United Press International - May 9, 2002
Sam Vaknin, UPI Senior Business Correspondent

People lead brutish and nasty lives only to expire in their prime, often inebriated. In the republics of the former Yugoslavia, respiratory and digestive tract diseases run amok. Stress and pollution conspire to reap a grim harvest throughout the wastelands of Eastern Europe. The rate of tuberculosis in Romania exceeds that of sub-Saharan Africa.

As income deteriorated, plunging people into abject poverty, they found it increasingly difficult to maintain a healthy lifestyle. Crumbling health care systems, ridden by corruption and cronyism, ceased to provide even the appearance of rudimentary health services. The number of women who die at -- ever rarer -- childbirth, skyrocketed.

Health care under communism was a public good, equitably provided by benevolent governments. At least in theory. Reality was drearier and drabber. Doctors often extorted bribes from hapless patients in return for accelerated or better medical treatment.

Country folk were forced to travel hundreds of miles to the nearest city to receive the most basic care. Medical degrees were -- and still are -- up for sale to the highest, or most well-connected, bidder. Management was venal and amateurish, as it has remained to this very day.

Hospital beds were abundant -- but preventive medicine and ambulatory care was not. One notable exception is Estonia, where the law requires scheduled prophylactic exams and environmental assessment of health measures in the workplace.

Even before the demise of central health care, some countries in Eastern Europe experimented with medical insurance schemes, or with universal health care insurance. Others provided health care only through and at the workplace. But as national output and government budgets imploded, even this ceased abruptly.

Hospitals and other facilities are left to rot for lack of maintenance or shut down altogether. The much slashed government-paid remuneration of over-worked medical staff was devoured by hyperinflation and has stagnated ever since.

Equipment falls into disrepair. Libraries stock on tattered archaic tomes. Medicines and other substances -- from cultures to vaccines to immunological markers -- are no longer affordable and thus permanently in short supply. The rich monopolize the little that is left, or travel abroad in search of cure. The poor languish and die.

Health care in Eastern Europe is irrational.

"As the formal privatization of health care proceeds, and health insurance systems are developed, health care access for poverty-stricken groups and individuals needs to be provided in a more reliable and systematic way," said the health care chapter of a report prepared by Center for Institutional Reform and the Informal Sector in the University of Maryland for U.S. Agency for International Development.

But this is hard to achieve when even the token salaries of health care workers go unpaid for months. Interfax reported on March 9 that 41 of Russia's 89 regions owe their health care force back wages. Unions are bereft of resources and singularly inefficacious.

The outcomes of a mere 6 percent of national level consultations in Lithuania were influenced by the health unions. Their membership fell to 20 percent of eligible workers, the same as in Poland and only a shade less than the Czech Republic (with 32 percent).

No wonder that "under the table facilitation fees" are common and constitute between 40 and 50 percent of the total income of medical professionals. In countries like the Czech Republic, Croatia, and chaotic Belarus, the income of doctors has diverged upwards compared to other curative vocations. It is not possible to obtain any kind of free medical care in the central Asian republics.

This officially tolerated mixture of quasi-free services and for-pay care is labeled "state-regulated corruption" by Maxim Rybakov from Central European University in his article "Shadow Cost-sharing in Russian Healthcare".

As though to defy this label, the Russian Ministry of Health is conducting -- together with the audit chamber and the ministry of the interior -- a criminal investigation against health care professionals.

Some 500 medical workers are currently being investigated on suspicion of a variety of offenses, such as taking bribes, using fake medical certificates, and reselling medicine at a profit, Yuri Shevchenko, Russia's minister of health said in a Rossiiskaya Gazeta, newspaper article.

The U.N.'s International Labor Organization warned of a "crisis in care," in a December 2001 press release.

"The economic and social situation in several East European countries has resulted in the near collapse of some health care systems and afflicted health sector workers with high stress, poor working conditions and salaries at or below minimum wage -- if and when they are paid," a survey from the U.N. agency and Public Services International said.

Rapidly increasing rates of sexually-transmitted diseases, HIV/AIDS, tuberculosis and numerous chronic diseases have created a crisis of care made all the more dramatic by diminishing public health structures, lack of training of health care professionals and general de-skilling of the workforce, said Guy Standing, director of the socio-economic security program at the U.N. agency and coordinator of the study.

"All of this has surely contributed to the catastrophic fall in life expectancy rates in Russia, Ukraine and some other countries in the region," Standing said.

The situation is dismal even in the more prosperous and peaceful countries of central Europe. In another survey, also done by the U.N. agency, 82 percent of families in Hungary claimed to be unable to afford even basic care. This is not much better than Ukraine where 88 percent of all families share this predicament. Agreements signed in the last two years between Hungarian hospitals and cash plan insurers further removed health care from the financial reach of most Hungarians.

Health care workers in all surveyed countries -- from the Czech Republic to Moldova -- complained of earning less than the national average and of crippling wage arrears. In some countries -- Armenia, Moldova, Kyrgyzstan -- few bother to clock in anymore. In others -- Poland and Latvia, for instance -- a much abbreviated work week and temporary labor contracts are imposed on the reluctant and restive health care workers. One in twenty hospitals in Poland had to close between 1998-2001. In an impolitic spat of fiscal devolution, ill-prepared local authorities throughout the region were left to administer and finance the health services within their jurisdictions.

The governments of east Europe tried to cope with this unfolding calamity in a variety of ways.

Consider Romania. Half the population claims to be "very satisfied" with their health services.

In Romania, the 1997 Health Insurance Law shifted revenue collection and provider payments to a maze-like coalition of 41 district health insurance houses headed by a national health insurance house. Romanian citizens are forced to foot one third of their health bills in a country which spends a mere 3 percent of gross domestic product on the salubrity of its citizens -- the equivalent of $100 per year per capita. Only a small part of this coerced co-financing is formal and legal.

About 70 percent of the meager state budget is derived from erratic payroll health insurance fund contributions, now set at 14 percent of wages. The national budget supplements the rest. Some of the contributions are distributed among the poorest regions to narrow the inequality between urban and rural areas.

The health insurance houses pay health care providers, based on number of people, or a projected global budget. They are experimenting now with fee-for-service reimbursement methods. All these payment systems, inevitably, are open to abuse. Monitoring and auditing are poor and relations are incestuous.

The Ministry of Health still makes all major procurement decisions. Many government organs -- the Ministry of the Interior, the transport system, the Army -- all maintain their wastefully parallel care provision networks. Donor funds, multilateral financing, and government money have all vanished into this insatiable sink of venality.

The only rays of light are private dental and medical clinics, laboratories, and polyclinics working side by side with private pharmacies and apothecaries. These cater to the well-to-do. But the government emulated them and "privatized" the institution of the family physician.

General practitioners in Romania now receive, on a contractual basis, payment per socially-insured patient treated. They make rent-free use of clinics and equipment in their workplace. Many of these doctors now borrow small amounts from willing banks -- a scarcity in Romania -- to open their own practice.

Expenditure on health in the Czech Republic amounted in the 1990s to about 7 percent of GDP per year (compared to 14 percent of a much larger GDP in Organization for Economic Cooperation and Development countries). But medical insurance firms cannot cope with vertiginous prices of imported medicines.

Hospitals now receive insufficient lump-sum payments rather than getting reimbursed for procedures and treatments carried out. Naturally, most of these go toward staff wages. Little is left for medical care.

Poland is in no better shape. Its embattled minister of health, Mariusz Lapinski, stumbles from crisis to criticism in his doomed effort to reform a ramshackle system. The two current scandals involve heavily subsidized drugs and a new health bill, fiercely opposed by progressive interests, such as medical doctors and nurses. The Polish weekly, Wprost, went as far as comparing Poland's health care to Egypt's, Turkey's, and Mexico's.

The World Bank discovered in 1998 that 78 percent of Poles had to pay illicitly to obtain basic care. Lapinski intends to dissolve the regional state health funds and resurrect them in the form of a national edition. But state-run hospitals in Poland are insolvent. Naturally, healthcare workers have little faith in the management skills of the state.

They are calling for open competition among teams of commercial health insurance funds and health care providers. They would also like to increase health insurance contributions to allow Poland to spend on health more than the current 5.5 percent of GDP.

United Press International reported recently about a strike of medics in Macedonia as typical of the problems facing the health care systems of all countries in transition: privatization, the involvement of the state, and Western influence of the reform process.

The transition to the western general practitioner model is hotly debated. As far as doctors are concerned, it is a lucrative proposition. But it could exclude poorer patients from medical care altogether.

Still, the main problem is the gap between grandiose expectations and self-image -- and shabby reality. Eastern European medicine harbors fantastic pretensions to west European standards of quality and service. But it is encumbered with African financing and Vietnamese infrastructure. Someone must bridge this abyss with loads of cash. Either the government or the consumer must cough up the funds. The sooner everyone come to terms with this stressful truth -- the healthier.

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