“Optimizing” Russian Healthcare to Death

Given the dismal state of Russian healthcare, many people practice folk medicine. Photo by TRR

Experts Predict Reduction in Number of Hospitals to 1913 Levels
Polina Zvezdina
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

Russian Government Refuses to Allocate 70 Billion Rubles to Combat HIV

Government Refuses to Allocate 70 Billion Rubles to Combat HIV
Polina Zvezdina
January 26, 2017

The Health Ministry has sent the government a plan for implementing the national strategy for preventing the human immunodeficiency virus (HIV) until 2020. RBC has a copy of the document, whose authenticity has been confirmed by a source close to the government, in its possession. The plan does not stipulate allocating additional funds for combating the infection. In the financial feasibility study appended to the draft plan, officials noted the agencies responsible for its implementation, as well as the regions, would have to finance the plan’s implementation.

Additional financing of the plan was stipulated in a earlier draft, also examined by RBC. In the draft, the Health Ministry had indicated additional monies from the budget, 17.5 billion rubles per annum, would be required to meet the strategy’s targets. There were plans to spend 13.2 billion rubles of this money on treatment, 3.2 billion rubles on diagnosis, and 1.1 billion rubles on treatment oversight. This funding should have made it possible for all HIV patients currently registered at AIDS centers to undergo special treatment and increase to 35% the share of the population tested annually for HIV. In 2015, 19.3% of the population was tested for HIV, while 37.3% of infected patients were provided with medical treatment.

It was the Finance Ministry that did not approve allocating the 70 billion rubles, judging by a ministry review sent to the Health Ministry on December 22, 2016. First Deputy Finance Minister Tatyana Nesterenko did not support the additional allocation, because these funds were not included in the approved federal budget for 2017–2019. In the review, the Finance Ministry argued that budgetary allocations for new spending could be contemplated only at the beginning of the fiscal year and provided that the government had additional revenues.

The government will continue its discussion of the draft plan for HIV prevention, said Denis Godlevsky, an expert at the HIV Assistance Foundation. There is a chance the Health Ministry will succeed in obtaining the full funding, he said.

"Percentages of HIV infected people in Russia. The percentage of people infected nationwide is 0.72%." In the original article, this map is interactive by region.
Percentages of HIV infected people in Russia by region. The percentage of people under the age of 60 infected nationwide is 0.72%. In the original article (go to the link at the top of the page), this map is interactive by region. The figures for Crimea and Sebastopol reflect the percentage of infected residents among all age groups. Infographic courtesy of RBC

Testing 35% of the population annually for HIV and providing 100% treatment for all registered patients were goals the Health Ministry hoped to achieve only if it received the “requisite” financing, as outlined in the HIV prevention strategy adopted by the government. If this money is not provided, the ministry proposes focusing on a different set of figures. Under the current healthcare budget, the number of people undergoing testing would increase to only 24%, while 56% of infected patients would receive treatment.

The Health Ministry has not responded to RBC’s questions as to which set of targets the ministry would follow when implementing the strategy.

If government agencies would use the funds already available effectively and rationally, the situation would begin to change for the better anyway, said Alexei Lakhov, deputy director for public relations at E.V.A., a noncommercial partnership.

“And when the situation changes for the better, a financial feasibility study can be done requesting additional appropriations,” Lakhov suggested.

The HIV prevention strategy was approved on October 20, 2016. It contained no information about funding.

Translated by the Russian Reader

Tear of a Komsomol Girl

Tear of a Komsomol Girl [cocktail recipe]

Lavender Toilet Water 15 g.
Verbena 15 g.
Herbal Lotion 30 g.
Nail Polish 2 g.
Mouthwash 150 g.
Lemon Soda 150 g.

—Venedikt Erofeev, Moscow to the End of the Line, trans. H.W. Tjalsma (New York: Taplinger, 1980), pp. 6970


Government to Introduce Excise Taxes on Medicinal Tinctures to Combat Alcoholism
Polina Zvezdina
December 13, 2016

The government has proposed imposing excise taxes on medicinal tinctures, household chemicals, and cosmetics containing alcohol. The reason is that the populace consumes them instead of the expensive liquour sold in shops. As RBC has previously reported, approximately 10% of Russians suffer from drugstore alcoholism.

Prescribe and Report
The Finance Ministry has drafted amendments to existing laws and the Tax Code that would impose excise taxes on alcohol-based pharmaceutical products, except for vital and essential drugs (VEDs). The ministry was ordered to do this by Deputy Prime Minister Alexander Khloponin, who oversees the alcohol market. In late October, he reported on the matter to Prime Minister Dmitry Medvedev. RBC has a copy of his letter. A spokesperson for Khloponin refused to comment on the document’s authenticity or its contents.

Due to a drop in incomes and an increase in prices for strong alcoholic beverages, Russians have been increasingly been drinking alcohol-based liquids not intended for consumption, Khloponin argues in his proposal. Among such liquids, he lists Cucumber Lotion, Boyara (a tincture of hawthorn and rose hips), and Bread and Wheat, two alcohol-based additives. The sales of such products have recently increased in Tatarstan, Ufa, Samara, Cheboksary, Saransk, and Kaluga, according to the document.

If the deputy prime minister’s undertaking is implemented, it will affect drugs used by the public for their intended purpose, such as Corvalol and Valocordin.

Currently, the Tax Code does not deem alcohol-based medicines, veterinary drugs, food products, and cosmetics sold in packages containing 100 milliliters or less as excisable products.

Vadim Drobiz, former head of the Research Center for the Federal and Regional Alchohol Markets (TsIFFRA), told RBC that between twelve and fifteen million [i.e., approximately 10% of the Russian population] regularly consumes medical tinctures and cosmetic lotions not intended for consumption. The “parallel” alcohol market’s capacity already accounts for around 20% of the official market’s turnover, as RBC reported in an investigation published on November 24.

Specific Proposals
Khloponin has proposed labeling all alcohol-based non-food products as excisable and abolishing the zero-rate excise tax for certain brands of cosmetics and household chemicals. The rate of the excise duty should be the same as that imposed on strong alcoholic beverages. Currently, the excise rate on strong spirits is 500 rubles per one liter of pure alcohol.

The excise taxes should be extended to all alcohol-based medicines, except for medicines included in the VEDs list, writes Khloponin. In addition, the pharmaceutical market should apply the Unified State Automated Information System (EGAIS) for accounting for the production and turnover of alcohol to the distribution of ethanol intended for the production of medicines. According to current laws, the EGAIS will be introduced to the pharmaceutical market from 2017, but it will record only ethanol production.

Khloponin argues that retail sales of the flavor additives Bread and Wheat should be banned altogether. The regions also need to have the authority to independently monitor sales of alcohol-based non-food products.

The Finance Ministry did not respond to RBC’s inquiry. The Health Ministry informed us that as part of the fight against “drugstore alcoholism,” the ministry had drafted a federal law bill banning the sale of alcoholic pharmaceutical products from vending machines [see article, below].

Hospital Budgets and Pensions
If the Finance Ministry finalizes its undertaking, the public will suffer, Elena Nevolina, executive director of the National Pharmaceutical Chamber, noted in an interview with RBC. Many popular tinctures, such as valerian, Corvalol, Valocordin, and Votchal drops, are not included in the VEDs list. After excise taxes are imposed, their prices will skyrocket or they will simply vanish from the market, she argues. This might indirectly impact the work of ambulance brigades, since pensioners, accustomed to consuming certain medicines, will be more likely to summon ambulance crews if the medicines are unavailable, Nevolina believes.

Aseptol handwipes. Image courtesy of Reviso

Another alcohol-based medication not included in the VEDs list is Aseptol, a topical solution widely used by medical personnel to disinfect their hands. The retail price for 100 ml of the solution is currently around 35 rubles. After the excise duty is imposed, its price could double, believes Nevolina.

Although hospitals purchase Aseptol in large quantities, it amounts to less than 1% of all sales. According to research by the DSM Group, purchases of Aseptol amounted to 179 million rubles in 2014, 195 million rubles in 2015, and 171 million rubles in the first nine months of 2016. The public procurement market for Aseptol accounted only for 549,000 rubles, 820,000 bules, and 936,000 rubles of these total sales, respectively.

Based on an excise tax rate of 500 rubles per 1 liter of pure alcohol, the price of Corvalol would increase by one and half times, and the price of Carniland (Votchal’s drops) and Valocardin, by a few percent.

The measures proposed by the government will enable better monitoring of the pharmaceutical alcohol market, said Dmitry Dobrov, board chair of the Union of Alcohol Producers.

“EGAIS and excise taxes have proven effective in the alcohol market. Sales and tax revenue have been growing, and illegal production has practically disappeared,” he said.

Major Pharmaceutical Manufacturers of Alcohol-Based Drugs
The Industry and Trade Ministry supplied RBC with a list of the major manufacturers of alcohol-based medicinal products. The leaders in terms of sales and production are Gippokrat from Samara (whose 2015 revenue was 980 million rubles and overall production, 51.8 million units); Flora Kavkaza from Karachay-Cherkessia (230.9 million rubles; 13.4 million units); Begrif from Novosibirsk Region (211.7 million rubles; 10.9 million units), the Tula Pharmaceutical Factory (251.5 million rubles; 9.6 million units); and the Ivanovo Pharmaceutical Factory (138.1 million rubles; 7.5 million units).

The market for alcohol-based drugs has been growing from year to year. According to DSM Group, it amounted to 3 billion rubles in 2014, almost 4 billion rubles in 2015, and 3.1 billions rubles in the first nine months of 2016.

Hawthorn lotion dispenser in Izhevsk. Photo courtesy of susanin.udm.ru
Hawthorn “lotion” dispenser in Izhevsk. Photo courtesy of susanin.udm.ru

Boyara 24 Alcodispenser Shows Up at New Location in Izhevsk
Argumenty v Izhevske
October 15, 2016

Yet another dispenser for selling the alcohol-based Hawthorn (Boyaryshnik) liquid has been installed in Izhevsk. As Susanin News Agency reports, the 24-hour sales point, where even a child could shop, has been installed on January 9th Street.

For 20 rubles, the Boyara 24 machine dispenses a bottle of liquid containing 75% ethyl alcohol. Hawthorn Lotion for Oily Skin, as indicated on the label, is designed to cleanse and tone the skin.

But few locals used the alcohol-based liquid as it was intended. The dispenser’s target market is society’s drunken stratum. To obtain a bottle of Hawthorn, you merely have to drop money into a coin slot and turn a handle. The dispenser imposes no limits on the times when the liquid is sold or the age of purchasers. It does not even need electricity to run round the clock.

During an experiment conducted by a Susanin News Agency film crew and concerned citizens, it transpired that the alcodispenser did not work properly. Four attempts were made to purchase Hawthorn Lotion, but the machine dispensed bottles only in two instances. Empirically, therefore, we established that the dispenser sells the alcohol-based liquid for 40 rubles rather than 20.

The first such dispenser showed up in Mechanical Engineers Village approximately two weeks ago. It was successfully dismantled, most likely by penniless alcohol enthusiasts.

Translated by the Russian Reader. Photo of lavender toilet water courtesy of knigi-janzen.de