From Seattle to Siberia
Health Administration Graduate Education Takes Root in Russia
Mary Richardson
Ann Marie KimballHealth care, considered a right of citizenship in the former Soviet Union, is changing dramatically Centralized planning and management in the old system gave high priority to training medical care providers and enhancing access to health care, even in remote areas. Health care system funding began to decline during the Brezhnev years (approximately 1964 to 1980). In the years preceding its financial collapse, the Soviet Union was the only major country where the proportion of the gross national product allocated to health care decreased, to 3-4% of GDP; it is now estimated to be below 2%. Corruption, including bribery for admission to hospitals and the graduation of unqualified practitioners, became rampant.
With the disintegration of the Soviet system, health care management has rapidly decentralized, although the delivery of care remains heavily dependent on hospital-based secondary or specialty care. Decentralization produced even greater cuts in government support and left many hospitals and clinics unable to pay salaries or purchase necessary supplies and equipment. Russia is now going through radical reform including a shift from a tax-financed national health system to a social insurance model, paralleled by the encouragement of independent health insurance. This shift is seen as a way to strengthen the financial base of health care, increase consumer responsibility, and move the system toward a primary care model.
Further complicating matters in the Newly Independent States (NIS), and Siberia in particular, is the pervasive damage to the environment from indiscriminate dumping of nuclear waste and other toxins. Health status indicators are declining consequent to the deterioration in environmental quality and health care services. Infant mortality in Russia was 17.4 per 1000 live births in 1990 and rose to 18.8/1000 by the first half of 1993, while in the United States it improved to and is now at 8/1000. Respiratory, infectious, and parasitic diseases cause nearly half of infant deaths. Male life expectancy at birth in 1990 was 63.8 years, 10 years less than in Western European countries, and declined even further by 1993 to 59 years. The leading causes of premature deaths in Russia are reported as trauma, poisoning, respiratory disease (often from smoking), and complications of pregnancy or childbirth. Alcoholism contributes to many health problems. By comparison, leading causes of mortality in the United States are heart disease, cancer, stroke, and emphysema, and smoking is more important in these than is alcohol.
Dr. Mary Richardson (second from right) with faculty of the Institute for Social Medicine in Novosibirsk, Siberia.
Developing University Partnerships
The NIS, including Russia, are trying to stabilize and restore collapsed economic, health, and social systems. In the wake of the failure of state-run health care, the U.S. government has provided advice and financial aid to encourage market-based reforms. In the midst of these changes, physicians and directors of hospitals and clinics, who were trained for a rigidly centralized Soviet style health care system, are now finding that little in their medical training or experience adequately prepares them to assume new management challenges in a more entrepreneurial environment.To address the need for management training, the Association of University Programs in Health Administration (AUPHA), which represents accredited graduate programs nationwide, has been sponsored by the U.S. Agency for International Development (AID) to introduce graduate-level health administration training programs in Russian universities. Participating universities also receive assistance in developing library resources in health administration and become part of an Internet-based communications network, the REPNET (Russian Education Project NET). The development of university-based graduate education will begin in Russia, and later, faculty from AUPHA member programs will train hospital managers throughout the NIS.
Initially four university programs in health administration were chosen to develop partnerships with four Russian universities. In early 1995 the Graduate Program in Health Services Administration (MHA Program) at the University of Washington entered into an unusual partnership with the Novosibirsk Academy for Management and Economics and the Institute for Social Medicine in central Siberia (see map). Collaboration between a medical institute and a less "prestigious" nonmedical academy is unusual in Russia. A Moscow-based collaborative was formed among the University of Minnesota, Tulane University, and the I.M. Sechenov Moscow Medical Academy and the Semashko Moscow Medical and Dental Institute. The University of Kentucky collaborated with the Khabarovsk Medical Institute in the Siberian Far East.
Four American universities have formed partnerships with academic institutions in Moscow, Novosibirsk, and Xhabarovsk to help develop graduate-level health administration training programs. The UW works primarily with two institutions in Novosibirsk.
As co-chairs for the Novosibirsk training program, we enlisted the participation of other School of Public Health faculty and health care leaders in the community The first visit included two faculty members from the MHA Program, Mary Richardson and Jenifer Ehreth, JoAnne Hoover of the MPH Program, and Marty Zoloth of Swedish Medical Center. Others included in subsequent visits were Victoria Holt of the MPH Program; Clay Roberts, CEO of Flashpoint Development; Philip Sandifer, CEO of Island Hospital in Anacortes; and Dennis Stillman, CFO of University of Washington Medical Center. They met individually with health care leaders and visited local hospitals and clinics. In addition, to support the other partnerships, UW faculty conducted seminars at Sechenov Moscow Medical Academy. Laura Larsson, Department of Health Services librarian, provided resource library consultation to all three partnership sites (Moscow, Novosibirsk, and Khabarovsk) to evaluate their resources and offer training to librarians and faculty on methods for improving their collections and services. Computing equipment purchased through the partner-ship allowed conversion of paper-based card catalogs into electronic databases of research materials. Recent books and journals are more accessible through these new electronic systems. The creation of a Web page, the introduction of e-mail, and the REPNET system make possible broad access to and dissemination of information.
Each partnership developed unique characteristics. Our Novosibirsk partners were happy to be part of a professional network, but were quite clear about the differences between their goals and those of a Moscow-based university. Specifically, they wanted assistance in developing a two-year graduate program in health administration, to be based at the Academy for Economics and Management. They intend to train physicians already holding management positions and medical students interested in pursuing management training. Initially they planned to delay adding a program for nurse managers, but included them shortly after the project began.
Curriculum and Resource Development
To prepare for Western-style graduate programs, the rector of the academy, Dr. Pyotr Shemetov, an economist, restructured the academic programs to create both bachelor's and master's level training. He had already created business-oriented graduate and undergraduate programs that provided an excellent base for the development of a graduate program in health administration. Our faculty assisted by applying existing management coursework to a new health administration curriculum and designed new coursework as needed. Curricular areas of greatest interest to the Siberian partners were marketing, finance, quality management, and statistics.UW faculty provided information and materials covering all of our curriculum and developed couses for the special topical areas. For example, recognizing the urgent need to improve public health, we emphasized epidemiology and biostatistics and focused on managerial applications for resource allocation. We specifically included material on managerial decision making that considers data acquired through research and clinical practice. As a model we used the new evidence-based decision-making process implemented by Group Health Cooperative of Puget Sound. In the area of marketing, we emphasized the need to institute both product and social marketing and to promote health through targeted community-based education while also securing market share. Also, we encouraged the inclusion of the broad spectrum of health services research throughout the curriculum.
A second goal was to introduce innovative teaching methods. Classroom instruction in Russia traditionally has been formal, rigid, and didactic, with minimal student participation. With some trepidation we introduced the use of case studies, role playing, team teaching, and similar techniques. Quite to our surprise, we found the much-touted Russian "flair for the dramatic" quickly surfaced. We explained "role playing," for example, in true American linear fashion, only to have it quickly adopted with passion! By the time our second visit ended, Siberian faculty were sharing with us the experiential techniques they had devised for their own classrooms.
Faculty exchanges occurred in both directions. Siberian faculty traveled to Seattle to participate in scheduled classes, community conferences, and special seminars graciously arranged by local health systems, including Virginia Mason Medical Center, Group Health Cooperative of Puget Sound, and the Pike Place Market Community Clinic. Four Novosibirsk faculty colleagues participated in the 1996 Northwest Center for Public Health Practice Summer Institute.
Lessons Learned
U.S. partners were impressed by the intensity of effort displayed by Siberian partners. During the first visit by Siberian faculty to the UW, faculty developed presentations supporting the primary topics of finance, management, marketing, statistics, and epidemiology. A few months later, UW faculty arrived in Novosibirsk to participate in a week-long seminar on those same topics. U.S. and Siberian faculty were paired according to topical expertise and each gave their respective presentations on a similar topic, such as marketing. In each case, much to our surprise, the Siberians used overheads and materials prepared by U.S. faculty for the previous Siberian visit to Seattle. They also were using these materials in the classroom.Fortunately, we weren't counting on recycling the old presentations! We all quickly recognized the responsibility we were assuming in choosing ideas or approaches to present. Moreover, we continually emphasized our own lack of knowledge about Siberian culture, customs, and government, and expressed the need for Siberian experts to determine what U.S. practices might be applicable and useful.
The Siberians also demonstrated their entrepreneurial spirit. Dr. Shemetov, in an effort to offset the draconian government cuts within the academy, bought an old printing press and began to rewrite and publish much-needed textbooks in economics, finance, and other areas. This venture generated enough profit to upgrade the publishing equipment. We hope that the use of these materials to train new leaders will influence economic thinking and the direction of reforms.
The Future
With UW faculty guidance, the academy has created a two-year graduate program in health administration with a current enrollment of 17 physician executives. Approximately 44 nurse managers enrolled in fall 1996. Although the U.S. AID-funded project ended in spring 1997, health authorities in Novosibirsk appear committed to continue funding the program. Our Siberian partners would like to maintain connections with us, although funding will determine whether that is continued via e-mail or in person.The benefits have been mutual. Our experiences have helped us become better teachers and to bring an interesting and fresh new perspective to our classrooms. We anticipate opportunities for collaborative research. We gained a new appreciation for the spirit of community that persists among those experiencing harsh circumstances. Despite little or no pay, Siberian health care professionals, academic faculty, and others are committed to building a better system for their families and fellow citizens. Their commitment is inspirational.
Recommended Reading
Barr DA, Field MG: Health policy and health care reform in Russia and the former Soviet Union. Am J Public Health 1996; 86:307-311.
Remick David: Lenin's Tomb: The Last Days of the Soviet Empire. New York: Vintage Books, 1993.
Zarkovic G, Mielck A, John J, Beckmann M: Reform of the health care systems in former socialist countries: Problems, options, scenarios. Medis, Institut für Medizinische Informatik und Systemforschung, GSF-Bericht, September, 1994, pp. 137-145.
Authors
Mary Richardson, Ph.D., M.H.A., is an associate professor and director of the graduate program in health services administration and co-director of the Center for Disability Policy and Research at the UW School of Public Health and Community Medicine. She chairs the board of the Association of University Programs in Health Administration, a national organization representing graduate and undergraduate programs.
Ann Marie Kimball, M.D., M.P.H., is associate professor of health services and epidemiology at the UW School of Public Health and Community Medicine.
Drs. Richardson and Kimball co-chaired the health administration graduate education program developed for the Novosibirsk institutions.
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Created: 3/17/98 Updated: 7/15/99
