fac conf pres 2011
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Official Discourses of Russian
Health System Reform
Faculty of Health Research Conference
November 2011
Kate Thomson
Territory
Healthcare in Russia 1991 mid-
00s
• Soviet model –centrally controlled state
healthcare
• 1993: move to insurance-based financing
structure
– CHI – payroll tax + regional govt contributions
• Problems:
Under-investment
Quality
Corruption
Health CrisisAccess
Percentage of Russians reporting paying for
medical assistance in 1994, 2000 and 2004
For a consultation with a healthcare practitionerFor tests and investigationsFor inpatient care, including medicines
Source: Shishkin et al (2008)
Russia‟s „Health Crisis‟
• High mortality/low life expectancy
compared to countries in region (esp men)
• Spike in male mortality –mid 1990s
– Societal collapse
(economy, structure, institutions)
– Alcohol
– Roads, working environments
• + Population „shrinkage‟
• „demographic crisis’
Life expectancy trends in
Russia, EU, Japan & USA, 1950-
2000
Source: Karlin (2008)
Key Policy Moments &
Documents
• National Priority Project
“Health” (2005)
• Concept of Health 2020
(2008)
• Health insurance law (2010)• Modernisation programme 2011-12
• Law on Basis of Health Protection (Nov
2011)
Policy directions & issues
2005• Increased Funding
• -wages, buildings, IT, hi-tech equipment
• Insurance contributions
• Access to medicines
• Addressing geographical disparities• Joined up system
• Clear delineation Federal, regional, municipal resps
• Incorporation of private hc providers
• Primary care & preventive services
Discourses
• „Systems of statements that construct an
object‟ (Parker 1992)
– Apparent in texts
– Context is important
– Reproduce power relations
– Ideological effects
• „systems of power/knowledge which are
socially and culturally located and which
construct subjects and their worlds.‟ (Gubrium and Holstein 2000).
CriticalDiscourse Analysis
Modernis-ation
Catching up
Standards
CompetitionResponsibility
Access
Official
discourse
s
Competition
• Принятие закона об обязательном
медицинском страховании – это важный
этап в модернизации здравоохранения. Мы
переходим к конкурентной модели, в
которой на первый план выходит пациент и
качество медпомощи.
“Passing the law (on compulsory health
insurance) is an important stage in the
modernisation of the health system. We
are moving toward a competitive model, in
which the patient and the quality of
medical care come first.”
Tat‟yana Golikova, November 2010
“Passing the law (on compulsory health
insurance) is an important stage in the
modernisation of the health system. We
are moving toward a competitive
model, in which the patient and the
quality of medical care come first.”
“ Material & moral stimulus” for staff
Standards
• „Standards‟ for conditions -specify
treatment that is free under state
guarantee
– Public & professional consultations
– Will be universal – across whole of Russia
• Set tariffs
• Specified responsibilities for levels of govt
• Professional education; CPD; skills
framework
Lifestyle & responsibility
• Goals: halve alcohol & tobacco use by
2020
• Lifestyle correction
• Raising the level of culture around health
“One novel thing in the Law is that everyone has a responsibility to care for themselves..”
Absences from the discourse
e.g. Corruption
• Disappearance of funds
(local govt / institutional
level)
• Payments for „free‟ servs
• Bribes
Pay & working conditions of health staff
Under-funding institutions
Cultural expectation &trust
Abortion rights
• Amendment to the new Health Law 2011:
• “ The aim is not to restrict women’s access
to a medical procedure. It is that the
woman who is making this decision to
terminate a pregnancy, has a chance to
think it over.” (V. Skvortsova, Dep Min Health &
Social Protection, 10/11/11)
Summary: challenges• Health indicator improvements
– Addressing structure as well as health system?
• Geographical disparities
– Governance issues
– Wealth
– Provision of facilities
• Trust in system
– Public trust in hc institutions & professionals
– Professional engagement with „modernisation‟
Summary: featured discourses• Re-contextualisation (Fairclough 2005) :
• Dissemination of global discourses, e.g.
– Competition & quality relationship• Private sector + public services
– Individual rights + responsibilities
• Recontextualisation in Russian setting:
– Geography
– Health challenges /‟crisis‟
– P ublic & professional expectations
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