Russia Health Profile 2012

Parts of the social security system (especially health care) are relatively well-developed in Russia, but they do not cover all risks for the entire population. Moreover, efficiency and availability to social aid is reduced by widespread corruption. There is almost no state support for the unemployed. Though pension payouts have been increased considerably in recent years, they are still insufficient to survive on. Without additional income, such as a job in the shadow economy, private farming or family support, pensioners are at risk of slipping into poverty. The bigger cities have large numbers of homeless people whom state social facilities completely fail to reach.

Economic improvements since 1999 have mitigated the country’s social problems, as wages and employment rates have risen and poverty has been reduced. But improvement in the state’s social insurance systems has been limited. Under President Vladimir Putin, the reform of the state’s social welfare system aimed at liberalization. However, most Russians lack the financial means to purchase private insurance and especially in the pension system, private companies are underdeveloped. Special government programs to improve health care and fight rural poverty have had only a very limited impact, mainly due to the size of the problem and the inefficiency of the state bureaucracy. For example, as the state health care sector employs 700,000 doctors and an additional 1.5 million trained medical personnel, even a rise of salaries to the average level for respective educational qualifications was impossible. Another problem with the special state programs is that they did not establish meaningful accounting mechanisms for the use of funds.

Equality of opportunity is not fully assured. There are substantial differences from one region to another. Members of non-Russian ethnic groups, especially those from the Caucasus, suffer systematic discrimination in the educational system and on the job market. In Moscow, for example, citizens from the Caucasus region have been banned from working at public markets. Social exclusion extends to people living in the Northern Caucasus, where in some regions living standards are far below the Russian average, a quarter of the population is unemployed and wages are far below the national average. There are sizeable communities of homeless people in the bigger Russian cities. Throughout the country, women have equal access to education but are underrepresented in the political system and in business management.

Until 1991 the health system of the Soviet Union was organized along highly centralized lines with the Supreme Soviet holding ultimate authority. Responsibility for health care provision was delegated to the Ministry of Health of the USSR which regulated management and resource allocation through the Ministries of Health within the 15 Soviet Socialist Republics, including that of Russia. Russian health care, then, was subject to the supervision of the Russian Soviet Socialist Republic’s Ministry of Health, which covered more than 80% of the territory of the Soviet Union. However, it took little part in policy formation and tended to carry out nationally determined supra-soviet directives. Departments within the All-Soviet Ministry included:

• curative health care services
• maternal and child health care
• medical and nursing education
• sanitary epidemiological services
• sanatoria and resorts.

The Ministry also directly supervised special, All-Soviet health services and institutions (largely highly specialized and research oriented) and oversaw the Plague Research Institutes and the USSR Academy of Medical Sciences, which in turn regulated individual republican research institutes.

This structure was broadly replicated within Ministries at the republican level. The Russian Ministry, through the agency of its various departments, provided both special republican health services and institutions, again with a
tertiary and research focus, and supervised regular health services. These republican organizations included medical educational institutes and research centres (some with beds and clinics), specialist republican hospitals and polyclinics (outpatient centres), nursing schools and sanatoria. The republican administration also directly controlled oblast (regional) san-epid centres responsible for monitoring infectious disease and environmental hazards, and oblast nursing schools.
The mainstream health service delivery was mediated through a series of local government structures, all incorporated within the formal local government organization, which provided accountability through the elected nature of local assemblies. City health authorities managed city hospitals and polyclinics for adults, women and children. Regional (oblast), autonomous republic or krai governments provided both tertiary and secondary hospitals, and outpatient services at a ‘state’ level. They also monitored “rayon bodies”, the next tier of administration down. Rayons oversaw smaller territories or districts and provided a central hospital and outpatient service (polyclinic). There were further rural councils providing uchastok (“micro-district”) hospitals and in remote areas either doctor-led ambulatory clinics or feldsher-midwife stations.
Current organization of the health care system The Russian Federation is administratively divided into three levels: the federal, the regional – comprising 21 republics, 6 krais, 49 oblasts, 11 autonomous entities and the cities of Moscow and St. Petersburg – and the municipal, consisting of rayons, cities, towns, villages and rural settlements. Depending on their size, cities may be divided into rayons or constitute a single rayon. The republics, krais, oblasts, autonomous entities and the two cities of Moscow and St. Petersburg (also known as “Federal subjects”) are referred to as territories at the oblast or regional level. There were 73 oblastlevel administrative territories until 1991, after which the addition of 5 republics and 11 autonomous entities raised the total to 89.
Following decentralization of the Russian administrative system after the dissolution of the Soviet Union, the health care system was also decentralized (see the section Decentralization of the health care system). The health care system follows the administrative structure of the country and is divided into federal, regional (oblast-level) and municipal (rayon-level) administrative levels.

According to the Constitution of the Russian Federation, the state is to be responsible for the regulation and protection of human and citizen rights and freedoms, and the federal and regional levels are to be jointly responsible for the coordination of health care issues. Legislation entitled “Fundamentals of the Russian Federation legislation on citizens’ health protection” of 1993 defines the following as the responsibilities of the federal government (36):

• protection of human and citizen rights and freedoms in the area of health protection;
• elaboration of a federal policy to protect citizens’ health;
• elaboration and implementation of federal programmes on health care development, disease prevention, medical care delivery, public health education and other issues to protect citizens’ health;
• definition of the percentage of expenditures for health care within the federal budget; elaboration of a fiscal policy (including tax exemptions, duties and ther payments to the budget) in relation to health protection;
• management of federal property used in health protection;
• establishment of a common federal statistics and accounting system in health protection;
• development of common criteria and federal education programmes for medical and pharmaceutical training, determination of a list of specialties in health care;
• establishment of medical care quality standards and control over compliance with them;
• development and approval of a basic programme of compulsory health insurance and establishment of tariffs for its premiums;
• defining benefits for certain population groups receiving medical-social care and pharmaceutical supplies;
• organization of the State Sanitary Epidemiological Surveillance (SSES); development and approval of federal sanitary regulations, norms and hygienic standards; securing state-sanitary epidemiological surveillance; organization of the system for the sanitary protection of the RF territory;
• coordination of the activity of state and administrative authorities, sectors of the economy, and of the state, municipal and private health care systems;
• establishment of procedures for medical expertise;
• establishment of procedures for licensing of medical and pharmaceutical activity.

The reforms of the health system in the Russian Federation were undertaken at a time of great upheaval and in response to pressing demands. The system is still very much in transition but some broad conclusions can be drawn. The threat to equity posed by the breakdown of services in the areas most effected by economic crisis in the early 1990s was acknowledged by planners and policy-makers. The reforms were drawn up with a clear aim of preserving access to a basic package of care for the whole population. The assumption at the outset was that the efficiency savings that would come about from the reform process would be sufficient to cover the costs of the minimum requirements. This has not proved to be the case. Further, the insurance mechanism did not lead to an explicit priority-setting process. Rather, de facto rationing now takes place without scrutiny. There are very serious threats to equity due to growing differences in economic performance and capability across regions, with implications for the regions’ capacities in services provision. In addition, as the system comes to be increasingly financed out-of-pocket and under-thetable, in the absence of a formal cost-sharing mechanism in place, equity is
clearly being compromised. Health status in the early part of the 1990s was severely affected. In the first instance this was the result of the long-term shortcomings of the Soviet health care system, which failed to anticipate the epidemiological shift or to address the huge importance of noncommunicable diseases. Even more significant was
the massive downturn in health indicators associated with the economic chaos following the break-up of the Soviet state. This evidently interrupted effective health care delivery but most critically appears to have directly impacted on individual health, most likely as a result of the stresses associated with great uncertainty and economic collapse and increases in alcohol consumption in times of stress. The reforms, by rationalizing the health care delivery system, were meant to free resources to address health needs more effectively. However, health indicators continue to be dismal, and although the reforms were intended to create incentives to shift the emphasis of care and to take appropriate action in the primary and preventive arena in time to secure real health gains, this has not happened.
Efficiency may have been enhanced in those units able to use incentives effectively, but it is very difficult to make any overall comments, since so much of what takes place is the result of crisis management. However it can be concluded that efficiency gains have not been made to the extent hoped, and this is in large measure due to the incomplete implementation of the health insurance legislation, and the only partial functioning of insurance companies as envisaged by the legislation.
Consumer choice has not been expanded, also contrary to what was stipulated in the legislation, except where consumers are able to pay, in which case they freely choose providers. It appears, too, that the quality of care has only improved in the private sector. It is unfair to attribute all the evident shortcomings to failures in the reform process, but it does seem clear that the reforms were over-ambitious in some respects. The economic background has made all reform and planning-related tasks extraordinarily difficult, but the urgent need to address health issues overrode the possibility of waiting for the situation to stabilize before embarking on a reform process. It is possible that the concept of reforms introduced through the new health care financing mechanism was biased excessively in favour of the perception that the fundamental problem in the health care system was a lack of sufficient resources. As a result, the issues of health, quality of care, effectiveness and efficiency in the use of resources, received too little attention as issues in their own right demanding separate consideration. It is not that these issues were ignored. It was believed, rather, they would be effectively addressed indirectly and automatically as a consequence of the workings of the internal market that was being created through the establishment of the health insurance system. The market was perceived as a panacea for resource shortages and the other ills of the system. It has not proved to be so, and the Russian health care system now faces the challenge of trying to secure health gains despite huge uncertainties and formidable constraints.