How to save Russian healthcare from death

In anamnesis – USSR

Vladislav Inozemtsev, "Newspaper.Ru"Over the past few years, the domestic authorities have been cheerfully reporting on achievements in the field of demography and healthcare.

Life expectancy increased from 65.3 to 70.7 years in 2005-2013 – it seems that it has never grown at such a pace in any country in the world. There is a natural increase in the population – for the first time since 1991. The national project "Health" has been implemented – and visiting foreign specialists invariably admire the equipment of Russian hospitals.

The "May decrees" are being carried out, the welfare of doctors is growing. However, words are increasingly being heard that behind this apparent splendor lies the actual defeat of Russian healthcare.

At the end of 2014 in Russia, according to Rosstat data, 33.7 thousand hospital beds out of 1.25 million were eliminated; 90 thousand medical workers out of 4.4 million were reduced (2.6 and 2.0%, respectively).

Financing of medicine is increasingly "descending" from the federal level to the regional level: only 391 billion rubles were allocated from the main budget of the country in 2015 for healthcare – 0.5% of GDP, 6.3% of the amount of defense spending. For comparison: in the United States, funding is $ 1.04 trillion (5.9% of GDP, or 168% of the amount of military appropriations).

As a result, mortality began to grow: in the first quarter of 2015 – by 6.4% compared to the same period in 2014. The number of deaths due to refusal of hospitalization and due to poor ambulance work is growing - and how can you live without it in a country where 17 thousand localities do not have medical facilities at all? Bureaucratization does not allow getting the most necessary medicines even for the most needy (everyone knows about the almost daily suicides of cancer patients who cannot purchase the necessary painkillers); doctors go out to protest and hold hunger strikes.

I am not a medic and not an expert in the field of medical technologies – and therefore I will focus only on one reason for the death of Russian medicine: economic.

Healthcare is an important sector of the economy all over the world. In most developed countries, it creates from 9 to 12% of GDP. In the USA – almost 18%, but this is rather an anomaly caused by the peculiarities of the American system of financing medicine.

Russia inherited its approach to healthcare from the Soviet Union, which, although it maintained this sector in quite satisfactory condition, attributed it to the non-productive sphere.

In the course of market reforms, this attitude de facto transformed into the interpretation of medicine as a kind of "costs" that society is forced to bear - and this best explains the approach of our political elite to healthcare. It is enough to hear about "optimization", which officials talk about excitedly, so that everything becomes clear: after all, no one says that it is necessary to "optimize", for example, investments in oil production, industry or infrastructure, in order to rejoice at the decline in economic growth. I repeat: this is because the oil industry, industry, and even a significant part of the service sector are perceived "at the top" as a productive sector of the economy, and healthcare, coupled with education, culture, etc., as costly.

A paradoxical situation. On the one hand, the state is not ready to give up control over healthcare: for example, in 2012, out of 4.43 million workers in this field, 4.09 million, or 92.2%, worked in state or municipal healthcare institutions. There is no such indicator in any developed country: in relatively "socialist" Germany or France, it is 23-27%, in the USA it is close to zero.

This, I note, does not mean at all that the state does not finance medicine: in the European countries already mentioned, the share of public spending reaches 77-78%, in the USA – a little less than 50%. However, the organization of medicine in all successful societies is radically different from the Russian one: in them, a doctor or hospital acts as a commercial entity that provides a service for which the consumer pays.

And how the client receives money for payment (takes it out of his pocket, is provided with state or private insurance or asks for charity), the doctor does not care. He does the work and gets rewarded for it.

And only an official can cut a doctor in our country; only a bureaucrat makes a list of necessary equipment for a private clinic; and, of course, only we have the lowest cost of claims for medical errors in the world – after all, the state acts as the defendant in most cases, and it is sacred to us!

At the same time, as an economist, I would venture to assume that the Russian authorities will not be able to "optimize" medical expenses. I already wrote some time ago that in the global world, when most medicines and equipment are imported in a country like ours, it is impossible to achieve a much lower cost of medical care than in Europe or the USA.

The experience of successful countries shows that medical expenses under the state (federal) budget and/or centralized health insurance funds should be at least $2.5 thousand per person per year – otherwise there will be no changes. In Russia in 2014, this figure was $244 – and there is no option to "pour money into the problem" in our case.

I see only one way out: the state should reduce not the financing of healthcare, but the costs in it, increasing competition, simplifying the organizational system and treating medicine not as a budgetary burden, but as a significant branch of the economy.

How is healthcare organized, for example, in France? Almost all the services of therapists, cosmetologists, gynecologists, dentists are provided by private doctors – I emphasize, doctors, not private clinics (in total, the share of private practitioners in the total number of physicians is ... 53%). This allows you not to buy expensive equipment (X-ray and ultrasound machines, procedural installations, equipment for analysis processing), but to send the patient or his biomaterials to specialized laboratories. The equipment is not idle there, costs are reduced.

The doctor himself keeps records, doing the main thing. The patient pays for his services, and then receives compensation for private or public insurance. All surgeons, cardiologists, oncologists, etc. cooperate with large clinics that treat patients seen by these specialists. Clinics are interested in attracting the best of the doctors with whom clients come. Business as usual is being done, and the state pays for its citizens to live longer and work better.

Yes, an employer in France deducts to the state health fund 12.8% of the salary accrued to an employee with a life expectancy of 82.3 years – and we have 5.1% with an indicator of 70.7 years. The solution to the problem in Russia, in my opinion, could be half provided by an increase in the standard of deductions and half – by an increase in the effectiveness of medicine itself.

Therefore, I would call the most important means of normalizing the situation in our medicine, firstly, the transformation of medical institutions into autonomous non-profit organizations and their withdrawal from the control of officials; secondly, the legalization of private medical activity and the rejection of "standards" of equipment of private clinics; thirdly, the abolition of all idiotic norms limiting the implementation of medicines under the pretext of "combating drug addiction"; fourth, providing citizens and legal entities to direct funds currently going to the CHI to purchase insurance medical products of any insurance companies.

If such measures were implemented, the productivity of doctors would increase and competition between medical institutions would intensify. This would lead to a natural reduction in the number of doctors due to the culling of the ignorant and those who are not capable of a normal attitude to the patient; as a result, there would be no such dissonance in the number of both doctors and hospital beds per capita (in Russia, respectively, 4.4 and 9.0 per 1 thousand inhabitants, in France – 3.6 and 6.1, in the USA – 2.5 and 2.8).

Another result would be an increase in the incomes of doctors – in the United States, without any "May decrees", the average medic earns $186 thousand a year, which is 5.5 times the income of the average American. But even this – if the proposed measures were implemented – should only be the beginning of real reforms in healthcare.

In my opinion, at least three processes could become promising areas for the development of health protection in Russia, which would determine its state for several decades to come.

Firstly, it is a shift of emphasis to the sector that is now called "high-tech medical care". This term hides the most promising part of medical services, which can become the commercial engine of the industry. Take, for example, joint replacement operations: in 2013, 76 thousand were performed in Russia, and more than 1 million in the USA.

Such operations have been put on stream for a long time, they are commercially profitable, and everything needs to be done in our country (including giving state subsidies to everyone in need of them) to increase the demand for such services.

Only by turning "high-tech" medicine from elite to mass, we will be able to create demand for innovations in healthcare, creating a market that in the future will become one of the drivers of economic growth in the country.

Medicine, like any production, must be mass in order to become effective. In the meantime, citizens strive to save on their health as well as the state on the health of the nation as a whole, we will not see significant changes.

Secondly, it is necessary to reform the pharmaceutical industry and the production of medical equipment. First of all, the country needs to introduce drug insurance, which is available everywhere in Western Europe and without which insurance medicine based on private medical practice institutes turns out to be simply meaningless.

In addition, it is necessary to officially consolidate the inventors' ownership of the results of innovations and discoveries in medicine and pharmacology, even made for state grants and in state laboratories (it is known that the Patent and Trademark Law Amendment Act, which opened this opportunity in the USA, became the basis for the technological revolution of the 1980s and 1990s). If we still believe in all sorts of Skolkov, no problem, but let's change the regime at least for medicine and pharmaceuticals!

Thirdly, a revolution is beginning in global healthcare today, associated with the formation of so-called preventive medicine. Genome sequencing makes it possible to detect predisposition to diabetes 3-5 years before the appearance of the first clinical signs of the disease; detection of so–called mobile malignant cells (Circulating Tumor Cells, CTCs) - to diagnose up to 40 out of almost 200 known types of oncological diseases 2-3 years before the formation of the first neoplasms.

Russia is not at the forefront of developing such technologies today, but this does not mean that we cannot use them: in a country that does not produce either mobile phones or signal transmitting equipment, one of the largest mobile penetration in the world has already been achieved.

Large-scale financing of preventive medicine and the most advanced diagnostic methods should begin immediately: today, those who use the latest equipment incur much less costs than those who invent and manufacture it.

The topic of reforms in healthcare is almost endless, and it is possible to list both our problems and other people's achievements for a long time. However, the conclusions, I believe, are simple. In a world where medicine has long been the leading branch of the economy, it is impossible to treat it as an area that "produces" only losses for the budget.

At a time when doctors are becoming one of the most creative professions of our time, it is crazy to subordinate them to bureaucrats. In an area in which every particular person is important and holy, approaches based on the "laws of large numbers" will not bring results – and the state does not know any others.

In other words, the problem of Russian healthcare for me, as an economist, is that it is almost the only industry organized in a Soviet way in the Russian market economy. In this form, she is doomed to a long and painful death. As, apparently, all those residents of the country who believe that everything in it goes "the way"…

About the author:
Vladislav Inozemtsev is a graduate of the Faculty of Economics of Moscow State University. Doctor of Economics. In the 1990s and early 2000s, he was a banker and financier. Since 1996 - Founder and Director of the Center for Post–Industrial Society Research. Author of almost two thousand published texts, including the book "The Age of Disunity", written jointly with Daniel Bell, the greatest sociologist of the second half of the twentieth century. A consistent supporter of liberal democracy, a staunch atheist who denies any apology for violence and war. The main principle is: "to talk about facts, not about ideological nonsense."

Portal "Eternal youth" http://vechnayamolodost.ru04.06.2015