Special Report Current Practices and Perspectives of Health Care in the Soviet Union

Armen A. Bunatian, MD, PhD, FFARCS* Department

of Anesthesiology,

emy of Medical

Sciences,

Introduction The first draft of my article “Perestroika (Restructuring) in the Soviet Union,” written in August 1990, contained five pages analyzing the political aspects of perestroika. I wrote about my positive attitude toward what President Gorbachev was doing. Now, while revising the article, I am grateful to the reviewer who suggested deleting the political portion of my contribution. While the article was traveling to and fro between our continents, the political and economic situation in my country changed dramatically. Earlier enthusiasm and even euphoria have given way to anxiety and bitter disappointment; ethnic conflicts have become sharper; and there have been bloody clashes in many regions. The president’s popularity has plummeted, and many of those who began the sweeping and encouraging changes are now retired. The new cabinet is enforcing financial reforms that stir but a cool response among the people. The military-

J. Clin. Anesth. *Professor

3:347-350,

1991

and Chairman

Address reprint requests to Dr. Bunatian at the Department of Anesthesiology, National Research Center of Surgery, USSR Academy of Medical Science, Abrikosovsky 2, Moscow 11987, USSR. Received for publication September 27, 1990; revised manuscript accepted for publication April 8, 1991. 0 1991 Butterworth-Heinemann

National

Moscow,

Research

Center

of

Surgery, USSR Acad-

USSR.

industrial complex has gained in influence; the far right has launched an open offensive on democratic freedoms. Thus, I decided to change not only the content of this article but the title as well. I believe no one, including professional politicians, can offer any forecasts. 1 can only hope that by the time you read this article, the word perestroikn will still be in use here.

Health Care on the Eve of Perestroika The current need to criticize has obscured the achievements in medicine and health care within our country. The most important of these is free medical care. During the seven decades of Soviet power, many infectious diseases have been eliminated. We have built thousands of hospitals and outpatient clinics and have set up about 80 institutes and hundreds of secondary specialized schools to train medical personnel. There is a powerful medical industry in the Soviet Union that produces medical equipment and drugs; there is also a network of sanatoria and rehabilitation centers. More than 6 million people, or 4.6% of the gainfully employed population, including 1.3 million doctors (nearly 50% of the 2.7 million doctors in the world), are engaged in health care. Every year more than 70 million people are treated free of charge in 25,000 hospitals; 5.5 million babies are born in maternity homes annually; there are more than 90 million emergency calls yearly; about 10 million patients are treated daily at outpatient clinics; between 7% and 12% of patients receive house calls. About 37% of the visits to general outpatient clinics are for preventive J. Clin. Anesth.,

vol. 3, September/October

1991

347

medicine. ‘l‘he figure is even higher for visits to pediatricians and obstetricians (58% and 57%‘. respectively).’ Of course, these figures do not describe the quality of health care and medicine in our country. The present crisis of our national health care system, which was originally based on the lofty principles of free medical care and central planning, resulted from a lack of funds and inadequate government attention. Between 1960 and 1985, the percentage of the national budget allotted to health care declined from 6.6% to 4.6%. ‘I-here were many reasons for this decline, including the war in Afghanistan, costly aid to other countries (which we could not afford), expensive domestic projects (which we did not need), and failure to exploit high technology to improve efficiency. The material base of Soviet medicine began to deteriorate rapidly, and soaring prices and inflation consumed the money allocated to feed our patients. ‘l-heir diets were better suited to those determined to lose weight! A few specifics illustrate the gravity of the crisis: of 3.3 million hospital beds, 1.2 million have no running hot water, while one in six lacks cold water as well. People were shocked to learn that 30% of our hospitals had no sewage system, while in others, the sewage system was in disrepair and did not meet modern standards.’ Vigorous attempts to reduce the cost of public health care resulted in ill-advised economies to save on the cost of equipping one hospital bed. In Czechoslovakia, 80,000 rubles (approximately $50,000) are invested to equip a hospital bed, while in our country, the figure is about 15,000 rubles (approximately $9,000). One can easily imagine the resultant difference in quality. Glasnost has revealed to an astounded public that our country’s infant mortality rate is fiftieth in the world (after Mauritius and Barbados), and we are thirty-second concerning life expectancy. Soviet hospitals lack an adequate supply of the most basic items, such as disposable syringes, catheters, and cannulas, among others. Very often, orthopedic plaster for casts and disposable electrodes for electrocardiograms (EKG) are not available. This list is even longer in the smaller hospitals outside the large cities. Medical equipment also is scarce and of inferior quality when compared with that produced in other countries. This is true for two reasons. First, the plants producing medical equipment hold virtual monopolies in our country and therefore have no incentive to improve their products or performance. Second, wages and salaries are too low to attract skilled labor. In 1988, Soviet hospitals and clinics lacked 400 million rubles (approximately $250 million) worth of equipment.” Many new hospitals stand idle waiting to be equipped. The pharmaceutical industry is in equally 348

J. Clin. Anesth., vol. 3, September/October 1991

poor shape. Kecen$, se\,eral ecologically darnnglllg medical enterprises were closed under public prf’ssure, forcing the government to spend $342 rnilliol1 to acquire medicine abroad. Still, the situation is far from adequate: too many things are difficult or inlpossible to obtain. One of the most sensitive problems is the qualit\ of medical training in the Soviet Union. Although ive have half of the doctors in the world, a recent ct.rtification program of about 350,000 young doctors revealed that one in ten (or 35,000) should be barred from practice. Another thousand were forbidden to practice because of lack of knowledge. A stricter certification process, as exists in the United States, Great Britain, and Germany. would eliminate even more applicants. The system of higher education in our country needs urgent improvement. The five or six months of postgraduate training in which a doctor is expected to upgrade his knowledge are not enough. We should emulate the rest of the world. where doctors are encouraged or required to study from 2 to 4 years. ‘l‘he doctor-nurse ratio, which is 1:2.8 in our country, is lower than anywhere in the world (1:s to 1 :4). ‘l’hirty percent of our doctors’ time is wasted performing nursing tasks. ’ Salaries in medicine art shamefully low: a doctor’s salary is two times lower than a bus driver’s wages. which explains the negligence and bribe taking that sometimes occur in WIhospitals. Doctors and nurses are united in their demands that we cannot continue in this way.

Perestroika in Health Care and Medicine One of the main goals of perestroika is to create a modern and efficient health care system worthy of a civilized state. ‘I’o reach perestroika’s goals, radical changes in four vital spheres are required: (1) organization and planning, (2) material and technical equipment, (3) improved medical training, and (4) research and deve1opment.l The current allocation of about 190 billion rubles (approximately $118 billion) toward improving medical services is an encouraging sign, but it is clear that one-time investments are insufficient. To calculate real needs, one must take into account stable factors such as the percent of the gross national product (GNP) allocated to health care, which is 8% to 12% in other developed countries and only 4% in the Soviet Union. One of our major tasks is to double this figure. Efforts are under way to diminish centralization and renounce the quaniitative assessment of medicine’s efficiency (patients per physician or hospital) in favor of qualitative ones. Excessive bureaucratization

Current perspectives on health care in the Soviet Union: Bunatian

is being eliminated. For instance, district health departments (the main source of bureaucratic procrastination) were abolished in cities with populations under 800,000. In 1991, the same will occur in cities with populations approaching 1 million. Pharmacies now use cost-accounting systems, which means they no longer are subsidized by the state but must demonstrate cost-efficient management. The free system of medical care is being supplemented by partially paid outpatient clinics and private practice. So far, their volume is only 0.6% of all medical care, but they are expected to increase fourfold by 1995.s It should be pointed out that people on the whole willingly accept the idea of paid medical services. According to recent polls conducted by the Institute of Sociological Studies of the USSR, 75% of patients already pay their doctors either with money or presents on the side. Medical cooperatives (similar to health maintenance organizations in the United States) are springing up throughout the country. Although their prices are high and beyond the reach of those in low-income brackets, many people go out of their way to use them because of their high level of medical advice and care. Medical insurance is seen as the most reliable solution to our health care problems. It combines the advantages of a more cost-effective medical service with purpose-oriented investments and the decentralized manner in which it is financed. In this way, taxpayers may have more control over how their money is used. Plans exist to couple the state medical system with medical insurance so that national programs receive greater attention (e.g., those for infant mortality, AIDS, and preventive medicine). This will improve the health of all individuals and society as a whole.’ Under an experiment conducted jointly with the Ministry of Public Health, several large research institutes engaged in surgery have increased their efficiency. Currently, the ministry pays for patients admitted beyond an annual quota (1987 was taken as the base year), provided this number is more than 20% of the entire number of patients and there were no fatal outcomes attributed to mismanagement. Salaries would be indexed to performance. The National Research Center of Surgery has increased its efficiency by 20% to 30% over what was believed to be the maximum. Naturally, salaries rose accordingly. To assess the performance of the anesthesiologists, we use a system of “units” borrowed from the United States. We hope the experiment will be extended to other medical specialties. To eliminate long and unjustified hospital stays, the Ministry of Public Health has proposed a program

of establishing large-scale diagnostic centers throughout the country. Today 14 such centers serve 600 to 1,000 patients daily, and another 150 centers are planned by 1995. Currently, we hospitalize patients for 2 or 3 weeks for diagnostic purposes, since outpatient clinics cannot accomplish this task. Conversion of the defense industry to meet civilian needs holds much promise. We hope that by 1993, we will be able to produce all the disposable syringes we need. Together with large-scale purchases of medical equipment abroad, we shall be able to meet our requirements with the latest medical equipment. Many hopes are pinned on joint ventures with foreign firms. Some are already in operation with Sweden and Germany, while others are being organized. In May 1990, an unprecedented number of American firms came to the exhibition Health Care 90 to seek joint venture opportunities. This is a good sign.

Problems and Prospects of Anesthesiology Thirty-five years ago, the first anesthesiologists were recruited from surgical services in the large centers of Moscow, Leningrad, and Kiev. Today, when praising past accomplishments is out of fashion, I would like to pay tribute to academician B. Petrovsky’s efforts to promote anesthesiology in the Soviet Union. As one of our best surgeons, he realized quite early that surgery and anesthesia should develop together. In his role as minister of public health between 1965 and 1980, he was able to accelerate the development of anesthesiology and intensive care programs. Between 1966 and 1969, all hospitals acquired either departments or groups of anesthesia and intensive care units (ICUs). In general surgery departments, there was 1 anesthesiologist for 75 beds; in departments of cardiac and thoracic surgery, there was 1 anesthesiologist for 25 beds. Each doctor was entitled to 1.5 to 2 nurses. (In our country, nurse-anesthetists are not supposed to work independently of doctors.) Today hospitals have the right to decide how many doctors in each specialty they need. In the 197Os, departments of anesthesia and postgraduate courses on anesthesiology appeared in medical colleges, institutes of advanced training, and research institutes. About 30,000 anesthesiologists have been trained in the past 25 years. Anesthesia is the fifth most populous specialty, though only 14% of our anesthesiologists receive adequate training for 2 to 3 years. Less than a third are classified as higher-level specialists. Recently, a l-year internship in anesthesiology and intensive care has become more accessible. Still, it is J. Clin. Anesth.,

vol. 3, September/October

1991

349

specml RepotI not sufficient. Doctors should be trained for 2 more years in clinical and other related studies. ‘1’0 obtain the status of specialist, doctors should sit for exams. It is hoped that current changes in the health care system will lead to new systems of training. Training of nurses for anesthesia departments and ICUs is far from adequate. Specialized medical schools are few, and the level of training falls below that in other countries. Low pay and overwork (one nurse manages three ICU patients) deter entry into this field. films, disposable equipment, Updated textbooks, drugs, and equipment also are lacking. Large hospitals use combined anesthesia techniques: nitrous oxide, halothane, fentanyl, ketamine, muscle relaxants, and other miscellaneous drugs. Enflurane and isoflurane are not widely used, and smaller hospitals still rely on ether. Preparations for parenteral and enteral feeding, colloid and crystalloid infusion solutions, infusion systems, syringes, adapters, and so on, are deficient. The ventilation and anesthesia equipment manufactured in this country is 20 to 30 years behind the times. We produce no pulse oximeters, capnometers, equipment for measuring cardiac output by thermodilution, arterial cannulas, state-of-the-art respirators for children and adults, and so on. Although some excellent monitoring computers are produced in the Soviet Union, they are too few. Some are used in the National Center of Surgery in Moscow and a few other hospitals, and our American colleagues have had a chance to see them. We have the potential to improve our quality of anesthesia care once we completelv transform the administrativecommand system now ruling the country and stop treating health protection as a field of minor importance. Anesthesiologists work 5 days a week, approximately 8 hours per day. In addition, every doctor must work an extra two or three times per rnonth for additional pay. Before recent changes occurred in the Soviet Union, doctors were not paid for this additional work but were to compensate by working shorter hours on other days, which very often proved impossible. Today, after a wide-scale media campaign, the situation has improved. Anesthesiologists and ICU nurses are paid 15% more than other specialists (including surgeons), they receive half a liter of milk daily, and

350

J. Clin. Anesth., vol. 3, September/October

1991

their

aruiual leave is 6 tla>s longer- than thal of 4111 ‘l‘he IIY’C\ pension Iaw envisages pref’crential treatment fi)r doctors and nurses rvorking in the I(:I: their retirement pension will be 70% to 75% of thei]salary instead of the present 50%. ‘I‘he retirement agt is 60 f’or men and 5.5 for women, though retirement is not obligatory. Many nurses and doctors continue working beyond their retirement age. Scientific research in anesthesia and intensive ca1.e occurs in research institutes dealing with surger). anesthesia departments of medical colleges, and illstitutes for advanced medical studies. The Problem Commission on Anesthesiology and Reanimatolog) (intensive care) at the Academy of Medical Sciences supervises research projects in five distinct areas: (1) mechanism of‘ anestliesia, (2) clinical anesthesiology. (3) reanirnatology and intensive care, (4) new drugs, and (5) new medical equipment. Research efforts are currently concentrated on items 2 and 3. l‘he lack of interest in new drugs and medical equipment is due to an absence of competition, the inadequate research base of’ the few monopolists in the field, 1ow wages, and no stimulus to perform better. ‘I-he level of clinical research depends on equipment and varies f‘rorn clinical observations to works published in the leading medical publication, Aw.cbimonthly with theriolo~~ and Kranimatology (published English abstracts), Heralds of theUSSRAd~my of ~Vf~tlid Scitwws. Mdical Lquipvnmt, and others. Lately, anesthesiology’s importance has been ~LII-ther recognized: two anesthesiologists were elected to the Acadernv of Medical Sciences, and, in 1991, two more corresbonding members will be elected. geo11s.

References Schepin OP: ‘l‘he development trends in public health care. 7’pr-Ar-kh 1990;62:3-7. Osipov EO: How to carry on and strengthen perestroika (based on the results of the 19th National Party Conference). SOUMed 1988;10:3-6. Pmudu, 12 May 1988. ChaLov EI: The problems of perestroika in health care. SOUZdmvookhr 1987;6:3-8. Kischenko LP, Kosterina TM, Shilenko YV: The economic aspects of the reconstruction in health care and medicine. Vcrtn Akad Med Nauk SSSR 1990: 413-g.

Current practices and perspectives of health care in the Soviet Union.

Special Report Current Practices and Perspectives of Health Care in the Soviet Union Armen A. Bunatian, MD, PhD, FFARCS* Department of Anesthesiolog...
505KB Sizes 0 Downloads 0 Views