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Russian Public Health Society.

HEALTH AND HEALTH CARE REFORM IN RUSSIA

HEALTH AND HEALTH CARE REFORM IN RUSSIA

Dr. Andrey K. Demin, M.D., PhD, M.P.H.,
Associate Professor (Social Medicine)
President, Russian Public Health Association

Written in 2000

HEALTH AND HEALTH CARE REFORM IN RUSSIA

1. General Overview of Population Health in Russia

Health Status of Russians

As a highly developed, industrialized country, with a literacy rate of approximately 100%, Russia registers some of the poorest health statistics in Europe. The deterioration in the health of the Russian people has been ongoing for a number of years and its reasons are varied and complex. The infant mortality rate in 1993 was 19.9 per 1,000 live births and the life expectancy for men in 1994 was 57.3 years (compared with 78 years for Japanese males). The chief cause of death in Russia is cardiovascular disease followed by malignant tumours, diseases of the respiratory system, accidents, trauma, and poisoning. Alcohol is a major contributing factor to many health problems, particularly the last three of the previously mentioned causes of death. The stresses of a society in transition have resulted in increased criminal activity and violence, the latter being a public health issue with profound implications for all of Russian society.

Russia is now in the process of implementing a transition from a totalitarian, closed, and over militarized society to a democratic one. For many years, however, the interests of the State, not of the individual, were of primary importance and population health was a neglected area. The military was a top priority for successive Soviet governments and up to 80% of industry in the former USSR was connected with this sector. Militarization and the production of an astonishing number of weapons required enormous resources, and the result was the diversion of resources from areas where they would have had a positive impact on population health to the military sector.

In the 1970s, the USSR managed to receive up to 50 billion US dollars annually from its speedy, careless, and large-scale oil field development in Western Siberia. The short-sighted mismanagement of these resources compensated for the ineffectiveness of domestic agriculture and industry and further boosted military programmes, including nuclear and space ones. During the same period, while the military system was experiencing unparalleled growth, the health of Russia's population was declining. Instead of addressing the problems of population health, the result was that in the 1970s, many health indices were officially closed for reporting.

A number of catastrophic events have contributed to the decline of the Russian population. In the former USSR, at least seven million people, of whom more than three million were Russian, died from a famine raging in 1933; an additional 27 million perished in World War II. The population has been declining steadily since World War II and the decrease from 1992 to 1995 was equal to 463 thousand. By some estimates, the population may shrink an additional 10 million by the year 2005.

In early 1995, the population of Russia was 148.2 million, 73% of whom were urban residents. In all economic regions, except the Central European one, the urban population and its proportion to the general population is decreasing. Population distribution is very uneven with one-fifth of it being concentrated in the central economic region (especially in and around Moscow). The Asian part of Russia (75% of its total territory) is inhabited by 32 million people, 22% of the total population. In 35 out of Russia's 89 territories, the proportion of men over 60 and women over 55 years of age in the population is 19.8%. Currently 11% of the population belongs to the 65+ age group and 56% of the population belongs to the working age group.

In 1993, two-thirds of the 89 administrative territories of Russia were receiving immigrants from mainly the states of Central Asia, Transcaucasus, and Kazakhstan (2/3 of the total number). In December 1994, Federal Migration Service registered 669,100 refugees and “forced migrants”, of which 547,700 were from the former USSR (62% of them were Russians). In 1994, the population of Russia increased due to the migration of 796,000 people. Population migration is influenced by the disintegration of the USSR; sovereignization of the former Soviet Republics; the rise of nationalism; political and socio-economical crisis; liberalization and democratization of life in the country; the development of rights and liberties of the individual, i.e., freedom to choose a place of residence.

The deterioration of the population’s health in Russia has been influenced by many factors. Among them are the following:

- an accumulation of negative changes over a long period of time;

- socio-political and economical instability partly connected with the disintegration of the USSR;

- decreasing living standards;

- inadequate social policy;

- the economic and social crisis which developed during the transitional period;

- impact of intensive stress on the population;

- population aging;

- increased migration of the population due to ethnic and military conflicts;

- high prevalence of unhealthy lifestyle habits, (e.g., 60% of men and 15% of women in the 20-69 year age group smoke);

- high level of alcohol consumption (14L of absolute alcohol per capita in 1993);

- decrease in the amount and quality of medical care available to the population, and a decrease in the availability of recreational facilities;

- intense social stratification and poverty;

- rising unemployment and criminal offenses;

- inadequate nutrition and poor quality of many foodstuffs;

- insufficient and inadequate housing;

- occupational environments harmful to health;

- environmental pollution.

Demographic Concerns

Since the late 1920s, the birth rate has been declining in Russia, with an unprecedented steep decline being registered in all territories since 1988. Since 1964-65, birth rates have been insufficient to provide even the simple replacement of generations. The total number of newborns in 1993 (1,361,500) was only 54% in relation to the total number in 1987 (2,500,000). In 1994, the number of children born was 1,397,000, giving a birth rate of 9.4 per 1,000 population as compared to 17.2 per 1,000 in 1987.

Over 90% of the decline in the birth rate is explained by decreased reproduction in childbearing age groups. Postponing childbirth until "better times" is prevalent. Modern family planning methods are not developed, explaining the fact that Russia probably tops the world in the number of annual induced abortions. There were 3.244 million officially registered induced abortions in 1993 (98 per 1,000 women aged 15-49, or 225 per 100 live births and stillbirths).

In 1994, the excess of deaths in Russia was 1.63 times greater than births; in some territories the excess was as great as 2-2.6 times. In 1994, the annual number of deaths increased by 785,000 compared to 1987, this represents an increase of approximately 1.5. Also, in 1994, there was a crude death rate of 15.6 per 1,000 population with 2,317,000 deaths being registered. During the same period, an intense mortality increase was documented in all age groups of the population (except age group 0-14 years).

The mortality rate of working age men is four times higher than that of women. In Russia, the mortality rate among men exceeded the European average four times and among women two times from accidents and 20.5 times and 12.2 times, respectively, from homicide. The suicide rate is high and it is increasing. The main causes of death are cardiovascular diseases, accidents, injuries and poisonings.

Infant mortality has not declined in Russia for a long period of time and in recent years, has increased. The rate in 1993, was 19.9 per 1,000 live births (in the first 9 months of 1994, it was 18.6%). The considerable increase of infant mortality in 1993 is, in part, explained by the adoption in Russia since January 1, 1993, of the WHO recommended International Criteria of Definition of Stillbirth and Live Birth. The main causes of infant mortality in Russia are conditions developing in the perinatal period and congenital anomalies (65% of infant mortality in 1993). Other leading causes are respiratory diseases, infectious and parasitic diseases, accidents, poisonings and injuries. The highest infant mortality rates in Russia are registered in the Tyva Republic, 36.6 per 1,000 live births.

Compared to 1992, the population death rate per 100,000 increased in 1993 by 18.9% and morbidity by 6.3%. This increase in mortality over morbidity leads to a questioning of the efficiency of the health care system. The system does not appear to be working well for it should provide timely diagnosis and adequate treatment of disease.

For many years, Russia has had an exceptionally low life expectancy for a developed country. Long-term negative trends are explained to a considerable extent by a stable, archaic structure of the causes of death. The main causes are accidents, poisonings, injuries, and cardiovascular disease. If the current pattern of premature mortality does not change, 46% of boys who are presently 16 years of age will not celebrate their 60th birthday.

A diminished health status is a constraint on the daily activities of 3-5% of children, 9-12% of adolescents, and 18-20% of adults. According to a May, 1994 poll in Moscow and the Moscow region, 43.2% of the population are not satisfied with their life. The main reasons given were lack of money for food, recreation, cultural activities, household and medical services, deteriorating health, concerns regarding employment and the future of their children. More than half of the population reported severe emotional stress experienced in the last year.

Women tend to report lower satisfaction with their health and the quality of their life than their male counterparts. Of the male respondents, 46.1% reported having improved their lifestyles lately (20.1% had become involved in regular exercise, 13.4% had quit smoking, 11% had become abstainers from alcohol). Women tended to be more conservative in their claims.

Vulnerable Groups

Although the transition to the new market economy has been a difficult time for all Russians, in many ways it has been particularly so for women and the elderly. The communist state that they helped to build has disintegrated and with it much of their former financial and social security.

As in many countries, women are frequently among the first workers to be let go when a government department or private enterprise experiences a financial crisis. Even many young Russian men will express the opinion that men are the chief bread-winners and should be given preference in the job market. The belief that women should take care of the home and family ignores the reality that many Russian women head single parent families and must juggle several jobs to survive. Many of these women and their children live in poverty - a known predisposition to ill health. Added to this problem is what many people regard as a growing violence against women as social disintegration gives rise to increasing rates of alcoholism and violent behaviour.

As the Russian birth rate declines, the elderly represent up to 30% of the population in some regions. Having believed in and worked for the Communist system that dominated their lives for over three-quarters of a century, their state is particularly poignant. In many instances they have been reduced from living in relative comfort to struggling for survival. Soaring inflation has virtually destroyed their savings and the cost of food and medicine has risen beyond the reach of many pensioners. In times of rising costs of living and decreasing state support, pensioners are surviving on the equivalent of $40.00 USD monthly.

There is also a psychological and emotional cost for the elderly. They struggle to comprehend the collapse of communism and many worry that their lives and work have been wasted. They see their proud country having to accept donations from the West and they see Western culture flooding Russia and becoming the idol of many of its youth. It is a confusing and painful time for the elderly. Many of them are becoming increasingly reliant on the state at a time when the social safety net is weakening.

Life Expectancy

The average life expectancy was increasing in Russia from 1947 to 1964 (up to 64 years among men, and 73 among women) along with a decline in the crude death rate. Since that period, however, the country has been experiencing a decrease in life expectancy and an increase in the crude death rate. The exception was during the 1986-1988 period which saw a marked increase in life expectancy. This has been attributed to the positive effects of the anti-alcohol campaign. During this period, there was a 2.6 year increase in the life expectancy of men and a 1.2 year increase for women.

A steep decline in life expectancy followed. In 1994, the life expectancy for men was a mere 57.3 years and for women 71.1 years. As a comparison, in Japan the life expectancy for that period was 78 and 82 years respectively.

Decreasing Use of Health System by Russians

Thirty-seven point five percent of physicians indicated that the number of contacts with patients is decreasing. Among the working-age population, the main reason for not using the health care system is a fear of being absent from work, i.e., of loosing benefits for which the ill are not eligible. Fifty-three point one percent of physicians report a decrease in the number of sick-leaves granted, especially those related to the care of a sick child.

The vast majority of physicians (80.4%) believe that recently the course of disease tends to be more severe. Ninety-one point seven percent of physicians, especially surgeons, claim that they are now seeing patients in more advanced stages of disease. People are relying on home remedies and attempting to circumvent the official health system because of economic concerns and a fear of being absent from work. Less than 42.3% of the population, however, possess skills for providing first aid.

Poverty

According to the State Statistical Office, in 1993, the Russian per capita income was estimated to be RUR 526,883 (equivalent to USD $500.00). Per capita income varies greatly in different territories and in different social groups. In February, 1995, the average annual income of 45.1 million persons (1/3 of the total population) was below the officially established poverty level. In households with children aged 15 years and less, the proportion of poor to that in the total population increased by 38.7-39.6%. In drawing comparisons between December, 1991 and 1994, the following decreases are noted - average per capita income by 59%; old-age pensions by 52%, and salaries by 40%. The "New Poor", those people with salaries below the minimal standard of living, account for every fourth person employed.

The redistribution of money in favour of high-income groups, the "New Russians", continues. According to the State Statistical Office of Russia, in January-March, 1995, the difference in income between 10% of the most well-off and 10% of the least well-off was 13.6 compared to 12.5 in 1994, and 4.5 in 1991. If unreported income is added, the difference is 20-25 times greater. In January-March, 1995, the average per capita income was below the poverty level among 30% of the population.

As Richard Wilkinson asserts, material differences are socially divisive, corrode shared values, and undermine the legitimacy of institutions. Not only does social inequality kill, through illness, disease and crime, but research suggests that it may also be a barrier to economic development. (Wilkinson, R.G., The Afflictions of Inequality, 1996.) The same research suggests that in societies where there is a lack of social cohesion, there is more social antagonism, more violent crime, more alcohol related deaths, more accidents, and more suicides. Life is not only more brutish, it is significantly shorter than in societies where there is less inequality and greater social cohesion.

Housing

An acute housing shortage is being experienced and efforts to change this are being hampered by many factors including a lack of financial resource and delays in reform related to property ownership. The result is overcrowding, unsanitary conditions, and accompanying social woes such as an increase in tuberculosis rates. The percentage of housing with basic conveniences is low, especially in rural areas. Fifty-one percent of houses have running water, 40% have central heating, 39% have sewage, 34% have bathrooms, 21% have hot water, and 77% have gas.

Environmental Impacts on Health

The impact of an unfavorable environment on the population’s health is increasing, especially among the vulnerable, i.e., individuals suffering from chronic disease, the aged, children and pregnant women. The environmental degradation is related to the low quality of drinking water, radioactive contamination and the chemical pollution of the environment (water, soil, food, etc.). The most important chemical pollutants are toxic metals, fluorine, dioxins, pesticides, and polychlorinated biphenyls. Roughly 20-30% of population morbidity can be linked to environmental pollution.

Environment-related diseases are on the increase and include infectious illnesses, diseases of the digestive and respiratory systems, congenital anomalies, and cancers. Recently in Russia, so-called "ecological" diseases which include "yellow" children, atypical forms of allergies related to the production of protein-vitamin concentrates (PVC), fluorosis (in areas around aluminum producing plants), and alopecia have become prevalent.

Environmental disaster zones now cover 14-16% of the Russian land mass, an area inhabited by roughly 40 million people. These zones are areas identified by the Ministry of Environment using 32 different indices ranging from water and air quality, to deforestation and desertification. The situation is an enormous risk for the health of the people and the life expectancy in these areas is anywhere from three to five years below the Russian average. A poor economic climate and ineffective legislation for enforcing environmental standards result in industrial enterprises neglecting their responsibility towards environmental protection.

About half of the population is of working age and the occupational environments to which they belong continue to deteriorate in Russia. In early 1994, 4.6 million people (1/3 of them women) were employed in conditions not corresponding to state sanitary hygienic norms. In large cities of Russia, 25% of the population reside in areas where the noise is above acceptable levels; 20 to 25 percent reside in areas where noise levels are designated as being consistent with acoustic discomfort (over 70 dB).

The latest public poll in the Moscow region shows that the ecology is now people's third largest concern after inflation and crime. The mayor of Moscow, Yury Luzhkov, has declared the environment as being the second priority for Moscow (after crime). Despite a growing public concern related to environmental matters, information from state authorities in the area of environmental health effects tends to be inadequate as does the training of medical personnel in this area.

Water and Nutrition

In the area of environmental influences on health, one of the first concerns must be the deteriorating quality of drinking water. Up to the present time, surface water has been the predominant source of drinking water. According to the State Committee of Sanitary-Epidemiological Surveillance, approximately 50% of the Russian population has to drink water that does not correspond to domestic hygienic standards. This results in the development of a variety of diseases. Forty percent of Russia's groundwater supply is now heavily polluted as a result of the unrestricted dumping of wastes over the years.

Poor nutrition is another area which has a major detrimental effect on the health of the Russian people. The impact of an imbalanced diet on the population’s health is further aggravated by the low quality of local and imported food. Nineteen percent of food imported in 1993-94 contained dangerous substances, or was sold after the expiry dates.

"Diet related non communicable disease, principally cardiovascular diseases, is the major cause of premature mortality in the countries of central and eastern Europe." ( International Summer School on Public Health Nutrition, WHO, 1995, p1) Russia is no exception. However, at this time there is no impetus to recognize cardiovascular disease as a public health issue requiring strategic action in the area of food and nutrition. Much education of health professionals and the general public regarding the role of nutrition and physical fitness in this area needs to be done.

Radio Nuclide Contamination

Russia holds the dubious distinction of being the country with the highest radio nuclide contamination in the world. This is the result of a variety of factors: nuclear testing, the largest depositories of radioactive substances in the world, a number of major nuclear accidents, and the deliberate release of radioactive wastes into the environment. Approximately 25% of the entire territory of Russia is thus contaminated.

Twelve territories have been affected by the Chernobyl disaster fallout, the damage from which might be much worse than originally feared. The original estimates showed 50 million curies of fallout. Now some experts claim that the fallout was at least more than three times the original estimates. About 4 million people inhabited the territory within 30 kilometers of Chernobyl which was contaminated by fallout, but some fallout, which was carried by the wind, fell as far as 100 kilometers away. The human health impact of exposure is reflected in the rising incidence of radioactive illnesses, cancer rates and congenital birth defects.

Apart from the 12 territories affected by the Chernobyl disaster, radio nuclide contamination exists in the Chelyabinskaya oblast; the Far North; the neighboring Novaya Zemlya (a nuclear testing site); Altayski kray (affected by the nuclear testing site in Semipalatinsk); an area of Krasnoyarsk city, affected by the disposal of radioactive wastes; Kola peninsula, due to the discharge of radioactive wastes into the Karskoye sea. According to a review done in 1990, the total quantity of radioactive wastes buried in Russia is 1 Billion Ci.

2. Health and Health Care Policy Reform in Russia

Since 1985, following a long period of neglect, attitudes towards health are changing. The Constitution of the Russian Federation, adopted in 1993, envisages the development of a state providing comprehensive social support for its citizens. Annual state reports on population health in Russia have been published since 1992. In 1993, the National Security Concept was revised and currently it includes, as basic components, population health and environmental security.

Legislation pertaining to health which has been adopted since 1993, includes the following:

- April 20, 1993, Presidential Decree N468 " Urgent Measures for Securing Population Health in the Russian Federation".

- 1994-1996, State Program of Urgent Measures for the Provision of Sanitary-epidemiological Well-being, Prevention of Communicable and Non-communicable Disease and Decreasing Premature Mortality Levels.

- 1993-1995, specific programs: "Development of State Sanitary-Epidemiological Service", "Federal Program for protection of Russian Federation from the importation and dissemination of especially dangerous communicable diseases of man, animals and plants, and toxic substances".

- 1994, Laws "On Radiation Safety", and "On AIDS Prevention". Currently are finalized draft Laws "On Quality of Food Products", "On Prevention by Means of Vaccination", "On Safety of Production and Use of Pesticides, Agricultural Chemicals and Biological Means of Plants Protection for Population and Environment".

Along with the adoption of the above-mentioned legislation, a number of important recent health policy documents have been developed, one being the Federal Government's 1995 concept paper entitled, Transition of Russia to a Sustainable Development Model. This was based on ideas introduced at the 1992 United Nations Conference in Rio-de-Janeiro. In 1993, with support from the Government of Canada and the WHO CINDI Project, the first health policy document was compiled: "Towards a Healthy Russia: Policy for Health Promotion and Disease Prevention. Focus on Non-communicable Diseases".

Currently, this latter document is being considered by the governments of Russia and its territories but it has not yet been officially adopted. Even after adoption, the tasks outlined will require much time and effort for implementation, and will require the collaborative efforts of both the government and non-governmental sectors.

At present the health care delivery system is in transition. The main direction of declared health care reform is a move to medical insurance. In 1991, the Law on Medical Insurance for Citizens in the Russian Federation was adopted introducing compulsory and voluntary medical insurance of the population. It also introduced market elements into the previously centrally planned, budget-funded state health care system. The aim of the Law was to secure a Constitutional right to health care by providing additional stability to traditional budgetary funding sources from compulsory medical insurance.

According to Articles 10-12 of the Legislation, insurance premiums (currently - 3.6% of payroll) are paid for the employees by their employer. For those people not gainfully employed, premiums are paid by local state executive bodies’ budgets. A central part in this system belongs to the Federal and Territorial Funds of Compulsory Medical Insurance. The Law has officially introduced paid medical services via direct payments and compulsory medical insurance. However, integration of the medical insurance system into the previously existing health care system is complicated. Development of the new system is compromised by the bankruptcy of many enterprises and the huge deficits experienced in Federal and local budgets.

Currently 55 of 89 administrative territories receive donations from the Federal budget. The medical insurance premium of 3.4% of payroll is collected at the territorial level and remains with the territorial compulsory health insurance funds. The Federal Central Medical Insurance (CMI) Fund collects a premium of 0.2% of payroll but does not possess enough funds or power to level great differences between the territories. Neither is there an ability to exercise adequate control over CMI spending in the territories. Critics point to the development of the CMI Funds Network as contributing to the additional excessive and expensive bureaucratization of health care. They also point to the absence of uniform norms for CMI system operation within the different territories of Russia and cite instances when CMI funds are used for purposes other than health care provision.

In late May, 1995, the ministries and departments of the Social Sector of the Federal Government proposed to revise the social policy, uniting currently isolated systems of Funds for medical insurance, pensions, employment and social welfare. It also suggested switching the collection of relevant premiums and taxes for these funds to the State Tax Service of Russia, perhaps as a single social tax. The amount of money accumulated in the above-mentioned funds equaled 40% of the federal government’s income in 1995.

In 1992, the State Committee on Sanitary-Epidemiological Surveillance of Russia (SCSESR) was established under the law "On Sanitary-Epidemiological Well-being of the Population". Previously, these functions were within the mandate and structure of the Ministry of Health. Within the SCSESR system there are approximately 2.5 thousand specialized centers, and 35 research institutions with a total staff of more than 220,000. In 1996, SCSESR was reorganized and its functions were again placed within the Ministry of Health.

The basic legislation on health protection of the Russian population was adopted in 1993. It contains articles on the rights of the patient and of the health care professional. Professional associations of physicians and other medical personnel, nonexistent in Soviet Russia, are now legally permitted and have been developing since 1991. These associations, with important rights granted by the legislature, are expected to become major actors in health care.

The Federal Government approved the basic program of medical insurance in 1993 and, at that time, determined the types of medical care, prevention, diagnostic and treatment procedures which would be covered. At the same time, different types of possible ownership of privately funded medical institutions was determined by new legislation. By-laws governing state and municipal health care institutions were jointly drafted by the Ministries of Health, the Medical Industry and the State Committee on Management of State Property. The stage-by-stage transition to a system of primary health care based on the concept of general practitioner/family physician continues. However, the implementation of many adopted health care programs is not adequately funded or monitored.

The approach to out-patient/in-patient care is changing. According to a May, 1994 poll, 20% of physicians try to use more out-patient treatment and, in some cases, this process is regulated by the administration of polyclinics. Twelve point five percent of physicians report that increasingly patients are rejecting being treated on an in-patient basis because of related costs.

According to expert assessments, in the 1990-95 period total health care funding was reduced by a factor of 1.5 times, despite the introduction of compulsory medical insurance. During the same time, hospital mortality increased by 1.5, a finding that has been related to inadequate health care. Eighty-eight point seven percent of physicians indicate their belief that disease outcome in patients is influenced by cutbacks in emergency medical care.

Cutbacks in emergency medical care is part of an overall shrinking in social programs, e.g., cuts in compensation for preventive treatment in recurrent or ongoing illnesses. According to a May, 1994 poll, physicians are less often recommending preventive treatment for their patients because patients lack money. The same constraint makes dietary recommendations difficult as well.

A deterioration in pharmaceutical supplies and health care facilities influences mortality rates, particularly from chronic diseases. At present, less than half of the required pharmaceuticals is satisfied by domestic production. According to a poll conducted in May, 1994, 90% of physicians think it is necessary to discuss the cost of medications with the patient before prescribing. For many patients, especially the aged, necessary drugs are inaccessible because of high cost.

A List of Priority Drugs has been approved by the Federal Government of Russia although in May, 1994, 25% of physicians were unaware of the list's existence. Most physicians use the list for prescribing, especially for the poor, since 50% of the cost is compensated. Over 70% of physicians believe that the list is not comprehensive enough. Forty percent of internists claim that it is insufficient for the treatment of coronary patients.

Sixty-five percent of physicians report that hospitals lack the necessary supplies of medications, blood and blood products, and parenteral fluids. This results in delays in elective and emergency surgery, and aggravates the course of disease outcomes. Thus, health care is operating in a changing moral, legal, and economic environment and with a population whose health behaviours are changing.

According to a recent poll 43.8%, of the Russian population practice self-medication. The main reason being given for this is dissatisfaction with health care facilities. Commercialization of health care, with high out-of-pocket payments by consumers, is a disturbing new phenomenon. This trend contradicts Article 41 of the Russian Constitution which declares free care in state and municipal health care facilities. The services of medical cooperatives are used by 19% of men and 21.9% of women while traditional healers and private practitioners are utilized by 7% and 10% respectively.

Approximately 70% of physicians practicing less than 20 years recommend that their patients use “fee for service” medical examination and treatment services. Despite being officially prohibited, every third surgeon advised “fee for service” surgery, and 50% of internists recommended that patients purchase the necessary drugs for inpatient treatment. The proportion of physicians recommending pay services is indirectly related to the length of their professional practice. Similar results are provided by a general population poll.

According to a poll conducted in May, 1994, some components of health care reform such as new forms of health care financing and insurance medicine are not fully understood by practicing physicians. This is, in part, because of inadequate information. Among those physicians who responded to the poll, 44% were negative towards the introduction of insurance medicine, 14.7% believed that it did not result in any changes in health care, and 41.3% were positive (the younger physicians were the more positive in their attitude to reform).

On the subject of Health Reform, 68% of health care administrators were positive, 8.7% were negative, and 23.1% had no definite opinion. Quality assurance is an underestimated area because public pressure for involving consumers in making choices is low. Consumerism is still in the cradle and endorsement of affirmative action by consumer groups is not a priority for policy makers.

The clinical professions generally do not have their own professional associations, and are not determined to retain the initiative in setting and maintaining standards for clinical practice and training. Neither is there an apparent desire by professional groups to demonstrate effective self-regulation in the face of growing management demands for accountability.

Low priority is given to quality management and customer satisfaction in both Russia's manufacturing and service industries. Health care reform relies heavily on insurance companies as the instrument of quality assurance, neglecting the key role of both providers and consumers. In March-June, 1995, the Ministry of Health and Medical Industry proposed that it should absorb the functions of the State Committee on Sanitary-Epidemiological Surveillance and of the Funds of Compulsory Medical Insurance. This proposal was debated along with possible changes to the health care policy.

After the Presidential elections of 1996, a number of changes were initiated to the structure of the health care system. The Ministry of Health Care and Medical Industry had its medical industry functions (responsibility for quality control of drugs and equipment) absorbed by the Ministry of Industry and thus became the Ministry of Health Care. The new Ministry of Health Care took on the functions of the State Committee on Sanitary-Epidemiological Surveillance of Russia and the latter ceased to exist. The recently reelected Health Care Committee of the State Duma recommends increasing compulsory medical insurance premiums to 12% of payroll.

It is too early to tell whether the recent reforms to the health system will result in an improvement of either the population's general health or the greatly compromised sanitary-epidemiological situation in Russia. Russian society is largely unaware of the magnitude of the country's health problems and are more concerned with the day-to-day difficulties of high prices, low wages, and salary payments that are delayed by months. A lack of financial resources is a major impediment to the implementation of reforms to the health system and the Russian Federal Government has recently accepted a multi-million US dollar loan for health care reform.

In order to break the emerging vicious cycle of poverty and disease, the current challenge is to develop a strategy for improving the health of the nation based on a concept of sustainable development. The prevailing opinion among many Russian policy makers, however, is that the first task is to improve the economy. They believe that only after the economy has been successfully addressed, is it possible to turn to issues such as health. The economy is a vital and understandable concern but when attention is directed towards it exclusively, there is a great danger of unwise policy choices being made. As a result, population health might continue to deteriorate needlessly.

A shift from a traditional medical/curative approach to health which is based on mortality data, to a comprehensive, intersectoral action which is based on a health protection/promotion, disease prevention model, is needed. A public health approach is required which will ultimately better serve the public and be more economical.

The Russian Public Health Association can be a very important resource to the country at this time, in helping it to reorient the system away from illness and towards a focus on health. Currently there is not enough effort and commitment to a comprehensive public health approach at the national level, including environmental health and occupational safety issues. While curative services are essential, health promotion and disease prevention must be developed and enforced. Many diseases originate in the environment and human behaviour and resources must be diverted to these areas as well as to diseases with a biological basis. The bulk of resources are currently devoted to curative services.

The following are some areas of the health system which require immediate action and improvement:

- Formation and implementation of a nation-wide, sound public health policy.

- Strengthening of health planning, research, and policy making at the federal and territorial levels.

- Health data and information system for professionals, consumers, and the population at large.

- Coordination and linkage between various health players in the health system.

- Manpower training. Quality assurance.

3. The Developing Role of the Non-Governmental Sector in Health Services and the Health Reform Process

Non-governmental organizations (NGOs) in Russia are part of the movement towards democratic reform and community participation which began in 1985. Relationships within the NGO community and between the NGO community and the Russian government are still developing. A new legislation has been adopted which formalizes the creation and functioning of NGOs in various spheres of Russian life, including the health sector. The legislation is still not comprehensive and is undergoing scrutiny in a number of areas, including that of tax exemptions for non-profit organizations.

The government values the activities of NGOs in providing some services and information and views their activities as being potentially complementary. Nonetheless, the government views NGO activities as secondary and less professional than those of the government itself. Close cooperation, as equal partners, between institutions of civil society and government in Russia is still a new concept which is, in some cases, meeting resistance and causing tension.

This resistance and tension is explained by a number of factors. The NGO movement in Russia is a new phenomenon and, although some are of excellent calibre, others are marked by low professionalism and poor sustainability. As well, NGOs must tread the difficult line between advocating for changes which are seen as necessary by their members and constituents, and working with government. Some NGOs are marginalized as they become increasingly vocal and involved in advocacy and are then seen as opponents of the government rather than partners.

The government, however, seems to be honestly striving towards working more effectively with NGOs. Recently, the administration of the President of the Russian Federation, the Russian Parliament, and the Russian Government’s Ministries, including the Ministry of Health, have established departments responsible for linkage and collaboration with NGOs.

The value of NGOs is accepted in national policy dialogue on social concerns, health and economic policy. However, their value in gathering and disseminating sound information on issues of national importance and their role in the development, implementation and monitoring of social and health programs is not fully understood. These have yet to be demonstrated to, and understood by, the government, society, and the NGO community itself. The contribution which NGOs can make in the areas of research, pilot demonstration projects, information, education and advocacy has not yet been adequately demonstrated or appreciated. This is an area in which the RPHA can make an important contribution. Perhaps the emergence of strong local NGOs, such as the RPHA who work in close collaboration with the Russian Government, will do much to demonstrate the value of NGOs in these areas.

The NGO movement in Russia is rapidly expanding and professional associations, such as the Russian Medical Association, the Association of Physicians of Russia, and the Association of Nurses, have also been started. Collaboration with WHO and international NGOs is developing and adding to the strength and competency of local organizations. One of the challenges facing local NGOs at this time is to effectively coordinate their activities and ensure that they fit with national objectives. This is another area in which the RPHA’s involvement would be useful to both the government ant the NGO community.


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