Ghostly pale, cancer patient Zinaida Smirnova huddles under a blanket at Moscow's Hematology Research Institute hospital. "It's very hard for us," she says, in the drab green room she shares with four others. The bedside call button doesn't work, and even if it did, nurses are scarce. Her family brings food, medicine, and fresh bedding. Several times a day, Smirnova hobbles down the hall to a toilet shared by 60 patients. Still, she feels lucky because a doctor gives her the chemotherapy she hopes will cure her.
Smirnova is a casualty of the collapse of one of the world's most complex health-care systems. As Boris N. Yeltsin's quintuple-bypass operation last year demonstrated, Russian medicine can still deliver first-class care. But ordinary Russians rarely get it. Most hospitals offer little more than beds. Patients supply everything from plasma to vodka for disinfecting wounds.
Health care in the Soviet Union was never up to Western standards. But the cash-strapped Russian government has slashed spending, leaving hospitals scrambling to survive. Inefficiencies compound the problem. So thousands of Russians die every year from lack of treatment that is routine elsewhere. Only about 2% of people who need heart bypasses, for instance, get them.
The crisis goes back to 1993, when the Kremlin dismantled the centralized Soviet-era health-care system and dumped responsibility for most hospitals onto regional governments. As part of the plan, employers were taxed 3.6% of their workers' wages, with the money going to regional medical cooperatives. Regional governments were expected to kick in enough to pay for health care for the nonworking population. If the program sounds like the Clinton Administration's failed 1993 health reform plan, it should: The Russian system is based on a model developed by Alan Enthoven, a Stanford University health-care economist who advised Clinton.
The Russian plan ran into trouble from the start. The tax is only a third of what's needed, and, at that, payment is spotty because some employers either don't pay workers or pay them in goods. Many Russians moonlight, with no record of their income. Meanwhile, local governments haven't come up with their shares. "In six months, we have gotten hardly a single kopeck," says Andrei Lishansky, deputy chief physician at Moscow's City Hospital No.1, a sprawling 1,600-bed complex.
Overcapacity and inefficiency eat up what little money comes in. Russia has twice as many hospital beds per capita as the U.S., and the Health Ministry estimates that half of all patients hospitalized could be treated in outpatient clinics. Once hospitalized, patients stay too long. "You don't really need to have patients spend two weeks in the hospital after a gallbladder operation," says Igor Denisov, a former Health Minister, who helped design the 1993 reform plan. With virtually no general practitioners in Russia, specialists treat even minor ailments. The sickest patients are supposed to go to specialty hospitals in Moscow, such as the one that treated Yeltsin, but there's no money for patient transportation. Many facilities sit half-empty but fully staffed, because layoffs are political dynamite.
REVOLVING CREDIT. Some hospitals are finding creative solutions. They have set up private floors, ambulance services, and specialty departments, such as cosmetic surgery for foreigners and wealthy Russians. Scientists at one Moscow research hospital sell medications they have developed to fund their department. In the provinces, doctors barter. Instead of paying employees, some Siberian clinics and hospitals give them credit cards good at local businesses. Shopkeepers get credit toward their workers' health care.
Patients, too, find ways around the system by paying bribes. Doctors' salaries average just $95 a month, and nurses' less than half that, so many take second jobs and show up at the hospital sporadically. In an orthopedic surgery ward at Moscow City Hospital No.4, patients rave about their free care--then tell a prospective patient to give a $100 "gift" to the doctor. Lena Goncharova, a Moscow secretary, lay in her hospital room for days after an appendectomy and never saw a nurse. She even helped care for others. So when her grandmother was hospitalized, Goncharova bribed nurses to care for her.
SNOWBOUND. The federal specialty hospitals fare worst of all. Their chief source of funds is the Health Ministry, which got only 38% of its expected 1996 budget of $836 million. The Hematology Research Institute hospital hasn't received money for supplies and maintenance in almost a year and owes more than $1 million to creditors. One wing is closed for fear that winter snows will collapse the roof. "This is one of the best clinical institutes in the country," fumes director Andrei Vorobiev. "What's happening is a national tragedy."
As bad as Russia's medical system is today, some say it's no worse now than under communism. While Soviet medicine promised free cradle-to-grave care, only the privileged received top-quality treatment. Soviet-made antibiotics were so weak, patients had to receive injections every few hours. Benjamin Munblit, a Moscow health-care consultant, says that when his mother fell ill in the 1980s, he was "ready to pay any money for the medicines she needed." But they weren't available at any price. Now, Western drugs are easy to obtain--at prices many patients can't pay.
But the health-care system on occasion performs miracles. When a boy playing with an ax cut off the thumb of her 11-year-old daughter, Moscow psychologist Masha Kapitsa rushed her to a hospital. The thumb was reattached in a six-hour operation. A year later, it's growing normally. By chance, the doctor on duty was "the best microsurgeon in Russia," says Kapitsa.
The best hope for Russian medical care may come from the West. Reformers in the Kemerovo region of Siberia have developed a plan that rewards doctors for holding down costs--just like in a health maintenance organization. They have cut the rate of hospitalization in half, with the savings going to expand outpatient clinics and establish intensive-care units. And the Moscow Medical Academy now trains hospital administrators in management, finance, and marketing. But such initiatives won't change health care soon. For patients such as Zinaida Smirnova, the road to recovery remains painfully long.