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Research Programs / Projects

Evidence about equity in the Russian Health care system

Problem description and urgency of project goals

1. Background

Universal access to effective health services of reasonable quality is considered by the World Health Organization as an essential requirement in an advanced society. The Russian government has defined better access to health care for all population and improvement of medical services quality as the main objective for health care public policy. In Russia, there is significant inequity in access to health care. This is caused by the very history of Russian health care system (along with public state institutions of health care, there simultaneously exist departmental health care systems), large-scale decrease of public health care funding during 1990-s, decentralization of public finance and sound differentials of economic potential among regions, increase of income inequality among various social and territorial groups. Current economic growth in Russia is featured by widening differences among regions by level of economic development and health care funding capacities. It produces new challenges for public policy aimed at assurance of health care accessibility.

A lot is already known about inequality in access to heath care in Russia, but the reliable evidence is quite restricted. State statistics shows the differences among regions in indicators of need for heath care (morbidity); health care resources; volumes of health care services delivered (outpatient visits, emergency calls, hospitalizations, bed-days, etc.). On the base of sociological data, health care seeking behaviour of people by gender, education, income, residence has been analyzed, and the inequality in access to free and to paid care has been revealed. Yet the data provides only a general picture of the inequity in health care system. Aggregate indicators of health care delivery conceal differences in the volume and quality of health care services available for different groups of population. Available large-scale surveys data (RLMS, NOBUS) are not used properly for the analysis of these differences.

Current inequalities and their trends require more detailed investigation and discussion for proper choice of public health policy priorities and tools.

2. Project objectives:
1) Reveal differences in the access to health care services for various social and demographic groups;
2) Reveal differences in usage of paid medical services for various social and demographic groups;
3) Analyze differences in access to free health care among residents of more and less economically developed regions;
4) Reveal differences in health expenditure burden among different income groups and among residents of more and less economically developed regions;
5) Explore people’s current visions of equity in access to health care;
6) Elaborate recommendations for public policy related to inequity in access to health care;
7) Determine perspectives of future research on differences in the quality of health care available for different social groups.

The project has been implemented in accordance with the Bilateral Cooperative Agreement between the Russian Federation and the World Health Organization for 2006-2007.

3. Methodology of Analysis

1. Differences in the accessibility of health care are considered as the differences:

2. The differences in accessibility of health care services for different social and demographic groups of population are analyzed as the differences in the following parameters:

As the sources of information to analyze the differences in use of outpatient and inpatient care the findings of three sociological surveys were analyzed:

“The Russia Longitudinal Monitoring Survey” (RLMS). The survey is conducted annually in 36 regions of Russia. The sample includes approximately 4,000 households (12.6 thousand of respondents). The latest available data of the 13-th wave (September-December of 2004) was used.

“The National Monitoring of Household Welfare and Participation in Social Programs” (NOBUS). The survey was conducted in April-May of 2003; a sample of 44.5 thousand households (117.2 thousand respondents) from 79 Russia regions is representative on the national level and for 46 regions separately.

“The Consumer Sentiment Index” (CSI), currently conducted by Independent Institute of Social Policy. Surveys are carried out by the Analytical Center of Yuriy Levada once in two months; the sample of 2.5 thousand respondents represents adult population (older than 16 years old). Besides of standard questions, the questionnaire designed specifically for accessibility of health care was included into the survey in March of 2006.

The analysis of differences in hospitalizations and estimations by the population of difficulties in making appointments with physicians and the quality of outpatient and inpatient care services delivered was carried out on the basis of the CSI survey data in March 2006.

According to the information of ROSNO-MS, one of the largest health insurance companies, the differences were analyzed in the volumes of outpatient care delivered (the number of visits to physicians of different specialties) and the inpatient care (the number of hospitalizations by profiles of the inpatient care facilities) for the population categories that differ in age and the place of residence (type of inhabited locality). The analysis was carried out for 4788.2 thousand insured citizens insured by ROSNO-MS company under the compulsory health insurance program in seven regions (51% of the total number of citizens in these regions).

3. The differences in use of chargeable health care services were analyzed by comparison of the share of persons that had spending on health care services and drugs for treatment in the inpatient care environment, in the groups of population that differ in social-demographic and economic characteristics. The source of data was the information obtained through the above mentioned surveys by RLMS, NOBUS.

4. The analysis of differences in access to free health care for the regions with different level of economic development was carried out on the NOBUS data, which allow calculating the share of patients that got only free services among the population of different regions.

5. The inequality in the distribution of health expenditure burden is analyzed as the difference in the share of health care expenses in the total household expenses minus the expenses for food. Such analysis is carried out on the survey data by RLMS and NOBUS.

6. In order to cope with the task of clarifying the ideas currently circulating in Russian society in relation to social justice in the access to health care, a special block of issues was developed on the subject, which was included in the survey held in July 2007 within the framework of “Consumer Sentiment Index” Project.

4. Main Results of the Project

1. To implement the project a working group was established consisting of:
Bondarenko N.V. – junior research fellow of Yuri Levada Analytical Center;
Burdyak A.Ya. – senior research fellow of the Independent Institute for Social Policy;
Kakorina E.P. – Department Deputy Director of the Ministry of Health and Social Development of the Russian Federation;
Kanatova N.B. – coordinator for scientific programs of the Independent Institute for Social Policy;
Kel’manzon K.M. – Councilor of OAO “ROSNO-MS” General Director;
Krasil’nikova M.D. – Head of “LEVADA-CENTER” sector;
Popovich L.D. – First Deputy Director General – Executive Director of ÎŔÎ “ROSNO-ĚS”;
Shevsky V.I. – Consultant of “Zdravconsult”;
Sheiman I.M. – Professor of the State University – the Higher School of Economics;
Shishkin S.V. – Research Director of the Independent Institute for Social Policy;
Selezneva E.V. – junior research fellow of the Independent Institute for Social Policy;
Svetlichnaya S.V. – head of information-analytical service of ÎŔÎ «ROSNO-ĚS».

2. On May 28, 2007 an expert workshop was held on the issues of equity in health care. At the workshop the findings were discusses of the analysis of inequality in health care accessibility, specified were the objectives of further work on the project.

3. On November 15, 2007 a round table discussion was held on the topic of “Inequity of access to health care”, where the basic results were presented and discussed of the implemented project. In the round-table discussion took part the responsible officers of the Expert Department of the Administration of RF President, the Ministry of Health and Social Development of RF, the Ministry of Economic Development and Trade of RF, the Federal State Statistics Service, the RAMS National Public Health Research Institute, the Setchenov Moscow Medical Academy, the RAS Institute of Economics, the World Bank, the Cochrane Collaboration Office for Russia and others.
The materials of the round table

4. The main conceptual results of the project are as follows:

4.1. The differences in access to health care services were detected and systematized for different social-demographic and territorial groups of population. The analysis of the obtained information allows making the following conclusions:

The system of health care in Russia is characterized with significant inequity of access to health care for groups of population different in the level of education, income, residence:

• Persons with higher education refer for the outpatient health care services more frequently, including consultations of specialists and diagnostic examinations, and less regularly for the inpatient care.
• The groups of population with a higher level of income refer for health care more often than the poor people.
• Rural inhabitants refer for the outpatient care less frequently in comparison with the urban residents. And here it is the population of big and largest cities, as compared with the inhabitants of small towns and villages, who have subjective perception of the outpatient care as less accessible and estimate the quality of primary care as lower;
• The inhabitants of villages, small and medium sized townships stay in hospitals more often than the residents of big and largest cities, which is, evidently, the consequence of both lower use of primary health care and low quality of diagnostics and more limited possibilities for getting outpatient care in the rural areas and small townships.

The obtained information is the evidence of some discrimination that exists for the people older than work age in favour of able bodied when getting specialized outpatient care and when referring to hospitals.

The exposed differences can justifiably be considered as the manifestations of inequity of access to health care services.

4.2. The practices used for getting health care for fees differ significantly among the population groups with different levels of income and place of residence. The rich pay for the visit to a medical specialist 2.5 times more frequently as compared with the representatives of low income groups, residents of largest and big cities would resort to payments for the outpatient care services than the inhabitants of medium sized and small towns and villages. These differences reflect inequity in the possibility of getting health care, conditioned by the differences in the level of income of the population.

4.3. Very significant are the distinctions in the accessibility of health care for the citizens of different regions of the country. The share of population that had the opportunity to take medical services fully free of charge is 1.3 times higher in the more economically developed regions as compared with the outsider regions. These differences appear as the regional inequity in the accessibility of free health care services.

4.4. Noticeable inequity in the burden of health expenditure exists between the populations with different levels of income. The poor spend on purchasing of drugs and medical services 1.5. times bigger share of their budget compared to the rich. The burden of health expenditure is higher for households that live in the regions with a lower level of economic development.
Over 8% of population have to bear catastrophic expenditures for health care and the burden of these expenditures is significantly higher for the poor than for the rich.

4.5. In accordance with the data obtained during the survey, health care is interpreted by the majority of the population as such sphere of human life where any factors of differentiation in accessibility are unfair. The conceptions of the greater part of population in Russia about the ways to ensure access to health care reflect the values of equal rights and paternalism.

5. The scale of inequity exposed in the use of health care and accessibility of free medical services for the communities of different regions, different types of inhabited localities, with different levels of income demand the revision of priorities in the public health care financing policy.
As the priorities of the Government policy towards inequity in access to health care the following can be recommend:

• To overcome the discrimination of people over the working age by increasing the financing provision for health care services for elderly people;
• To improve the level of financial protection of patients with “catastrophic” expenditures on health care by development of the state program for supplementary drug supply;
• To increase the range of measures to control chronic diseases and prevent their complications on the basis of programs for chronic disease management;
• To improve the arrangement of specialized care for residents of small settlements by way of forming a controlled multi-level system of care delivery in every region;
• To improve the level of public awareness on the matters of health care;
• To smooth inter-regions differences in the level of development of health care systems by way of implementing a long-term federal objective program for smoothing inequity in financial provision for health care in different regions.

6. The results of the conducted survey are evidence of the necessity to continue the analysis of access to health care services for different categories of the population. As the lines for further research the following can be recommended:

• To analyze the influence of factors of differences in modes of living and attitudes to own health and the factors of organizing the delivery of health care and informing the population on the use of different types of health care for the inhabitants of built-up areas of different types and persons with different levels of income.
• To study the impact of regional differences in the organization of secondary health care delivery to the population on the differences in its accessibility for the inhabitants of different types of inhabited territories in different regions.
• The do the in-depth study of reasons for the current differences in the level of admissions for the inhabitants of different types of built-up areas and the differences in the access to secondary health care for the persons of working age and older than the working age.
• To analyze the differences in the set of health care services, and in the degree of compliance of the delivered health services with the standards of care, in the clinical effectiveness of the delivered health care services by the population categories, which differ by place of residence, age, education and income levels.
• To determine the differences in the access to free health care and in the burden of health expenditures of patients with different kind of diseases.

The system of monitoring of inequity in access to health care for different groups of population should be created.

7. The analytical report with the results of the project was submitted to the Expert Department of the RF President, the RF Ministry of Health and Social Development, the RF Ministry of Economic Development and Trade and was placed on the site of the Independent Institute for Social Policy (www.socpol.ru).

The detailed description of the obtained results is presented in the report “Evidence about Equity in the Russian Health Care System”.