In the race for Venezuela: how much "free" medicine really costs for Russians

Together with the experts Novye Izvestia figured out what is all this will lead to.

Victoria Pavlova

After the parliamentary elections, during his communication with the government, Vladimir Putin separately noted the need to work on the development of medicine - the population's satisfaction with the medical care provided is not growing. On the other hand, paid medicine is developing very well: even in Siberia, this market in 2021 should show an increase of 18–20% compared to last year. In other federal districts, the position of private clinics is even stronger: in the Siberian Federal District, according to RBC, there are about 300 private network clinics. In the Volga and North-Western Districts - slightly more, and in the Central Federal District - more than 568. Trends are such that people are more and more afraid of state clinics (in 2019, 77% of Russians applied to state clinics, and in 2020 - 72%), and more and more prefer private ones (in 2019 46% of Russians turned to private traders, and in 2020 - 48%).

Not all help can be obtained from private owners for compulsory medical insurance, mainly it concerns expensive procedures, but nevertheless, for the commercial company Medicina, the compulsory medical insurance system in 2019 provided 47% of revenue, for Medsi - 27%, for EMC - 16 %, “Mother and Child” - 11%.

There is a choice, but for some reason people are still waiting for high-quality free medicine. According to VTsIOM polls, for 52% of Russians free medical care is one of the most important social guarantees. Are such expectations a relic of the past and it is high time to admit that in the modern world you have to pay for everything out of your own pocket?

The President of the League for the Protection of Patients Alexander Saversky does not believe that the mixture of paid and free medicine is beneficial to people:

- Chaos occurs when paid and free medicine is mixed. Because according to the Constitution, in our state and municipal institutions, assistance is free. This is an imperative that state and municipal institutions are obliged to fulfill, but for some reason no one cares about the constitution.

- Health turns into a commodity that has no price, because health is priceless. And a product that has no price cannot be an object of civil law - a transaction, because at any moment you will pay the money that is demanded of you. Health is not a refrigerator, it is not clear there what will help, how it will help, and whether it will help at all. The patient is actually a vulnerable bargainer, and I think healthcare deals are onerous. The patient does not have the autonomy of the will to complete the transaction. And in these conditions, he becomes an ideal target for making money, the principle of "wallet or life" operates. Therefore, services are often imposed, and it is naive to think that the same does not happen in the CHI system, there is simply a different payer. All the stories with "postscripts" are just about the fact that in the system of state institutions they make money in the same way, extorting money from the state in other ways.

Sometimes money is extorted, sometimes people voluntarily pay for treatment in the hope of getting better quality care or in an effort not to face the hassle in clinics, sometimes there are simply no other options - doctors do not always have all the necessary medicines available. One way or another, and personal expenses "out of pocket" of patients are steadily growing. Moreover, as noted by the first vice-rector of the Higher School of Organization and Management of Health Care Nikolay Prokhorenko, these costs are not at all a trifle, and they did not appear yesterday:

- We have had such a bias in the direction of paid medicine for the last 15 years. And although spending on health care from the pockets of citizens is still less than the state funds allocated for health care, about 5 trillion rubles are spent in total, of which about 3 , 2-3.3 trillion is public funds, in other countries out-of-pocket spending is much less. That is, in Russia, the share of citizens' participation in these expenses has fluctuated in recent years from 30% to 40%. In developed OECD countries, this share does not exceed 20%. In countries such as France, Sweden, Switzerland, people pay from 2 to 7% for health care - almost everything there is absolutely free.

Alexander Saversky, using WHO data, gives an even more unpleasant assessment:

- If the expenditures of the consolidated budget on healthcare are 4.2 trillion rubles, the drug market is somewhere around 1.3 trillion rubles. About 400 billion of them are covered by the state, the rest is on the citizens. 48% of health care costs are spent by citizens themselves, according to estimates by the WHO and our NFI. But this estimate was made about 7 years ago or more. Accordingly, during the crisis, the growth of citizens' spending on medicine increased by 36% - this is critical, it brings us generally closer to the Middle Ages, when a citizen pays for himself.

Indeed, the forecast of health care spending until 2030 from the NFI (Scientific Research Financial Institute of the Ministry of Finance of the Russian Federation) takes into account the WHO estimate of 48%. The WHO is likely to have a more negative view of the problem due to the larger estimate of informal health spending. According to WHO, they account for 30% of all out-of-pocket expenses. But even without taking into account the informal costs of “gratitude” to doctors, Russia is lagging behind European countries in financing health care. If in Europe people are forced to pay themselves because of the high cost of medical care (the profession of a doctor in many countries is very respected and highly paid), then in Russia - because of the catastrophic underfunding of health care. And even expensive oil will not help rectify the situation. This requires a strong-willed political decision of the authorities and a change in state priorities.

As a result, Russia was in 121st place out of 189 in last year's WHO ranking of total expenditures on health care. In the United States, which ranks second, cumulative expenditures amount to 17.1% of GDP, and in Russia - 5.3%. We are much closer to the outsider Venezuela spending a ridiculous 1.2% than to the leaders. And whatever the methodology, the conclusion is the same for all experts.

Even the state scientific research institute concludes in its research:

“Although there are some methodological features of comparing public expenditures in Russia and abroad (the presence of so-called cross-over expenditures on health care, which are taken into account in other sections of the budget classification, differences in the level of taxation), it is indisputable that even if they are taken into account, health care expenditures in Russia is much lower than in developed foreign countries ... In order to improve the quality and availability of medical care in Russia in the future, it is necessary to increase overall health care expenditures, primarily due to an increase in government spending. The share of private spending on health care should be reduced, while it is necessary to replace informal payments of the population with legal ones”.

Alas, medicine and bribes are inseparable - this is confirmed by Mikhail Prokhorenko:

- Of these 2 trillion rubles that citizens spend, about 1 trillion are just these acquisitions in pharmacies of all that is needed for treatment. And the rest consists of voluntary medical insurance, from paid services that are provided by both private and state medical organizations, from payment for rehabilitation in holiday homes and sanatoriums, and from illegitimate payments (bribes), the share of which, according to some data, is estimated at 110-120 billion rubles (but in fact, many experts agree that this share is underestimated and such payments amount to about 300-350 billion rubles a year).

So maybe, if government funding is reduced, and people's money goes into the shadow sector and does not contribute to the development of health care, it is worth abandoning the so-called free medicine, which in fact is not such at all, and go completely on a commercial track? If you get sick, you pay; if you are healthy, you save. And to rewrite the Constitution, which, as it were, guarantees free medicine, as practice shows, is not a problem at all. Last year, the State Duma has already got the bill that eliminated the prohibition to refuse medical facilities to patients to help. The first step has already been taken. However, according to Mikhail Prokhorenko, this is a dead-end path:

- To abolish free medicine together with the abolition of insurance premiums to the compulsory medical insurance is, at first glance, a logical message, but it is deeply methodologically untenable. There can be no purely paid medicine in any country, because there are people who do not work - people with disabilities, children, old people, and they are not able to pay for medical care from incomes that are barely enough for bread. Therefore, some kind of common fund, where money is collected together, is in any country in one form or another. The question of fine-tuning the system - whoever receives a lot may be obliged to donate some not very large share to the general fund and then pay for individual insurance or simply issue a certificate or voucher for access to the extended program. As for basic medical care for all citizens - if the state considers itself socially oriented and modern, then these packages should be the same in both public and private medicine and be provided for the poor at the expense of the state and the general fund, and for the haves - partially at their own expense. check.

At the moment, the situation looks depressing. Healthcare requires a lot more money to provide quality services, but the state prefers to support the army and security forces. Before the United States, the leader in healthcare spending, we are like the moon. But Mikhail Prokhorenko believes that there is hope: mountains of money are not yet an absolute guarantor of quality services. Much depends on the management:

- The medical aid system is characterized by at least a hundred parameters. Each country has its own range of such parameters. Therefore, first of all, we are talking, of course, about the organization. Generally speaking, the optimal financing system is in those countries where, with a cost-to-benefit ratio, correspondingly, the costs are the lowest.

The Bloomberg index is suitable for a global macro-assessment of countries' health systems. We rank 55th out of 55 compared countries on the Bloomberg Index. And in the top ten - Singapore, Spain, Hong Kong, Israel - they are among the benchmarks for this particular index, because there are other indices. USA in 53rd place.

Again, everything rests not on some insurmountable objective barriers, but on the unwillingness or inability of the authorities to take a sensible look at the problem and set priorities in accordance with those that were publicly announced by the president.