Balabanova Dina, McKee Martin, Pomerleau Joceline, Rose Richard, Haerpfer Christian
Health Serv Res. 2004 Dec;39(6 Pt 2):1927-50. doi: 10.1111/j.1475-6773.2004.00326.x.
In the past decade, the countries that emerged from the Soviet Union have experienced major changes in the inherited Soviet model of health care, which was centrally planned and provided universal, free access to basic care. The underlying principle of universality remains, but coexists with new funding and delivery systems and growing out-of-pocket payments.
To examine patterns and determinants of health care utilization, the extent of payment for health care, and the settings in which care is obtained in Armenia, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia, and Ukraine.
Data were derived from cross-sectional surveys, representative of adults aged 18 and over in each country, conducted in 2001. Multistage random sample of 18,428 individuals, stratified by region and area, was obtained. Instrument contained extensive data on demographic, economic, and social characteristics, administered face-to-face. The analysis explored the health seeking behavior of users and nonusers (those reporting an episode of illness but not consulting).
In the preceding year, over half of all respondents visited a medical professional, ranging from 65.7 percent in Belarus to 24.4 percent in Georgia, mostly at local primary care facilities. Of those reporting an illness, 20.7 percent of all did not consult although they felt they should have done so, varying from 9.4 percent in Belarus to 42.4 percent in Armenia and 49 percent in Georgia. The main reason for not seeking care was lack of money to pay for treatment (45.2 percent), self-treatment with home-produced remedies (32.9 percent), and purchase of nonprescribed medicine (21.8 percent). There are marked differences between countries; unaffordability was a particularly common factor in Armenia, Georgia, and Moldova (78 percent, 70 percent, 54 percent), and much lower in Belarus and Russia. In Georgia and Armenia, 65 percent and 56 percent of those who had consulted paid out-of-pocket, in the form of money, gifts, or both; these figures were 8 percent and 19 percent in Belarus and Russia respectively and 31.2 percent overall. The probability of not consulting a health professional when seriously ill was significantly higher among those over age 65, and with lower education. Use of health care was markedly lower among those with fewer household assets or a shortage of money, and those dissatisfied with their material resources, factors that explained some of the effects of age. A lack of social support (formal and informal) decreases further the probability of not consulting, adding to the consequences of poor financial status. The probability of seeking care for common conditions varies widely among countries (persistent fever: 56 percent in Belarus; 16 percent in Armenia) and home remedies, alcohol, and direct purchase of pharmaceuticals are commonly used. Informal coping strategies, such as use of connections (36.7 percent) or offering money to health professionals (28.5 percent) are seen as acceptable.
This article provides the first comparative assessment of inequalities in access to health care in multiple countries of the former Soviet Union, using rigorous methodology. The emerging model across the region is extremely diverse. Some countries (Belarus, Russia) have managed to maintain access for most people, while in others the situation is near collapse (Armenia, Georgia). Access is most problematic in health systems characterized by high levels of payment for care and a breakdown of gate-keeping, although these are seen in countries facing major problems such as economic collapse and, in some, a legacy of civil war. There are substantial inequalities within each country and even where access remains adequate there are concerns about its sustainability.
在过去十年中，前苏联解体后独立的国家，其继承的苏联医疗模式发生了重大变化。苏联的医疗模式是中央计划型的，提供全民免费的基本医疗服务。普遍性这一基本原则仍然存在，但同时新的筹资和服务提供系统以及自费支付的情况也在不断增加。
研究亚美尼亚、白俄罗斯、格鲁吉亚、哈萨克斯坦、吉尔吉斯斯坦、摩尔多瓦、俄罗斯和乌克兰等国的医疗服务利用模式和决定因素、医疗保健支付程度以及获得医疗服务的场所。
数据来源于2001年在每个国家进行的针对18岁及以上成年人的横断面调查。通过多阶段随机抽样获得了18428名个体，样本按地区和区域分层。调查工具包含了关于人口、经济和社会特征的大量数据，通过面对面访谈进行收集。分析探讨了使用者和未使用者（那些报告患病但未就医者）的就医行为。
在前一年，超过一半的受访者看过医疗专业人员，比例从白俄罗斯的65.7%到格鲁吉亚的24.4%不等，大多数是在当地的基层医疗设施就诊。在报告患病的人群中，20.7%的人尽管觉得应该就医但并未就诊，这一比例在白俄罗斯为9.4%，在亚美尼亚为42.4%，在格鲁吉亚为49%。未就医的主要原因是没钱支付治疗费用（45.2%）、用自制药物自我治疗（32.9%）以及购买非处方药（21.8%）。各国之间存在显著差异；支付不起费用在亚美尼亚、格鲁吉亚和摩尔多瓦是一个特别常见的因素（分别为78%、70%、54%），而在白俄罗斯和俄罗斯则低得多。在格鲁吉亚和亚美尼亚，65%和56%的就医者以金钱、礼物或两者兼有的形式自费支付；在白俄罗斯和俄罗斯，这一比例分别为8%和19%，总体为31.2%。65岁以上以及受教育程度较低的人群在患重病时不咨询医疗专业人员的可能性显著更高。家庭资产较少或缺钱以及对物质资源不满意的人群对医疗服务的利用明显较低，这些因素解释了年龄带来的部分影响。缺乏社会支持（正式和非正式的）进一步降低了不咨询医疗专业人员的可能性，加剧了经济状况不佳的后果。对于常见病症寻求医疗服务的可能性在各国之间差异很大（持续发烧：白俄罗斯为56%；亚美尼亚为16%），而且常用自制药物、酒精和直接购买药品。一些非正式应对策略，如利用人脉关系（36.7%）或给医疗专业人员送钱（28.5%）被视为可以接受。
本文采用严谨的方法，首次对前苏联多个国家在获得医疗服务方面的不平等情况进行了比较评估。该地区正在形成的模式极为多样。一些国家（白俄罗斯、俄罗斯）设法让大多数人能够获得医疗服务，而在其他一些国家情况则近乎崩溃（亚美尼亚、格鲁吉亚）。在以高医疗支付水平和守门机制崩溃为特征的卫生系统中，获得医疗服务的问题最为严重，尽管这些情况出现在面临经济崩溃等重大问题以及在一些国家还存在内战遗留问题的国家。每个国家内部都存在严重的不平等，即使在医疗服务可及性仍然充足的地方，人们也担心其可持续性。
