Within the project “Empowering Civil Society Networks in an Unequal Multipolar World –
BRICSAM”
INEQUALITIES IN ACCESS TO HEALTHCARE IN RUSSIA.
POLICY ANALYSIS
By Oleg Kucheryavenko for GCAP Russia
This project is funded by
The European Union
This project implemented by
Global Call Against Poverty
Russia (GCAP Russia)
This publication has been produced with the assistance of the European Union. The contents of this
publication are the sole responsibility of GCAP Russia and its partners and can in no way be taken to
reflect the views of the European Union.
1. INTRODUCTION
Limited access to health care for a significant number of people in the Russian Federation is
an issue of concern of all social groups, non-governmental organizations and political
parties. Access to health care in the country in general cannot be considered satisfactory.
Depending on their social status and place of residence, various groups of citizens are
experiencing inequality in such access. It especially concerns rural communities, senior
citizens, large families, migrant workers, prisoners and persons with no fixed abode. Thus,
there is a lack of available health care for homeless people and migrants, while a great
number of people with low income, persons suffering from severe chronic diseases,
prisoners and residents of remote areas fail to get the health care complying with the
national standards.
The analysis of data by Rosstat (Federal State Statistics Service) demonstrated higher
mortality rate in many small towns and regions of Russia in comparison to the average
mortality rate in Russia (average mortality rate in the country at the beginning of 2014 – 13.1
per 1000 personsi, in Pskov region – 19.6, in Tver region – 18.3, in Novgorod region – 17.9,
in Tula region – 17.7ii). In 40 entities of the Russian Federation, deaths exceeded births, with
13 entities facing this excess by 1.5-1.8 times. The death rate in rural areas is still higher
than the one among urban population (14.8 against 12.8 per 1000 persons respectivelyiii)
Migrant workers, residing in Russia, are as a matter of fact deprived of access to health care
services since they lack the certificate of compulsory health insurance and, all too often, the
legal registration.
Russian prisons are a main source of drug-resistant tuberculosis. However, not every
prisoner has an opportunity to be promptly treated due to health care underfunding, a lack of
required training of the healthcare staff, and inappropriate interaction between various
agencies of the penitentiary and healthcare systems. As the experts of “Doctors Without
Borders” calculated, the treatment of all prisoners in Russia according to the DOTS method
(Directly Observed Treatment, Short course) will require purchasing medicines costing more
than 2 million US Dollars, excluding thousands of patients suffering from drug-resistant
forms of the disease, as their treatment will cost more.
A group of citizens with no fixed abode, often having no passport of the Russian Federation
or certificate of compulsory health insurance, deserve special attention. Over one third of
homeless people do not have any documents. Around 26% of homeless people, having no
documents, were refused health care when they requested it. Moreover, there is inequality
when it comes to receiving free medicines, as only people having a passport with permanent
residency in the Russian Federation, may receive free medicines.
Inequality in access caused by inequality in incomes
The Russian healthcare system is characterized by significant differences in requests for
medical assistance among social groups with different incomes. Social groups with a higher
income request health care more frequently than those with less income. Inequality is
reflected by a widespread health care service on a cash-basis: high-income persons pay 2.5
times more for a visit to a health care institution than those with a low income. Poor people
spend 1.5 times more of their household budget on medical care than well-off people.iv
2
The years 2003-2013 witnessed a great number of amendments in the legislation of the
Russian Federation, which influenced health care availability for people both directly
(through the changes in their rights to receive health care) and indirectly (through the
procedures of tax collection, allocation of funds, changes of government institutions and
procedures of health care facilities’ funding). The main issue that citizens of the Russian
Federation face, when requesting medical care in state health care institutions, is a failure to
receive the required, complete package of medical services for free.
State guarantees of free health care
According to part 1, article 41 of the Constitution of the Russian Federation every person has a
right to health care and medical aid. It is specified that “medical aid in state and municipal health
care facilities is provided to citizens free of charge from the corresponding budget resources,
insurance contributions and other receipts”.
In furtherance of the provisions conferred by the Constitution of the Russian Federation, Federal
law of the Russian Federation No. 323-FZ “On the fundamentals of health care for citizens of the
Russian Federation”, issued 21.11.2011, also confers the right to the citizens for the guaranteed
scope of medical care according to the State Guarantees Programme on free medical care to the
citizens (article 10, point 5 of the law). According to the law, refusal to deliver medical care is not
considered acceptable according to the State Guarantees Programme as well as collecting
payments for medical care by state health care facilities and medical staff.
According to the requirements of the legislation the Government of the Russian Federation
annually approves the State Guarantees Programme on free medical care to the citizens of the
Russian Federation. The above mentioned programme contains the list of types of diseases with
free medical care.
Therefore, citizens of the Russian Federation are entitled by law to receive free medical care and
there is a mechanism to exercise this right.
3
2. HEALTHCARE ANALYSIS
Issues built until they became obvious to an alarmed public. It was no longer possible to
ignore state underfunding, health institutions irrationally saving money, shortages of
personnel and medicines, as well as the negative and vocal opinions of professionals and
civil society about the health care system.
The Russian market of health care services, in general, cannot be regarded as good. Since
1990, the material and human resources of the health care system have been reduced: bed
space has decreased by 12%, the number of doctors has dropped by 46%, and nursing staff
by 10%. Yet, the Russian Federation is still among the top countries of the world in terms of
the number of doctors and hospital beds per 1000 persons. According to the World Bank,
this indicator of Russia is four times higher than the indicators of other BRICS countries
(Russia – 4.3 per 1000 persons, Brazil and China – 1.8, Republic of South Africa – 0.8, India
– 0.6).v Therefore, the existing system is unlikely to be efficient (Appendix 2).
In the context of limited resources, programmes aimed at reduction of the bedspace and
consolidations of hospitals by means of their merging are being implemented all over the
country in order to save funds. A lack of infrastructure and the conditions to deliver health
care are key factors for the closure or merger of curative and preventive health care
facilities. For example, in January 2013 the government of the Yaroslavl region took a
decision to close 7 obstetric departments in district hospitals, which led to protests by the
local communities. The established Committee of the Ministry of Healthcare of the Russian
Federation considered such a decision rational. “Conveniences in some maternity clinics
leave much to be desired – restrooms are nothing but pit toilets, there is no hot water.
Maternity clinics lack neonatologists. The professional background of the employed medical
staff and, above all, their experience falls short of standards as well”, said Oleg Philippov,
head of the Committee, deputy director of the Department for child healthcare and maternity
obstetric services of the Ministry of Healthcare of the Russian Federation.vi
Underfinancing
Being lower than the average of CIS countries, total expenditures for health care in Russia
fall significantly behind the same indicator in the countries of the European Union (EU)
(Appendix 2). Health care expenditures per capita remain relatively low as well (Appendix 3).
Unlike the countries of the European region of WHO, state financing of health care in Russia
is quite low, while its share in total expenditures for health care for the period 1995-2011
reduced from 73.9% down to 59.7% (Appendix 4). The segment of personal expenditures for
health care is formed mainly by personal payments of citizens, since the provision of
medicines for outpatients is excluded from the State Guarantees Programme (Table 1,
Appendix 5).
While all countries are experiencing growth in expenditures for health care, Russia is still
spending considerably less than the minimum required scope of health care financing,
defined by WHO as 5% of GDP. Russian state expenditures are several-fold lower than the
ones in the countries of the European Union (in Hungary, the Czech Republic, and Poland 6% of GDP, in Germany - 11%). At the same time in the course of the transition to a singlechannel financing, i.e. financing exclusively through the Compulsory Health Insurance Fund,
federal expenditures on health care will reduce in nominal terms by 1.5 times in 2015. Under
adverse regional budgets, the system of compulsory health insurance and citizens will bear
the responsibility for the financing of the Programme of State Guarantees. 3.8% of the
4
federal budget was allocated to health care in 2013, however in 2014 it is to be reduced to
3%, and in nominal terms from 515 billion RUB to 417.4 billion RUB, or by 19%. More than a
half of the entities of the Russian Federation have a substantial budget deficit caused by
heavy expenditures and reduction of production capacity, meaning that current conditions
call for the reduction of expenditures. The government has taken a decision to save
expenditures by spending less for social services including health care.
Table 1. Trends in health care expenditures in the Russian Federation, 1995-2011, selected
years
1995
2000
2005
2007
2009
2011
Total health care expenditures per capita according to
PPP (RUB for USD)
300
369
615
893
1177
1361
Total health care expenditures in % of GDP
5.4
5.4
5.2
5.4
6.2
6.1
Share of state expenditures in total health care
expenditures, %
73.9
59.9
62.0
64.2
67.0
59.7
Share of personal expenditures in total health care
expenditures, %
26.1
40.1
38.0
35.8
33.0
40.3
Share of personal payments of citizens in personal
health care expenditures, %
64.7
74.7
82.4
83.0
82.4
87.8
Share of external financing in total health care
expenditures, %
0.1
0.2
0.0
0.0
0.0
0.0
Share of official payments of citizens in personal
health care expenditures, %
64.7
74.7
82.4
83.0
82.4
87.8
Share of official payments of citizens in total health
care expenditures, %
16.9
30.0
31.3
29.7
27.2
35.4
Share of health care expenditures in total state
expenditures, %
9.0
12.7
11.7
10.2
10.0
10.1
State health care expenditures in % of GDP
4.0
3.2
3.2
3.5
4.1
3.6
Source: European Health for All database
Note: PPP- purchasing power parity; GDP- gross domestic product.
In Russia, inpatient care accounts for about 70% of total expenditures allocated to health
care, as opposed to 35-40% in western countries. This means that in the context of general
health care underfinancing, outpatient clinics are financed from the remaining funds, if there
are some. The doctors providing primary health care in Russia account for 20-25% of the
total number of doctors, while in countries with advanced health care systems this indicator
reaches 60% (for example, in Canada). The hospital admission rate is 21 per 100 persons,
but 12-15 in western countries. The average duration of treatment is 17 days, compared to
8-10 in foreign countries. The frequency of referrals to specialists by district doctors
constitutes a minimum of 30% of primary visits, while abroad it totals 4-10%. Indicators of
bed space and medical staff availability are approximately two times higher than in western
countries.vii The scope of the hospital care in Russia is several times higher than in leading
western countries, yet the amount of state financing and its share of GDP is much lower
(Table 2).
Table 2. Comparative analysis of efficiency of health care systems in selected countries for
5
2010
Indicator
Russia
Brazil
India
China
USA
EU
CEE
Hospitals, total
6200
6772
18667
17080
5803
10875
12149
State hospitals
5693
2097
8027
15714
1293
5686
11012
%, State hospitals
92
31
43
92
22
52
91
Number of hospital beds per 10000
people
92.9
23
7
22
31
48
82
Number of doctors and healthcare
workers per 10000 people
50
15
7
15
26
41
42
Total health care expenditures in % of
GDP
6.1
9.2
4.1
4.6
16.4
10.7
6.4
Health care expenditures per 1 person
(USD per year)
549
964
56
208
7794
4160
607
Share of state expenditures in total
health care expenditures, %
59.7
46
33
50
48
75
n/a
Source: Rosstat, Unified Interdepartmental Statistical Information System, WHO, Espicom -Understanding Russia’s Regional
Health Markets».
Note: EU-European Union, CCE - countries of Central and Eastern Europe.
The Russian health care system faces a serious challenge, i.e. to deal with the
consequences of health care underfinancing, which has caused a reduction in the quality
and availability of medical care, a technological lag of the medical equipment, and the
deterioration of the fixed assets. The health care system is not a top priority for the
government, while health preservation is not among the basic values of Russian citizens.viii,ix
Health care development strategy until 2020 contains theoretical plans for branch
modernization in several areas, including the provision of universal access to health care for
citizens. However, the plans specified in the Strategy are not backed by sufficient funding.
On the contrary, 2013 witnessed a decision to reduce health care expenditures, even if
compared to the most conservative scenario. To tackle the issue of underfinancing, the
government has to constantly search for new sources of savings. For this purpose, the largescale reorganization and consolidation of health care facilities through hospital mergers is
supposed to be implemented. One of the ways to save money is to tighten the conditions
under which free health care is provided through specification and a possible reduction of
the State Guarantees Programme. Moreover, for the first time, starting from 2014, the lists of
free and fee-based health care services will be available, which is tacit recognition by the
state that the principle “everything to everyone for free” is not feasible in modern Russia. It is
expected that cases of refusal of medical care or to provide medicines might take place due
to a lack of funding.
Rosstat data tracks the trend of growth of expenditures for health care services and
purchase of medicines. From 1994 to 2007, they grew in comparable prices by 7.9 times,
while until 2006 state expenditures exceeded the 1994 levels only by 1.1-1.5 times. Within
the period from 1995 to 2011 private expenditures tended to prevail over state expenses
with a general growth of personal expenditures’ share in total health care expenditures by
2.1 times. In the structure of personal expenditures for health care, a half and more is
constituted of expenditures for retail purchasing of medicines and healthcare products by
citizens (Table 3). Expenditures for paid health care services and unofficial payments
amount in total to 87.9% of personal expenditures. Contributions for voluntary health
insurance are equivalent to 7% of personal spending. It should be noted that there is a
6
sustainable growth of monthly spending for health care per household per capita. For
example, health care expenditures have grown by 8.6% in the households with lowest
income (10% of the most disadvantaged citizens) and by 14% in the households with highest
income (10% of the most affluent citizens) within the period from 2011 to 2012.x Out of all
health care services, expenditures for the purchase of medicines make the greatest
contribution to the consumer expenditures – up to 2.4% of all consumer expenditures in
Russian households.xi
Table 3. Private healthcare expenditures (in %) for 10% population groups in Russia (20112012)
10% most disadvantaged
Russians
10% most well-off
Russians
2011
2012
2011
2012
100
10
100
100
Medicines and medical
equipment
86.4
87.0
40.6
43.3
Outpatient services
13.6
13.0
46.9
40.0
In-patient services
0.0
0.0
12.5
16.7
Private healthcare expenditures
for :
Source: Federal State Statistics Service (2013) Consumer household spending for 10% population groups
Given the current trends in healthcare financing and structure of informal payments for
health care services, the forecast of expenditures for prescription drugs (not considering
their given standards) seems negative, what increasingly outlines the problem of inequality
in Russia. According to experts from the ‘Higher School of Economics’ Research University,
private expenditures will rise from 331.9 billion RUB in 2013 to 1305.5 billion RUB in 2020,
considerably outperforming state expenditures (255 billion in 2013, 365.6 billion in 2020). It
is particularly visible if we consider private spending for medicines. Russia is one of the few
countries where almost no medicines are provided for outpatient health care, where
prevention of diseases is far cheaper when compared to inpatient health care.
New legislative initiatives in healthcare imply a gradual reduction of federal financing hrough
the redistribution of financial flows – most of the financing will go through the Federal
Compulsory Health Insurance Fund. 2013 and 2014 are a transitional phase as triplechannel financing is introduced. In 2015 all funds will come from the Federal Compulsory
Health Insurance Fund subventions, thus shifting the whole health care system to the
regional level. However, if we consider the actual situation in the entities of the Russian
Federation, increased financing from regional budgets seems unlikely. 2013 witnessed the
rise of debt burden in all the regions, where budget deficits do not allow for planned
economic growth. For example, debt burden of the Southern Federal District reached 47.7%,
the one of the Volga Federal District – 39.8%. The Tyumen and the Perm Regions have the
smallest debt burden (0.6%) in Russia. The Nenets Autonomous District holds no debt at
all.xii
The explanatory note of the Russian Government’s decree “On establishment of the Russian
Federation state program ‘Development of healthcare’” points that in 2014 direct budget
allocations will be reduced by 16.2 billion RUB, in 2015 – by 17.3 billion, in 2016 – by 28.9
billion, provided that the Federal Compulsory Health Insurance Fund’s budget, which
allocates money for the state program, will rise by 40.8 billion RUB in total in 2014 and 2015
7
with the subsequent decrease by 329.1 billion rub in 2016.
At the National Council meeting in 2013, Minister of Healthcare Veronika Skvortsova
stressed the issue of underfunding and increasing inequality with regard to access to
healthcare services, “Each region has its own programs, but their funding runs a significant
deficit. In 2012, the deficit of 66 regions was 164 billion RUB. This year [2013], even with its
budget tensions, the picture looks slightly better, but it is still gloomy. The deficit of 54
regions exceeds 120 billion RUB.” In the report she stressed the need to make a clear list of
free public medical services, provided under the regional programmes, “The mess we have
with these issues leads to corruption and extortion, which forces people to pay for the
services that are free under the Constitution. There are a few cases like this.” The report
underlines that today more than 70% of requests for paid services result from a lack of
awareness about the Public Guarantees Programme and requirements for the provision of
free healthcare services.xiii
According to Minister Skvortsova's preliminary estimations, the budget deficit for public
guarantees could amount to 140 billion RUB in 2015 and 754 billion in 2018. The money for
medicines, equipment, supplies, and maintenance of healthcare organisations will be
insufficient.
Ineffectiveness of accumulation and allocation of public funding
The current budget and insurance model of healthcare funding proves cost-ineffective when
compared to the model of public tax funding adopted in most EU countries. Three funds
channels (federal, regional budgets and compulsory health insurance) will have been
narrowed down to one channel – compulsory health insurance system by 2015. This model
is being implemented through private healthcare insurance companies aimed at raising
money from penalties imposed on healthcare providers. Financial principle ‘money follows
the patient’ and ‘money per treated patient’ proved that healthcare providers have economic
interest in examination and treatment of their patients and do not send them to other
providers even when it is a necessity, because money will ‘follow’. The second principle
made healthcare providers interested in big quantities of ‘treated patients’, preferably with
severe conditions leading to long-term treatment. Here the public interest clashes with the
one of healthcare providers, which remains focused at the process, not the result, of medical
treatment.
Compulsory health insurance is not a magic bullet for all financial problems. It is a bulky and
expensive system. Numerous insurance companies, acting as agents between healthcare
providers and compulsory health insurance funds, are not responsible for the quality of
treatment, but take their part from pitiful financing of a healthcare provider for their own
needs. Medical and economic standards of the compulsory health insurance system are
deficient, provide for a longer in-patient treatment and excessive tests, whereas their rates
are dramatically low and do not cover financial expenses for treatment and examination of a
patient. However, numerous inspections made by insurance companies divert doctors from
their work and impose penalties for the flaws that have nothing to do with the outcome of
treatment, punishing them for mistakes in patient profiles (wrong indications for hospital
admission, no information about medicines and their dosage for concurrent conditions in the
patient’s history). Control in the system of compulsory health insurance is not a matter of
quality of healthcare services, but rather the account of bed-days in hospitals and tests
made according to the medical and economic standards. Federal law №326 ‘On compulsory
8
medical insurance in the Russian Federation’, adopted in 2010, outlines the grounds for
penalties, where their scope is the matter of agreements between insurance companies and
healthcare providers within the compulsory medical insurance system. Recommended
penalties were specified in the separate letter of the Federal Compulsory Medical Insurance
Fund (№ 1257/30-4/и dated 15.03.2011). Penalties for certain violations amounted to 500%
of the financial standard for regional State Guarantees Programmes. Besides, compulsory
health insurance system contradicts the principle of solidarity, when the rich pays for the
poor, the employed – for the unemployed and the healthy – for the sick. In Russia,
employers pay compulsory insurance contributions from the Remuneration Fund, i.e. from
underpaid salaries, rather than its own revenues. As the result, working population
contributes ever more to the compulsory medical insurance, the system gets increasingly
expensive and healthcare less affordable.
Programmes for treated patients listings are also far from being perfect. There is no single
compulsory insurance database and access to insurance holders listings. When a patient
changes his place of residence or work, he/she gets a new insurance certificate, which is not
registered in the database and is not covered by insurance company accordingly.
For instance, in 2013 a Russian citizen with a compulsory insurance certificate issued in
Moscow was entitled a free surgery to replace an opaque lens with an intraocular one
(‘artificial lens’, cataract surgery through phacoemulsification) in the S. Fyodorov Eye
Microsurgery Clinic. The costs of the surgery were reimbursed from compulsory medical
insurance funds, patients paid the price for an intraocular lens only (10.000 rub). In 2014
new conditions for the healthcare service were introduced, where all Russian citizens with
compulsory insurance certificates issued in Moscow have to pay the full cost of surgery and
the lens (more than 35.000 rub). However the monthly quota for the surgery at the cataract
department is 30 patients with 700 people in the waiting list. Thus, the availability of
healthcare was dramatically reduced, forcing patients to seek fee-based services as the
result of severe damage to the quality of life associated with this disease.
Informal payments
There are expert estimates of informal payments for healthcare services. According to these
estimates, total private healthcare expenditures in Russia, including private businesses and
NGOs, account to 2.5% of GDP in 2011. Private healthcare spending include informal
payments, cash payments, and voluntary insurance and amount to 40% of total expenditures
on healthcare, which is a significant amount when compared to EU countries, where this
index was 23.4% in 2011.xiv Interestingly, private payments are less common in Russia than
in other BRICS countries (Table 4).
9
Table 4. Private healthcare spending in BRICS countries (2011)
Brazil
Russia
India
China
SAR
Private spending in
total healthcare
expenditures, %
54.3
40.3
69.5
44.1
52.3
Personal payments
in total healthcare
expenditures, %
31.3
35.4
59.8
34.8
7.2
Private insurance
spending in private
healthcare
expenditures, %
40.4
7.0
4.7
6.4
81.1
Source: WHO National Health Accounts, 2011.
It is interesting to compare the correlation of formal and informal payments for different types
of services. Payment for diagnostic examinations and tests, medical materials, appointments
and advisories are usually made legally. In most regions people tend to pay informally for
such services as referrals for further examination, statements of treatment performed,
appointments with assistants or nurses. Payments for referrals to other healthcare
institutions, sick leave certificates or medical notes without relevant medical conditions,
payments to nursing staff for any information are performed informally by default. xv
Understaffing and medical staff disproportion
Russian healthcare providers employ 2.162 million people, with 639.303 doctors and
1.299.297 nurses working within the system of the Ministry of Healthcare. According to the
experts at the panel meeting of the Ministry of Healthcare (24.05.2013), “we see the greatest
deficit of doctors in such fields as anaesthesiology and intensive care, neonatology,
oncology, narcology, anatomic pathology, paediatrics and phthisiology.” Understaffing in
certain fields has reached 35%, i.e. 40.000 doctors and 270.000 nurses in absolute terms. xvi
Surplus of doctors in the country is putative, since Russia takes top positions in terms of
medical staffing (43-44 doctors per 10.000 citizens), but Russian statistics takes other
professionals in the field of remedial gymnastics, physical therapy, public health service, and
dentistry for ‘doctors’. As the result, the number of doctors is arbitrarily based on the number
of university graduates. According to the data of the Ministry of Healthcare, along with the
lack of doctors, 8% of medical staff quit the profession annually (22-25.000 professionals).
The Ministry of Healthcare reports (2012) say that Sakhalin has just 50% of medical staff,
the Arkhangelsk region – 27%, Tula – 40%, etc. In the Krasnoyarsk region shortage of
doctors has amounted to 7000 people. In general, staff deficit in the healthcare system is
even across all Russian regions. It is important to remember that staff deficit is aggravated
by aging of healthcare professionals – about 40% of doctors are retired or about to retire.
Low salaries of healthcare workers remain to be the second issue of deep concern. In 2013
compulsory health insurance funds covered 85.5% of salaries for medical staff. In general,
the Federal State Statistics Service data say, that the average salaries of doctors and other
medical workers with the university degree is higher than a payable average salary in
Russia. Statistics show that in 2013 average salary in Russia was 29.940 rub, average
salary for doctors was 29.960 rub (it varied from above 60.000 to less than 17.000 RUB
across regions) xvii. However the reality hasn’t changed. A number of high-profiled scandals
10
in Russian regions, triggered by numerous resignations of doctors as the result of low
salaries and critical working conditions, prove that. In 2012, half a year after the president
adopted ‘May decrees’, dozens of doctors resigned from Chelyabinsk city clinical hospital
№6. “Last year salaries virtually halved and both the hospital and the clinic can’t provide
even basic medicine… We have 20 meters of gauze per week, with the standard of about
100 meters. Patients have to pay for most medicines,” said Svetlana Funker, deputy chief
doctor of Chelyabinsk hospital №6. xviii
47 doctors resigned from the maternity clinic in the city of Chita in February 2014. Among
the reasons were miserly salaries, improper working conditions, and enormous workload.
“The workload was unthinkable: a doctor has to deal with 35 patients a day, spending 10
minutes per person, which is technically impossible, provided that half of the doctors work
without nurses, who resign because of low salaries. At the end of the modernization program
salaries of doctors and other medical staff bottomed down at 8.000 rub. That was the last,
but not the only reason to resign,” commented Elena Vorobets, head of prenatal department
at the maternity clinic in the city of Chita.xix
The governor of the Vladimir region believes that understaffing remains a main scourge of
healthcare system in the region. In 2013-2014 60 junior physicians came to work there and
the region relies on them as future GPs. “But only two of them are paediatricians. That’s an
enormous challenge for us,” said Mikhail Kolkov, vice-governor on social policies of the
region.xx
Lack of affordable medicine
Russia continues to fall behind Europe and USA, where average consumption of medicines
is three and five times bigger, correspondingly. This volume of medicines’ consumption (133
USD per person) is smaller only in Brazil and China – 118 and 31 USD.xxi,xxii There are
numerous bureaucratic obstacles to those seeking free medicines, where the entitled
citizens have to be fit to fight for the medicine they need. Most pharmaceuticals are
produced abroad. In the context of enforcing the rules of the World Trade Organization and
absence of own production, Russia may become fully dependent on imported medicines,
which will result in increasingly expensive health care. Besides, the data of the Federal
Service on Surveillance in Healthcare indicate that 90% of fake medicines refer to those
produced abroad. xxiii
The allocation of money for medicines is irrational. Allowed per capita expenditures for
medicines for oncologic patients in the amount 10-15 Euro, suggested by the Karolinska
Institute (Sweden) is not achieved in Russia with the present amount of financing and is as
little as 3,3 Euro. The calculations demonstrate that there is a need of 4 times increase of
the budget for the treatment of oncologic diseases, innovative medicines should be used on
early stages of the disease according to the international recommendations, and not on the
last stages, as it is commonly practiced in Russia. Such approach leads in reality to throwing
money away. Moreover, it is planned to transfer expenditures for treatment of oncologic
patients to the system of Compulsory Health Insurance by 2015 that will not have enough
money to treat such group of patients.
“Regionalization of Health Care” implies reduced federal financing of health care against
increased regional financing, while only 17 out of 83 entities of the Russian Federation are
relatively trouble-free, as the experts say.xxiv Russians, who suffer from oncologic diseases,
may face discrimination based on place of residence. As the experts of the Social Economy
11
Centre say, budget deficit for oncologic treatment is present in the large majority of country’s
entities, while in some regions the gap between actual and required financing of such care is
10-fold. The following is stated in the address of the executive committee of VII Forum
“Movement against cancer” to the President of the Russian Federation Vladimir Putin: “Many
regions do not have an opportunity to find sources of financing for expenditures needed to
purchase necessary medicines and cure severely ill patients. Refusal to provide them with
free or reduced-price medicines, especially when it comes to expensive medicines, leads to
progressive disease and forced escalation of costs for treatment and untimely death of
patients”.
About 60% of Russian oncologists had to refuse to write a free prescription to the patients
entitled to benefits and discounts for reasons with no legal basis (for example, “due to
insufficient funding”) in 2013.xxv Patients were either deprived of treatment or purchased
expensive medicines on their own. More than one-third of inhabitants of Moscow and 40% of
those who live in the Moscow Region think that there is no access to the guaranteed free
medical care or it is difficult to access it.xxvi
The possibility for each region to have its own list of free and reduced-price medicines
deprives many Russian citizens of the right to receive medical care. For example, the
section of the Federal List of Vital and Essential Medicines concerning “Antitumor medicines
and immune modulators” includes more than 80 titles, while a similar list within the
framework of Territorial State Guarantees Program of Krasnoyarsk region for 2014 includes
only 15 titles. Saint Petersburg Chief Oncologist G.Manihas gives the following evaluation of
the situation: “Regionalization is incompatible with the standards (of treatment), financing
and level of development of health care system in various regions differ drastically. If a
patient is registered in Moscow, 43,5 thousand RUB is given for his/her treatment, in Saint
Petersburg – 7 thousand RUB, in other towns of North-West federal district – from 3 to 5
thousand RUB”. Thus, regionalization of pharmaceutical provisions created inequality
between the entities of the Russian Federation.
Same problem concerns patients with a nosology, threatening national security of the
Russian Federation, i.e. HIV/AIDS. Starting from 2013 purchasing of medicines for treatment
of patients with HIV has been transferred from federal to regional level. Before this transfer,
medicines were purchased by the Ministry for Healthcare through auctions and were further
distributed among pharmaceutical stocks in the regions of the Russian Federation.
Beginning in 2013, the regions receive money to procure the medications on their own,
which led to dramatically growing inequity among the regions in terms of access to
treatment. A closer look at the data of 5000 auctions in 83 entities of the Russian Federation
allows to assert the presence of economic abuses during auctions in the regions – not only
has the price for medicines grown in comparison with 2012, when procurements were
centrally-controlled, it differs many fold among the regions.
In particular, the Department of Healthcare and Social Safety of the inhabitants of Belgorod
region purchased a combined medicine Abakavir+Lamivudin (trade name “Kivexa”) at the
price of 5755,50 RUB a package, while Ministry of Healthcare of Karachaevo-Cherkesskaya
region purchased medicine Zidovudin+Lamivudin (trade name “Virocomb”) at the price of
567,82 RUB a package, Regional AIDS Prevention and Treatment Centre of Zabaikal region
– at the price of 3064,94. Thus, procurement prices may differ 3-10 times between the
regions. Attention should be paid to the fact that the amounts of subsidies to the entities of
the Russian Federation from the federal budget differ greatly, which means that allocated
12
money will not be enough to provide all the patients with the free medicines they need. xxvii
According to the draft of the federal budget for 2014, funding for purchases of medicines for
HIV treatment will not be increased. The Federal AIDS Centre determined that out of 300
thousand patients who need HIV medication, only half of them have real access to the
drugs.
The fact that 80% of medicines, included in the Federal List of Vital and Essential Medicines,
are not approved from the point of view of their safety and effectiveness is a key factor for
financing of pharmaceutical aid. Thus, about 500 billion RUB are wasted every year, while
many medicines with proven safety and effectiveness are not on the list.
Inequity in access to healthcare services in rural areas
The issue of free healthcare availability for the majority of citizens, including those who live
in rural areas within the entities of the Russian Federation, remains pending. In the process
of social system transformation and in the result of poor healthcare system, small-size
medical centres were the ones to be shut down first. Such reduction of rural healthcare
facilities is also expected for 2014. The number of medical centres was reduced from 7418
to 1392 between 2005 and 2012. According to official statistics, staffing level of medical
centres is 96,2% for rural outpatient clinics and 99,2% for district hospitals (Appendix 1). xxviii
However, there are different data in the survey, conducted by the Independent Institute of
Social Politics. While in big cities the most significant constraint is difficulties in making
appointment to the doctor’s, in small towns and rural areas it is the absence of doctors
needed. The inhabitants of villages and rural settlements have the least opportunities to
receive free healthcare they need and of the required quality. Free and fee-based healthcare
availability for various social groups decreases dramatically with the reduction of available
resources and size of the settlement. In this respect, the type of settlement is a more
significant factor of inequity in availability than available resources. People with low income
have to spend most of it for medical needs, mainly for medication, but they cannot be
compelled to follow the dosage prescribed, or opt to forego the medication altogether.xxix
3. RECOMMENDATIONS FOR STATE POLICY
Healthcare funding
1. To increase the amount of health care funding and change the mechanisms of funding
through step-by-step 2-fold increase of funding, however no more than 5% of GDP
(according to WHO recommendations). Greater allocations from GDP indeed do not
guarantee equality in medical care provision, however in the present day scenario it is a
prerequisite to reach target values in health of the Russian citizens.
2. To transfer from insurance health care, aimed mostly at private insurance, to state-funded
health care system, financed from the budget funds (collected with taxes), where the
minimum scope of health care is determined, which must be of high quality and must be
provided to the citizens free of charge. State Guarantees Programme shall not be vague;
it must contain a precise list of medical services, guaranteed by the state, which shall
ensure not only treatment, but also disease prevention and rehabilitation. The list may be
extended for corresponding reason.
3. To develop the system of voluntary health insurance as an additional source of health
care funding for citizens with high income or those who are ready to pay for certain good
conditions of their treatment: extra-comfort, no lines, etc.
13
4. To mobilize resources by means of developing innovative financing within the country: to
introduce special fees for large and profitable companies, currency transactions, charges
from the mobile phone, Tabaco, alcohol and junk food excise duties.
Building healthcare system
5. To centralize healthcare system, removing needless healthcare governing bodies, which
will lead to easier management of the system, less administrative operational and staffing
costs, no expenditures to the intermediates.
6. To organize a state mission on ensuring medical services to population in the form of the
agreement between the governing bodies and curative and preventive health care
institutions with payment for preliminary determined scope of healthcare, quality and
results assessment. This will allow to set national priorities in terms of public health, to
develop disease preventive and early detection programmes. The core of state-financed
healthcare model is as follows: public health is country’s priority, in comparison to modern
market model, where health is a personal responsibility of each individual.
7. To revise State Guarantees Programme. This includes not only assessment of state
finances, though limited finances will no doubt be a key factor. State Guarantees
Programme shall be transparent both for organizations, providing services, and for
people, which presupposes more precise description of the types of health care, its
scope, procedures and terms of health care provision.
8. To enhance coordination within the system of health care and to shift the focus from
inpatient care to outpatient care, precisely – to primary health care. It is outpatient care,
which according to WHO ensures best quality-to-price and cost-to-results ratio. This will,
first and foremost, help to correctly set state priorities, i.e. prevention, early diagnosis and
timely treatment. Secondly, outpatient care is cheaper than inpatient one. Number of
hospital admissions and length of hospital stay can be significantly reduced with more
people covered by outpatient types of treatment. The share of outpatient care must be
70% of the overall public health care.
9. To increase availability of medicines for outpatients. Financing of medicines' supply
requires manifold increase. The list of medicines, guaranteed from the state, shall include
those with proved effectiveness and safety.
10.
To implement the methods of health technology assessment (HTA),
pharmaeconomics, and pharmacoepidemiology, in order to determine priorities for
medicines supply and health care high-technologies provision to the citizens of the
Russian Federation.
11.
To determine types, forms, and grounds of responsibility for persons, refusing to
provide free health care or providing inappropriate health care in state health care
institutions.
Personnel reform
12.
To scale up the salaries of all health care providers. A salary shall be formed of two
parts – constant, depending on scope of work and work performed, and varying,
depending on the quality of work.
13.
To change the ratio between doctors and medium-level medical personnel to 1:4, to
increase the role of nurses, and to increase their responsibilities.
14
14.
To review the Federal State Standard for Medical Education, to change the paradigm
of medical education – to eliminate redundancy of courses under study, to gear medical
education to scientific approach, not an empirical one.
15.
To bring back work placement of graduates by the state with compulsory 3 years of
work, as well as to bring back the so called target-oriented enrolment in higher education
establishments and secondary medical education establishments from the local citizens
(with a healthcare facility guarantying the employment of the graduate).
15
APPENDIX
Appendix 1. Healthcare facilities, providing health care services to rural population.
2005
2008
2009
2010
2011
2012
Overall number of healthcare facilities
7418
1894
1804
1692
1530
1392
number of hospitals out of overall
number of healthcare facilities
3637
1387
1354
1321
1212
1148
their bed capacity
187922
179912
172190
149740
155489
135117
Number of central regional hospitals
1734
1749
1752
1754
1755
1719
their bed capacity
345086
363548
350087
337958
324057
280982
Number of district hospitals
2631
481
438
400
301
237
their bed capacity
62325
14099
12411
11160
8252
5388
bed space (annually)
187922
164120
156357
149740
139476
135117
Outpatient clinics
7404
2740
2626
2859
2812
2587
independent outpatient clinics
3811
524
450
371
318
244
Number of medical and obstetric
centres
42164
39179
38332
37591
34919
34733
Source: Ministry of Health Care of the Russian Federation. Rural health care in Russia in 2012.
16
Appendix 2 Healthcare expenditures (in % GDP) in Russia and other countries between 1995
and the latest available year
Source: WHO National Health Accounts, WHO European Health for All Database, 2011.
Appendix 3 Per capita healthcare expenditures according to Purchase Power Parity in US
Dollars from 1995 till the last year available
Source: WHO National Health Accounts, WHO European Health for All Database, 2011.
17
Appendix 4. Share of state healthcare expenditures in overall healthcare expenditures from
1995 to the last year available
Source: WHO National Health Accounts, WHO European Health for All Database, 2011.
Appendix 5. Trends in private expenditures of citizens and state expenditures in the structure
of healthcare expenditures from 1995 to the last year available
Source: WHO National Health Accounts, WHO European Health for All Database, 2011.
18
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20