STRIKE WHILE THE IRON IS HOT: POST-SOVIET HEALTHCARE REFORMS AND THE CRITICAL JUNCTURE OF THE 1990S
Advisors: Mark Beissinger, Grigore Pop-Eleches, Deborah Yashar
With the rise of international public health standards over the last century, many governments have embarked on health system reform to address inefficiencies in financing and provision of care. Yet even similar initiatives within geopolitical regions have produced significantly different healthcare system designs across countries. Despite sharing the historical legacy of the Soviet Union and similar health challenges, the post-Soviet states have followed a wide variety of reform trajectories. Countries as poor as Moldova and Kyrgyzstan and as wealthy as Russia have introduced insurance mechanisms and private provision of care. Countries as wealthy as Kazakhstan and as poor as Ukraine and Uzbekistan have maintained state-financed healthcare systems with state provision of care.
My dissertation tests several explanations for these patterns in the post-Soviet states since 1991. I demonstrate the importance of both timing and incentive for major structural reforms, arguing that the long-term trajectories observed in the post-Soviet healthcare systems can be traced back to a critical juncture for major healthcare system reforms in the 1990s. I contend that decisions made at that time led to the institutionalization of reform trajectories through the development of legal (de jure) and practical (de facto) state responsibility for financing and provision, contradictions between these two concepts of state responsibility, and resulting patterns of political rhetoric, public opinion, and outcomes surrounding reform efforts. Utilizing historical institutional analysis and process tracing methods, I show that the decisions in the 1990s were significantly shaped by the prioritization of long-term state-building efforts, and that, because of the dual nature of healthcare as a policy area – connected both to the economic sphere and the human rights sphere – threats to state stability were the most pressing concern for decision makers in considering reform designs. When national cleavages aligned with divisions of economic ideologies in regions, state leaders avoided introducing major reforms, instead preferring to maintain consistency in the state’s role as they sought to build legitimacy for the system. These findings contribute to our understanding of institutional change in the post-Soviet states and of the politics surrounding healthcare reforms in middle- and lower-income countries.
HEALTHCARE POLITICS DATASET
I am currently developing a full database of healthcare reform process characteristics across the globe. I was inspired to develop this dataset during my years of dissertation research, during which I discovered the paucity of data on healthcare reform processes themselves, as opposed to data on health outcomes, which are widely available. I envision this dataset as being useful not only for academic researchers, but also for groups looking to promote healthcare reforms across the globe. I aim to have this dataset as it develops available via an interactive website soon. Ultimately, I hope to connect this to my Stanford U.S.-Russia Forum research group's work on epidemic vulnerability.
"RHETORIC, COMMUNICATION, AND HEALTHCARE REFORM: aNALYZING PATTERNS OF STATE-SOCIETY COMMUNICATION IN POST-SOVIET HEALTHCARE REFORM EFFORTS"
How do governments communicate planned healthcare system changes to the public? A rising interest in the role of health literacy with regard to insurance and health decisions has highlighted the importance of the public's understanding of health systems in efforts to improve health outcomes. While some analysis has been completed on particular programs (such as the spread of information during Ebola epidemics) and in higher-income democracies (such as efforts surrounding the ACA in the United States), little has been done to examine the way in which major changes to systems in middle-income and lower-income countries are communicated in the course of state decisions about reform efforts, and how this may affect the success of implementation later in the process. This project examines these patterns in state communication with the public during the reform process, with an emphasis on pre-implementation strategies. Using content analysis methods in R, I analyze how often and in what way the state attempts to explain and promote current and future reform efforts. Initially, I am focusing on the cases of Ukraine and Russia, building off of my dissertation work on elite decision making about the structure of reforms themselves by moving to the next step in that reform process: presenting the plans and efforts to the public in order to build support and inform citizens of changes to the system. Utilizing the Ministry of Health's Twitter posts, news releases on the government websites, statements by prominent health decision makers, and other relevant communication efforts, I aim to develop an understanding of the way in which the government shapes its message to the public, as well as the public's corresponding feedback, when there are attempts at major structural change - in other words, significant changes in the state's role in the financing and provision of services - in the healthcare system. In the long term, the findings of this project will be incorporated into the healthcare politics dataset on a broader scale, expanding to other post-Soviet states, and, eventually, to larger global coverage.
"PACKAGES OF REFORMS OR THE REFORM OF PACKAGES? THINKING GLOBALLY ABOUT HEALTHCARE SYSTEM DESIGN AND CHANGE"
Do the overall designs of welfare institutions uniquely impact the political landscape around their reforms? Or can the challenges faced be attributed to the cumulated impact of specific characteristics? This project compares reforms in the former Semashko healthcare systems to those in healthcare systems of Beveridge, Bismarckian, and privatized designs to determine if differences across these groups of systems can best be understood as strictly categorical, or if their differences and similarities in the reform experience overlap based on particular financing and delivery design choices. In this project, I seek to challenge the widely accepted standards of healthcare system categorization. By asking how we can better organize and understand the relationship between types of healthcare systems across the globe, I look to develop a more comprehensive framework for the study of health and healthcare reform.
"UNPACKING THE 'WELFARE STATE': THE IMPACT OF ASYMMETRICAL INFORMATION ON THE POLITICAL DYNAMICS OF WELFARE POLICY MAKING IN UKRAINE"
“CHANNELS OF AID PROVISION IN SEPARATIST MOVEMENTS: THE CASE OF THE WAR IN DONBAS”
The Donbas conflict that started in 2014 has forced separatist movements to the forefront in Europe in a more violent way than has been seen since the “Time of Troubles” of the IRA and the Yugoslav wars in the early 1990s. Not only has the conflict brought about such tragedies as the MH17 crash, but it has also raised Cold War-like tensions between Russia and the Western world, with Russia supporting the separatist movements, and Europe and the U.S. supporting the Ukrainian government. During the conflict, Russia has sent several aid convoys to the Donetsk and Luhansk regions, much to the dismay of the Ukrainian government. But what does aid, besides humanitarian assistance, actually do in separatist conflicts? Are there political consequences to the provision of aid? Does it stoke the conflict, or does it help with its abatement? This project examines these questions, focusing especially on the Ukrainian conflict as a case study, but within a wider analysis of the trends of separatist movements after the provision of aid. Preliminarily, I theorize that, due to the influence that aid has on perceptions of dependence and welfare, the effect of aid on separatist conflicts depends on the channel through which that aid is provided - specifically, whether it is distributed by the domestic government, a government- or separatist-supporting country, or a neutral third country or international organization. This expands upon the “moral hazard” theories of the humanitarian assistance literature, which focus largely on third-country assistance for rebels in civil war situations and theorize about adverse effects of intervention.
“U.S.-Russia relations are at a real low. Here ’s the diplomacy that is working”
“Russian health-care protests continue despite Putin’s popularity"