Healthcare in Russia

• 1. Introduction

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  Healthcare in Russia is a system built on a constitutional promise. Since 1993, the Russian Constitution has guaranteed every citizen the right to free medical care. That promise has been tested repeatedly, strained by political upheaval, economic collapse, and decades of under-investment.

  In 2008, Russian hospitals employed 621,000 doctors and 1.3 million nurses. The country had 9.3 hospital beds per thousand people, nearly double the OECD average. Yet spending per person was just $957 in 2013, a fraction of what Western nations spent. By 2016, about 146.8 million people depended on this system.

  How did Russia build, dismantle, and try to rebuild one of the world's largest healthcare networks? The answers stretch back to the Tsarist era, run through the revolutionary ambitions of the early Soviet state, and land in the complicated present, where a constitutional right and the reality of care are sometimes very different things.

• 2. Tsarist Foundations

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  In 1912, an interdepartmental commission delivered a stark verdict on the state of medicine across the Russian Empire. Its conclusion was blunt: a vast part of Russia had absolutely no provisions for medical aid.

  The numbers behind that finding were grim. The All Russia League of Struggle Against Venereal Disease counted 1.5 million sufferers in 1914. One in ten men conscripted to the army carried tuberculosis. Healthcare spending across the empire amounted to just 91 kopeks per head of population. Nearly all medical supplies, drugs, and equipment were imported from Germany, which made the outbreak of World War One an immediate supply catastrophe.

  The war itself devastated the medical workforce. Between 1914 and 1920, as many as 10,000 conscripted doctors died. Among the wounded, mortality was very high; more than 16 percent died from typhus alone.

  Yet the tsarist era was not without ambition. The Medical Sanitary Workers Union was founded in 1820. Smallpox vaccination became compulsory for children from 1885. By 1903, ten factories in Moscow operated their own small hospitals, and 274 had medical personnel on site. Legislation passed in 1912 encouraged the growth of contributory hospital schemes.

  More surprisingly, in one specific domain, tsarist Russia led the world. By 1900, it had granted school doctors more authority over school buildings and children's health than France, Germany, the United Kingdom, or the United States. In the field of school hygiene, at least, the empire had outpaced its neighbors.

• 3. The Soviet Experiment

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  Nikolai Semashko became the People's Commissar of Public Health of the Russian Soviet Federative Socialist Republic on the 11th of July 1918. He held that post until the 25th of January 1930, and the system he built carried his name for decades.

  The Semashko model was centralized, integrated, and hierarchically organized. All health personnel became state employees. The government provided healthcare to every citizen at no direct cost. A 1921 decree charged the commissariat with "responsibility for all matters involving the people's health" and the elimination of every condition prejudicial to it.

  The ambitions of the early years were sweeping. In 1918, spending on medical services was already climbing. By 1923, it reached 140.2 million rubles per year, rising to 384.9 million rubles by 1927. Two thousand new hospitals were built between 1928 and 1932. In 1929, Gosplan projected health spending would account for 16 percent of the entire government budget.

  The system achieved real results against infectious disease. Tuberculosis, typhoid fever, and typhus, which had ravaged tsarist Russia, came under control. By the late 1970s, free medical care covered the entire population, though modest charges applied to spectacles, dentures, and certain surgical appliances. Nearly half the population was exempt even from those.

  By the 1960s, life and health expectancies in the Soviet Union were comparable to those in the United States and Western Europe. That convergence would not last. A 1989 survey found that 20 percent of Russian hospitals lacked piped hot water. Three percent had no piped cold water at all. Seven percent had no telephone. The system that had once been called a coherent and cost-effective model had become something else by the late 1980s.

• 4. Collapse and Reform

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  When the Soviet Union fell, Russia's health system fractured along with it. Drastic funding cuts sent the state-run system into decline. Private clinics moved into the gap, marketing themselves on quality the public hospitals could no longer deliver.

  The 1993 constitution's Article 41 reaffirmed every citizen's right to healthcare. The mechanism chosen to fund that right was compulsory medical insurance, known by its Russian initials OMS. More than 300 private insurers entered the market alongside numerous public ones. The reformers envisioned genuine competition, patient choice, and resources migrating toward demand.

  The reality, as the OECD later reported, was that the reforms only made existing problems worse. Real competition for patients was rare. Insurance companies functioned mostly as passive intermediaries, channelling funds from regional OMS pools to providers without acting as informed purchasers. A "mosaic" of federal and state agencies complicated management further.

  By 1997, WHO estimated healthcare spending per person in Russia at $251. Spain spent $1,211 per person that year. The United States spent $3,724.

  Boris Yeltsin's resignation shifted priorities. Vladimir Putin restored higher funding to the state system, and throughout the 2000s, spending climbed. Health expenditure per person rose from $96 in 2000 to $957 in 2013. Infant mortality fell from 18.1 per thousand in 1995 to 8.4 in 2008. By 2006, public health spending had surpassed its pre-1991 level in real terms.

  Then came the financial crisis of 2014. Major cuts followed. About 40 percent of basic medical facilities ended up with fewer staff than required. Some closed entirely. Waiting times lengthened, and patients were made to pay for services that had previously been free.

• 5. Private Insurance and Its Limits

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  Voluntary health insurance was introduced in Russia in October 1992. In the years that followed, dissatisfaction with public hospitals drove steady growth in the private market.

  By 2014, revenues for the leading private medical institutions reached one billion euros. In Moscow alone, 3.1 million people held voluntary insurance policies that year, covering 20.8 percent of the city's population. The average yearly cost of an employer-sponsored scheme ranged from 30,000 to 40,000 rubles in 2016, roughly $530 to $700. Individuals buying coverage on their own paid about 30 percent more.

  Private insurance in Russia is largely a corporate product. Corporate clients account for 90 percent of all policies. Small and medium-sized businesses rarely offer it. Entry-level policies often exclude critical conditions such as cancer or heart disease.

  The leading insurers include Sogaz, Allianz, RESO-Garantia, AlfaStrakhovanie, and the formerly state-owned Rosgosstrakh and Ingosstrakh. RESO-Garantia stands apart from the others: individual customers account for 40 percent of its policies, an unusually high share for the market.

  The largest private healthcare provider by revenue has the Sistema conglomerate as its main shareholder. Foreign providers have also established a foothold. Fresenius operates a network of dialysis centers. Fertility and maternity care represent a significant segment; the Mother and Child clinic network handles 9 percent of all IVF treatment cycles in the country.

  The financial crisis trimmed the market. The proportion of companies offering health insurance fell from 36 percent to 32 percent in 2016. Immigrant workers, required by law to carry coverage for work permits, became an important secondary market for insurers.

• 6. Occupational Health's Hidden Gaps

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  Mikhail Lomonosov wrote about the health of mine workers in 1763, in a book titled "First foundations of metallurgy or ore affairs." His concern for ventilation and recovery for people working underground is considered the first Russian engagement with what would later be called occupational health.

  The Soviet period built formal structures around that idea. The scientific research institute of hygiene and occupational health opened in Moscow in 1923. The Labour Code of 1918 was expanded in 1922 to cover work in dangerous conditions, the labor of women and children, and night shifts.

  Russia's official occupational disease statistics today tell a paradoxical story. In 2014, only 8,175 cases of occupational diseases were reported across the entire country, representing 5.5 cases per 100,000 people. That rate is far lower than in many European countries. Yet official government data also states that 1 in every 3 workers in Russia is exposed to harmful conditions that exceed national hygiene standards.

  The gap between those two figures is not good news. Researchers point to several explanations: too few trained specialists in occupational medicine, inadequate procedures for diagnosing and registering diseases, and economic pressure on medical organizations that conduct mandatory examinations for employers. Workers also fear losing their jobs if they report illnesses.

  The distribution of what does get diagnosed falls heavily in one sector. Mining accounts for 68.4 percent of all newly recognized occupational diseases. Agriculture, hunting, and forestry account for 8.3 percent. Manufacturing contributes 7.5 percent, and transport and communications 6.6 percent.

  For decades spanning 1990 to 2010, the officially registered occupational morbidity rate held between 1.0 and 2.5 cases per 10,000 employees. In mining, that same rate reaches 30 per 10,000 workers, a reminder of where the real burden falls.

• 7. Demographics and the Birth Rate

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  Russia's demographic trajectory has shaped healthcare policy in ways that go beyond medicine. By 2010, the number of ethnic Russians had fallen by 4.31 percent, or 4.87 million people, compared to the year 2000. The total Russian population dropped by 1.59 percent over the same period, from 145.17 million to 142.86 million.

  The government's response was direct. Since 2007, women who had a second child have been eligible for a one-time payment of 250,000 rubles, roughly US$4,000 at the time. Monthly child support payments were doubled.

  In 2007, Russia recorded its highest birth rate since the collapse of the Soviet Union. The First Deputy Prime Minister announced plans to invest about 20 billion rubles, approximately US$1 billion, in new prenatal centers in 2008 and 2009.

  In May 2012, President Putin signed the May Decrees, which included a commitment to double the wages of healthcare staff by 2018 and a plan for gradual privatization of state health services. The wage increases carried unintended consequences. In November 2014, the implementation of the Moscow wage rises led to the closure of 15 hospitals and 7,000 redundancies in the city.

  Dentistry offers a small but telling arc within this larger story. In 1991, the average 35-year-old in Russia had between 12 and 14 cavities, fillings, or missing teeth. Toothpaste was often unavailable. Since the Soviet collapse, dental skills, products, and technology have improved significantly, a quiet measure of how much the system has changed.