The doctors' protests that dominated local media headlines earlier this year may have slipped from the spotlight, but a handful of determined Moscow doctors continue to battle the reforms that they say have made their job impossible with a so-called Italian strike, otherwise known as the "work-to-rule" tactic.
"We go to work and do our job, the difference is we act in strict accordance with existing legislation," Yekaterina Chatskaya, a doctor participating in the strike and a co-chair of doctors' professional union Deistviye (Action), told The Moscow Times in a recent phone interview.
The Moscow health care reform launched last year shook the city's medical community to the core. Leaked plans showing that City Hall intended to shut down 28 hospitals in Moscow and the Moscow region, laying off more than 7,000 medical staff, sparked massive street protests by doctors and nurses in November 2014.
The drastic cuts were needed to make the system work more efficiently, Leonid Pechatnikov, deputy mayor for social development in Moscow, insisted at the time.
But doctors say that far from improving the medical system, the doctors who kept their jobs now have a bigger workload because of the layoffs, while salaries remain low — despite city officials' claims — and working conditions have worsened.
Doctors are now required to see more patients a day, but spend less time on each of them, which often leads to them working overtime, and through lunch and any other breaks. Dozens of Moscow doctors joined the Italian strike in March, hoping to persuade the authorities to acknowledge the problem and do something about it.
Those taking part in the Italian strike are refusing to work overtime unless they are paid for it, spending as much time with patients as they consider professionally necessary and communicating all their complaints through official letters to their bosses, said Chatskaya, a gynecologist at Outpatient Clinic No. 180 in northwest Moscow.
She said she joined the union — and then the strike — out of pure despair.
"I saw no other option. I complained to my clinic's administration multiple times about the conditions I've been working in, but to no avail. I was working overtime so often that I literally had no other life," she told The Moscow Times.
"It's the only way we can influence the situation," said Albina Strelchenko, a physician at Outpatient Clinic No. 107 in northern Moscow who is also participating in the strike.
Among the strikers' demands are the hiring of more staff and an objective assessment of doctors' workloads.
"It's not so bad now since it's summer, but this spring I had to work all day long without any time for breaks because there were so many patients," Strelchenko told The Moscow Times last week.
It's not just the doctors who are suffering, she said. Patient visits were restricted to no more than 12 to 15 minutes, which is not enough for qualified medical care. "How can I help a patient in such a short amount of time?" Strelchenko said.
Taken for Granted
Another issue that bothers the doctors is working on weekends, with no compensatory days off during the week and no bonuses in addition to their salary — a clear violation of Russian labor legislation, Chatskaya said.
"Once I opened my schedule on the IMIAS [Integrated Medical Information and Analytical System, the electronic system through which all appointments at municipal clinics are made] and was shocked to see that the whole of my Sunday, from early morning to late evening, was booked," she said.
"And no one had even bothered to warn me that I was needed to work on Sunday, no one offered me extra money for it. So I politely but firmly refused to do so," she said.
Doctors are also expected to participate in so-called mobile brigades that visit patients at their homes, though there is no legal provision for them to do so, according to Strelchenko.
"Last week I saw that it was impossible to book an appointment with me on July 6 via IMIAS. I asked my supervisor whether that meant that I was due to work in a mobile brigade, and the answer was 'yes,'" Strelchenko wrote on her Facebook page last week, adding that this kind of work is not stipulated in her contract or any other paperwork. She has filed two official complaints to the clinic's administration about that, she said.
Under the reforms, municipal clinics launched a number of paid services, and doctors are under instructions to convince their patients to make use them, Chatskaya said. "But why should I persuade people to use paid medical services if they have public health insurance that covers everything?" she said.
More Work, Same Pay
Some media had speculated that the aim of the layoffs enacted under the reform was to enable Moscow authorities to achieve the increase in the average doctors' salary promised by Vladimir Putin shortly after he returned to the presidency in 2012. Putin said that doctors should be paid at least twice the average salary in the region, which in Moscow last year was reportedly around 56,000 rubles ($1,000).
But the striking doctors say that despite the layoffs and introduction of paid services, they still earn far from what the president promised.
"We often hear officials say that the average doctor's salary is 80,000-120,000 rubles [$1,428-$2,142 per month]. But at Diagnostic Center No. 5, for example, we haven't seen a salary like that since 2013," Anna Zemlyanukhina, a doctor at the diagnostic center in northern Moscow who is also taking part in the strike, wrote on her Facebook page last week.
According to her, the average doctor's salary in the center of Moscow is currently about 40,000 rubles ($714).
No Cause for Complaint
City officials say there is no reason for the doctors to be discontent or go on strike.
Shortly after the strike began, the head of the Moscow health care department, Alexei Khripun, called it a "political provocation" and suggested the Moscow medical community as a whole did not support it. Pechatnikov, the deputy mayor for social development, agreed with him, saying only two doctors were taking part in the strike.
An official request for comment sent by The Moscow Times to the city's health care department went unanswered by the time of publication.
Lyudmila Stebenkova, head of the Moscow City Duma health care committee, told The Moscow Times last week that the situation in municipal clinics had in fact improved in many ways, and there was no reason for the doctors to complain.
"We completely changed the way municipal clinics function," said Stebenkova, a deputy for the ruling United Russia party. "Today clinics work according to the needs of the patients. Those who want to work another way should probably consider looking for a job at private institutions," she added.
On the subject of the most common complaint — patient visits being restricted to 12-15 minutes — Stebenkova said it was not a restriction, but simply the gap between appointments in the IMIAS, and said it was up to the doctor how much time they spend with the patient.
"Of course if the doctor decides to spend 30 minutes with the patient, their next appointment will have to wait," she said.
It was not immediately clear how a doctor would be able to see all the patients with appointments under her proposal, however.
Pressure From Above
When the strike began in Moscow in March, about 20 doctors from different municipal clinics supported it, Chatskaya said. They were soon joined by another 30 — but not for long, she lamented.
"As soon as we announced the strike and filed an official letter with our demands [to the authorities], our clinic administrators started pressuring us into giving up," the doctor said.
The head doctors of the clinics talked to strikers, trying to scare them or even buy them off, and in some cases they succeeded, Chatskaya complained.
By early July there were only 15 doctors still on strike, but the union co-chair expects the number to grow in autumn when people return from their vacations.
Complaints to the clinics' administrators, doctors said, result in nothing at best. In the worst case scenario, doctors get blamed for the issue they complained about or face retaliation.
Two weeks ago, The Moscow Times reported on the case of a young dental surgeon, Ivan Stepanov, who was beaten up by the head of his clinic and her deputies for filing a complaint to Moscow Mayor Sergei Sobyanin about restricting patient visits to 15 minutes. He was taken to a hospital with a suspected concussion and multiple injuries, only to be discharged soon after, despite the protestations of another doctor from the union who was present.
Stepanov's case at first looked hopeless: Moscow health care department officials claimed it was he who had started the fight and attacked the head doctor and her deputies. But 60 of his colleagues at the clinic stood up for him and signed a petition against the head doctor, and she was suspended from work pending an investigation. It was not immediately clear, however, whether his original complaint would lead to any result.
Chatskaya also said she had been persecuted for complaining about conditions. She said she had sent a complaint to Roszdravnadzor, the state health care watchdog, about not being able to refer one of her pregnant patients for an ultrasound because all the appointments were booked up for the next two weeks.
In mid-June, Roszdravnadzor officials wrote back — and Chatskaya was shocked to learn that an investigation had been launched into her for allegedly violating rules and not informing her pregnant patient about any state-funded options.
"I was summoned to a meeting with Roszdravnadzor, where they told me that the investigation into the situation was over and had established that I was to blame," she wrote on her Facebook page after the meeting. "I wonder what kind of investigation they conducted, sine they didn't talk to me or my patient," she wrote.
Chatskaya told The Moscow Times she refused to accept the accusations and demanded that Roszdravnadzor officials at least interview her patient.
Two weeks later, on July 2, the doctor was fully exonerated at another meeting with the watchdog.
"I think it's the media attention that did the trick," Chatskaya told The Moscow Times after the meeting. "They were very polite and friendly, listened to my arguments and to my patient's story and let me go, dropping all the charges," she said.
But the original problem — not having enough ultrasound specialists in the clinic to accommodate all the patients — has not gone away, she added, although the clinic hired one after she filed her complaint and made the procedure of referring the patients through IMIAS technically simpler.
The war may be ongoing, but the individual small battles won by Chatskaya and Stepanov give the strikers hope that victory — in the form of changes to the system — is ultimately possible.
"I'm positive our strike will eventually help change things. We just need to stick with it," Strelchenko told The Moscow Times.
"Of course we hope for victory," agreed Chatskaya. "But it's not an easy win — it will take time for all these issues to change," she said.