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Soviet Union

Provision of Medical Care

Having emphasized quantitative expansion of medical services, the Soviet Union, by the 1980s, took first place worldwide with respect to the number of hospital beds and physicians per 10,000 people and had in place a huge network of hospitals, polyclinics, consultation centers, and emergency first-aid stations throughout the country. As in the education system, administration and control of these numerous medical facilities was carried out by a centralized, hierarchically structured government apparatus. In cooperation and consultation with CPSU organs, the Ministry of Health set basic policies and plans for the entire nationwide health care system. These in turn were transmitted through the administrative chain of command, starting with the republic-level health ministries down through the territorial, regional, district, municipal, and local levels.

In coordination with Gosplan, the Ministry of Health developed nationwide annual programs for all aspects of health care services. The ministry's planning effort reflected an overwhelming concern "with numbers and complex formulas," such as setting norms, standards, and quotas with virtually no flexibility, spelling out the number of new 1,000-bed hospitals to be built, the number of patient visits and medical exams to be performed, and even the number of sutures per given type and size of laceration.

The numerous administrative entities and planning offices spawned a huge bureaucracy, with all the attendant problems of overbureaucratization, red tape, and paper deluge. Most affected and afflicted were physicians, who devoted 50 percent of their time to filling out medical forms and documentation.

A large portion of the Soviet annual health care budget (about 18 billion rubles) was allotted to construction of a vast and complex network of medical facilities, including polyclinics, consultation and dispensary centers, emergency first-aid stations and ambulance services, hospitals, and sanatoriums. In 1986 more than 40,000 polyclinics provided primary medical care on an outpatient basis. They ranged in size from huge urban complexes staffed by hundreds of physicians and responsible for the health care needs of up to 50,000 people, to small rural clinics consisting of several examination rooms and three or four doctors, whose training was often at the physician's assistant or paramedic (fel'dsher) level.

Generally, the first place turned to for medical assistance was the polyclinic. Individuals and families were assigned to a specific polyclinic, based on their place of residence, and could not choose their physician within the polyclinic system. Outpatient services stressed prevention and provided only the most basic medical treatment, including preliminary diagnosis and evaluation by a general practitioner or internist (tevrapet). If the patient's condition was determined to be a more serious or complicated one (hypertension, heart disease, or cancer, for example), the individual usually was referred to another specialist and/or was hospitalized for more extensive diagnosis and treatment. The polyclinic system was delivering 90 percent of the country's medical care in the 1980s.

An important facet of medical care was the provision of services at the place of work, reflecting the country's focus on maintaining a healthy labor force. Large production enterprises (see Glossary), factories, and plants, as well as many other institutions, such as research facilities and universities, had their own clinics or medical units. The railroad workers' union operated its own autonomous health care system, including rest homes and sanatoriums.

Consonant with the nation's concern with worker productivity and loss of valuable production time, workplace clinics allowed workers to get medical attention without leaving the work site. They also monitored and controlled worker absenteeism through issuance of sick leave certificates. In 1986 approximately 4 million workers (about 3 percent of the total work force) were on sick leave each day; about 700,000 of them, mostly women, stayed home to care for sick children.

Nationwide, in 1986 there were 23,500 hospitals with more than 3.6 million beds. In an effort to eliminate duplication of medical services by combining general and specialized hospital care, beginning in the mid-1970s the Ministry of Health began building large urban hospital complexes that provided specialized care in the hospital and on an outpatient basis. A 1,600-bed hospital was built in Novosibirsk; Rostov-na-Donu had a 1,700-bed hospital tower; huge multidepartment hospitals appeared in other cities as well.

Although the thrust of hospital care was to provide diagnosis and treatment of more complicated health problems and to provide facilities for surgery, people suffering from such minor illnesses as influenza or gastroenteritis were often hospitalized. This exacerbated the already serious crowding problem in hospitals despite the large number of hospital beds per capita. The situation stemmed in part from official specification of exact periods of hospitalization for each and every type of medical problem, for example, ten days for childbirth, appendectomy, or gallbladder surgery; two weeks for a hysterectomy; and eight weeks for a heart attack. These prescribed "recovery" periods were strictly adhered to, even when the patient clearly no longer needed further hospital care. In the early 1980s, one-quarter of the population was hospitalized each year. The average hospital stay was 15 days, with a nationwide average of 2.8 hospital days per person per year (the average hospital stay in the United States was 5 days, with 1.2 hospital days per person year).

The propensity for medically unwarranted, extended hospitalizations reflected old-fashioned practice, the inefficiency of hospitals (for example, delays in diagnostic tests caused by excessive paperwork and shortages in medical equipment), and the difficulty for patients to recover at home because of crowded living conditions. In addition, patients tended to prefer hospitalization to curative treatment in the clinics because hospitals were generally better equipped and better staffed.

A pivotal concern of the public health system was the care and treatment of women and children. More than 28,000 women's consultation centers, children's polyclinics, and pediatric hospital facilities focused on prevention and cure of women's and children's health problems. A number of institutes of pediatrics, obstetrics, and gynecology conducted research to improve diagnosis and treatment of disease and contribute to overall health and well-being, especially of pregnant women, infants, and young children. All maternity services were free, and women were encouraged to obtain regular prenatal care; expectant mothers visited maternity clinics and consultation centers on an average of fourteen to sixteen times. About 5 percent of physicians specialized in obstetrics and gynecology. Women had ready access to free routine examinations, Pap smears, and prenatal care. Abortions were also available on demand but sometimes required a small fee.

The Ministry of Health operated an extensive network of emergency first-aid facilities. This "rapid medical assistance" (skoraia meditsinskaia pomoshch') system consisted of more than 5,000 emergency first-aid stations and included 7,700 specialized ambulance teams. Dialing "03" on any telephone (pay telephones did not require the usual 2 kopek coin) called out an ambulance (skoraia, as it was popularly called). Most often ambulances were equipped with only the barest first-aid basics: stretcher, splints and fracture boards, oxygen equipment. But specialized antitrauma ambulances with portable equipment, such as an electrocardiograph, electric heart defibrillator, and anesthesia equipment were available for major emergencies. After administration of first aid, patients with major medical problems or severe trauma were taken to special emergency hospitals because most regular hospitals were not equipped with emergency rooms. In the early 1980s, the average ambulance arrival time was eight minutes in Moscow and eleven in Leningrad.

Rounding out the nation's health care system, and giving it a uniquely Soviet coloration, was the country's large network of sanatoriums, rest homes, and health resorts, which was both an integral part of Soviet health care and extremely popular among the people. Labor unions controlled about 80 percent of the sanatoriums; generally, a person's place of work granted the highly desirable putevka (ticket) to such facilities. Some sanatoriums were specialized, providing therapy for children, diabetics, or hypertensives; many health resorts offered mud baths, mineral springs, and herbal therapies; all of them offered a much-welcomed period of rest and recreation in pleasant natural surroundings along seacoasts and in forests with fresh air. Demand for such facilities, dubbed "functional equivalents of tranquilizers" by one Western observer, far exceeded availability. In 1986 over 15,800 sanatoriums and rest homes served more than 50.3 million people, less than 20 percent of the population.

The most outdated and abuse-ridden area of health protection was the system of psychiatric services. In the mid-1980s, psychiatric care continued to operate primarily on the outdated principles on which it was originally based in the 1950s: Pavlovian (conditioned-response) psychology, a black-and-white approach to diagnosis of mental illness, heavy reliance on psychotropic drug therapies, very little practice of individual or group counseling, and an emphasis on work as the best form of treatment and therapy. The average citizen avoided seeking psychiatric help, convinced it was "better to suffer" than have one's life ruined--an almost certain outcome of Soviet psychiatric clinics and services.

Among the corrupt practices (including bribery and blatant disregard of individual rights), the gravest and most infamous abuses in Soviet psychiatric medicine were political, namely, using mental hospitals as prisons for political dissenters. Along with schizophrenics and violent prisoners, dissenters were institutionalized in special psychiatric hospital-prisons operated by the Ministry of Internal Affairs (see The Ministry of Internal Affairs , ch. 19). Anyone who actively disagreed with the official Soviet ideology could be easily and swiftly declared "insane" by a committee of psychiatrists, locked up in a mental institution, and subjected to compulsory treatment with powerful, at times permanently damaging, psychotropic drugs. In the mid-1980s, estimates of the total number of political prisoners in Soviet psychiatric facilities numbered from 1,000 to several thousand.

A harbinger of possible reform of the psychiatric system came in January 1988 with the issuance of a decree by the Presidium of the Supreme Soviet transferring the special psychiatric hospitals from the Ministry of Internal Affairs to the Ministry of Health, which operated a system of regular psychiatric hospitals and polyclinics. A number of government-sponsored private psychiatric clinics offered slightly better levels of therapy and counseling, for a fee.

In 1985 Soviet officials began publishing limited statistics on the incidence of mental illness among the population, reporting 335 cases of schizophrenia per 100,000 people and over 1.3 million children suffering from mental retardation. A total of 335,200 hospital beds were devoted to psychiatric care in 1986, compared with 863,000 for general medicine, 526,900 for surgery, and 411,500 for pediatrics.

Between 1960 and 1986, the number of physicians and dentists increased from 400,000 to 1.2 million, and mid-level personnel increased from 1.4 to 3.2 million. Medical training for physicians (vrachi) required six or seven years. The emphasis was on practical training with little exposure to basic research or pure science (of ninety-two medical institutes, only nine were attached to universities). Beginning in the 1970s, specialization began early, in the third year, and became increasingly more narrow, resulting in a serious decline in the number and quality of general or family practitioners. The majority of doctors were women. As was the case in teaching and other social services areas, their salaries were low (in the mid-1980s, physicians earned about 180 to 200 rubles per month compared with 200 rubles per month for industrial workers).

Mid-level medical personnel included physician's assistants, or paramedics, midwives, and nurses. These categories required only two years of practical training and little or no scientific background. These mid-level health practitioners frequently served as physician surrogates in rural areas, where the shortage of trained physicians was serious.

Although the underlying principle of Soviet socialized medicine was equality of care and access, the reality was a multitiered, highly stratified system of care and facilities. The disparity between the services provided to the general populace and to special groups was great. The so-called "fourth department" of the Ministry of Health operated a separate network of clinics, hospitals, and sanatoriums exclusively for top party and government officials as well as for other elite groups, such as writers, musicians, artists, and actors. These special facilities were far superior to those found in ordinary health care networks. They provided the best care, were staffed by top-ranking physicians, and had the latest equipment, including Western-made modern diagnostic and treatment units. The medical care available in cities, which tended to have the better equipped hospitals and clinics, differed considerably from that available in rural areas, which often lacked specially constructed medical facilities.

Similarly, although in principle health care was free, citizens often paid money or gave bribes to receive better treatment. Moreover, hospital patients routinely paid for basic services, such as changes of bed linen and meals.

Data as of May 1989

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