Cuba's Health in Transition and the
Central and Eastern European
Countries Experience.

There is a positive correlation between life expectancy and infant mortality and health expenditures. For example, in Table 2, the CSFR spent the least percentage of its GDP in health expenditures.(17) It can be easily seen that the life expectancy of the CSFR is slightly low and the infant mortality is the second highest of the group listed including former soviet block countries and western democracies.

Table  2. Selected health statistics in Western European countries and CSFR  
(1988-1988).  (17)

Cuba's infant mortality in the comparable period of time summarized in Tables 1 and 2, (1970's through 1980's) was of the order of 27 to 11 per 1000 life births respectively. (18) This health statistic for Cuba was similar, at that point in time, to those of Hungary and the FRG. Life expectancy, however, was comparable in magnitude to the data of the Eastern European states listed in the table. Observers have concluded that the decline in soviet health was associated with the stagnation and decrease in life expectancy in the Soviet Union. Indeed, life expectancy seemed to stagnate in the Soviet block through the 1970's and 1980's. However, Cuba's life expectancy did not decrease during that same period or during the "periodo especial" in the 1990's. (19) Cuba's urban population in 1980 was of the order of 72%, a value that is appreciably higher than that of most socialist countries at the time except for the Soviet Union, the Czech Republic, and Germany.

During the transition period, the health statistics of the former soviet-block countries did not always behave in similar fashion in terms of life expectancy. In the Czech Republic, for example, life expectancy improved rather quickly after 1990. (17) Hungary followed later and lastly Romania recorded health benefits through the health in transition. (20)

In Bulgaria, there was initially a slight increase in infant mortality during the early transition. It was noted that in Bulgaria there was an increase in the general adult mortality after the onset of the transition. Mortality rates also increased in Bulgaria because of an increased incidence of strokes. At that time in Bulgaria's transition, health data improved. It was observed that improved statistics on life expectancy in Bulgaria were due to falling death rates among the young and middle age men and women over 65 years of age.

Perhaps the most difficult health statistics to follow during the transition are those of the former German Democratic Republic (GDR). (11) In 1990, the GDR joined the Federal Republic of Germany and since then the health data reported to the WHO reflects data for Germany without distinctions on weather the data came from the former East or the former West. Despite these serious limitations on data gathering and reporting, it has been possible to document that during the transition East Germans have had a higher mortality rate from accidents, homicides and suicides (external causes) than West Germans. East Germans also had a higher than expected mortality rate from cardiovascular diseases. (21) Investigators have suggested that the latter increase in cardiovascular mortality has been associated with be the low availability of fruits and vegetables in East Germany even after the transition began. (22) These foodstuffs are known to be excellent sources of B vitamins, folic acid, and antioxidants thought to be effective is combating unstable atherosclerotic plaques and intravascular thrombosis leading to heart attacks, strokes and sudden death.

In the context of fresh fruits, vegetables, antioxidants and the prevention of atherosclerosis it should be pointed out that the mortality rate from atherosclerosis (coronary heart disease, heart attacks, and others) in Cuba has been increasing throughout the revolutionary period. One factor that may have played an important role in the increased mortality from these diseases in Cuba is the low intake of fresh fruits and vegetables through the Cuban "libreta" diet. (19) More serious nutritional deficits were observed in Cuba during the "periodo especial" when the lack of B vitamins and nutrients were peak when the "optic neuritis" epidemic became widespread affecting more than 50,000 Cuban's in the early 1990's. (22)

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Mental Illness

The transition period has been recognized in all former soviet block countries to be a time of relatively high stress. It should not be surprising, therefore, that during the transitions from totalitarian socialism to more open societies Eastern European countries recorded an increase in the use of and intoxication with psychoactive substances and drugs in the legal and illegal markets. (23)

In a study reported from Bulgaria, alcohol was the most common agent involved in intoxications and poisonings accounting for a peak of 78% of all intoxications. (24) However, the single agent that was responsible for the greatest number of intoxications were heroin and narcotics in general. The third most common cause of overdosing during the transition in Bulgaria was the "multiple category" where more than one agent had been found to cause the overdose. The latter mixtures included cannabis, sedatives, cocaine, various inhalants and other drugs.

The rates of intoxications and poisonings in Bulgaria peaked at 13.5 per 100,000 population, (25) This epidemiologic level of intoxication was 2.34 fold greater than the average rate of intoxication during the early 1990's. These data suggest a worsening of mental illness in the general population during the transition.

In Cuba, like in Bulgaria, alcohol is the most common central nervous system depressant available in society. The conditions and phenomena that seemed to have been associated with the higher rates of alcohol intoxication in Bulgaria were:

• Unemployment,

• Poverty,

• Crime and violence

• Social insecurity,

• Disruption of family ties, and

• Uncontrolled emigration.

It can be argued that these factors could be important and intense in the Cuban transition. Obviously, measures to prevent these trends must be sought in order to prevent greater stress on society during the transition.

Effective anti-drug laws were not always immediately available in all countries of the former soviet – union during the early period of the transition. (25) However, proper laws were legislated by the year 2000 and these had a favorable response in the intoxication trends in Bulgaria.

Nowhere else is the seriousness of the social and economic stressors during the transition from totalitarian socialism more evident than in the mortality data from suicides. Two main factors have been proposed to explain the correlation of social change and suicides:

• Unemployment,

• Alcoholism.

Indeed, both of these indicators of distress and ill-health increased in most countries undergoing the transition from socialism. Table 3 summarizes the trends in suicide rates in various former soviet-block countries immediately prior to and after the transition. Although suicide rates in the former soviet-block countries tended to increase during the transition, two countries demonstrated a decrease in these unfavorable health trends: The Czech Republic and Hungary.

Table 3. Changes in suicide rates in selected countries for the former soviet -block during two five year periods before and immediately after the transition. (26)

An analysis of these data and a number of health and social indicators suggests that suicide rates changed in direct proportion to these fundamental factors; (25)

• Alcohol consumption

• Unfavorable economic changes

• Social disorganization

• Political uncertainty

• Lack of tolerance

• General stress

All of these factors that have been found to be important in the transition of Eastern European countries are likely to occur in Cuba. Attention to these areas at all levels of health care from the local to the national level should be focused in order to improve services, prevent mental deterioration and eventually suicide.

Unfortunately, democracy brought to some of these countries unfavorable, transient economic changes and political uncertainty. It should not be surprising that some epidemiologists have a found a  positive correlation in the "degree of democracy" and suicide rates. (23)

Despite these ominous challenges, it seems reasonable to attempt to prevent or minimize the suicide risks while providing proper communication, socio-economic safety nets, having accessible and rapid counseling and providing therapeutic, sensitive, and effective intervention in situations where a high risk of suicide is deemed likely from the sociologic, medical and psychiatric points of view.

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Physicians, Hospital Beds, and Nursing Personnel.

The number of health care professionals and personnel in all communist countries as dictated by the central government. Under the Semashko health systems prevalent under communism, all health professionals were paid a fixed, not-negotiated salary. Most countries eventually had a relative excess of certain professionals considering the various degrees of inefficiency and foreign commitments of the various states. Furthermore, the distribution and offerings in the various medical specialties were also dictated through a centralized governmental mechanism. Therefore, in some countries the distribution of physicians into primary care physicians and specialists varied widely according to state priorities. In some countries the specialty of family medicine, for example, simply did not exist.

In 1989, for example, there were 57,940 physicians in the Czech Republic. (27) This relatively high rate of physician population (37 per 10,000) was composed of 18% generalists and 82% specialists. Table 4 summarizes the number of physicians and nurses per 1000 population in various countries of the former soviet block.

In the 1990's, physicians salaries were of the order of 191 US dollars per month and nurses earned an average of 102 US dollars monthly. Invariably, in all countries undergoing the transition process, health professional organizations were organized. In 1991, all physicians were legally required to join the "Czech Chamber of Physicians." Small increases in wages for health professional began to take effect early during the transition at a rate of 8 to 10% increases per annum. These discrete increases in salaries have been accompanied, however, by the dismissal of approximately 8,000 health care workers.

By 1992, the Czech Ministry of Health was able to decrease the health care debt from 54 million US dollars to 25 million.

 Table 4. Rates of Physicians and Nurses in the former soviet-block. (10,28)

It is obvious from Table 4 that Cuba has a relative excess of physicians or conversely a deficit in the rate of nurses. Cuba can be considered a country where perhaps the so-called demystification of health care had led to an equal number of nurses and physicians. The only other country with a similar ratio of nurses to physician rates is Hungary. In general, one would expect that the number of nurses should be higher than the number of physicians. However, orthodox communism theory in terms of health services purports to breakdown the hierarchy in the various professions providing health care. Therefore, in considering the transition in health, the number of nurses and physicians in Hungary may be more significant to the transition than other factors. The similarities in these statistics between Cuba and Hungary may respond to issues beyond the actual health service requirements for staffing and trained personnel for certain evaluations, skills, and procedures. The similarities may be due to ideological issues.

The usual history of health care development in Central and Eastern European countries of the former soviet-block is well represented by the sequence of events in Bulgaria. Bulgaria had in 1944 only 1.6 beds per 1000 population. (29) Hospital bed data and utilization parameters for other former soviet-block countries is summarized in Table 5.

After the communist revolution in Bulgaria, a highly centralized National Health Service was organized. Universal health care was free at the point of service for all Bulgarians. In 1982, Bulgaria had 11.1 hospital beds per 1000 population and an infant mortality of 18.2 per 1000 life births. (29)

Table  5.  Hospital beds and utilization data for selected countries in Central and Eastern  Europe.  (28, 29)

In 2000, Cuba reported a hospital bed rate of 5.2 per 1000 population. (30) The occupancy rate was 69.4%, somewhat less than the values reported for the countries in Table 5. It should be noted, however, that the number of beds per 1000 population in Ciudad de La Habana in 2000 was 9.2. (30)

The length of stay in Cuba was 9.4 days per admission in 2000. The latter health statistic is similar to that of Romania, recognized as one of the most inefficient Eastern European countries. It should be added that LOS in Cuba during the 1990's peaked in 1993 at 10.3 days per admission.

Regardless of the rates or numbers of professionals, health services depend on utilization, that is, how much is expected by the people. Data for several countries in the transition period and the European average are summarized in Table 5. Two studies on patterns of health services utilization in Bulgaria are reported. (31,32)

In a 1994 study, 3 out of 4 respondents consulted a physician in the state (official) sector while only 1 out of 5 consulted a private physician (non-official sector). Data on physician's contacts for other countries in the former soviet-block is summarized in Table 6.

Table 6. Physician's and primary care contacts per person per year in selected countries of the WHO European Region in 1998. (33)

Studies carried out in 1995 and 1997 in Bulgaria revealed that the levels of illness perceived by the people may have increased. In 1995, 12% of men and 8% of women reported an illness in the four weeks prior to the survey. In 1997, however, 17% of men and 24 % of women reported an illness in the prior 4 weeks. In Germany, in 1990-1991, the rates of utilization were much higher: 43% of men and 54% of women consulted a physician in private practice in the four weeks prior to the study. (10)

These studies on utilization and self perceived illness can yield widely variable results. For example, in Finland, 24% of men and 29% of women received medical care in the four weeks prior to the study. However, in England, 15% of men and 19% of women had an acute illness in the previous 2 weeks.

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Individual and Collective Economy

The financial foundation to any type of health service is fundamental. Therefore, it is important to appreciate that through the transition from communism to democracy proper economic and financial planning has proven extremely important in all Central and Eastern European countries.

In the former countries of the Soviet block there has been some privatization in certain industries but in general not in health care. Total health expenditures expressed in terms of percent of the GDP in selected countries in Europe are summarized in Table 7.

Table 7. Health expenditures increased in all countries during their transitions. (34)

Most data for health expenditures given so far have been expressed in terms of percentages of GDP. The actual amount of money spent per person in health can be a clearer indicator of health expenses. The following table summarizes data for some of the countries involved in the transition.

Table 8. Per capita health expenditures in selected countries (1997). (33, 34)

Regarding out-of-pocket-expenses, both formal and informal user fees are paid to health care providers staffing state facilities. In Bulgaria and Romania, the state portion of the health care budget, however, decreased steadily. By 1997, the health care expenditures were down to 50% of those in 1989. By the end of the 1990's, health care was said to be a lesser priority than 10 years earlier.

Table 9. Out-of-pocket payments in various countries of the former society block during the transition. (10, 33, 34, 35)

Not all attempts to establish a working health insurance fund were successful. In 1991, Estonia began to organize an insurance fund for health services. (2) The fund was 100% financed through contributions from individuals. Unfortunately, the fund failed and the State budget had to cover the financial deficits of the flawed system.

The Russian Federation and Ukraine started an insurance fund in 1993. (10) The Russian insurance system was intended to have several tiers: a compulsory one, a voluntary one, and a State governed one. All citizens are guaranteed a basic health service through the Russian State.

Higher standards may be obtained through the other tiers of the Russian system.

The official data for out-of-pocket expenses are much lower than the available data for a limited number of countries. In Poland, for example, out-of-pocket payments were officially reported to be 9% of the total expenditure on health services. (35)

Furthermore, the average percentage of health costs involved in the out-of-pocket category during the transition was of the order of 30% of the health expenses. These expenses were mostly unregulated and untaxed. Often, they served to create an atmosphere of corruption and hidden privileges obtained through under-the-table payments. In some instances, the values fluctuated appreciably inside a given country. For example, in Poland informal payments to hospital staff by inpatients amounted to 46% of the health costs. The latter sums were informally and preferentially handed to physicians who increased their salary by 15%.

The fundamental role of health in society can be appreciated from the events that preceded the transition from communism to democracy in Eastern Europe and the Soviet-Union. The winds of reform began to blow in the former Soviet-Union in the mid-1980. It was widely recognized that the Russian health services were extremely backwards in comparison with other industrialized countries. (10) It was also well documented that there was widespread corruption in the health services where "under-the-table" payments would be used in order to bet ahead of a surgical list or obtain a particular medication. It has been noted that in the late 1980's, certain decentralization of health care began to occur officially in the Soviet Union. By 1988 two models had been launched in Russia to deal with the inefficiency, lack of satisfaction and corruption prevalent in Russian health. The two systems or experiments were labeled: Kemorovo and Leningrad. The latter changed name after the dissolution of the Soviet-Union to St. Petersburg. It should be noted that by 1988 there were already some reforms being implemented in Poland's health services.

Both Russian pre-transition, experimental systems intender to allow health system managers a greater flexibility and control of resources. It was hoped that this approached would satisfy the needs of each community. The Kemorovo system provided a per-capita funding for the local polyclinics. These local entities acted as purchasers of health services for their patient's "lists." The Kemorovo budget for the polyclinics included itemizations for diagnostics, hospital referrals, and emergency services. The financial backing for the Kemorovo budget came from a compulsory payroll deduction which was initially 20% but later was lowered to 10% of the payroll.

Under the Kemorovo model, physicians could form autonomous groups and contract with polyclinics and hospitals. Likewise, hospitals could form autonomous groups of health workers. A "Kuzbass" or sickness fund type of insurance was organized in 1992, well into the actual transition after the dissolution of the former Soviet-Union. The "Kuzbass" collected income from employers, employees, and local authorities.

The Leningrad or St. Petersburg model was similar to the Kemorovo system but the basic unit was not the polyclinic but group practices that were set up to provide care for the population under this system of health administration. Each St. Petersburg group practice was set up to provide health services for approximately 8,000 persons with a medical staff that included: three general physicians, two pediatricians, one gynecologist. The group practice received a payment calculated on a per-capita basis. A regional authority, The Territorial Management Association (TMA), was formed to deal with and control the relations of the group practices. In both the Kemorovo and the St. Petersburg systems, the basic units, the polyclinics in one and the group practices in the other, were able to retain the savings made at the primary care level. In the first four years of the Kemorovo system admissions to hospitals were decreased appreciably from 846,500 in 1988 to 804,700 in 1989. Some indicators of improved efficiency were noted. In the areas served by the St. Petersburg system, the number of hospital beds deemed redundant was 2,500.

Each system used the retain earnings differently. In the Kemorovo system investments were made in management information systems and public health and management training. In the St. Petersburg system funds retained were used for purchase of more up-to-date diagnostic equipment, treatment facilities, and staff benefits. Both systems seemed to improve primary care and efficiency of the health care facilities.

Cuba has reported health expenses of the order of 14.9 to 59.2 pesos per person per year since 1989. (36) These figures come from the official Cuban State budget. The lower figure belonged to 1993, the year when the "optic neuritis" epidemic peaked. All of these figures for Cuba in comparison to those in Table 8, are in Cuban pesos. It must be appreciated that utilizing even with the most optimistic conversion rates (of the order of 26 Cuban pesos per USD), Cuba's expenditures are appreciably lower than that of the Russian Federation, the country with the least per-capita expenses in the Table 8.

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Decision-Making and Professional Ethics.

One advantage of the totalitarian systems that governed the former soviet block before the collapse of the USSR was the apparently unified goals of the three main stakeholders in terms of health: the state, the professional groups, and the politicians. All "factors" seemed to desire the same level of services and technology. There were no major or open arguments about the importation of newer, more expensive, technologies such as CT scanning, PET scans, MRI, etc. because most of the technology available in socialist countries hospitals was made behind the "iron curtain." An exception was made for some facilities where the top communist party members and the elite got medical care.

With the advent of the transition, an open, market economy and the availability of financing for the latest medical instrumentation, all countries have had to look more closely at their priorities, possible rationing of certain types of medical care, and the organization of their health care services. (2) The experience in the Central and Eastern European countries that have embarked in the transition out of communism suggest that rationing of health services may occur because of many factors:

Prohibitive costs
Lack of effective financing
Improper physical resources, plant, infrastructure.
Uneducated or unwilling patient base.
Lack of community infrastructure, and continuity of care.

All issues involved in the dilemma of rationing of health services must be discussed by appropriate representatives of the people, the professions involved in health care, and government regulatory and legislative agencies. The influences of marketers, industry, or other persons or entities who do not represent the national interests must be minimized and actively avoided in order to reach a community consensus and practical conclusions that will truly be the best for the population served under the national health service. (37) Obviously, private health services may be able to afford certain medical instrumentation that may be prohibitive for the public health service. Even under an open, liberal social order, it may be reasonable to consider the enactment of regulations such as "certificate of need" mechanisms under national or regional authorities in order to maintain certain health standards and financial responsibility.

Although most of Europe had already embraced the guidelines of the World Medical Association enunciated in 1964 on the ethical issues of medical research on humans, the Soviet block finally adopted the same principles but only by October, 2000. (38) The Declaration of Helsinki of 1964 (39) dealt with the design and performance of experimental procedures involving human subjects, the establishment of independent committees to oversee and regulate ethical issues dealing with research and decision-making in human subjects, and guidelines for the laws and regulations of the each country dealing with these matters.

Centralized decision making in the former soviet-block countries covered all health related decision-making including community health and health research. By the time the transition was underway, all countries had some form of committee or collegiate decision-making body enabled and responsible for making decisions on health care and health research issues. By 2000, Albania, Bulgaria, the Czech Republic, Estonia, Lithuania, Hungary, Lithuania, Poland, Romania, the Russian Federation, and Ukraine all had functioning bioethics committees overseeing research on human subjects. In all of these countries except for Albania, these ethics committees were comprised of both medical and non-medical members.

The term ethics has to do with morals, with norms, and with behavior or conduct. It is paradoxical that in the medical schools that operated in the former soviet block countries, the communist block, instruction on ethics was extremely scarce. In Poland, for example, the medical curriculum covered 6,300 contact hours of instruction. (40) The lessons on medical ethics amounted to only 30 hours, which is less than one percent of the total instruction time. Until 1996, there was no course in medical ethics in Bulgarian medical schools.

The ethical dilemma during the transition centers on the fact that the health care workers and the people feel dissatisfied with the old forms of social order and the wasteful institutions that plagued the communist system. However, the same parties, professionals and populace alike, lack the self assertion, the individual fortitude, and the civic courage to take the appropriate risks required to become protagonists of their own transition and future. Together with these "down points", the new leadership of the professional groups and the people has not had in the former soviet block countries easy access to mass communications and the press. In 1990 in Hungary, decision-making in hospitals was changed to a system involving the medical and professional staff of hospitals. A "consensus management" was introduced bringing together medical, nursing, and economic directors. (42)

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Specific Health Issues in Various Countries in Transition

An assessment of the issues and progress in health care and health issues in the various countries involved in the transition from state, absolutist socialism, communism, has been reported through an "Observatory" on health data. The "Observatory is formed by an international organization bringing together the WHO Regional Office for Europe, some of the various governments involved in the transitions, other countries of the region in particular Norway and Spain, the World Bank, and other institutions of health and finance. (10, 43) The partnership formed in this "Observatory" supports and promotes evidence-based health policy-making through comprehensive and well-defined analyses of studies on health and health care systems in the region. The summaries that are described below for some representative countries of the former soviet-block are based on the reports of the "Observatory" through its various Health Care Systems in Transition (HiT) series.

The general health issues that are summarized in the HiT profiles are:

• Financing, organization and delivery of health care.

• Process and content of health care system reform and their implementation.

• Identification of common challenges with their processes and content.

• Provision of a mechanism for sharing and disseminating of information

Such information networks may be valuable in the Cuban transition. A similar type of tool may be envisioned to assist the leaders and workers of the health transition in Cuba. Obviously, with the increasing accessibility of the internet, this relatively new arena may serve to link Cuban health administrators and workers with the "Observatory" already organized through the WHO Regional European Office

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Bulgaria (43, 44, 45)

Bulgaria is located in Southeastern Europe in the border between Asia and Europe. It covers 110,910 square kilometers and had a population of 8.2 million inhabitants in 1997. The level of urbanization was 67% in 1997, somewhat lower than that of Cuba, however. Bulgaria was admitted to the United Nations in 1955 but it remained one of the most isolated countries of the former soviet-block.

In 1948, the communist administration of Bulgaria took the classical steps that were all common in other soviet block countries and Cuba. The existing health system was replaced by the Semashko health care model while the following steps were taken:

• Private hospitals were nationalized and brought under Ministry of Health control.

• Pharmacies were nationalized and brought under Ministry of Health control.

• Health insurance system was abolished.

• Central government became the sole funder and provider of health services.

• The Bulgarian medical association was abolished and replaced with a single communist trade union to represent all health care workers.

• Medical training was centralized and controlled by the Ministry of Health.

Health services in Bulgaria, under communism, were notoriously backward for Europe.(43) In the 1950's, Bulgarian public health was dealing with the control of tuberculosis, typhoid fever, malaria and other parasitic diseases already controlled in other countries in the region. One achievement is lauded, however, by the Bulgarian communists in terms of health care. All Bulgarians were guaranteed free access to health care. By the 1970's, many communicable diseases were controlled. However, the Bulgarian health system was criticized as being inflexible, centrally controlled and having little capacity to respond to changing disease prevalence and risks of the population. Eventually, the demand for health services and better quality increased beyond what the centralized government could provide with its financial infrastructure. Observers point out that the Semashko type of health service of Bulgaria had become discredited by 1989.

The communist leadership was deposed in November, 1989 through an internal coup d'etat in the Communist Party. By June 1990, the Communist Party had changed its name to the Bulgarian Socialist Party. The other major political groups formed a coalition labeled the Union of Democratic Forces. A new constitution was adopted in 1991. Power shifted back and forth through the nineties. By 2000, Bulgaria was recognized to be a multiparty democracy with a single chamber parliament composed of 240 seats elected for four years. A summary of health statistics and indicators in summarized in Table 10. (43)

Table 10. Demographics and Health Statistics for Bulgaria 1975-1999. (43)

At the onset of the transition, the Bulgarian health system was essentially a Semashko type of health service. It was highly centralized. Attempts were made to transfer responsibilities for health services to the municipalities. However, financial problems ensued. In 1997, Bulgaria's health financing still depended 100% from the state budget. (43) The Bulgarian inflation rate increased from 23% in 1989 to 438% in 1990. It decreased in 1992 to 79,5% but steadily increased to 578% in 1997. It should not be surprising that health indicators deteriorated in Bulgaria as a function of a worsening economic situation.

In the early 1990's Bulgaria experienced a major economic shock and large-scale macroeconomic restructuring that seemed to deplete the national resources. The health facilities infrastructure has remained essentially unchanged since the collapsed of the Soviet Union.

However, there was no coherent health care reform before 1997. By that time, a number of health crises were instrumental in guiding the Bulgarian authorities to deal with their new reality.

Some of the negative outcomes in terms of health during the transition in Bulgaria were characterized by the following:

• The breakdown of social safety nets,

• Increasing poverty,

• Income polarization, and

• Growth of out-of-pocket payments for health care.

Life expectancy for men and women was 74.8 and 68.1 years in 1990. These health indicators moved slightly down through the transition. In 1997 they were, 74.4 and 67.2 years respectively.

Infant mortality in Bulgaria was 14.4 in 1989. This important health indicator increased to 17.8 per 1000 live births by 1997. The rate of death in the under five years of age category, also increased in the same interval. In 1989, the mortality rate for 1-5 years of age was 18.3 per 1000 live births. The rate had increased to 23.5 by 1997.

The Ministry of Health maintained during the Bulgarian transition control and responsibility for overall supervision of the entire health system and the health systems of the 28 established regional health centers. Some ministries other than the Ministry of health have maintained in Bulgaria their own health services networks. These include the Ministry of Defense which maintains military health care facilities, 14 military hospitals, and health care services for the military personnel and their families. The Ministry of Interior Affairs maintains health care facilities and hospitals for the police and their families. These facilities have their own network of outpatient clinics, polyclinics, and other services. The last of these "parallel" official health services is maintained by the Ministry of Transportation. The latter operates 8 hospitals and adjacent facilities.

Bulgaria is said to be a country with relatively high tobacco smoking rates in Eastern Europe. In 1997, 38.4% of men and 16.7% of women smoked. Dietary patterns in the transition were plagued with problems. The supply of fresh fruits and vegetables was not well developed in Bulgaria. A dietary study carried out in 1997 revealed deficiencies in the B vitamins and folic acid.

The rates of certain diseases increased during the transition. There were increases in the reported cases of active tuberculosis. The mortality from cardiovascular diseases increased from 85.4 deaths per 100,000 persons in 1989 to 100.1 in 1994. Equally, the mortality from stroke and cerebrovascular disease increased in the same period (1989 to 1994) from 63.7 to 74.4 deaths per 100,000 population.

The rate of induced abortions in Bulgaria was 118 per 100 live births in 1989. The rate of abortions did not decrease in Bulgaria. In 1997, the rate was 137 abortions per 100 live births. The rate of induced abortions in Cuba has been of the order of 104 per 100 live births.

Universal health care without individual costs was approved in the new Bulgarian constitution. The latter also legalized the private practice of medicine. Private practices by physicians were licensed in Bulgaria by the local municipalities. Thirty percent of Bulgarian physicians opted for providing private health care services. All of those physicians who undertook the private practice of medicine also worked for the state institutions. The number of dentists who opted for private practice was appreciably higher at 80%. Most of the dentists working in private practice did not work in state institutions, however.

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Czech Republic (17,27)

Following the collapse of the Soviet Union in 1989, the Czech Slovak Federative Republic (CSFR) embarked on radical economic, social and political changes that resulted in a major restructuring of the country. Since 1968, under Communist rule, health care had been administered in each of the two republics by a separate ministry of health. A legal separation of the Czech and Slovak Republics occurred in 1992. The population of the Czech Republic was of the order of 10.3 million persons in 1999. The urban population amounted to 65% of the total. During the transition from totalitarian socialism, each republic engaged in a different manner of reform in terms of health services.

Early in the transition, about 15 medical specialists from the Czech Republic launched a document stating their vision for health care in the future. The proposed changes in the health services for the Czech Republic were distributed among physicians and health care workers. The document focused was in the areas of:

• Improving the quality of care provided,

• Improving the efficacy of the system and all its parts,

• Improving the efficacy in terms of health expenditures and resources, and

• Improving the national overall health status.

The document was circulated widely and provisions were made for consultations and revisions. Eventually, the physicians and health professionals voted on the reform document and 83% of them were in favor of adopting the proposed, revised program. In December, 1990, the government approved the revised final draft of the document spelling the new "System of Health Care."

At the onset of the transition, the health status of the Czech Republic lagged behind in some of the health statistics when compared to other countries of Western Europe (Note the relatively high infant mortality rate for the CSFR in Table 2). Noticeably, however, the relative expenditures on health care were least in the CSFR. However, as the decade of the nineties finished, the Czech Republic was among the healthiest countries in Central Europe. Life expectancy at birth was 71.1 years for men and 78,1 years for women and infant mortality as 5.2/1000 live births in 1998. The leading cause of death is diseases of the circulatory system, especially ischemic heart disease or heart attacks.

High abortion rates have been documented in the Czech Republic, particularly in the Bohemian region. (46, 47) This problem has also been an important issue in Cuba and Hungary. The peak incidence of abortion in the Czech Republic occurred in 1988 at 94 abortions per 100 live births. This figure is less than that of Cuba at 104 abortions for 100 live births. A study of reproductive practice and health in the Czech Republic revealed that only 15 percent of women used an intrauterine device for contraception while only 5 % used oral contraceptives. These levels of contraception in women of reproductive age are very low suggesting that a high prevalence of abortion maybe related to deficient contraceptive practices and/or lack of sexual education.

During the transition, the Czech authorities prepared a new abortion bill through which patients would have to pay for the abortion unless the pregnancy posed a dangerous health risks or the pregnancy was the result from rape. The costs for abortion in the Czech Republic were of the order to 71 to 107 US dollars or the equivalent of an average monthly salary. (17)

Despite the fact that the Health Care Act of 1966 considered health care a civil right in the CSFR, inequalities existed in the Czech health services for more than 30 years before the transition. In practice, gratuities, under-the-table payments, and political influences were instrumental in determining the quality of care, choice of physician, access to specialists, position on a waiting list, acquisition of imported medications, and perpetuation of the inequalities. An unofficial fee for service sector already existed in socialist CSFR under Communist rule. That is, there were direct, under-the-table payments to physicians and health care workers made by patients and their families. In 1988, it was estimated that these untaxed revenues amounted to 210 to 290 million US dollars annually.

From 1990 to 1991, the Semashko type of health care system was liberalized. Since 1991, legal amendments to the Czech National Health Care Act were passed by the transition parliament. The new Czech health system moved quickly to a compulsory social insurance model of health care with multiple health insurance funds. Czechs have still the right to health care with the added benefit of being able to choose the physician, practitioner and health care facility of their preference. During the totalitarian, communist regime, Czechs were assigned to physicians and health care facilities by the authorities.

Administrative staffing changed during the transition in the Czech Republic. Eighteen months into the transition in the Ministry of Health, 80% of the top-level officers and 40% of its staff had been changed. A similar trend occurred at the community level where 90 % of the directors and 70% of the department heads were replaced.

Under the totalitarian, communist rule, the health budget of the CSFR was administered and financed solely from the state budget It has been widely recognized since then that the much propagandized "free health care for all" Czechs was an illusion. It has been said that: "health services financing derived from nontransparent governmental tax revenues, which gave vested interests groups the power to distort national priorities to suit their own interest groups."

The new Czech health services are being funded from a national budget plus: municipal taxes, health insurance funds through compulsory participation, direct payment for health services, and fines for environmental and health risks and damages.

The Czech Republic has a national formulary consisting of approximately 6000 drugs. Seventy-one percent of these are considered indispensable and covered by the National Health Service. The other categories of drugs, non-indispensable, require a co-payment from the patient or their family. Subsidies for the incapacitated and the poor are provided by the State. Co-payments were only begun being collected about three years after the transition began in the Czech Republic. The practice of collecting co-payments at the point of service has been found to be useful in health care for the prevention of over utilization.

Insurance premiums in the Czech Republic have been organized to cost from 5 to 10 % of the employee's salary. The premiums are paid as follows: one third is paid by the employee and two thirds are paid by the employer. The national insurance agency contracts with providers, private physicians, and public facilities regarding prices and procedures covered.

The new Czech health system is based on decentralization and demonopolization. One year after the onset of the transition, in 1990, all regional health authorities of the Czech communist health system were replaced by district and community bodies that were responsible for assuring the basic health needs of the people they served. Most governmental facilities began to undergo a major transition and became autonomous. By 1992,500 such facilities in the Czech Republic had undergone the transition into a "plurality of ownership." The Czech Health System expects that these autonomous facilities will function along side of private and religious health care facilities in the future.

The private practice of medicine and nursing is part of the new Czech health system. Regulations for these types of practices were discussed and passed by the Czech government in 1992. (47) By the mid 1990's, however, only 37% of Czech physicians were engaged in the private practice of medicine. It is expected, that the "Chamber of Physicians" will be an instrumental and major role in monitoring physician attitudes and behavior, overseeing physician training and credentialing, accreditation of health care facilities, setting ethical standards and clinical guidelines, and collective negotiations between all parties or stakeholders in the national health system.

The liberalization of the Czech health system led initially to overuse of services. This led to overcrowding of certain services such as specialist services leading to financial deficits and patient and provider dissatisfaction.

In summary, the current Czech health system is a Bismarckian social health insurance system with mandatory participation for the entire population and a public/private mix for the provision of health care. The insurance funds are funded by the contributions by individuals, employers, and the state. The diversity of providers of health care goes from the private, ambulatory health care providers to the public (state) hospitals. A diagnostic related group (DRG) type of reimbursement methods has been adopted. Health facilities enter into contractual arrangements with the various insurance funds and the state in order to come up with their own financing. There is wide spread joint negotiations of all key actors or stakeholders in health care on the coverage and reimbursement issues. Remedial mechanism has been important in sustaining the activities and progress of the reformed Czech health system. However, some of the Czech health insurance funds have gone into bankruptcy. Indeed, the challenges of the Czech health system have centered on financing and debt management.

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Germany (8, 9, 10)

Germany covers an area of 356,978 square kilometers. This is roughly three times the size of Cuba. The total population is 82 million, more than seven times the population of Cuba. Germany is a federal republic consisting of 16 States or Lander. Each of the Landers has a constitution and in most of them there is a health ministry. The national legislative authority lies in the Landers except for the specific areas defined in the Basic Law of the Federal government. The areas of concern to the National government (Federal government) are:

• Foreign affairs                                                     

• Defense

• Military matters

• Air travel                                                                                                                              

• Some elements of taxation

• Where Lander specifically yields to the federal level the right to enact framework legislation.

All internal administration lies in the hands of the states.

The German Democratic Republic, East Germany (GDR) was unique in that it was rapidly absorbed into the Western European system when it fused with the Federal Republic, West Germany (FRG). The Germans have a long history of health care system organization. The Bismarck system originated in Germany. During the national-socialist (Nazi) regime, the health care financing, organization and delivery system remained unchanged. In 1934, the national associations of physicians were organized and entrusted with making decisions regarding the registration of private physicians and their office-based practices. These organizations are functioned to negotiate contracts with the various insurance funds. The Nazi regime did intervene in health matters beyond the health experimentation, torture, murder, detention in concentration camps, separation of families, and genocide of prisoners, however.

Access to adequate health care was increasingly restricted in Nazi Germany to the Jewish population and other stigmatized minorities. Early in the Nazi regime, Jewish doctors were prohibited to treat patients or to participate in the insurance funds. Up to 1938 the Jewish physicians were allowed to treat Jewish patients. After this date, they were not allowed to practice medicine at all. Unfortunately, the majority of the medical profession practicing and licensed in Germany at the time, welcome the exclusion policies against Jewish doctors.

After the fall of the Third Reich in May 1945, the Germans divided in the FRG and the DRG. The Bismarck system prevailed in the FRG and the Semashko system was adopted in the DRG. The DRG health system was very much like that of the Soviet Union except that in Germany, the structural division between ambulatory and hospital services seemed better coordinated than in the Soviet Union. A social insurance fund was maintained in the DRG. In the FRG, local sickness funds, labor unions, and the Social Democratic Party worked for a single insurance fund for health, old age, and unemployment benefits. Eventually, some funds where managed by corporatist representatives with little, if variable, transparency and democratic rights for the insured.

Public lack of satisfaction led to protests in favor for political and economic reform in the DRG. The movement led to the fall of the Berlin Wall in November, 1989. Essentially, the sovereignty of the DRG ended. In 1990, the Treaty of German Re-Unification was signed integrating the 17 million citizens of East Germany to West Germany.

Very early in the transition, West German Health Service was made available to the former GDR immediately. Data on health on the two parts of Germany is confounded also by the appreciable migrations from East to West Germany that occurred early in the 1990's. By the end of the decade, 1999, the data from East Germany was not identical but approaching the data on life expectancy from West Germany. Only minor compromises were made concerning the financing and delivery of health care in the unified Germany. The Treaty for Re-Unification granted the community healthcare center, the polyclinics, only five years grace period after which they were to negotiate jointly with the regional organizations of physicians. Physicians were remunerated through a capitation type of system in the polyclinics. However, the payments of physician services were based on fee-for-service schedules when services were rendered in an approved private office. By 1992, 91% of German physicians engaged in patient care were running their own private practices.

The differences in life expectancy for men and women in Germany, East, and West Germany provide a health parameter whereby it is possible to judge the progress of the unification of the "two Germanics" throughout the transition. These data are summarized in Table 11.

Table 11. Life expectancy at birth for East and West Germany
(1980-1997). (10)

Since unification, the gap in life expectancy has evidently narrowed. This is slightly more evident for women than form men. Several observers have suggested that these data can be explained from the following considerations.

• Adoption of a federal social welfare system, a safety net

• Adoption of the FRG health system to cover the new, unified Germany. That is discarding the Semashko system of the former GDR.

• Greater personal, individual freedom.

• Greater attention and improvements in the environment.

According to the 1995 micro-census, 9.4 million persons (12.3% of the population) were "not-healthy." Of these, around 8.4 million people in Germany considered themselves sick and 0.7 million reported being injured by accidents. In 1998,852,400 people died and 785,000 were born. The main causes of death were cardiovascular diseases amounting to 50% of all deaths and malignant tumors, approximately 25% of all deaths. The mortality rates of cardiovascular disease and malignant neoplasms are higher in Germany than the average for the European Union.

The key elements of the German Health Care Act were (10)

• Legally   approved health spending caps.
• Legally   fixed health budgets.
• Introduction of a prospective payment system for certain diagnoses, certain    procedures.
• Loosening of strict separation of inpatient and ambulatory services.
• Introduction of ambulatory surgery centers.
• Freedom to select a sickness fund by any user.
• Introduction of risk compensation scheme.

In terms of health, the Federal government is responsible in Germany for:

• Administration, regulation of financing and international relations

• Pharmaceutical, medical products licensing

• Long-term care

• Health care standards

• Statutory health insurance

• Consumer related issues

In 1992, the budget for health services in Germany imposed a cap in the expenditures for pharmaceuticals at 26.7 billion DM.

The State, Land's, responsibilities in Germany is summarized by these points:

• Public health services( Vaccination, epidemiology, etc.)

• Environmental hygiene and inspections.

• Health promotion

• State-owned hospital management, infrastructure and operation.

• Hospital and medical equipment planning             ,

• Supervision of health professionals and their professional organizations.

• Supervision of pharmacies, pharmacists and their professional institutions.

It should be noted that the Land's have the right to yield their responsibilities in terms of health care to the Federal government. By 2000, half of the Lander had yielded these responsibilities to the Federal government.

The last level of organization in the current German system is the so-called "corporatism." These corporatists are essentially boards that supervise and manage the various health funds and their interactions with the physicians, health care providers, and the State. AH sickness funds are non-for-profit organizations.

Some of the responsibilities of the "corporatists" are:

• Self regulation of health institutions

• Interaction of health institutions with the judicial system.

• Negotiation prices with various stakeholders

• Adjusting contributions of payers to the various health funds.

The health system of the former DRG was highly centralized. After the Treaty of Re-Unification, decentralization became policy. Some of the state powers were delegated to corporatists. Some privatization of health services has occurred in Germany since the re-unification. Most of the privatized services have been in the areas of medical office based services, ambulatory services, pharmaceutical services and dental services. Both for-profit and not-for-profit organizations coexist side by side. In 1998, 55.3% of hospital beds were under State ownership (governmental), 37.9% were private not-for-profit, and 6.8% were private for-profit.

In summary, the German system puts emphasis on free access, high numbers of able and willing providers, and controlled technological advances within the financial and budgetary controls of the federal system. Cost-effectiveness and cost-containment are essential to the German system. Unlike some of the countries, waiting lists and rationing have been avoided in Germany. These priorities have been accomplished though a complicated decision-making system in the framework of statutory health insurance system. The latter includes a number of co-payments which limits are set by law.

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Hungary (13, 48, 49)

The territory of Hungary, 93,000 squared kilometers is slightly smaller, by a factor of approximately 16%, than that of Cuba. The population of Hungary, however, is 10.1 million. Hungary is one of the former soviet-block countries whose population has been decreasing in the past 15 years due to decreasing natality rates and high emigration rates. Health and social statistics for Hungary contain data for their most numerous minority, the Roma or Gypsy population. The life expectancy, infant mortality and other health parameter for this minority of approximately half a million persons is lower than that for the majority population of Hungary.

Before the transition, Hungary had the worst health indicators in central Europe. Health services were managed through a Semashko type of health system with a highly centralized hospital-centered service. Concern by health care providers and patients began to increase in the 1980's. The Hungarian health system offered little choices and a poor standard of care.

Since October 1989, Hungary has begun a progressive transition from communism. It has been governed by coalition governments and a unicameral parliament with 386 seats whose members are cyclically elected every four years. Unemployment increased slightly during the first years of the transition. Under communist rule, in 1989, the rate of unemployment under socialism was 0.5%. By 1992, the rate of unemployment increased to 13.9%. It peaked in 1993 at 14.0% Since then, it has decreased. However, by 1998, the unemployment rate was 7.8%, a cipher which is much higher that the pre-transition level of unemployment.

Life expectancy in Hungary in 1996 was 74.7 for women and 66.1 for men. These levels are appreciably lower than the corresponding figures for the average European Union, 80.8 and 74.2 respectively. The life expectancy for men decreased slightly in Hungary during the early years of the transition from 65.1 in 1990 to 64.2 in 1992. Life expectancy for women, however, did not increase during the transition.

Table 12. Changing Health indicators in Hungary during the transition. (48)

Some mortality rates for specific diseases have decreased in Hungary during the transition. The rate for cardiovascular diseases has fallen to 16.3 deaths per 1000 population in 1996. This rate, however, is still appreciably higher than the average rate for the European Union, 7.4/1000 pop. A similar trend has occurred in cancer mortality. The Hungarian rate has decreased to 2.8 deaths per 1000 population secondary to cancer. The corresponding average mortality for cancer in the EU was 1.9 in 1996. An impressive decrease in the mortality from infectious disease has been registered in Hungary during the transition.

Life expectancy in men did increase during the early transition years. A summary of worsening health statistics for Hungary during the transition is summarized in Table 12. Life expectancy for males has improved since 1998, however. Most observers agree that the poor performance of these health indicators, except for abortion inducement, are due in great part to high consumption of alcohol, tobacco smoking, and high saturated fat diet. Contrasting with these observations, Hungary has maintained a 100% vaccination rate according to the WHO European Region data for 1998.

The health sector became a priority in Hungary because it dominated the state's financial difficulties from 1994 to 1998. (13) The Ministry of Health had difficulties in providing continuity for its goals and services. Throughout the Hungarian transition, the following points seemed important:

• Establishment of a national health insurance fund

• Decentralization of health services

• Shifting the role of government as the dominant provider

• Transferring of ownership of most health care facilities to local governments

• Organizing the privatization of some health facilities and services

• The adoption of mother concepts of public health

• The strengthening of primary health care.

A Health Insurance fund has been established in Hungary. Originally, the insurance fund worked in a highly centralized fashion but the tendency throughout the transition has been to decentralize its operation. Throughout the transition, however, Hungary maintained the principle of universal coverage for all the people. The Ministry of Health interacts with the Ministries of Finance and Education providing administrative and financial resources for health care facilities and universities.

Hungary increased slightly the number of physicians and hospital beds during the transition. This is important to point out because Hungary is known to have had more doctors per population ratio than most countries in Europe. There were five Hungarian medical schools graduating approximately 700 physicians per year by 1997.

Table 13. Physicians, Bed Utilization, and Selected Economic Parameters in Hungary before and during the transition. (1970, 1992). (42,48)

By 1990, the Hungarian health expenditure had increased to US $ 1,838 billion. Insurance was introduced during the transition. Employees pay 10% of their earnings through a payroll deduction. The employers pay 43% of the wages to the same fund. In Hungary, this combined fund includes health benefits, retirement benefits, worker's compensation, unemployment benefits, and other social benefits. It is noteworthy that a substantial portion of this fund, 33% of the collected premiums paid into this multipurpose fund, is dedicated to health care. In 1990, the social insurance provided 58.3% of the health expenses. Personal out-of-pocket expenses by patients and their families was 16.4%. The balance to 100%, 25.3%, was provided by governmental state financing.

Price negotiations in issues involving health care are undertaken by government committees. Consideration is given to the Hungarian social and economic situation and international and regional trends and standards. Hungary signed up in 1992 to the European Free Trade Area agreement and the Pharmaceutical Inspection Convention.

A National Pharmaceutical Institute operates with a mission that is said to be similar to the American FDA. Hungary is unique in that is a drug exporter second only to Switzerland. Therefore, 80% of drugs used in Hungary are produced in the country.

A physician just out of school earns a base salary of about US $ 125 per month. This is only 114% of the minimum wage in Hungary. After the transition, however, monetary benefits were added into the economics of health care. Bonuses are given to physicians for increased patient load, age distribution of patients, and years from graduation.

Annual medication costs in Hungary are of the order of US $ 50.00 per person. There is a co-payment of 15% of the price for medications used outside the hospital. The pharmaceutical formulary is controlled by a national pharmaceutical institute. Most drugs consumed in Hungary are, however, produced in Hungary. In fact, Hungary is an exporter of medications. Hungarian pharmaceuticals account for 5% of the global drug market. Furthermore, two-thirds of the medical instrumentation used in clinics and hospitals in Hungary was produced domestically.

In Hungary, there is a national, state, county, and city hierarchy of medical institutions. A parliamentary multipartisan committee controls health care laws and their implementation. The national medical structure is handled through the Ministry of Welfare. Through this ministry, the states or regions obtain block grants on the basis of population, development, and previous allocations. These funds are distributed to each of the 19 states and the city of Budapest. Each of these committees has an elected membership and an executive committee. The municipalities or counties are involved in the administration of the local polyclinics. In Budapest alone, for example, there are 22 counties with an equal number of autonomous medical centers. These polyclinics serve approximately 5,000 persons with 2 general physicians, one pediatrician, one dentist, one "factory" doctor, 9 clinic nurses, 4 home visitor nurses, and 2 "district" nurses.

Quality of services is assessed every five years. Hungary is already part of the European Union. Therefore, EU organizations such as the European Community's Medical Health and Research Coordination Program are involved in the Hungarian health services.

In 1996, there were 162 hospitals in Hungary. Municipal hospitals had an average of 370 beds serving about a 100,000 person population. These hospitals have internal medicine, general surgery, obstetrics and gynecological, and pediatrics services. They serve a network of primary care providers in a particular region. The second tier of hospitals is known to be -.County Hospitals." These inpatient facilities had an average of 1,200 beds providing services hemodialysis services, invasive cardiology, oncology, psychiatric and other highly specialized services. A third tier of services is provided by the medical universities and the health institutes. These facilities provide highly specialized services in the care of complex trauma, transplantation, vascular surgery, and advanced rehabilitative services. Since the transition, the number of beds in Hungary, likewise to other countries of the former soviet-block in the transition, has decreased. 1990 Hungry had 7.1 beds per 1000 population. The rate decreased to 5.8 beds per 1000 during the transition.

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Poland (13, 51, 52)

The Republic of Poland is the largest country in Eastern Europe with 312,685 square km of territory. The population in 1997 was 38.6 million. Poland is also the most ethnically homogenous country in Eastern Europe. Although Poland is more than three times larger than Cuba, much of the relative health data for Poland is similar to that of Cuba. Except in the number of medical schools where Poland has 11 institutions and Cuba had 22 in 2000.

Worsening economic problems during the 1980's provided an important stimulus for the reforms that eventually led to the organization of the Solidarnosc movement and the break up with the Soviet Union. In 1990, a presidential election was held and in October of 1991 elections were he for the delegates to the two houses of the Polish parliament.

Life expectancy at birth has improved slightly during the first 10 years of transition out of communism. By the latter part of the 1990's, life expectancy at birth for males had improved from 66.1 in 1991 to 68.1 years in 1996. A similar trend was observed in the data for life expectancy j birth in females where the rate was 75.3 in 1001 and 76.6 years in 1996. Experts in Poland's health have suggested that the improvement has been due to the consumption of an improved diet. Infant mortality has decreased throughout the transition. This important health parameter was 18.2 deaths per 1000 live births in 1991. By 1996, the infant mortality in Poland has decreased to 12. per 1000 live births.

The health transition in Poland, however, was accompanied by relatively "little" change in the services and structures of health services during the early 1990's. Not all health statistics have been favorable in the Polish health transition. For example, in middle-aged men and women, Poland has had an increase in general mortality. Diseases of the circulatory system are the major cause of death, followed by cancer. The rate of deaths due to suicide and "external causes" increased by at least 7% in Poland during the transition.

Paradoxically, when the Soviet Union fell in 1989, Poland took the lead in proposing widespread political reform. It was assumed that health reform would follow. However, the Polish Ministry Health (MOH) was not reorganized to handle the expected changes that would have been logics in the context of an overall social, economic, and political reform. Poverty levels increased during the early transition when inflation reached a peak in 1996 to 20%. These unfavorable social an< economic conditions were also associated with rising rates of unemployment. The unemployment rate in Poland in 1993 was 16.4%.

Since Poland was the first Eastern European country to break up with the former Soviet-Union was though that it would embark in radical transformation of its health services soon after its "independence." However, Poland's health transition occurred somewhat more slowly than in other countries of the region.

The health transition in Poland has been occurring through three fundamental steps: (50)

• Decentralization
• Transfer of ownership from the central government to a diverse group of entities:
  • Voivodships  (provinces)
  • Local governments (Gminas)
  • Cooperatives
  • Voluntary, religious organizations
  • And finally the private sector.
  • Establishment of 16 regional (provincial) health insurance trusts providing universal health coverage for the entire population.

These three goals were not accomplished immediately after the break up with the former Soviet Union. Decentralization began to be implemented in 1990. It progressed from the central government to the voivodships. These provincial units then further decentralized their power to the smaller population units. By 1991, the administration of all health services had been transferred to the voivodships.

The financial aspects of these transfers did not begin until 1993. At that time and on an ongoing basis, financial transfers began to occur towards the provinces and the local governments. The third arm of the Polish health transition did not begin to take place until 1997 when the insurance legislation was passed and enacted after several amendments.

After Poland began to assess and address their health needs during the transition, prevention continued to be their most important priority to the exclusion of all other health issues. There were 81,641 physicians in Poland in 1990. License to practice medicine in Poland has been granted by a "Doctor's Chamber" at the regional level. However, little has been done in order to provide health professionals to the rural areas at a similar level than the urban centers. Medical specialties in Poland have not included Family Medicine. During the health transition, this specialty was introduced into the Polish medical training programs.

Since 1992, the European Community has funded programs for family medicine training in Poland. Integration of medical education programs with regional countries has improved the overall prospects for young physicians in Poland.

Furthermore, there were no appreciable measures taken to adapt the profiles and rates of specialists versus generalist physicians to the needs of the population and the market for the transition period and beyond. Hence, the Polish medical profession has become dominated by specialists with interests that perhaps are not necessarily those of the local communities. This may present a dilemma since the local governments and communities have the organizational power and the financial responsibility for health care services.

Polish physicians are allowed to practice medicine privately but only after finishing their duties in the public sector and outside the premises of public health facilities. All hospitals in Poland are state owned. However, 6% of outpatient facilities were owned by private physicians in 1990. Paradoxically, the number of these entrepreneurial projects decreased as Poland advanced through the early nineties. Some observers have documented the fact that private facilities had unsurpassable financial difficulties in the emerging private health market.

Poland organized an insurance system late during its health transition. Universal obligatory insurance is, however, available for all working persons. Other insurance funds cover special groups and exceptional or catastrophic needs.

Some have argued that the lack of progress in the health services in Poland has been due to economic instability. Indeed, early in the transition there were discussion of reforms but the means of implementing the reforms were never identified or adopted. By the latter part of the decade of the nineties, WHO, Project Hope, and the Polish Ministry of Health and Social Welfare organized conferences where definite plans were discussed and agreed upon. These task forces established priorities in national health promotion, primary care, infrastructure, regionalization of services, decentralization, networking, and financing. Two years after these conferences began to function, changes were already evident in the clinics, the fields, and the health data for Poland.

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Romania (20)

The estimated population of Romania was 22.8 million in 1999. Romania had the highest percentage of population in poverty in Europe according to the World Health Report. During the transition after 1989, the working population dropped by at least 13%. Unemployment was 8.8% in 1997.

Romania had a Semashko type of health system for four decades. The transition from communism in Romania has been said to have been the slowest of all Eastern European countries. Romania was not particularly famous for its health services during the Communist era. From 1985 to 1989, Romania dedicated only 2.2% of its budget to health services. The amount increased to 2.8% early in the transition, 3.9% in 1999 and 4.0% in 2000. By the latter year, the health budget increased to US $ 1,340 million.

Romania had one of the highest rates of tuberculosis in Europe before the transition. (20) Romania was reported to have an un-expectedly high rate of pediatrics HIV/AIDS. By 1998, the leading causes of death reported were cardiovascular disease, cancer and respiratory diseases. By 1995, Romania had reformed the centralized health system prevalent under communist rule. By the end of the 1990's, Romania had operating several health insurance funds that worked through contractual agreements with various facilities and providers. Health insurance is mandatory, linked to employment, and financed in equal proportions by employees and employers.

Table 14. Health care providers in Romania during the transition.
(1989-1999) (4,20)

* Ratio of rate per 10,000 population in 1999 to the rate in 1989 subtracted algebraically from 100%.

In the Bismarckian type of insurance system of Romania, the employees pay 7% and the self employed pay 14% of their gross income before income tax deductions for health care. This system is similar to the Solidarity type of insurance of Poland. Employer's pay a part of the premium which is equal to 7% of the total amount of salaries. A portion of the social security budget goes to this insurance fund to cover the needs of the elderly. The local health districts provide funds for the unemployed and employees on maternity leave. Since its introduction, the Romanian health insurance fund has increased from zero percent of total national health expenditures in 1995, to 60% in 1998, and 85% in 2000.

Since 1995, laws and regulations began to be passed in Romania in order to decentralize the health service administration. Other legislation dealt with the establishment of a college of physicians, practice of the medical profession, and social health insurance. It was not until 1989 that the law on social health insurance was implemented in Romania. The process of decentralization of the decision-making and other priorities in health care in Romania had not been completed in 2002.

"District Directorates" were organized to serve the population at large. Essentially, these are semiautonomous units of the Ministry of Health representing a public health authority in each district. The directorates are responsible for preventive medicine, health promotion, medical public health inspection of various public and private facilities, licensing controls, financial responsibility, and statistical review of health and demographic data.

Romania has a relatively low number of physicians when compared to Poland or Cuba. In some countries during the transition, the number of health professionals has increased (Bulgaria), but in others like Romania, they have decreased.

The number of beds in Romania may seem disproportionately high at 7.3 hospital beds/1000 population. If this figure is adjusted so that it does not include psychiatric and tuberculosis beds, the rate is more reasonable, 5.3 beds/1000. The length of stay in Romania hospitals is appreciably higher than in other countries in the region. This obviously adds to the inefficiency and the high costs of care in a country where the expenditures for health care are relatively for on a per=capita basis.

Privatization in the area of health has been miniscule. It has involved dental and pharmacist service centers. However, unlike Poland where there are no private hospitals, in Romania there were in 1998 two privately owned hospitals.

The remarkable progress of Romania has occurred in the financing of health services. In 1996, almost 60% of the health expenditures were provided by the state budget. This amount has decreased to 10% in 2000. The balance has been filled through the insurance funds, local budgets, and out-of-pocket expenses.

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Russian Federation (28)

The corner stone of the former Soviet-Union turned into the Russian Federation after 1989. It is an immensely diverse country with more than 75 nationalities and ethnic groups. Its population in 1995 was 147.9 million and 72.9% of the lived in urban areas. The latter figure suggests that most of its 17.1 million square kilometers are either uninhabited or very sparsely so. All aspects of health have been dramatically influenced by the transition from the former Soviet-Union to the Federation.

During the Russian transition, industrial output and gross domestic product declined. These tendencies exerted a dramatic influence in the health budget for the Russian Federation. With a dwindling budget and increasing autonomy of the various republics that formed the Soviet Union, it is not difficult to appreciate the calamitous situation in which Russian health began its transition.

The Soviet-Union had been recognized with accomplishments in health services. For example, the central health related accomplishments included universal coverage, compulsory immunizations, periodic health checks and equitable access to health care. However, health services and health status in the former Soviet-Union were poor in comparison with industrialized countries.

The health status of Russians has not improved during the transition, however. There has been a dramatic increase in the mortality rates and consequent decrease in life expectancy at birth. The main causes of death in Russia are diseases of the cardiovascular system, cancers, trauma, suicide and "external causes" and respiratory ailments. Cardiovascular diseases including heart attacks, heart failure, and strokes have increased by 7.5% during the transition. The rate of neoplasms (cancers) has increased by 7.3%. The most impressive rise in mortality in Russian during the health transition has been documented in the area of suicide and "external causes" by 191.2%. Respiratory mortality has increased by 1%.

In 1993, a national survey, the Russian Longitudinal National Survey began tracking the health status of Russians. From September 1993 to December, 1994 there was an appreciable increase in the consumption of alcohol. The consumption of alcohol increased by 136% in men and 71% in women during the transition.

Considering the increased mortality rates for diseases of the heart and others and the high prevalence of alcoholism and tobacco smoking (60% of men and 25% of women), it should not be surprising that important health indicators have deteriorated during the transition. Indeed, from 1990 until 1994, life expectancy at birth for Russians decreased by seven years. In fact, the life expectancy for males at birth in Russia in 1994 was 57.3 years. The latter health indicator is a par with the life expectancy for males in Pakistan.

Although there is widespread concern about the dietary practices in Russia, the nutritional status of children is most worrisome. Stunting, an indicator of chronic malnutrition, has almost doubled during the transition. In 1990, the rate of stunting in children up to 24 months of age was 6.9%. By 1994, the rate of stunting had increased to 12.8% in the same age range. Infant mortality has also increased from 18 per 1000 live births in the early 1990's to 20 by 1993.

Women's health was not optimal in the former Soviet-Union but it has deteriorated further during the transition. Maternal death rates in Russia were of the order of 51.6 per 100,000 live births in 1993. This figure is five to ten times greater than the equivalent international levels in Europe.

A relatively high percentage of maternal deaths in Russia during the transition are due to abortions. During the Stalin regime, Russia had an aggressive pro-natality policy. Contraception was prohibited and clandestine abortions became the only available method for natality control for the simple people. Almost 30% of the maternal deaths in Russian are due to complications from abortions. The rate of abortions performed in Russia is 224.62 abortions per 100 live births is nearly doubled that of Cuba.

The private sector in health care is permissible in the Russian Federation. However, it has not been developed to any extent. Ownership of hospitals remains 100% in the hands of the state. It has been observed, however, that there were a number of "closed clinics" in the former Soviet-Union. These facilities served the high party officials the so-called nomenklatura, and specially invited foreigners. These "closed facilities" were not accessible to the Russian population before the dissolution of the former Soviet-Union. After the transition, these formerly "closed" health facilities, have been the only ones capable to amass the fee-for-service health services of the transition era. The private sector has made advances in the pharmaceutical industry, ophthalmological practices and surgery centers, and dental clinics.

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Cuba's health in transition vis-a-vis the experiences of the for former soviet block countries.

Cuba's health services have been dominated by a Semashko type of health system since the early 1960's. Despite the gains in health indicators in Cuba during the 1970's, most Cuban health care workers and physicians remained dissatisfied with the Cuban health system. In a report that followed an official visit to Cuba's health installations, Conover and others found that the ambitions of Cuban physicians were not different from those of their American counterparts at that time. They essentially wanted to go for advanced training, acquire specialized skills with which to attend patients, and be able to dedicate time to their family life. Cuba's health services were described in these terms after they left the island. The authors had been invited to Cuba by the Castro regime. They wrote after leaving Cuba:

"In the 20 years since the revolution, Cuba has gone from the health profile of an underdeveloped country to that of a developed one. Heart disease and cancer are the leading causes of death. Infant mortality has been drastically reduced. Maternal mortality is lower than any other Latin American country. Improvements have been accomplished through better nutrition, a medical system that is national, free, accessible, and well-organized, and health education and immunization programs. The health system is doctor-dominated. The nurse is subservient to the doctor, who has acquired technical skills and status comparable to his American counterparts. Curative, rather than preventive, medicine is emphasized. The diet is high in fat and sugar. Many in the population, including the medical profession, smoke cigarettes." (53)

At the conclusion of their paper, however, they conceded:

"Cuba has created a generation of doctors who believe that they make the primary contribution to the people's health. Although most physicians support the ideals of the revolution, status is still accorded to those with diagnostic acumen, specialized qualifications, and academic credentials." (53)

Considering the priorities of the socialist health services described earlier in this work, it is unlikely that Cuba completed the socialist goals that seemed important to socialist health planners. The curative health services were still important in the early 1980's. Furthermore, the "demystification" of medicine and physicians in particular seemed to have been started but it never got completed. Notice that Cuban doctors were concerned about Improving their skills and attaining higher academic credentials.

Cuba stands out among the former soviet-block countries in various demographic indicators. These data are summarized in Table 15. (54)

Cuba's health indicators can be satisfactorily compared with those of the Czech Republic and Germany. It will be recalled that these two countries were promoters of the transition in their health services.

The population of Cuba can be considered a relatively younger population among all of these countries. Twenty-three percent of the population is younger than 15 years of age. In this column, Cuba competes with Romania and the Russian Federation. However, Cuba has the lowest percentage of population 60 years of age or older. In this column, Cuba fairs equally low with the Czech Republic.

The health services of Cuba have been known to be plagued with under-the-table payments. As far back as the 1970's Cubans used gifts and tips in order to get health benefits. The harsh realities of the "período especial" in the 1990's aggravated the under-the-table payments. With the advent of the "dollar economy" Cubans used dollars obtained in their "bizne" or through the funds sent from their relatives outside of Cuba, mainly in the United States, to obtain medications and health services that would not be available to them otherwise. A formal separation of the egalitarian, socialist health service under communism and a fee-for service system has evolved in Cuba in the past 10 years. The system may be called a "health apartheid" reminiscent of the discriminatory practices of South Africa many years ago. It is widely known that the Castro regime in the past years has organized and operates separate health services for tourists and the "dollar areas" where Cubans are not allowed to be treated through their national health system.

The process of the transition in Cuba may have already begun in the minds of many Cuban health care workers and physicians. Since 1996, groups associated with the dissident movements in the island have entered into an informal but fruitful dialog regarding the changes that must be made in Cuba's health system. At the end of one of these meetings in San Antonio de Los Altos in Venezuela, the following agreement was signed by approximately 15 physicians. (55)

• The corner stone of the new Cuban health service shall be the highest respect for life and the dignity of all human beings in whatever state of health they may be.
• There must be uniform access to health care by all the population irrespective of race, age, religious beliefs, economic status or political affiliation.
• The highest quality of medical care will be offered through continued monitoring and improvement in the skills and standards of the physicians and all health care personnel.
• The practice of medicine, the practice of clinical investigations and medical teaching will be carried out in accordance with the highest scientific and moral values. There will be a democratically agreed upon set of codes of conduct and medical ethics that will serve to include all patients and all practitioners.
• Physicians and all health care professionals will be allowed to associate themselves for the purposes of governing their professions, to be able to enter into contracts, negotiate their terms of employment, and other matters that during the socialist regime were considered off limits.

A proclamation such as this one and the encounter that generated it may well serve to begin the national dialog that will launch the Cuban transition in the health services.

Cuba has at this time more than 30 medical journals. (56) While it is tempting to provide a venue for publication to medical workers in the island and the rest of the world, these publications carry in them a price tag. However, in a market economy, it ma be possible to obtain advertising dollars for the financial requirements of these projects.

The serious mental disorders and substance abuse, including alcohol that became •ore prevalent in certain countries in Central and Eastern Europe during their transition do threaten Cuba's transition. Furthermore, it is more evident now that several years ago that role of stress and sudden social change in the development of tie Post-Traumatic Stress Disorders. Unfortunately, this syndrome associated with anxiety, depression, poor worker productivity, and violence has not always been prevented in optimal fashion. Recently, a group from the University of Miami published a study where it was found that all children that were housed in the Guantánamo Naval Base refugee camps in 1994-1995 suffered from Post-Traumatic Stress Disorder. Not all children had the same clinical features. Some had depression; others had poor attention span, etc. But all had some elements of this syndrome. Obviously, a transition involving all aspects of society may place the population at risk of this disorder. However, advance knowledge of these stressors and of the population itself, may be used in order to minimize the severe effects of these changes. (57, 58)

The nutritional factors that led to the health disasters of the early 1990's in Cuba must be avoided through a well planned and executed system of national nutrition. In the experience of the Central and European countries transition, it was evident that lack of certain vitamins in the diet may have been aggravated by the social changes occurring. During the socialist Cuban experience it has been customary to pass the blame for all shortages, including the shortages of Cuban grown tubers and fruits, on the American embargo. Indeed, a number of international publications have echoed the Castro regime rationale for the scarcity of food in Cuba. (56)

Finally, Cuba's role in the WHO must be maintained and if possible expanded. Recently, Cuba was part of a control study together with Argentina, Saudi Arabia, and Thailand. The study dealt with the provision of antenatal care to pregnant women in various cultural and clinical setting. (59)

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Conclusions.

The development of the Cuban socialist health services through the early 1960's was indeed similar the development of the socialist health services in most Central and Eastern European countries. All socialist health services were organized according to the criteria of the Semashko health system implemented in the Soviet Union in the 1920's under communist rule.

The socialist countries began to experience a stagnation and decline in health indicators in the 1980's. Soon after the debacle of the Soviet Union in 1989, health services began to enter into a transition from the Semashko system to various other models. The changes began to occur in Germany almost immediately since the Eastern German health system was integrated into the West German health service. The latter had a system of insurance funds that originated in Germany under Bismarck in the XTX Century. By the end of the 1990's, all Central and Eastern European countries had undergone a campaign to decentralize their health services and provide various ways of financial coverage of health services besides the state budget

Professional organizations that had been universally eliminated with the advent of communism resurged. They formed in each country a basis for self-governance, medical ethical standards, and practice. However, in most countries, physicians continued to work for the institutions and did not venture to go into private practices.

Cuba has a demographic profile and health indicators that fit the profiles of the Czech republic and Germany. The Cuban health service has been discredited through the common use of under the-table payments required to obtain services in a system that is supposed to be free of payments at the point of service. These under-the-table payments were found to be important elements of dis-stabilization in the former soviet countries at the beginning of their transitions.

It is advised that Cuban physicians and health care workers and others interested in the Cuban transitions, initiate and continue to enter into a fruitful dialog that will serve to establish the priorities upon which the new Cuban health service will be built and reformed.

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Notes and References.

1.   Nanda A, Nossikov A, Prokhorskas R, Abou Shabanah MH. Health in the central and eastern countries of WHO European Region: An Overview. Rapp. Trimest. Statist Sanit. Mond. 1993. Vol. 43; 158-165.

2.   Post-Socialist Health Care: An Aimsless Transition? Health Care Analysis 1994. Vol. 2; 89-99.

3.  Deacon B. Medical care and health under socialism. Intern. J. health servs. 1984. Vol. 14;453-480.

4.  Bara A, van den Heuvel, W JA, Maarse JAM. Reforms of health care system in Romania. Croatian Med. Journal 2002. Vol. 43, pp 446-452.

5.  Roemen M. "organized Programs of Medical Care." In Maxcy-Rosenau Public Health and     Preventive Medicine. Eds. John M. Last. Appleton Century Crofts, New York. Ppl634-1688.

6.   The Beveridge agreement dates back to 1942 in England. Its content may be accessed at: <http://www.weasel.cwc.net/beveridge.htm>. Last accessed July 6, 2003

7.   Highlights of the Semashko health system may be accessed at:

http://www.reprohealth.oig/reprohealthDB/doc/02%20Powerpoint%20Presentation%20s ession201.pdf.  Last accessed July 6, 2003.

8.   Nolte E, Shkolnikov V, McKee M. Changing Mortality Patterns in East and West Germany and Poland I: Long term trends (1960-1997). J. Epidemiol. Community Health 2000. Vol. 54;890-898.

9.   Nolte E, Shkolnikov V, McKee M. Changing Mortality Patterns in East and West Germany and Poland H:Short term trends during the transition in the 1990's.. J. Epidemiol. Community Health 2000. Vol. 54;899-906.

10. European Observatory on Health Care Systems. Health Care Systems in Transition: Germany. WHO Regional Office for Europe. 2000. pp 1-128.

11. Vienonen MA, Cezary Wlodarczyk W. Health care reforms on the European scene: evolution, revolution or seesaw? Rapp. Trimest. Statist Sanit Mond. 1993. Vol. 43; 166-169.

12. Nolte E, Scholz R, Shkolnikov V, McKee M. The contribution of medical care to changing life expectancy in Germany and Poland. Social Science & Medicine 2002. Vol. 55; 1905-1921.

13. Roemer ML Recent Health System Development in Poland and Hungary. J. Community Health 1994. Vol. 19; 153-163.

14. Deacon, B. Sociopolitics or Social Policy: Bulgarian Welfare in transition? Int. J. Health Services 1987. Vol. 17, pp 489-514.

15. Albert, A., Bennett, C., Bojar, M. Health Care in the Czech Republic: A system in transition. J. Amer. Med. Assoc. Vol. 267, pp 2461-2466,1992.

16. Nolte, E., Shkolnikov, V., McKee, M. Changing mortality patterns in East and West Germany and Poland I: Long term trends (1960-1997). J. Epidemiol. Community Health, VoL 54, pp 890-898, 2000.

17. Albert A. Bennet C, Bojar M. Health Care in the Czech Republic: A System in Transition. J. Amer. Med. Assoc. 1992. Vol. 267; 2461-2466.

18. PAHO. Health in the Americas. Washington, DC. 1998. Vol 1, p 70.

19. Kuntz D. The Politics of Suffering: The Impact of the US Embargo on the Health of the Cuban People. Int. J. of Health Servs 1994. Vol. 24; 161-179.

20. European Observatory on Health Care Systems. Health Care Systems in Transition: Romania. WHO Regional Office for Europe. 2002. pp 1-9.

21. Wortz M, and Busse R. Structural reforms for Germany's health care system? European Observatory on Health Care Systems. Newsletter of the Health Care Systems. WHO Regional Office for Europe. 2002. Vol. 4; pp.1-3. Ample information may be accessed regarding Germany GDR 2001 at: <http://www.coe.int/t/e/social cohesion/population/demographic year book/2001 Edition/ >. Last accessed no June 20,2003.

22. Jiménez Acosta S, Porrata C, and Pérez M. Evolucion de algunos indicadores alimentario-nutricionales en Cuba a partir de 1993. Rev. cub. med. Trop. 1998. Vol. 50; 270-272.

23. Makinen HI. Eastern European transition and suicide mortality. Social Science & Medicine 2000. Vol. 51; 1405-1420.

24. Balabanova D, and McKee M. Patterns of Alcohol Consumption in Bulgaria. Alcohol & Alcoholism 1999. Vol. 34;622-628.

25. Diev, Y., and Akabaliev, V. Acute Poisoning with Psychoactive Substances in 1990-2000 Period of Socieconomic Transition and Crisis in Plovdiv Region, Bulgaria. Vet. And Human Toxicol. Vol. 44, pp 132-135, 2002.

26. Makinen I.H., Eastern European transition and suicide mortality. Soc. Sci. and Med. Vol. 51, pp 1405-1420, 2000.

27. European Observatory on Health Care Systems. Health Care Systems in Transition: Czech Republic. WHO Regional Office for Europe. 2002. pp 1-9.

28. European Observatory on Health Care Systems. Health Care Systems in Transition: Russian Federation. WHO Regional Office for Europe. 1998. pp 1-75.

29. Deacon B. Sociopolitics or Social Policy: Bulgarian Welfare in Transition? Int. J. Health Servs. 1987. Vol. 17;489-513.

30. PAHO, Health in the Americas. Washington, DC. 1998. Vol. 1, page 238.

31. Balabanova D, and McKee M. Access to health care in a system in transition: The case of Bulgaria. Int. J. Health Plann. Mgmt. 2002. Vol. 17;377-395.

32. Georgieva L, Powles J, Genchev G, Salchev P, et al. Bulgarian Population in Transitional period. Croatian Med. Journal 2002. Vol. 43;240-244.

33. Balabanova D, and McKee M. Understanding informal payments for health care: the example of Bulgaria. Health Policy 2002. Vol 62; 243-273.

34. Krizova E, and Simek J. Rationing of expensive medical care in a transition country-nihil novum? J. Med. Ethics 2002. Vol 28;308-312.

35. Tymowska K. Health Service Financing in Poland. Int. J. Health Plann. Mgmt. 1987. Vol. 2; 147-157.

36. Ministerio de Salud Publica (MINSAP) 1999. "La Salud Publica en Cuba: Hechos y Cifras." La Habana. Dirección Estatal de Estadísticas.

37. PAHO. Health in the Americas. Washington, DC. 2002. Vol. 2, pp 198-212.

38. Coker, R., McKee, M. Ethical approval for health research in Central and Eastern Europe: an international study. Clinical Medicine Vol. 1, pp. 197-199,2001.

39. Note * from the Declaration of Helsinki of 1964. "The design and performance of each experimental procedure involving human subjects should be clearly formulated in an experimental protocol. This protocol should be submitted for consideration, comment, guidance, and where appropriate, approval to a specially appointed ethical review committee, which must be independent of the investigator(s), the sponsor or ay other kind of undue influence. This independent committee should be in conformity with the laws and regulations of the country in which the research experiment is performed. The committee has the right to monitor ongoing trials."

40. Szawarski, Z. Poland: Biomedical ethics in a socialist state. The Hastings Center Report, pp 27-29. June 1987.

41. Levenstein C. Environmental and occupational health during social transition in central and eastern Europe. Int. J. Occupational Medicine and Env. Health 1997. Vol 10;461-467.

42. Mendoza EM,, and Henderson BJ. Hungary: a health system in transition. Physician Executive 1996. Vol 22; 29-33.

43. European Observatory on Health Care Systems. Health Care Systems in Transition: Bulgaria. WHO Regional Office for Europe. 1999. pp 1-60.

44. Popova S. Nursing ethics: What lies ahead? The case of Bulgaria. Nursing Ethics 1996. Vol. 3; 69-72.

45. Dive Y, and Akabaliev V. Acute poisoning with psychoactive Substances in the 1990-2000 Period of Socioeconomic Transition and Crisis in Plovdiv Region, Bulgaria. Vet. Human Toxicol. 2002. Vol 44; 132-135.

46. Koupolova I, Epstein H, Holcik J, Hajioff S, et al. Health needs of the Roma population in the Czech and Slovak Republics. Social Science & Medicine 2001. Vol. 53; 1191-1204.

47. Koupilova I, McKee M, and Holcik J. Neonatal mortality in the Czech Republic during the transition. Health Policy 1998. Vol. 46; 43-52.

48. Albert, A., Bennett, C, and Bojar, M. Health Care in the Czech Republic: A system in transition. J. Amer. Med. Assoc. Vol. 267, pp 2461-2466,1992.

49. European Observatory on Health Care Systems. Health Care Systems in Transition: Hungary. WHO Regional Office for Europe. 1999. pp 1-100.

50. Elekes Z, and Kovasc L. Old and new drug consumption habits in Hungary, Romania, and Moldova. Eur. Addict Res. 2002. Vol. 8; 166-169.

51. Sheldon T. Great Expectations... Health Service Journal 1990. Vol. 100; 1070-1071.

52. Sheahan MD. Prevention in Poland: Health Care System Reform. Public Health Reports 1995. Vol 110;289-292.

53. European Observatory on Health Care Systems. Health Care Systems in Transition: Poland. WHO Regional Office for Europe. 1999. pp 1-58.

54. Conover S, Donovan S, and Susser E. Cuba's health Services. Lancet 1981. 1(8218);223-224.

55. In the form of an appendix, a copy of the document in Spanish is attached at the end of this manuscript.

56. A current list of Cuban medical journals can be accessed at: <http;//bvs.sld.cu/revistas/indice.html>

57. Role of the USA in the shortage of food and medicine in Cuba. Lancet 1996. Vol. 348; 1489-191.

58. de Jong JTVM, Komproe EH, Van Ommeren M. Commmon mental disorders in postconflict settings. Lancet 2003. Vol. 361.

59. Villar J, Ba'aqueel H, Piaggio G, Lumbiganon P, et al. Who antenatal randomized trial for the evaluation of a new model routine antenatal care. Lancet 2001. Vol. 357; 1551.

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Appendix.

Stage I

Consensus on the need to change the health system.

• Depolitization of health services.

• Availability of services and what services.

• Quality of services.

• Professional responsibility and liability.

• Individual and family responsibility on health matters.

• Financing of health budget:

• National Budget.

• Regional or Federal or Local Budgets.

• Government mediated health funds for the employed population.

• Consideration of standards on out-of-pocket expenses to aid in controlling over-utilization at the point of service.

• Coding, billing and accounting in health services.

Dialog of health professionals and the population at large to define the fundamental issues and provide guidance for political leadership regarding health.

• Personal communications.

• Consider internet base communications.

• Meetings.

• Mass communications.

Discussion of medical education issues.

Assessment of currently operating medical schools:

• Physical facilities

• Programs of study

• Faculty

• Graduates

Financial issues regarding schools and the output of professionals.

Issues regarding health professions other than medicine:

• Nursing

• Laboratory technicians

• Etc.

Ample discussion on medical ethics, expectations, decision-making issues.

• Decentralization.

• Responsibility of the individual and of society.

• Ethical standards.

• Qualifications and standards for health information dissemination on the mass media.

Consideration of guidelines on licensing and clinical conduct for private practice of various practitioners.

Stage II.

Legislation on a new health system for Cuba.

Establishment of a pharmaceutical and biotechnology industry policy.

Establishment of professional organizations.

Legislations and establishment of licensing and standards for private practice of various professions.

Organization of community based health organizations

Division of the current MINSAP into three main ministries of health for three federal-type of regions:

Occidental

Central

Oriental

Establishment of multiple funding mechanisms to diversify the national health budget

Stage III.

Diversification of financial resources.

Completion of the decentralization process and transferring of financial control the central ministries to the periphery, communities.

Completion of establishment of private, workers groups, and mutualistic type of insurance funds.

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