Russian Public Health Society.
Policy for Control of Demographic Decline of Russia
Policy for Control of Demographic Decline of Russia
EUPHA-ASPHER 2nd European Public Health Conference.
Human Ecology and Public Health. 25-28 November 2009, Lodz, Poland
Policy for Control of Demographic Decline of Russia
Andrey K. Demin, M.D., M.P.H., Doctor of Political Sciences, President of Russian Public Health Association, Professor of I.M. Sechenov Moscow Medical Academy, Moscow, Russia. firstname.lastname@example.org www.rpha.ru +7 919 760-2600
This paper consists of five parts:
I. Global background and health care reform agenda relevant for Russia;
II. Russian health care reform challenges;
III. Alcohol and tobacco use prevention and control – absolute priorities for Russia;
IV. Global Tobacco vs. Russia: case study.
I. Global background and health care reform agenda relevant for Russia
The main incentive for development of health care as a part of social security, has always been threat of political instability related to large scale deteriorations in public health caused by epidemics, wars, dramatic natural and social changes, for example, industrialization and, most recently, by globalization, global energy, food, financial, employment, environmental and public health crises.
Response of the adequate ruling elites, aimed at populations, included introduction of social aid (1605), insurance (1883), programs of state guarantees (1918), usually supplemented by political repressions.
After 1991 (break up of FSU, disappearance of Soviet example of social security, new phase of globalization), new global trends emerged:
1. Advent of “new medieval age”, destruction of social security, fragmentation of medical care and development of multi-layer care, according to individual’s wealth and proximity to elites. Increasing emphasis on social equity in care.
2. Increased division of global population into “the clean” and “the dirty” – increased flows of human capital, i.e. healthy, adequate, professionally and socially successful individuals to countries with higher (sometimes virtually!) standards of living and vice versa.
3. Transnational corporations and elites underestimate public health and health care, do not consider it as part of development agenda.
4. Converging development of health care systems of developed countries on the basis of market competition created and managed by the state.
5. Strengthening of leadership of developed countries in development and implementation of global public health and health care policy as part of global security, based on modern social, information and medical technologies, aimed first of all at management of “complex humanitarian emergencies.” These emergencies include global pandemics (avian flu, swine flu, etc.); uncontrolled large-scale migration in the context of political and economic instability, climate change, etc.
6. State sovereignty in health care and social security, especially in countries with ineffective health care management, unable to participate adequately in global regulation, is also subject to change, and this requires ensuring balance of interests of various countries. There is perceived need for international legislation on public health and health care guarantees, currently absent.
7. Emergence of global scale socially responsible private sponsors. So far these are predominantly representatives of US businesses (Soros, Gates, Bloomberg, Ellison, Buffett, etc.), however representatives of other countries, including Russia, might be expected to join in.
8. Further decline of the role of UN (WHO), strengthening of global financial institutions, World Bank. More domination from bureaucrats, experts in management, economics and marketing compared to health care professionals in health care management. Inadequacy of global economic development agenda to public health and environmental realities.
9. Conflict between professional responsibilities of medical professionals, the progress, promising attainment of individual eternal life, and ability to pay.
10. Emphasis on medical technologies and pharmaceuticals, attempting to substitute lack of social improvements and poor standards of living and pay for work.
11. Development of global public health policy and regulation, first examples - control of “Global Bads” such as tobacco and alcohol industry – including WHO Framework Convention on Public Health. Emerging issue – infectious disease prevention and control.
12. Increasing understanding of global actors that declining social security and public health are major destabilization factors of states and societies, and that improving these spheres could be cheaper and more efficient, compared to military and information interventions. For example, in July 2009, during Moscow Summit, Russia-US collaboration in health care, including Global Health, was re-started. Among regions where two countries could work jointly is former Soviet Central Asia.
Ideas for health care reforms, prevalent and tested in many countries of the world in recent 30 years, are not numerous (J. LeGrand, 2006, A. Mills, 2006).
II. Russian public health and health care reform challenges
There might be outlined at least 9 distinct periods in development of health care in Russia after 1917 until present with specific challenges (Demin, 2008).
Since 1991 private insurance business started to dominate in health care development, and this domination is now being questioned as ineffective, unable to control demographic decline, resulting in rise of pay services, poor and inequitable access to services, dissatisfaction of health professionals, etc.
The current major issues are what should be the standard of free services guaranteed by the state, the future role of compulsory health insurance and private insurance, how to control pay services, and how resources and responsibilities should be divided between the Federal, regional and municipal levels of administration. Related issue is how to control and balance influence of special interest groups in the reform debate. Equality of citizens living in various territories is important. In 2007, actual tariff per insured person within Program of state guarantees (without consideration of Federal budget) was 1723,5 Rubles in Republic Ingushetiya and 26918,1 Rubles in Chukotskiy Autonomous Okrug.
There are plans to introduce pharmaceutical insurance, establish a system of pharmaceuticals supply based on state corporation, and also to merge agencies responsible for protection of consumer rights.
Since 1991, political importance of health care, first of all access to pharmaceuticals, and care for the old-age pensioners, has been rising, in the context of demographic crisis.
In 2004 the remains of the Soviet era social security were abolished within confiscation type reform, structural adjustment reform started. In 2004 Federal health ministry was merged with Ministry for social development, and since then Russian Federal health ministers are not medical doctors. In 2004-2007 Minister was M. Zurabov, formerly head of private medical insurance company, then advisor to the President of the Russian Federation, currently ambassador to Ukraine. Main obstacle to health care reform, according to Minister M. Zurabov (2006) is low pay for work in the national economy.
The current Minister T. Golikova (2007-) is economist who came from position of deputy Federal Minister of finance, responsible for the state budget. The Russian leadership is still looking for internal reserves in the health care system, in view of surplus of physicians and beds inherited from the Soviet period.
Since 2006 National priority project on health care is being implemented, emphasizing primary health care, preventive medicine (mainly vaccinations and health checks) and availability of high technology care (construction of high technology centers), enumeration of health care resources was started. However the aim of the project did not include attainment of better health indicators.
In the end of 2006 large scale corruption was found by the state in Federal Compulsory medical insurance (CMI) fund.
Shortly afterwards pilot projects on health care reform, run by the Federal Fund for CMI began in 19 territories of Russia, and their experience reviewed in 2008 is being used as the basis for country-wide health care reform. The following approaches to health care modernization were successfully tested in the pilot projects:
- Switch to one-channel or predominantly one-channel funding of health care institutions according to final results;
- Implementation of single standards of provision of medical care and standards of equipping;
- Implementation of elements of partial or full fund-holding (“money follows the patient”);
- Implementation of personified reporting of volumes of provided medical care in CMI system with payment on the basis of normative of financial expenses, calculated according to standard of medical care;
- Reforming pay for work according to volumes of provided medical care on the basis of coefficient of participation in work;
- Attempt to develop payment according to full tariff in inpatient institutions and per capita funding in out-patient institutions.
However in pilot project introduction of new standards resulted in considerable increase in costs of services. Proportion of pay services in various territories is 1-10%.
In 2008 system of payment to health care professionals was changed to improve efficiency of work; construction of network of perinatal care centers was started; extended National priority project included programs to control cardiovascular disease, traffic accidents, cancer, development of blood transfusion service.
An outstanding issue, especially in current economic decline, is whether the Government should preserve the system of compulsory medical insurance, which was started in 1992, and channels social funds to health care providers through private insurance companies, or to switch to budgetary health care funding without such intermediaries. So far insurance business resists such discussion and changes.
According to Health and Social Development Ministry (2008), major challenges, necessitating modernization of health care in Russia:
- Poor quality of medical care; - High proportion of pay medical services; - Unequal accessibility of free high technology medical care to citizens of various territories; - Dissatisfaction of citizens with the current system of implementation of their constitutional rights to free medical care and health protection.
Plan of health care reform includes: - Improvement of the system of health care management: better quality of forecasts and effectiveness of planning health care resources, introduction of results-based budgeting, financial management; - Creation of the system of management of quality of medical care, based on a single system of standardization and funding of medical care linked to volumes and quality of services; - Modernization of the system of compulsory health insurance; - Establishing institutes of protection of patients’ rights and insurance of professional liability of health professionals; - Introduction of effective measures aimed at raising motivation of health professionals towards quality work, introduction of systems of payment, linked to quality and results of work; - Ensuring further development of Russian science and production of medical equipment, pharmaceuticals, and modern medical technologies; - Creating conditions and incentives for increasing investments of citizens and employers in health, high priority of health in the system of social values;
- Developing a competitive network of health care institutions for providing citizens with free medical care with introduction of single standards of medical care, list of equipment and staffing; - Changing organizational-legal forms of health care institutions and providing state contracting for them; - Interaction of the state and professional medical associations on accreditation of medical institutions and licensing of health professionals.
After 1992 demographic decline became the main political issue. However demographic decline was put at the top of political agenda only in 2000, by President of Russian Federation Vladimir Putin in his first Presidential Address.
Concept of demographic policy issued in 2001 and revised in 2008 until 2025, is a somewhat belated response to demographic challenge, including measures aimed at increasing birth rate, decreasing death rate and regulation of migration. All these approaches necessitate involvement of health care.
Currently preparation of draft Concept of development of health care till 2020 is being finalized, supporting demographic concept.
The main challenge of health care reform in Russia is preventing demographic decline. The new concept claims that to ensure sustainable socio-economic development of Russia, one of priorities of state policy must be preservation and promotion of health of population on the basis of development of healthy lifestyle and increasing accessibility and quality of medical care. Effective functioning of healthcare necessitates improvement of organizational system, availability of trained health professionals, development of infrastructure and resource supplies: financial, material-technical and technological (including informatization), normative-legal provisions.
Aims of the Concept: By 2020 increase number of population up to 145 million, life expectancy up to 75 years, decrease infant mortality down to 7.5, maternal mortality down to 18.6, develop healthy lifestyles of population, including decreased consumption of tobacco and alcohol, increase quality and accessibility of medical care, guaranteed to the population. Thus for the first time in Russia health care system took up full responsibility for main health indices and many risk factors, related them to social determinants of health.
Goals of the Concept: - Create conditions, possibilities and motivation for population to live healthy lifestyles; - Improve system of organization of medical care; - Set up state guarantees related to provision of free medical care to citizens; - Improve provision of citizens with pharmaceuticals within outpatient services within system of CMI; - Develop effective model of management of financial resources of the program of state guarantees; - Increase qualification of medical professionals and create a system of their motivation towards quality work; - Develop medical science and innovations in health care; - Develop informatisation of health care.
Two main directions of activities: Development of healthy lifestyle; Guaranteed provision of population with quality medical care.
Development of healthy lifestyles includes: - Improvement of medical-hygienic training and education; - Establishing an effective system of measures to control harmful habits; - Provision of healthy nutrition; - Development of mass physical culture and sports; - Decreasing risk of impact of harmful environmental factors; - Establishing a system of motivating heads of school education system towards health protection and development of healthy lifestyles among schoolchildren; - Establishing a system of motivating citizens towards healthy lifestyles and participation in preventive actions; - Establishing a system of motivating employers towards participation in health protection of employees.
This forms the basis of mass prevention of risk factors of NCD.
Guaranteed provision of population with quality medical care includes: - Specific state guarantees of provision of free medical care; - Standardization of medical care; - Organization of medical care; - Provision with pharmaceuticals; - Ensuring a single staffing policy; - Innovation development of health care; - Informatization of health care; - Modernization of system of financial supply for provision of medical care; - Legal and normative regulation.
Principles of development of state guarantees of provision of free medical care: - Legal regulation of provision of free medical care within program of state guarantees; - Development of program of state guarantees for 3 years with annual reviews; - Development of regional programs of state guarantees on the basis of program approved by the Federal government, establishing territorial financial normative; - Linking financial indicators to quality of medical care.
Standardization of medical care envisages preparation of methodological guidelines and clinical protocols, orders of provision of medical care; standards of provision of medical care; medical-economical standards; list of vitally important pharmaceuticals; registry of inpatients.
In reality, funding of the Program of State Guarantees in Health Care for 2010, recently adopted by the Federal Government, remains at the level of 2009.
III. Alcohol and tobacco use prevention and control – absolute priority for Russia
The absolute priority is to support development of prevention, treatment and rehabilitation programs, health protecting legislation related to two top causes of demographic crisis in Russia – alcohol abuse and tobacco use, claiming respectively up to 650 thousand and up to 400 thousand lives annually.
Recently the Public Chamber of Russia published detailed reports on alcohol and tobacco and provided recommendations for decision makers.
Despite declarations, government alcohol and tobacco policy is still weak. Alcohol policy is at the dangerous crossroads. Government does not regulate foreign beer industry, which took over Russian market after 1991. Excise tax is very low. Vodka turnover is seen by the Federals, for the first time after 1992 abolition of State monopoly, as source for budget in the era of cheap oil. Federals try to take vodka under control, with declared (and false) reason to save population dying from falsified liquor. Alcohol industry suggests to decrease excise tax, in order to improve tax collection, prevent illegal production of “bad quality” vodka, and provide cheap quality liquor. In economic crisis accessible vodka is seen as social anesthesia. Excise tax on strong alcohol – the main killer – will remain dangerously low. The new Federal government agency on alcohol regulation is headed by the industry representative.
IV. Global Tobacco vs. Russia: case study
Russian annual tobacco equation: 350, 000 premature deaths, over 400 billion sticks produced; 95% of production by foreign companies – JTI, PM, BAT, market estimated at over 20 billion USD. Excise tax is 17 times lower compared to EU. High prevalence - 63% males, females - 7% in 1992, and 19% in 2008. 66% of 13–16 old teenagers have experience of smoking and 35% are regular smokers.
Reframing the attitudes to tobacco use in Russia: Prior to 1970 “unhealthy habit”; from 1970 + risk factor within CINDI and other health care programs, however poorly communicated to decision makers and general public; from 2000 + smokers’ vs. non-smokers rights’ debate, YSP and CSR programs orchestrated by the industry, + political analysis of tobacco and health started; from 2006 + industry influence on legislation development on the basis of internal documents search and analysis started; from 2008 + FCTC ratification, + healthy lifestyles to control demographic decline, + industry influence on economic decisions based on transparency and denormalization of the industry.
Industry: Leader of regulation, present everywhere, especially in PR/GR; Sophisticated promotion: TTL=ATL+BTL, estimated funding more than 2 billion USD annually; Investment, production, profits, export/import concentrated in Saint-Petersburg, Leningrad region and Moscow. Distribution also concentrated to 70-80%. Declared production 413 billion, capacity – 700 and more. Industry plans to decrease concentrate global production in Russia. 2 phases on penetration: 1) after USSR breakup; 2) after 1998 economic crisis. Extreme profitability. Global and European region management centers recently established by Japan Tobacco International and operate in Saint-Petersburg, complemented with secondary centers in Kuala-Lumpur, Malaysia, and Toronto, Canada, to provide global 24/7 services in 17 languages. Industry speaks to government on behalf of smoking majority and emphasizes political risks, especially in economic crisis.
Current FCTC-related legislative process split and under industry pressure: 1) Federal Law “Technical Reglament” prepared by the industry to protect from FCTC, through State Duma Committee on Trade and Entrepreneurship, supported by Committee on Agriculture. Disagreement of MoH ignored by the Government. TR adopted after FCTC ratification, violates Russian legislation and FCTC, includes “exotic” forms of tobacco use, pictorial warnings blocked, enforced from Dec 2009.
Civil society: Population-at-large priorities daily economic survival and physical security. Still need to develop large scale civil society capacity, capable to ensure protection of national interests. Health or Tobacco national forums in 2006 and 2009. BGI support in Russia in recent few years: TFK, IUTLD, WLF. Projects to support GATS, development of national strategy, smoke free legislation, smoke free hospitals, regional activities, seminars for staff writers etc. WB hosted presentation of report on benefits of excise tax increase. July 2009 - Russia-US civil society leaders forum parallel to Political Summit: WG on public health emphasized tobacco control. September 2009 – Civil chamber of Russian Federation report on tobacco epidemic and industry role. Economic and production analysis withdrawn. Industry outraged with denormalization approach. Newsletter “For Motherland free from tobacco” prepared and published at www.rpha.ru Current paradox: Civil society groups and individuals under fire from the foreign industry, pretending to be local, on patriotic, anti-American and xenophobic pretext.
Current sanctions are weak. According to Code on administrative legal breaches, there is fine of 100 RRubles (about 2.2 Euros) only for smoking in suburban trains. According to Article 5.27 of this Code employer failing to equip smoking places might be fined in the amount of 1,000-5,000 RRubles (240-1200 Euros) or activity of the enterprise might be suspended for up to 90 days. According to Federal Governmental decree #1036 dated 15 August 1997 “On approving Rules of providing services of public catering”, Article 5, owners of bars, restaurants, cafes independently decide whether to allow smoking, designate specific tables or introduce total ban. There are no sanctions for smoking at the workplace in the Labour code, except cases when this issue is included in agreement with employer. Thus this law does not introduce total ban of smoking in public places, and also obliges employer to introduce special places for smoking. As a result it is ignored by many employers who do not permit smoking at workplaces. The law does not envisage protection of mass catering and hospitality services from passive smoking at the working places. Also, this law blocks adoption of smoking bans in public places at the regional and municipal levels.
Future challenges: Updated Law on limiting smoking – in preparation. Currently most resisted by the industry: total ban on smoking in public catering and hospitality, workplaces, ban on sales in kiosks. Russia needs introduction of total ban on smoking in closed areas to protect non-smokers and smokers, including workplaces, educational and medical and transportation facilities, and also hospitality services. There might be considered stage by stage introduction of smoking ban in public places: first at workplaces, education and medical facilities and transportation, and later to hospitality services. Besides that there is need to remove legislative limits on control of second hand smoke only at the Federal level, and authorize regions and municipalities to introduce smoking bans according to FCTC Article 8. FCTC –related legislation development according to “ceiling” standards. Closing gaps with the best existing practices, including smoke free and warnings, introducing plain packaging approach. Preventing industry influence on the basis of monitoring and denormalization. Developing support from general population and civil society. Developing cooperation with antitobacco community. Need for cooperation with European networks, because attitudes to European organizations might be positive. In current economic climate decreasing tobacco use, especially among the underprivileged groups of population, women and children, should become one of key public health strategies. Need to return to state monopoly to curb epidemic caused by extreme profitability of tobacco business, and to channel resources generated on tobacco to the national benefit.
General factors promoting tobacco industry GR activities in Russia:
increasing dependence of economic development from the state; crisis of political PR after political system adjustment in 2006 precipitated by Beslan disaster; development of industry professional GR departments; arrival of international lobbyist companies in Russia such as Cassidy & Associates, The PBN Company, Mmd, etc.; development of GR committees at Association of managers of Russia (AMR), Russian PR association (RASO) and the like. Extreme concentration of vital foreign industry functions after primary penetration in Russia in 1991 also should be taken in consideration. Out of 84 regions-subjects of Russian Federation, foreign tobacco industry investment, import/export, production, management, financial operations concentrate absolutely in three: Saint-Petersburg, Leningrad region and Moscow. Political importance of these three subjects of RF related to other 81 subjects could be an extremely powerful factor promoting effective industry GR in Russia. Tobacco epidemic in Russia is sort of foreign industry affair with these three regions, concentrating 66% of tobacco products production and 80% of revenue from tobacco product sales. 49% of total tobacco capital investment in Russia was absorbed by Leningradskaya Oblast. Russia is practically not growing tobacco and virtually all tobacco and relevant chemicals are imported; 95% of these imports come through Saint-Petersburg; major part of sanitary-epidemiologic surveillance is currently suspended by Federal Customs Service based on ordinance of Federal Service of Protection of Consumers Rights. 80% of tobacco products distribution in Russia is provided by one company. JTI’s global service desk (GSD) and business service centre (BSC) playing leading role in JTI global operations, have been established in Saint-Petersburg recently. Economies of city of Saint-Petersburg and Leningradskaya Oblast are deeply dependent on tobacco industry activities.
GR in Russia is a priority for the industry due to obvious special role of Russia in
industry regional and global strategies. Russia emerged as production and management, distribution industry center for former USSR, EEMA, Europe and globally, as a focal point for influencing regional, European and global pro- and anti-tobacco policies. Achieving friendly regulatory climate in Russia is of key importance for the industry.
Besides GR per se, significant aspect of GR is PR of government bodies via public and civil society. This aspect is grossly underdeveloped in Russia, and direct, possibly corrupted, collaboration between industry and government might prevail. Most often used forms – establishing direct contacts or acting via industry association.
Direct formal and informal industry – Government contacts take place by providing
expert information to decision makers, participation of industry representatives in various governmental meetings, in development of draft legislation and promotion of industry-friendly legislation. Currently in Russia leader of the company is usually its prime and most effective GR person. Former government officials also often work in industry GR structures.
Indirect forms of pressure include organizing influence groups inside governmental
structures, including, for example, “former” industry members of State Duma. For example, Ivan Savvidi, owner of majority of shares of “Donskoy Tabak”, has surrendered his tobacco business shares to his wife and continues to serve as State Duma Deputy, first as a member of Committee on excise, and most recently as a member of Committee on international affairs. For Russia are also typical CSR, voluntary social reporting and charity.
Industry GR structures are sophisticated, numerous and possess huge budgets. For
example, senior BAT GR functioners are Aksionov V.K., advisor to the managing director and Lyutiy A.G., director on corporate relations. Directorate of corporate relations supervises GR Department, responsible for developing relations with all branches of state and municipal power. This GR department includes five subdepartments: 1) on relations with Federal Assembly of RF; 2) on links with regulatory (controlling) government bodies, 3) on regional policy (interaction with regional executive and representative state bodies, municipalities, territorial departments of the Federal ministries and agencies); 4) on prevention of dissemination of illegal and counterfeit products (intellectual property protection); 5) on interaction with competitors, industry communities and all-Russian business associations (industry relations). Number of staff at BAT Directorate on corporate relations is about 30, annual budget – appr. 80 million Rubles. It should be mentioned that this might be only the open part of GR budgets, which are confidential, and may exceed those published.
Thus even the open total annual GR budget of JTI, PM, BAT and Imperial Tobacco in
Russia might exceed 1-2 million USD. According to estimates of V. Kochetkov of IK “Finam”, on average, tobacco companies spend 10-12% of net profits for marketing promotion7. In 2007 BAT net profits in Russia reached 3.64 billion USD8, PM in first half of 2009 reported profits of 3.02 billion USD9, JTI in the second half of 2009 – 452 million USD.10 Thus annual profits of these three leading companies in Russia might reach 11-12 billion USD, so that promotion budget might reach 1.1 billion USD. At the same time, funding of all social advertising in Russia is estimated at only 20 million USD.
GR functioners of tobacco industry are highly qualified. For example, V. Aksionov and V. Bocan-Harcenko are diplomats, graduating from prestigious MGIMO (Moscow institute of international relations), A. Lyutiy used to work as foreign correspondent of TASS in Washington, D.C. and Communist Party newspaper Pravda in London, L. Sinelnikov used to work as director of the best Soviet tobacco factory Yava in Moscow.
Activities of GR functioners are intensive, they participate in numerous commissions, committees, conferences, etc. According to SuperJob.ru, vice president on GR of large company salary is appr. 500,000 Rubles per month, head of department - 200,000, manager - about 75,000 plus social package. It is typical that GR officers migrate from one company to another, so that top GR officers of Russia-based leading companies might have served for the big tobacco.
There are documented facts on industry penetration in decision-making at the Federal level. The industry is making donations to civil society organizations, first of all related to Youth Smoking Prevention programs promoted by the industry. Among PM recipients in 2006, is the fund “Severnaya Korona” headed by wife of Russian minister of finance.
The leading company in Russia – JTI is government owned, and relies on Japanese
government support, including GR. For example, a few years ago the Japanese embassy actively responded to Russian Government tax claims towards JTI, mentioning chances for more Japanese investments in Russia. Thus it is obvious that the leading tobacco companies in Russia might use their governments’ resource.
Industry GR is based on intransparency of industry activities in Russia. For example, Korean tobacco company is building a new factory in Kaluzhskaya Oblast. The population opinion was not considered, and it is not guaranteed that residents of Oblast are aware of construction, and agree with this project. Statistical reporting on tobacco of the Russian government is inadequate and in many cases industry statistics is used. Tobacco industry is leading debate and activities in CSR. Attempts are underway to legalize GR in Russia. Tobacco related activities of center “Lobbying.ru”, could be promoting industry interests. The centre regularly conducts ratings of GR officers, highlighting tobacco industry officers. GR activities of tobacco industry are treated as exemplary. In 2009 the centre published a paper pretending to analyze lobbying in tobacco field, depicting conflict between tobacco and antitobacco lobbies. The report emphasized BGI involvement and seriously undermined position of leading tobacco control organizations such as KonfOP and specific activists.
Key issues of activities of tobacco industry GR: Support and protection of Technical reglament as a vehicle against FCTC, improving industry status and achieving their aims; industry friendly state excise policy; issues of containment of limitation of smoking; counteracting WHO; achieving friendly advertising policy in the area of smoking.
Except for counteracting WHO, industry GR groups are quite successful.
So far GR activities of industry changed minds of legislators in Russia: that FCTC and Russian legislation must be separated into two distinct isolated parts: primary - on production issues (Technical reglament), and the secondary, on human rights protection, undermined by the industry, far from being adopted. State Duma Committee on health activities are undermined by industry through committees on economic development, agriculture and others. Most GR successes of foreign tobacco industry in Russia were achieved in the periods of economic, social and political crises: after break-up of USSR, in 1991-2, and after August 1998. There is a risk of more industry GR successes if economic situation in Russia will deteriorate.
There is a window of opportunity for control of demographic decline in Russia. It is critically important to convince the Federal Government that if it takes measures aimed at control of alcohol and tobacco, first of all at raising taxes on alcohol and tobacco, the state of demography and public health will improve considerably. If Government will follow alcohol and tobacco industry initiatives, Russian demographic decline will speed up.
Tobacco case study might suggest that Russia is still unprepared for effective countering of GR activities of foreign tobacco companies, which effectively lead public debate and decision making in their interests. Industry GR legalization efforts are underway, which include undermining trust in tobacco control community and FCTC, BGI. There is a need for more developed Russian civil society basis in tobacco control, involving regions. Russian Public Health Association should become the focal point for developments, as the national civil society organization active in tobacco control since 1993 and possessing a positive domestic and international image. Patriotic rhetoric on behalf of Russian civil society might be productive.
More involvement and emphasis on former USSR and European organizations is needed to cool down industry criticisms that tobacco control in Russia is represented and dominated by BGI. There is a need to concentrate on tobacco control issues where the industry can’t resist much, such as smoke free health care, education, sports, culture, and the like. GATS evidence for Russia should be well commented, otherwise it would be used by the industry to prove that no special additional tobacco control measures are needed. Russian civil society should ask the Government to implement the highest standards of FCTC, including Article 5.3. provisions, and also to adopt a law on the conflict of interests. Activities aimed at industry transparency and denormalization should be continued. There is need to dedicate much more time, effort and resources to analysis and neutralization of GR/PR activities of the industry and dissemination of evidence among decision-makers and population-at-large. Industry regulation should become the issue for bi- and multilateral governmental negotiations. Industry vulnerabilities in Russia should be identified and used for countering industry GR activities. Similar activities should be done in sphere of alcohol industry regulation.
 From 1929 until late 1960s social determinants of health were greatly neglected in USSR, later till break-up of the country in 1991, health issues were split into medical care and health protection, the latter focusing mainly on infectious disease prevention and control. Russia inherited and continued this Soviet approach in 1991-2007. Public health and health care information used to be classified in 1929-1993.
 This part of document has been produced with the help of a grant from the International Union Against Tuberculosis and Lung Disease (The Union). The contents of this document are the sole responsibility of the authors and can under no circumstances be regarded as reflecting the positions of The Union or those of the Donors. Complete document with references: http://www.rpha.ru/gr_russia.pdf
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