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Reviving an effective health-care system in its current form presents a near-impossible task. Many important medical research centers, especially at the federal level, have been left without proper financial support. Progress in all spheres of health care is under great stress. Faced with this situation, the Russian government has attempted to reform the health-care sector through privatization, marketing services in state-owned facilities, and promoting the private medical sector. One of the main goals of reform is to establish compulsory health insurance financed through taxes and operated by both the state and the private sector. However, the reform has yet to produce noticeable results. Russians are used to receiving free health care and many are unwilling and frequently unable to pay for health services.

In addition, serious health-care problems exist that extra spending alone will not address. There are no clearly defined federal and local health-protection policies, no effective programs for monitoring outcomes, and no openly declared systems of control and delegation of responsibilities for state and public health institutions. Moreover, the incidence of destructive behaviors, such as violence and alcohol consumption, has increased. Heavy tobacco use contributes to a high rate of mortality from lung cancer, which occurs 60 percent more frequently in Russia than in the United States. Without attention to these problems, additional funding for health care per se is likely to have little effect.

Looking Toward the Future: Policy Outlook

The current economic crisis significantly limits the Russian government's ability to deal with demographic trends through policy intervention. In particular, the problems of the elderly will be difficult to manage. The retired population is growing, while the financial resources the state devotes to the elderly dwindle. With the declining real value of pensions and the rising costs of health care, the elderly are among the most economically disadvantaged and vulnerable social groups in Russia. The problems that appear most amenable to policy intervention are those related to the health-care system. Thoroughly crafted health-care reform components are essential; an ill-designed benefit package, hasty decentralization, and overreliance on the private sector will only aggravate the situation. At the same time, promoting healthier lifestyles among Russians--reduced smoking and alcohol consumption, better diets--could improve health substantially.

Knowledge about Russia's demographics should help dispel the popular notion of a demographic crisis. The continuation of several long-term patterns, such as declining fertility and historically high mortality, accounts for many of the current trends. While it is undoubtedly true that economic conditions have aggravated current problems, there is no strong evidence linking these problems with recent economic and political reforms. Some of the most dramatic changes appear to be compensatory effects following the abandonment of previous policies: for example, the retreat from pronatalist and anti-alcohol initiatives of the 1980s. In fact, it has been suggested that whatever crisis features are present in Russia's current situation might be attributable to a delay in reforms--for example, delay in reforming the health-care system. This delay hampers the adaptation of social institutions to the new realities of economic and family behavior in Russia. Furthermore, the most recent data suggest that the mortality and life-expectancy situation has begun to improve.

The new demographic realities in Russia are not fundamentally different from those facing most industrial nations--a decreasing population, aging, shifts in family composition. Since it is impossible for Russia to avoid these changes, the challenge lies in addressing them effectively. Toward that end, a great deal of further research is required to disentangle the effects of earlier policies, current reforms, and other factors in explaining Russia's demographic patterns. Although they may not add up to a crisis, these trends will continue to pose difficult challenges for those deciding the direction of Russian policy

Alexander V. Myskin, gr. 301

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