Russian health care: A healthy future?

Dr. Christopher J. Gerry, senior lecturer in political economy at University College, London, discusses Russian health care reform and the country’s prospects in this sector.

Russia’s sharp post-Soviet demographic decline and its principal causes have been well documented. Today’s population is over 6 million lower than that of two decades ago, while mortality rates remain higher and birth rates lower. On virtually every health indicator, Russia lags considerably behind her European neighbors and is among the most vulnerable of the European and Eurasian countries. More than half the deaths that occur are attributable to cardiovascular disease, with further large shares accounted for by cancer and external causes (e.g. accident and trauma).

Recognizing the seriousness of these problems (not least for the economy), since 2005 the Russian government has made improving the health of the population a national priority; launching the National Priority Project (NPP) for health in 2006, with a budget equating to more than 400 billion rubles over 2006-2009. This substantial injection of finance to the Russian health system has funded the main activities of the NPP: increasing the salaries of primary and emergency care physicians; facilitating the purchase of primary care equipment; buttressing vaccination programs; providing free medical examinations; promoting fertility; and constructing new high-tech centers for tertiary care.

During the period of the NPP there is little doubt that health and demographic trends have gradually improved and continued to do so despite the recent economic turbulence. Fertility rates have increased from 10.2 to 12.4 per 1000, mortality rates have fallen from 16.1 to 14.2 per 1000 and life expectancy has risen from 59 to 63 for males and from 72 to 75 for females. These are relative successes trumpeted widely by Russian government officials.

Untangling the precise role that the NPP has played in raising health outcomes is not straightforward. The initiative made little impact on the structural or practical deficiencies plaguing the Russian health care system: basic healthcare remains underfunded; the majority of care is still provided by the hospital sector; the failings of the mandatory health insurance scheme remained unaddressed; informal payments are still pervasive; and there was little concrete effort to address population health behavior.

Indeed, following a decade of reforms with no finance, the NPP package of measures became ironically caricatured as ‘money without reforms’.   

Against this background and with a growing concern at the numerous reports cataloguing the rising proportion of deaths linked to alcohol, tobacco and poor infrastructure, President Dmitri Medvedev last month signed into law another large scale Russian health care reform, worth up to 460 billion rubles ($15.1 billion) from 2011 - 2014.

These latest reforms are more specifically targeted at addressing the structural imbalances of the post-1990 healthcare system. In particular, the measures: transfer the responsibility for basic health provision from municipal to regional administrations; reform the mandatory health insurance scheme; promote greater competitiveness in insurance and provision; and endeavor to bridge the funding gap by increasing employer salary contributions from 3.1 percent to 5.1 percent. New lines of funding are to be found to modernize the 30 percent of medical institutions that Prime Minister Putin described as “hazardous or in need of major repairs”.

The new iteration of the mandatory medical insurance program will enable the patient to choose a doctor, healthcare provider and insurance company and the latter, in turn, will be encouraged to compete for customers through their offers.

Finally, the new legislation goes beyond the conservative focus on health care delivery by emphasizing population health, the promotion of healthy behaviors and the combating of non-communicable diseases (NCDs), including socially driven conditions relating to smoking, alcohol, sexually transmitted infections and drug abuse.

Indeed, to this end, Russia is the venue for the first international ministerial conference on NCDs and Healthy Lifestyles (April 28-29, 2011) – a joint venture with the WHO, designed to inform the high-level meeting of the UN General Assembly later in the year.

So, what are we to make of this extended commitment to health care reform and its likely implications for the demographic and health challenges facing Russia?

The NPP money, while certainly a necessary input, was by no means a sufficient input and the requirements for structural reform have remained writ large over the Russian health system. Implementing the proposed structural reforms will not be easy. The means to overcome corruption, to end the tradition of informal payments, to link the allocation of finance to sensible health targets and to ensure a sustained increase in integrated health financing are not yet in place.

Moreover, until Russians choose to stop smoking and binge drinking, to improve their diets and to take more exercise; and until the Russian public and private sectors can guarantee healthy air, water and food quality, safe roads and safe work environments, then no amount of structural reform or finance will address the demographic and health challenges that loom large in the years ahead

The 2011 reforms represent a more ambitious attempt to deliver structural change, but – as ever – the proof of the pudding will be in the eating.