Facing the Challenge
Impact of economic transition on health care in Eastern Europe and the Newly Independent States
Von Manfred Zahorka / Schweizerisches Tropen- und Public-Health Institut (Swiss TPH)
For most of the countries of Central Asia and Eastern Europe the transition period from Soviet style governance to a free market economy and democratic governance has brought deterioration in living standards, accompanied by shortcomings in the health and education sectors. There are tremendous challenges for the public health system in Eastern Europe and the need for reform is evident.
All the republics of Central Asia and Eastern Europe have witnessed a serious economic crisis, and framework conditions, such as legislation, the judicial and tax systems, and the fight against corruption have not yet been sufficiently consolidated to allow the development of the private sector and small and medium-sized enterprises in particular. Economic decline and social disruption have lead to widespread poverty in the newly independent states (NIS) as the countries of the former Soviet Union are now called. Massive social changes including mass unemployment, economic insecurity and the deterioration of social safety nets influence peoples’ lives in the region. Frustration about joblessness and limited future perspectives increase vulnerability particularly of youth and adolescents.
Risking health for a decent living
Widespread poverty, migration and declining health and education services have led to a massive increase in individual high-risk behaviour. Increasing poverty has forced women into sex work as their only source of income. While the rigid social control of the past has eroded, new common norms and values are still flimsy. The lack of common social norms and values has lead to an increase of drug abuse, particularly with injection drugs together with drug production and trafficking, early and unprotected sex and other high risk behaviour particularly of young people. The general lack in sex education together with the ever earlier onset of sexual activities lead to a rapid increase of sexually transmitted infections especially among those under 25 years of age. Unprecedented numbers of young people do not complete their secondary schooling. Several countries have experienced setbacks in the human development index (HDI, used by UNDP for the Human Development Reports) over the past two decades.
Migration to neighbouring countries by parts of the family, particularly for men searching for work, is a common form of income generating activities since the opening of borders in the early 1990s. The increased mobility has as well increased the likelihood for the spread of a variety of diseases including HIV/AIDS and other sexually transmitted infections. In the early 1990s HIV/AIDS made rare appearances in the region, but today 8 from 10 known HIV subtypes are found in an area spreading from Belarus to the Russian Pacific coast.
Collapsing systems and services
Massive budget cuts for social security and public services have lead to a collapse of the public health system, including those components responsible for the treatment and control of infectious diseases like tuberculosis (TB) and HIV/AIDS. An only slowly adjusting health care system and relatively shrinking health budgets have reduced access to quality health care. Preventive care services including health promotion, education and information are seriously suffering from the budget cuts. The public health response to high risk behaviour and increased vulnerability of the population remains weak or non-existent. Centralised structures of health care systems, the reduced capacity for investment and a lack of maintenance systems lead to deterioration of medical infrastructure de-favouring peripheral and rural populations in particular. Many institutions depend on private donations for the renovation and adaptation of structures to changing consumer needs. The increase in consumer prices and low salaries in the health sector have introduced unofficial users fees in many institutions rendering access to health care systems more difficult to the poor. Emerging private health care providers are accessible only to the wealthy. As tax based health care financing is increasingly unable to guarantee health care for all, insurance based schemes are only slowly developing. In recent years health care reform efforts have encouraged decentralisation and a trend away from institutionalised care towards an ambulatory system with several referral levels leaving many institutions with large overcapacities, which increase the burden to the health budget. A tendency away from budget allocation based on the number of beds per institution and towards per capita based or even diagnostic groups related payment systems have put many larger hospitals into a financially volatile situation.
Although there is an increased opening to the international medical community and most countries are reporting to WHO using international disease classification standards (ICD 9 or 10), there are still large differences in quality standards, diagnostic guidelines and even case definitions, which have an impact on the quality of care provided and the international comparability of health care statistics. In the Soviet period reporting within the health care delivery system was largely depending on centrally set plans and objectives and non accomplishment of targets had often serious consequences on budget allocation or even personal carrier perspectives. In order to monitor the system a vast amount of data was collected at central level. However, the information was frequently biased towards targeted values. Even after several years into health care reform, it is frequently difficult to obtain unbiased information as health care providers fear for personal consequences if the information provided does not correspond to expected values. Today there is a significant lack of reliable information making health planning and monitoring a tedious exercise and renders the establishment of national and international support programs more difficult. Additionally, the low level of computerisation of health records limits the possibility of getting a complete picture.
The patient’s name: public health
Despite the changing health care systems the old hierarchical thinking is still predominant in many countries of the former Soviet Union. Clinical procedures and guidelines are often based on single senior experts’ views and not necessarily on internationally accepted knowledge or evidence based criteria. In many countries it is difficult for younger physicians to acquire independent knowledge as access to international sources is constraint due to limited access to information technology or simply the lack of English language proficiency.
Civil society organisations like non-governmental organisations (NGOs) in the health and social sectors were non existent in the Soviet period and are now slowly developing. In many countries however, NGOs are managed by civil servants who work at the same time in public institutions and serve as an alternative way to fill the financial gaps in the public system. Nevertheless, many local NGOs receive international support as other alternatives are missing.
Under these circumstances the public health response to emerging or re-emerging epidemics like HIV/AIDS or Tuberculosis remains weak and spurious. Countries in Eastern Europe and Central Asia today have the fastest growing HIV/AIDS epidemic in the world. At the same time there is a near total lack of infrastructure and capacity to provide any HIV/AIDS-related services, whether through prevention programs, voluntary counselling and testing, treatment or care for people living with HIV/AIDS. Tuberculosis as well is on the rise with an average increase of 10% per year in the Russian Federation. The increased number of treatment resistant strains of Tuberculosis due to incomplete treatment forms a particular public health threat not only limited to the region.
There are tremendous challenges for the public health systems in Eastern Europe. Most countries in the region have engaged in some form of adjustment of the health care system supported by national and international efforts. Health education and disease prevention play an important part to reduce the vulnerability of the general population and the youth in particular. Whilst looking for alternative financing mechanisms for health care it is a public health priority to provide equal access to quality health care services for all.
*Manfred Zahorka is a family practitioner, public health expert and epidemiologist by training. He has been working for more than 15 years in public health and health systems development in developing and transitional countries in Eastern Europe, Central Asia and Africa. Currently, he is working with the Swiss Centre of International Health within the Swiss Tropical Institute in Basel. Contact: Manfred.Zahorka@unibas.ch
- The Determinants of the HIV/AIDS Epidemics in Eastern Europe, MAP report, www.hsph.harvard.edu/fxbcenter/MAPreports.htm
- UNDP Human Development Reports, http://hdr.undp.org
- Martin McKee, Judith Healy and Jane Falkingham (eds.) Health care in central Asia, European Observatory on Health Care Systems Series, Open University Press Buckingham Philadelphia, 2002, www.euro.who.int/observatory