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The ills of Central and Eastern
European health care
A grim picture of diminishing public health structures, deteriorating working conditions and staff pessimism emerges from a recent survey of Central and Eastern European health care. The situation is especially grave due to a severe deterioration in public health in much of the region over the last decade, in some cases with life expectancy plummeting.
GENEVA - A recent survey of a specific class of workers in Central and Eastern Europe has produced some startling results. In Ukraine, 75 per cent said their pay had diminished in the last five years. In Romania, some 93 per cent said not being able to live on their wages was their biggest concern. In Lithuania, 43 per cent said they feared losing their jobs in the next year. And in Moldova, workers said they are often paid months late, if at all.
On the face of it, it would appear that the decade since the fall of communism has not been a paradise for most workers. Yet, those surveyed aren't employed in declining industries, former state-run enterprises or collective farms.
Instead, these workers - many of whom are suffering from great uncertainty, lack of pay, poor working conditions and general demotivation - are part of the health care infrastructure, a sector which in the current conditions of Central and Eastern Europe might be more needed than ever.
These data come from a new series of studies carried out jointly by the ILO and Public Services International (an international trade union federation of public sector workers).* The studies focused on the experiences and views of those working on the front lines of the health services in Central and Eastern Europe, people who not only have seen and experienced first-hand the harsh results of the past decade, but are also in a position to affect the lives of others by their work. If they lack the means to deliver a decent service, then the rest of the population is in trouble.
However, public health provision often appears unable to deliver basic affordable health care and, according to the survey, health staff are increasingly paying the price of this failure.
How did this happen?
How did public health care in these countries come to this? The issues involve the changing political landscape, health service restructuring and economic weakness.
Following the collapse of the Soviet Union, and often with the support of the World Bank, many nations in the former East bloc began radical surgery on their health services.
Typical reforms included a shift from state-provided health care to mainly insurance-based financing, decentralization, and a greater emphasis on general-practicioner (local doctor) based primary health care.
The introduction of privatized health care at first remained mostly confined to services such as dentistry, although lately significant private health care has begun to emerge in several countries.
The changes represented a huge experiment in health care restructuring, one not attempted in this manner ever before. However, the cutting of public funding coupled with the decentralization of funding responsibilities left many local authorities without the resources or administrative capacity to meet new obligations. This, combined with a serious deterioration in public health and an increase in many chronic diseases, helped produce the current crisis.
Health care declines
The surveys show that optimism over significant future improvement appears in short supply; nearly two out of every five respondents from the Czech Republic thought that future government plans would actually make their situation worse. The state of under-funding is so bad in Kyrgyzstan and Armenia that large proportions of health care workers are on "administrative leave", failing to come to work because the hospitals and clinics lack funds to pay them. In Moldova, Europe's poorest country, the health system is said to be near collapse.
Three out of every four Romanian and Lithuanian workers surveyed said their pay had fallen in real terms over the last five years. Yet falling pay did not appear to be accompanied by any increase in job security; indeed, quite the opposite: a staggering 43 per cent of Lithuanians feared they could lose their jobs in the next year alone.
With little certainty over pay and future funding, the health care systems have had to increasingly rely on other ways of paying staff. The lack of funds has encouraged doctors and others in direct contact with patients to demand or expect illegal payments; in many countries, revenue from secondary sources now accounts for more than a third of total income. In Russia, for example, such "under-the-table" arrangements represent an estimated 40 per cent of all expenditures by persons seeking medical care. Less formal forms of income are not a proper solution to the health crises though, because an increasing number of citizens have found themselves unable to pay. The ILO People's Security Surveys (PSS), for example, found 88 per cent of families in Ukraine and 82 per cent in Hungary were unable to afford basic health care.
The populations' health needs, however, are huge, and increasing. Over the last decade in Russia, tuberculosis incidence more than doubled, the level of registered drug addicts increased almost nine-fold and the incidence of sexually transmitted diseases grew forty-four times. During 2000, the number of HIV-positive people increased two-fold, and an estimated 23,000 people died of alcohol poisoning. It is a pattern with grim echos across much of the region.
What is to be done?
Tackling such health crises would be a challenge even to an adequately funded and wellfunctioning system, one where staff were properly remunerated and working conditions good. This is hardly the case in the countries surveyed. Instead, health care workers often attempt to cater to the needs of an increasingly impoverished and ill population in the face of huge job insecurity and poor working conditions.
Whether the situation will be dramatically improved soon is far from obvious. What is clear though, and demonstrated by the recent survey, is that the experience of those on the front line - the health workers trying to keep things running - will have to form a key part of the solution
* Socio-Economic Status of Heath Care Workers in the Russian Federation - Stepantchikova, Lakunina, Tchetvernina, December 2001. Health Care Reform, Privatisation and Employment Conditions in Central and Eastern Europe: A Four Country Study - Beck, Watterson, Woolfson, December 2001.