bearing age was launched in 1991, including special preventive and treatment centers and the promotion of birth spacing, although these initiatives may be too recent to have had such striking results.
Infectious diseases have generally not been important in determining the health of the general population, with the possible exceptions of tuberculosis and diphtheria. While the incidence of tuberculosis may be underreported, the official incidence of diphtheria has risen sharply across the region. In the Kyrgyz Republic and Tajikistan, the rates rose in both countries from about 0.2 per 100,000 in 1990 to 6.8 and 33.4, respectively, in 1994. Rates in Russia rose from 0.8 to 27 over the same period. Available evidence suggests that the rates of sexually transmitted diseases (STDs) have also risen rapidly—in Russia, from 32.2 cases per 100,000 in 1990 to 127.3 in 1994—even though rates are still likely to be underreported. Very few AIDS cases, fewer than 100, have been reported in the entire region.
This section describes and evaluates the basic health systems of Russia and Central Asia in terms of expenditures and the availability and use of services. The systems are discussed in the context of the goals of health system reform: improving health status, ensuring access and equity, achieving microeconomic and macroeconomic efficiency, improving clinical effectiveness, and ensuring quality and consumer satisfaction.
The systems in Russia and Central Asia are based on the centrally planned national health service model of the former Soviet Union. The characteristics of this system were, and largely remain, as follows:
Eligibility—The entire population is eligible for services.
Benefits—The state provides all necessary health services at no charge.
Financing—The public system is financed from the general state budget (e.g., national general revenues), enterprise budgets, and extrabudgetary funds. Private payments in the past were limited to a few nonessential services and some unofficial payments to public providers for preferential treatment.
Payment of Medical Care Providers—Virtually all facilities were owned by the state, and all health-care personnel were state employees. Polyclinics and hospitals were reimbursed on the basis of 18 category line item budgets. Physicians and other health personnel were salaried employees. Provision and financing were combined (the public financing authority owned, budgeted, and managed facilities).
Service Delivery System—The system was conceptually a well-integrated hierarchical structure of feldsher stations; health posts; polyclinics; and local-, regional-, and national-level hospitals. The human and physical capital