Healthcare Reform, Demographic Trends, and COVID-19 In Russia: A Conversation With Professor Judyth Twigg

Dr. Twigg is a professor of Political Science at Virginia Commonwealth University who specialized in public health reform in post-socialist states. Yana Gorokhovskaia talked to Prof. Twigg about the success of Russia’s healthcare reform, the reliability of Russia’s recorded COVID-19 deaths, and how political conservatism has impacted the health of vulnerable populations.

– Over the course of the last fifteen years, Russia has undertaken major reforms to overhaul the health care system it inherited from the Soviet Union. Life expectancy has improved and consumption of alcohol and tobacco has gone down. But problems with efficiency – Russia ranks last on the Bloomberg Health-Efficiency Index – and lack of care in rural communities remains. How successful have the reforms been overall?

– The answer depends on what you mean by health system reform and what your goals are. The increase in life expectancy and the decrease in consumption of alcohol and tobacco is the product of really smart public health policies: the restrictions that Russia put in place, starting about a decade ago, on the drinking age, the age at which you can buy tobacco, advertising of alcohol and tobacco, reducing the availability of alcohol and tobacco in retail settings and increases in taxes on these products.

Russia correctly identified that one of its biggest demographic and health problems was the premature mortality of working-age men from noncommunicable diseases such as cardiovascular disease and stroke. It followed established international best practices by reducing the availability and increasing the price of alcohol and tobacco. There’s a fair amount of good evidence that these policies worked. They probably didn’t work to the extent that the health ministry claims – it claims to have achieved a 40% reduction of alcohol consumption – which seems unlikely. But I do think that there have been some tangible improvements in life expectancy that directly follow these policies. The Russian government gets credit for that.

Another area of health sector reform concerns infrastructure health care delivery. They have poured billions of dollars into new construction and new equipment. For the last ten or fifteen years, as part of the National Projects that go back to Medvedev, Russia has built new maternity and neonatal care facilities, which is a smart thing to do if you’re worried about your low birth rate. And they have built a lot of cardiac care centers, which is also a great thing to do if you’re worried about premature mortality from a heart attack and heart disease. They have built health maintenance centers where people can get a check-up and talk to a doctor about their blood pressure and cholesterol. That’s all very smart.

Access is not universal and the changes have been implemented in a way that hasn’t been as efficient as we’d like it to be. There’s been plenty of corruption. There’s been plenty of equipment purchases instead of the distribution of these new resources based on health mapping because that’s seen as politically beneficial to local and regional politicians. But on the whole, there’s been a lot of improvement in terms of quality of health care, especially in Moscow and St. Petersburg and some other larger cities. The investment has paid off in important ways.

But there’s another element of health system reform that has been controversial: reform of health care financing. The Soviet system prioritized universal access. Based on socialist principles of equality, they constructed a health care system that provided access to some basic level of medical care even out in the middle of sparsely-populated Siberia. The system worked according to principles of central planning within the command economy: the priority was to distribute quantity. They had plenty of doctors, hospitals, and clinics. But they were horrible with quality. And not great with efficiency or controlling costs.

Output plans for hospitals were based on how many beds were occupied. So you had way more beds than were needed. And people were kept in them for more nights than was needed. This led to over-hospitalization and long average lengths of hospital stays. To prepare for minor surgery at the hospital, all the preliminary x-rays and blood tests that you do on an outpatient basis here would be done during two weeks of hospitalization before the procedure. This practice remains ingrained in today’s system.

The limited resources of the health care system were wasted on the most expensive part of the sector: hospital care. The system was imbalanced: spending too much for hospital care and not enough for out-patient primary care. In the Soviet model, a primary care doctor was rewarded for how many people came through the door. There was no concern for patient outcomes. Those doctors either signed a health certificate that got you out of work or they directed you to a specialist at a hospital. Over time, people began to think of hospitals as their first recourse if they got sick and needed care.

In the 1990s, a couple of really good health care economists in Russia who had studied other systems understood the need to create a different set of incentives for health care providers. Primary care doctors needed to pay attention to patient outcomes and be financially rewarded for treating patients instead of referring them to hospitals. And hospitals needed to be rewarded for outcomes instead of just keeping people in beds.

The system of compulsory health insurance was put in place in the 90s that changed the provider payment mechanisms. Basically, it introduced a set of incentives with the aim of saving money and saving scarce resources. The priorities of the sector would be flipped: less money spent on hospitals and more money spent on good quality primary care. The money should follow the patient.

Post-Soviet Russia inherited too many hospitals as well as hospitals with incredibly low occupancy rates. Over the last ten or fifteen years, there has been a lot of consolidation of hospitals and closures of old hospitals. A lot of “rationalization” of the system. On paper, this makes sense. But when it was implemented, in many cases in a politicized and not thought through the way, it resulted in the closure of rural facilities which left millions of rural residents with limited or no access to care. The thing that makes sense from an efficiency perspective ends up being a catastrophe from an access perspective. In the cities, these efficiency reforms placed a larger burden on primary care doctors without providing them with training, staff, or infrastructure. They just got a much higher patient load with an increased set of expectations for outcomes without additional tools.

I would have said, until three months ago, that despite the access issues in rural areas and the legitimate concerns of doctors protesting hospital closures and increased workloads, the health economists who pushed for the efficiency-oriented reforms were correct. But the coronavirus has shown that the kinds of things that are undesirable in an efficient system – like excess hospital capacity – may be needed in a crisis. The pandemic is definitely making people think in a different way about efficiency arguments. And right now, no one has an answer to the question of how to balance the drive to achieve a cost-effective system with a set of imperatives that makes sure that you have surge capacity when you need it. The answer everywhere, so far, has been to build new facilities and convert facilities into COVID-19 treatment centers but this is not sustainable. Not just for Russia, but globally, we are the beginning of a hard conversation about how you structure and fund hospitals going forward.

– We usually talk about Russia as an authoritarian outlier, but the problems that it has experienced in connection to COVID-19 mirror problems elsewhere, with the exception of the additional complications posed by import substitution schemes and sanctions. How did these factors impact Russia’s pandemic preparedness?

– The import substitution drive predates the sanctions and the epidemic. Even before COVID-19, the health sector was feeling the impact of import substitution. Substituting imported medications with Russian-produced generics impacted the availability of insulin and pain medications for cancer patients. We were hearing stories from around Russia, about shortages or inadequacies of Russian medications. If one of the drugs that an HIV patient was taking was switched to a supposedly equivalent Russian generic, it would impact their health. We were hearing about websites where patients were exchanging and trading medications with people from other parts of the country. HIV/AIDS patients were going to Europe to buy meds. We already knew that the Russian-produced meds weren’t a good substitute for Western-produced meds.

It’s unclear to what extent these problems impacted care for COVID-19 patients. Russian physicians working in COVID-19 wards and hospitals, like everywhere else in the world, were experimenting with a trial by fire in trying to save and prolong the lives of COVID patients. Physicians complained about the lack of certain drugs but I haven’t seen enough to say whether these shortages were caused by the sudden increase in demand or if the shortages were caused by a shortfall in Russian production.

Back in early March, when we were seeing the first wave of the virus hit Russia, everyone was trying to count ventilators because we were thinking that a lack of ventilators would be the thing that caused the Russian health care system to crack. But, in reality, the shortages in Russian hospitals weren’t of ventilators or other high-tech equipment, but instead, they were shortages of gowns and masks. This has been an acute and critical shortage and impacted the ability of health care staff to protect themselves and patients. This is what has been killing doctors and causing cross-infection in hospitals.

– Is that the result of the same problem posed by interrupting supply chains from China that America also discovered at the onset of the outbreak?

– Yes but there’s a twist to the story. Russia bought most of its personal protective equipment (PPE) from China. When China’s epidemic started in December and January, Russia sold its stock of PPE back to China. When the pandemic hit Russia, it couldn’t get PPE from China not only because it was using this supply but also because production was at a standstill. Russia has to try and make this stuff itself which was hard to do because the industrial equipment for making PPE is sourced from China or Europe. Russia was forced to bid against everyone else for PPE and the equipment to make PPE. All of that significantly slowed Russia’s ability to equip its health care staff. It now looks like they are starting to address these shortages.

– The topic that seems to be in the news the most recently is the reliability of Russia’s very low rate of reported deaths from COVID-19. Do incentives to manipulate health data exist in Russia? Have there been other cases of data manipulation in the past?

– This pandemic isn’t changing anybody, it is just highlighting existing patterns. That’s true of Russia and it’s true around the world. It’s not that there’s an incentive to implement some sort of a scheme by Putin to hide the real numbers. It’s not that insidious. It’s a product of the unique bureaucracy of Russia’s vertical system of power where everyone at lower levels wants to tell the boss what he wants to hear. We see that with COVID and we saw it before with the billions of dollars that were spent on health care through the National Projects that have been in place since the mid-2000s.

Back in 2012, the May Decrees set targets for health care that were attached to spending. These were targets in the reduction of deaths from cardiovascular disease and other ailments. And we saw movement in the rates according to what the targets were. We saw this, especially with tuberculosis. A patient with HIV/AIDS doesn’t actually die from HIV/AIDS. HIV compromises your immune system so that you die from an infection that your immune system would have otherwise been able to fight off. An HIV death is death from an opportunistic disease. The most common opportunistic disease is tuberculosis. So it was curious that we saw an increase in deaths from HIV/AIDS when they set reduction goals for deaths from TB. They had incentives to code TB deaths as deaths from HIV/AIDS. And there are lots of these kinds of examples that predate COVID-19.

– What have been the consequences of Russia’s political turn toward conservatism for public health, especially in terms of women’s reproductive health and HIV/AIDS?

HIV/AIDS tends to disproportionally impact vulnerable and marginalized groups. These are groups that tend to have their behavior and identities criminalized in conservative and authoritarian societies. Men who have sex with men, drug users, sex workers are pushed to the sidelines and are increasingly vulnerable to criminal penalties and ostracism.

When those populations are pushed underground, it takes them farther and farther away from access to health care and public health messaging on strategies that would keep them healthy. It prevents them from having access to harm reduction methods like needle exchanges or methadone treatment, which is completely illegal in Russia. Political conservatism is terrible news for people who have or are at risk of contracting HIV/AIDS in Russia.

The other important element is the degradation of Russia’s relationship with the US and the rest of the world and the pushing out of funding for civil society that battles the epidemic. That’s taken away the vast majority of the support that members of those vulnerable groups did have in Russia. There are only a small handful of brave and smart NGOs that continue to work in this space. And they are under threat all the time.

In terms of women’s reproductive health, the anti-abortion turn in Russia over the last decade, with the significant leadership of the Orthodox Church, has meant that women have had their access not just to abortion but also to reproductive health care reduced. This has been an issue during the COVID-19 lockdown because people are neglecting all kinds of non-COVID related healthcare. Heath facilities have been repurposed for COVID-19 care and people under lockdown may perceive that they are not allowed to go to the doctor or are afraid to go to the doctor because of the risk of infection. People are neglecting treatment for health conditions and health maintenance. Even in the US, visits to primary health care providers are down 50% and so a lot of practices are at risk of going out of business because their revenue streams have been interrupted significantly. In Russia, this lack of access is great news for the conservative forces that want to limit abortion. The Moscow Times reported recently that as many as 100,000 women had to forgo medical abortions during the lockdown period in Moscow.

– Population decline is a serious concern for the Kremlin, which has enacted different pro-natal policies, including a program of maternity capital, to boost birth rates. You’ve suggested that Russia may not be able to overcome the fertility gap left by the dramatic fall in birth rates during the early and mid-1990s. How can Russia more effectively use the human capital of its shrinking population? 

– Russia’s maternity capital program is very expensive but politically it makes it look like the government is doing something. There are plenty of countries that have tried to pay women to have babies. Originally, maternity capital was the equivalent of $12,000 before sanctions led to the collapse of the ruble. Now it’s in the neighborhood of $8,000 or maybe a little more. It’s not enough money to raise a kid. As a financial incentive, there’s very little evidence to suggest that it’s enough to change a woman’s or family’s planning decisions. Some research has shown that there might be an incentive in Russia’s rural areas.

However, if you look at the global literature on what works in terms of pro-natal policies, the answer consistently seems to be childcare. France is the poster child for having come up with decent childcare provisions that turned around a demographic crisis. Russia hasn’t landed on that as the solution to its problem. In the Soviet Union, you had the help of multigenerational families living together and grandparents taking care of children. That’s not the case anymore. Childcare could be a powerful incentive to boost the fertility rate based on global evidence.

More broadly, if you look at demographic trends, Russia needs to find the best use for the human capital that it does have. This is something that Russia is not good at and the Soviet Union was terrible at. How do you make better use of what you have rather than throwing more resources at the problem? How do you get from an extensive to an intensive model of growth? When it comes to demographics, it means better education and training for the people that are there. How do you make sure that the skillset and the health of the population that you do have are adequate to do whatever it is that you want your economy to do? It’s not clear that Russia is thinking about the problem in those terms.

– It seems that there is a tension between policies that would improve people’s quality of life and the nature of the political system. Data on emigration seems to bear this out as people with the most education and versatile skills are the most likely to leave Russia.

– There is a fundamental tension between a political leadership that wants to maintain control and the instincts of people who have the education, expertise, and creativity to participate in an information-based global economy and do not want to live an authoritarian society with economic problems. Russia hasn’t figured out how to hang on to those people.