Crisis in East European health systems — "Europe's best kept secret"

Where might you be treated by a doctor who'd worked 1000 hours of overtime in the past year, who was earning $ 15 a month but hadn't even been paid for the past five months, who was working without medications or bandages, with leaking roofs in operating theatres, no running water, no heating in winter, and where there's been no investment in the infrastructure in years?

Perhaps a remote corner of Africa? No, it's Eastern Europe, according to Ellen Rosskam, a Senior Work Security Specialist at the International Labour Organization (ILO). "This is Europe's best kept secret" said Rosskam.

According to new ILO studies of health workers' views of the health systems of East Europe and the former Soviet Union, just published, such conditions are widespread. General working conditions have greatly declined for health workers across the region since the collapse of the old Soviet system, which — while unlamented in many ways — did support a nationwide public health system designed to be big enough to meet epidemics as well as day-to-day health care.

But wide-ranging economic and political reforms have shrunk the health systems dramatically.Varying degrees of responsibility and funding have been passed from the state to local authorities, creating great disparities between richer and poorer areas. "For example there's a great under-provision in many of the rural areas, leaving large sectors of the population without access" says Rosskam, while under the old system "there were polyclinics and village health clinics in every region".

Now "there's no money going into the rural areas, plus you can't get the doctors to go there."

As a result of these and other failures, there have been great increases in TB, HIV/AIDS and STDs all over the region, with "soaring levels of stress-related illness in the population due to ten years of having to work two or three jobs just to survive," says Rosskam. "So the life expectancy of men, for example, has dropped by ten years."

Last year the ILO People's Security Surveys found that 88% of families in Ukraine and 82% in Hungary were unable to afford basic health care. According to the new studies, in the Republic of Moldova, the poorest country in Europe, the health service is close to collapse and workers are paid months late, if at all. In the Czech Republic and Lithuania, most health care workers said their working conditions and pay had worsened in the past five years. Even in relatively prosperous Poland, 5% of hospitals have closed in the last three years.

According to the ILO studies large proportions of the health care workers in such countries as Kyrgyzstan, Armenia and the Republic of Moldova simply fail to come to work because hospitals and clinics can't pay them. Other countries are suffering "presenteeism", where sick workers stay on the job for fear of losing their posts — or their tips from patients.

According to the ILO, health workers in many of the East European countries now depend for their living on tips.

"Tipping is common practice, now", making income unreliable, Rosskam told the Bulletin. "You have to pay to get any services ... but tips are unofficial, gratuity payments ... And the biggest tips go to frontline workers — particularly doctors, while support staff, technicians and administrative staff, who form the backbone of any health system, fall through the cracks" said Rosskam.

Health workers in the region are seriously demoralized, according to the ILO surveys. "The word `humiliation' has come up more than once during workshops where we've presented our conclusions to affiliates from the region" said Rosskam.

ILO's solution? Apart from proper funding for an effective public health system, which is the primary need, health workers' trades unions need greater recognition and capacity-building, says Rosskam. Paradoxically, the concept and practice of collective bargaining is new in this ex-"socialist" region; in the past trades unions only had to deal with the state. Now there's a multitude of private organizations to deal with — organizations which themselves show little interest in collective bargaining and maintaining social dialogue, according to Rosskam.

"The health unions also need to address very complex issues, such as the legislation arising from countries' applications to join the European Union, privatization, and economic and political restructuring. Another major challenge is how to face the huge wealth gaps in the region," says Rosskam.

ILO's goals now are to make more information, such as the results of these studies, available to the trades unions; to help develop the capacity of the unions to negotiate; to work with WHO; and to work with the World Bank, which is "the main influence on these countries with a direct impact on the health sector," Rosskam argues. "Health workers must not not be mistreated with impunity, exploited or oppressed" says Rosskam. "We need to shake up the policy-makers who may be offended at hearing these words. It's what you've got to do in countries where problems such as TB are as bad as in sub-Saharan Africa and there is no public health system to respond to them." n

Robert Walgate, Bulletin

World Health Organization Genebra - Genebra - Switzerland