HEALTH POLICY IN RUSSIA Part 1. Irina Campbell, PhD, MPH ivm1@columbia.edu www.CampbellHealthAssociates.com

1. HEALTH POLICY IN RUSSIA Part 1. Irina Campbell, PhD, MPH ivm1@columbia.edu www.CampbellHealthAssociates.com

2. 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:

3. 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.

4. 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.

5. 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.

6. 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.

7. IMPLICATIONS:(cont.) The Moscow Health Profile

8. 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.

9. 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.

10. Health promotion and disease prevention policies in the early twentieth century emerged in industrialized nations as a response to social pressure from workers.

11. 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.

12. 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).

13. 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.

14. 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.

15. 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.

16. The Russian Parliament anticipated IMF policy requirements to encourage market relations, grappling with these fundamental issues in formulating the Health Insurance Act of 1991:

17. Russia's first health insurance legislation was signed into law by President Yeltsin in June 1991.

18. 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.

19. 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.

20. 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.

21. The health reform proposals of post-coup Russia departed sharply from previous policy.

22. 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.

23. SOCIALIZED MEDICINE

24. This model of socialized medicine, established in the 1930s, was categorized by Davis (1988) for analytical simplicity into seven basic input components:

25. 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.

26. Local health care organizations were responsible to the institution in which they were housed.

27. 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."

28. 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.

29. 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.