The NYT article on the Russian health care system (JRL
#5003) isn't particularly helpful in understanding the problem that the
system faces.
1. Tuberculosis, AIDS, alcoholism and many other such diseases overwhelming
the system are not solved by better health care, but by solving the problems
of poverty and social instability. Death rates and illness rates in general
are far less connected with the quality of the health system than are partly
the wealth but more importantly income inequality and social conditions
of the country in question (thus the previous - economically poor - communist
countries could maintain life expectancy at a far higher rate than the
size of their economies would otherwise produce through stable and more
equal social conditions, and West Europeans continue to do the same in
comparison with other similarly-strong economies.). Furthermore the disaggregation
of the state socialised economy has led to fewer general health checks
(profosmotr) and fewer people who could be subject to them. Alas, prophylactic
work is the one part of a health system that could have any great influence
of death and illness rates, and little to do with the
2. The article confuses best medical practice with best medical organisation.
It is laudable that Dubna and other cities and regions are encouraging
exchanges of knowledge and practice. But that is no grounds for calling
for "private hospitals and clinics...to be nurtured and made more accessible
to poor and rural Russians". Those I have interviewed in Russian
healthcare have no wish to pursue an American model of healthcare organisation
- where around 20% have little or no access to healthcare through being
neither rich enough nor poor enough to receive treatment, and where costs
are far higher than anywhere else in the developed world. State guaranteed
universal access is still sacred and this is a motivational resource that
should not be squandered. Moreover if private healthcare institutions
could flourish in Russia for the benefit of anyone else but the very rich,
they would have to be able to compete with underfunded and cross-subsidised
state institutions. As with attempts to introduce self-financing co-operatives
in the late 1980s and early 1990s these would almost certainly fail because
they wouldn't match prices. All they would do is temporarily misdirect
resources or retreat to "specialise in diseases of the wealthy". Any problems
of poor medical training would not be solved, as entrepreneurial doctors
are simply better entrepreneurs, not necessarily better doctors.
3. As for philanthropic oligarchs, it is not widely broadcast that the
Russian criminal class does sponsor healthcare. It has been known to ensure
that particular hospitals (out of very many) and especially their trauma
units are better funded on the condition that any wounded hoods will receive
priority treatment and confidentiality from the law enforcement agencies.
I'm not sure this is what the editorial intended, but there is nowhere
near as strong a private philanthropic tradition in Russia as there is
in the US (indeed, I imagine nowhere has such a strong tradition as the
US). Furthermore, it is hard to see why any oligarchical philanthropists
would prefer to fund capital investment in far flung rural areas when there's
no one important to show them to. It is important to work with the grain
of the society, which is a more collective, and statist tradition.
4. The article curiously remarks upon "the passivity that paralyzes
efforts to revitalize Russia's heath care system elsewhere". First of all,
the Dubna exchange is far from being a rare circumstance, and the World
Bank among others has indeed sponsored similar technical assistance. But
more generally and surprisingly the article doesn't mention Compulsory
Medical Insurance, which has been in operation for seven years and is moving
towards being the dominant source of healthcare funding. Despite initial
difficulties - corruption and incompetence on the part of many insurance
companies, resentment on the part of medical staff at suffering the innovation
of medical audits sometimes undertaken by poorly qualified or unsympathetic
people, and also continuing debate as to the complexity of the system and
the wide regional variations in how the system operates, it is now widely
agreed that the system has helped to stabilise funding (albeit at too low
a level, although at least now there is a partly-fixed rate of funding
as opposed to Soviet residual funding). It also allows some degree of co-ordination
between healthcare institutions which has been made difficult by other
democratic innovations such as the law on local self-government. It has
also prompted greater consideration of the focus of healthcare - on end
results of treatment as opposed to intermediate output numbers of beds
and doctors), and on the value of general practice as opposed to over-specialised
polyclinic primary care. Although there has been little success in achieving
reductions, there is at least now widespread debate in lowering excess
hospital capacity (which eats up resources). There is also better
information gathering necessary for the system to operate. All this points
towards ultimately positive development, probably more so than immediate
piecemeal technical assistance here and there in specific areas.
This is not to say there are no problems. The system is in most places
chronically underfunded, with often only pay and pharmaceutical costs being
covered - and then often through operating regional-wide barter-exchange
systems (vzaimorashchet) and debt notes (vekselya). But these are problems
of economics and politics - of cash shortages, and of official corruption.
These often involve white knight foreign companies giving personal incentives
for doctors and administrators to purchase their more expensive products
- something I understand is also a problem in the US, as well as the problems
you
might expect in Russia in awarding state contracts to one group over another.
I agree with the article that raising doctors' pay is necessary, not least
to lessen the burden upon them to act as informal means-testers - effectively
judging how much they feel they can charge a patient by his or her appearance.
There is also a public lack of confidence in the abilities of the doctors.
And it would be criminal to ignore the serious health problems of the population
which would overwhelm ANY system.
However I feel that the general tenor of the article places far too
much emphasis on the need to change healthcare without realising it IS
changing, and
not enough on the real issues affecting the system - poverty and inequality,
the problem of raising adequate revenues for any activity year after year
(rather than any temporary assistance) and social-economic instability.
Cameron Smith
Dept of Social Policy
University of Edinburgh
George Square
Edinburgh
EH8 9LL
United Kingdom
Tel: +44 (0)131 650 3920
Fax: +44 (0) 131 650 3919
casmith@afb1.ssc.ed.ac.uk
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