Selected Papers l No. 42

HealthServicesin theUSSR

By ODIN W. ANDERSON

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:,’ 4’ I.

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GRADUATE SCHOOL OF BUSINESS

UNIVERSITY OF CHICAGO

ODIN W. ANDERSON is Professor of Sociolology inthe Graduate School of Business and Departmentof Sociology of The University of Chicago, andDirector of the University’s Center for Health Ad-ministration Studies (CHAS). Professor Andersonreceived B.A. and M.A. degrees in Sociology at theUniversity of Wisconsin, and a B.A. in Library Sci-ence and a Ph.D. in Sociology at the University of i’

Michigan. At Michigan, he helped establish theBureau of Public Health Economics of the School 1of Public Health. In 1949, he berame the first full- , .

time sociologist on a medical school faculty, joining6 .

the faculty of medicine at the University of WesternOntario where he was also in charge of the Social ;Aspects of Medicine in the Department of ClinicalPreventive Medicine. In 1952 he became Research irDirector of the Health Information Foundation, 1.

then in New York City; in 1962 the Foundationcame to The University of Chicago Graduate School ;

of Business, ultimately to become part of CHAS.While in New York, Professor Anderson was as-sociated with the faculties of the New York Uni-versity Graduate School (Sociology) and the Co-lumbia University School of Public Health andAdministrative Medicine. He is the author of land- Imark studies in the health care field. Amongworks of which he is author or coauthor are: ADecade of Health Services (University of Chicago t

Press, 1967), Hospital Use-A Survey of Patientand Physician Decisions (CHAS, 1967), The Un-easy Equilibrium: Private and Public Financingof Health Services in the United States, 1875-1965(College and University Press, 1968), Toward anUnambiguous Profession: A Review of Nursing(CHAS, 1968), and Health Services in a Land ofPlenty (CHAS 1968). His most recent work, HealthCare: Can There Be Equity? comparing the Ameri-can, Swedish, and British health systems, was pub-lished by John Wiley and Sons, Inc., in late 1972.Professor Anderson is an Honorary Fellow of theAmerican College of Hospital Administrators, andin 1951, was a World Health Organization Fellowin Preventive Medicine to Great Britain, Norway,Denmark, and Sweden. In addition, he is a Fellowof the American Sociological Association, the Ameri-ran Public Health Association, and other profes-sional organizations.

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Health Servicesin the USSR

DURING the month of September, 1972, I wason an officially-sponsored trip to the SovietUnion, arranged under terms of the 1958 ex-change agreement between the USSR and theUSA. My companion on this trip was Dr.Robert Daniels, formerly of The University ofChicago and now at the University of Cincin-nati.

The timing of the trip coincided fortuitous-ly with the health exchange agreement which,among others, resulted from President Nixon’svisit to the USSR in March, 1972. This par-ticular agreement designated three researchareas for collaboration between the two coun-tries: heart disease, cancer, and environment.Dr. Daniels and I were told by Washingtonofficials that we were regarded as the first waveof visitors after this new agreement who wereinterested in health services delivery systems.My particular interest was, and is, in long-term trend data on the health services indi-cators paralleling the data in my book onthree-country comparisons.1

Both the USSR Ministry of Health and theAmerican Embassy in Moscow were informedof our flight and arrival time, and from themoment of our arrival at the internationalairport in Moscow, at 6:00 p.m. on Sunday,September 3, we were the guests of the Minis-try.

On Monday, September 4, we met at theHealth Ministry with Dr. Andre Kishelev, thecoordinator for official American visitors. On

1 Odin W. Anderson, Health Care: Can There BeEquity? The United States, Sweden, and England (NewYork: John Wiley and Sons, Inc., 1972).

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the basis of what and whom we wanted to see,we arranged to spend three weeks in Moscowand one in Leningrad.

We were primarily interested in the over-allhealth services structure and operation. Thisnecessitated obtaining a great deal of dataas to personnel, facilities, use of services, andfinancing-preferably long-term trends.

The arrangements were carried out by theMinistry, through Dr. Kishelev, in an exem-plary fashion. We had conferences with allthe people we wanted to see, and visited hos-pitals and polyclinics of the types which inter-ested us. Our hosts were open, friendly, andgracious. We visited adult, pediatric, and ma-ternity hospitals, a psychiatric hospital, andthe Moscow medical emergency service. Some-what parallel visits were made to facilities inLeningrad and arranged by the LeningradDepartment of Health.

From my own standpoint, the most impor-tant visits were those made to the SemashkoInstitute, the enormous research arm of theMinistry of Health, which deals with researchin the organizational aspects of the USSRhealth system, and which has immense dataresources relating to the structure and oper-ation of the USSR health system and researchin progress.

We were given a great deal of oral infor-mation, whatever literature there was in En-glish, some French publications, copies of theequivalent of the U.S. Statistical Abstract inRussian, and a set of forms used to gatherdata from the local, up to national levels andprocessed by a division of the Semashko In-stitute.

THE PHILOSOPHY, structure, and operation ofthe health services in the USSR can be under-stood as they are related to the social, eco-nomic, and medical development at the timeof the revolution in 1917 and subsequent

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plans to reconstruct the country. At the timeof the revolution and into the 1920’s, circum-stances in the USSR differed considerablyfrom those of the developed countries in Eu-rope and North America, and these circum-stances shaped a USSR health service systemquite different organizationally and philo-sophically from those of the West.

In 1917, the USSR could be regarded as anundeveloped country relative to the West.Although there were the beginning of an in-dustrial infra-structure and occasionally bril-liant medical scientists, both the industrialbase and the health services base were grosslyundeveloped. The economy was still largelyagricultural; illiteracy was high.

The disease picture was like that of Europein the early 1800’s, if not earlier-typhus,cholera, typhoid, smallpox, malaria, and dis-eases from malnutrition. Infant mortality wasreported to be at about the 275 mark (per 1,000births) when it was about 100 in Europe andNorth America; the average length of life wasabout 38 years when it was about 60 in Europeand North America. And, although there wasa cadre of physicians, auxiliary personnel, andhospitals, these were hardly equal to the enor-mous tasks facing the country. It can be as-sumed that such personnel and facilities asthere were, served mainly the small segmentof the upper classes and urban areas.2

SUCH WAS the situation facing the new govern-ment when the Civil War ended in 1921 andthe Bolsheviks under Lenin assumed full con-trol over the economy and society accordingto the principles of classic communism. Leninwas sufficiently alarmed by the deplorablehealth status of the country to remark: “Either

2 A much more elaborate and well-organized back-ground can be found in Mark G. Field, Soviet Social-ized Medicine: An Introduction (New York: Free Press,1967).

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the lice will defeat socialism or socialism willdefeat the lice.“3

All means of production, distribution, trans-portation, and communication and all pri-vate property, such as land, houses, and apart-ments, were appropriated by the state. Allworkers-professional, white collar, and bluecollar-became employees of the state. Salarieswere set low and within a narrow range rela-tive to American and European standards, butabove the subsistence level at the lowest rangeand above a bare-amenity level on the highestrange.

The salaries of health personnel became, ofcourse, part of this salary structure. Phy-sicians were paid somewhat less than engi-neers. Skilled and productive workmen onpiece-work could earn more than physicians.

The state-owned productive enterprisesyielded their profits to the state and therewas (and is) hardly any personal income taxin the Western sense. The Supreme Soviet,the legislative body of the government, to-gether with the parallel party apparatus, de-termined the priorities on which the profitsfrom the enterprises should be spent. Amongthese priorities, health services were high onthe list. A generously proportioned health ser-vice, relative to concepts in Europe and NorthAmerica, was visualized from the start.

Since health conditions in the USSR at thetime of the revolution were analogous to thoseof Western Europe 100 to 150 years earlier,one can see why the state set a high priorityon eliminating the scourges with the meansthat had become available. Public healthmedicine had lost its dominance to curativemedicine in the West; in the USSR, it hadhigher priority. Curative medicine was notignored-it received and receives much atten-

3 Quoted in USSR Ministry of Health, The Systemof Public Health Service in the USSR (Moscow: TheMinistry, 1967), p. 23.

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tion-but there was and continues to be apervading concept of prevention, or as it istranslated locally, “prophylaxis,” which isbroader than prevention in the Americansense of the term. Prophylaxis not only en-tails primary prevention by means of immu-nization, but also constant surveillance andfollow-up of population segments and peoplein certain disease categories. The health sys-tem from the start was regarded as an activeagent aggressively protecting the health of thep e o p l e .

The USSR health system was, therefore,naturally established as a unified system com-bining the preventive (prophylactic) and cura-tive systems under one administration. Al-though there is a division of labor between,for example, sanitary doctors and primarydoctors for ill people seeking care, the systemappears to be so interlocked with preventiveand curative concepts in the same personnelthat it is difficult to differentiate between thetwo types of activities operationally and finan-cially.

FROM EARLY ON, the health of the people wasregarded as a national asset to increase theproductive capacity of the country, as well asa condition for a contented population. Thehealth services were conceived and plannedalong rational lines according to the acceptedplanning precepts of the medical experts whoshaped the system. All enterprises in the USSRare designed by the relevant experts-engi-neers, educators, physicians, and so on-andthe USSR health service, accordingly, was de-signed by medical professionals.

Professional judgment, in the absence offormal scientific criteria, normally results inrecommendations that are relatively generousin the use of resources. In view of the highpriority given by the state to health services,professional medical experts were then ac-

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corded rather wide leeway. As early as the1930’s, for example, a norm of 10 outpatientvisits to physicians per person per year wasestablished for the first five-year plan.4 Thisgoal was not attained during the first fiveyears, but is now being exceeded. No healthsystem then or now has set goals as high asthe USSR. This goal, in 1930, was undoubted-ly established by professional expert opinionof the time, since there were then no system-atic criteria (they are barely being establishednow) for such a standard. Professional stan-dards. err on the side of safety.

Intertwined with the reliance on expertsis the concept of targets and goals. Obviously,health conditions were such during the 1920’sthat through well-directed public health mea-sures certain types of communicable diseasescould be eradicated one by one. Teams ofspecialists for literally each disease were es-tablished. Specialization in health services andin all other fields of endeavor has been de-veloped to an exceedingly refined degree inthe USSR. Refined specialization facilitates avery high degree of accountability, a primecharacteristic of the USSR economic and SO-

cial system. It is a system which finds am-biguity and discretion uncongenial to its oper-ations.

From the start, as indicated, the expertwas on top rather than on tap, to reverse anold phrase. There was a vast country withvast resources to develop and it must havebeen and continues to be a heady experiencefor the expert specialists. There was no placeto go but up.

The USSR has a very different social, economic,and political system from those of the liberal-

4 I. D. Bogatyrev, ed., Morbidity in Cities and Stan-dards of Care (Moscow: Meditsina Publishing House,1967). From a translated manuscript to be publishedby the Fogarty International Center for AdvancedStudy in the Health Sciences, Washington, D.C.

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democratic-welfare states of Western Europeand North America (or as the Russians callthem, capitalistic states), and the health ser-vices system reflects in detail the character-istics of the larger system of which it is a part.

The core of the health services system isthe polyclinic, the first point of medical con-tact for the general population. Within thepolyclinic area of services there are furtherpopulation subdivisions into ustuchoks (dis-tricts) for each first contact physician; i.e.,each such physician serves a designated popu-lation. The polyclinics are staffed by primarydoctors (analogous to internists). All are sala-ried.

Each polyclinic has its exclusive catchmentarea in some standard ratio to population.The primary doctors are backed up at thepolyclinics by a range of specialists accordingto a specialist-population ratio. These doctorshave no hospital affiliation. There are severaltypes of polyclinics with areas that overlapgeographically but not functionally: adult,pediatric (14 and under), and maternity. Eachis staffed with its primary pediatric or ma-ternity physician plus supporting specialists.

Hospitals are organized in some sort ofgradation by size and complexity with estab-lished population catchment areas so that thepopulation base is known and exclusive. Hos-pitals are staffed on a salary basis by a rangeand quantity of specialists, according to pro-fessionally agreed-on norms. There are spe-cialized hospitals by age and/or disease: adult(15+), pediatric, and maternity; and specialconditions, T.B., and mental disease.

In addition, there are specialized dispensaryagencies for specific conditions, such as T.B.,venereal and skin diseases, and mental dis-ease; other diseases are being added. The dis-pensaries receive referrals from the polyclinicsand/or the hospitals. The concept is one oflong-term surveillance of patients with the

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particular diseases. Again, the dispensarieshave their catchment areas according to somemeasure of a population base yielding certaintypes of patients.

AN ELABORATE SYSTEM of emergency serviceshas been developed for the larger cities, as asubsystem of the larger system described, butstill autonomous as to staffing and operation.There is a central medical emergency servicestation in each city with a switchboard andoperators who handle all calls. A standardnumber (03) can be dialed from all telephones,home and pay phones, free of charge. Thereason for the call is screened by the operator,a trained medical auxiliary (usually a woman),who determines the nature of the call andadvises on sending the ambulance or goingto the patient’s polyclinic, or even on a homecall from the polyclinic. Substations are scat-tered throughout the cities. The emergencysystem has fleets of ambulances staffed by aphysician, two assistants of the feldsher5 grade,and a driver. There are also a few specializedambulances, such as for heart attacks, withthe appropriate equipment.

In rural and remote areas of the countrythere are district doctor stations staffed bydoctors, when possible, with f e l d s h e r assis-tants; when doctors are not available, feldshersoperate the stations and have contacts withthe nearest hospital and polyclinic for guid-ance and supervision.

It is well to mention the psychiatric ser-vices. Although they are geared into the largersystem described in the foregoing, psychiatricservices are a separate service with separatestaff and facilities. There are relatively fewpsychiatric beds (an estimated 10 percent ofall beds as against 50 percent or so of all bedsin the U.S.). However, the outpatient and

6 A feldsher is better trained than a nurse, but not sowell trained as a physician.

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day-care services are well developed, cateringto a large ambulatory patient population.

Finally, mention should be made of the ser-vices provided at the work place by factories,trade unions, and collective farms. There arefirst aid stations, physical screening stations,and also, apparently to some degree, treatmentfacilities, and personnel. The places of workfinance rest homes, sanitoria, health clubs,and other amenities.

THE HIGH DEGREE of specialization makes theadministration of this system seem compli-cated. On examination, this does not turn outto be so. The Ministry of Health in Moscowis the sole national administrative agency re-sponsible for the entire health services enter-prise-service, education, and research-andwith its own national budget for the guaran-teed basic services supplemented, as indicatedpreviously, by contributions from industry,trade unions, and collective farms for nation-ally approved projects. The budget is dis-tributed to the 15 republics, presumably onsome sort of population basis and accordingto some criterion of need.

Within the republics the administrativeareas are divided into for all govern-mental administrative purposes, and into re-gions for health service purposes (rayons) withpopulation catchment areas of several hun-dred thousand people. Each republic has acentral administrative agency reporting to theNational Ministry of Health. Within therayon each of the hospitals, polyclinics, andsanitary services reports directly to the rayonadministrative agency for both urban andrural services separately. Rayons report totheir oblasts. Below the National Ministry ofHealth the budgets are controlled by theMinistry of Health of each republic throughthe oblast level, down to the city level.

Projections and planning for the future

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presumably take place at all levels, but theover-all planning starts at the rayon level tothe obllast, to the republics, and finally to theMinistry of Health.

The Ministry undertakes five-year plans,whereas the republics can engage in one-yearplanning within the national five-year plan.The ministries on both the national and re-public levels are essentially directing andplanning agencies; they do not administerservices. The oblasts and their rayons actuallyadminister the services.

All facilities and personnel are distributedthroughout the system according to criteriaestablished by expert opinion, guided, pre-sumably, by the resources available and pro-jection of such resources for the future.

AS IN ALL countries, the USSR health servicehas grown very rapidly, but the USSR growthhas been particularly great because of the un-developed base from which it started after the1917 revolution. I would guess that alongwith the educational system (and likely themilitary) the health services have expandedmore rapidly than the economy itself, eventhough the latter has also experienced rapidgrowth.

Perhaps 1950 can be regarded as the “take-off” point following the devastations of WorldWar II and subsequent recovery, althoughthere was considerable growth up to 1940.

Expenditures from the national budget (i.e.,not including expenditures by collective farm,trade unions, and industry) increased from3.12 thousand million rubles in 1955 to 7.4thousand million rubles in 1967, and 9.2 in1972; 10.7 is allocated for 1973.

The statistics indicate that the USSR spendsrelatively more than any other developedcountry on health care personnel, facilities,and use. If we in the United States providedas many comparable units of service as did

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Per 1,000Population

1950 Latter 1960’sH o s p i t a l B e d s 5 . 6 1 0 . 0Physicians* 1 . 6M i d d l e - G r a d e S t a f f : :

2.4.4 7 . 3

Hospital admissions increased from 150/1,000 to 201/1,000 in urban areas from 1950 to the 1960’s, and from77/1,000 to 189/1,000 in rural areas for the sameperiod.

* Probably includes dentists who are regarded astechnicians, approximately nine percent of total physi-cians.

t Includes feldshers, nurses, midwives, and lab tech-nicians.

$ All foregoing data from Public Health Services inthe USSR, op. cit.

the Russians, we would certainly have todouble and perhaps treble our present $80billion rate of expenditure.

In urban areas of the Soviet Union (no datawere published for rural areas) the number ofphysician visits per person annually was aboutseven in 1940, rising to about 10 by the latter1960’s. Visits to pediatric clinics were higher-12 to 15.

The number of hospital days per 1,000population per year is currently about 3,000in the USSR, as compared with from 1,000 to2,000 in developed countries of the West.

Planned projections expand the current.

N u m b e r o f P o l y c l i n i c sPolyclinic Population per

Primary PhysicianA d u l tChildMaternityP s y c h i a t r i c

Polyclinic Population perPolyclinic

A d u l tPediatric

Hospital Beds/l,000Population

N u m b e r o f Physicians/lO,OOOM i d d l e Medical/lO,OOO

Current Projected39.000 more

l/2,0002/1,000

??

45-50,000 same15-18,000 same

1 0 . 8 1 3 . 22 8 . 3 34.67 3 1 0 4

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figures into the fairly indefinite future. Be-cause it was sometimes difficult to differentiatebetween current data and projections, theabove are current figures with future projec-tions where I believed they were given as such.

The emergency medical care services havealso been expanding. For a population ofeight million in Moscow, currently there are1,000 physicians and 4,000 middle medicalpersonnel on the staff, plus drivers for 600ambulances, of which 150 are in operationat any given time. There are five million callsa year, of which two million result in visits.There are 25 geographic posts.

The time interval between call, dispatch ofambulance, if indicated, and arrival of ambu-lance at site of call is. very rapid. Ninetypercent of the calls are completed within 15minutes. More than 97 percent of the switch-board calls that require ambulances are com-municated to the ambulance teams withinthree minutes.

Ambulance physicians are usually young(28-40), are trained for emergencies, and get40 percent higher pay, longer holidays, andperhaps better housing arrangements. In Mos-cow most of the physicians are men, in Lenin-grad most are women, but all feldshers aremen. They say men are needed for heavylifting. Calls are increasing every year in bothcities.6

As can be seen, the orderly assembling ofdata based on limited publications in Englishtranslation and translated interviews havetheir limitations, but certainly one gets a“feel” for the system which can guide futurerefinements of data if further research is pos-sible in collaboration with USSR researchersand statisticians.

6 More details are provided in Medical Care in theUSSR, report of the U.S. Delegation on Health CareServices and Planning, May 16-June 20, 1970, by Pat-rick B. Storey, M.D. U.S. Department of Health, Edu-cation, and Welfare Publication No. (NIH) 72-60.

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THE MINISTRY of Health bears the responsi-bility of supplying the USSR health servicewith both facilities and personnel (except resthomes, sanitariums, etc., financed by the col-lective farms, trade unions, and industry).Various levels of personnel are trained alongspecialized tracks and are divided into phy-sicians, middle-medical feldshers, nurses, mid-wives, and technicians; the lowest level in-cludes orderlies, maids, and other supportingand maintenance personnel.7

All levels are admitted to their varioustraining tracks after 10 years of general edu-cation or about the age of 17. From the start,students accepted for training as physiciansmust commit themselves to one of five special-ties, and subspecialties within the respectivespecialties. Those who go on for postgraduatetraining are selected later. Unless the studentscommit themselves to specialties as set up byplanning quotas, they are not accepted.

There are 10 applicants for every post (asreported on this trip) and applications can bemade to only one medical school. Shifts inspecialization after commitment are rare andpresumably frowned upon. The tracks are:(1) medical faculty, which includes internalmedicine, surgery, obstetrics, and gynecology;(2) pediatric faculty; (3) stomatological facul-ty; (4) sanitary medicine and social hygienefaculty (public health); and (5) pharmacologicfaculty (not to be confused with the trainingof pharmacists).

Medical training is provided in free-stand-ing schools called Medical Institutes, unre-lated to universities. Not all Medical Insti-tutes have all tracks but the majority havethe first three listed. Each of the tracks hasseparate facilities and curricula even though

7 More detail on medical education in the USSR thanbeing presented here is available in Storey, op. cit.,p. 30.

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during the first two years the content is simi-lar.

Currently, the training period is six yearsplus one year more or less analogous to theAmerican straight internship or a “first-yearresidency.” During the internship studentspotentially can be assigned anywhere in thecountry depending on openings, and there isstiff competition to get desirable spots whichenhance future connections. The more spe-cialized training takes place after the intern-ship and usually after a three-year period ofwork in an assigned post. Again, I understandthat securing the posts is highly competitive,and assignment to undesirable posts is moreor less by default.

It can be seen, then, that Russian physiciansare ready, in effect, to practice medicine atthe age of 24. This is not to say they aregeneral practitioners; there is no such classifi-cation in the USSR. All are specialists but,as the saying goes, some are more specializedthan others. The more specialized physiciansare ready for “regular” posts for which theycan vigorously compete at the age of 27.Russian physicians are thus legally practition-ers three to four years earlier than Americanphysicians, an important consideration wheninvesting in medical manpower.

The training period for middle-medical per-sonnel varies from one year and 10 months totwo years and six months. The pharmacist,nurse, and dentist (stomatologists are phy-sicians) take longer. Thus middle-medical per-sonnel are ready by 18 1/2 years (nurse) or 19 1/2(general feldsher and midwife).

There is no tuition and for the most partthere are stipends for subsistence support.

THE MEDICAL establishment-and it can becalled that-has major influence on the cri-teria of supply and operation. As I said ear-lier, the experts run the economy and various

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enterprises. Since high priority seems alwaysto have been given the health services, themedical experts have had a great deal of roomin which to maneuver.8 Physicians may notbe paid much in relation to American stan-dards, but they certainly have been accordedprofessional incentives to build a generouslyproportioned health services system.

The Ministry of Health apparently formu-lates five-year plans by coordinating all therecommendations that bubble up from thelocal areas, particularly at the oblast and re-public levels. The ministry then projects aplan according to norms set by experts. Thenorms are applied downward, as it were, butit is likely that the medical judgments on thelocal level are regarded respectfully if theyappear to relate to conditions peculiar to thearea such as rurality, disease pattern, and agestructure. So much for the administrativelevel.

On the legislative level, medical judgmentalso comes into play. The Supreme Soviet ofthe USSR, like the U.S. Congress, worksthrough appropriate committees. It was re-ported that there are 30 to 40 physicians whoare elected members of the Supreme Sovietand, as a matter of course, the entire com-mittee on health services (10 to 15 members)is made up of physicians! Recommendationsfrom all committees are coordinated in theover-all plan for the country (Gosplan). Inthis connection, I was unable to elicit theview that there must be a great deal of haul-ing and pulling at this level among the vari-ous priorities. The answer invariably was,“No, we work by expert norms and every-thing falls into place.”

8 See more details on, at least, the formal aspects ofthe planning process in: I. V. Pustovoj, “The Train-ing of Medical Staff in Health Planning in the SovietUnion,” International Journal of Health Services 1:28-36, 1971.

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The USSR, like Western countries, is afuture-oriented society, but more so. Takingthe standard of living of the West as its refer-ence point, the USSR expects that its standardwill eventually equal and possibly exceed theWestern standard and that goods and serviceswill be distributed more equitably than in theWest. The USSR health service is naturallyan integral part of this view, and it is ex-pected that it will be “bigger and better.” Inthis regard, it is of interest to note that theUSSR health service is already bigger andbetter distributed than health services in theWestern countries. Whether or not it pro-vides “better” services than other countriesdeserves much more than an impressionisticjudgment. Western observers (myself included)can observe that the USSR facilities andequipment are unit for unit (with likely ex-ceptions given the vastness of the system) notup to Western standards. The Russian medi-cal authorities who travel must certainly knowthis, and most certainly, also, I would assumethat in their long-range planning they visual-ize improvements in facilities and equipment.0

So far, the future of the USSR health ser-vice is based on the desire for “more,” anastonishing goal to Western observers whoare now thinking in terms of rationalization,efficiency, cost-benefit, and retrenchment.

The criteria of need and use translated intofacilities, personnel, and expenditures as es-tablished by professional judgment (or astranslated by Russian expert medical opinionfrom high-level clinicians) have resulted in

9 Note the statement by Dr. Venediktov who workedfor four years in New York with the USSR Missionto the United Nations: “We know that the compo-nents of our health service must be strengthened, butwe are satisfied with the general relationship amongthese components. In the United States your compo-nents are of extremely high quality, but the properrelationships are not established. We must improveour pieces; you must collect yours.” In Muller, op. cit.,p. 694.

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abundant resources and high use relative toWestern experience. (I deliberately selectedthe word rather than standardsbecause in the West there are no systematicstandards of use and resources to accommo-date this use.) The USSR medical planners,however, have a great deal of faith in thecriteria set by experts. Future criteria, how-ever-and already being projected-will bebased on scientific findings flowing from avery large morbidity study in various samplingpoints of the USSR. Expert opinion will stillbe employed, but with reference to detailedmorbidity data correlated with physicianvisits, physicians supply, hospital bed supply,and so on.

THE USSR GOVERNMENT is investing 17 millionrubles (more than $20,000,000) in a morbiditysurvey sample population in nine medium-sized cities in various economic areas. Somedata have already been published.10

This elaborate and expensive survey willlay the factual basis for the indefinite future.Dr. Bogatyrev, the director of the SemashkoInstitute, is the apparent originator of thisreally stupendous study, which epitomizes theUSSR reliance on and faith in systematic dataand expert opinion. The population base inthe nine cities is about six million, anda sample of 50,000 patients has been drawnfrom this base (from surnames beginning withL and K.)

In addition, 12,000 individuals from the

10 I. D. Bogatyrev, “Establishing Standards for Out-patient and Inpatient Care,” international Journal ofHealth Services 2:45-49, 1972. The survey reported inthis article lists five cities in various economic areas.Since the results were publicized in 1968, this studymust be a forerunner of the current study in progresscosting 17 million rubles. See also: I. D. Bogatyrev andothers, “L’efficience Cconomique de la liquidation decertaines maladies ou de la reduction considerable deleur niveau,” La Sante Publique, Revue Znternationale1:43-54, 1972.

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population were selected for physical exami-nations by teams of physicians. Thus, it waslearned what proportion of the populationhad not sought services in a year, and whatproportion had undetected symptoms andconsequently untreated diseases. On these datathe experts make estimates as to need andoptimum demand were the people to seekservices for all conditions found. The expertsregard this as the proper norm, and long-rangeplans are being made accordingly.

There were also described time and motionstudies of what physicians do which are ex-pected to yield criteria for the number ofphysicians needed. It was learned that 40percent of physicians’ time is spent filling outforms. This high percentage was not expected.Accordingly, there are attempts to make theforms easier to fill out by check marks, codes,and so on, but apparently not to reduce theamount of information already being record-ed. I gathered the underlying rationale wasdetailed accountability for everything donein the health system.

CURRENTLY, employed people and childrenhave periodic physical examinations. Futureplans are to give an annual physical exami-nation to every citizen in the USSR and ex-pand specialized facilities and personnel toenable follow-up treatment and preventionfor the entire population. This is called the“dispenserization” movement, a nucleus ofwhich already exists for heart disease, dia-betes, and T.B., and possibly other diseases.There will thus be total health surveillancefor the entire population leaving hardly any-thing to the initiative and discretion of theindividual. There is a great deal of outreachnow, but eventually there will be total out-reach. Currently, when patients are asked toreturn for further treatment and review,records are kept and “malingerers” are checked

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out by an automatic filing system daily, andthey are followed up.

When the USSR has the resources it feelsis necessary, there will and should be 16 visitsper person to physicians a year (one-half ofthem prophylactic), 50 percent increase inphysicians as well as other personnel, a 20percent increase in general hospital beds, andso on.

The feldshers currently working more orless by themselves in rural areas will be phasedout and replaced by physicians. Feldshers willcontinue to play an important part in emer-gency medical services, first aid stations, andother supportive roles to the physicians.11

I am convinced these projections are re-garded seriously and have the support of thehighest policy-making bodies. The Sovietshave conquered more than lice, and they nowintend to conquer disease, or control andmanage it to the maximum extent. The in-tent is to make medicine and medical careso scientific that professional judgment willbe drastically reduced. Precise accountabilitywill then be possible and annoying subjectivejudgment, the bane of planners, will not benecessary. When all agree on scientific cri-teria, all are free of each other.

i

FROM A COMPARATIVE standpoint, what I findoverwhelming is the seemingly lavish use ofpersonnel-particularly physicians-and thegreat number of specialized hospitals, beds,and polyclinics, and programs. The result, ofcourse, is a very high use of services com-pared with Western countries. I am sure thateven if we standardized the types of servicesunit for unit, the extent to which the Rus-

i, 11 Patrick B. Storey, M.D., The Soviet Feldsher as a

Physician’s Assistant. Washington, U.S. Department ofHealth, Education, and Welfare, 1972. (DHEW Publi-

I cation No. CNIH) -72-58, February, 1972.

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stetrical-gynecological specialties and in inter-nal medicine, as well as extremely open entryinto other specialties.

HOW DOES ONE evaluate the health services inthe USSR? Well, how does one evaluate anynation’s health service? The USSR health ser-vices should be judged in the Russian contextcurrently, and in the economic context his-torically. In those terms the health servicescome out rather well.

It is a plausible assumption that the Rus-sian amenities in its health service comparefavorably with the general amenities of Rus-sian households and hotels. It also seems thatthe Russians can make dazzling exceptionsif they so desire when one experiences theirconcert halls, operas, and ballets and theirsubways, airplanes, and express passengertrains.

The opportunity to compare USSR andWestern policies and philosophies of healthservice is indeed fascinating. We in the Westwould say that the USSR is creating a de-pendent population by a relatively lavishhealth system where hardly any initiativeneeds to be taken by the citizen; the USSRcritics would say that we capitalists (welfarestate notwithstanding) are withholding ser-vices from the people in order to save taxes.It would seem that the USSR health servicewill give us an opportunity to study the oper-ation and possibly the impact of a near-saturation type of health service. No Westernmodel affords this opportunity.