In 1982, despite many inadequacies, the socialist healthcare system of the former Soviet Union earned recognition from the World Health Organization for promoting equity and universal access.1 Now with a capitalist economy, Russia has reformed the funding and delivery of health care to tackle the shortcomings in efficiency and quality.

Previously, health care was centrally planned and funded. But now, in line with new market based ideas, compulsory insurance allows competition between healthcare providers and between private insurance companies.2 Health indicators are not encouraging, however; average life expectancy for 1998-2000 fell for the whole population with men worst affected. Although not simply because of the reforms in health care, these statistics must be considered when assessing the reforms.3

The Russian constitution still includes the principles of equitable health care and access for all. But, arguably, funding of the insurance scheme undermines these principles because employers and municipal governments make contributions to insurance funds. This creates a discrepancy between coverage for the employed and unemployed and also discriminates against more marginalised groups such as women and elderly people.4 This might be one explanation for the observed decline in the use of healthcare services.

The reforms have also been criticised as inappropriate because the economy lacked the developed insurance system and available independent healthcare providers needed. The resulting drastic underfunding of health insurance has reduced the quality of care available,4 and led to poorly kept buildings, decreased drug availability,5 and more corruption among medical personnel, who are unsure of a regular wage. The growing number of people infected with HIV, who need treatment, will place further strain on healthcare resources.

REX/PODERNY WHITE

Despite the failings of the healthcare system, many of the current major health concerns in Russia are social problems and products of the general political and economic climate.6 The rapid increase in HIV infection has been largely driven by intravenous drug use,7 and alcohol misuse is a significant problem. Related to this is the incidence of violent deaths, which has risen, especially among young men. The prevalence of infectious diseases is another worry; the incidence of tuberculosis increased from 34/100 000 in 1991 to 90/100 000 in 2000. It is notable that the groups most affected are not those that are traditionally most vulnerable such as young children and elderly people. These statistics show that the health situation in Russia must be viewed in context, as some elements of the health crisis might actually be distinct from the healthcare crisis, although they may serve to exacerbate it.