LAUSR

“At least in those days, I had no rent and no heating bill to pay, I had free access to doctors, and the state would make sure my children are educated and in good health”, says Evguenia, a babouchka I spoke with recently in Moscow. Health is one of the areas where nostalgia for the Soviet Union is still common among Russians and people living in countries in the post-Soviet space. Most Russian adults alive today witnessed the dramatic deterioration of health care in the 10 years after the end of the Soviet Union. These people have seen the social safety net provided by the Soviet system abruptly disintegrate, inequities grow sharply, and elderly, sick, and disabled people become left behind while the country painfully and erratically transitioned from a planned economy to capitalism. Another reason for the lingering nostalgia is the persistent perception that health care should be provided by the central government, with little or no responsibility on the part of the individual. The Soviet Constitution of 1936 stated that citizens of the Soviet Union have the right to health protection ensured by free, qualified medical care in state institutions. In the years after the 1917 revolution, Russia created a centralised and integrated state health-care system based on concepts introduced by Nicolaï Semashko, the People’s Commissar for Public Health from 1918 to 1930. The health-care system relied on an extensive network of primary care clinics and specialised hospitals staffed by large numbers of doctors and health-care workers, and it provided universal coverage, accessible to everyone, even in the most remote parts of the country. The improvements in health care during the first half of the 20th century were quite remarkable, with life expectancy in the Soviet Union in the 1960s similar to that in the USA. However, the system rapidly deteriorated in the 1970s. Reduced funding from the central government and increasing bureaucratic and economic inefficiencies resulted in inadequate availability of medical drugs and technologies, poorly maintained facilities, worsening quality of health care, and falling life expectancy. The transition of health systems from the Soviet facility-based model to patient-centered and decentralised standards of care is far from complete. Throughout the region, national funding allocations are based on number of doctors and beds (rather than on outputs). For example, tuberculosis care in many countries in the post-Soviet space is still provided through a hospital-centric system, where patients are admitted to hospital for standard tuberculosis treatment; not only is this system costly and inefficient, it has contributed profoundly to the rapid increase in the incidence of multidrug-resistant tuberculosis in the region. Public health budgets barely cover the salaries of health-care staff. Drugs are often paid for out of pocket, and bribes are often a way to access better quality service. The private health insurance market is expanding among urban middle-class employees as this population increasingly turns to private health-care networks. Another key feature of health care in the post-Soviet context has been the dominance of treatment and curative approaches, with little focus on prevention and public health. The fast spread of the HIV epidemic in the region is attributable in part to this vertical, providercentred, treatment-oriented system with almost no cooperation with the non-governmental sector and grossly inadequate attention to prevention. Nevertheless, there are also reasons to believe that change is possible, even in the face of the tremendous health challenges in the region. But change is down a long and arduous road. The many sources of resistance include health-care professionals themselves, corrupted intermediaries who have been taking advantage of the system, and political elites who are reluctant to change structures they have benefitted from, directly or indirectly. This is well illustrated by the bitterness that prevails with Lancet 2017; 390: 1611–12