The physician manger in Eastern Europe and the former Soviet Union.

Although the myth of "monolithic" Communism has been debunked, health care systems throughout the Soviet Union and in Central and Eastern Europe (CEE) were remarkably similar, particularly in the sense of a government-run health care service funded by the government. There were a number of characteristics that were similar throughout CEE and what are now the New Independent States (NIS) of the former Soviet Union and mostly remain true today. These include:

* Centralized planning and budgeting, typically through the Ministry of Health, the city, the region, or the district.

* Huge hospitals that represent the core of the health care system and that are associated with regional networks of smaller hospitals that, theoretically, link one to the other. Hospitals of more than 1,000 beds are very common in NIS and there are probably more 1,000-bed hospitals in Moscow than there are in the entire United States.

* Large multispecialty "polyclinics" that often see 1,000 patients a day and that may or may not be closely associated with a hospital (although all of them are linked through the networking system); in rural areas, regional clinics down to first-aid stations manned by nonphysician personnel, usually a nurse mid-wife and another health care worker.

* What appears to the Western observer as an overabundance of health care workers, particularly in hospitals, who are usually paid less than the average wage for other workers and do not enjoy the professional status that is afforded in Western countries.

* Stereotyped medical education, although there are changes now being made, more of them in CEE. This includes six-year medical school programs (ages 18-24), often with early "specialization" at the fifth year and yet with relatively short postgraduate specialty training periods, more on a preceptor basis than is found in the West.

* A remarkable professional isolation not only from Western physicians and medicine, but also from most of the rest of the world. Obviously, this varies considerably, and the countries of CEE were far less isolated than, for example, Central Asia of the NIS. Nonetheless, the availability of medical and scientific literature, library communication, interaction of like professionals, and ability to attend medical meetings are far less than one would find in most other countries in the world.

* All physicians state employees and salaried. There were few economic incentives.

* Management of virtually all health care facilities by physicians, almost all of whom have had little or no managerial training to assume this responsibility. The combination of the lack of managerial training and inability to control budgets and planning creates an obvious managerial problem.

With the fall of the Berlin Wall in late 1989, the U.S. government reacted to many concerns and problems in CEE, including health. This was accomplished through the U.S. Agency for International Development (USAID) and included, among other programs, a health partnership program linking institutions in the United States with counterparts in CEE to address major, health problems being experienced by these countries. Specific emphasis was placed on cardiovascular disease (the leading killer), cancer, emergency medicine, and diseases of children. Ten partnerships were established in six countries (Poland, The Czech Republic, Slovakia, Hungary, Romania, and Bulgaria).

After the break-up of the Soviet Union in December 1991, the U.S. Secretary of State convened a meeting in Washington in January 1992 to coordinate aid to the NIS. A medical working group was established, and a site visit to 10 NIS republics was accomplished in February and March 1992. This included some 30 health care professionals representing 14 countries and international organizations; I was delegation coleader, along with physicians from France and Japan, and we traveled on a NATO plane.[1] During this and many subsequent trips, I have now visited more than 125 health care institutions in CEE and NIS. A partnership program was also developed for the republics of the NIS by the United States, again through USAID and the American International Health Alliance. In only one year after mid-1992, 21 partnerships were established.[2]

My role as Medical Advisor in the Bureau for Europe and the New Independent States of USAID has enabled me to interact with hundreds of physicians and to do so on a professional basis relating to my experience as a physician manager and in clinical practice in internal medicine and gastroenterology. Because most physician managers have a dual role in a medical practice, they must also balance health care delivery, educational activities, and managerial responsibilities.

The Current Situation

The political, economic, and social upheaval that has been the subject of worldwide attention over the past four years has had an effect on both the health care system and on the professional and personal lives of the physician managers involved.[1-4] While virtually all expressed positive feelings, and even exhilaration, at the changes, a frequent comment was that there is now "more freedom but less money," a disruption of the supply systems, of central planning, and of authoritarianism. This has created significant professional ambivalence.

Frequently, one finds a distinct cultural identity,[5] and this is particularly true in CEE and NIS republics beyond the Russian Federation. Regardless, the overall structure of health care delivery and medical education continues to be similar to that found previously. Significant advances are occurring in CEE,[5] but altering the structure is much more of a long-term activity. In most countries, particularly CEE, there are varying degrees of privatization, usually based on a prior tradition. Often these take the form of managed care activities, including even the equivalent of health maintenance organizations and faculty practice plans. Individual private practice and fee-for-service medicine is understandably not highly developed, and most physicians remain state-employed. Nevertheless, many of the organizational problems of delivering care to the population, including a "social safety net," have many characteristics found in U.S. hospitals. Likewise, the development of ambulatory medicine has lagged far behind Western medicine, and relatively long hospital stays are still common.

One of the greatest changes relates to the financing of health care, and once again U.S. technical assistance programs are helping. Development of private insurance, managed care plans, and financial management are important parts of the evolutionary process.

One of the more striking elements of health care services in CEE and NIS has been the relative lack of patient and public awareness, both in terms of public education and patient satisfaction. With the high incidence of cardiovascular disease, smoking by the population, and concerns over environmental adverse effects on health, public education should have significant priority. Likewise, awareness by patients of the quality of services provided, involvement in their own health care decisions, and their ability to choose physicians are only gradually developing.

From physicians' perspective, the creation of professional organizations, which can either be representational or serve a regulatory function, has been another interesting and challenging development. In many CEE countries, professional organizations that are taken for granted by Western physicians have been present for only 2-3 years. Licensing of physicians was previously done exclusively by the state, with far less stringent specialty certification, hospital credentialing, accreditation of programs, or development of quality assurance programs by hospitals and other health care organizations. USAID-sponsored technical assistance programs are being directed at these activities as well.

The Future

The challenges facing the health care systems in CEE and NIS are daunting and largely mirror the other more publicized economic and political upheavals that have occurred. 3-1 First and foremost, of course, is the need to provide good health care for citizens. However, because the entire health care system was highly organized previously,[3,4] any approach must be made with this in mind. Second, cultural integrity must be maintained,[5] and there certainly should not be attempts to transpose the U.S. or any other system to them. Nevertheless, there are many generic organizational problems to be addressed and a great need for technical assistance.

It has been my observation that technology deficiency is not the primary problem; rather, professional isolation and lack of opportunity for both clinical and managerial interaction with physicians and other health care counterparts in Western countries have been the major problem experienced by most health care professionals.[1,2,4] These vary from the need for direct managerial counseling to continuing medical education at the clinical level, which can be both disease- and health service delivery-oriented. Obviously, professional satisfaction can be a great stimulus to patient satisfaction, as well as to patient awareness and public education. I have only rarely encountered ideological discussions, although most physicians are quite aware of the high degree of technology found in American medicine. As we address health care reform in our own country, it is both fascinating and challenging to observe how many generic health service delivery, medical education, health care financing, and managerial issues we have in common with our colleagues in Central and Eastern Europe and the New Independent States of the Former Soviet Union.

Let me offer a final anecdote. In Central Asia, I encountered a woman pediatrician, in her 60s, who had been the director of a 1,000-bed pediatric hospital for many years. We asked her if they had received any humanitarian aid, and she said that they had recently received 80,000 condoms (not from the United States!), which she had bartered for antibiotics. This only proves that one of the most important attributes of a physician executive is resourcefulness.

References

[1.] Farmer, R., and others. "Health Care and Public Health in the Former Soviet Union, 1992, Ukraine - a Case Study." Annals of Internal Medicine 119(4):324-28, Aug. 15, 1993.

[2.] Farmer, R. "The Last Word. Soviet Crisis: A Matter of Perspective." Hospitals and Health Networks 67(16):56, Aug. 20, 1993.

[3.] Baumgartner, L. "A Doctor Diagnoses Soviet Medicine." New York Times, May 17, 1959, p. 42-4.

[4.] Schultz, D., and Rafferty, M. "Commentary: Soviet Health Care and Perestroika." American Journal of Public Health 80(2):193-7, Feb. 1990.

[5.] Albert, A., and others. "Health Care in the Czech Republic. A System in Transition. JAMA 267(18):2461-2466, May 13,1992.

[6.] MacKenzie, D. "Can Europe Save Its Eastern Promise?" New Scientist, Feb. 8, 1992.

[7.] Casanova, J. "Lessons from the Soviet Health Care System." Physician Executive 19(2):10-2, March-April 1992.

Further Reading

Davis, A Health Care after Chernobyl: Radiation, Scarcity, and Fear." PSR Quarterly 2(1):3-24, March 1992.

Delamothe, P. "Helping Russia." British Medical Journal 304(6839):1432-4, May 20, 1992.

Feshbach, M., and Friendly, A. Ecoside in the USSR. New York, N.Y.: Basic Books, 1992.

Gellert, G. "International Health Assistance for Eurasia." New England Journal of Medicine 326(15):1021-4, April 9, 1992.

Gore, A. Earth in the Balance. New York, N.Y.: Houghton Mifflin Co., 1992.

Ryan, M. The Organization of Soviet Medical Care. London, England: Basil Blackwell and Mott, Ltd., Oxford and Martin Robertson and Co., Ltd., London, 1978.

Storey, P., and others. "Cooperation between Health Professionals from the United States and the Union of Soviet Socialist Republics: Conclusions from a Trip to the Soviet Union." Annals of Internal Medicine 13(11):882-4, Dec. 1, 1990.