By Jodi Koehn
"There has been wide variation among Russia's eighty-nine regions in terms of the severity and dynamics of the health and demographic crisis, remarked Judyth Twigg at a Kennan Institute lecture on 2 October 2000. Twigg, Assistant Professor, Department of Political Science and Public Administration at Virginia Commonwealth University went on to say that the Russian government's response to this crisis has been to try to reform the structure of the health care system, in the hope of providing better health care to the Russian people. That effort, too, has experienced wide regional variation, Twigg stated.
According to Twigg, one of the recent problems with the Russian health care system is that the State is not paying for much of what is supposedly--according to Article 41 of the Russian Constitution--free health care. There are also problems at the provider level with doctors and nurses not being paid their wages for months at a time and the fact that those wages are alarmingly low when they are paid, Twigg remarked.
Twigg examined health care system reform at the regional level in order to answer three questions. First, what is happening in health care reform. Second, why is it happening or not and more precisely, why it has progressed more successfully in some regions and virtually not all in other regions. Third, and perhaps most importantly, what has been the impact of reform of the Russian health care structure and the impact of those structural reforms on health status throughout the country.
In order to determine what is happening with health care system reform in Russia, Twigg focused on a sample of forty-one regions according to fourteen variables. Those variables were: the degree of payment of health insurance taxes; provider reimbursement mechanisms; the degree to which the region has moved from inpatient to outpatient care; the move toward using general practitioners instead of specialists; global budgeting; co-pays and voluntary medical insurance; the move toward eliminating excess capacity; salary variation; quality reviews; comprehensive insurance benefits; subsidies to the poor; geographic coverage; and whether insurance companies and international intervention are present.
According to Twigg, the analysis showed that the regions which were more progressive in the reforms were the ones most mentioned in the West: Karelia, Novgorod, Moscow city, Tver, Tula, Penza, Samara, and Kemerovo. The average regions were the bulk of the forty-one, with twenty of the forty-one falling into that category. The non-reformers were: Ryazan, Kursk, Tambov, Kalmykia, Astrakhan, Karachai-Cherkess, Krasnodar, Stavropol, Udmurt, Orenburg, Chelyabinsk, and Amur.
According to the study, Twigg found that wealth enables health care system reform. The regions with more money to work with achieve greater success in implementing these health care system reforms--as one would expect. Another finding was that urban areas seem to be a bit more reformist than rural areas, Twigg stated.
The last question Twigg discussed was whether the reforms mattered for health outcomes; whether the changes made a difference in the health of the Russian people. According to Twigg, in terms of several of the most important indicators--life expectancy, maternal mortality, and infant mortality--the answer is no. For life expectancy, this is not surprising as many determining factors--such as behavior and environmental factors--are not directly related to the structure of the health care system. But infant and maternal mortality are thought to be correlated with the quality of the health care system, Twigg argued. Twigg posited that if similar research were conducted a few years from now, there might be different results. Perhaps it is too early in the process of implementing these health care structure reforms for them to have had a significant impact on health outcomes, Twigg argued.
According to Twigg, there is a more positive interpretation of the findings. In response to those who fear these health care structural reform efforts actually harm health care status, Twigg stated that there was no such evidence. If it is true that these structural reforms produce monetary savings or enhanced efficiency opportunities for the Russian health care system, so far they do not seem to be a detriment to the health outcomes that are related to the quality of the health care system.
It would be dangerous to infer causality in any of these relationships at this point, Twigg added. In terms of correlation, this study has confirmed that there is wide variation among the regions, not only in terms of health status, but in terms of health system quality and structure. The data showed that money does make a difference. If it is true that wealthier regions have the material ability to get farther in health system structure reform, Twigg concluded, we can begin to speculate that the health insurance system might be doing some good; that the regions that are the farthest along in implementing the insurance mechanism have progressed further in restructuring their health care systems. In terms of the impact of health care structure reform on health status in either a positive or negative direction--Twigg argued that it is still too soon to make that judgement.
By Jodi Koehn