To be sick at your own expense: budget spendings on everything in a row are growing, but on medicine are decreasing

Experts are sounding the alarm: medicine tattered by the pandemic may not withstand another cut in budget spending on health care.

Victoria Pavlova

At the Moscow Financial Forum Mikhail Mishustin reported on the success of the federal and regional budgets for the first half of 2021: there is money. The prime minister especially noted how the regions' opportunities are growing, because they earned and received more funds than in the pre-crisis 2019. Along with opportunities, expenses also increased: they spent 41.6% more on transport than in the same period last year, on the road industry - 22.0% more, added 13.8% on housing and utilities, and 14.3% on education, family and child protection was financed by 59.8% better, physical education and sports - by 12.6%. The numbers are pretty, but where is the health care? Why has this most important, especially at the present time, sphere remained hidden?

We believe because funding for medicine has decreased, and very significantly. Novye Izvestia, together with experts, found out which regions were most affected by the post-crisis economy, and which, on the contrary, were able to maintain last year's pace of medical development.

For the analysis, we took the actual expenditures of the budgets of the constituent entities of the Russian Federation for the period January-July 2021 - the most relevant information available on The single portal of the budgetary system of the Russian Federation, and compared the data with the same period in 2020. The results exceeded expectations, and only for the worse.

Money is not for everyone

This situation runs counter to statements about the increased capabilities of the regions. This is especially true for 21 regions, where spending on medicine has been cut by more than 25%. Director of the Financial Research Institute of the Ministry of Finance Nikolay Avksentyev says that nothing terrible happened - just last year was anomalous, and now there is a high base effect.

- Last year is a covid story. Then there was a large unpredictable increase in costs. The current decrease is a return to the previously taken trends. It's just that 2020 should be seen as something outstanding.

But such a return to previous trends would look appropriate if the covid in the country were finally defeated. Official statistics so far suggest otherwise. At the peak of the first wave in the first half of 2020, a maximum of just over 11.5 thousand infections and up to 230 deaths per day were recorded. The third wave of covid showed that it could easily be 25 thousand infections and 700-800 deaths per day.

President of the "League for the Protection of Patients" Alexander Saversky draws attention to another important detail:

- To understand the whole picture of health care, it is necessary to look at consolidated expenditures, and not just expenditures of regional budgets. Funding comes from both the federal budget and the MHIF. In addition, it is not the first year that there has been talk of a transition to a single-channel financing system. And gradually this process is moving.

"Novye Izvestia" Earlier, they also wrote about a multichannel financing system: money for medicine comes from the federal budget, the budget of the constituent entities of the Russian Federation and the Mandatory Health Insurance Fund. But the federal budget also cut costs: according to the Unified Portal of the RF budgetary system, 766.3 billion rubles were allocated for medicine in 7 months of 2020, and 746 billion rubles this year. The fall is not as terrible as that of regional budgets, only by 2.7%, but still significant. The Accounts Chamber explains the reduction in budget expenditures at all levels not by the fact that the equipment modernization program has ended and all the necessary ventilators have already been purchased, but by the fact that there are fewer people treated. "In the section" Health ", a decrease of 14.1% was recorded due to a decrease in the volume of medical care after the introduction of restrictions related to COVID-19", - it says in the operational monitoring of the Accounts Chamber.

But the Mandatory Health Insurance Fund has really increased its costs. In 2019-2020, the MHIF transferred 2.36 trillion rubles to medical institutions, and 2.54 trillion rubles are planned to be allocated for 2021. 185 billion rubles are not superfluous. But they still do not compensate for the budgetary savings. Based on the results of 7 months, the total funding is approximately 17.4 billion rubles less than last year .

Funding shortfalls are not just abstract numbers in accounting records. This is a real threat to the sick. For example, the money for the purchase of drugs for HIV patients in 2021 has already ended, although the physical volume of supplies of antiretroviral drugs was 15% less than last year. In order for more than 60 thousand people to receive therapy in full, the Ministry of Health is forced to spend funds planned for 2022. Now the problem is being solved, but next year the deficit may be even greater.

Such a different concern: how are things with spending on medicine in the regions after the pandemic?

And we must not forget that not all regions have cut funding equally. As our research has shown, the financing of medicine to a large extent depends on the capabilities and wishes of the regional authorities.

Regional healthcare financing has never been homogeneous. But now the difference between the best and worst constituent entities of the Russian Federation is only increasing. Figures show that regions such as the Smolensk region are under the control of Alexey Ostrovsky and North Ossetia, led by Sergeн Menyailo, who are already among the outsiders in financing health care per capita (for 7 months they allocated about 2 thousand rubles for each resident), are cutting funding more than others. And the most generous regions are Kamchatka under the leadership Sergey Solodov, Tyumen region with Alexander Moor and Chukotka with Roman Kopin at the head, allocating from 10 to 34 thousand rubles for each resident, on the contrary, increase funding for medicine.

Despite the good news about budget revenues, the main expenses are expected in the second half of the year. And by the end of the year, the regions may come, according to the HSE, with a deficit of 1.2 trillion rubles. The budgetary provision of many regions does not allow fulfilling all obligations in full. But the arrangement of priorities, which is carried out by the regional authorities, should not be disregarded either. The most “frugal” regions spend on health care from 7.5% to 10% of all their expenses. And regions from the TOP of the best - from 10% to 20%. So there is money. The question is what they are spending on. And this is a big problem. As the first vice-rector of the Higher School of Organization and Management of Health Care Nikolai Prokhorenko notes, the authorities have created many problems themselves, and now they are forced to disentangle them.

- Of course, while reducing costs, the quality of medical care suffers. When the pandemic began, we faced a shortage of beds, doctors, some drugs, personal protective equipment, and ventilators. If the shortage of PPE and ventilators was characteristic of the whole world, then everything else is all our man-made, made during the years of optimization, when we decided that the basis should not be the need for help, but the money that is in the budget. It turned out, as in the saying "how much money - so many songs." Hospitals now face a shortage of oxygen concentrators, for example. Each hospital should have an oxygen station in the yard, and there should be portable concentrators on the premises. The health care system in the last 2 decades has been catastrophically underfunded - by about 2 times. Now about 70% of fixed assets are outdated.

Alexander Saversky also warns that disregard for health financing is no joke. The current level of public spending of 4.1% of GDP is severely insufficient.

- Underfunding of health care in some regions leads to the fact that people are forced to travel to neighboring more successful regions for treatment. And underfunding on a national scale leads to an increase in mortality. World practice shows that only expenditures of 6% of GDP and above allow maintaining a stable mortality rate.

The Smolensk region is clearly experiencing a shortage of beds. The region is faced with a difficult choice - to treat patients with covid, or to treat everyone else. Recently the choice fell on the latter: two hospitals refuse from the reception of patients with covid. In North Ossetia in early August at the republican hospital perished 9 patients due to lack of oxygen. In the Arkhangelsk region, patients complain about need to borrow queue from 4 in the morning to get the coveted voucher for an appointment with a doctor. In Orsk, Orenburg region, people complain on completely inhuman conditions in the children's infectious diseases hospital. And there are a lot of such examples in regions where they do not want to spend money on medicine.

If you want to be healthy - pay

Despite the good news about budget revenues, the main expenses are expected in the second half of the year. And by the end of the year, the regions may come according to the HSE, with a deficit of 1.2 trillion rubles. The budgetary provision of many regions does not allow fulfilling all obligations in full. In the meantime, people who want to receive high-quality and effective medical care have to pay for the treatment themselves. Free medicine as points out Alexander Saversky , has long remained in the legends of bygone times.

- The main problem is the organization and amount of government funding. The share of paid medical services is constantly growing in Russia. The sectors of public and private clinics are beginning to overlap: private ones begin to provide compulsory medical insurance services, and public clinics - paid services. The line between paid and free medicine is blurring. As a result, 48% of all health care costs are borne by patients themselves, paying for services and buying drugs. No other developed country has such a high proportion of personal expenses.

The same opinion is held by Nikolay Prokhorenko - Russians too often have to pay for treatment out of their own pockets:

- On average, in OECD countries, the population pays out of their own pockets about 20% of all health care costs. In Switzerland, Germany, Sweden, France - from 2% to 6%. In our country, people pay more than 40% of all expenses on their own. The state should increase its own expenses by 2 times and direct this money, first of all, to drug provision on an outpatient basis, and to increase the salaries of not only doctors, but also milestones of industry workers, including IT specialists, accountants and others.

Since the governors cannot cope with the financing of health care themselves, then maybe it is worth regulating this process at the federal level? Why wouldn't the Ministry of Health, for example, legally oblige the regions to spend at least 10% or 15% of their budgets on medicine? But in the current configuration of areas of responsibility, this approach will not work, experts say. Alexander Saversky indicates that the Ministry of Health does not have the authority to influence either the decisions of regional governments or the decisions of the MHI Fund, which allocates money for the purchase of drugs by medical and preventive institutions. A Nikolay Prokhorenko emphasizes the need to leave personal responsibility to governors.

- The regions themselves can regulate funding depending on how much money they received from the federal budget, what their features are. Health care should remain on the governors' conscience - if in Moscow half of the money spent on tiles was spent on health care, then we would see a completely different level of medicine. And the residents themselves should know what share of all regional spending goes to health care in their region and in the neighboring one.

As a result, all the "good fellows" - both the regional authorities, which distribute money for any projects, except for healthcare, and the federal authorities, which only talk about financial success, but do not give money. In the meantime, until people's health becomes a national priority, people will be forced to either engage in dubious self-medication, and give their last money to hospitals and doctors.