To line up for a blood test, Yelena Kopylova, 49, came to the doors of her local state clinic in a Moscow suburb at 7 a.m. — an hour before opening.
She was not the first in line.
"I have diabetes, and I can faint while waiting," Kopylova, an obese woman there to test her blood sugar on an empty stomach, told The Moscow Times as she waited at the clinic doors last month.
The line ended up being dozens of people long, and many never saw their turn despite hours of waiting. The savvy knew, however, that all they needed to jump the line was to slip 200 rubles ($6) to the nurse.
Such scenes are ubiquitous in Russia, where public health care since the collapse of the Soviet Union has been underfunded, understaffed and underequipped.
In a bid for change, the government proposed a sweeping health care reform this year. While not inciting the war of words that followed recent U.S. reforms, it nevertheless generated much heated debate, which was renewed Tuesday, when President Dmitry Medvedev signed the reform bill into law.
The bill aims to eliminate on-the-ground graft of the sort that Kopylova witnessed at her clinic. But this is to be done through legalizing paid medical services in state facilities — which, critics say, is a step toward abolishing free health care in the country.
But it was a right that was routinely violated, and never more so than in post-Soviet times, when the health care system became plagued by insufficient financing and began slowly falling apart.
Patients are often forced to pay for supposedly free services, both officially and under the table, either because medical facilities lack financing or because doctors, embittered by crowds of patients and low pay, are reluctant to do their job.
Even to get to poor-quality service from a sour-faced doctor, patients often have to book an appointment long in advance, line up and deal with rude medical personnel and other patients looking to vent their frustration on their neighbor.
Money From Nowhere
Since 1991, state spending on health care "practically didn't grow" in real terms, said Larisa Popovich, director of the Institute of Health Care Economy with the Higher School of Economics.
A hefty 70 percent of all money spent on allegedly free public health care comes from legal and "informal" payments by patients, Popovich said at a roundtable organized by Johnson & Johnson in Moscow in September.
But even given those payments, per capita spending on health care in Russia "approximately equals" that in Latin American countries, she said.
Though the government plans to increase military spending to 20 trillion rubles ($640 billion) by 2020 — a spectacular sum harkening back to the days of the Cold War — no such figures are allotted for "social spending," including health care.
Total spending on health care is to rise almost three times from 540 billion rubles ($17 billion) in 2010 to 1.4 trillion rubles ($45 billion) in 2015, said Vladimir Zelensky, a department head at the Health and Social Development Ministry.
But he failed to say where the money would come from.
Federal and regional authorities are also jointly funding a two-year health care modernization program in 2011 and 2012, Zelensky told The Moscow Times. The program includes salary increases, the purchase of new equipment and repairs at medical facilities.
The federal budget is allocating 460 billion rubles for the program, while the regions are providing another 200 billion rubles, Zelensky said.
Not all are convinced this is possible.
Health and Social Development Minister Tatyana "Golikova believes that we have enough money to secure the standards, I stubbornly believe that we don't," Popovich said.
Health care will be "financed on leftovers," said Communist lawmaker Oleg Kulikov, who sits on the State Duma's Public Health Committee.
Moreover, whatever the state spends on public health care is spent "non-optimally," Popovich said.
For example, almost half of all senior patients who check into hospitals do that "not for medical reasons but for social ones," like the absence of access to doctors at a local polyclinic or lack of money to "eat properly," she said.
Almost one third of hospitalizations in Russia stems from "ineffective work" of polyclinics, Popovich added.
Meanwhile, Russia remains the only country in Europe where patients don't pay for obligatory medical insurance, Popovich said.
Free vs. Paid
The new reform, which takes effect in January, will replace free public health care with a program of state guarantees for most — but not all — kinds of medical aid.
The 18-page note attached to the 213-page bill explicitly acknowledges that a "black market of medical services" is thriving in the country — which is ascribed to the absence of regulations for paid medical services.
The new bill, available on the State Duma's web site, guarantees four types of free medical aid, including primary care, specialized aid, emergency aid and care for the terminally ill.
The actual list of ailments treated and medical services provided for free is to be defined by the government and updated every year.
A list released on the government's
Plastic surgery, cosmetic procedures and dentistry, as well as extra comfort in hospitals, will be the only things that patients would have to pay for, said several State Duma deputies interviewed for this story.
Zelensky of the health ministry added that patients would also have to pay for extra checkups they request.
The list of free medical services will be posted on the wall at every polyclinic and hospital for all to see, legislators said.
Nikolai Gerasimenko, first deputy head of the State Duma's Public Health Committee and a member of the ruling United Russia party, which supported the bill,
These include state responsibility for providing aid, social protection for patients, detailed listing of free medical help available and "priority of preventive care," which he said is a legislative novelty.
When asked to elaborate, Gerasimenko said the questioning was "going into too much detail."
Instead, he pointed out that the bill introduces unified treatment and insurance standards — something he said is currently absent and contributes to the poor quality of medical services.
"Now, aid is provided higgledy-piggledy — everything depends on the amount of money local authorities have, doctors' skills and equipment available in hospitals," Gerasimenko said.
The bill would boost the quality of medical services and reduce their costs, Veronika Skvortsova, Deputy Health and Social Development Minister, told The Moscow Times at an event in Moscow in mid-November.
A vital change is in the funding system: providing health care is now mainly the job of regional, not municipal authorities.
This is an improvement because municipalities "have no money" for it, said Kulikov of the Communist Party. But he pointed out that the federal authorities have effectively shifted the health care burden to the regions.
Insurers also like the bill. Nina Galanicheva, head of the Rosno-MS insurance company, welcomed the introduction of aid-quality checks, which she said would curb violations related to subpar medical services.
Cough It Up
Meanwhile, the public remains worried that health care, whatever its quality, will not be free in a country where 23 percent of people live below the poverty line, according to State Statistics Service data from July.
Deputy minister Skvortsova dismissed such fears as "unfounded."
But insurer Galanicheva urged authorities to clearly spell out not just free medical services, but the paid ones as well to prevent abuse.
Some say, however, that clarity alone would not suffice because doctors would go out of their way to impose paid services on patients.
"When a doctor gets a list of paid services, he will be interested in the patient using them," Yaroslav Nilov, a State Duma deputy with the Liberal Democratic Party, said in a telephone interview.
United Russia's Gerasimenko pointed out that the bill restricts contacts between doctors and pharmaceutical companies in order to "prevent secret dealings between them." But it remains to be seen to what extent the attempt to curb graft through legislation will work on the ground.
Some of the medical policy innovations also raise ethical questions.
The bill legalizes the forced sterilization of legally incapable people without their consent, the transplant of organs without consent of the donor or his family and abortions for girls older than 16, Nilov said.
The law also legalizes surrogate motherhood, said Olga Letnikova, a member of the central council of the Association of Parental Committees and Communities.
"It will be possible to breed children for sale, including to same-sex couples," Letnikova said in a telephone interview.
The bill also introduces time limits for resuscitation: Doctors must now only spend 10 minutes to 20 minutes trying to revive a newborn, and no more than 30 minutes for the rest. "Unpromising" patients with fatal chronic diseases or traumas can be refused resuscitation altogether.
There are also many issues with children's rights, Letnikova said. Some clauses can also be interpreted as allowing doctors to apply medical procedures to children, she said. Parents will now also be refused information about their kids' health once a child turns 15. On the other hand, the bill allows children to be taken away from low-income mothers, including at maternity wards.
The parental association got more than 1,500 people in the regions to take part in two three-day hunger strikes in November to protest the new law, Letnikova said.
Though the Health and Social Development Ministry reported taking most criticisms into consideration when working on the bill, its opponents, including prominent children's surgeon Leonid Roshal, have accused it of ignoring most key grassroots proposals.
An early version of the bill also contained proposals from hard-line conservative legislators to severely tighten abortion legislation. The proposals were eventually dropped, but not before sparking a wave of public protests nationwide.
"We fear good intentions would breed new types of corruption, other crimes and deterioration of public health care," lawmaker Nilov said.
The public is also in for a paperwork-related headache because the health care reform envisages replacing current medical insurance policies with new ones by March, said Popovich of the Higher School of Economics.
The populace was never informed properly of the upcoming exchange, outlined by a related bill passed last November, she said.
A patient will not be able to get any medical aid with an old policy. New policies will be issued to Russians, foreigners and people without citizenship.
Moreover, under the new rules insurance companies may opt to refuse obligatory medical aid to clients because fines for them would often be less than the cost of providing treatment, Popovich said.
"Currently in insurance companies, greed is fighting avarice," she joked darkly.
Medical workers were also never informed of the new bill in an orderly fashion, said an urologist at a Moscow polyclinic. He said he first learned about the legislation from The Moscow Times.
After studying the new law, the doctor, speaking on condition of anonymity for fear of reprisal, criticized the absence of "legal protection of medical workers from unfounded demands of patients," saying the issue was "pressing."
"People are already calling a doctor to cut their nails, and drunks ring up the ambulance to drive them home from a restaurant," he said.
What Should Be Done?
Opposition legislators did not argue the need for paid medical services, but said the list should be as short as possible.
Nilov of the Liberal Democrats said paid services for patients should be "reduced to the minimum." Communist Kulikov added that state and commercial medical facilities should be banned from working in the same building.
Nilov also urged that "tight control" over abortions and organ transplants should be established.
Kulikov drew on the Soviet legacy, proposing to oblige graduates of medical colleges to work in the regions for several years, thus solving the problem with understaffing.
The state should also provide free medication for nonhospitalized patients and foot bills for costly treatment, said Oksana Dmitriyeva, deputy head of A Just Russia faction at the State Duma. Her party tried to include these provisions on the law, but United Russia rejected them.
The urologist, who spoke anonymously, said the bill also does nothing to reduce paperwork for doctors, currently a very time-consuming task.
It also preserves the Soviet system of drawing plans in advance for how many patients should be treated, leaving doctors obliged to fulfill quotas no matter what, he said.
"Doctors must not be detracted from their main responsibilities — diagnosing diseases and treating them," the doctor said.
Nilov also urged senior officials to stop going for medical treatment abroad.
"How can they talk about ways to reform the system when they don't know what is happening on the ground?" Nilov said.