H.POWELL / CAMERA PRESS
Tim Ensor takes a tour round the ruins of the Soviet healthcare monolith,
where basic needs are being left out in the cold.
Ceauscescu, the Romanian dictator, proudly boasted that his policies had made the Romanian people so healthy they had no need for higher spending on medical care. The exposure of widespread abortion used as a means of contraception, hellish orphanages and rising mortality rates gave the tragic lie to this assertion.
Not just in Romania but throughout all 27 countries of the Former Soviet Bloc, from the bright lights of Prague and Budapest to the outer reaches of Siberia, healthcare is in crisis. And Western aid attempts have sometimes caused further pain.
The common tie which bound together such a large and heterogeneous collection of countries was an economic and political system which imposed a single structure on more than 400 million people. Health services were dominated by targets based on inputs – numbers of doctors, nurses and hospital beds, rather than numbers of patients treated or recovered. A hospital would get more money if it increased the number of beds or kept patients in hospital longer and so had more doctors. As a result the Soviet Union had three times as many doctors per head of the population as Britain.
They often ended up doing mundane, unskilled tasks. Most doctors were poorly paid and badly equipped – despite the widely recognized work of centres of medical excellence, which pioneered the surgical correction of eye defects in Russia or the treatment of cerebral palsy in Hungary. In Bulgaria a doctor earned less than half the average wage, while in Romania she – since the majority of doctors are women – might earn less than a cloakroom attendant. Most held down a number of jobs to survive. The soliciting of informal gifts – in kind or in money – reached epidemic proportions. Some doctors were able to earn many times their state salary in this way and frequently kept patients waiting for operations until they made the expected gift.
Family doctors do not exist in the Former Soviet Bloc. Instead patients are assigned to large and impersonal poli-clinics where they may see a different doctor at each visit. Consumer views and preferences receive little weight. Patients have become used to receiving indifferent and often surly service. This attitude is reflected even in the way Westerners are shown around hospitals; doors are opened and shut with little regard for patient dignity. The newly expanding private sector offers the one element of choice – but only for those who can pay.
In the post-Communist shake-up the number of patients treated has declined and key indicators of health have deteriorated. Infectious diseases like diphtheria, hepatitis and TB, which were previously under control, are now on the increase in Russia and Central Asia. Environmental pollution, widespread cigarette smoking, high alcohol consumption and a large fat intake are increasing the incidence of heart disease, cancers and strokes.
The economies of the region are in a state of rapid change. State factories employing whole towns are closed or shrunk in size, making way for smaller private- and joint-sector companies. Cities from Tallinn to Tashkent sprout well-stocked private-sector kiosks, open day and night, replacing big state-run shops and their meagre wares. Some people have got rich very quickly as evidenced by the growing number of BMWs and Volvos now jostling Ladas, Trabants and Volgas for road-space.
Such change can appear exciting, yet it has its social cost. Poor health conditions have been exacerbated by declining incomes and rising unemployment. The rise in poverty is especially marked in countries suffering from civil war, like Georgia and Armenia. Health budgets have been slashed as government revenue from state companies has dried up. In many countries patients must now bring their drugs, medical supplies, food and blankets with them to hospital.
In Russia much of the old Soviet healthcare structure still remains. But the break-up of the Union has meant that ministries of health in republics previously governed from Moscow are suddenly having to direct policy. In time this could be beneficial, but for now there is a lack of policy co-ordination, particularly in the control of epidemics.
Healthcare for rural communities has suffered too. The Soviet system required all new doctors to serve in rural areas before they were allowed to specialize or move to the cities. This ensured rural access to health workers – even if they were the least experienced. Now these restrictions no longer exist and many doctors have migrated to cities.
There was much that was obsolete about the Soviet system, but it did lead to many improvements in basic health. At the turn of the century around 25 out of every 100 Russian children died before they were a year old – double the British rate at the time. By the early 1960s the figure had been reduced to 2 in 100.
By destroying its old healthcare structure without replacing it with a workable alternative, the Former Soviet Bloc runs the risk of losing such gains. Some countries have already begun to copy the worst Western practices. Those where the reforms first began, like the Czech Republic, have encountered similar problems to the US of spiralling healthcare costs and a proliferation of expensive, minority treatments.
The privatization of hospitals is, in many countries, advanced as a way to encourage competition. But without regulation there is a real danger that hospitals which should provide basic services will choose to offer only luxury treatments. Some already lease parts of their buildings to computer companies or Western drug firms.
Another Western-style reform is the introduction of state insurance schemes that citizens must contribute to in order to obtain services. The funds operate outside the control of ministries of health. Last year a scandal shook the Estonian insurance system when it was revealed that the directors of several funds had invested money abroad without proper accountability.
In the midst of all this upheaval Western charities, equipment manufacturers and multinational donors have rushed in to provide medical aid. One observer commented wryly that hardly any plane lands in Moscow without a group of Western experts disembarking to tout their own vital product or a panacea for the health system. Stories abound of countries being given pharmaceuticals past their sell-by date. Equipment donated by Western companies often turns out to be a clever sales ploy, earning many times its original value from spare parts and maintenance over the years.
The plight of Albanian and Romanian orphanages stirred public sensitivities abroad and led to an outpouring of aid. But many argue that such money has gone to prop up a discredited system for getting rid of unwanted children. The lack of co-ordination of this aid and the resentment that local inhabitants feel, when they see the living standards in these institutions far exceeding their own, raise further questions. Aid has had a beneficial impact as well, but there is resentment that Western largesse has been handed out in indiscriminate and unthinking ways.
The number of private clinics that provide services outside office hours, offer appointments and give courteous services to patients is growing rapidly, providing a stark contrast to the state alternative. There is a need for the health service to harness this dynamism. Inevitably this will mean concentrating resources on fewer facilities and personnel, creating widespread medical unemployment. Pumping resources into the health sector is not a realistic option in view of the economic shambles.
As in other parts of the world, the Former Soviet Bloc must focus much more on which treatments are effective in order to make maximum use of the very scarce resources available. The health sector in these countries has the opportunity to introduce radical policies that emphasize illness prevention and health promotion. The alternative – unregulated privatization and a continued decline of the state sector – will sustain ineffective, unnecessary treatments and, when it comes to basic healthcare, leave most of the population out in the cold.
Tim Ensor is a research fellow at the Centre for Health Economics, the University of York, England.
©Copyright: New Internationalist 1995