Russia Profile August 29, 2006 It Could Be Worse Post-Soviet Medical Care Isn’t Perfect, But There Are Some Positive Trends Comment by Alexei Pankin
In 1998, a relative who worked as the head doctor at a village hospital in the Saratov region came to my grandfather’s funeral. His tales still ring in my ears. At the time, he was not being paid in cash, but on a “barter scheme”in vodka or eggs or some other village produce. The money for his ticket to Moscow had been collected in nearly all the surrounding villages. They scraped together enough for a one-way ticket, so the Moscow relatives had to send him back again. When he got back, he planned to butcher a calf in order to pay his debts. The situation regarding his hospital’s supplies of medicines, bandages, and gasoline was pretty much the same. And I believe that his situation was not exceptional, given the state of medicine in the first ten years after the fall of the Soviet Union.
But I remain optimistic, guided by the classical formula from the years of developed socialism: It could be worse.
In the Soviet Union, socialized medicine was a matter of official pride, subjected to the contempt and scorn of the people, first because there was a feeling of social injustice, and second because of the multiple inconveniences associated with receiving medical attention. The injustice had to do with the fact that there was a separate healthcare system for party functionariesclean clinics with virtually no lines, spacious hospitals equipped with world-class equipment housing wards for a small number of patients, and special drugstores with no shortage of medicines.
In contrast, ordinary people had to spend hours in line at their clinics. If, God forbid, they had to be taken to a hospital, they would lie in the corridors and scour drugstore after drugstore to find anything more complicated than aspirin. And, of course, medicine at that time was not entirely freein a deficit economy, any medicine could be procured for a bribe, good spots in the hospital were bought underground, and time spent waiting for an operation could be decreased with the help of an additional donation to the doctor or hospital involved.
But the basic level of care was quite high nonetheless, and medical services, as far as I can tell, were universally available. Satisfaction was derived not so much from overcoming everyday discomforts as from contradicting socialist ideology. That medical care was free and universal was taken for granted, but everyone wanted better quality of service, first, and for public servants not to be in a privileged position vis-a-vis the populace, second. It is possible that these priorities could have been reversed.
As a result of all our reforms and transformations, Russian healthcarewhich had never quite reached the stated goals of equalityis now in a de facto legal state of stratification. The new democratic ruling class maintained, or even expanded, the privileges of its communist predecessor, and continued to be treated in the same clinics, the same hospitals and the same sanatoriaalthough it is true that the newly rich could also now afford to get in. Paid services became legal and private clinics and doctors appeared. But most people simply had the option of obtaining free medical care at a lower level.
I don’t think that anyone now is seriously troubled by the issue of providing better medical care for officialdom. Normal people understand that at the end of the 1980s, the democrats led them into a fight against communism under purely Bolshevik slogansdeprive the nomenclature of their privileges and distribute them among the people.
As a result of the victory of the anti-communist revolution, the new elite got it easier than the old, while the people were materially worse off. So it is not really surprising that no one is actively working to change things again.
The appearance of private medicine is also in some ways a godsend. After all, the possibility of choice is a good thing in and of itself; and if people have the means and are prepared to pay for better service standards, then this can only be welcomed. Whether treatment is better or worse there, nobody knows. People still remember that patients at “Kremlin clinics” did not trust doctors there, since their treatment was aimed not so much at curing patients but at removing all responsibility from themselves should something go wrong.
As for popular medicine, I am hard pressed to say whether it has gotten worse or better. Compared with the Soviet era, it is probably worse. However, it could become worse still. Ask anyone, and they will tell you that the paramedics duly answer calls at any time, day or night. Despite their low pay, pediatriciansat least the ones I have come acrossare invariably well qualified and really care about children’s health. Injections are given, orders for necessary treatment signed promptly, and examinations carried out.
Doctors in Russia are wonderful, I think, and no liberal reforms have managed to do anything to change this. And if their salaries are raised and they are given modern equipmentas proposed under the national projectsthen we’ll manage to survive.
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Russia Profile August 29, 2006 Beating the System? The Real Differences Between State and Private Clinics are Cosmetic Comment by Yelena Rykovtseva
Russia’s state medical system is a terminally ill patient, and it is ill with a disease similar to leprosy. This patient has long been infected with the virus, but for many years, it did not affect his appearance. That is how medical care was in the Soviet period. From outside, everything looked wonderful: the Soviet Union had the best medical education in the world; therefore it had the best doctors and nurses. It also had free medicine and the best medical equipment.
Probably the most accurate of the Soviet era slogans regarding medical care was the one praising the professionalism of hospital staff, who did, in fact, work miracles. Often foreigners were amazed by the skill of Soviet doctors, who managed to treat patients while using techniques and equipment that were prehistoric.
In fact, medical care in the Soviet Union was not really free. Ostensibly you paid nothing. But you would be informed that imported medicine would more effective in your case, and since there was none in the hospital, you would have to get it yourself. There was a widespread system of bribes to nurses, ward supervisors and doctors. In theory, you could pay nothing for medical treatment, but to do this, you needed nerves of steel, since everyone involved would tell you that everything would work so much better if only you pay ahead. Incidentally, I don’t think this is true: Soviet doctors were not beasts. But who wants to take a chance with their health? It is too much of a responsibility, so everyone paid.
In this sense, absolutely nothing has changed today. Formally, medical care is still free. All Russians can get free insurance from the state that entitles them to analysis, diagnostic tests, free dental care, consultations, hospital treatment and operations. And all of this is completely free.
But no one is happy with this and people with any money at all go to expensive private clinics because state clinics are scary, decrepit, and smelly. Over the years they have become utterly worthlessjust as leprosy irreversibly mutilates a sufferer’s appearance over time. Additionally, to receive treatment in any state-run clinic, you are subjected to endless lines. First you must stand in line to make an appointment with the doctor; then you stand in line outside the doctor’s office; and then outside the offices where medical procedures are carried out. Going to the clinic even for the simplest reason can take up to six hours. The worst part of the system, which forces everyoneeven people who are not poorto go to state clinics is that only state clinics can issue sick notes –official documents that allow you to claim a sick day from your employer. In theory, you can buy annual medical insurance in Moscow that includes sick notes, but it is very expensive. Although I can afford sometimes to pay for private doctors, I am not prepared to empty my wallet on commercial insurance.
It would be wrong to speak of competition between state and private medical care. What competition can there be between something free and bad, and something expensive and good? They are entirely different systems. It is not a question of the market, but a question of one’s ability to pay.
Genuine competition can only happen inside one of the two systemsprivate clinics. And such competition exists, especially in the dental sector. Paradoxically, this is an area of medicine that appeared to suffer in the Soviet Union, but is now flourishing. There are thousands of private dental clinics with excellent equipment and cutting-edge materials. All you have to do is choose.
Many private clinics employ people who simultaneously work at state institutions. There is nothing bad about this either. I have already said that doctors in Russia are well trained, but they are ridiculously underpaid. Only when a doctor works in the evening at a private clinic after completing a day shift at the state one, is he making decent money. And when patients pay to see him in the evening instead of getting to see him for free at a state clinic during the day, they are saving time that could have been lost standing in line. And everyone’s happy!
I once witnessed a monstrous hybrid of private and state medical care. A friend told me that there was a good neurologist working at a local clinic, and that it was possible to jump the line to see him by paying 200 rubles ($8). I went to the clinic, was welcomed warmly in a special room for paying patients, the receptionist took my money, wrote me a receipt, and escorted me into the doctor’s office. And next to the office I saw a massive line of old women. The administrator guaranteed that I could get in without waiting, and I did, but I was subjected to unreal verbal abuse from the women in the line. So of course the level of comfort and the equipment is better in private clinics. But not the doctorsthey are the same.
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