Читать книгу The Political Economy of the BRICS Countries - Группа авторов - Страница 84

After the collapse of Soviet Union, the Russian Federation continued with a universal system of basic health care that was state run and free at point of access (Linda, 2015). This system helped to improve and stabilize health outcomes over the years to a large extent, though there remained problems of access to non-basic care. However, during 1980s and 1990s, lack of reforms led to a deterioration of the health system and even basic health outcomes worsened significantly. Lack of personnel and modern equipment were some of the major concerns for the ailing health sector. To this was added the problem of huge influx of migrant workers resulting in deepening of inequality in access and outcomes (Linda, 2015).

The 1993 Health Insurance Law introduced the legal framework for the health insurance system (Danishevski et al., 2006). In 1996, the Russian Constitution provided all citizens right to free healthcare under Mandatory Medical Insurance in 1996. The National Priority Project in Public Health came into being in early 2000s. With this came a series of reforms and changes in the health system — introduction of medical insurance, competitive contracting, co-payments, and privatization — that resulted in rapid and “massive destatization” (Judyth, 1998). The system did not perform as expected mainly because it was not preceded by administrative, regulatory, and legal reforms. OOPS increased and state finances declined sharply. Two channels of government financing were created, one based on wage taxes and the other on general tax revenues, the latter being the more unstable source (Danishevski et al., 2006). The underfunding of inputs, including that of personnel, created “shadow commercialization”, which essentially meant that government-appointed medical personnel used informal shadow payments for their services (Blam and Kovalev, 2005).

In 2010, the law on Federal Mandatory Insurance Fund (FOMS) was introduced in Russia, In 2012, a set of measures was announced designed to overhaul the health care system in Moscow, and some major proposals around personnel and equipment were made that caused a significant level of controversies and protests in the country. The Russian system of decentralization has raised many concerns; the three tiers of the system — federal, regional, and municipal — each have their revenue-collecting and service-providing functions, but the management and regulation of the entire system remains complex (Danishevski et al., 2006). The chronic deficit of FOMS, mismatch between fixed rates for medical services and actual costs, centralized administration of an attempted decentralized system, and chronic personnel shortage have led led to a situation which has often led to alarmist conclusions (Epple, 2015) and a cry for real reforms.⁶

With relatively high health spending, Russia is a case of substantial inefficiencies in spending which translates into suboptimal health outcomes, high OOPS, and significant inequalities in access and financing across regions and economic and social classes (Linda, 2015; Gordeev et al., 2011). Private health insurance has increased over the years in Russia (Popovich et al., 2011). While its health outcomes are close to that of China and Brazil, in comparison to OECD countries, Russia does not perform that well. However, there is evidence of sincerity in health sector reforms, and evidence does suggest that incremental changes have been taking place, though a much more evidence-based approach is required to yield superior results.