Health Care and Public Health in the Former Soviet Union, 1992: UkraineA Case Study

Background

Health Care System of the Former Soviet Union

The republics of the former Soviet Union are highly centralized with well-organized health care systems and large numbers of health care workers [2]. In the past, the Ministry of Health administered the budget from the center to the periphery through the republic, oblast (state), rayon (district), and city levels. (The population of a rayon varies from 40 000 to 150 000 persons, and 10 to 50 rayons compose an oblast.) In theory, the entire population had access to all health services free of charge. Until 1991, health care facilities were allocated fixed amounts of money based on the number of hospital beds and polyclinic patient visits. Because of the inherited rigidity and hierarchical organization of health care services, the basic system has remained largely intact in each republic, despite the political dissolution of the Soviet Union.

Hospitals have been central components of the health care system and range in size from 1000 to 2000 beds in referral or republican level facilities, to 50 to 250 beds in regional and district levels. Polyclinics, which are frequently adjacent to hospitals, provide outpatient services to as many as 1000 patients per day. The Ministry of Health managed most of the hospital beds. Parallel health care systems had been created for the military, transportation workers, and the party elite. During 1991, there were up to 140 hospital beds per 10 000 persons in the Soviet Union, compared with 120 beds per 10 000 persons in the United States [3, 4]. In addition, there were approximately 40 to 50 physicians per 10 000 persons compared with 26 per 10 000 persons in the United States [4].

Profile of Ukraine

With 51.8 million inhabitantsof whom 17 million live in urban areasUkraine is the second most populous state in the NIS after the Russian Federation. The population density is 84 persons per km²: 8% of the population are younger than 5 years, and 18% are older than 60 years. Ukraine comprises 27 oblasts, which are subdivided into 477 rayons.

In 1989, the infant mortality rate was 13.6 deaths per 1000 live births (U.S. rate, 9.8 [4]). In 1990, life expectancy in Ukraine was slightly higher than that in the Russian Federation (70.5 years compared with 69.3 years, respectively but, as is characteristic of the NIS republics, both rates were substantially less than those of the European Community [76.3 years [3] and of the United States [75.4 years [4]). The most common causes of death are malignancies, ischemic heart disease, cerebrovascular disease, and injury.

The overall ethnic composition of Ukraine has remained stable; ethnic distribution within the republic varies. In particular, western Ukraine is predominantly Ukrainian, whereas the rest of the republic is more ethnically diverse. Ukrainians account for 73% of the total population; Russians, 22%; and Jews, 1%. Approximately 40% of the Jewish population in the NIS resides in Ukraine.

The population of Kiev, the capital of Ukraine, is 2.8 million, of whom 640 000 are children and 700 000 are retirees. In addition to more than 12 000 physicians, basic health care resources in Kiev include 28 000 hospital beds; military and veterans hospitals meet the special needs of survivors of the Afghan war. Facilities in the rural areas of the oblasts (states) include small hospitals (that is, 20 to 50 beds), polyclinics, and the feldsher village stations (see below).

Excluding the city of Kiev, the population of the Kiev oblast is 1 175 000 (including 350 000 children). The region is served by 7500 doctors and has 25 000 hospital beds; in addition, there are six independent children's hospitals and 20 to 40 pediatric beds in each district hospital.

Unlike the newly independent republics in Transcaucasia and central Asia, Ukraine and Belarus have been autonomous republics, as well as members of the United Nations, for 40 years. Thus, the emergence of nationhood has been relatively unencumberedparticularly the development of a legislature and constitutional infrastructure. Even so, these advantages are counterbalanced by the rigidity of the hierarchy.

Health CarePublic Health Infrastructure

The following description of the health care-public health infrastructure in Ukraine and other republics of the former Soviet Union is a composite based on observations made during the assessment. The basic features of the infrastructure appeared to be similar in each of the 10 republics visited. Republics varied little in per capita numbers of physicians, hospital beds, hospital admissions, and outpatient visits [3]. The following description may facilitate understanding of other findings from the field assessment.

Basic Organization

Basic public health services are organized under the Ministry of Health at four levels: republic, oblast, rayon, and feldsher stations and ambulatory clinics (local). Core public health services include coordination of the activities of public health organizational components; procurement of vaccines for the republic; the monitoring of water quality (does not include assurance of high quality); and the provision of central laboratory reference services for microbiologic, parasitic, and food and water analysis.

At the oblast level, basic public health functions include management oversight for implementation of immunization programs within the rayons; laboratory support (serving as a reference laboratory for the rayons); and the microbiologic testing of food and water. Many clinical and public health services are available at the rayon level. These services are delivered through polyclinics, pharmacies, the rayon hospital, and the bacteriology laboratory.

The feldsher station is the basic unit of primary care at the village level and generally is staffed by two persons: the feldshera person with paramedic-like skills who has had 2 years of training beyond secondary educationand a midwife. Services provided through feldsher stations include the diagnosis and treatment of infectious diseases and other basic medical problems; immunization activities performed in conjunction with polyclinics and school-based delivery efforts; basic gynecologic care and initiation of family planning services; and well-child care (for example, growth monitoring). The feldsher station also serves as a worksite for consultant specialist physicians from the rayon hospitals.

Sanitary and Epidemiologic Stations

Services provided by the sanitary and epidemiologic stations are also organized within the Ministry according to the basic four-tiered system. The stations have two principal functions: 1) to carry out basic public health surveillance activities such as monitoring the occurrence of infectious diseases and implementing basic measures to control or prevent specific diseases; and 2) to order vaccines for appropriate health care units.

Maternal and Child Health

Maternal and child health care is provided through a well-developed system for prenatal, postpartum, and pediatric services. These services are provided through maternity hospitals in the republic, as well as other units at all levels of the system.

Methods

On their arrival in each republic, members of the expert working group generally first met with the Minister, Deputy Minister, and other senior officials of the Ministry of Health, as well as key program managers. These meetings helped to clarify for the host officials the objectives of the assessment, provided the working group with an introduction to the health care and public health system, and facilitated organization of agendas for each subgroup. During all meetings and visits, interviews were conducted with the assistance of professional English-Russian interpreters who accompanied the working group, as well as by several members of the working group who were fluent in Russian.

In each republic, the hospital-health care subgroup conducted assessments in the following facilities: republican (that is, national) hospitals and referral centers; rayoni (that is, district) hospitals; specialty hospitals (for example, obstetrics, infectious diseases, and trauma and emergencies); local hospitals in both urban and rural areas; polyclinics (that is, multispecialty facilities); rural polyclinics; and feldsher stations. At each facility visited, the group systematically assessed several factors: available services, staffing, medications and supplies; administrative and financial resource considerations; the credentialing and continuing education of personnel; and status of the facilities (including equipment). In Ukraine, the subgroup visited 15 hospitals and other health care facilities (Table 1).

The strategy of the public health subgroup was to examine all levels of the public health system in each republic by interviewing senior decision makers, program managers, service providers, and consumers (that is, the end-users of public health services). When possible, these interviews were conducted at each organizational level within the republic (including national, oblast, rayon, local, and general public) and within all categories of facilities in which public health services are provided (for example, administrative offices, hospitals, polyclinics, primary care clinics, and feldsher stations). The systematic collection of information was ensured through the use of a standard data collection outline of categories (for example, infectious diseases, water and food safety and availability, maternal and child health, and health promotion and education). Information also was sought regarding environmental and occupational health, as well as other issues.

In Ukraine, information sources for the hospital-health care and public health subgroups included those at the central, middle, and basic delivery levels, as well as the Red Cross (see Table 1). In addition, we interviewed adults and children in village settings.

In the 10 CIS republics visited, the pharmaceutical subgroup assessed 16 production plants, 23 central distribution companies, and more than 45 pharmacy outlets and hospital pharmacies. The goals of the subgroup were to determine the short-term needs in pharmaceutical procurement, production, and distribution and the medium- to long-term needs in the pharmaceutical industry. The group clarified the systems of production, distribution, quality control, pricing, product planning, and drug policy, and it obtained information on drug supplies and policies relating to the distribution of humanitarian aid. At the conclusion of each meeting, the group provided information on the World Health Organization (WHO) essential drug list. At the production sites, the group evaluated the circumstances of production for conformity to the internationally recognized Good Manufacturing Practices.

Health Care in Ukraine

Policy

There was consensus among physicians in Ukraine that health care policy in the Republic must undergo fundamental changepossibly even privatization. At the same time, these physicians continued practices that had been standard in the former Soviet Union. The Chernobyl disaster imposed a substantial burden on this system because of the increased use of health care services.

Structure

The health system of the Soviet Union and therefore that of Ukraine was highly centralized; physicians managed all health care facilities. This enabled tight control but also uniformity of professional behavior, which resulted in some economies of scale and uniform planning. However, centralization resulted in a rigid bureaucracy, to which the Ukrainian physicians were reacting, and enhanced further the desire for change. The parallel systems of health care for the military and for the staff of large organizations (for example, factories, airlines, and railroads) detracted from the overall efficiency of the health-care system and led to inequitable access and allocation of resources.

Management

All health care facilities and services were managed by physicians, who used a formula approach that had limited flexibility. Sudden change afforded what one physician-manager characterized as more freedom, but less money. In addition to the excessive supervision of and the poor information resources available to for managers, training in financial management for physicians has been limited. Thus, despite the positive outlook related to new freedoms, there was great concern regarding physicians' ability to manageparticularly on a day-to-day basis. Virtually all physician-managers adhered to the principle of free access for all health care services and believed that their highly integrated system accomplished this aim; however, physicians were convinced that access might be impaired in the future.

Finance

Funding for specific health care facilities was determined using a formula related to the number of beds in a hospital and the number of visits in a polyclinic. Another factor in budget determination was the number of patients in a hospital at a given time, an incentive that compromised efficiency. There was no evidence that cost accounting principles were being used, thereby precluding cost/benefit comparisons of different processes and procedures, a factor of great concern for physician-managers.

Staff

The number of staff appeared to be adequate at most levels in the health services. In the context of overall employment policies, the efficiency and cost of health services would benefit from a thorough review of staffing needs as they relate to service provision.

Education and training in health professions in the NIS did not appear to equal that of other countries. The creation of professional associations that establish and monitor training courses and standards of practice is required where these do not already exist. Exchanges with similar institutions in other countries should be encouraged, and other measures (for example, engaging in personal exchanges, providing current literature, and assisting in language training) should be used to overcome the isolation of professional staff.

Public Health in Ukraine

Infectious Diseases

The system for collecting infectious diseases surveillance reports appeared to be intact. Reports at all levels underscored concern about recent increases in the occurrence of diphtheria (approximately 1100 cases in 1991); the incidence of diphtheria appeared to have increased substantially since about 1986 as a result of a planned modification of and decrease in vaccine potency as well as a greater reluctance on the part of parents to have their children vaccinated because of perceived side effects.

Bacille CalmetteGurin (BCG) vaccine was in short supply (an estimated 1.5 million doses were needed), and measles and DTP (diphtheria-pertussis-tetanus) vaccine supplies were inadequate. Spot checks of stocks in refrigerators indicated that the storage and the management of some vaccines were not in complete conformance with WHO standards. However, supplies of antibiotics were reported to be adequate.

Water and Food Safety and Availability

Republic-wide, only 15% to 20% of water was being obtained from artesian wells, and the primary concern regarding water supplies was the pollution of surface water. Although there had been no recent reports of bacteriologic contamination of drinking water in urban areas, public health officials requested equipment for and training related to water purification and monitoring.

Since August 1991, food costs had increased approximately 300% to 500%. Although food supplies seemed to be adequateparticularly in rural areas and in certain institutional settings (for example, schools and certain work environments)access to food had been complicated because of the conversion of rubles to Ukrainian currency. Consistent shortages had been reported for some dairy products, and sugar was being rationed.

Maternal and Child Health

From 1985 through 1991, the infant mortality rate declined slightly (15 deaths per 1000 live births to 13.6 deaths per 1000 live births, respectively [3]), although WHO criteria had not been used to measure either these rates or those for premature births. Abortion was the most common form of birth control, and abortion rates reportedly approximated birth rates.

Most births occurred in hospitals, regardless of the mother's risk status. However, breastfeeding at the time of discharge varied substantially by oblast (from 27% to 80%). At the same time, infant formula was reportedly not available. Despite such problems, programs for pre- and postnatal health promotion for mothers and children were intact and appeared to provide broad coverage.

Vulnerable Groups

Groups considered to be most vulnerable with regard to health included elderly persons (>60 years old), large families, single parents, persons who lived alone, orphans, disabled veterans, displaced persons (for example, Chernobyl evacuees), and street children. Of the 13 million pensioners (approximately 25% of the total population), an estimated 2 million lived alone; although one fourth of these persons required daily social or medical assistance, only 150 000 received such care.

The Special Problem of Chernobyl

The health effects of the Chernobyl disaster in April 1986 were still evident 6 years after the mishap. Ramifications of this disaster were global [5], but obviously the primary effect was in the immediate geographic area. The disaster affected 19 of the 27 oblasts in Ukraine, as well as parts of neighboring Belarus. Since 1986, approximately 90 000 persons had been evacuated from a zone with a radius of 30 km from the reactor, and an additional 40 000 persons had moved from adjacent areas. Overall, an estimated 1.1 million persons, including 350 000 children, were affected in some way by the disaster [6].

The most severely affected persons were sent to Moscow for bone marrow transplantation and other treatment [7]; however, fears about radiation have persisted [6]. Cases of thyroid cancer have been reported recently [8], and routine monitoring of thyroid function continues.

Discussion

Our findings were consistent with and substantially expand the information base provided in previous reports about the former Soviet Union and other Eastern European countries (for example, the Czech Republic [9]). For example, health care services in the Soviet Union, particularly those relating to public health and to the development and use of technology, had reportedly lagged behind those in the West [11]. However, the patterns of diseases and other problems we found in Ukraine and in other republics of the NIS closely approximate those found in Western countries [12]. Thus, there are the twin problems of public health and chronic illness, coupled with significant shortages of basic medicines and supplies. In Ukraine, these problems are further compounded by the effect of the Chernobyl disaster, as well as the disruption of supply networks after independence. Despite these problems, we found, throughout our visit, a spirit of optimism and a pervasive belief by health professionals in Ukraine and elsewhere that their problems were temporary.

After completion of the mission, a meeting of the Medical Working Group was held in Geneva, Switzerland, 30 April to 1 May 1992, and the results of this meeting were presented at the follow-up Coordinating Conference on Assistance to the New Independent States in Lisbon 23-24 May 1992. Subsequently, the United States and other countries developed individual programs for assistance. In July 1992, a team from the United States visited Ukraine to consider hospital partnerships in several locations. Findings of the assessment were confirmed during a meeting of the working group in Tokyo in October 1992. Subsequently, partnerships with U.S. hospitals have been established in Kiev (with the University of Pennsylvania, Children's Hospital of Philadelphia, and Pennsylvania Hospital) and Odessa (with Coney Island Hospital [Brooklyn] and the New York City Health and Hospital Corporation).

Although the medical and health problems facing the Ukrainian Republic and the other republics of the NIS are indeed daunting, these countries have highly organized health care systems that can provide health care access to the entire population. Assistance by others in the form of provision of short-term needs, as well as the longer-term development of professional relationships, should benefit both health care and public health. Ultimately, these benefits should enhance political and economic stability in Ukraine and other CIS republics.

Appendix

Members of the Hospital-Health Care Subgroup included H. Beerstecher, MD, PhD (Netherlands [NATO]); R. Farmer, MD (United States); M. Harlow (United Kingdom); M. Kekomaki, MD (Finland); K. Okuyama, MD (Japan); J. Kilhamn, MD (Sweden); J. Tcheriatchoukine, MD (France); and T. Tezic, MD (Turkey).

Members of the Public Health Subgroup included C. Callow, MD (NATO); R. Baldwin (United States); P. Walker, PhD (International Federation of the Red Cross-Red Crescent); C. Bostvironnois, PhD (France); R. Doan, MD (Project Hope); S. Kessler, MD (UNICEF); J. Sherry, MD (UNICEF); R. Goodman, MD (United States); A. Kendal, PhD (WHO, European Regional Office); and D. MacFadyen, MD (WHO, European Regional Office).