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Soviet Union [USSR] 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 Soviet Union USSR - 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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