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Towards a suitable health insurance system in Syria: Options and the necessary procedures before implementation, based on qualitative analysis and international experiences [Elektronische Ressource] / Mania Mershed. Betreuer: Reinhard Busse

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Towards a suitable health insurance system in Syria: Options and the necessary procedures before implementation, based on qualitative analysis and international experiences Vorgelegt von Mania Mershed Aus Swaida (Syrien) Von der Fakultät VII - Wirtschaft und Management – Institut für Technologie und Management – Fachgebiet Management im Gesundheitswesen der Technischen Universität Berlin zur Erlangung des akademischen Grades „Doktorin der Wirtschaftswissenschaften“ - Dr. rer. oec. - genehmigte Dissertation Promotionsausschuss: Vorsitzender: Prof. Dr. Thomas Mansky Berichter: Prof. Dr. Reinhard Busse Berichter: Prof. Dr. Christian Gericke Tag der wissenschaftlichen Aussprache: 22. 7. 2011 Berlin 2011 D83 i Contents Figures and Tables ......................................................................................................... vi Acknowledgment .......... viii Zussamenfassung ........... ix Summary ...................................................................................................................... xvii Abbreviations ............. xxiv 1. Introduction .............. 1 Objectives .................... 3 The scope of the study ................................................................................................. 3 The structure of the thesis and thesis strategy ...........................

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Published 01 January 2011
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Towards a suitable health insurance system in Syria:
Options and the necessary procedures before implementation,
based on qualitative analysis and international experiences


Vorgelegt von
Mania Mershed
Aus Swaida (Syrien)

Von der Fakultät VII - Wirtschaft und Management
– Institut für Technologie und Management –
Fachgebiet Management im Gesundheitswesen
der Technischen Universität Berlin
zur Erlangung des akademischen Grades
„Doktorin der Wirtschaftswissenschaften“
- Dr. rer. oec. -
genehmigte Dissertation


Promotionsausschuss:

Vorsitzender: Prof. Dr. Thomas Mansky
Berichter: Prof. Dr. Reinhard Busse
Berichter: Prof. Dr. Christian Gericke



Tag der wissenschaftlichen Aussprache: 22. 7. 2011




Berlin 2011
D83










































i
Contents


Figures and Tables ......................................................................................................... vi
Acknowledgment .......... viii
Zussamenfassung ........... ix
Summary ...................................................................................................................... xvii
Abbreviations ............. xxiv
1. Introduction .............. 1
Objectives .................... 3
The scope of the study ................................................................................................. 3
The structure of the thesis and thesis strategy ............................. 3
Methodology used ....... 4
2 Health Care Systems and Health Financing Functions ........ 6
2.1 What is a health system? ....................................................................................... 6
2.2 The major influences on health care systems ........................ 8
2.3 Health system functions 8
2.4 Financing of health care systems ........................................................................... 9
2.4.1 Health financing functions ............. 10
2.4.2 Models of health care systems based on the main source of their funding ... 27
3 The Current Syrian Health Care System ............................................................. 44
3.1 Background.......................................................................... 44
3.1.1 The geography and sociodemography ........................... 44
3.1.2 The economic context .................................................... 47
3.1.3 Health status ................................... 49
3.2 Organizational structure and management .......................... 53
3.3 Health financing functions .................................................. 56
3.3.1 Collection of Funds ........................................................ 59
3.3.2 Pooling of Funds ............................ 64
3.3.3 Purchasing health care services and health providers‟ payments .................. 66
3.4 Health care delivery system................................................. 68
3.4.1 Private providers of health care ..................................... 68
3.4.2 Philanthropic providers of health care ........................... 72
3.4.3 The health services provided by the government sector ................................ 72
3.4.4 Health human resources ................................................................................. 78
3.5 Health insurance in Syria ..................... 82
3.5.1 The health benefits schemes .......... 82
3.5.2 Private health insurance companies ............................................................... 86
3.5.3 The new health insurance law ........................................ 88
4 Interviews on the Current Health System and Future Health Insurance in
Syria ......................................................................................... 90
4.1 The qualitative data analysis method .................................. 90
4.1.1 The difference between qualitative and quantitative data analysis ................ 91
4.1.2 Theories and methods in qualitative data analysis ......................................... 91
4.1.3 Methods of collecting qualitative data ........................... 92
4.1.4 Why was the qualitative data analysis method selected? .............................. 93
4.2 Study design ........................................................................ 93
4.2.1 Defining the research questions ..................................... 93
4.2.2 Design of the interviews ................ 94
ii
4.2.3 Selecting the interviewees ............................................................................. 95
4.2.4 Data collection ............................................................... 99
4.3 Data Analysis....... 99
4.3.1 Transcription .................................................................. 99
4.3.2 Translation ..... 99
4.3.3 Familiarization ............................................................. 100
4.3.4 Identifying a thematic framework 100
4.3.5 Coding .......................................................................... 100
4.3.6 Charting ....................................... 100
4.3.7 Interpretation 101
4.4 The results ......... 101
4.4.1 Interview 1 ................................................................... 101
4.4.2 Interview 2 ................................... 107
4.4.3 Interview 3 ... 112
4.4.4 Interview 4 ... 116
4.4.5 Interview 5 ................................................................... 120
4.4.6 Interview 6 ................................... 125
4.4.7 Interview 7 ... 129
4.4.8 Interview 8 ... 133
4.4.9 Interview 9 ................................................................... 138
4.4.10 Interview 10 ............................................................... 142
4.4.11 Interview 11 147
4.4.12 Interview 12 150
4.4.13 Interview 13 ................................ 155
4.4.14 Interview 14 ............................................................... 159
4.4.15 Interview 15 163
4.4.16 Interview 16 168
4.4.17 Interview 17 ................................ 172
4.4.18 Interview 18 ............................................................... 175
4.4.19 Interview 19 181
4.5 Comparison of interviews results ...................................... 185
5 Other Health Care Systems and Lessons Learnt ............... 207
5.1 Criteria of selecting the countries studied ......................................................... 207
5.2 National Social Health Insurance System in Colombia .... 212
5.2.1 Historical background .................................................. 212
5.2.2 The major reforms of the health care system ............................................... 213
5.2.3 The structure of the National Social Health Insurance System ................... 214
5.2.4 Extending population coverage and the basis for entitlement ..................... 215
5.2.5 Health financing function ............................................ 217
5.2.6 The benefits packages .................................................. 222
5.2.7 Lessons that can be learned from the experience of Colombia ................... 223
5.3 The Social Health Insurance system (SHI) in Germany ................................... 225
5.3.1 Historical background .................................................. 225
5.3.2 The major reforms of the health system ...................................................... 227
5.3.3 The structure of German Social Health Insurance ....... 228
5.3.4 Extending population coverage and the basis for entitlement ..................... 229
5.3.5 Health financing functions ........................................................................... 231
5.3.6 The benefits package ................... 239
5.3.7 Lessons that can be learned from the experience of Germany .................... 240
iii
5.4 The Social Health Insurance System in Romania ............................................. 242
5.4.1 Historical background .................................................. 242
5.4.2 The major reforms of the Social Health Insurance system .......................... 243
5.4.3 The structure of the Social Health Insurance system ................................... 244
5.4.4 Extending population coverage and the basis for entitlement ..................... 245
5.4.5 Health financing functions ........................................... 246
5.4.6 The benefits package ................................................... 253
5.4.7 Lessons that can be learned from the Romanian experience ....................... 254
5.5 The National Health Insurance System in South Korea .................................... 255
5.5.1 Historical background .................................................. 255
5.5.2 The major reforms in the Korean National Health Insurance system .......... 258
5.5.3 The structure of the National Health Insurance system ............................... 259
5.5.4 Extending population coverage and the basis for entitlement ..................... 260
5.5.5 Health financing functions ........................................................................... 261
5.5.6 The benefits package ................... 270
5.5.7 Lessons that can be learned from the South Korean experience ................. 271
5.6 The National Health Services system in Spain .................. 273
5.6.1 Historical background ................................................................ 273
5.6.2 The major reforms of the Spanish National Health Services system .......... 275
5.6.3 The structure of the Spanish National Health Services system ................... 276
5.6.4 Extending population coverage and the basis for entitlement ..................... 276
5.6.5 Health financing function ............................................................................ 277
5.6.6 The benefits package ................... 283
5.6.7 Lessons that can be learned from the experience of the Spanish National
health Services system .......................................................................................... 284
5.7 The Health Care System in Tunisia ................................... 285
5.7.1 Historical background .................. 286
5.7.2 The major reforms of the health care system ............... 289
5.7.3 The structure of the health care system ....................................................... 290
5.7.4 Extending population coverage and the basis for entitlement ..................... 291
5.7.5 Health financing functions ........................................... 292
5.7.6 The benefits package ................... 296
5.7.7 Lessons that can be learned from the experience of Tunisia ....................... 298
5.8 The National Health Services system in the United Kingdom .......................... 299
5.8.1 Historical background .................................................................................. 300
5.8.2 The major reforms of the National Health Services system ........................ 301
5.8.3 The structure of the National Health Services system ................................. 302
5.8.4 Extending population coverage and the basis for entitlement ..................... 303
5.8.5 Health financing functions ........................................... 303
5.8.6 The benefits package ................................................... 307
5.8.7 Lessons that can be learned from the experience of the UK ....................... 307
5.9 Comparison of health care systems ................................... 309
5.9.1 Background and the main reasons for the establishment of the health care
systems .................................................................................................................. 309
5.9.2 Population coverage ..................... 310
5.9.3 Collection of revenues ................. 311
5.9.4 Risk pooling and the extent of its integration .............. 312
5.9.5 Purchasing of health services ....................................................................... 313
5.9.6 The benefits packages .................. 314
iv
6. Designing the Health Insurance System Models for Syria ............................... 318
6.1 National Health Services system versus Social Health Insurance system ........ 319
6.2 The general framework to design the models .................................................... 324
6.3 The first model: improve the efficiency of the current health financing system
............................................................................................. 328
6.3.1 Extending coverage ...................... 329
6.3.2 Collection of funds ....................................................... 332
6.3.3 Risk pooling ................................. 335
6.3.4 The purchasing function .............................................. 336
6.3.5 The stewardship and regulation ... 339
6.3.6 The pros and cons of the first model ............................................................ 339
6.4 The second model: introducing social health insurance step by step ................ 341
6.4.1 Extending coverage ...................................................... 342
6.4.2 Collection of funds ....................... 346
6.4.3 Risk pooling ................................................................. 349
6.4.4 The purchasing function .............. 350
6.4.5 The steward and regulation .......... 352
6.4.6 The pros and cons of the second model ....................................................... 352
6.5 The third model of the health financing system is the national health insurance
(big push) ............................................................................. 353
6.5.1 Extending coverage ...................... 354
6.5.2 Collection of funds ....................................................... 355
6.5.3 Risk pooling ................................................................. 358
6.5.4 The purchasing function .............................................. 360
6.5.5 The stewardship and regulation ... 363
6.5.6 The pros and cons of the third model .......................................................... 364
7. Assessment of the Proposed Models vs. the Current System ................... 367
7.1. Definition of the criteria used to assess the proposed models 367
7.2 Assessment of the current system and the three proposed models according to the
defined criteria ..................................................................................................... 368
7.2.1 Assessment of the current health care system ............. 369
7.2.2 Assessment of the first model ...... 372
7.2.3 Assessment of the second model . 375
7.2.4 Assessment of the third model ..................................................................... 379
7.3 The Health Financing Models Comparison ....................... 382
7.4 Achievement of universal coverage through applying a succession of the
proposed models .................................. 390
Conclusion ................................................................................... 393
References .................................................... 396
Index 1: Survey of population opinion on ability and willingness to pay for health
insurance................ 409


v
Figures and Tables

Figure 1.1: Chart structure of thesis ................................................................................. 5
Figure 2.1: Describing the functions of the health financing system ............................ 11
Figure 3.1: Map of Syria ................................................................................................ 45
Figure 3.2: Life expectancy at birth, 1970-2009 49
Figure 3.3: Development of some health indicators in Syria, 1970-2008 ..................... 50
Figure 3.4: Life expectancy at birth (years) for males and females in some MENA
countries, 2008 ................................................................................................... 50
Figure 3.5: Infant mortality rate and under-five mortality rate (per 1000 live births) in
some MENA countries, 2008 ............. 51
Figure 3.6: Causes of death in Syria, 2007 .... 52
Figure 3.7: The ten most prevalent diseases in Syria, 2007 ........................................... 53
Figure 3.8: Organizational chart of the public health care system 54
Figure 3.9: Total expenditure on health as percentage of GDP, and general government
expenditure on health as percentage of total government expenditure in Syria
and selected countries, 2007 ............................................................................... 57
Figure 3.10: General government health expenditure and the private health expenditure
as a percentage of total health expenditure in MENA countries, 2007 .............. 58
Figure 3.11: Total health expenditure and the general government health expenditure
per capita at international dollar rate in MENA countries, 2007 ....................... 59
Figure 3.12: Health care financing flow chart ............................................................... 60
Figure 3.13: The development of the budget of MoH and Health Directorates, 1992-
2008 .................................................................................... 61
Figure 3.14: Per capita spending by MoH and MoLA (in S.P) in each governorate, 2003
........................................................................ 61
Figure 3.15: Government health expenditure in million S.P, 2006 ............................... 65
Figure 3.16 Supply of hospital beds (public, private) per 10 000 population according
to Syrian governorates, 2008 .............................................. 69
Figure 3.17: Development the number of local medicine factories, 1970-2008 ........... 71
Figure 3.18: Number of national medicinal products, 1970-2008 ................................. 71
Figure 3.19: The average number of the people served by each health centre, 1970-
2009 .................................................................................................................... 74
Figure 3.20: The number of population (in thousands) served by one health centre,
2004 75
Figure 3.21: Ambulatory care provided by public health centres as a percentage of total
ambulatory care utilisation per governorate, 2005 ............................................. 76
Figure 3.22: Hospital beds per 10 000 populations in some MENA countries, 2009 ... 77
Figure 3.23: Development in the number of health workers in Syria, 1970-2008 ........ 80
Figure 3.24: The number of physicians and nurses per 10 000 of population per
governorate, 2008 ............................................................................................... 80
Figure 3.25: The number of general practitioners and specialists, 1997-2008 .............. 81
Figure 3.26: The numbers of physicians, nurses and midwifery personnel, dentistry
personnel and pharmaceutical personnel density (per 10 000 of population) in
some MENA countries, 2009 ............................................................................. 81
Figure 6.1: The general structure of the health system according to first model ......... 336
Figure 6.2: The structure of the health financing functions according to the second
mode ................................................. 349
vi
Figure 6.3: The proposed structure of the national health insurance system in Syria . 359
Figure 7.1: Feasibility of the health financing models ................................................ 384
Figure 7.2: Efficiency ofaltncing models ................. 386
Figure 7.3: Sustainability of the health financing models ........... 387
Figure 7.4: Equity of the health financing models ....................... 388


Table 2.1: Comparing the main health financing systems ............................................. 29
Table 3.1: Population (million) in Syria, 1960-2009 ..................... 45
Table 3.2: The total fertility rate per 1000 women, 1970-2009 ..... 46
Table 3.3: Structure of the economy as percentage of GDP in Syria, 1985-2008 ......... 48
Table 3.4: The development of gross domestic product, and GDP per capita, 1980-2008
........................................................................................................................................ 48
Table 3.5: Child immunisation Coverage (%), 1981-2007 ............ 51
Table 3.6: Public and private health care expenditure in Syria as a percentage of total
health expenditure (THE), 2000-2007 ... 56
Table 3.7: Trends in the total number of hospitals, sanatoriums and beds, 1949-2008 . 70
Table 3.8: General and specialised health centres in Syria, 1970-2008 ......................... 74
Table 3.9: Total estimated public and private expenditure on health (in million SP)
according to different categories of health services in Syria, 2003 ....................... 78
Table 3.10: The number of health professionals, 1946-2008 ......................................... 79
Table 4.1: The respondents´ main characteristics .......................................................... 97
Table 5.1: General information about the selected countries ....... 210
Table 5.2: Health expenditure ratios, 2007 .. 211
Table 5.3: Financing sources as a percentage of the total expenditure on health (THE),
and expenditure on health in South Korea .......................................................... 266
Table 5.4: Coverage of public health insurance schemes over total population according
to the development of GDP per capita over the time .......................................... 316
Table 5.5: Evolution of the collecting, pooling and purchasing organizations over the
time ...................................................................................... 317
Table 6.1: Comparison the main health financing function between the three models 326

vii
Acknowledgment


I am deeply indebted to my supervisor, Professor Reinhard Busse, for his constant
support. Without his help, this work would not be possible. I am heartily thankful,
Professor Christian Gericke, his encouragement and help enabled me to develop a good
understanding of the subject.
My thanks to Professor Detlef Schwefel for his help of providing me with many
researches and lots of information about the Syrian health care system.
I would also like to thank my colleague Ewout van Ginneken for his valuable efforts in
reviewing this thesis, my full appreciation to his advises and encouragement. I would
also like to thank my colleague Miriam Blümel for her priceless advises about
Qualitative Data Analysis.
I would not forget my colleague and best friend Christine Hoffmann who helped me to
complete different tasks including the computer work and translating some of my texts
to Germany. I highly appreciate her engorgement and support.
I offer my regards and blessings to all my colleagues and the secretarial staff who
supported me in any aspect during the completion of the project.
A special thank goes to the Syrian Higher Education Ministry, who has provided me
with the scholarship, supported me financially, and so granted me the chance to study in
Germany and complete my PhD.
I am very grateful to all my friends who made my life easier.
Lastly, I would like to thank all the members of my family for their support. I am
greatly indebted to my brother and sisters. Above all, I express my full gratitude to my
parents who used to support me, assure me, and give me confidence. I dedicate this
thesis to my mother and father.
Finally, I would like to thank everyone has helped me to achieve my PhD and writing
this thesis. I hope they accept my apology as it is hard to mention all their names.
viii
Zussamenfassung

Die vorliegende Dissertation verfolgt zwei Hauptziele. Erstens wird erörtert, mit
welchen Finanzierungsmethoden eine realistische und machbare vollständige
Versicherung aller syrischen Bürger (universelle Versicherung) erreicht werden könnte.
Zum Zweiten entwirft sie drei für Syrien geeignete Alternativen zum gegenwärtigen
syrischen Gesundheitsfinanzierungssystem.
Der erste Teil der Doktorarbeit beschreibt Gesundheitssysteme und die Finanzierung
von Gesundheitssystemen im Allgemeinen. Der erste Abschnitt analysiert die
Hauptfunktionen der Gesundheitsfinanzierung: Einnahmen sammeln, Streuung von
Risiken und den Einkauf von Gesundheitsleistungen. Der zweite Abschnitt definiert die
Haupttypen von Gesundheitssystemen. Diese sind ein Nationaler Gesundheitsdienst
(steuerfinanziertes Modell), ein Sozialversicherungssystem (das beitragsbasierte
Modell), die Krankenversicherung auf Gemeinschaftsebene und die private
Krankenversicherung. Die Schlüsselcharakteristika, Vor-und Nachteile werden
dargestellt.
Gegenstand des zweiten Teils der Arbeit ist das gegenwärtige syrische
Gesundheitssystem, mit einer Darstellung seiner Organisationsstrukturen und seiner
Verwaltung: die Funktionen der Gesundheitsfinanzierung, das neue
Krankenversicherungsgesetz, die Rolle der privaten Krankenversicherung und die
Krankenversicherungen in Syrien allgemein.
In der Organisationsstruktur des syrischen staatlichen Gesundheitssystems ist das
Gesundheitsministerium verantwortlich für die Koordinierung und Verwaltung der
Erbringung von Gesundheitsleistungen. Weitere Verantwortlichkeiten der Finanzierung,
Verwaltung und Leistungserbringung obliegen folgenden Körperschaften: dem
Finanzministerium, dem Ministerium für Lokale Verwaltung, der Staats-und
Planungskommission, dem Ministerium für Hochschulwesen, dem Ministerium für
Soziales und Arbeit und dem Verteidigungsministerium. Zusätzlich gibt eine gewisse
Anzahl von Krankenkassen, die Gesundheitsleistungen für Mitarbeiter in vielen
Ministerien, öffentlichen Unternehmen und Mitglieder von Berufsverbänden
bereitstellen. Die meisten dieser Krankenkassen decken nur wenige Leistungen ab und
können die Versicherten nicht vor finanziellen Risiken schützen. Ungefähr 15% der
Bevölkerung sind Mitglieder dieser Krankenkassen, die sich in der Anzahl der
ix