The collapse of the Soviet Union left Russia's social services reeling. Nowhere is this more true than in the country's health-care sector, which has seen its funding slashed, and with it, its ability to treat generations of Russians raised on free medicine. In the first in a two-part series on Russian health care, RFE/RL looks at how the rising cost of medical treatment is forcing many people to do without.
Moscow, 5 July 2002 (RFE/RL) -- In summertime, many Moscow pensioners leave the city for the fresh air and gardens of their country dachas. But 70-year-old Stanislav Andreev has had to cut his vacation short. Andreev, who has diabetes, is one in a long line of elderly city residents at Clinic No. 98 in Moscow's northeast Alekseevskii Raion waiting to receive the free medicine they are promised by the state.
But Andreev, who has spent much of the past two weeks lining up at the clinic, comes away empty-handed yet again after clinic employees tell him they still have not received new supplies of diabetes medication. "I'm a pensioner. I've been coming here for two weeks already to get the medicine [I'm entitled to] for my diabetes. But I can't get it. I'll go to the Prosecutor's Office if I don't get my medicine. [The clinic] says it doesn't have the supplies -- they've been saying this for two weeks. Here is my prescription. Can you see? In two weeks' time, I might have died. Thank God I was hospitalized and got some medication there, but now even that is finished," Andreev said.
Andreev said the medicine he needs can be easily found in any Moscow pharmacy. But with a monthly pension of just 1,900 rubles ($60), he says he can't afford to pay for it.
Seventy-five-year-old Olga Knyazeva is another pensioner waiting at Clinic No. 98 for her medicine. Knyazeva, a former factory worker, suffers from circulation disorders linked to diabetes, and moves very slowly. She said it takes her more than an hour to make the trip to the clinic, but like Andreev, she cannot afford to buy the medicine at a pharmacy closer to home. "I came here from Lyanozovo [in the northern part of Moscow]. I took a bus and then the metro. No one cares about old people now. Before, we never would have imagined that people would treat the elderly like this. They don't love us, old people. They don't want to take care of us," Knyazeva said.
Soviet health care -- which promised subsidized health care and medicine to all citizens -- was already considered lacking by Western standards. But following the collapse of the Soviet Union, the health-care system dissolved, leaving hospitals unfunded, doctors underpaid, and patients suddenly unable to afford the health care and medicine they needed.
Sergei Shishkin of the independent Social Policy Institute think tank said some experts estimate that in 1999 Russia spent four times less on health care than it did in 1991. Although state spending has increased over the past two years, he said it is still considerably less than most Western European countries spend on health care -- just $50 to $60 per person per year on health care, compared to almost $1,700 per person per year in the European Union. The World Health Organization, in its global rating of health-system performance, ranked Russia 130th in the world, directly behind Guyana and Peru.
A series of health-care reforms in the early 1990s left Russia with a two-pronged funding system for medical care. In addition to funds from federal and local budgets, health care is now financed by so-called Mandatory Medical Insurance, or MMI, funds. The MMI system, which collects funds from insurance premiums paid by employers, is similar to health-financing schemes in Western Europe. But while employer contributions in the West can amount to between 8 and 12 percent of employee salaries, in Russia employers pay just 3.6 percent. Last year, the MMI system contributed some $3.2 billion to Russian health care -- nearly half of the total budget.
Shishkin said since the MMI system was introduced, many regional administrations have used the opportunity to slash health budgets, leaving health-care systems with no noticeable gain. Moreover, he said, the dual-financing program has only exacerbated what was already a complicated and bureaucratic system. "In practice, medical institutions receive money from two sources -- from the Mandatory Medical Insurance and from [federal and local] budgets -- for the same purposes. This situation doesn't help the money be used effectively, and this is the major problem regarding the financing of our health-care system," Shishkin said.
According to Russian law, disabled people, infants under 1 year old, pensioners, and the chronically ill are all entitled to free or discounted medicine. But Shishkin said health-care funds are insufficient to cover the costs of such subsidized medicine, and that many people are forced to pay for treatment out of their own pockets. "In most of our regions, patients have to buy medicine when they are in the hospital, because there isn't enough funding. Formally, a hospital has to dispense medicine for free. But the money [hospitals] get for this is insufficient. [Hospitals] can afford cheap medicine, but if a medicine is expensive, hospitals don't have the money to buy it, and they have to ask patients to buy it for themselves," Shishkin said.
This creates a situation that is troubling not only for patients but for their doctors, as well. Apollon Karseladze of the Russian Cancer Research Center said that, although the state is officially obliged to reimburse cancer hospitals for much of their specialized and expensive services, such expenditures are rarely compensated. That leaves doctors in the uncomfortable position of telling cancer patients they must find money to pay for their care -- or face likely death. "Modern medical treatment for cancer patients is very expensive. For example, chemotherapy can [cost] thousands of dollars -- $50,000 to $60,000. This makes it very hard for doctors who have to tell patients they have to pay for their treatment themselves, even though health care in our country is officially free. Doctors find themselves in a psychologically difficult situation. They feel uncomfortable all the time, because they have to convince patients to undergo very expensive treatment. Moreover, doctors also have to choose less expensive therapy, and this usually means it isn't the best treatment," Karseladze said.
General practitioners feel the pinch as well. Natalya Levidze is a doctor at a neighborhood clinic in northeast Moscow. She said the chronic shortages of free and subsidized medicine in Russia have left her unable to help many people in need of care, particularly pensioners, who have no way to pay for expensive medicine and treatment. "The major problem linked to the health-care profession are people's economic situations and their inability to buy the medications we prescribe. This is a financial problem. As far is diagnostic work is concerned, we have good equipment and we can examine patients and help them. But often the patients can't afford to buy the medicine they need. Most people have this problem," Levidze said.
Levidze herself may be among them. With more than 20 years of professional experience, Levidze earns a basic salary of just $60 a month. By taking on additional shifts and responsibilities, she said, she can boost her earnings to $100. But the extra work takes its toll -- and keeps hospitals and clinics chronically understaffed as people leave in search of better jobs. "It is very hard. We have to take on several positions at a time. In practical terms, this means there are no doctors who simply work a [normal] shift. Most doctors work two to three shifts [in a row]. What's more, they do the work of nurses and even attendants as well. All this makes things very hard for us. We don't have time to read professional literature, we don't have time to rest, and many doctors are ill themselves. This is what's happening. Nobody cares about us. Most of my colleagues -- who are over 40 -- don't have anything. No money and no savings," Levidze said.
It is a situation that bodes ill for the future of Russian health care. Despite improved access to Western research and medical technology, fewer and fewer young Russians are opting to pursue a career in medicine.
Levidze, who at 47 is the youngest doctor at her clinic, said, "Young people want to earn money. They won't work for a miserable salary."
(This is Part 1 of a two-part series.)