Massive Reforms : Soviet Goal: Resuscitate Health Care

The Soviet Ministry of Health is an inconspicuous building in the heart of downtown Moscow, but excitement is palpable within its creaky corridors. The energy emanates largely from the corner office of Health Minister Yevgeny I. Chazov.

From there, he is directing a colossal program to modernize this country’s massive health care system, which has become antiquated, inefficient and bogged down in bureaucracy after years of under-funding and neglect.

In an era when most other governments are searching for ways to slash health spending, the Soviet Union intends by the year 2000 to triple its annual health budget, estimated by Western analysts to be about $34.2 billion.

Billions of Rubles

In the meantime, Chazov said in an interview, he will be spending more than 6 billion rubles in the next 2 1/2 years to upgrade everything from technologically deficient clinics and hospitals to the way patients are treated and doctors are paid.

If the ambitious effort comes close to achieving reality--and that remains to be seen--Soviet citizens someday will wait in shorter lines at clinics, be offered the chance to have annual physical exams and experience fewer shortages in drugs and medications.

At the same time, Soviet doctors, long known for their surliness, who work in neighborhood clinics may find the government looking over their shoulders like never before--but also dangling before them financial incentives to provide more effective patient care.

Some of the reforms already have gone past the talking stages. Set to take effect later this year, for instance, is a nationwide program to test each physician’s competency every five years.

Part of the Program

These reforms, a part of Soviet leader Mikhail S. Gorbachev’s much-heralded program of perestroika, or economic restructuring, are also being dictated by a grim reality that even bureaucrats can no longer ignore: Statistics show that the health of the Soviet Union’s 280 million citizens has been on a downward slide for much of the last two decades.

The country is the only industrialized nation in which infant mortality has increased during the 1970s and early 1980s while, during the same period, overall longevity has declined.

Infant mortality is a widely used indicator of general health status. The Soviet rate, when calculated in the same manner as in the United States, rose from 26.2 deaths per 1,000 live births in 1971 to 35.6 deaths per 1,000 births by 1976, according to Dr. Murray Feshbach of Georgetown University’s Center for Population Research. That rate today has been reduced to 29.9 deaths per 1,000 births as a result of a crash program begun several years ago, when, according to Chazov, teams of maternity and infant care specialists roamed the country. (The U.S. rate was 10 in 1987).

The average life expectancy for Soviet males fell from 66 years in 1964 to 64 years today. (The American male lives an average of 71 years today.) Death rates in the Soviet Union at almost all ages began rising in the mid-1960s, according to Soviet data gathered by Feshbach.

Official Concerns

Such rising mortality rates and sharp increases in infectious diseases, heart disease, cancer and alcoholism have become an official source of concern.

“Until the 1960s, their health system was not too bad, but from the mid-’60s they devoted more energies to the military, and the civilian sector slid,” said Mark Field, a Boston University sociologist and a fellow at Harvard’s Russian Research Center. “After years of neglect, the regime is giving health a better priority.”

But Field, like Feshbach and other Western experts, does not expect to see sudden changes.

“Much of what you hear will remain on paper, as has happened with other programs in the past,” he said. “But remember, they are talking about a schedule that will go well into the next century. Their plans are grandiose--but appropriate. The next question is how much will be initiated into reality. My guess is that it will take them 20 years to turn around.”

Facing Obstacles

Shortages of capital, sheer bureaucratic inertia and a lack of incentive for workers to do their best are among the obstacles that Chazov and the entire government face.

The typical Soviet citizen, always skeptical about promised reforms, speaks cynically of the health reform.

“The bureaucrats, with 70 years of experience, can outpace any reform 2 1/2 times faster than any reformer can act,” one Muscovite told a reporter.

Soviet officials are truly concerned about the deteriorating health status of their people. If not checked, it could be a serious impediment to remaining a superpower. The most striking evidence of official concern is Chazov’s surprisingly candid criticisms of the system he oversees.

In interviews in the Soviet press, Chazov has roasted Soviet medical science, the state of cleanliness in Moscow’s maternity hospitals, medical education, hospital planners and past policies that doggedly put a premium on quantity even in the face of plunging medical quality.

New Awareness

Vladimir Gubayev, science editor of Pravda, the Communist Party newspaper, explained in an interview the sudden rash of frank public criticism: “We are now aware that if we don’t solve the problems of health and social welfare, we will not be able to move forward.”

The new national program for restructuring the health system received Politburo approval last August and was published in the Soviet medical newspaper Meditsinskaya Gazeta late last year.

The newspaper said the document sets out “ways of radically improving the work of health care agencies and institutions, research institutes and medical schools, making more effective use of the health services’ personnel . . . and significantly enhancing the quality of medical assistance to the public.”

“Large-scale measures,” the paper said, “have been outlined to strengthen the preventive aspect of health care, improve the environment, improve Soviet people’s working and living conditions and their leisure, involve them in regular physical exercise, step up the battle against drunkenness and alcoholism and improve the structure of the public’s diet.”

Problem for Society

The basic principle of the reform, Chazov said in an interview, is that health is the responsibility not only of the medical profession and the individual but of all the other ministries, government agencies, trade unions and factories--in short, the entire Soviet society.

To accomplish the extensive restructuring of the health system, he said, the budget “will increase threefold by 1995-97,” including some $10.2 billion to be added over the next 2 1/2 years.

Chazov said the Soviet Union spends about 4.1% of its gross national product on health. Obtaining precise Soviet statistics is difficult, however. Feshbach, the Georgetown University expert, estimates the state budget for health at about $34.2 billion. One Soviet source quoted last September in Lancet, the British medical journal, states that in 1985 the Soviet budget for national health was $30 billion. If the amount spent on health by other public sources was added, the total rose to $38.6 billion.

For the same year the United States spent $425 billion for health, or 10.7% of its GNP. Because the Soviet GNP is only about 55% of that of the United States, this helps to explain some deficiencies in their health system.

Treatment Targeted

While Chazov emphasizes anti-smoking, anti-alcoholism and other preventive programs as the mainstays in the restructuring, he made it clear that major new infusions of funds will go toward upgrading treatment for those already ill.

The 59-year-old physician in 1985 shared with Dr. Bernard Lown, an American cardiologist, the Nobel Peace Prize for founding the International Physicians for the Prevention of Nuclear War. Chazov has traveled widely and is keenly aware of his country’s inadequate medical resources.

Except for a few national institutes and a handful of hospitals in major cities, most Soviet hospitals are old, poorly maintained and minimally equipped.

Even showcase facilities like the U.S.S.R. Oncology Research Center in Moscow, which is only 10 years old, bear signs of poor design and neglect. In some hallways, the concrete walls are so soft that it is possible to scratch them with one’s fingernail.

Frank Interview

“We have pursued a goal measured in the number of beds, unconcerned about whether or not they met present-day standards of medical technology or even sanitary norms,” Chazov acknowledged in an interview published in Literary Gazette.

He said many hospitals in the Central Asian republics “still lack not only a hot-water supply but even rudimentary sewage and water mains.”

Even in Moscow, he told a reporter for the Literary Gazette last year, “women are well aware of the disastrous condition of the capital’s maternity hospitals.” He said many women go outside Moscow to deliver their babies.

“Out of 33 maternity hospitals (in Moscow), only 12 meet present-day standards and sanitary norms,” the health minister said.

The restructuring of the Soviet Union’s health care system has several specific goals. One, intended to bring down death rates for the entire population, is to provide complete annual physical examinations to every man, woman and child in the country, an approach that American experts view skeptically because of the enormity of the task.

Diagnostic Centers

But Chazov said this goal can be accomplished by building special diagnostic centers with state-of-the-art equipment and new laboratories throughout the country.

Also, he said, the hospitals that contain 1 million of the nation’s 3.6 million hospital beds will be closed and replaced.

In addition, equipment such as ultrasound, CAT scans and monitoring instruments, which account for only 10% to 12% of the cost of building a hospital, will increase to 20% to 30% of the cost, Chazov said. (In the West, technology accounts for about 40% of the cost.)

Major changes also are in store for doctors who staff the neighborhood clinics, known as polyclinics, where 80% of all treatment takes place.

Squeezing Them In

Until recently, most doctors were paid a salary according to the number of patients they managed to crowd into a day, and patients had no choice in selecting their doctor. Doctors were said to spend no more than six or seven minutes with each patient.

Today, the biggest patient complaint with the health system is directed at polyclinic doctors, whom patients accuse of every sin from sheer incompetence to bribe taking for providing care that should have been free--ignoring patients in a waiting room, for example, unless tipped heavily.

A headline in the government newspaper Izvestia last December illustrates the patient resentment: “It’s Bad to Be Sick, but Worse to Be Treated.”

”. . . Clinic doctors are awful,” one disgruntled Muscovite told The Times. “They are arrogant. They are rude. They sound like walking textbooks, but the texts are from the 1950s.”

Pilot Programs Watched

If pilot programs launched by Chazov in Moscow, Leningrad and several other cities bear fruit, patients will be able to choose which doctor to see, and at the same time polyclinic doctors will be paid largely based on the patients’ satisfaction with the treatment.

For instance, doctors who attract more than a certain number of patients will receive salary raises of up to 30%; less popular practitioners will be subject to being tested for their professional competence and attitude toward patients--at the risk of being removed from service permanently.

Another method to measure physician performance is already in place in Leningrad and two other cities as part of a pilot program launched Jan 1.

This program scrutinizes the number of sick-leave passes a doctor grants. The number is deemed an indicator of a doctor’s ability to keep patients healthy by emphasizing preventive measures and being alert to diagnose medical problems before they develop into serious illnesses. (To discourage doctors from refusing to grant passes for legitimate illnesses, records will also be kept of the number of times a patient seeks emergency care for conditions that a clinic doctor should have attended to. If such a patient has to call an emergency ambulance for treatment of such a condition, his doctor may be charged for the expense.)

Factory Fines

According to Dr. Victor A. Fokin, vice director of Leningrad’s public health department, money that factories save through this prevention program will be funneled into the health budget. In addition, factory managers who allow hazardous working conditions will be fined and the money will be allocated to health care.

According to Fokin, the Health Ministry has authorized Leningrad authorities to oversee the quality of care of all the health facilities in their jurisdiction. In addition to receiving statistical information such as illness and death rates from polyclinics and hospitals, the local administration also evaluates data supplied by the unions and other mass organizations to evaluate competency.

In a further check on doctor competency, set to take effect nationwide in the near future, every physician will be tested every five years.

Recent trial tests on 350,000 of the nation’s 1.3 million doctors resulted in 30,000 being certified provisionally and 1,000 others being denied the right to practice, apparently forever. (The Soviets graduate an estimated 35,000 physicians a year, compared to about 16,000 in the United States.)

Students ‘Coddled’

Chazov has been quoted in the Soviet press as saying that medical students have been “coddled” by school authorities who are concerned only with the number of graduates they turn out.

“And we have turned over these infantile people to the public health system. . . . Approximately 40% of them are completely lacking in practical skills,” he declared recently.

A small number of so-called pay clinics, which have existed for years but which deliver only about 1% of all medical care, charge patients $3 to $4 a visit. They are seen as another alternative to ordinary polyclinic care. Chazov said there are plans to expand “to a small degree” the number of such pay clinics, which are run by the state. Many patients are willing to pay the small fee to escape long waiting lines at polyclinics.

In addition to pay clinics, private practice exists in the Soviet Union on a very small scale. Doctors’ cooperatives whose members, often retired, are allowed to charge fees, on which they pay taxes. According to Chazov, perhaps 400 to 500 physicians practice privately in Moscow and a much smaller number in Leningrad.

Moonlighting Dentists

In Leningrad, Fokin said, part of the pilot program is to allow private dental practice by dentists who work for the state during the day. Untreated dental problems are said to be a serious problem throughout the country.

Chazov and Fokin said they have no fear that a further expansion of private practice will fractionate the state program.

“The state structure stays intact,” Fokin said in an interview. “We are only adding things in order to place less load on the state. But the major emphasis is on the state system.”

HEALTH CARE: U.S. vs. U.S.S.R. LIFE EXPECTANCY AT BIRTH (1985) Men USSR: 64 US: 71.2 Women USSR: 69 US: 78.2 Sources: Soviet Central Statistics Office; U.S. National Center for Health Statistics INFANT MORTALITY (Per 1,000 Live Births)

USSR US 1970 (reported) 24.7 20.0 1970 (adjusted)* 28.3 20.0 1976 (reported) 31.1 15.2 1976 (adjusted)* 35.6 15.2 1987 (reported) 25.4 10

Sources: U.S. Bureau of Census; National Vital Statistics, except for reported Soviet figure for 1987 , from the USSR Ministry of Public Health * According to international health authorities, the Soviet definition of infant mortality differs from the World Health Organization definition used by the United States and most other nations, resulting in an overstatement of the Soviet rate. The adjusted figures represent an estimate of the Soviet rate when calculated using the WHO definition.

USSR US Population 284,000,000 243,827,000 Area (sq. miles) 8,649,489 3,615,123 % of GNP Spent on Health-1987* 4.1 12 Doctor Ratio to Population 1 per 350 1 per 500 Number of Hospital Beds 3.5 million 1 million Birth Rate per 1,000 Population 20 15.7 Legal abortions (1987) 5.5 million (1985) 1.5 million

*GNP in the U.S.S.R. is approximately 55% of that of the U.S. FO(Bulldog Edition) Health Minister Yvgeny I. Chazov directs effort to modernize the massive Soviet system.