Corrosive Reforms: Failing Health Systems in Eastern Europe and the Former Soviet Union
Rosskam's research focused on changing economic and social insecurities of health care workers in the decade after the fall of the Soviet Union. Some key findings of her study included the low level of state and local investment in the health care system, and the accompanying fall in healthcare workers' wages. In many cases, workers were paid either at or below subsistence levels, if they were paid regularly at all. In Moldova, Rosskam found wage arrears to last 5 months, and indeed, one-third of Moldovans went into debt just to pay their health care costs.
Between 1990 and 2000, many health care workers in the successor states were told not to come to work because there was no money to pay them. Many workers reported that they went to work in health care settings when they themselves were ill because missing even one day of 'under the table' direct payments they received from patients meant being unable to provide basic necessities to their families.
Rosskam emphasized that taking under-the-table payments directly from patients is a serious factor of the "endemic corruption" that has plagued the health sector in countries across the region since 1990. These direct payments have made healthcare workers' incomes unreliable and unpredictable. The practice has also created a large income gap amongst healthcare workers because there are tens of hundreds of health care personnel who don't have the "front-line" contact with patients that doctors do. These hospital administrators, janitorial staff, lab technicians, and others simply don't have the opportunity to receive extra payments. However, Rosskam reported that results from a 2.5 year project in Moldova which ended in 2009 revealed that the corruption level varied among different public health facilities, with the key variable being the "moral leadership" of senior management.
With the fall of the Soviet Union, which had supported a nation-wide health care system, funding and centralization of health care disappeared. In many cases the responsibility to maintain health care infrastructure went to local authorities but lacked the funds necessary to them to perform their job. Lack of investment in the sector across the region resulted in the complete closure of countless Soviet-funded clinics in the countrysides and most underserved areas of many countries.
An under-provision of services after 1990 led to a rapid increase in tuberculosis (TB), HIV/AIDS, and STIs. Indeed, Russia has been host to the fastest growing HIV/AIDS epidemic in Europe since 1990. Meanwhile, the rate of TB in Romania in 2000 was equal to that of sub-Saharan Africa. Rosskam noted that such infectious diseases, coupled with a lack of infrastructure to deal with epidemics should be given serious international attention. The health sectors in many countries across the region would have difficulty or be unable to contain outbreaks of diseases considered to be global health threats, whether they occurred naturally or were released as biological warfare by outside groups.
Improvements since 1999 have occurred mainly in countries that have acceded to the EU or where international development aid has stepped in. Rosskam focused specifically on three countries: Moldova, Kyrgyzstan, and Mongolia. Working on a project funded by the Millennium Challenge Corporation, Rosskam participated in the effort to reform the health sector in Moldova through an anti-corruption approach with impressive results. Prior to 1999, there was no state funding or administrative capacity for a health system, family doctors were inadequately trained, and corruption varied from small under-the-table payments to significant misallocation of resources. As a result of western funding and technical assistance, Rosskam added, improvements have been made in the distribution and access of services, the creation of a full set of clinical protocols, and improvements made in the medical school curriculum.
In Kyrgyzstan, which also received international assistance, Rosskam reported that the government has built a nationwide health insurance system introduced clinical protocols, and has trained a large number of personnel in primary health care services, resulting in demonstrable improvements in health outcomes. Similarly, from 2009-2014, a U.S. government funded project in Mongolia is working with the government of Mongolia and other partners in the country to reduce deaths from non-communicable diseases (e.g. cardiovascular disease, diabetes, etc) and traffic accidents, which are the leading causes of death for Mongolians. Rosskam emphasized that the progress made in all three countries was dependent on strong leadership and commitment from the top-most level of the country's government. Foreign assistance was also crucial in terms of providing money and technical expertise, but without government collaboration and strong government commitment, very little would be implemented.
While the work of governments and aid agencies has contributed to exemplary achievements in some countries, Rosskam emphasized that we should not forget the health care workers themselves, many of whom throughout the 1990s and still today have become "completely demoralized" in their line of work. Nevertheless, they have remained dedicated to providing their patients with whatever level of health care their environment permits, and perhaps this is the most heartening development of all.
By Larissa Eltsefon
Blair Ruble, Director, Kennan Institute
Ellen Rosskam // Southeast Europe Policy ScholarVisiting Professor in the Work Environment Department of the University of Massachusetts in Lowell and Visiting Senior Fellow in the European Institute of Health and Medical Sciences at the University of Surrey, England