Official Discourses of Russian

Health System Reform

Faculty of Health Research Conference

November 2011

Kate Thomson

Territory

Healthcare in Russia 1991 mid-

00s

• Soviet model –centrally controlled state

healthcare

• 1993: move to insurance-based financing

structure

– CHI – payroll tax + regional govt contributions

• Problems:

Under-investment

Quality

Corruption

Health CrisisAccess

Percentage of Russians reporting paying for

medical assistance in 1994, 2000 and 2004

For a consultation with a healthcare practitionerFor tests and investigationsFor inpatient care, including medicines

Source: Shishkin et al (2008)

Russia‟s „Health Crisis‟

• High mortality/low life expectancy

compared to countries in region (esp men)

• Spike in male mortality –mid 1990s

– Societal collapse

(economy, structure, institutions)

– Alcohol

– Roads, working environments

• + Population „shrinkage‟

• „demographic crisis’

Life expectancy trends in

Russia, EU, Japan & USA, 1950-

2000

Source: Karlin (2008)

Key Policy Moments &

Documents

• National Priority Project

“Health” (2005)

• Concept of Health 2020

(2008)

• Health insurance law (2010)• Modernisation programme 2011-12

• Law on Basis of Health Protection (Nov

2011)

Policy directions & issues

2005• Increased Funding

• -wages, buildings, IT, hi-tech equipment

• Insurance contributions

• Access to medicines

• Addressing geographical disparities• Joined up system

• Clear delineation Federal, regional, municipal resps

• Incorporation of private hc providers

• Primary care & preventive services

Discourses

• „Systems of statements that construct an

object‟ (Parker 1992)

– Apparent in texts

– Context is important

– Reproduce power relations

– Ideological effects

• „systems of power/knowledge which are

socially and culturally located and which

construct subjects and their worlds.‟ (Gubrium and Holstein 2000).

CriticalDiscourse Analysis

Modernis-ation

Catching up

Standards

CompetitionResponsibility

Access

Official

discourse

s

Competition

• Принятие закона об обязательном

медицинском страховании – это важный

этап в модернизации здравоохранения. Мы

переходим к конкурентной модели, в

которой на первый план выходит пациент и

качество медпомощи.

“Passing the law (on compulsory health

insurance) is an important stage in the

modernisation of the health system. We

are moving toward a competitive model, in

which the patient and the quality of

medical care come first.”

Tat‟yana Golikova, November 2010

“Passing the law (on compulsory health

insurance) is an important stage in the

modernisation of the health system. We

are moving toward a competitive

model, in which the patient and the

quality of medical care come first.”

“ Material & moral stimulus” for staff

Standards

• „Standards‟ for conditions -specify

treatment that is free under state

guarantee

– Public & professional consultations

– Will be universal – across whole of Russia

• Set tariffs

• Specified responsibilities for levels of govt

• Professional education; CPD; skills

framework

Lifestyle & responsibility

• Goals: halve alcohol & tobacco use by

2020

• Lifestyle correction

• Raising the level of culture around health

“One novel thing in the Law is that everyone has a responsibility to care for themselves..”

Absences from the discourse

e.g. Corruption

• Disappearance of funds

(local govt / institutional

level)

• Payments for „free‟ servs

• Bribes

Pay & working conditions of health staff

Under-funding institutions

Cultural expectation &trust

Abortion rights

• Amendment to the new Health Law 2011:

• “ The aim is not to restrict women’s access

to a medical procedure. It is that the

woman who is making this decision to

terminate a pregnancy, has a chance to

think it over.” (V. Skvortsova, Dep Min Health &

Social Protection, 10/11/11)

Summary: challenges• Health indicator improvements

– Addressing structure as well as health system?

• Geographical disparities

– Governance issues

– Wealth

– Provision of facilities

• Trust in system

– Public trust in hc institutions & professionals

– Professional engagement with „modernisation‟

Summary: featured discourses• Re-contextualisation (Fairclough 2005) :

• Dissemination of global discourses, e.g.

– Competition & quality relationship• Private sector + public services

– Individual rights + responsibilities

• Recontextualisation in Russian setting:

– Geography

– Health challenges /‟crisis‟

– P ublic & professional expectations