Antonio Maria de Gordon

• Executive Summary.

• Introduction.

• Demographics, Life Expectancy and Mortality.

• Mental Illness.

• Physicians, Hospital Beds, and Nursing Personnel.

• Individual and Collective Economy.

• Decision-Making and Professional Ethics.

• Specific Health Issues in Various Countries in Transition:

  • Bulgaria

  • Czech Republic

  • Germany

  • Hungary

  • Poland                                                                             

  • Romania

  • Russian Federation

• Cuba's health in transition vis-a-vis the experiences of the former soviet-block countries.

• Conclusions.

• Notes and References.

• Appendix.

 

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Executive Summary

All countries that adopted the ideology and social systems associated with Marxism-Leninism had a socialist type of health service. The original model for this type of health administration was organized in the former Soviet Union. Since then, it has been known in public health circles as the Semashko type of health system. The features of the Semashko health systems were essentially based on two premises: the ideology of Marxism-Leninism and the socio-economic realities of the countries where it was adopted.

The Semashko type of health system provided through the socialist health services: universal coverage, centralized planning and decision-making, and a culture and atmosphere that attempted to demystify medicine by breaking down any barriers that existed between physicians and other health care workers, nurses, laboratory personnel, etc. The latter scheme fit the social and economic order through which, theoretically, all types of workers and social organisms functioned and operated in the context of an egalitarian communist society.

The development of the socialist type of health services in the Central and Eastern European countries of the former soviet-block began and developed in a remarkably similar manner in all countries. Essentially, historical reports from the late 1940's assert that health services had been sub-optimal before the arrival of socialism in each of those countries. With the advent of socialist regimes, health care facilities were confiscated, professional organizations were dissolved, and health care was placed under a centralized system of financial and operational organization controlled by the communist state. There were some variations in the implementation of socialist services, however. In some countries, there was partial participation of private services. In other countries, a pharmaceutical industry developed serving both the internal and export markets.

The health statistics of the Soviet Union began to stagnate in the 1970's. Indeed, airs of reform began to blow in Russia in the 1980's. At that time, two systems of health care began to be researched and organized before political reform ever took place. The Kemorovo system and the Leningrad system were both organized in Russia during the 1980's. Historically, they can be considered pre-transition systems of health care administration that provided a framework from which other reforms took place. In the Kemorovo system, a "Kuzbass" fund was established through which per-capita payments were made to the polyclinics belonging to the system. Presumably, these measures would remunerate polyclinics that treated a greater number of patients. The Leningrad system organized "standard medical practices" of primary care providers. These practices were funded according to the number of patients served. Patients had the ability to change from one practice to the other according to their preference.

All Central and Eastern European countries that belonged to the former soviet-block began to change their health care system after 1989. Not all countries carried out their health systems through the transition at the same time or in the same exact manner. Germany and the Czech Republic seemed to have taken the lead in enacting health systems reforms. Health statistics are easier to follow in the Czech Republic in comparison to the health data for the former German Democratic Republic. The health data for the former East Germany are reported, since German re-unification, to the World Health Organization (WHO) as part of Germany.

Certain health issues were recognized as important transitional elements in the process of the health in transition in the former soviet-block countries. These issues centered around improving morale of both patients and health care providers, updating equipment and facilities, controlling and decreasing the costs of health care, transferring decision-making process from the central government to various local and community levels, and the organization of the professions according to a regulated self governance system in a framework of a market economy.

Health services in transition were invariably traumatic and stressful in all countries. Health statistics and demographics can provide an insight into the overwhelming aspect of the transitions in regards to health in the Central and Eastern European countries. Not all countries behaved in the same manner, however. For example, the population decreased in Bulgaria but not in all other countries. Life expectancy at birth improved slightly in some countries, decreased in others. The country that seemed to have faired the worse was the Russian Federation where life expectancy at birth bottomed during the transition at the level expected for an underdeveloped country of Central Asia, 57 years of age for men. Infant mortality tended to decrease in most countries. However, mortality rates from cardiovascular diseases, intoxication, and suicides tended to increase in all countries.

The health indicators of mental illness also seemed to have generally worsened during the transition in most countries. These evaluations are based on well-documented data where an increase in the use of psychoactive medications legally and illegally, increases in the rates of alcoholism and increases in the mortality rates from suicides have been reported from various studies in several countries. Alcohol was generally the most common intoxicant that led to serious consequences, trauma, hospitalization and/or death during the countries undergoing the transition.

With the advent of the transition, physicians and health professionals usually required members of the professions involved to participate in professional organizations. The number or rate of physicians per population unit did not generally increase appreciably in any of the countries. However, discrete increases were found in some countries. However, in other countries there was an excess of unemployment for doctors and other health professionals that amounted to 8,000 individuals at a particular point in time in the Czech Republic.

The administration of hospital services during before the transition was usually the responsibility of the central state. In the transition, responsibility for hospital administration was usually transferred to the municipalities or local communities. Regardless of number of physicians or rates of physicians per population unit, physician or primary care provider contacts per person per year did increase in most countries ranging from 5 to 18 visits annually per person.

Health expenditures tended to increase in all countries in transition. The expenses, however, were not all assumed by the state budget. At the onset of the transition, all countries financed 100% of their health expenditures through their centralized state budget. With the onset of the transition, the role of the central government state budget in the health expenditures decreased. In some countries the decrease in the role of state budgets occurred early in the transition. In other countries like in Bulgaria and Romania, the involvement of centralized government in local health finances was still appreciable by the end of the 1990's.

One aspect of socialist health has been recognized to be a demoralizing factor for the egalitarian policies of communism. It was the "under-the-table" payments made by patients and relatives to health care providers in order for the patient or client to be placed ahead from others in a particular list for a treatment or surgery or obtain a particular drug. The practice of 6ut of pocket expenses was indeed prevalent throughout the former socialist community before the transition began. It has been postulated that this practice served as a promoter of eventual change through its demoralizing effect on the health care personnel and system. After the transition, these informal payments tended to be formalized though legislation and/or fee schedules in most countries. However, it has been documented that under-the-table payments have persisted as a clandestine operation in some settings.

The centralized nature of the financial and clinical organization of health services in all former soviet-block countries led socialist societies to ignore individual or personal ethical considerations. Under socialist health care, ethics was seldom if ever an issue because both the patient and the health care provider behavior was determined by rule or by fear by he state priorities and values. Anything that deviated from the state perspective was deemed deviant or counter-revolutionary. Medical ethics, therefore, did not begin to appear in the medical school curricula of the former soviet-block countries until the late 1990's. Ethics has to do with practice guidelines and decision-making. In the communist health service decision-making was usually not the priority of the individual physician or the individual patient Social and societal priorities, guidelines and centralized, unquestionable authority were the rule. In the rest of the world, there was wide recognition of the guidelines of the World Medical Association and the Declaration of Helsinki of 1964. These ethical guidelines were adopted in Europe in the 1960's but only in October, 2000 by the former communist countries. Continued interest in decision-making at the national, local and personal levels in the transition with regards to health matters must be encouraged and nourished for the good and growth of all entities.

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Introduction

The transition from the absolute, totalitarian type of society and government prevalent in all former communist regimes into a more open, democratic system of government in the context of a market economy began formally around 1989.(l, 2)Since then, the transition process has involved all important aspects of the social order in each of the nations. Invariably, health and health care have been important issues for all transitions in the former Soviet block countries of Central and Eastern Europe. The nature of health services, the interrelationships of these services to the economy and financing, and the expectations of not only the people or consumers but also the various professionals or providers in the formerly communist countries have been important factors in all of these transitions. It is not difficult to appreciate that the transitions in these former soviet-block countries in their health care services have been operationally challenging, academically interesting, and historically important. These qualifiers are indeed the more relevant when one has an interest a country with a health system similar to those of the former soviet-block countries facing a transition process, Cuba.

An understanding of the importance of health care in the context of the transition out of communism can be easily appreciated from the following historical note. The following is a succinct expression of the viewpoint of Communist ideology in terms of health care. The following quote is attributed to Vladimir Lenin, the founder of Marxism-Leninism. (3) In it, Lenin explains his views on the people in general, their working conditions and the relationship between wealth producers and the wealthy in terms of the consequences for the health of the latter. Lenin said:

"Thousands and tens of thousands of men and women, who toil all their lives to create wealth for others, perish from starvation and constant malnutrition, die prematurely from disease caused by horrible working conditions, by wretched housing and overwork”. (3)

The perceived challenges in the communist understanding of humanity are evident from this quote. Therefore, it is no wonder that these "horrible health conditions" have been approached world-wide through the communist health care services in the former soviet-block countries and in other revolutionary governments and movements who have aligned themselves and followed similar ideological leanings throughout the world including the Castro regime in Cuba since the 1960's.

Not all socialist health services in the former soviet-block countries were identical. However, all of them have had important similarities. (3) They were all organized following in the so-called Semashko type of health service with a centrally financed and decision-making type of organization. Health services in the former soviet-block socialist countries were invariably administered and directed from a centralized, governmental committee. They were also all run from and through a politically dominant perspective. Decision-making was essentially a top-down approach in all countries with regards to change. Anything else was the exception rather than the rule.

Perhaps the nature of socialist health services may be deduced further from the statement quoted above. For example, it may be argued that the ideal socialist health policy should be designed to liberate workers from the toil, from the starvation, and premature death. It is not entirely evident, however, from an extensive multinational review published in the 1980's that socialist health planners that socialist health services were in fact implementing communist idealism. (3) Historically, communist health services purported to exclusively use preventive health services at the exclusion of all others including the curative services in order to attain the "liberation" from the calamities enumerated in the Lenin quote.

Consequently, the official approach from socialist health ministries has been to attempt to prevent the ill health exclusively through prevention. Observers have pointed out, however, that socialist prevention, despite the totalitarian nature of the former soviet-block regimes, has not been successful in eliminating "the toils, the starvation, etc" and other social disgraces described by Lenin. This health services approach in the context of a totally or nearly totally controlled society has more often proved to be more like denial than actual prevention. (4)

There is another feature of socialist medicine and health care that must be identified in this context regarding the transition out of communism. It is that socialism is credited in medical historical circles with the launching of the concept that medical knowledge had to be ^“demystified." (3) That is, it seemed important to socialist health leaders to break down barriers of authority and status among health care workers and in between themselves and their relationships with the people that is the patients and clients.

Beyond socialist ideology, socialist health services should be looked at and assessed in the context of the transition away from totalitarian socialism from a general perspective of public health organization and the non-Communist paradigms of health care. Traditionally, three types of health systems have been recognized during the XX Century and used in the developed and developing world to organize and to explain health services.(5,6,7)Namely,

• The Semashko type whose prototype was the health system of the Soviet Union, all of the former Central and Eastern European countries of the soviet block and Cuba under Castro.

• The Bismarck system whose prototype was the health system of the Federal Republic of Germany, and

• The Beveridge system whose prototype was the British National Health Service.

An understanding of all three of these health systems applicable to both public and individual health is necessary because the Central and Eastern European countries that have begun a transition in health services have adopted parts of all of them in the course of their transitions out of communism. While it is noteworthy that all former soviet-block countries seemed to be willing to change their health care services and administration during the transition out of communism, they all did it differently in terms of timetables, values, and order of factors.

All former Soviet block countries at the onset of their transition period were familiar with the Semashko type of health services. (6) The features of the Semashko type of health service are:

1. It provides universal coverage.

2. It is 100% state financed.

3. Planning is centralized.

4. There is free access at the points of service.

5. All workers and health care professionals are reimbursed through a fixed salary.

In 1989, a massive exodus of socialist countries from the soviet block began. (8, 9) By the early XXI Century, there were two main types of health services that attracted the attention to the former soviet-block countries: The Bismarck model (10) and the Beveridge types. (6) The former provided health services through both individual and collective participation of the people through insurance funds and groups. Premiums were paid according to market, health status, projected prices, costs, and risks. In the Beveridge type of health care system there is a mix of regional and national governmental organizations, partial participation of the individual consumers in costs, and strong controls on available services, treatments, drugs and prices through governmental agencies.

The Bismarck health care system can be dated back to 1883 in Germany. (10) At that time, the German parliament made a national health insurance compulsory for all Germans. During the following years, a statutory social insurance system was organized under Bismarck. The latter had the following features:

• Alleviation of work related accidents and invalidity.

• Old age and disability benefits.

• Provision of long term nursing home care.

At the onset of their transitions, all of the former soviet block countries of Central and Eastern Europe began to center their concerns on health care around these other points: (11)

• Controlling costs of health care

• Lowering costs of health services

• Improving cost-effectiveness in health value

• Proper identification and distribution of controls and decision-making.

• Assessment of quality and safety

• Assuring a proper supply and distribution of professionals

• Providing proper instrumentation and maintenance of facilities.

• Avoiding waste, corruption and theft.

• Provision and maintenance of research and development of new instruments, clinical methods and therapies.

In the process of recognizing these points, searching for resources and arriving at a consensus on community and national values, all Central and Eastern European countries ended up approaching their transition in health care services in somewhat of an individual manner. Some of the countries like the Czech Republic and Germany planned the health services through their transition rather early. (12) Others like Poland and Bulgaria introduced some reforms immediately but only several years into the transition embarked in the legislation and enforcement of more radical reforms in their health services. (13)

 

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Demographics, Life Expectancy and Mortality.

Comparisons of health and health care between different countries can be difficult. However, it is possible to look at various countries with differing features, various ethnic populations, resources, and cultures through certain health statistics. Life expectancy and infant mortality data may be used in this context. These statistics have been found to be reliable in terms of identifying survival, disease prevalence, living conditions, nutrition, and access to health care across geographical and cultural barriers in different countries.

From Table 1 it is evident that all socialist countries listed had a fairly narrow distribution in life expectancy data (65-70 years for men and 71 to 77 years for women). (14,15,16) he same cannot be stated about infant mortality data, however. One major problem in terms of the infant mortality data in Table 1 is that it contains data for different time-periods in the course of each country's history. Despite this difficulty, it is evident that there is a wide variation in infant mortality data in these socialist countries from the 1960's to the 1980's but the tendency was to achieve a lower infant mortality rate as a function of time.

Table 1. Comparative Demographics and Health Statistics in some of the former Soviet block countries in Eastern Europe and West Germany. (10,14,15,16)

Country	L. Ex. (male)	L. Ex. (fem)	Inf. Mart	Urban pop	GDP/pop
Albania	65yrs	71yrs	86.8(1965)	37	US $ 895
Bulgaria	69yrs	74yrs	21.8(1978)	64%	US $ 3820
GDR	69yrs	75yrs	15.4(1973)
FRG	70yrs	77yrs	22.7 (1973)
Poland	66yrs	74yrs	18.2(1991)	66	US$4237
CSFR*	67yrs	75yrs	11.9(1988)
Hungary	67yrs	74yrs	24.3(1979)	54%	US $ 2100
Romania	67yrs	72yrs	31.2(1977)	48%	US $ 2540
USSR	68yrs	74yrs	14.0(1977)	91%	US $ 9110