Evgenii Chazov, Unhealthy Health Service. April 1987
Announcer: Top officials of the USSR Ministry of Health recently held a press conference at the Academy of Medical Sciences for journalists from the central press, television and radio. The discussion was about ways of restructuring Soviet health care, a problem which directly concerns and interests every one of us. In his address, Academician Evgenii Ivanovich Chazov, USSR Minister of Health, said in part:
Chazov: The residual principle of planning, condemned by the 27th Party Congress, had a negative effect on the development of our society in general and also damaged the Soviet health services. Another thing that should be stressed is that all our planning work was guided by principles of extensive development and the value of quantitative indicators, which led to serious negative results. I have already said before and there’s probably no need to remind this audience–that we were trying to procure a large number of hospital beds, but in any case our hospital beds are not up to modern requirements, as you know. The average space for each bed in our hospitals for example, is, 4-2 square meters in contrast to the public health norm of seven square meters. Moreover, as I pointed out at the collegium, our hospital beds are not suitable for industrial production, and expenditure on medical production engineering amounts to only 15 per cent, while in the other socialist countries this figure is as high as 40 per cent.
Quantitative indicators have also done damage to primary levels of health care, particularly service at outpatients’ clinics. Why do outpatients’ clinics operate badly? Apparently because, like GPs, they are dominated by quantitative indicators. After all, how are our outpatients’ clinics financed? They are financed according to the number of people treated. Logically, the more patients there are, the more people are treated, the more money the outpatients’ clinic gets. If in the future we are going to assess a doctor’s work according to figures, one of the figures would be the number of people he treats. Naturally, under conditions where there were no qualitative indicators of a doctor’s work, it was simply impossible to get an outpatients’ clinic to function properly.
That is one example. Then there is the health-care management system, of course. The quotas for everything were set, as it were, in Moscow. The number of nurses and medical technicians, not to mention the various specialist doctors, were all laid down by the planning and finance department, perhaps with the participation of the Semashko Institute, which we have greatly criticized for its poor work. Naturally, it was simply impossible to create a good health-care service within such a cumbersome and sluggish system of management. There was no independence, not only for the head doctor of an outpatients’ clinic or a hospital, but even for the minister of a republic.
The second important part of our work involves personnel. Unfortunately the system of cadre training that has evolved in recent years, or in the past decade, let us say, has led to a reduction in the level of knowledge of the Soviet doctor, in particular his practical skills. So the training of personnel is the second important problem.
Hospitals Without Running Water
The third question involves the material and technical foundations. I have already spoken about hospitals. In their efforts to come up with enough hospital beds, I shall speak frankly and say that some people went in for a certain amount of figure inflation. Included in the calculation of numbers of hospital beds were beds sited in residential buildings and even those in wooden huts and hostels. All this was included in the total number of hospital beds. In Central Asia, many hospitals in our country today do not have sewerage systems or running water, let alone a hot water supply. Rural health services are in a bad way, too. Only 21 per cent of the outpatients’ clinics and doctor’s surgeries in rural areas, for example, are in purpose-built buildings.
There is also the matter of equipment. Unfortunately the equipment produced by Soviet industry–the medical industry and industries producing goods for the health service–has not been up to requirements. For example, when a surgeon operates, he has to sharpen his scalpel after only two operations because it would be good for only two operations; for the third the blade would need sharpening. I am not speaking of sophisticated equipment like computer tomographs, angiographic equipment and so on. But do you know what the new Minister of Health had to busy himself with when he first took up his post? He had to procure teats for babies’ bottles. That problem had to be solved by the Ministry of Health, because of the 250 million teats required only 130 million had been supplied. There was a shortage of the simplest things in our country. And incidentally, no one spoke up about it. Not one single newspaper found out and printed the fact that the demand for medicines in our country is satisfied only 85 per cent. This means that 15 per cent of our sick people have no medicines. What talk of health care can there be when the demand for certain cardiovascular preparations and antibiotics was satisfied to only 40-60 per cent of the requirements? These are vital preparations on which lives depend. So the third part of our work concerns material and technical supplies.
Fourth, and finally, comes science. I find it embarrassing to speak about the problems of science within the walls of this Academy, where we are meeting, but I must tell you that today to a large degree it does not correspond to modern standards. To put it frankly, out of the–I think–333 institutes in the healthcare system, perhaps 50 or 60 are actively providing practical results for the medical services. Another 100 perhaps are working on the solution of practical, but run-of-the-mill problems. But 80100 or so could be closed down today with absolutely no problem, and neither the health-care services nor the population would be hurt by the fact that they had been shut down .
“Very Grave State”
What I have spoken about, of course, are the shortcomings. What, though, do we intend to do? What I must say–and probably there are people from the Moscow newspapers here–is that the Moscow health service is in a very grave state, a very grave state. It is, perhaps, one of the most backward health-care systems in our country today, or, let us say, it is at a substandard level. I won’t just say that without giving any proof. For example, of the 33 maternity homes in Moscow city, only 12 are up to modern requirements and public health standards. Although we have specialists in virology and infectious diseases sitting here who are at work on this problem, I must say that over the past 10 years in Moscow not one extra hospital bed for infectious diseases, for example, has been provided, and meanwhile one major hospital has been closed down. Many other examples of shortcomings could also be cited concerning dentistry and other medical services in Moscow city.
So what do we plan to do? You are probably saying that this is all very well and good, but what are the reasons for these shortcomings? Well, I would say that it would be a good idea to remember what Mikhail Sergeevich said at the January plenum of the Central Committee. “You know,” he said, “in the past decade we have been deaf to the needs of the social sphere.” I think that the fault here lies with the USSR Ministry of Health, which was not very active in raising issues: there was no headquarters, no health-care headquarters, to define the organization, the policy or the management. The fault, of course, lies with the State Planning Committee, the Finance Ministry and other departments and organizations which did not respond at the proper time and failed to notice the needs of the health service …
Then there is management. We regard qualitative indicators as of paramount importance. What do we mean by qualitative indicators? The mortality index, the infant mortality index, the sickness rate, the temporary inability to work index, the complex illness index, the number of severe cases in the regions, severe cases of illness, the number of complaints received from the population. These qualitative indicators will determine the work of our medical establishments. We are going to try to create conditions for the public to have a free choice of a doctor. At first, of course, this is going to be done on an experimental footing, but we believe that this is something we must strive for. Incidentally, in some socialist countries, indeed, in many of them, this principle already exists. And naturally a doctor who gets extra new patients should receive more pay.
We consider it essential to reinforce pre-hospital medical care. It is wrong for a patient to have to go to hospital for a diagnosis to be established. Quite frankly, it is uneconomic. Another thing we have forgotten in health care is economics. Somehow or other we have not been counting the money …
And, of course, we must have renovation. For example, we are raising the issue of trying, during the current Five-Year Plan period, to ensure that there are no hospitals in our country which do not have running water and sewerage systems. How, you may ask. Well, for example, a program is now being projected in conjunction with the Ministry of Geology to provide water supplies for all the country’s hospital establishments in various regions. We believe that up to about the year 2000 we are going to have to reconstruct old hospitals to provide one million and 1.5 million beds ….
Transfusion by Anesthetist
There are many problems concerning education. We are now considering not awarding doctors’ diplomas to all those who complete their studies, but of giving paramedical assistants’ diplomas to those who do badly and who are incapable of mastering the practical skills. The prestige of the doctor is of course an important
area of work. We have bad doctors and good doctors, bad polyclinics and good polyclinics. We have bad hospitals and good hospitals. I have given many examples. But a doctor’s work isn’t easy either; as no doubt you know, it is difficult work. All the same, I’ve been going on and on the whole time about operating theatres, hospitals and so on. I will never forget that recently there was a case where an essential operation was being carried out, a serious and complicated one, on the aorta, when fibrinolysis started, the blood ceased to clot, and the patient was bleeding to death. A direct transfusion was urgently needed. He had to be given blood. There was no time to run off and find a donor. There were about eight people in the operating theatre, so they asked–there was nothing else to do–who has No. 3 or No. 4, or whatever it was, blood group? All doctors know their own blood group. The anesthetist, in the process of giving the anesthetic, said: “That’s my blood group.” And as he stood beside his anesthetic equipment–at that very moment they brought the transfusion system up to him. He held out his arm and his blood was transfused to the patient, while with the other hand he controlled the anesthetic. These are not isolated examples. This is a fact of our life, you understand, a fact of our life.
Source: George R. Urban, ed., Social and Economic Rights in the Soviet bloc: a documentary review seventy years after the Bolshevik Revolution (New Brunswick: Transaction, 1988), pp. 166-169.