Health care

   Since 1991, the health care system in the Russian Federation has been in transition from a hierarchal, centrally controlled system of medical provision, wholly financed from Soviet government revenues, to a more decentralized, diverse, and insurance-based system. It has also been a shift away from a two-tier Soviet medical system, which had separate health care services for ordinary citizens and the nomenklatura>, to a more market-based system that, on the one hand, provides free medical care and, on the other, does not prevent citizens from purchasing health care services from private medical establishments. The process of transformation began in the early 1990s but was abandoned under Boris Yeltsin due to the lack of funds and Yeltsin’s disinterest in the nation’s health problems, which partially accounts for the demographic problems Russia is facing today. Health care policies were reintroduced under Vladimir Putin; however, the process of transition has not been completed.

   Russian health care suffered most in the transitional period of the 1990s with crumbling hospital infrastructure, lack of vital medicines, and poor-quality service. In the 1990s, it was not uncommon for Russian citizens scheduled to have surgery to purchase and bring the medical supplies on the day of the procedure. The social status of doctors was undermined as many of them were accused of corruption. Health care also became an arena for profiteering for entrepreneurs who managed to capitalize on the disintegration of the Soviet distribution system. Many talented medical students abandoned their careers and instead set up medical cooperatives.

   The largely dysfunctional health care system accounts for many health-related demographic challenges, including a high mortality rate. These are caused by a number of factors, including alcoholism, malnutrition, and high levels of stress. Economic growth under Putin had little impact on the main indicators of human welfare; however, there are signs of improvement both in terms of the quality of medical care and life expectancy among average Russian citizens. Still, the number of deaths caused by malnutrition and infectious diseases, linked to poverty-related problems, remains very high. At the same time, the average life expectancy remains quite low for a country of Russia’s level of economic and social development.

   The Soviet health care system was an extension of the Stalinist industrialization project, favoring large centralized medical institutions, normally established in areas with high concentrations of Soviet factory workers. There was little emphasis on primary care, and quite often people were admitted to specialist and hospital care, putting unnecessary strain on the system. In post-Soviet Russia, general practioners have replaced terapevts (physicians), doctors with similar qualifications and focus on primary care; the name change, however, did not have any structural impact. Low prestige and poor payments of doctors and health workers encourage many doctors to join private hospitals and medical centers. Many health services are available only in private hospitals, resulting in the de facto privatization of health care. Russian health care carries the social burdens of the Soviet system, whereby access to certain medical services was available only to nomenklatura or required an informal payment for what is meant to be a free service. There also remains a huge divide between urban centers and rural areas: while people residing in provinces by law have access to large medical centers in urban centers, the sheer remoteness of many settlements prevents patients from accessing medical institutions. Access to private health care, especially to health care abroad (Germany, the United States, and Israel are popular destinations), has become an issue of social prestige, further undermining the principles of social equality and the very reputation of Russia’s health care system. Therefore, access to the health care system in Russia is becoming significantly more unequal, irrespective of the free provisions guaranteed by the constitution. To combat corruption and increase the quality of health care, the Russian government introduced the unified social tax in 2001, which is now the main source of financing health care. In principle, patients have the right to choose their insurer and medical service provider; however, in practice it is hard for them to exercise their right because of the complex bureaucratic system. As a result there is no real competition, and hospital and medical care providers are left with conflicting incentives.

   See also HIV / AIDS.