Download PDF

Public health: a priority for Putin

Context

It’s not difficult to see why Putin included health care among the four Priority National Projects launched in 2005 (the others being Education, Housing and Agriculture; for more details, see Priority National Project on Health Care). Even the official figures paint a grim picture of the health of the Russian nation. That picture shows up most starkly in demographic data, especially the male death rate (see our related 'Public Judgements' piece Russia's demographic crisis revisited).

Two of the biggest killers, especially of Russian men, are all-too-obvious even to the casual visitor to Russia: vodka and cigarettes. The World Health Organisation (WHO) maintains that nine litres of alcohol a year per person is a dangerous amount. In Russia, average consumption stands at fourteen litres per person. Cigarette advertisements on billboards are everywhere, and, even though these are due to be banned in 2007, simply walking down any populated street in Russia will reveal that smoking is much more common in Russia than in Western Europe or the USA.

Behind such external manifestations of the health problem, the real problems lie deeper. Material hardship for the vast majority of the population since the Soviet collapse has been compounded by the psychological disorientation of old certainties dissolving. Vodka and cigarettes rushed in to fill the gap. Social degradation is worst of all the countryside.

Less obvious to the outside observer is the way in which the primary health care system – the foundation of Soviet medicine – has crumbled due to a lack of state funding. Or the way in which even in Soviet times, technological advances in available health care were not keeping up with growing medical problems, such as cardiovascular diseases and cancer.

Post-Soviet Russia has meanwhile failed to tackle the spectre of HIV/AIDS. In recent years this has changed from being a disease primarily afflicting drug-users and prostitutes to one being spread more and more by heterosexual activity. Only now are serious attempts being made to shake off prudishness and educate young people of the dangers.Government spending on fighting HIV/AIDS is set to double in 2007 to Rb7.7 billion ($289 million). But specialists say that this will still be too little, too late. According to the UN AIDS programme, AIDS is spreading faster in the former Soviet Union than in any other part of the world. By October 2006 there were over 370,000 registered HIV cases in Russia, although this is believed to be only one third of the real total. 100 new cases are being reported each day.

There are some glimmers of hope. Male life expectancy has inched up to 59 from a low point (unprecedented in peacetime) of 57 years. Official infant mortality figures for Jan-Oct 2006 showed a 31% YoY decline. And government spending on health care is rising.

Rising government spending on health care...

...still remains well below the WHO target of 5% of GDP

Federal budget spending on health care, % of GDP, 2001-6 & 2007F*

*a similar aggregate level of spending is disbursed through regional budgets

But Russia still has only just over half the number of doctors it needs to serve the population and two-thirds of the necessary medical equipment. Funding is lacking also for national vaccination programmes; and only 15% of the planned total for health education of the population is being made available. Speaking at a meeting of the Presidium of the State Council on 2 October 2006, Putin claimed that the National Project on health was heading in the right direction, but warned that there was still a long way to go before any radical improvement would be seen.

Public Judgements

By making health care a Priority National Project, the Kremlin acknowledged the seriousness of the situation. But whilst all commentators agree that the system needs urgent attention, there are differing views on prioritisation.

What should be the main priority for health care reform?

Primary health care

• Priority National Project for health Care Harking back to the 1960's, this stresses that Russia must recreate a system of primary health care, to ensure that the basic needs of the population are met. There must be sufficient numbers of health professionals; they must be properly paid; maternity care is crucial; and greater use must be made of technology.
• Gennady Onishchenko, Russia’s Chief Medical Officer. Thousands of doctors, nurses and orderlies across Russia have already benefited from pay rises. In Moscow, at least, this means doctors are receiving salaries higher than the average national wage, an important change from Soviet times. The 2007 federal budget increases health spending by 72% YoY. He acknowledged in September 2006 that only 10-12% of Russian schoolchildren could be considered as “healthy”, describing reports of 30% as “very optimistic” (Interfax, 7 Sept 2006). Earlier, in August, Onishchenko had announced that school canteens were to stop selling sweets and crisps, in an effort to resist the tide of junk food which has been attracting Russian schoolchildren in recent years.

Specific problems: HIV/AIDS; smoking; alcohol

• Dr Vadim Pokrovsky, Head of the Federal AIDS centre. For years, Dr Pokrovsky has been a voice crying in the wilderness about the need for the sort of public education which cuts through the traditionally prudish Soviet approach to sexually-related issues; and on the desperate shortage of cash for AIDS programmes. He has blamed poor education on health issues; a lack of political will; and the hidden nature of the spread of HIV/AIDS for the alarming rate at which the infection has spread in Russia. He acknowledges that the funding situation is now better, but with just 20,000 infected people being given drugs by the end of 2006 - when over 350,000 are officially acknowledged to have the disease, and the real figure is possibly over one million - he says there is still far too little publicity and too little money being spent.
• World Bank, Report on the state of Russia’s health (December 2005). This detailed report concluded that cigarette smoking was the single most preventable cause of disease and death in Russia. 61% of men smoke and the number of women who smoke is increasing. (Dying too young: addressing premature mortality and ill health due to non-communicable diseases and injuries in the Russian Federation, p.10)
• The Economist, Report on public health in Russia (9-15 September 2006). Russians are four times more likely to die in traffic accidents than are Britons. With rapid growth in car ownership, there needs to be a serious campaign to educate the public about safety on the roads and at work - even before addressing the problem of poisoning from bootleg vodka. 40,000 Russians died of alcohol poisoning in 2005; in America it kills a few hundred each year.

Education is the key

• Stanislav Belkovsky and Roman Karev, Moscow’s National Strategy Institute. ( Kommersant, 5 Sept 2006) The Russian Government will have to increase its contribution to public health care far more dramatically than is planned in the National Project if there is going to be a significant improvement in the health of the nation. Russia has been spending just 2% of its GDP on health care, whereas the World Health Organisation recommends 5% and the G7 countries spend between 7% and 15%. Belkovsky and Karev maintain that the Health Care National Project was not intended to solve that question, anyway. They see its real goal as political. The Projects are in the hands of Dmitry Medvedev, who is a strong candidate to succeed Putin as President in 2008. Raising the salaries of doctors - one of the Project's aims - will persuade them to tell their patients how great the Kremlin’s successor is. Belkovsky and Karev say that if it is genuine, then the Project should ensure that far more is done to educate the population on how to help themselves. As well as advice on how to avoid diseases and illnesses, this should also include measures such as teaching accident prevention and limiting alcohol and tobacco intake.

Wrap

Given the enormity of the problem, the cynicism of Belkovsky and Karev about the Putin administration's health care initiative would strike a public chord in Russia. Their more positive point that the real test of policy seriousness should be public education campaigns makes sense - and echoes the well qualified judgements of the AIDS campaigner Dr Pokrovsky and several others. Official figures show that only 15% of the planned total budget for health education is currently being spent.

The scale of the challenge lends support to government apologists as well as critics - in particular, the authorities' line that the National Project on health is a major departure. A start had to be made, and the only place to start is the sharp spending increases now being seen. The fact that at least half incremental spending is going into the pockets of underpaid health care workers is significant and positive. In this connection, the Chief Medical Officer (Gennady Onishchenko) is right to talk up the fact that doctors and nurses in primary care are now paid more than the national average wage.

Besides the money now being thrown at the problem, Onishchenko himself has shown a new openness in discussing public health issues, a necessary pre-condition for any serious improvements in the situation.