Prague, 20 May 1997 (RFE/RL) -- In recent weeks, two horror stories from Romania have spotlighted what may be the worst health-care system in Central and Eastern Europe.
At the end of April, a 41-year-old Bucharest man diagnosed with tuberculosis was denied entry to three hospitals and then was dumped from an ambulance to die on the street.
And just last week, it was revealed that doctors at a hospital in the central Romanian city of Cluj were storing the corpses of 15 dead babies in a chemical solution because they could not afford to bury them.
There are, however, glimmers of hope in the two stories. In the first case, several hospital directors and doctors were fired, and the paramedic who dumped the man from her ambulance was arrested and could get up to seven years in jail.
In the second case, local health authorities, faced with growing popular discontent over the crumbling medical care sytem, have pledged to find a quick answer to the problem of the dead babies, who were between one month and two years old and were abandoned at the Cluj hospital.
And both cases have sharply highlighted the need for comprehensive health reform in Romania, which, along with neigboring Bulgaria, has the worst health-care system in the former Communist countries of Eastern and Central Europe.
In both Romania and Bulgaria, health care is in theory free and guaranteed to everyone. The reality is that most services must be paid for by a fairly formalized system of cash gifts, tips and outright bribes -- a practice that started in the Communist days and has not changed since the advent of the free-market economy.
Most citizens understand that doctors and nurses are severely underpaid, and therefore accept that they must supplement their salaries with informal fees. In Romania, the average salary for medical workers (doctors and nurses together) was the equivalent of $60 in March, compared to an average worker's salary of more than $72 a month.
Romanians have a clear idea of what level of so-called gifts are expected of them. For an ordinary office examination, a Romanian goes to the doctor with flowers, packages of cigarettes, bottles of whisky or something between $2 and $5 in cash.
But the real bribes kick in when a Romanian goes to the hospital. There "you need to bribe everyone," says one Romanian man who has just gone through the experience. To get a Caeserean operation for his pregnant wife, he had to pay a total of $200 for the surgeon, nurses and food for one week. That sum of money is out of the reach of many average Romanians.
In Bulgaria, the situation has become even more desperate after the recent economic collapse. The hyperinflation that hit Bulgaria last year caused the cost of medical treatment to soar more than six-fold. According to a recent survey, some 40 percent of Bulgarians said they could no longer afford medical treatment.
Boika Blagoeva, a head of department at Sofia's Alexandrova teaching hospital, told Reuters last month: "When I write a prescription I can't be sure that the patient will buy the medicines. Some patients have told me directly that they cannot buy them."
Although Bulgarian pharmacies were for a time empty because of the crisis, now they are full of medicines that many cannot afford. A package of Bulgarian aspirins costs 50 cents and the least expensive domestically-produced antibiotic costs $2 a package. Those are considerable sums in a country where pensioners get only the equivalent of $15 a month and the average monthly pay of a state employee is $50. Most imported medicines are completely out of reach.
In most Bulgarian hospitals, patients are expected to bring their own medicines, bandages, syringes, and even food.
Although free medical care is guaranteed for all, in reality only emergency care is free. Everything else -- as in Romania and many other former Communist countries -- must be paid for unofficially, at rates that not everyone can afford. In Bulgaria the rates are $4 to $7 for setting a broken arm and anything between $15 and $50 for a stay in hospital, depending upon the type of treatment.
Guy Ellena, a senior health economist for the World Bank, based in Hungary, says this system of "gratuities" prevelant throughout all the former Communist systems has introduced a terrible inequity that is the antithesis of what Communism promised.
Ellena puts it this way: "Patients according to their income go to some places and don't go to others, although everything is supposed to be public. People name hospitals as a hospital for the rich and hospital for the poor. And when asked, 'why do you say that, because clearly these hospitals are free?' they say, 'the hospital is free, but not the doctors you meet.'"
This is one of the challenges of countries like Romania -- which has vowed to reform its health care system -- to replace bribes with formal fees which will be met in part by universal health insurance and in part with payments from patients' pockets.
Ivan Gyarfas, a Hungarian cardiologist who is working closely with the World Bank on health care reform, says any new system must guarantee the equity which the inherited Communist system failed to provide.
As Gyarfas puts it: "Equity is the most important thing. We shouldn't leave people without decent care."
(Radu Busneag in Bucharest and Petko Georgiev in Sofia contributed to this report. This is part three of a four-part series about health in Central and Eastern Europe. See Condition: Serious -- Health In The East