A vital link

Public health in Russia

RUSSIA faces a triple challenge in health. First, there is a large health gap between Russia and its Western European neighbours. The gap is due mostly to non-communicable diseases, accidents, and injuries among adults, and to new diseases, the most prominent of which is HIV/AIDS. Adult mortality rates illustrate the problem. For example, if the current death rates remained constant, then about 43 per cent of Russian males who are aged 15 today would be dead before the age 60. In Poland, the equivalent rate is 23 per cent. There are also important variations among social, economic, and geographic subgroups within Russia, in terms of financing, access to services, and health outcomes.

Second, like many other countries, Russia is struggling to meet with finite resources the growing demand for health services, yet it makes inefficient use of those limited resources both in terms of allocation and technical efficiency. The health financing system in Russia is currently very fragmented and much more decentralized than in most middle- or high-income countries. Most public sector funds, over 85 per cent, are raised and allocated at the regional level through general revenues and a payroll tax. In effect, it is a collection of multiple systems. There are multiple streams of funding, each for different purposes, and sometimes for different sets of providers. Finally, Russia has a more fundamental challenge than disease control and the rationalization of health services. This is the difficulty of reforming a strong tradition that is grounded in the Soviet-era health system.

What and how to improve the system

The World Bank recommends that the following developments be made to upgrade the quality of health care in Russia. First, improving the aggregate health status of the population. To achieve this goal, it is important to pay attention to prevention at the levels of the household, outpatient services, and inpatient care.

Second, there is a major need to restructure the health services delivery, in line with the needs of the population, with an emphasis on a shift from inpatient to outpatient care. At the same time, inequities in access to services and poor quality of care need to be addressed. Weak governance and management could be addressed through needsbased funding of services, performance-based contracting of services, and improved systems of licensing of health staff, external assessment via accreditation of providers, health technology assessment, and operational research. The use of clinical practice guidelines, improved quality of equipment in line with needs, and performance monitoring, would be useful for improving the quality of care.

Third, there should be an updating of the quality and quantity of skills among medical professionals, as well as adjusting training to develop those skills. Lastly, the World Bank has identified a number of key changes to be considered in the area of health finance.

World Bank activities

Over the past three years, the World Bank has had a growing involvement in Russia. There is an array of non-lending activities underway. For example, an economic impacts model was developed looking at the impact of HIV on GDP growth over the next two decades. The results showed that the cumulative number of HIV-infected individuals by 2010 might rise to at least 2.3 million, which could lead to a decline in GDP of 10.5 per cent by 2020.

The World Bank is running two projects in the country with a third in development. The first is a tuberculosis and AIDS control project, which aims to improve surveillance, monitoring, strengthen case detection and improve case management. The HIV/AIDS control component will support public information campaigns, strengthen surveillance and monitoring, improve laboratory service to ensure that the use of antiretroviral drugs can be properly monitored and enhance blood safety. The second is a health reform implementation project to pilot a new model of health care delivery for the Russian Federation.

On the non-lending side, the Bank will need to work closely with partners to improve access to affordable antiretrovirals.

There are several areas where a future collaboration between the World Bank and the International Federation is possible, in particular in the area of the care of the disabiled in Russia. The World Bank is also very interested in the risk mapping exercise that the International Federation is currently undertaking for natural and man-made disasters.

Russian prisoners suffering from tuberculosis take their medicine at a prison camp outside the Siberian city of Kemerovo.
©Reuters / Andrei Rudakov, Courtesy www.alertnet.org

Crisis looming

While TB might be the biggest public health concern today, these are early days for the HIV/AIDS epidemic in Russia. Lars O. Kallings, special envoy of the United Nations secretary-general on HIV/AIDS in Eastern Europe explains why it should be at the top of Russia’s public health agenda now. “Let me make clear why I think HIV/AIDS must be in the forefront of concerns of the Russian Federation: because the epidemic is spreading rapidly, because it threatens young people especially, and because there still is an opportunity to curb the epidemic before it does massive damage to the Russian Federation’s future.”

HIV/AIDS first appeared in the country among needle-sharing drug users. Although it is not known how far it has spread, through sex, to the population at large, statistics indicate that the epidemic is headed in a worrisome direction. Some 85 per cent of those living with HIV in the Russian Federation, according to UNAIDS, are under the age of thirty – two thirds are under twenty-five, and twenty per cent of the total are still teenagers. A World Bank study predicts that by 2020 up to 10 per cent of an already decreasing population could have the virus.

Economic development would be reversed as well. Projections from the World Bank and the Russian Federation AIDS Center show gross domestic product 4 per cent lower as a result of AIDS by 2010 and 10.5 per cent lower by 2020, unless there are more effective preventive measures taken.

Each day Russian Red Cross staff and volunteers are confronted with the spreading epidemic in their work in prisons, as well as with migrants and other vulnerable groups. Until now, a conservative attitude within the National Society has prevented it from facing this new crisis. Regional branches, as a result, have taken the lead with some starting harm reduction programmes and peer education initiatives. But plans are being made to expand existing programmes and initiate new one.

The ICRC in the Russian Federation

THE ICRC has been working in the Russian Federation since 1992. From its regional delegation in Moscow, the ICRC carries out a range of programmes aimed at the integration of international humanitarian law (IHL) treaties in national legislation as well as teaching and promotion amongst the armed and security forces, universities, secondary schools and civil society.

In northern Caucasus, the ICRC runs a major humanitarian operation comprising both protection and assistance programmes as well as the promotion of IHL. Although this operation remains hampered by the volatile security environment, the ICRC assists the most vulnerable people by delivering material aid to the resident population in Chechnya and to internally displaced people in Ingushetia and Dagestan.

The ICRC also supports the repair of public infrastructure such as the water supply and sewerage systems in Chechnya, Ingushetia and Dagestan. As far as medical assistance is concerned, the ICRC assists 12 hospitals in the region, as well as the Grozny central blood bank, clinical laboratories and the Grozny limb-fitting and rehabilitation workshop.

The ICRC strives to visit people detained in connection with armed confrontations in Chechnya. It also implements mine risk education programmes in order to help the civilian population in general, and children in particular, to avoid the dangers of mines and unexploded ordnance in Chechnya and Dagestan.

On the move

Despair and an inability to respond to social challenges: these are the issues that the Russian Red Cross programme for migrants deals with on a daily basis.

“Since 1997, the Russian Red Cross has accumulated significant experience in this field” remarks Alla Yastrebova, adviser to the Russian Red Cross President. “Our network of consultation and counselling centres, summer camps for children and work at railway stations supports migrants and helps to promote tolerance, an acute issue in Russian society,” she says.

Russian Red Cross has been running a programme for over 5 years in the Orenburg region, which borders Kazakhstan. This region is one of the largest in the Russian Federation, an important trade centre standing at the crossroads between Europe and Asia. Here, roads from the Central Asian republics, Siberia and the Russian Far East meet those from Moscow and Ukraine.

Sixteen passenger trains carry 110,000 passengers through the city every day. Some 86 per cent of all migrants coming here from the former Soviet states are from Central Asian.

Some 300,000 people — a population of a medium-sized city — have settled in Orenburg region since the programme began, giving it the third highest number of migrants after Ingushetia and Ossetia, which neighbour Chechnya. During the past three years about 23,000 people in Orenburg have received free legal consultations and socio-psychological support from the Red Cross.

Population movement exists in any state. There are many reasons why people migrate, especially in a state with the kind of dislocated infrastructure Russia has had since the collapse of the Soviet Union.

The unfavourable economic climate, social conditions and internal conflicts push not individuals, but whole families into moving on against their will.

How can they prove individual persecution, a requirement for getting legal status? Red Cross lawyers help them to formulate the reasons correctly. Unlike state bodies, the Red Cross makes no distinction between refugees, forced migrants or unregistered involuntary migrants.

“Obtaining Russian citizenship is the most difficult problem,” says Vladimir Kessler, Red Cross reception centre lawyer in Orenburg. “Then come accommodation problems.”

About 3,000 forced migrants are on the waiting lists for housing in Orenburg region alone. “We help people get used to their new environment and together we write applications to relevant bodies. Instead of fighting with the state machine in vain we advise them how to deal with it in a correct legal way and thus avoid stress and frustration,” Vladimir said.

“Sometimes our colleagues in neighbouring states help to retrieve their documents,” he added.

In the world of migrants, full of misfortunes, the Red Cross with its free and independent consultations and counselling represents an island of conscience and goodwill.

According to Alexey Spitsin, head of the Federal Migration Service in Orenburg, there is a big discrepancy between the number of migrants registered (84,000) and the actual number living in the region (300,000).

“I must admit,” he confesses, “that as a state we are not able to solve all their existing problems,”

In April 2003, the Russian authorities said there were 472,300 forced migrants and refugees registered in the Russian Federation. Around 43 per cent of them came from Kazakhstan, 13 per cent from Uzbekistan and 10 per cent from Tajikistan. About 17 per cent were forced migrants within Russia.

The Russian Red Cross is determined to continue its help to people on the move and will seek further funding for the programme both within Russia and from external donors.

This year, the programme in the northern Caucasus is funded by the ICRC, while the programmes in Kemerovo, Nizhni Novgorod, Orenburg and Smolensk regions and at West-Siberian railways are supported through the International Federation, primarily by the Red Cross Societies of Sweden and Denmark.

The International Federation programmes

ADDITIONAL support to the Russian Red Cross activities is provided through programmes managed and financed through the Russian delegation of the International Federation secretariat. These include:
• provision of medical equipment and humanitarian supplies in times of disasters
and epidemics;
• food distribution during extreme weather conditions and in isolated territories;
• financial support to migrants centres, offering legal counselling, social support and
• summer camps for children;
• psychological support following major accidents or terrorist attacks;
• training for headquarters and district committees in resource development and
financial management;
• technical and financial support for the HIV/AIDS peer education programme;
• technical and financial support for TB programmes; and
• support for small local development projects.

International solidarity

There is no doubt about the Movement’s solidarity and support for the Russian Red Cross. Ten National Societies are running joint programmes with it, from HIV/AIDS harm reduction initiatives to food distribution for victims of cold waves. But, while outside support is still vital, the National Society, after a decade of transition, has emerged stronger, respected and much needed for the decades to come.

As Tatyana Nikolaenko, the president of the Russian Red Cross, sums up: “The Russian Red Cross has always been there — in times of national emergencies, whether natural, man-made, health or social disaster. And we plan on remaining a national resource in times of need.”

Margarita Plotnikova
Margarita Plotnikova is International Federation information officer in Russia.