Guest post by Oleg Kucheryavenko | Coordinator for Health Policy & Advocacy | GCAP Russia
Originally posted: http://www.globalhealthcheck.org/?p=1745
During 2014, we both had a chance to work on an exciting project of analysing inequality trends in Russia as part of Oxfam’s programme on Empowering Civil Societies in an Unequal Multipolar World (ECSM BRICSAM). Through the project, we’ve got to work on the issues of both economic inequality and inequality in access to healthcare in Russia, which are central to Oxfam’s inequality campaign. This blog reflects some of our findings and learning from the project.
According to the 2013 representative population survey, Russians think that the two forms of inequality most strongly affecting the well-being of the country’s population are:
• Income inequality (72 per cent of respondents)
• Inequality in access to healthcare (47 per cent)
The income inequality percentage may not surprise outside observers, as Russia has witnessed one of the most radical increases in economic inequality in the last two decades following the collapse of the Soviet Union, and is now on par with other high inequality G20 peers like Turkey and Mexico. Inequality in access to healthcare may come as a bit more of a surprise, taking into account that Russia formally has universal health coverage and the right to free healthcare is enshrined in its constitution. Moreover, BRICS are now being looked at as important players in the global health arena.
So, what does inequality in access to healthcare actually look like in Russia? What are the main causes of inequality in access to healthcare? And how does economic inequality, ravaging the country is related to the inequality in access to healthcare?
Inequality in access to healthcare Russia has three key dimensions:
- Geographic. Availability of free healthcare decreases dramatically with the reduction in the size of settlements. Moreover, interregional inequality is very high, since the financing and the level of development of healthcare system in various regions differ drastically. Regional differences in per capita financing of healthcare reach 10–12 times.
- Social: Discrimination of specific groups, such as homeless, migrants and inmates is common. For example, 26% of homeless people without documents have been refused healthcare.
- Economic. The Russian healthcare system is characterized by significant differences in demand from the various socioeconomic classes. Social groups with higher incomes request healthcare more frequently than those with lower incomes. Moreover, over 8% of population have to bear catastrophic expenditures for health care and the burden of these expenditures is significantly higher for the poor than for the rich.
Key drivers of inequality in access to healthcare:
- Under-financing. Currently, the share of healthcare budget in the total government budget stands at 9.4% (significantly lower than 15% recommended in Abuja declaration). Moreover, the share of healthcare budget has been gradually reducing in the recent years. According to the Ministry of Finance, government spending will be cut by 22.9% in next three years. The document also suggests that private expenditure may rise from the current value of 40% of total expenditure on health.
- Ineffective healthcare financing model. Compulsory health insurance model introduced in Russia after the collapse of the Soviet Union and the parallel collapse of the Soviet Semashko model of healthcare financing has proved to be ineffective in the accumulation and allocation of public funding. Private health insurance companies through which insurance is being implemented have financial interest as their primary goal– they raise money from penalties imposed on healthcare providers. Moreover, the financial principles of: ‘money follows the patient’ and ‘money per treated patient’ adopted by the Ministry of Health in 2007 lead healthcare providers to have economic interest to manage patients. For example, GPs do not send patients to other providers even if necessary because in this case money will follow the patient .This means that some GPs who are un-trained as ophthalmologist may treat cataract with eye drops when the patient needs surgery. Providers are also interested in big numbers of ‘treated patients’, who preferably have chronic conditions leading to long-term treatment. Therefore, the public interest clashed with the one of healthcare providers.”.
- Understaffing. While Russia is often cited as one of the global leaders in terms of the number of medical staff (43-44 doctors per 10,000 citizens), these numbers are based on the number of medical university graduates rather than reflecting the reality. For example around 8% of medical staff quit the profession annually (22-25,000 medical staff) and 40% of doctors are at, or nearly at, pension age, but continue working despite lack of training opportunities to upgrade the old knowledge. Moreover, understaffing in some regions reaches the level of 73% (e.g. Arkhangelsk). Medical staff continue quitting the profession, as the salaries of medical staff remain unacceptably low. In some regions staff salary only slightly exceeds a living wage.
- Lack of access to affordable medicines. Overall, only certain categories of population such as disabled people, patients with certain diseases including TB, HIV, cancer and military veterans are entitled to get medicines for free in Russia. But even for these groups access to free medicines is severely limited. Currently, only 3.3 euro per patient per month is allocated for treatment of cancer patients.Availability of funding for medicines is also very uneven across different regions. In some regions the funding gap between actual and required financing is 90%. In our study, about 60% of Russian oncologists have to refuse writing a free prescription due to insufficient funding. Consequently, patients were either deprived of treatment or had to buy medicines themselves. Out of 300,000 patients in need of HIV medication, only half is estimated to have real access to the medicines. Over half of the private expenditure on healthcare is for retail purchasing of medicines and other healthcare products.
Clearly the lack of publicly funded health service makes people’ income the decisive factor in a person’s chances of getting healthcare in Russia. Private expenditure on healthcare of the richest 10 per cent of the Russian population is now eleven times greater than that of the poorest 10 per cent. The combination of lack of investment in health service and rising economic inequality will continue to exacerbate inequality in access to healthcare, which, in turn, will lead to further perpetuation of income inequality at the country enters into this vicious circle.