By Irina Glushchenko and Renfrey Clarke
MOSCOW — Free, universal health care is fast vanishing from the Russian Republic. In theory, it is to be replaced from the beginning of next year by a compulsory system of medical insurance.
But as the public health system is starved of funds, medicines and equipment, huge areas of medical care are now being spontaneously privatised. People who cannot afford fee-for service doctors and market-price medicines are increasingly being forced to do without health care altogether.
According to a report in Nezavisimaya Gazeta at the end of February, the Yeltsin government has now decided to introduce compulsory insurance in various parts of the country as soon as the necessary preparations can be made.
Free health care is to be retained only for children, students, chronic invalids and pregnant women. Ambulance and casualty services, along with treatment of a number of life-threatening diseases, will remain free for the population as a whole.
In practice, however, very little is likely to remain of the state-funded health care system. The Yeltsin government has starved public health of funds in order to encourage the growth of private medicine. Public hospitals and clinics are acutely short of staff and have few drugs with which to treat patients.
If you get sick in Russia today, your first choice if you can possibly afford it will be a private medical cooperative. According to Nezavisimaya Gazeta, 35% of the population of Russia as a whole, and 65% of Muscovites, make use of these services. The private clinics attract the best-qualified staff — wages in the public system are an insult to those who work there — and are better placed to help patients find scarce medicines.
In many cases, private medical cooperatives have been set up on the premises of public institutions. The relationship of these firms to their hosts is often parasitical. At the Sklifosovsky Institute, one of the city's main casualty centres, a careful audit revealed that five cooperatives operating within the institute were plundering it of medicines and equipment.
A revived public health system, based on a universal insurance levy, would at least provide competition to the private entrepreneurs. But the private clinics have no immediate need to fear for their profits. After two years of discussion, and
close to a year after the adoption of a "Law on Medical Insurance", the Russian Ministry of Health still has not prepared basic documents. There is no clear system for evaluating the cost of medical services, and the would-be insurers lack professional knowledge. Medical staff have no idea who will pay them or how.
No-one seems to have addressed the most vital question of all: how are the masses of Russians to pay for medical insurance when they cannot even afford to eat properly?
"More than half of the population are in no condition to pay", people's deputy of the republic T. Pekarskaya observed recently. "People will be dropping on the streets, dying on the metro, and no-one will give them qualified medical help."
Even if the state were to fund hospitals and clinics properly, that still would not solve one of the fundamental problems — the lack of medicines.
Shipments of imported medicines are often delayed for long periods in customs, or are simply stolen. A key obstacle to increasing local output is the fact that the chemical firms which supply the raw materials prefer to export their produce for hard currency. Almost the only way the pharmaceutical plants can get supplies is through cumbersome barter deals.
Free prices for most medicines have not solved these problems, and have multiplied the difficulties faced by patients. On average, the price of pharmaceutical goods quadrupled in January. A kilogram of cotton wool, which not long ago sold for 1 rouble 75 kopecks, now sells for 125 roubles.
The situation has turned many doctors and nurses into determined militants. In mid-January, leaders of the Russian Health Workers Union reported that members in almost 70 regions of the country had declared their readiness for collective action. Their key demands are wage rises in line with the rise in prices, and increases in funding to ensure that all citizens have access to effective medical services.
A campaign of strikes, demonstrations and pickets began during the last week of January. In the city of Vologda, medical staff struck on January 24, demanding pay rises, proper medical supplies and subsidies for hospital cafeterias.
In Moscow, the best-publicised action by health workers was a three-hour warning strike on February 4 by staff at the Sklifosovsky Institute. Supported by ambulance workers, the staff members held a demonstration which blocked traffic on the city's inner ring road.