HEALTH AND HEALTHCARE IN RUSSIA TODAY AND TOMORROW G.E. ULUMBEKOVA, ASSOCIATION OF MEDICAL SOCIETIES FOR QUALITY © ASMOK

CONTENTS 1. Demography and Health Indices of Population in Russian Federation 2. Key healthcare problems today 3. Future demographic, social and economic challenges in healthcare 4. What should be done 5. About ASMOK and its strategy in medical education

PART 1 Demography and Health Indices of Population in Russian Federation

LIFE EXPECTANCY AT BIRTH (YEARS) Life expectancy at birth (LEB) has dropped from 70 years in 1985 to 68,7 years in It is 6,3 years smaller than in “new” EU countries and 12 years smaller than in “old” EU countries

Crude death rate (CDR), the number of deaths of any reason, increased from 10,5 in 1985 to 14,2 in It is 1,3- and 1,5 - fold greater than that in the “new” and “old” EU countries, correspondingly CRUDE DEATH RATE (PER 1000 PERSONS)

Major causes of fatal outcome:  Circulation system diseases – 56,5%  Neoplasm – 14,6%  External causes – 11,2% (suicide, traffic accidents, alcohol poisoning, homicides) CAUSE-SPECIFIC MORTALITY DISTRIBUTION

MORBIDITY (PER PERSONS) Morbidity of population has grown by 42% since 1985 from all diseases. In the last years the circulatory diseases (44,5%) and malignant neoplasm (17,6%) prevailed in the structure of morbidity

LEADING RISK FACTORS Tobacco consumption The proportion of daily smokers among adults is twice higher than the average in OECD countries Alcohol consumption In liters per capita for adult population is twice higher than the average in OECD countries

DISPARITIES IN HEALTH INDICES In mortality In life expectancy Regions (between the extremes) 140%3,5–4,5 years Urban/rural 20%2,7 years Men/women38%12 years

CONCLUSIONS  The most health care and demography indices in Russia are worse than those in “new” and “old” EU countries  The persistent elevation of the share of senior people necessitates the sustainability of medical social service on the long-term care  The predominant role among the factors aggravating health of population in Russia was played by unhealthy lifestyle:  wide spread of alcoholism  tobacco smoking  drug abuse  poor working conditions  lack of long term government strategy aimed to improve population health

PART 2 Key healthcare problems today

STRUCTURE OF PUBLIC HEALTHCARE IN RUSSIA  Funding is based on a mixed budget-insurance model  Organization of medical aid inherited some features of N.A. Semashko healthcare model POSITIVE FEATURES: — Totally free — Budget finance — Vertical integration — Governmental providers — Polyclinics — Separate pediatric services — Prophylactic approach NEGATIVE FEATURES: — Extensive type of development — Underfinanced — Lack of quality control — Administrative-command style — Lack of high technologies  Three administration levels: Federal, Regional, Municipal  Three property forms of medical aid providers involved in SGP (State Guarantees Program) realization: government (Federal and Regional), municipal and private

POOR HEALTHCARE FINANCING As a share of GDP Russia is spending on healthcare twice less than OECD on average Total and government spending for healthcare expressed in GDP share in various countries

POOR HEALTHCARE FINANCING Per capita government spending in Russia is 635 ($PPP) i.e. 3,4-fold smaller than the average spending in OECD nations and 1,5 – 2 times smaller than in the EU countries Total and government per capita spending on the healthcare in various countries

EXPENDITURE ON PHARMACEUTICALS FOR AMBULANT THERAPY In the relative values (GDP share) the public expenditures on pharmaceuticals in RF is only 0,23%, while the corresponding figure in the developed countries is 4-fold greater (0,9%)

INTERDEPENDENCE BETWEEN HEALTHCARE FUNDING AND POPULATION HEALTH INDICES To achieve LEB of 73–75 years and CDR of 11.0–10.0, the government per capita spending on the healthcare should be no less than 1100–1200 $PPP

NOT EFFECTIVE MANAGEMENT To attain CDR of 11,0, Local Guarantees Program (LGP) spending should be doubled to the level of 15 thousand rubles which corresponds to 1000 $PPP Dependence of CDR on LGP (per capita) spending

SALARY OF MEDICAL PERSONNEL The salary of doctors in 2009 was 10% lower than the average wage in RF (16,8 and 18,6, correspondently). At present, the salary of doctors in OECD countries is higher by 3-5 times than the average wage in corresponding countries

COMPARISION OF INTEGRAL EFFICIENCY OF HEALTHCARE SYSTEM IN RF AND OECD NATIONS IndexValue in RF Value in OECD nations Preventable death. It is assessed by the number of potential years lost for life (PYLL) per 100 thousand persons Not measured 3700 Share of population satisfied with quality and availability of medical aid 31%70% Treatment efficiency: mortality of the patients with myocardial infarction in a hospital (nonstandardized index) 20%7.7% Treatment efficiency: five-year survival rate among the patients with breast cancer 56%85% Treatment efficiency: lethality among the patients with bronchial asthma per 100 thousand adult population (older than 18 years)

THE REASONS OF POOR PHYSICIANS PERFORMANCE The reasons of poor performance:  Continuous medical education — only 1 time in 5 years, 15% doctors even didn’t match this indicator  Educational programs not always up-to-date and taught without using distant technologies (4 month out of work)  Physicians lack evidence based literature at the point of care  Physicians don’t have access to electronic support systems and electronic medical library NOTE: the products are available on the market

To solve these problems we need the systemic, targeted, and coordinated long-term Strategy of National Healthcare CONCLUSIONS The basic problems of healthcare in Russia are:  Underfinancing and not equal distribution of healthcare resources between various regions of RF  Unclear directivity of the healthcare system on the patient’s needs  Insufficient qualification of the medical personnel  Inefficient management in the strategic development of the national healthcare system  Disproportions in healthcare supply in favor of specialists and hospital care  Lack of innovations coming from academia  Lack of coordination with Russian pharmaceutical industry and medical device industry

PART 3 Future demographic, social and economic challenges in healthcare

DEMOGRAPHIC CHALLENGES The medium variant of projection toward 2025 (Federal Agency for Statistics): If mortality is 15,0 (no change), birth rates will be 9,6 per 1000 population (decline) and migration will rise by 50% In 2025:  Total population will decline by 5 mln (from 142 mln to 137 mln);  Working age population will decline by 14 mln, it’s proportion will diminish from 63% to 55%;  Over working age population will increase by 6 mln and it’s proportion will rise from 21% to 27%;  Life expectancy will be – 70 years

ECONOMIC CHALLENGES If LEB of the men is elevated by 5 years to 2020, almost 60% men would reach the age of 65 years (the minimal retirement age established in all developed countries), which corresponds to the curve (II). In contrast, the present variant (I) shows that merely 48,6% men will reach retirement age

EXPECTATIONS OF PLAYERS INVOLVED Population Shorter waiting lists Polite doctors Lower charges (copayments) Medical personnel Salaries increase 2-3 fold Opportunities for continuous medical education and professional growth Less paper work Government Improve population health Satisfy population Decrease disparities Pharmaceutical industry Higher sales Less regulation More transparency in government decisions More influence on opinion leaders and physicians Private providers Access to public finance Less regulation Revenue growth

NATIONAL PRIORITY PROJECT “ZDOROVIE” 830 thousand additional lives of Russian citizens were saved (0,6% population of RF)

PART 4 What should be done

President of RF Dmitry Medvedev Prime-minister Vladimir Putin «On Adoption of the Conception of Demographic Policy in Russian Federation toward 2025” Decree of RF President № 1351 of 9 November 2007 “ Conception of the Long-term Socioeconomic Development of RF toward 2020” Instruction of RF Government № 1662-r of 17 November 2008 THE AIMS ARE OUTLINED DEMOGRAPHIC STRATEGY LONG-TERM SOCIAL ECONOMIC STRATEGY OF RUSSIAN FEDERATION

THE PRINCIPLES OF HEALTHCARE STRATEGY  Solidarity  Total coverage  Equity: payments + health status + access  Fair resources distribution  Transparent and evidence-based decisions  Honesty of managers and no place for corruption  Strategic and managerial approach in stewardship  Open reports on results to government and public  Share of responsibilities on health improvement between government, business and population

KEY TASKS FINANCE  Increase the spending on state healthcare system at least 2-fold toward 2014  Create conditions for fair distribution of the spending burden on medical services for rich and poor strata of the society  Adopt the system of predominantly single payer and single fund manager for spending on the medical aid under SSP – the law is already passed  Create the conditions for leveling of the financial provision for SGP in various RF subjects - the law is already passed  Enhance efficiency of procurement of medical services from the suppliers  Update the norms of SGP on free medical aid to RF citizens  Eliminate unofficial payments in patient care institutions

KEY TASKS IMPROVEMENT OF ORGANIZATION OF MEDICAL SYSTEM  Ensure availability and quality of medical drugs to RF population — 3-fold  Enhance the salary of doctors — 2-fold  Restore the medical aid system inherited from the Soviet Union and adapt it to modern conditions – industrial and school medicine  Ensure availability of medical aid to rural population  Reform the hospital-based medical aid  Improve the medical aid system for the patients with social-motivated disease (AIDS, tuberculosis, etc.)  Create the control system over the quality of medical aid

KEY TASKS RESOURCES  Enhance qualification of medical staff through Continuous Medical Education (CME)  Enhance motivation of medical personnel to qualitative work  Ensure the optimal structure of medical personnel (the over-all number and available specialties)  Elaborate the long-term program of sustainability of infrastructure and re-equipment of the patient care institutions  Actualize the standards for the number of hospital beds  Enhance innovation character and the quality of the research work in medicine and health care  Develop the combined cooperative plan of the healthcare system, pharmaceutical and medical industry – already started

KEY TASKS CONTROL OF HEALTHCARE SYSTEM  Introduce the strategic approach to realization of the state policy  Restore partially the vertical control over the healthcare system  Strengthen the state control over Medical Care Quality (MCQ) and the medical aid tariffs  Extend autonomy of the state and municipal Medical Prevention Institution (MPI) and organize competition among the suppliers of medical services of all property forms  Adopt the economically efficient (market) methods of control healthcare  Enhance professional skills of the management personnel  Diminish the corruption risks and strengthen transparency and justification of the adopted decisions  Actualize the normative legal instruments in the healthcare system

KEY TASKS ACTUALIZATION OF THE PROGRAMS ON HEALTHCARE PROTECTION  Promote motivation in population of RF to the healthy life-style  Enhance responsibility of population and the employers for maintenance and strengthening the health  Expand conditions for healthy life-style in RF  Actualize the struggle program against tobacco smoking  Actualize the struggle program against alcohol overconsumption  Actualize the struggle program against drug addiction  Extend prevention and prophylaxis programs  Improve the sanitary-epidemiological surveillance in RF  Ensure integration and coordination in the control over the programs on health protection

PART 5 About ASMOK and its strategy in medical education

ABOUT ASMOK ASMOK was founded in May 2005 in order improve quality in medical education and services provision The way how we work:  methodology development  analytical documents  educational products initiation and coordination

MEMBERS

The outcomes of ASMOK activities Coordination of work Evidence based guidelines ~ 340 “National guides” ~ 60 Modern and constantly upgrading sources of information, providing medical doctors with vital materials on prevention, diagnostics and management of different diseases. Developed for continuous medical education. The series covers all major specialties. Each title is accompanied with a CD based on Physician’s Consult platform. The leading Russian experts and key opinion leaders participated in the development of the series.

Web-based medical decision support systems The outcomes of ASMOK activities Independent evidence based information Powerful built-in search engine for finding relevant information within seconds Independent drug information, free from the biases introduced by marketing Patients information EBM Guidelines CME Textbooks CME Online and Portfolio management, etc…

Web-based library for medical students The outcomes of ASMOK activities More than 300 textbooks Built-in eLearning tools Multimedia clinical skills Built-in eLearning tools

“Healthy Living Schools”. Either for those suffering from non-infectious chronic diseases or for those having risk factors for their progression. Health promotion and patient education Materials for healthy people and for all groups of society: pregnant women, children from 0 to 14, adolescents, young and middle age, elderly people, women’s health. The materials were highly evaluated in 7 test regions. 1–1,5% of the regions needs were supplied : the information materials on healthy lifestyle, delivered by ASMOK, were expanded within the framework of the political project “Zdorovoye serdtse” (Healthy heart) under guidance of the Chairman of the Supreme Council of the party “Edinaya Rossiya” (United Russia) Boris Grizlov. This project was highly evaluated all over Russia. The outcomes of ASMOK activities

Independent drug information, free from the biases introduced by marketing EBM Drug Reference Guide Online version has a powerful built-in search engine for finding relevant information within seconds The outcomes of ASMOK activities

41 Journal and website on problems and development of Medical education and professional development. CME and CPD Evidence based educational content New technologies in medical education

International conference “Medical Education in Russia and the World: Traditions and Innovations”

Analytical documents developed by ASMOK : Healthcare in Russia. How to cope with current challenges The conception for advancement of CME in Russia Clinical guidelines and standards of care The program of state guarantees for Russia Public-Private Partnership in Healthcare The outcomes of ASMOK activities

Association of Medical Societies for Quality ASMOK works closely with over 100 higher medical schools throughout Russia and CIS. ASMOK is founding member of Russian National Chamber of Physicians. ASMOK is Premium member of AMEE (Association for Medical Education in Europe) ASMOK is your RELIABLE partner in Russia

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