HEALTH POLICY IN RUSSIA.
Part 1
I.V. McKeehan Campbell, Ph.D., M.P.H.,
Inter-Health Data Associates
COLUMBIA UNIVERSITY
irav@joimail.com
AIMS AND OBJECTIVES:
This lecture is one part of a more comprehensive
report which describes a city-wide profile of
health-related quality of life (HRQOL) in
Moscow. The Health Profile examines both
individual and environmental risk factors one
month after the August Coup and shortly before
the dissolution of the USSR. Central goals of the
Moscow Lifestyle and HRQOL Survey were to:
METHODS:
A random citywide sample of Moscow adults
with household telephones (N=2000) was
collected Sept. 17-19, 1991, one month after the
August Coup, and had a completed interview
rate of 81.8%. The questionnaire replicated
items from the California Alameda Study on
Health and Ways of Living, and the US Health
Interview Survey in a Russian translation.
RESULTS:
This study demonstrated that it is feasible to
include several dimensions of HRQOL as
individual outcome and look for determinants at
the social level. Social inequity had a significant
contextual impact on individual HRQOL,
independently of individual life choice. The
importance of assessing the hierarchical data
structure has been shown in comparing logistic
models with multilevel models.
RESULTS (cont):
Lack of social cohesion consistently predicted
poor HRQOL in all logistic and hierarchical
linear models. If poor self-rated health predicts
mortality, then the lack of a civic community
may act as a stressor not only to increase the
likelihood of poor health but of premature
mortality, as well.
IMPLICATIONS:
The health profile of the city of Moscow
examined health-related quality of life in
relation to three dimensions: life choices, social
inequity and material inequality in life chances,
and a civic community.
IMPLICATIONS:
(cont.)
The Moscow Health Profile
The health care crisis in Russia represents one
of the most significant challenges to public
health policy today. The intensification of the
premature mortality crisis in Russia remains
unexplained and requires relevant research
and policy suggestions, which contrast liberal
democratic and post-communist policy
approaches to health care, including
examination of such relationships as social
capital, stress, lifestyle, civic community and
socioenvironmental impact on health and
mortality.
A comparative analysis is useful
in clarifying the extent to which
variations in health status can be
weighted by structural factors of
a centralized, planned social
system and economy, or by such
factors of culture as social
choice, individual preferences,
and values.
Health promotion and disease
prevention policies in the early
twentieth century emerged in
industrialized nations as a
response to social pressure from
workers.
Primary care and preventive
health policy in the USSR made
an ideological leap after the
Communist Revolution of 1917,
promulgating the intrinsic value
of health, but they lacked
implementation.
Social costs in lost years of
productive life, medical
expenditures, and increased
debility from chronic diseases
have become a major concern for
both the public and private
sectors in the new democracies of
the Eastern bloc, as much as the
West (World Bank, 1993).
In the United states, policy debates
have centered on who was
responsible for providing what type
of health care, to whom, and at what
cost, in the public and private
sectors (Davis, 1992). The Former
Soviet Union (FSU), in contrast,
seeks to improve workers' health as
a way to increase economic
productivity.
In April 1992, IMF Director
Camdessus (New York Times, 1992)
pointedly noted that the hallmark of
a sound democracy was the
functioning of a well-developed
social welfare system. A nation's
health, quality of life, and sense of
well-being were contingent upon the
integrity of its educational, public
health, and social security programs.
The IMF emphasized the fact that
the Russian Federation exhibited a
low standard of living similar to
other ethnic republics of the Former
Soviet Union. All showed the signs
of having borne similar cultural and
economic costs of Communist party
ideology.
The Russian Parliament
anticipated IMF policy
requirements to encourage
market relations, grappling with
these fundamental issues in
formulating the Health Insurance
Act of 1991:
Russia's first health insurance
legislation was signed into law
by President Yeltsin in June
1991.
Health is an international
phenomenon, situated in the
larger context of a global
community. Not only does each
individual's health status affect
others, but the health of one
group in a society can influence
the welfare of other groups.
The United Nations Charter of
1948 adopted Article 25, the
Universal Declaration, which
stipulated that all people had the
right to a standard of living that
guaranteed health.
A 1978 World Health Organization
Conference in Alma-Ata, the capital of
Kazakhstan, a republic of the former
Soviet Union, supported the global
issue of equity through accessibility to
"Health for All by the Year 2000, "by
recommending the implementation of
primary health care and disease
prevention in national policies.
The health reform proposals of postcoup Russia departed sharply from
previous policy.
Although the initial version of the
1991 Health Insurance Act of
Russia was primarily concerned
with the financial mechanisms of
medical care, several provisions did
attempt to link quality of life to two
basic issues.
SOCIALIZED MEDICINE
This model of socialized
medicine, established in the
1930s, was categorized by Davis
(1988) for analytical simplicity
into seven basic input
components:
The centralized state bureaucracy
acted as manager of medical care
finances, employer and provider
of hospital and physician
services, producer and consumer
of medical goods, and
administrator of health planning
and policy.
Local health care organizations
were responsible to the institution
in which they were housed.
Differential access and poor
quality care resulted in an
informal and illegal mechanism
of private fee-for-service
payments, given "under the table"
as bribes, commonly known in
Russia as "blat."
Although Soviet socialized medicine was
based on systematic health planning, public
administration, and financing, Robbins,
Caper, and Rowland (1990) explain how
the difficulties with providing universal
coverage, comprehensive services, highquality care, integrated treatment and
prevention, and rational distribution of
medical personnel remained as substantial
problems for the Soviet state.
Reassessments of the socialized
model of medicine were
undertaken by both the USSR
and Russian Federation
Ministries of Health only after
Gorbachev's appointment as the
first President of the USSR.