. About the same time he conceived for Mirabeau
the greatest contempt, and asserted that it was “impossible to know
944
him and not to despise him.”
Elliot was a man of far higher stamp than Miles. As we have
seen, he had had a distinguished diplomatic career, and might be
termed the saviour of Gustavus III in the acute crisis of 1788. He was
brother of Sir Gilbert Elliot (first Earl of Minto), and of Lady Auckland.
In the summer of 1790 he was home on furlough. On 7th August he
wrote from Beckenham, Auckland’s residence, congratulating Pitt on
a favourable turn in the Spanish dispute. When the outlook once
more darkened he requested leave to go to Paris in order to use his
influence with his friend, Mirabeau, in the interests of peace. Pitt
must have referred the proposal to the King, and received a very
guarded reply, dated Windsor, 26th October. George enjoined great
caution, as we had hitherto held entirely aloof from the French
troubles, and must on no account be mixed up in them. Yet, for the
sake of peace, he did not object to this attempt, so long as it was
entirely unofficial; but he was “not sanguine that Mr. H. Elliot and his
French friend” would succeed where so much caution and delicacy
945
were necessary.
As this affair is wrapped in mystery, and concerns not only the
peace of the world, but also that most interesting personality,
Mirabeau, the draft of an undated letter of Pitt to the King must be
quoted in full:
The hints here given imply that Mirabeau, and probably other
patriots as well, accepted British money, but both our envoys were
discreet enough to give few details in writing. It is quite probable that
Mirabeau first accepted Spanish gold for procuring the vote for the
arming of forty-five French sail of the line, and then accepted an
equivalent sum from Miles or Elliot for the decree which rendered
that step innocuous. His control over the Assembly was scarcely less
951
than Montmorin’s; and that nervous Minister would certainly
welcome a course of action which enhanced the prestige of France,
and yet averted all risk of war. Nevertheless, Pitt did not set much
store by the help of Mirabeau. He decided to bring the whole dispute
to an immediate issue, without waiting for the issue of the golden
proposals of Elliot and Miles. Possibly he heard from other sources
that France would do no more than rattle the sword in the scabbard;
or else he was emboldened by the marked success and zeal
attending the British naval preparations, the mutinies in the French
fleet, the readiness of our Allies to play their part, and the
unreadiness of Spain. A brief survey of these considerations will
reveal the grounds of his confidence.
The chance of hostilities with the two Bourbon Courts was
threatening enough to call forth all the energies of the race. Through
the months of August, September, and October naval preparations
went on with the utmost vigour. Officers and men vied with one
another in zeal to equip and man the ships with all possible speed
and thoroughness. Sir John Jervis afterwards assured the House of
Commons that he had seen captains paying out their own money by
hundreds of pounds in order to expedite the equipment; others sailed
their ships down Channel with mere skeleton crews in order to