HEALTH POLICY IN RUSSIA

Part 1.

Irina Campbell, PhD, MPH ivm1@columbia.edu

www.CampbellHealthAssociates.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 post-coup 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, high-

quality 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.