“Optimizing” Russian Healthcare to Death

Experts Predict Reduction in Number of Hospitals to 1913 Levels
Polina Zvezdina
RBC
April 7, 2017

The optimization of healthcare has led to massive hospital closures and a decrease in the quality of medicine in Russia, experts say. By 2021–2022, the number of hospitals in the country might drop to the level of the Russian Empire.

Hospitals of the Russian Empire
Between 2000 and 2015, the number of hospitals in Russia halved, dropping from 10,700 to 5,400, according to calculations made by analysts from the Center for Economic and Political Reform (CEPR), based on data from Rosstat. In a report entitled “Burying Healthcare: Optimization of the Russian Healthcare System in Action,”  CEPR analysts note that if the authorities continue to shutter hospitals at the current pace (353 a year), the number of hospitals nationwide will have dropped to 3,000 by 2021–2022, which was the number of hospitals in the Russian Empire in 1913. (RBC has obtained a copy of the report.)

Healthcare reform kicked off in 2010, when the law on compulsory health insurance was adopted, David Melik-Guseinov, director of the Moscow Health Department’s Healthcare Organization Research Institute reminded our correspondent. It consisted in optimizing costs by closing inefficient hospitals and expanding the use of high-tech health facilities. The authors of the CEPR’s report explained that they examined a fifteen-year period when Vladimir Putin was in power, including his tenure as prime minister. In addition, the vigorous reform and optimization of healthcare kicked off between 2003 and 2005, as is evident from the statistics on the numbers of hospitals and outpatient clinics.

Hot on the heels of the hospitals, the number of hospital beds also decreased during the fifteen-year period: on average by 27.5%, down to 1.2 million, according to the CEPR’s calculations. In the countryside, the reduction of hospital beds has been more blatant: the numbers there have been reduced by nearly 40%. These data have been confirmed by Eduard Gavrilov, director of the Health Independent Monitoring Foundation. According to Gavrilov, the number of hospital beds has been reduced by 100,000 since 2013 alone.

Melik-Guseinov agrees the numbers of hospitals and beds have been decreasing, but argues these figures cannot be correlated with the quality of medical service and patient care. The primary indicator is the number of hospitalizations, and that number has been growing, he claims. For example, 96,000 more people were discharged in Moscow in 2016 than in 2015. This means that, although hospital bed numbers have gone done, hospital beds have been used more efficiently. Each hospital bed should be occupied 85–90% of the time, Melik-Guseinov stresses. If beds stand empty, they need to removed.

Outmaneuvering Outpatient Clinics
As the CEPR’s report indicates, the trend towards a decrease in hospitals and hospital beds could be justified were resources redistributed to outpatient clinics, but they too are being closed in Russia. During the period from 2000 to 2015, their numbers decreased by 12.7%, down to 18,600 facilities, while their workload increased from 166 patients a day to 208 patients.

“The planned maneuver for shifting the workload and resources from hospitals to outpatient clinics did not actually take place. The situation became more complex both in the fields of inpatient and outpatient care,” conclude the authors of the report.

In its report, CEPR also cites the outcome of an audit of healthcare optimization performed by the Federal Audit Chamber. The audit led the analysts to conclude that the reforms had reduced the availability of services. As the CEPR notes, the incidence of disease increased among the population by 39.1% during the period 2000–2015. Detected neoplasms increased by 35.7%, and circulatory diseases, by 82.5%. The analysts personally checked the accessibility of medical care in the regions. The report’s authors tried to get an appointment with a GP in a small Russian city, for example, Rybinsk, in Yaroslavl Region. If they had been real patients, they would have waited 21 days to see a doctor. In addition, write the analysts, hospitals do not have a number of drugs, such as dipyrone, phenazepam, and ascorbic acid.

Melik-Guseinov is certain that one cannot rely on data on the incidence of disease among the population as an indicator of deteriorating healthcare in Russia. He points out that what is at stake is not the incidence of disease per se, but diagnosis. The fact that the more illnesses are detected is a good thing.

Fastfood Wages
The CEPR’s analysts write that the lack of medicines in hospitals reflects another problems in Russian healthcare: its underfunding. The government constantly claims expenditures on healthcare have been increasing, but, taking inflation into account, on the contrary, they have been falling. The CEPR refers to an analysis of the Federal Mandatory Medical Insurance Fund. Their analysts calculated that its actual expenditures would fall by 6% in 2017 terms of 2015 prices.

The report’s authors also drew attention to medical personel’s salaries. Taking into account all overtime pay, physicians make 140 rubles [approx. 2.30 euros] an hour, while mid-level and lower-level medical staff make 82 and 72 rubles [approx. 1.36 euros and 1.18 euros] an hour, respectively.

“A physician’s hourly salary is comparable, for example, to the hourly pay of a rank-and-file worker at the McDonald’s fastfood chain (approx. 138 rubles an hour). A store manager in the chain makes around 160 rubles an hour, meaning more than a credentialed, highly educated doctor,” note the analysts in the CEPR’s report.

According to a survey of 7,500 physicians in 84 regions of Russia, done in February 2017 by the Health Independent Monitoring Foundation, around half of the doctors earn less than 20,000 rubles [approx. 330 euros] a month per position, the Foundation’s Eduard Gavrilov told RBC.

Compulsory medical insurance rates do not cover actual medical care costs, argue the CEPR’s analysts. For example, a basic blood test costs around 300 rubles, whereas outpatient clinics are paid 70 to 100 rubles on average for the tests under compulsory medical insurance. Hence the growing number of paid services. Thus, the amount paid for such services grew between 2005 and 2014 from 109.8 billion rubles to 474.4 billion rubles.

The authors of the report conclude that insurance-based medicine is ineffective in Russia. Given the country’s vast, underpopulated territory, one should not correlate money with the number of patients. This leads to underfunding and the “inevitable deterioration of medical care in small towns and rural areas.”

“It is necessary to raise the issue of reforming insurance-based medicine and partly returning to the principles of organizing and financing the medical network that existed in the Soviet Union,” the analysts conclude.

RBC expects a response from the Health Ministry.

Translated by the Russian Reader. Thanks to Comrade AT for the heads-up