Reflections on a painful transition: from socialized to insurance medicine in Russia.

After the collapse of the Soviet Union in 1991, Russia decided to replace its deeply flawed and under-funded system of socialized medicine by a scheme of health insurance that involved the decentralization of health services and of off-budget financing. Every enterprise would pay 3.6% of its salary fund into a Regional Health Insurance Fund, and the Fund would finance private insurance companies that would compete for clients. The non-working population would have its insurance premiums paid from the budgets of regions or municipalities. The transition from one system to another has been problematic and plagued with a variety of problems not the least of which is that the Russian economic structure is not geared to sustain an insurance system at the present time. The Russian case presents an instructive experiment with the premature introduction of a scheme touted as an "anti-model" to socialized medicine and geared to market and legal arrangements that are, as yet, largely non-existent. Under-funding of health services remains and leads to the polarization of the population into those few who can afford private care, and the vast majority for whom this care is difficult to obtain, or unobtainable. This has ominous political implications.

From assurance to insurance in Russian health care: the problematic transition.

OBJECTIVES: Given the declining health status of the Russian population and the negative social impact of ongoing economic reforms, it is important to understand the nature and scope of Russia's innovations in health care financing. METHODS: Data on Russian health care and its financing were gathered from Russian newspapers and journals. US government agency reports, recent press accounts, and the authors' observations and interviews in Russia. RESULTS: The 1991 statutory basis for the Russian mandatory medical insurance system replaced the traditional, state-funded medical care system with a regional system principally reliant on an enterprise-based with-holding tax plus supplementation by local government and, to a minor extent, federal funds. The regional agent for distribution and management of these funds is a series of Territorial Health Insurance Funds. Implementation thus far has been highly uneven among territories. CONCLUSIONS: An insurance model patterned after the Western example may not be the optimal solution to Russia's current health financing problems. Given the chaotic nature of political and economic reform, Russia may simply not be ready for market-based medical insurance.

The current state of health care in the former Soviet Union: implications for health care policy and reform.

OBJECTIVES: Given the many profound health care problems facing Russia and the other former Soviet republics, there are a number of fundamental policy questions that deserve close attention as part of the reform process. METHODS: Summary data regarding Soviet health care issues were drawn from government agency reports, scholarly books and journals, recent press reports, and the authors' personal research. RESULTS: Smoking, alcohol, accidents, poor sanitation, inadequate nutrition, and extensive environmental pollution contribute to illness and premature mortality in Russia and the other newly independent states. Hospitals and clinics are poorly maintained and equipped; most physicians are poorly trained and inadequately paid; and there is essentially no system of quality management. While efforts at reform, which emphasize shifting to a system of "insurance medicine," have been largely unsuccessful, they have raised several important policy issues that warrant extensive research and discussion. CONCLUSIONS: Without considering the implications and consequences of alternative policy directions, Russia and the other states face the very real possibility of developing health care systems that improve the overall level of care but also incorporate limited access and escalating costs. Russian health care reform leaders can learn from the health care successes in the West and avoid repeating our mistakes.

Management of late-life psychosis.

Since the average lifespan is becoming longer, the number of older patients with psychoses is expected to increase. Late-life schizophrenia is prototypical of these chronic psychotic disorders. Antipsychotic drugs are the most effective symptomatic treatment. Pharmacotherapy in older patients, however, is complicated by alterations in pharmacokinetics and pharmacodynamics. The risk of many adverse effects is considerably higher in the elderly. For example, we found the cumulative annual incidence of tardive dyskinesia among patients over age 45 to be 26%, which was five to six times greater than that reported in younger patients. Studies suggest that most patients with schizophrenia relapse without neuroleptic maintenance therapy, exemplifying the need for improved pharmacologic regimens. Data concerning the use of the newer serotonin-dopamine antagonists in patients with late-life psychoses are limited. Initial studies suggested that clozapine is efficacious, but its use is limited by side effects. Risperidone is also clinically beneficial and is generally well tolerated, but needs to be prescribed in lower doses than those recommended for younger adults. Antipsychotic use in the elderly should be accompanied by careful conservative dosing and close patient monitoring.

The health crisis in the former Soviet Union: a report from the 'post-war' zone.

Observers of the Soviet health and demographic scene have noted that many of the phenomena (particularly mortality) were unprecedented in 'peace time.' In fact, the Cold War (or Third World War) was 'war time,' although not in the conventional military sense (it was ideological, political and economic warfare). The health crisis in the former Soviet Union is partly the result of that lost conflict by the Soviet side due to its inability to match the West in defense outlays and to provide for the needs of the civilian sector. Health conditions began to deteriorate in the late sixties, and were exacerbated by the collapse of the Soviet Empire in late 1991. These were reflected in increasing mortality and morbidity, decreasing natality, a deteriorating health service, and an environment ruined by the heedless drive toward industrialization and militarization. This resulted in a 'systemic' breakdown of the Soviet system, not only its health care structure. The situation of the former Soviet Union is that of a country that has suffered a humiliating national defeat with all the consequences of a 'post-war' situation, including inflation, anomie and social polarization. The health crisis is likely to get worse, and will not be resolved until a viable political, economic and social order is established. Today's deteriorating health and demographic situation will create 'echo' problems in the decade to come.

Alcohol consumption in France: production, consumption, morbidity and mortality, prevention and education in the last three decades.

This paper examines trends in the French consumption of alcohol over the last three decades, and includes data on the production of alcoholic beverages, the consumption of different types of alcoholic and non-alcoholic beverages, morbidity and mortality related to the consumption of alcohol, and a brief description of French preventive and educational measures in this area. In the last 15 years, the average alcohol consumption has ceased growing and even began to decrease. Data are given comparing consumption trends in several European countries, as well as more detailed data of alcohol consumption and related phenomena in France by region, by sex, by age and by socio-economic status (the last two categories for men only). Finally, a schema of the social dynamics of alcohol consumption is presented.

The position of the Soviet physician: the bureaucratic professional.

The social position of the Soviet physician is a paradoxical combination of corporate powerlessness and bureaucratic power. As employees of the state, physicians are subject to its discipline and directives; they lack the control over their own work that is essential to a profession. In contrast to Western physicians, however, individual clinicians exercise enormous power over patients and subordinates by virtue of their position in the bureaucracy. The Soviet case suggests that as medical care in the West becomes increasingly bureaucratized and the profession loses autonomy, individual physicians may gain rather than lose authority in clinical decision making.

Reflections on medical technology as a special type of capital. Some implications for the hospital.

The classical equation for the production of goods and services, that is, the combination of labor, capital, and knowledge, constrained by the time dimension, may also be used to examine the production of medical and hospital services. However, this is qualified by the special nature of the "capital" used in health care, particularly medical technology. Because of the particular nature of health services, the adoption and the use of technology follows rules that are different from those in the industrial sphere. These differences are examined in some detail as are the implications for the health field in general, and for the hospitals where most of the new (and often costly) technology is located.

American and Soviet medical manpower: growth and evolution, 1910-1970.

Between 1910 and 1970 the number of physicians in the United States increased 2.5 times, in Soviet Russia almost 25 times. The number of physicians per constant unit of population remained fairly stable in the United States, rising slightly in the last few years. In the U.S.S.R. that number increased 16 to 18 times, and now stands about 50 per cent higher than in the United States. About 10 per cent of American physicians are women; in the U.S.S.R. it is about 70 per cent. Neither society has resolved the problem of deploying physicians to the rural areas. American physicians are more specialized than their Soviet colleagues. The article concludes with general remarks about the two health systems, pointing out resemblances and divergences. The hypothesis of a possible "convergence" is entertained.